HC Deb 15 March 1990 vol 169 cc684-731

Order for Third Reading read.

Mr. Speaker

Before calling the Minister, I remind the House that this is a three-hour debate.

4.26 pm
The Parliamentary Under-Secretary of State for Scotland (Mr. Michael Forsyth)

I beg to move, That the Bill be now read the Third time.

This Bill stands for everything that the Labour party cannot stand. It stands for choice for patients. I am delighted to see that the hon. Member for Glasgow, Cathcart (Mr. Maxton) agrees with me on both points.

Mr. John Maxton (Glasgow, Cathcart)


Mr. Forsyth

It stands for greater freedom, flexibility and responsibility for general practitioners and for individual hospitals. It stands for a shift away from centralisation and bureaucracy in the NHS—the centralisation and bureaucracy with which the Labour party is so closely identified when in government and in opposition. It stands, too, for a partnership between the public sector, the private sector and the voluntary organisations for strengthened management and accountability and for standards and quality of care. The Government have set out to build a patients' charter, and this Bill sees us well on the way to achieving that.

Throughout the passage of the Bill, the hon. Members for Peckham (Ms. Harman) and for Livingston (Mr. Cook) had nothing constructive to say on the future direction and organisation of the Health Service. They relied on a campaign fostering misinformation, suspicion and anxiety among patients, instead of putting forward constructive arguments and an alternative proposal. Their entire campaign was based on myths. The first of these myths was that indicative budgets would mean that the patients would not get the drugs that they needed. I see that at least one hon. Gentleman still subscribes to that ridiculous view.

Last year, in the nine months between the publication of the White Paper in January and the meeting of my right hon. and learned Friend the Secretary of State with the BMA, we saw in general practitioners' surgeries up and down the country irresponsible leaflets from the BMA and others, and we heard speeches from Labour Members arguing that patients would not be able to get the drugs that they needed. To the credit of the BMA, at a meeting with my right hon. Friend on 27 September it said that it now accepted that, in fact, patients would be able to get the medicines that they required. So far as I am aware, that is not the view of the Opposition. I hope that they will make it clear today that the Labour party now accepts that patients will be able to get the drugs they desire as a result of indicative budgets being introduced.

Mr. James Couchman (Gillingham)

A fair amount of misconception arose because of the reference in the White Paper to placing downward pressure on expenditure on drugs". Might it not have been better to have said, "downward pressure on the growth of expenditure on drugs"?

Mr. Forsyth

My hon. Friend makes his own point. He must be aware that, for example, through prescribing generic equivalents it is possible to bring downward pressure on expenditure without affecting the quality of patient care.

Ms. Harriet Harman (Peckham)

We would accept the Minister's assurance that patients will not lose because of cash-limited drug budgets if he had accepted our new clause, which merely sought to write into the Bill the guarantee that he is trying to give us. Guarantees given in the House are worth nothing; they need to be written into legislation. If the Minister means what he says, why did he call on his hon. Friends to vote down our amendment?

Mr. Forsyth

In Committee I pressed the hon. Lady to say whether she supported the existing system for controlling GP prescribing. She did not seem to recognise that there is in place a system based on peer review and that there are appropriate penalties for doctors who overprescribe. She should recognise that there is nothing different about indicative budgets. If the hon. Lady is still arguing that there is a risk to patients, she is out of line not only with this side of the House but with the BMA and with doctors themselves, and is becoming increasingly isolated as she peddles these myths.

Mr. Nicholas Bennett (Pembroke)

My hon. Friend is absolutely right. I have here a copy of a letter, dated 27 February, which the hon. Member for Peckham (Ms. Harman) sent to all local medical committees. First, I question whether it was in order because it was a circulated letter and I do not think that the rules of the House allow circulated letters to be printed on House of Commons notepaper—[Interruption.] Opposition Members are always keen to be in order, yet we know how often they misuse the facilities of the House. The first thing the hon. Lady said in her letter to medical committees was: GPs' drug budgets will be cash limited.

Mr. John Battle (Leeds, West)

On a point of order, Mr. Speaker. If a hon. Member feels that another hon. Member has infringed the rules of the House in the way that he has used the stationery, there is a proper procedure for that to be reported. That has not been undertaken. Therefore, is it in order for the hon. Member for Pembroke (Mr. Bennett) to castigate my hon. Friend?

Mr. Speaker

I do not know whether it is alleged that this was an individual letter or a circular. If there has been an infringement of the rules, it is a matter for the Services Committee.

Mr. Nicholas Bennett

Further to that point of order, Mr. Speaker. You will recall that I referred the matter to you on a previous occasion, when the hon. Member for Livingston (Mr. Cook) did precisely that. It is a circular letter and I shall be happy to refer the matter to the Select Committee on Privileges.

Mr. Forsyth

My hon. Friend the Member for Pembroke (Mr. Bennett) is right to focus attention on the arguments of the Opposition. Everyone, including the BMA, accepts that indicative budgets will not result in patients not being able to get the drugs which they require.

Mr. Allen McKay (Barnsley, West and Penistone)


Mr. Forsyth

I am not giving way. I have already given way generously on that point.

The next myth that has been peddled by Opposition Members is that GPs who become fund holders will run out of money and will turn away expensive patients. [Interruption.] The hon. Member for Peckham smiles and takes pleasure repeating it. That myth has caused needless anxiety to thousands of patients and elderly people who are in great distress. It is totally without foundation. It was made clear in Committee that GPs who become fund holders will have made available to them funds to take account of the nature of their patients and of their past expenditure.

If GPs exceed their budgets, patient care will not be threatened or diminished. I hope that the hon. Member for Peckham will now acknowledge that. As became clear in Committee, the worst that could happen to a fund holder who had exceeded his budget would be that he could no longer be a fund holder. He would then revert to the status quo.

Ms. Harman

The Minister knows that Opposition Members are worried about cash limits on GP budget holding because they fear that patients will not necessarily get the treatment, drugs and the tests that they need. The doctor will not just be thinking about patients and their clinical needs; he will be looking over his shoulder at his budget. If the Minister wants us to accept the guarantee that he has given in the House, why did Conservative Members speak and vote against our new clause, which would have added that guarantee to the Bill?

Mr. Forsyth

The hon. Lady continues to repeat her accusation, despite the clear evidence of the facts. The facts are that a GP's budget will be determined by his past expenditure and the profile of his patients. If a OP exceeds his budget, patient care will not in any way be threatened or diminished. The hon. Lady also argued that no GP was interested in the scheme, and that it was a crackpot scheme that had been invented by people who were out of touch—[Interruption.]

Mr. Robin Cook (Livingston)


Mr. Forsyth

I will not give way to the hon. Gentleman. I will happily give way to the hon. Lady. who can reject—[Interruption.]

Madam Deputy Speaker (Miss Betty Boothroyd)

Order. For the moment the Minister has the floor.

Mr. Forsyth

I am not giving way to the hon. Gentleman. I will give way to the hon. Lady when I have made my point, and she can reject the point when she knows what it is. I can tell by the way that the hon. Member for Livingston is jumping up and down that we are beginning to draw blood.

The hon. Gentleman is just as guilty. He has associated himself with the view that the proposals in the White Paper are not supported by the medical profession, and both he and the hon. Lady have made speech after speech saying that the Government are out of touch with the profession. My right hon. and learned Friend the Secretary of State answered a parliamentary question on the subject yesterday. His answer showed that almost 900 GP practices are impressed enough with the scheme to want to take matters further and to ensure that their patients have the possible benefits from the scheme.

Ms. Harman

The position remains that there is no support among GPs for the concept of fund-holding practices. I accept the Secretary of State's assertion that many GPs have put their names forward to become fund holders. However, that is because they are choosing between the lesser of two evils. They regard fund holding as the only way to escape from the restrictions on their right to referral, which will clamp down on them if they do not become fund holders.

Mr. Forsyth

The hon. Lady refutes one myth by embarking on the next. She accepts that nearly 900 GPs are queueing up—even before the Bill has been enacted—to become fund holders or budget holders. They are doing so because they recognise the benefits for their patients and the opportunities for their practices. The hon. Member for Livingston completely misread the demand for the proposals, and also for self-governing hospitals.

Mr. Bill Walker (Tayside, North)

Does my hon. Friend agree that GPs who have shown an interest have come forward voluntarily—that is certainly the case in my constituency—because they believe that what is proposed is in the best interests of their patients and their practices?

Mr. Forsyth

That is right, and in my hon. Friend's constituency there is a proposal from a hospital to become an NHS trust. We now have twice as many proposals in Scotland as the target we set when the White Paper was published.

Mr. Allen McKay

Although the Minister talks about the number of GPs who are in favour of the scheme, is he aware that GPs are queueing up in my area to throw money in the till to take the Secretary of State to court to prevent him from implementing these proposals?

Mr. Forsyth

GPs who put their money in that direction, because they believed that my right hon. and learned Friend was acting improperly, were not only proved wrong in that respect, because they lost their action, but have throughout been proved wrong in their opposition to our proposals.

The third myth that we had in Committee from the hon. Member for Peckham and her hon. Friends was that GPs would no longer be able to send patients to hospitals which were, in their judgment, required to meet those patients' clinical needs. In trying to rescue her position on the previous myth, the hon. Member for Peckham repeated the third myth about GPs not being able to send patients where they thought they should be treated.

That assertion is completely and utterly untrue. We made the position clear in Committee on many occasions, as we have throughout the period since the White Paper was published. In view of those assurances, I hope that the hon. Lady will now withdraw from the position that she has taken all along. General practitioners will be able to send their patients to the hospitals where they believe that their clinical requirements require them to be sent. I say that without qualification. That has been made clear throughout our debates on the Bill and it is wholly irresponsible of the hon. Member for Peckham to continue to go about the country repeating statements that are, frankly, not true.

Ms. Harman

If the Minister would have us accept that patients and their GPs will retain the choice that they now have—to decide where patients should be referred in the patients' best clinical interests—why did the Government refuse to accept our amendment which would have written into the Bill a provision saying that, irrespective of the NHS contract system, patients may go where they and their GPs choose, rather than on the basis of some contract based on some previous pattern of referral?

Mr. Forsyth

I hope that people throughout the country are listening to what the hon. Lady is saying because on three major issues—[HON. MEMBERS: "Answer."]—about which she and her party have caused anxiety throughout the country, the only justification that she offers for her position, in the face of the assurances that she has been given, is to say, in effect, "If that is the case, why did you not accept our new clause?" That new clause was not needed as part of the Bill and it was no excuse for the campaign that the hon. Lady has waged throughout the country.

Ms. Harman

Now answer my question.

Mr. Forsyth

My answer is that the Opposition new clause was not necessary. It would not have been desirable to write on the face of the Bill the rules for referral when those rules should clearly be left to the judgment of medical practitioners according to their individual patients' needs.

Mr. Ieuan Wyn Jones (Ynys Môn)

Will the hon. Gentleman give way?

Mr. Forsyth

No, I will not give way to the hon. Gentleman.

Mr. Robin Cook

The Minister says that there is no need to write the assurance that he is giving into the Bill because referrals will be decided locally in the process of negotiation. How on earth can the Minister expect the House to accept his assurance that any GP will be allowed to refer any patient to any hospital of his choice when he just said that that can be done only subject to local negotiation in relation to local rules?

Mr. Forsyth

I credit the hon. Gentleman with some understanding of the Government's proposals. He knows well that a GP's referrals will be based on a contract which will be negotiated either by the GP himself, where he is a budget holder, or by the health board. He also knows that if a GP wished to send a patient to a hospital where there was no contract, he would be able to do so if it was an emergency case—[HON. MEMBERS: "Ah!"]—in the absence of a contract. If it was not an emergency case, there would be time to negotiate a contract.

The key issue is whether the GP would be able to send the patient to the hospital of his choice, and the answer is yes. It is totally irresponsible of the hon. Member for Livingston to go round the country telling people that that is not the case when it is.

Mr. Cook

The Minister did not answer my question simply by saying that the answer was no. Consider two cases, first that of a patient who wishes to go to a particular hospital where his fund-holding GP has not placed a contract and where that GP is not prepared, and does not have the money in his budget, to place a contract. How does that patient get into that hospital?

Consider, secondly, the many GPs—still a wide majority who have not applied for fund-holding practice budgets—whose district health authorities have not negotiated contracts for the hospitals to which they wish to refer their patients. There may be time, with a non-emergency cases, to take that step. But what do they do if the district health authority says, "No, thank you very much, but we have spent our allocation for the year and we do not propose to negotiate a fresh contract. You will have to send your patient to a hospital where we have placed a contract"? What happens to freedom of choice then?

Mr. Forsyth

Freedom of choice continues to be exercised by the GP. The hon. Gentleman knows well that a contingency fund is made available to meet exactly the example of his second case. In his first example, he was asking not about doctor choice but about patient choice. The key point is that where a doctor believes that a patient should be referred to a hospital, wherever it is in the United Kingdom, whether or not a contract exists, arrangements can be made for that choice to be exercised and for the patient's needs to be met.

Ms. Harman

The Minister will live to regret saying that.

Mr. Forsyth

The hon. Lady says that I shall live to regret that, as though I had just annunciated some new doctrine. My right hon. and learned Friend has been saying it all over the country for months. The fact that we arrive at the Third Reading of the Bill and a Labour Front-Bench spokesperson is still learning that is indicative of the poverty of opposition that we have enjoyed during the passage of the measure.

Mr. Ieuan Wyn Jones


Mr. Forsyth

The argument of hon. Members for Peckham and for Livingston that GPs would not refer patients to where they thought were the best hospitals for them is an insult to the medical profession. Not only are GPs under a moral obligation to do what is best for their patients; they are under an ethical and legal obligation to do so, and it is wrong to suggest otherwise.

We have heard a number of other myths from the Opposition. We had the myth that self-governing hospitals or NHS trusts would withdraw key services. The hon. Member for Peckham has been telling people all over the country that they will no longer be able to get maternity services—that self-governing hospitals will not wish to run such services because they would not be profitable.

The hon. Lady knows well, after more than 109 hours in Committee, that the NHS trusts will operate under contract to the health boards or health authorities, that those authorities in those contracts will specify the range and quality of service to be provided and that the hospitals will need to provide those services if they are to see their resources.

It is totally irresponsible of Opposition spokespersons to go round peddling such myths, saying that people will lose local services, when the effect of NHS trusts will be that the quality of services will be defined for the first time and hospitals will be held to account for delivering them.

Ms. Harman


Mr. Forsyth

I have been very generous.

Ms. Harman

It is ludicrous for the hon. Gentleman to say that he has been generous when much of his opening speech has been spent attacking our assertions.

The White Paper acknowledged that under the NHS contract system, district health authorities would he able to place contracts outside their districts and require patients to travel to those hospitals for treatment. That is why, in the White Paper, the concept of core services—services to which patients should have guaranteed local access—emerged. But that concept of core services did not find its way into the Bill, and the Government rejected an Opposition new clause which would have inserted in the Bill the promises made by the Government in the White Paper.

Nothing in the Bill guarantees local access to vital facilities such as maternity and child health care and services for the elderly and mentally ill. There is nothing in the Bill to stop district health authorities requiring people in their areas to travel to obtain those services.

Mr. Forsyth

I despair. If we had put in the Bill everything that is needed to reject every accusation made by the hon. Lady, it would run to 600 clauses rather than 60. She talks about core services. In Committee, one of the few Opposition Members who played a constructive role was the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy). What is a core service in his constituency might not be a core service in a hospital in the middle of a city. It would be ludicrous to try to define core services in legislation. The health authorities will be responsible for the contract and for defining core services.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

May I just express relief that we are not on television at the moment? What does the Minister have against me?

Mr. Forsyth

I could tell the hon. Gentleman, but if did the hon. Member for Peckham might insist that I put it in the Bill. I would not wish the hon. Gentleman to have such a permanent monument.

The truth is that Opposition Members understand the argument and support us. They support us on quality of care, efficiency of the delivery of care, more information for consultants and GPs, further devolution of management to hospital and unit level, flexible accounting systems to reflect clinical-led doctor-patient choice and medical audits.

Mr. D. N. Campbell-Savours (Workington)


Mr. Forsyth

The hon. Gentleman says rubbish. He implies that the Opposition does not support us on those things. I have here a document produced by the hon. Members for Kirkcaldy (Dr. Moonie) and for Strathkelvin and Bearsden (Mr. Galbraith), who cannot be with us today. It is entitled "Working for Patients—A Critique." It is published by the Labour party in Scotland. Under a section entitled "What's Good in the White Paper" and under the heading "Quality of Care", it says: This has largely been taken from Labour's White Paper. Under the heading "Efficiency in the Delivery of Care", it says: Yet again this is taken from Labour's White Paper. Under the heading "More Information Available to Consultants and General Practitioners", it says: We welcome this, because it will improve services. Under "Further Devolution of Management to Hospital and Unit Level", it says, surprisingly: This should be done and is being done already within the current structure. We would issue hospitals with their own budgets, but only WITHIN health boards. Savings should go back to the health board". The difference between us and the Opposition is that although we both believe in devolving budgets the Government believe that the budgets and savings should remain at local level so that those who provide care can use them effectively.

Under the heading, "A Flexible Accounting System to Reflect Clinical Led Doctor/Patient Choice", the document says: We support money following patients. That is not what the hon. Member for Peckham told us in Committee.

Ms. Harman

Will the Minister give way?

Mr. Forsyth


Mr. Edward Leigh (Gainsborough and Horncastle)

Will my hon. Friend give way?

Mr. Forsyth

If my hon. Friend will allow me, I must insist on reading out the Labour party's policy document because it is so sensible. Under the heading "Audit", it says: Again taken from Labour's White Paper. Why has it taken the Government so long to be interested in this? I know that the Labour party in Scotland is unilateralist on defence, but I had no idea that its position extended to supporting the provisions in the Bill.

Ms. Harman

We support money following the patient. The problem is that in the Bill the patient will follow the money because the patient will go where the contract is. If we had a system of fund allocation that recognised where patients were treated and compensated the hospital that treated them, it would be one thing. But the patients will not be able to go to a hospital unless a contract has been placed there. Where is medical audit in the Bill?

Mr. Forsyth

I am sure that if the hon. Lady had a word with the hon. Member for Livingston, the Front-Bench spokesman on health, or the hon. Member for Kirkcaldy, they would be able to explain the position.

The biggest threat to the NHS would be the election of a Labour Government. The Labour Government cut, cut and cut. They cut nurses' pay and they cut capital spending by a third. They closed one hospital every week and cut expenditure on the Health Service from 5 per cent.——

Mr. Tom Clarke (Monklands, West)

Will the Minister give way?

Mr. Forsyth

No. I have given way generously.

Mr. Clarke

How much longer?

Mr. Forsyth

The hon. Gentleman complains that I am taking too much time.

Mr. Clarke

On a point of order, Madam Deputy Speaker. The Minister's remarks were based on the reply that he gave to my hon. Friend the Member for Falkirk, East (Mr. Ewing) the other day. My hon. Friend produced information which showed that what the Minister said was a complete distortion. Will he withdraw it now?

Madam Deputy Speaker

Order. That is not a point of order, but it is a good opportunity for me to remind the House that a Third Reading deals with what is contained in the Bill. I hope that hon. Members—[Interruption.] Order. I call both sides to order. I hope that from now on hon. Members will debate precisely what is in the proposed legislation.

Mr. Forsyth

I realise that it is a painful experience to describe Labour's record but I accept your strictures, Madam Deputy Speaker, and I shall return to the substance of the Bill.

In contrast to what appears to be the Opposition's position, the purpose of the Bill was set out clearly in the foreground to "Working For Patients" by the Prime Minister. She spelt out in one short sentence the key thinking behind our proposals. She said: The National Health Service will continue to be available to all, regardless of income, and to be financed mainly out of general taxation. We are building a National Health Service on that principle. It will be more responsive to patients' needs by devolving decision making to local level, to general practitioners, to NHS trusts, and to district, region and health board level, where appropriate. We shall direct resources to where a patient's need is met. I am delighted that the hon. Lady now says that she supports the money following the patient.

We shall end the efficiency trap in which doctors and units that provided a good service ran up against the barriers of their budgets. The money did not come in on the backs of the patients. The position at present is that the patient follows the money and that is why the reforms are necessary. We are building a streamlined management in the NHS because we believe that a better-run Health Service can better care for the sick. We are emphasising quality of service through our proposals on audit and guidance on matters such as waiting areas, appointment areas and choice of consultants.

In our proposals on care in the community, we are ensuring that there are clear lines of responsibility and a system of funding which enables the many elderly people who wish to remain in their own homes to do so. We shall end the perverse system of funding that makes putting people into residential care a more attractive option for many local authorities.

Mr. David Hinchliffe (Wakefield)

Will the Minister outline what action the Government have taken in the Bill to develop alternatives to institutional care? It is all right to say that the Bill ends the perverse incentive to institutional care, but what alternatives are there for vast numbers of elderly people? The Government are doing nothing about developing alternatives or genuine community care.

Mr. Forsyth

I disagree with the hon. Gentleman. He must recognise that the changes that we propose end the incentive for local authorities to recommend a residential placement where care and support, perhaps through home help or other provision, could have enabled an elderly person to remain at home. That is a fundamental change which will bring considerable benefit to many thousands of elderly people.

The Labour party emerges from our proceedings on the Bill as a party with nothing new to offer the Health Service. It has shown itself wedded to the vested interests of the trade unions. It has no vision of what the National Health Service should strive for during the 1990s, and the opposition that we have had has been a catalogue of political drum-beating, with no coherent strategy on the table.

Our record is one of success, dedication and commitment to the National Health Service, its staff and its patients. That is why we can take our reforms forward confident in the knowledge that we can translate words into actions.

Under this Government, more resources have been made available to the National Health Service than ever before in its history. We have more doctors and nurses, and a record number of patients are being treated. We have a record of which to be proud. The Bill will ensure that our success and commitment can be built upon during the rest of the decade.

The Bill deserves the support of the House in the interests of millions of patients throughout the United Kingdom. It is the charter for patients that we promised when we published the White Paper. It is a charter for choice, quality and freedom for the patient, and I commend it to the House.

5 pm

Mr. John Maxton (Glasgow, Cathcart)

The Minister is right: we have emerged from the earlier stages of the Bill into this Third Reading debate. I do not have the exact poll figures before me, but it is worth noting that, back in December last year, the Labour party was about 9.5 per cent. to 10 per cent. in the lead. We are now 21 per cent. in the lead in the United Kingdom as a whole; and in the area in which the Minister has an interest as chairman of the Conservative party in Scotland our lead is 31 per cent. and rising, despite all his efforts. After the Prime Minister's disastrous visit to Scotland last weekend, we can assume that our lead will soon be considerably greater.

The Minister made a disgraceful speech. It had nothing to do with the Bill. He spent the whole time talking about what the Labour party had said and what the Labour party was doing and made no reference to the Bill. Moreover, he took some 35 minutes to do that, although he and his colleagues have imposed an unnecessary and unwanted timetable upon our Third Reading debate under which discussion is limited to only three hours. I know that many of my hon. Friends, and some Conservative Members who still have reservations about the Bill, want to make some comments on it, and I shall therefore try to keep my remarks brief.

First, let me place on record my thanks, and the thanks of all Labour Members and of the vast majority of the British people—who have the highest regard for the National Health Service and believe that this Bill will damage it—to my hon. Friend the Member for Livingston (Mr. Cook), who has led the opposition to the Bill. He has ensured that the issues have been placed eloquently, clearly, constructively and forcefully before both the House and the general public, and the general public believe my hon. Friend much more readily than they believe the Secretary of State.

I also thank my hon. Friends the Members for Peckham (Ms. Harman), for Monklands, West (Mr. Clarke) and for Cardiff, South and Penarth (Mr. Michael) for their assistance, and my hon. Friend the Member for Barnsley, West and Penistone (Mr. McKay) for his work as Whip on the Committee. I also thank all those organisations representing the medical profession, patients, local authorities and the broad spectrum of medical care in Britain, which oppose the Bill and which have briefed us so usefully.

I shall leave the community care aspects of the Bill largely to my hon. Friend the Member for Monklands, West because it is probably now acknowledged that he is one of the greatest experts on the matter in the country.

In his Second Reading speech, my hon. Friend the Member for Livingston made clear our fundamental opposition to the Bill. Nothing that has happened since then—in Committee or on Report—has lessened that opposition. If anything, we are now more worried about the future of the Health Service than we were before. Despite our opposition in principle to the Government's proposals, we attempted in Committee to amend the Bill sensibly and by rational argument.

We attempted to look into what the Minister has described as the "myths". We claimed that there was a hidden agenda and we tried through amendments to give the Government an opportunity to dispel those so-called myths. In the end, all our arguments, and all the arguments of those representing doctors, nurses and other medical workers, carers and patients, were rejected. The Government rejected all our amendments. The only amendments that they considered with any sympathy were those tabled by Right-wing ideologues on their Back Benches, who were trying to persuade them that they were not going nearly far enough to privatise the Health Service in Scotland.

Mr. Andrew Rowe (Mid-Kent)

Will the hon. Gentleman give way?

Hon. Members

Give way to a Right-wing ideologue.

Mr. Maxton

I would hardly describe the hon. Gentleman as a Right-wing ideologue, although there are one or two of them present today.

The Minister today did what he and his colleagues have done throughout the Bill's passage, and uttered a lot of honeyed, hypocritical words about choice and improving the service. The Government know that the National Health Service is the most popular public body in the country. They know that they cannot openly express their real views on it—particularly the real views of the Under-Secretary of State for Scotland—or openly reform it as they would if they were following their natural ideological bent. They know that to do so would be electorally disastrous. Thus, they hide their true intent behind sweet words and devious legislation.

But the people of Britain do not believe them. At least a small part of their present low-standing in the opinion polls—as I said, they are 21 per cent. behind Labour—is due to the fact that the public know what their true intentions are.

Mr. Nicholas Bennett

Does not the hon. Gentleman realise that the same thing will happen to Labour's lead in the opinion polls now as happened in 1984–85 and in 1982, when the public see——

Madam Deputy Speaker

Order. That has nothing whatever to do with the Bill. Mr. Maxton.

Mr. Maxton

I think that I agree, Madam Deputy Speaker, with The Guardian, if I may briefly——

Madam Deputy Speaker

Order. What is good for one side is good for the other. The House should come back to the Bill.

Mr. Maxton

I shall, of course, accept your ruling, Madam Deputy Speaker.

The Secretary of State has said that the Bill represents the most major reform of the National Health Service since its inception. He is right. The Bill is designed to create a structure for the Health Service which will allow the Government to push it ever faster towards the sort of profit-led care that is prevalent in the United States, in which they believe, despite all their sweet words. We shall have hospitals managed as separate units, health authorities forced to operate market structures, general practitioners operating their own budgets and others working with indicative budgets. When we tabled amendments to dispel all those so-called myths, the Minister would accept none of them.

All that will fragment the Health Service and mean that each part of the service will be forced to work financially separately from the others. Of itself, the Bill does not give us the commercial system that the Tories instinctively want, but taken with the financial restraints that the Government are imposing on the system, it will create an atmosphere in which sections of the public will accept the gradual erosion of a universal Health Service that is free at the point of use. Let me give two examples. In February last year, the Secretary of State said that his proposals for opt-out hospitals would encourage local pride in our hospitals and give the local people more ability to take the big decisions in their own part of the service. Those were fine words, but when the Bill was printed it merely said: The Secretary of State may by order establish … National Health Service trusts. Both for England and Wales and for Scotland, we tabled amendments in Committee and on Report that were designed to give employees, patients and local people the right to decide, or to be consulted, on the future of their hospital. Not one of those amendments was accepted. The Bill remains unchanged, and legally the Secretary of State for Health and the Secretary of State for Scotland may force hospitals to opt out, with no consultation and against the wishes of the majority of people in their area.

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

The hon. Gentleman is following the example of his hon. Friend the Member for Peckham (Ms. Harman) and supporting his allegation by saying that we did not take amendments in the Bill, as if that gives it some sort of credibility. His hon. Friend is a lawyer, but I do not think that the hon. Gentleman is; however, I am sure that he is an experienced parliamentarian, and realises that legislation is necessary to give a Government and a Secretary of State legal powers which they otherwise lack. One does not write political slogans all over legislation or answer political allegations made by the Opposition. Because some unnecessary amendment was thrown out, that is not a basis for inventing all kinds of groundless allegations and for saying that they are sustained because they are not contained in the law.

Mr. Maxton

That was a remarkable intervention by the Secretary of State. It was an intervention by an English lawyer, but in Scotland what is carried out is in the Bill and has to be in it. If it is not, the Bill has no statutory or legal standing.

Mr. Clarke

That is not true.

Mr. Maxton

It is true. If the Secretary of State does not understand Scottish law, that is a great pity.

Whatever assurances the Secretary of State has given, and whatever he may say, the simple fact is that we now have no idea what will happen in Scotland about possible opting out. I shall give a Scottish example.

A new hospital is being built in Ayr. The consultants who work in the hospital were called to a meeting—they did not ask for it—by the general manager of the Ayrshire and Arran health board. They were dragooned by him, or it was strongly suggested that they might like, to write to the Scottish Office to seek futher information about National Health Service trust status for that hospital. The vast majority of them have made it quite clear that they were opposed to the whole concept of opting out. Only six of them were in favour and that was because they had been given a clear hint—I do not know whether it was by the Scottish Office or by the general manager—that, if they did opt out, the second phase of the hospital was likely to be built more quickly than if they remained within the National Health Service.

There is certainly now a rumour circulating in the area that consultants at the hospital have expressed support for opting out. I think it was late yesterday morning when the junior Minister from the Scottish Office, the hon. Member for Stirling (Mr. Forsyth), said that four hospitals in Scotland have expressed an interest in opting out. He refused to name them. Perhaps he can tell us now whether Ayr hospital is one of them. I give the Minister the opportunity to do so.

Mr. Michael Forsyth

A number of hospitals are in discussions with the Scottish Office. A number of consultants and others have expressed an interest in self-governing status.

Mr. John Home Robertson (East Lothian)

They had their arms twisted.

Mr. Forsyth

They have expressed an interest. They come to the Scottish Office and say that they want to find out more about the proposals and whether they will benefit their patients. It is perfectly reasonable for them to do so. However, they expect us to maintain confidentiality.

It is wholly irresponsible for the hon. Member for Glasgow, Cathcart (Mr. Maxton) to go around telling tales of the kind that he has just related to the House. Frankly, they are mischievous. He knows that we are not in a position to respond without breaking our undertaking to maintain confidentiality. It is another example of myth and mischief-making and has nothing to do with any argument of principle about the Bill.

There are people, for example at the Royal Scottish National hospital, who see a benefit in these trusts.

Mr. Maxton

The length of that speech was ridiculous. I take it that the answer to my question about the hospital in Ayr was yes. The Minister could have said that more quickly than he did.

Yes, that hospital is one of the four that the hon. Gentleman mentioned, and I have just described the circumstances. The Minister said that he has to maintain confidentiality. Does that mean that people in Ayr and the people that that hospital will serve are not entitled to know that it is considering opting out?

What does that have to do with consultation? What does it have to do with local people taking decisions in their own area and being able to decide what happens in their own hospitals? The Minister is prepared to keep all those things under his hat.

I do not want to take up the same amount of time as the Under-Secretary of State, so I shall move on. It is claimed that the reforms will create patients' choice, because the patients will take the money with them—we are in favour of that if there is any money to take—to buy whatever services they require from the GP or the hospital. The Government claim that they will provide the money, as they do at present, but for how long? As they restrict budgets and control expenditure, they will force GPs into fund-holding status and force hospitals to opt out.

Patients who require expensive, lengthy treatment may find that the GPs or the hospitals say that they are sorry, they would like to treat them but that the health board cannot pay sufficient money for their services. They will say, "If you care to top it up yourself, we can help you." People who can afford to pay will pay out of their own pockets or take out insurance policies. Those who cannot afford to pay will be forced to accept second-rate health care.

The Government believe that, ultimately, choice depends upon the resources available. At no stage of the Bill's consideration would they give any guarantee about improving or even maintaining resources for the NHS.

The NHS is not inefficient, as the Government constantly claim. There are no more massive savings to be made by so-called efficiency improvements. It is already underfunded. It now has a structure that will allow the Government to exploit the fears of sick people and to make them accept a commercially driven health service—whatever their denials, that is on the hidden agenda of the Bill. The present structure of the NHS does not allow for such a development but the new structure will.

The Bill, taken together with the Government's drive to privatise services—from cleaners, laundry services and catering to pharmacies, medical records, laboratory services and radiography—make it obvious what road the Government are taking the Health Service down by devious means.

The British public are on our side on this matter. They want a Health Service that does not depend on income—one which will provide equal service to all, whether rich or poor. Every opinion poll bears that out. The public have rumbled the Government's true intention in the Bill. If they insist on going ahead, they will pay the political price that they so richly deserve. We shall continue to oppose the Bill by all legitimate means. I ask my hon. Friends, hon. Members from other Opposition parties and those Conservative Members who have expressed concern during the passage of the Bill to join me in voting against giving the Bill a Third Reading.

5.17 pm
Sir David Price (Eastleigh)

At this late stage I shall, for the first time, make a few comments on the Bill. When the House was debating Second Reading I was, as the Scottish say, "No weel"—I was in bed with the 'flu and could not take part.

I read the Hansard report of the Second Reading debate carefully and I detected a common criticism in many of the speeches, to the effect that my right hon. Friends were wrong to put together in the same Bill the implementation of the recent White Paper, "Caring for People" and the reforms in the management of the NHS. I reject that criticism and I welcome the fact that reform of the NHS and reform in care in the community have been brought together in the same Bill.

My reason is simple. In the real world—not the world of parliamentary debates—health care is a complete spectrum. It goes from the person's home through various degrees of hospital treatment, to the acute ward and back again. For example, schizophrenics suffer many degrees of disability. Even people with AIDS have episodic conditions that require them to go into an acute ward, to come out and to be cared for in the community. Therefore, it is right that we should consider the whole spectrum.

Both the White Papers on which the Bill is based concentrated on the organisation and management of all direct patient care services". That is my right hon. and learned Friend the Secretary of State's description, not mine. That concentration is reflected in the Bill.

The most important factors in any consideration of the future of health care are these. First, we must assess the trend in the demand for services. Secondly, we must calculate, as best we can, the various options by means of which those demands can best be met. The Select Committee has drawn attention to the gap, which I believe is growing, between rising demand and rising resources. My right hon. and learned Friend has scolded the Committee on numerous occasions for doing so. However, we are merely doing what any market researcher would do—or, to put it in military terms, time spent on reconnaissance is never time wasted.

The Select Committee has also drawn attention to the importance of better information about the outcome of health care. In that, I suggest, may lie one way of achieving a more productive use of the large resources that are now devoted to health care.

The Government argue, in my judgment perfectly reasonably, that if existing resources can be used more effectively, the need for additional resources becomes less urgent. Their method of achieving that desirable end is through the establishment of what, in the jargon, we call an internal market within a wholly, or nearly wholly, publicly financed Health Service.

That is an entirely novel concept. It has not been attempted anywhere else in the world. Therefore, no one can say with confidence that it will work; nor, conversely, can anyone say with confidence that it will not work. That is why the Select Committee took a cautious view of the Government's proposals. Nothing that has happened throughout the passage of the Bill—I have read most of the Committee proceedings—has led me to drop the caution that the Select Committee felt collectively—

Ms. Dawn Primarolo (Bristol, South)

If it is impossible to say with confidence that the internal market will or will not work, ought we to interfere with the massive range of services that the hon. Gentleman has so clearly identified are provided for community care, right through to hospital services? Ought we to interfere if we cannot be sure that such interference will not be to the detriment of such important services?

Sir David Price

That is a fair point. That is why the Select Committee recommended in various reports before the Bill was introduced that trials should take place. That remains my view. When the Bill is implemented, in practice my right hon. and learned Friend will be conducting trials. Hospitals that opt for trust status will be volunteers. Furthermore, doctors who decide to opt for budgets will again be volunteers. It may not be the planned trial that I would personally like, but it will nevertheless be a trial by volunteers. The problem is that statisticians will tell us that it is not a random sample. However, there is far more of a trial element in the proposals than is recognised outside Parliament.

If we face a resource problem over the future of the National Health Service, I believe that we face an even greater resource problem over care in the community. On a number of occasions throughout this Parliament I have tried to draw attention to the great unsatisfied need out there for care in the community. The need is far greater than is generally realised. We are given some guidance on that by the report of the Office of Population Censuses and Surveys on the disabled. Far more people are crying out for help than is recognised in any official statistics. I intend to quote from evidence that was given to the Select Committee two weeks ago by the Alzheimer's Disease Society. I could, however, give 50 or 100 more examples of a similar nature. The society's evidence stated: The Alzheimer's Disease Society believes the White Paper"— upon which the Bill is based— fails overtly to recognise the scale, growth and awareness factors that are going to drive increased demand for improved provision in the next ten years for people suffering from dementia (Alzheimer's disease being the most common form), let alone their carers, mostly family members, husbands, wives, sons or daughters. The Society estimates the pressure on carers is going to increase by a factor of four. I leave the House to reflect upon the consequences of that estimate.

That takes me logically to the funding problems arising out of care in the community policies. They are dealt with in parts III and IV of the Bill. With this debate in mind, the Select Committee published an urgent report entitled, "Community Care: Funding for Local Authorities." I commend it to the House. For reasons of brevity, I shall not take the House through the report. However, I draw its attention to two of our comments. In the introduction we said: Sir Roy Griffiths has pointed out one major difference between his proposals for the future of community care and those set out in the Government's White Paper: 'I had provided a purposeful, effective and economic four-wheel vehicle, but the White Paper has redesigned it as a three-wheeler, leaving out the fourth wheel of ring-fenced funding'. The ring-fenced funding issue is one that we must continue to pursue. In our report to the House we also said: Almost all the evidence we have received expresses regret, or dismay, that the Government has not decided to 'ring-fence' local authorities' resources for community care. Every written submission that we have received has been along the same lines.

I hope that the Government will think again about this major problem of ring fencing. It does not require an additional amendment to the Bill; it can be done administratively. In view of the difficulties that the Government are experiencing over local government finance, I urge them to welcome our proposals and embrace them. I hope that they will do just that.

5.26 pm
Dr. Kim Howells (Pontypridd)

The people of Wales will be disappointed with and angry about the Bill. They will be disappointed because they will regard it as a missed opportunity to do much for the National Health Service that could have been done right now. It is a missed opportunity, in that it will lead to an experiment instead of to solid policies that would improve the NHS as it stands.

I do not defend all National Health Service practices; I am sure that many other hon. Members have sat at night, as I have done, in miserable hospital waiting rooms. I have been unable to receive service when my children needed it. However, the NHS has come to be seen as part of our heritage—as something that is indivisible from our definition of a civilised society.

People are angry about the Bill. Their anger is reflected in the political polls. They believe that the Bill poses a real threat to that part of their heritage. They believe that it threatens the whole basis of the NHS: that, when somebody is ill or requires treatment, he receives it free of charge and that the treatment he receives is the best that is available at the time, wherever he needs it.

My constituents, and the constituents of many right hon. and hon. Members, see hospitals falling apart before their very eyes. They do not believe that the Bill will result in waiting lists disappearing overnight, or even within years. They see no end to the Government's terrible tendency throughout the last 10 years to depend on the goodwill of hospital personnel and of people outside hospitals to spend their spare time on the streets collecting for vital pieces of diagnostic machinery and other machinery that is used for treatment—machinery that cannot be bought because of the shambles of this Government's administration of the NHS. People want to know what the Bill will do about it.

I believe that the Bill will do nothing. The weasel words it contains will try to encourage the staff of hospitals not to do what they should be doing—improving their own standards of excellence and practice—but to be out in the streets as part-time charity workers trying to raise money for vital pieces of equipment. That is not good enough and it will be reflected at the next general election—indeed, I hope that it will be reflected in a couple of week's time.

When patients go to hospitals after the Bill becomes law, will they find that there is a different reception for them when they go into the out-patients' or casualty departments? I am afraid that they will be met by the same junior doctors who have probably been awake for so long on duty that they cannot diagnose the condition of their own socks, let alone the condition of someone else's heart.

People will ask how the Bill will affect the position of patients who have been turned out from long-term care facilities. I and others have seen such people wandering the streets because there is not sufficient back-up resources or finance to look after them when they have been turned out. What will the Bill do about that? I cannot see that it will do anything.

Ms. Primarolo

As I mentioned earlier, I am a member of a district health authority. In preparation for the Bill, and to improve its corporate image, Bristol and Western district health authority is to spend £7,000 on new uniforms for the reception area of the hospital. That may not be a huge amount, but it is a lot of money when it comes to the closure of beds or wards. We can expect glitter, but no service.

Dr. Howells

I could not agree more with my hon. Friend. Just two weeks ago, I spent long hours at the side of the bed of my two-year-old son. I had plenty of time, as did every other parent in the ward, to contemplate the peeling paintwork on the walls, the antiquated cots and the cracked windows. That is the condition of hospitals in my constituency, which is by no means exceptional.

I and many other parents have had such a chance to contemplate what we see around us and such contemplation is good for increasing awareness of what is needed and what is not needed. We do not require glitter or corporate images. That £7,000 could have been used to purchase paint for the parents' waiting area. Currently, the nurses chip in to buy paint for it and they do the painting themselves because there is no money for it in the hospital budget. What will the Bill do about that? It will do nothing.

When one spends time in hospital, it is interesting to talk to the staff and to the consultants, who are beginning to understand the "hidden agenda" of the Bill, as my hon. Friend the Member for Glasgow, Cathcart (Mr. Maxton) described it. I know what the hidden agenda is. It is a screenplay that will impose on the House at some future date a hefty Bill called the Privatisation of the National Health Service Bill.

All the signs of that hidden agenda can be seen in the Bill. Let us look at the words—"trusts", "fund-holding practices", "originating capital debt", and "indicative budgets". The contracts between general practitioners and hospital trusts start to resemble the arrangements that Sainsbury might make for purchasing a slightly battered carcase of meat from a wholesaler or a case of hazelnut yogurt that requires some salmonella-infected pots to be removed.

Patients are not commodities, and people do not regard themselves as the financial part of an equation that can be worked out by accountants. The NHS was not created for that and that is not why it has been run since. People in Wales have rejected those ideas time and time again in every election and by-election. I am sure that the people of the rest of the country will do the same.

5.34 pm
Mr. Michael Morris (Northampton, South)

Once again, I must declare an interest as I am married to a general practitioner and I act as an adviser to two pharmaceutical companies.

It does not give me great pleasure to make this speech, because I recognise that my right hon. and learned Friend the Secretary of State for Health and my hon. Friends the Minister for Health and the Parliamentary Under-Secretary of State for Health are motivated by a desire to improve patient care; I want to put that on record. The sad thing is that the Bill will not achieve that aim. If its objective were to produce a dramatic improvement in the financial management of the National Health Service, as a member of the Public Accounts Committee I should give it three cheers. However, it represents an attempt to create an internal market driven by a decision to cash-limit the whole of the NHS, and that is a big change. Medical appraisal will no longer be the key determinant. Once the Bill reaches the statute book, cost and not patient need will be the driving issue. That is why I oppose the Bill in principle.

If the Bill had resulted in a level playing field with some in-built mechanism whereby wage costs were automatically funded by the Treasury, progress would have been made. However, when I looked at the Bill, I related it to the most recent report of the Comptroller and Auditor General—report No. 566, which was produced in July 1989. In paragraph 5 on page 1, the Comptroller and Auditor General said: Health authorities have faced uncertainties concerning pay levels which are decided at national level and price increases, which have tended to be greater than the average for the economy". That rather blows a hole in my right hon. Friend's recent statement that price increases in the NHS did not have to include an allowance for mortgage interest increases. We must remember that any report from the Comptroller and Auditor General has to be agreed by the Department responsible, so that report must have been agreed by the Department of Health.

At a sitting of the Public Accounts Committee, I asked the chief executive of the National Health Service whether he was constrained by cash limits. The answer was yes. I asked the Treasury whether it was likely that the difference between the allowance for wage cost increases of about 5 per cent. and the actual cost of nationally agreed settlements would be made up by the Treasury and the answer was no.

Against such a financial background one has to ask specifically why, at almost every turn, the key people who can make people well again—the doctors—are treated with such disdain. It is a foolhardy person who ignores the advice of the royal colleges. I hope that their advice will not be ignored in the other place. No patient will be made better by 4,000 new accountants; they are more likely to be made better by 400 new consultants.

I hope that the regulations that will ensue from the Bill will ensure that at the very least—my right hon. and learned Friend the Secretary of State did not have the chance to make this point yesterday—there is proper medical representation as of right at every tier of authority. I also hope that the medical advisory committees will be extended to cover all health authorities and National Health Service trusts, because that is a key issue.

My hon. Friend the Under-Secretary of State for Scotland, the Member for Stirling (Mr. Forsyth), raised the question of indicative drug budgets. Given that the Government have shifted their position, why on earth is clause 18 still in the Bill? The pharmaceutical price regulation scheme controls the profitability of the pharmaceutical industry and prescribing analyses and costs are being used on a trial basis by a number of family practitioner committees, available as a control mechanism to help GPs with prescribing difficulties.

I am not convinced about cash limits on prescriptions. I have asked many times what will happen when all the GPs in a region overspend. Where will the money come from ? Will it come from some other aspect of patient care or out of the Government's contingency budget? In a telling intervention the other evening, my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) gave a concrete example of a hospital, with licensed medicine only on partial release, being restricted because the North West Thames health authority had said so. Similar cases have been reported in the press. The reality is that there are constraints on prescribing and the Government must get their act together and ensure that that does not happen on the ground. It is no good saying that it does not, because it is happening at the moment.

Why do we not learn from the experience of countries such as the United States where much research covering 47 states, not just some minor town, shows that restricted formularies lead to more money being spent on hospital care? If people do not use modern medicines, more people go into hospital care. For my hon. Friend the Under-Secretary of State to say that generic medicine is just the same shows a degree of ignorance that is not right in a Minister of the Crown in this important area.

This is the fourth reorganisation of the NHS since I have been a Member of the House, but Ministers have failed to understand that they must take the people with them if they are to make changes which will affect the largest employer in Europe. They may have to argue, discuss and take difficult decisions but, as sure as anything, they must take the people with them. It is outstanding that the great majority of employees in the NHS at any level are not in favour of the changes.

The opportunity in the Bill for devolution to a lower tier is greatly to be welcomed. We all have a district general hospital crying out for some independence, but instead we have the NHS trust, some transatlantic concept. I do not know how many hospitals will take that up. At first there were 350. That figure dropped to 120 and it now stands at around 80. My guess is that we shall be lucky to have 50. As my hon. Friend the Member for Eastleigh (Sir D. Price) said, we had a skewed sample. How much better it would have been to start with a properly structured sample so that we could have had a reasonable test market to see whether the proposal worked; if it did, it could have been extended.

The Bill is full of dangerous precedents. It is full of the bureaucracy that the Public Accounts Committee has grown to question. I have been reading the contracts for health services, and they are only the beginning. I have spent 10 years on the Public Accounts Committee trying to get rid of this sort of stuff. I have clearly failed dismally. One aspect of the Bill that could be welcomed is medical audit. The other evening some hon. Members raised the question of quality of care, to which my right hon. and learned Friend the Secretary of State seemed to respond. That should be written into the Bill. I do not agree with the Opposition's suggestion that there should be a committee which will meet only twice a year. Such quality control should take place all the time. However, I think we are all at one on the importance of the quality of care and I hope that that will be written into the Bill in another place.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I do not want my hon. Friend to conclude and suffer in agony for the rest of the short debate in the belief that our intention is to cash-limit the NHS, in particular at national, regional FPC and individual doctor level. My right hon. and learned Friend the Secretary of State made that clear in Committee, on which my hon. Friend did not serve. But for the avoidance of doubt I repeat that there is no intention to cash-limit the family Health Service in the sense that drugs and prescriptions are part of that service. I hope that my hon. Friend will accept that. I appreciate his powerful arguments, which are largely a repeat of what he said on Second Reading, but I hope that he will accept my assurance on behalf of the Government on that narrow point.

Mr. Morris

I am grateful to my hon. Friend. I think that he has clarified the point, but I shall have to consider carefully what he said.

We did not discuss amendment No. 118 on the medical practices committee on Report. Why on earth do we have to upset the medical practices system which has worked perfectly well for years? Everybody is satisfied with it, but now we are to have some sort of subjective assessment which will turn it upside down.

The Bill does not destroy the NHS, and anyone who suggests that it does is way off beam, but it does not enhance it. Millions of hours will be spent as a result of it, but, sadly, waiting lists continue to grow. We all know—it is better that we say it—that in the next few weeks and months more wards will be closed. Things will not get easier. Every survey shows the grave disquiet felt by the public.

It cannot be right that the House has to keep producing early-day motions to save the Elizabeth Garrett Anderson hospital for women or the Mount Vernon skin graft hospital. It cannot be right to have Jimmy Savile charging round the country trying to save Stoke Mandeville hospital. Just down the road from here we have the world's leading hospital, the Maudsley, yet there too there are cuts. That is a crazy way to go on. I hope that all that will be considered in another place.

We get our health care pretty cheap in Britain, at about 6.1 per cent. of GNP. It is the most cost-efficient health service among 18 industrial nations. The Bill will be good news for accountants and lawyers, but I sincerely question how it will benefit patients. I remain unconvinced, so I shall oppose it.

5.47 pm
Mr. David Hinchliffe (Wakefield)

We have had some excellent contributions so far. The hon. Member for Northampton, South (Mr. Morris) said that the Bill will not destroy the NHS. But I agree with my hon. Friend the Member for Pontypridd (Dr. Howells) that it is a paving measure that will move us towards American-style private health care. Conservative Members may not understand that, but the people do. They can see the real agenda and they know what they want to avoid.

I want to concentrate on the forgotten part of the Bill—community care. That is an afterthought. I thought that the Under-Secretary of State for Scotland would sit down without mentioning it. That has happened before and I thought that it would happen again. But he referred to it in passing, so I could not say that he did not.

The Government have had 10 years to develop a strategy for community care, but the Bill is a major disappointment. It is a missed opportunity. The more one looks at the events of this week and in Committee, the more one can see that the legislation is full of holes. It will be only a matter of time before we have inquiries and recommendations, which will make us get down to looking at the issues that the Opposition and some Conservative Members have pointed out during the Bill's passage.

The main feature of the Bill is the way in which the Government have put their free market ideology before what is needed in the development of community care. The Government talk about their wish to establish a flourishing independent sector but also about the avoidance of unnecessary institutional care. It is clear from all the evidence that those principles are contradictory, because the private sector is interested in one thing only—the provision of institutional care, as that is where the money can be made. The Bill financially discriminates against directly provided local authority care, and that will add to the problem and further stimulate the private sector. At the same time, the Government expect the local authority to provide for the many people rejected by the private sector because they need levels of care that the private sector will not provide, or they cannot afford to pay the price for which the private sector asks.

Is a market model appropriate to community care? My hon. Friend the Member for Pontypridd has, on a number of occasions, asked whether a market model is appropriate for the provision of health care. I reject a market model in the caring of vulnerable, elderly, handicapped and dependent people, because it is a licence for exploitation. As we have said on several occasions, the type of provision that the Government are prepared to fund, through what was previously open-ended income support, is unplanned provision, ill-thought-out provision, in mansions and large houses. The bulk of provision on the south-east coastal belt does not reflect the needs of our society. It is unplanned. It is there because there are empty bed-and-breakfast establishments for substantial parts of the year. People think that they can make some money by shunting in people who require community care. That is all wrong and the Bill should have tackled that problem.

Provision is aimed only at institutional care. There is no attempt to develop alternatives by the private sector. Businesses do not see any means of making money in that way.

Ms. Mildred Gordon (Bow and Poplar)

Does my hon. Friend agree that there is no programme for rehabilitation of severely disabled people who no longer need acute care in hospitals and no proper provision for the funding of their care in the community? In Tower Hamlets, at least 10 severely disabled people who are ready to leave hospital and live at home cannot do so because such care would cost about £40,000 a year each. There is constant conflict as to who will pay for that—the Health Service or the social services. There are demarcation disputes about who will do the nursing jobs.

One young ex-service man of 28, who is completely disabled from the neck down, has been found a flat, which has been empty since last June. Conflicts such as those that I have described are preventing him from leaving hospital and now the housing department is saying that it cannot keep the flat for him any longer. I am sure that my hon. Friend will know of many such cases. The policy has not been thought out, and provision has not been properly made. The money is not there and many people have to remain in hospital occupying beds when that is no longer necessary and they could live happy lives in the community, if that were done properly.

Mr. Hinchliffe

My hon. Friend has made a clear and eloquent case. Such cases are not confined to her constituency. Every hon. Member who takes an interest in what is happening in his area is aware of such cases. The problem that we have to get over is the Government's tunnel vision about what is needed by elderly and handicapped people. Through that tunnel vision, they see only the institutional model, so people such as the young man whom my hon. Friend described are pointed in one direction only. The cards are stacked against any alternative to that person being in an institution or hospital care. We have to get away from that.

Mr. Rowe

I am listening with great attention, as I always do, to what the hon. Gentleman has to say. Will he agree on two points? First, the thrust of the Bill is to provide an assessment and a care manager, the purpose of which is to keep people out of institutional care. Secondly, in many authorities, mine included, the thrust of the development over the past 10 years has been to diminish residential care as a priority placement.

Mr. Hinchliffe

The hon. Gentleman is most consistent, because he has made that point in interventions in my speeches at least four times during the passage of the legislation, and I shall make the same response. An assessment by a social worker, or whoever, is based on what is available. My criticism of the Bill is that it encourages the provision of only institutional care, rather than preventive, domiciliary care. That is my central concern.

In Committee, the Opposition made the point, several times, that the worst practice is rewarded by the market model system developed by the Government. The larger the home, the more profitable the venture, and the more people who can be packed in, the more money will be made. Home owners will agree with that. I have already referred to the new nursery home in my constituency, with 100 beds. That is not a home. I should not want to live somewhere with 100 beds, The people setting up the home told me that they had that many beds because they could make economies of scale—the more one gets in, the more money one makes. That is wrong. It is not in the interests of the people whom we should be representing.

Mr. Allen McKay

This is a growing problem. My local authority has received six planning applications for extensions of existing homes or the building of new ones. Those places will have between 80 and 100 beds. They are not homes: they are institutions.

Mr. Hinchliffe

My hon. Friend is right. He knows the sort of homes that we are talking about. We are going back 20 or 30 years, to the workhouse environment where people were packed in. We should be sensitive to people's needs.

The crux of the matter is a point that I have tried to raise on several occasions and that will be understood by my hon. Friends who served on the Standing Committee. It is whether caring for profit in such circumstances is morally right. Are we happy about attracting into provision of care for the elderly and handicapped organisations such as Stakis plc, a hotels, leisure and property group, or Kunick plc, an amusement arcade group? What relevance have amusement arcades to the care of handicapped people? What expertise in caring for demented and senile individuals, who may be doubly incontinent, have such people?

Buckingham International, a disco and leisure company, is now to move into the private care market. Are those the people whom we want to be caring for our mothers and grandmothers—dependants and the vulnerable? Are those the companies that we want to attract to a welfare state based on a market model? Ladbroke now has over 1,000 beds in caring provision. Boddingtons and Vaux Breweries are also moving into this sector. What relevance do breweries have to caring for the handicapped and elderly? Univent Ltd. has become well known for its practices. When residents in its homes go into hospital, it clears out their possessions, shoves them in a cellar and gives the bed to somebody else. That is the practice that the Government are encouraging with this market model. Is that appropriate?

Mr. Dennis Turner (Wolverhampton, South-East)

In the midst of the changes in residential care, when we have to be ever more careful and conscious of the accommodation being made available and the people and organisations that lie behind it, where is the ethic responsibility of social services within the Bill, or the resources that will be necessary for them to do the policing of the new major administrative roles? We know that the Government have made no provision for resources for the new personnel who will be needed, so they will not be policed. The authority in my constituency has estimated that when the Bill is enacted it will need £2 million to £3 million to do the job in the way in which the Government say it should be done. It knows, however, that that will not be possible. As we know that there will be a lack of resources, we should tell the people now what the real position will be. People will not receive the services that they need and social service departments will lose out.

Mr. Hinchliffe

My hon. Friend has an excellent track record in local government and speaks with experience of the problems that are being faced at the grass roots. He is right to say that the resources will not be available to enable authorities to provide the services that are needed. Resources must be concentrated on the alternatives to institutional care. In that respect, the Government have tunnel vision.

The White Paper referred to enabling individuals to have choice and the Government have claimed that the advent of private care homes has given people choice. I do not know how many hon. Members have spoken to their constituents to learn what choice means. It means that now and in future, where there is a vacancy in a home, one person will take the vacancy. That is the reality of the present choice.

If there were real choice, there would be the option of not going into a home. People would be able to remain in the community. They would be able to remain in their own homes where they have lived all their lives. They would be able to stay in their own communities. They would not have to be shunted into an institution miles away from their families and friends. Instead, the Government have hammered alternative care and options to the institution, which means living in large groups miles away from families and friends. They have hammered the home help and meals-on-wheels services, sheltered housing and every real attempt to keep people out of institutional care. As a result, the market has been stimulated. That was the aim behind the Government's policy.

What should the Bill have done? It should have provided for genuine community care, developing options to the institution that were based on a real choice, which would enable people to stay where they have always lived. The Bill should have introduced planning and the co-ordination of community care to replace the shambles and ragbag that exists between different Government Departments and departments at local level.

We need a community care Minister. There is no reference to such a Minister in the Bill. The establishment of such an office is a policy commitment of the Labour party. I am proud to say that that will shortly be Government policy in this place. A legal duty should be placed on local authorities—this idea was resisted by the Government in Committee—to develop options to institutional care. I return to the argument of the hon. Member for Mid-Kent (Mr. Rowe): we must ensure that social workers make genuine assessments and not those that are restricted by what is available in the way of institutional homes. Assessments should be based on what is available in a person's community, to keep him or her out of an institutional home and in his or her own home as a member of the community.

Mr. Ian McCartney (Makerfield)

As I understand it, my hon. Friend is saying that a home care service should be provided, not merely a home help service. He is advocating the development of skills through the home help service, with opportunities for training and retraining.

Madam Deputy Speaker

Order. I am sorry to stop the hon. Member, but he is attempting to divert the hon. Member for Wakefield (Mr. Hinchliffe) from the provisions that are set out in the Bill. Perhaps the hon. Member for Wakefield will speak to the Bill.

Mr. Hinchliffe

My hon. Friend the Member for Makerfield (Mr. McCartney) has read my mind completely. He said exactly what I intended to say.

Madam Deputy Speaker

I am pleased that the hon. Member for Makerfield (Mr. McCartney) has read the mind of the hon. Member for Wakefield. That means that the hon. Member for Wakefield does not have to repeat what his colleague said.

Mr. Hinchliffe

I want to see the development of options to the model that we have been promised by the Government. It is a conservative model of what we have had for far too long. Other countries have developed options. They do not believe that when a person reaches a certain age or has a certain degree of incapacity he or she must leave the family home and go into an institution.

We must have more sheltered housing. We need very sheltered housing. My hon. Friend the Member for Makerfield has described the domiciliary support that is needed. There should be support seven days a week in a person's own home if that is needed. Why should not the person to whom my hon. Friend the Member for Bow and Poplar (Ms. Gordon) referred have that sort of support? In many instances it would be cheaper for the public purse to provide it instead of shunting such people into an institution. We should be thinking of transforming residential care into a completely different model. We should facilitate community care and stop incarcerating people.

The Government have ducked the challenge of having a completely different vision of community care. They have failed to meet the challenge of keeping people in the community. We should look to future provision and ensure that community care means care in the community, not away from it. On that basis, the Government have failed completely.

6.6 pm

Sir Michael McNair-Wilson (Newbury)

I shall not take up the remarks of the hon. Member for Wakefield (Mr. Hinchliffe), who has an enviable knowledge of the community care part of the Bill. I begin by saying that I support the Bill and the concept behind it, which is to open all the facilities in the National Health Service to all the patients within it. Such a concept is long overdue. It will enable a measure of choice to be introduced in the care of patients. The patient will be able to choose whether he is cared for locally or at a distance, and that will have a bearing on the time that he may be asked to wait for an operation. That choice should have been there all along.

I must, however, chide my Front Bench colleagues. They keep telling me that the Bill is a patients' charter. It may be that I am sensitive because I helped to produce a patients' charter, as the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) kindly reminded us last night, with the Association of Community Health Councils. A patients' charter can be produced only by patients and patients' organisations. The best that the Bill can do is be a patients' charter produced by a Government who think that they know what patients want. I assure my right hon. and hon. Friends that what the patient wants and what he gets may be rather different things.

I regret that to some extent CHCs have been downgraded as a result of the Bill. We have not put an institution in their place that will speak for patients as I think the voice of the patient should be heard. I hope to return to that subject in later debates.

In the end, what is the Bill about? It is about better service for the patient or it is about nothing. It is about better care from the general practitioner, and an extension of the service that the GP can offer his patient. It is about better hospital care, more consultants in the NHS and making better use of resources. Some may say that if I make such a statement I imply that the Health Service is of a poor standard. It is not. I know that the NHS is a political hot potato that we like to kick around in the Chamber, but the NHS is doing a superbly good job. I can say so because, as I think everybody knows, I am dependent on the Health Service for my life. I declare my interest: I am a kidney dialysis patient. I receive kidney dialysis three times a week through the NHS. I am the president of a kidney patients' charity. I have, therefore, considerable experience of the Health Service.

I listened to the hon. Member for Pontypridd (Dr. Howells) telling us about the hospital in which his son, sadly, is being treated. He referred to broken windows, peeling wallpaper and so on, and he placed the blame for that on the Government. I have been in many NHS hospitals, and some are good and some are bad. Some are well decorated and some are not. It amounts to good management or bad management. In some instances those who run a hospital notice such things and in others they do not. We are all guilty because we often find that we live in shabbier surroundings than we imagined when we compare those circumstances with others elsewhere. Lei us not imagine that the Government decide whether a ward is painted or whether someone hangs pictures and makes the place more attractive for patients. Very often such matters are for the people who run our hospitals.

Mr. Martin Flannery (Sheffield, Hillsborough)

Will the hon. Gentleman give way?

Sir Michael McNair-Wilson

I shall not give way because time is short and I know that others wish to contribute to the debate.

I am sorry that the Government do not appear to want to follow through my next point. If we are to decide whether our hospitals are coming up to the standard that we expect, we must consider whether there should be a separate hospitals inspectorate. Although it may be a bureaucratic concept that may not find favour on the Treasury Bench at the moment, I ask my right hon. and hon. Friends to give it a little more thought. Perhaps a third body, such as the Health Advisory Society, which looks at mental hospitals, could be applied to the overall realm of the National Health Service and might help to raise standards and to identify the sort of problems that some of us notice when we go round hospitals and wonder why they are not as we would wish them to be.

If the Bill is about treating patients, in the end it is also about creating a form of accountability for the resources used to treat patients. Therefore, I welcome the idea of clinical audit and the fact that the Audit Commission is to have a say. By definition, all resources in the National Health Service are precious. It is a demand-led service, where the demand is infinite. If the demand is infinite, clearly the resources available to us will always be limited. No hon. Member should imagine that somebody somewhere in this or any other political party will he able to find all the resources that the Health Service will need one day. They will not. I have heard the hon. Member for Livingston (Mr. Cook) say just that. Whichever Government are in office, they will have to impose some limits on the resources that are available.

The important point, which I believe the Bill addresses, is getting the most out of resources and making all those who spend the resources conscious of the fact that they are spending something precious. Therefore, I welcome the cash-limiting of the drugs budgets. That must be right. I also welcome hospital trusts, and budget-holding practices. I welcome anything that makes those who are spending public money ask themselves whether they are getting the most from the money that they are spending. No practitioner, no matter what he is doing, who handles public money can divorce himself from the cost of the treatment that he intends to provide. Of couse, the cost is not, and should not be, the dominant consideration, but it must play a part.

As I have said, resources are the one thing that must be treated as what they are—precious gold. They must be used as prudently and as economically as possible, so that the greatest number of people can benefit from them. To that extent, the concept that now appears to have all-party support—although I did not know that until this evening—of the money travelling with the patient is of the greatest significance. If the money travels with the patient, that means that the money goes with the treatment. That has the corollary that once the Bill becomes law, a patient who goes outside his region for treatment will take the resources with him, out of the district. That must introduce a new thinking into the minds of district health authorities.

Perhaps the House will allow me to illustrate what I am trying to say in terms of kidney dialysis facilities. In the United Kingdom, we have 1.2 kidney dialysis units per 1 million of population, whereas in the Federal Republic of Germany there are 5.8 such units; in France there are 4.1; in Italy there are seven; and in Spain there are five units per I million of population. Even in the German Democratic Republic, there are 3.5 units. The fact that those countries have more centres per 1 million of population also discloses that they also have more kidney specialists for their populations. Because of the small number of centres in this country, many patients must travel long distances. Plenty of Health Service studies show that both acceptance of new patients and treatment rates are inversely proportional to the distance of the patient's home from the treatment facility.

A renal consultant has written to me stating that the ethos of the Bill may promote change … One would expect that a District exporting all its (valuable) renal patients might wonder why it does not keep those patients and treat them for itself. In addition, the District might also look at the cost of ambulance services required for shipping patients to the remote centre"—— that is the kidney dialysis centre— and decide that these charges could be turned into a clear saving. It is thus possible that a certain number of patients would between them generate sufficient funds to establish a new Unit and pay for a new Consultant Nephrologist. I am hearing from the patient organisations that British patients would prefer to be treated in small centres where relationships with individual doctors and nurses are maintained rather than in vast centres where they are lost in anonymity. I suggest that as a result of the Bill that renal consultant's hopes will become a reality. I admit that that is a small example, but it underlines the potential of the Bill. Therefore, for that reason as well as for the others that I have given, I shall support the Bill on Third Reading. However, I add just one caveat. Perhaps it was a good idea to take the Health Service and the community care elements together in the same Bill, although I am one of those who believe that they should have been in two different Bills. But I am still worried about the co-ordination between health and community care. I believe that we shall have to return to that subject and I shall look forward to suggestions made in another place which may return to us as an amendment at some future date.

6.15 pm
Mr. Charles Kennedy (Ross, Cromarty and Skye)

Over the past decade—and longer—this has been a Government of reforming zeal on so many fronts. Much of that zeal has been well placed, such as the sale of council houses and the encouragement of democracy in trade unionism. However, the zealotry has now begun to blind common sense, not least in relation to the National Health Service. Ten years in office can cocoon a Government from reality.

To paraphrase the earlier critical speech from the Government Back Benches, the hon. Member for Northampton, South (Mr. Morris) pointed out what is manifestly the case, yet the public are not behind the Bill one iota. At times the Government would do well to remember the Churchillian dictum of trusting the people. They may well find that, when the people next have an opportunity to give a national verdict on the Government's continuing reforming thrust, not least in relation to health and welfare services, they will lose badly, but deservedly.

My fundamental objection to the Bill is its lack of intellectual honesty. There are two reasons why the Government have felt it necessary to introduce a Bill to reform the National Health Service. The first is straightforward: the Health Service is both big and bureaucratic. It is the biggest civilian employer in western Europe. Anything like that is bound to attract the disdain of a Government such as this, who do not like to respond to, or to have to deal with, any group in society that can wield the kind of power that the National Health Service can.

Secondly, and derived from that, the Bill is a response to political frustration. After 10 years of being told that the Government are spending more, employing more, treating more and building more, the public do not believe them. From the evidence in their own communities, the public do not believe the rhetoric of Ministers at the Dispatch Box. Largely out of the sense of frustration, the Prime Minister insisted on a political and legislative response. She split the Department of Health from the Department of Social Security, downgrading the then Secretary of State for Health and Social Security. She then dismissed him and brought back the previous Minister for Health, who has had to pull together this ill-assorted ragbag of ideas and try to present it as a coherent political philosophy when, in its basic analysis, it is not, because it is a response to political rather than patient needs.

My principal objection to the Bill is that it seeks to impose on the main providers of health care a costly and untried administrative structure, which is designed in the first instance not to improve health care or to increase the resources given to health care, but to impose a sense of structured competition in a totally inappropriate form and setting. In so doing, Ministers have made it clear that they do not have sufficient regard for the professionals who are the Health Service or, indeed, for the patients who are dependent upon it. If they had, they would have built in throughout the Bill far more consultation and far more guaranteed representation for both those groups. At every stage at which these arguments have been raised—at times they have not just been Opposition arguments but have been supported by Government Back Benchers—they have been resisted throughout the Committee stage and the truncated Report stage in the last few days. I shall touch very briefly on a few of the issues that arise.

The National Health Service contracts will remove clinical responsibility from doctors. They will remove the proper voice in health care that I believe patients should have—I agree with the hon. Member for Newbury (Sir Michael McNair-Wilson), who has done so much in this field—and at the end of the day they will hand over final control and major decisions to administrators. That will create monopolies, which I suggest will add to costs.

Self-governing trusts will break the link between the community and the hospital, undermine planning in terms of both health care and staffing, and force people to travel for treatment that they should rightly expect in their locality, not least in rural areas, without giving them or the staff any direct democratic say in the decisions.

General practitioner budgets, particularly in the light of the new GP contract, can only undermine the essence of the relationship between patient and doctor, which has been one of the greatest strengths of the NHS and is the interface—horrible word—between the vast bulk of the population and the family doctor service.

I agree with Government Back-Benchers that the Government have refused to write in a guarantee that drug budgets will never be used to reduce expenditure on drugs. The Minister gave some assurances at the Dispatch Box on this matter, but they do not appear in the Bill.

The Minister makes a face. I know the reason that the Secretary of State enunciated why they have been unwilling to write things in at certain times, but let us go beyond that on this question of drug budgets. This was a major opportunity to take a significant step forward down the line of generic substitution, of looking at patent life in a European Community context with a view to a better deal for the United Kingdom pharmaceutical industry, which, at a time when our balance of trade is disappearing over the cliff, is one of the major net contributors to British exports. But, unfortunately, the Government have not chosen to go sufficiently down that road. This is an extremely sad missed opportunity.

On health authority membership, the Government announced earlier this week a shake-up in the membership of health authorities throughout England and Wales. It was a disgraceful announcement in terms of the number of people with proven links to the Conservative party—we have been over this before in the course of the Bill—and business backgrounds. I do not object to business backgrounds, but all too often the criterion for appointment, or, more important, the criterion for not reappointing somebody who has served on a health authority, is, first and foremost, their political orientation rather than their professional commitment to a good National Health Service.

Mr. McCartney

The position is that a majority of the members of our health authority do not live in, work in or belong to the community for which they are the authority. After this Bill is passed and local authority representation is removed, there will be a majority of people on that body who do not live or work in or have any connection with the community to which they are appointed.

Mr. Kennedy

I am grateful to the hon. Gentleman. That is a serious and genuine complaint, which has been repeated in many other parts of the country. I can only say, given the difference in geography and demography between our two parts of the country, that I hope it does not begin to happen in the Scottish Highlands, because it would be farcical to have somebody sitting in Glasgow on the Highlands health board.

Mr. McCartney

A modern-day Highland clearance.

Mr. Kennedy

That is one way of putting it.

On the question of medical teaching—sadly, we were not able to come back to an all-party amendment on this matter on Report—there is, as the Minister knows, continuing concern and anxiety, particularly for the big teaching hospitals attached to and aligned with some of our great universities, about the role of those who are both in the academic sector and aligned or attached to the National Health Service. The Committee of Vice Chancellors and Principals has expressed particular concern about this. Given the educational lobby in another place, this is a matter on which the Government will be subjected to significant scrutiny, and I hope that there will be constructive amendment at that stage in the Bill.

I come to medical practice committees. The hon. Member for Northampton, South had some caustic remarks to make about this and I quite agree with him that it is gratuitous and unnecessary to take powers to reduce the number of doctors, if necessary by imposing directions on the MPCs. In particular, it will be disadvantageous to both the inner cities and the rural areas. It is striking at one of the real success stories in the British Health Service since 1947, which is the growth in the number of general practitioners and the expansion of the family doctor service in accessible areas in every community.

Rural dispensing committees are also abolished—a decision made by the House with hardly any discussion, which is not at all a good way to go about legislation.

Coming, finally, to the community care section. while the principles behind it are welcome, even though the Government had to be dragged kicking and screaming over the Rubicon, not least where local authority input is concerned, and only after excessive delay, there is no provision, as the hon. Member for Eastleigh (Sir D. Price), the distinguished Vice-Chairman of the Select Committee on Social Services, made clear, for ring fencing, an essential concept of the Griffiths report. There are no national standards.

The provision for the funding of residential homes is known by all—indeed, at one stage earlier this week, for a few magic moments, by a majority of the House—-to be inadequate. There is no proper provision for carers and, in the context of one of the admittedly more minor amendments that was moved last night, no proper protection yet for residents in homes of four people or fewer through their being subject to proper scrutiny by the inspectorate. Within Scotland, there are no moves to introduce a proper inspectorate.

This Bill has been a response to political pressure. It has been born out of governmental frustration rather than a genuine, formative effort to improve the National Health Service. It did not feature as a manifesto commitment I think that the Government are wildly out of touch with so much connected with this measure, and that they will reap the return from that at the ballot box in the next election.

6.27 pm
Mr. Quentin Davies (Stamford and Spalding)

I felt very privileged to take part in the work of the Committee that considered this Bill because I believe that it is one of the most important Bills going through the House in this Parliament, in the essential sense that it will have an enormous impact on the welfare and, indeed, the lives of our constituents.

I paid great attention to the Report stage and it is now clear to the House, and will be clear to the country, that the essential political difference between the parties in this House on the Bill is extremely simple. On the one side, the Government have decided that, after 40 years, it would be sensible to introduce a number of radical reforms into the NHS, not merely or even largely to improve the efficiency of the service, although improving value for money becomes ever more important the more money is allocated to the NHS and the greater the share of the Government's budget and of national income is absorbed by the NHS. But it is also necessary to get rid of some of the major perversities that have emerged within the operations of the NHS. Those perversities have, for example, led to a number of hospital managers having an incentive to reduce the throughput of their hospitals and to local authorities feeling that there is an incentive to dump people into institutional care as a first, rather than a last, resort.

One of the great human benefits of this Bill will be that, for the first time, an attempt will be made to assess individual needs and, wherever possible, to support people in their own homes rather than consign them to institutional care, however dedicated and competent that care may be. The Government believe that it is now possible to introduce into the National Health Service a greater measure of patient choice and to make the system fundamentally more responsive to patient needs and demands.

The Opposition's position has been equally clear. Throughout the discussion on this Bill, in Committee and on Report, the Opposition have opposed, almost in every particular, any change in the 1948 structure—as though it were a crime even to touch that structure, and as though that structure represented a sacred totem. Perhaps to certain hon. Gentlemen and hon. Ladies of the Opposition it is a sacred totem. To a visitor unfamiliar with the British political debate it might seem that such blind defence of the NHS reflected a very large measure of satisfaction with the workings of the service. Of course, we know that nothing could be further from the truth. Throughout this Parliament the Opposition have subjected us to an endless litany of complaints about its operation. How does the Labour party explain this fundamental contradiction—on the one side, defence of the NHS in its present form, and on the other, the most serious, and often vituperative, complaints against its operation?

Mrs. Alice Mahon (Halifax)

In respect of the complaints against the NHS, we say to the Government quite simply, "Fund it properly."

Mr. Davies

I am glad that the hon. Lady mentioned funding. That is precisely how the Labour party, at least during the first two years of this Parliament, attempted to reconcile the contradiction to which I have drawn attention. We all remember how, in 1987, 1988 and 1989, we continually heard from the Opposition the suggestion that there was nothing wrong with the NHS except that it needed more money—as though throwing more money at it would solve its problems. Over the past two years something very interesting has happened. In 1988 Opposition leaders were regularly calling for the expenditure of another £1 billion or another £2 billion on the service—some Opposition Members seem to like multiplying round figures. In fact, the Government have come forward with £3 billion, £4 billion and £5 billion more.

Mr. Chris Mullin (Sunderland, South)


Mr. Davies

I will give way to the hon. Gentleman in a moment. I have observed—I hope that the hon. Gentleman who is about to intervene will show that I am right—that recently the Opposition have ceased their attempts to outbid the Government in respect of financial plans for the NHS.

Mr. Mullin

It is not just the Opposition who have been saying that the Health Service is underfunded. According to the local Tory newspaper in Sunderland, the chairman of the Northern regional health authority, who was appointed by the Government, said last week: Fundamentally we are underfunded consistently. It is absolutely frustrating to feel so useless. The person who made that comment is not a supporter of the Labour party.

Mr. Davies

Had the Government accepted the funding arrangements that the Labour party suggested for the NHS two years ago, the service would be funded at a lower rate today than is actually the case. The increase in expenditure on the service has been considerably greater than was demanded by the Opposition only two years ago.

Throughout the Committee stage and Report stage debates I listened with great attention, but entirely in vain, for the slightest suggestion by Opposition Members that if, by mischance, they were to come to power they would spend more on the NHS than the Government are planning to spend. I will give way to any hon. Member who is prepared to give a specific commitment to spend on the NHS more than the Government are currently planning to spend. I notice that not a single Opposition Member—least of all, the hon. Member for Monklands. West (Mr. Clarke)—is attempting to catch your eye, Mr. Speaker, or mine with a view to answering that challenge.

The hon. Member for Halifax (Mrs. Mahon) drew attention to the ruse by which the Labour party attempts to cover the contradiction in its attitude towards the NHS. That party gives the impression that, somehow, it will come up with more money than the Government have provided. That notion has been exploded, and, against this background, the Labour party's opposition to every element of the reforms being suggested by the Government is fundamentally mindless.

Mr. Frank Field (Birkenhead)

If even half of the hon. Gentleman's assertions are true, it must be galling for him. He is telling us how much the Government are spending on the NHS, but no one outside believes him. It is absurd to try to get the Opposition to outbid the Government on the question of funding arrangements. This Bill is about the delivery of health care. Our stance is that the Health Service has been a tremendous success story. Let us set the proportion of GNP spent on the Health Service against mortality and morbidity rates. Britain gets a good deal, and the electorate understands that. Surely it would be sensible to ask in what ways we can improve the service. Instead, what we have is a pig-headed decision that certain schemes, without even having been tried out, are to be introduced on a massive scale. I am therefore grateful for the hon. Gentleman's contribution. I hope that many people outside are listening, because the more he says, the fewer there will be who think that the Health Service is safe in his and his hon. Friends' hands.

Mr. Davies

The hon. Gentleman has raised a number of important points which I am only too pleased to address. I am glad that he, too, has come to the conclusion that it would be pointless to conduct this debate on the basis of the two sides trying to outbid each other in terms of promised NHS expenditure. That would indeed be futile. I believe that the Labour party's commitments have lost all credibility. Nevertheless. I repeat that there is a fundamental contradiction between the Opposition's defence of the NHS in its present form and their continuing complaints about the workings of the service. The only answer that the Opposition can give is to say that the problem is one of funding and that they are in a special position to resolve that problem. Now that the Labour party has dropped the claim that it will spend more money on the NHS, that means of reconciling the contradiction falls away. Thus is exposed the hollowness of the arguments that we have heard throughout this debate.

I have the highest regard for the hon. Member for Birkenhead (Mr. Field), but I hope that, before we next have a debate on Health Service matters, he will spend a little time in the Library. I urge him in particular to look at the OECD figures on life expectancy and infant mortality of which, obviously, he is unaware. In 1948, when the National Health Service was introduced, this country was in the OECD's top quartile for life expectancy, for men and women, and in the bottom quartile for infant mortality. We are now in one of the two most unfavourable quartiles in respect of both. That is a serious relative deterioration in the general health of the British population. I say "relative" because, in absolute terms, the health of the population has improved greatly.

Mr. Frank Field

It is slightly barmy to make such comparisons. In the period after the second world war much of Europe was starving. Therefore, we would expect that to show up, particularly in the infant mortality figures. It is not comparing like with like to compare us with the rest of Europe in that period and then at present.

Mr. Davies

It is a good rule that one should attempt to display elementary familiarity with figures before one quotes them in the House.

Dame Elaine Kellett-Bowman (Lancaster)

Is my hon. Friend aware of the startling discrepancy in expectation of life within quite a small region? For example, the expectation of life in the north-west as a whole is well below the national average, whereas in Lancaster it is above the national average because we run our affairs properly. That is one of the fallacies of the National Health Service. There are enormous discrepancies even between adjoining districts. That is one problem which the Bill will address and cure.

Mr. Davies

I congratulate my hon. Friend on health achievements in her constituency.

I welcome the Bill not because it enshrines some useful reforms but because the Government have resisted the temptation to replace one monolithic, global, systematic structure, introduced in 1948 and apparently valid for all time, with another monolithic, global, systematic structure, also apparently valid for all time. The Government have adopted an extremely pragmatic approach and have introduced a number of radical but specific reforms into a structure that continues to enshrine the basic principles of the NHS.

The Government have not been afraid to look round the world and to learn from foreign experience when it had something to teach us. To a certain extent, the fund-holding practice concept owes something to the system of health management organisations in the United States. Clearly, the introduction of self-governing hospitals will produce a structure more akin to that in continental countries such as France and Germany.

The Government have also learnt from analyses over many years of the experience of the NHS. Elements of the Bill reflect some of the thinking of Professor Enthoven in his famous report and reflect his concept of an internal market. They also reflect much of the thinking which that report inspired.

The Bill brings in useful and vital reforms. I have already mentioned some. If their operation is properly monitored and controlled, they should provide a basis for continuing uprating of the National Health Service. That is vital because we cannot legislate for the NHS once and for all and then forget about it for the next 40 years. It deserves, and will receive, detailed continuing attention. The Government did a good day's work for the country when they introduced the Bill, and I am proud to support it.

6.42 pm
Mr. Ieuan Wyn Jones (Ynys Môn)

The debate has demonstrated graphically the ideological gulf between the Government and the Opposition. Unfortunately, the Minister, the hon. Member for Stirling (Mr. Forsyth), used the debate simply as debating practice. It seemed as though he wanted to earn brownie points from his friends on the Front Bench rather than tell us about the merits or demerits of the measure. I contrast that speech—34 minutes of doing nothing other than baiting the Labour party—with the compassionate speech of the hon. Member for Pontypridd (Dr. Howells). He and I share a background from which we can say that the National Health Service is part of our heritage. We are conscious that the Bill will undermine the philosophy upon which the Health Service was founded.

One reason why the hon. Member for Stirling refused to give way to Opposition Members was that he forgot to tell the House that, despite the fact that the Government have introduced a number of sweeteners to persuade doctors to accept budgets, we still get letters from the British Medical Association telling us that the proposals for budgets are flawed. The BMA also tells us that support for the Bill, even among Conservative voters, is declining dramatically and that a majority of Conservative voters do not believe the Government's rhetoric.

In Committee I was concerned about the way in which Ministers defended the principle of setting up NHS trusts. The Government referred to them as centres of excellence. None of us wants any hospital to be other than a centre of excellence. If hospitals are compared, and one is regarded as a centre of excellence, it must mean that the others are not. We are worried because the principle enshrined in the Bill will create two tiers of hospitals. The hospitals which become trusts will become centrepieces of the Government's new philosophy, while other hospitals will be starved of cash.

The desperate shortages in key services and key personnel within the Health Service have not yet been addressed on Third Reading. There is a shortage of physiotherapists, clinicians, speech therapists, occupational therapists, community psychiatric nurses and pharmacists. The position in speech therapy is disgraceful. Speech therapists are paid less than almost every other similar profession. Speech therapists are despondent because, after four, five or six years of training, they have no proper career structure and their work is not properly valued by the Government, because they are grossly underpaid.

In recent months I have spoken to speech therapists who are so disgruntled about their pay that they are changing profession and becoming teachers. How can that be in the interests of the Health Service? Teachers are underpaid, yet speech therapists are moving to that profession. I urge the Government to do something about rates of pay for speech therapists. Many health authorities are in a Catch 22 position. Even if they had the cash to employ more speech therapists, not enough people are going into training. I urge the Government to consider that.

On the NHS side of the Bill, the philosophy of contracting within the new Health Service after 1991 will be meaningless in rural areas. Even if NHS trusts are established, there will be no opportunity for a meaningful relationship between a hospital and the provision of services by contract. By their very nature, hospitals in rural areas are monopolistic. There cannot be competition between them. The provisions on the setting up of NHS trusts are irrelevant to the people of Wales.

I know that other hon. Members want to speak, but I wish to touch briefly on community care. Although I welcome in principle the provision transferring assessment procedures to local authorities, I am concerned whether there will be proper funding for the service.

I commend to the House the words of the hon. Member for Eastleigh (Sir D. Price) who is the Vice-Chairman of the Social Services Select Committee. He quoted from Sir Roy Griffiths's report on ring fencing. I would also like to quote from the social services inspectorate report on the implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986. The summary of the report says of funding: The lack of resources made available by Central Government (despite provision for the Act being made in recent Rate Support Grant settlements) was a reason given by a number of SSDs to explain why they had allocated little, or not as much as they would have liked, to the operation of the Act. That must be a case for ring fencing. Although the Government have made general provision, under the rate support grant, for allocation of funds, local authorities have found themselves constrained and have failed to send the resources where they should have gone—to implement the 1986 Act. The only answer to that is ring fencing.

I appreciate the point made by the Minister in Committee about the danger of eroding the independence of social services departments and local authorities in how they allocate their funds. However, the other cases are unanswerable. The rate support grant system means that local authorities will have to prioritise their spending. I urge the Government to think again to ensure that the grants for social services departments are ring-fenced for community care.

6.52 pm
Mr. Edward Leigh (Gainsborough and Horncastle)

Unlike the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy), I do not believe that the genesis of the Bill came from the desk of some Right-wing ideologue in the Adam Smith Institute.

Mr. Robin Cook

You know them all.

Mr. Leigh

I do not know them all. With my hon. Friend the Member for Stirling (Mr. Forsyth), I wrote a booklet for the No Turning Back group. We were the first to talk about the principle of money following the patient. That was not the genesis of the Bill: that lies in the creation of the National Health Service.

No one doubts the sincerity of the Labour party's defence of the NHS. It views the NHS as a monument to Socialism—and there are precious few left. I am pleased to see the right hon. Member for Blaenau Gwent (Mr. Foot) in his seat. I remember him saying that he wished that the wartime spirit could return. Actually, the creation of the NHS was less the work of the Attlee Government than that of the wartime coalition and the Beveridge report.

I say that the genesis of the Bill lies in those days, and not in the work of some ideologue, because the NHS badly needs reforming and modernisation.

Mr. Flannery

Will the hon. Gentleman give way?

Mr. Leigh

I will not give way; I have only two or three minutes.

The principle of the NHS is based on a highly centralised structure, which was common in those days in all our nationalised industries and, indeed, in Government Departments. That structure has developed into the regional and district health authorities that we know so well, and it is now creaking at the joints. I suspect that, if we were now faced with a Labour Government, they would be implementing many of the reforms that we are discussing today. No one who looked into a crystal ball in 1979 would have believed that, 10 years later, a Conservative Government would be spending £28 billion on the NHS—more than they spend on defence. No one would have believed it possible that we would now be treating 30,000 more patients every week than 10 years ago. However, those are the facts.

This debate is not about ideology, but about balancing priorities with resources. The Bill is—I hope the phrase is appropriate—a fundamentally and gradualist and Fabian measure. It is not a radical privatising measure, by any stretch of the imagination. Let us look at the core elements of the Bill—for instance, indicative drug budgets. The genesis of that proposal lies in the cash limits that the last Labour Government placed on health authorities, but these are not even cash limits. Is it unreasonable for the House—the guardian of the £28 billion that we give on behalf of our constituents to the providers of the NHS—to insist on accountability and cost control? That is the essence of indicative drug budgets.

Nor do I think it unreasonable for us to seek to modernise the NHS by bringing more choice and accountability down to the grass roots and away from the centralised structures to which I have referred. That is the basis of self-governing hospitals and of fund-holding practices. There is nothing radical in the Bill, in the sense of NHS privatisation. The Bill will introduce a more businesslike approach, but it is not about making the NHS into a business.

I regret the phrase "internal market", because it sets the alarm bells ringing on the Opposition Benches. We were not talking about an internal market; in a sense, that is a contradiction in terms. We were talking about providing a better service for the public. The Bill will achieve that, and that is why I will support it tonight.

6.57 pm
Mr. Tom Clarke (Monklands, West)

The hon. Member for Gainsborough and Horncastle (Mr. Leigh) has confirmed my conviction that all Conservative Members who made serious speeches either had strong reservations about the Bill or—in at least in one case—opposed it.

In a telling withering speech, the hon. Member for Northampton, South (Mr. Morris)—who was interrupted by several hon. Members who had not even heard the speech—gave an analysis of the Bill that I considered profound. He said that the Government have failed to take the people with them: surely that is self-evident. It is one of the problems that we have in trying to ensure a reasonable debate on the Bill.

The Bill is the baby—many would say the folly—of the Secretary of State for Health. We attempted in Committee—whatever he has said since—to be constructive and helpful, and to offer alternatives. However, none of our amendments was accepted. That is not surprising because of the self-imposed infallibility of the Secretary of State, which is—so far as I know—shared only by the hon. Member for Stirling (Mr. Forsyth). However, we in Scotland understand that aberration, even if we do not agree with it.

The Secretary of State's obsession is not surprising. After all, he told The Independent on 25 September 1989: I have been spectacularly more successful than any of my predecessors. When a Gallup poll commissioned by the British Medical Association suggested——

Mr. Kenneth Clarke

Read on.

Mr. Tom Clarke

I will be even fairer to the right hon. and learned Gentleman by quoting what he told The Daily Telegraph——

Mr. Kenneth Clarke


Mr. Tom Clarke

I will not give way to the Secretary of State. The Under-Secretary of State for Scotland spoke for 34 minutes, and would not give way to me. My speech is much shorter. I am being fair to the Secretary of State by quoting what he said to The Daily Telegraph so that we fully understand his approach to these matters. When a Gallup poll commissioned by the BMA suggested that only 15 per cent. of all voters approved of the Government's proposals, the Secretary of State said: That poll shows that three out of four people are mistaken. I will now reluctantly give way to the Secretary of State, but it will be the last time, in view of the limitation that the Government have imposed on me as well as on other hon. Members.

Mr. Kenneth Clarke

The hon. Gentleman is free to criticise my views, but he should not take half-sentences to attribute ridiculous allusions to me. On his first point, he knows that I said that I had been more spectacularly successful than any of my predecessors in achieving increased spending on the National Health Service out of the Treasury. That is factually correct. I did not make other generalised boasts, as the hon. Gentleman made it sound.

On the second matter, the hon. Gentleman knows that I explained that poll by saying that it measured the success of the BMA in misleading the public and therefore leading to so many members of the public being mistaken. I do not object to the hon. Gentleman attacking my views fairly, but using half sentences in such a ridiculous fashion does not help anybody.

Mr. Tom Clarke

The House will respect my view that the injury time that the Secretary of State has taken might be deducted from the Minister when he replies to the debate. I have no desire to distort the views of the Secretary of State. Why should I? Last night, despite his fine words, there was massive support for our modest new clause. But he persuaded enough of his troops to oppose it and to support him after what had been a squalid response on his part.

There are no positive measures in the Bill to deal not just with the crisis in the NHS, which hon. Members in all parts of the House have identified, but with the enormous problem of community care, to which the hon. Member for Eastleigh (Sir D. Price) referred in some detail. The hon. Member for Ynys Môn (Mr. Jones) was right to draw attention to the Government's disgraceful approach to the non-implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986.

If the Government really believe in community care, they have the basis on which to work, and in that respect they need not listen only to me. The Department's inspectorate produced a devastating report about non-implementation and the Government's disgraceful role in that lethargy. I invite the Secretary of State and the Parliamentary Under-Secretary of State for Scotland 10 try to defend themselves against what is said in that report about their lethargy. Despite the Government's fine words, there is nothing in the Bill for carers. The Government regard care as a commodity; carers are part of the market philosophy which we are supposed to support.

Our debates in Committee confirmed that we are confronted by a Government who will not listen. Not only will they not listen to hon. Members, but they will not even take note of what was said in the Griffiths report. It is not surprising that we said little about community care in Committee and in this restricted debate on the Floor of the House. After the Griffiths report was submitted, the Government held on to it for 20 months before commenting. Then they tried to find every way possible round the report's central recommendations.

Although the lack of debate about Griffiths and community care is no accident, we are still left with the problems of community care—of people leaving long-stay psychiatric hospitals and going into non-existent community care, of the trenchant criticisms of the Audit Commission, of the reality of people who must live in cardboard homes with cardboard hopes. Faced with those problems, the Secretary of State is like a man caught between washing and wringing his hands and offering no positive response. My hon. Friends the Members for Wakefield (Mr. Hinchliffe) and for Pontypridd (Dr. Howells) made that clear in their remarks.

We invited the Secretary of State to address the important issues involved in community care, to which Griffiths and others referred, and to do so on a level playing field. We met with no success, even though the right hon. and learned Gentleman claims to be committed to the mixed economy.

Between the statutory and independent sectors, all the advantages are going to the private sector. If anybody doubted that, proof came in the debate on income support. With income support and housing benefit denied to local authorities, the Government—although they say that they understand the problem—are so dogmatic, even on that issue, that they will not take on board the will of the House.

A few hours after that debate and the House taking its decision, some of us saw on television the Secretary of State for Social Security. I admit that it was a confusing time and that he did not appreciate why such a strong rebellion had taken place. Like many, I found his interview unusual and I did not understand what he said. Indeed, I got the feeling when the interviewer asked Mr. Newton, how are you going to respond to this decision? that not even Isaac Newton could have understood what the Secretary of State was trying to tell us.

The issues that have been raised on community care are absolutely clear, even though the Government pretend that they are not. The case for ring fencing—for earmarking funds—is overwhelming, and it is shameful of the Government not to have accepted that view. In their rejection of the mixed economy in a real sense and in their attitude to proper provision for local authorities, the Government are influenced overwhelmingly by dogma, as we have witnessed in other areas of Conservative legislation. We saw it with the social fund, and the difficulties that local authorities, voluntary organisations and others are facing with the social fund apply to the Bill.

That is why it is not surprising that the voluntary organisations are reminding us that the Government are declining to accept their responsibilities. The Spastics Society, the YMCA and the Salvation Army tell us that they are bursting at the seams because the Government, having failed to accept their responsibilities, are leaving it to the wider community—to charities and others, everybody but themselves—and are adopting a mean-minded approach which the British people find thoroughly unacceptable.

We have in the measure not one but four Bills. We have had one on health and community care for England and Wales, and likewise one for Scotland. Nobody can pretend that there was adequate consultation or that the views of the people of those nations were taken into account by the Government before bringing their proposals forward. When Conservative Members objected even to the short debates initiated by my Scottish and Welsh hon. Friends, English Members who were fair-minded enough to listen to those debates found that they were constructive, and they confirmed that more time should have been provided for discussion of the Scottish and Welsh issues raised by the Bill.

The opinion polls show that the Bill has little support among the people. That applies to the provisions on opting out, to what the Government have said about the role of junior doctors and to cash limits for drugs——

Dame Elaine Kellett-Bowman

There is none.

Mr. Clarke

If there is none, why is that not written into the Bill? The Secretary of State and the Under-Secretary of State for Scotland have been at their most unconvincing on that point, when they have pretended that on those matters the British public have been misled and that my hon. Friend the Member for Livingston (Mr. Cook), brilliant though he has been, has persuaded 55 million people about something. If the Government really believe what they have been saying, why have they not been prepared to write it into the Bill? I shall tell the House why.

One of the most compelling speeches that I have heard in our ridiculously restricted debates was that of my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) yesterday. He referred to the debate in July 1946 when Aneurin Bevan, introducing the concept of the National Health Service into the House, said: Quite frankly, I do not believe that they ever intended to have a universal health service."—[Official Report, 26 July 1946; Vol. 426, c. 467.] Those words are just as true in 1990 as they were in 1946, and the Secretary of State and his hon. Friends know it.

There is a colossal division of opinion about the NHS. There is a great gap between the Government and the Opposition, as Opposition Members have said both in Committee and today. In fairness to several Conservative Members, it is clear that many of them do not go along with the Bill either. I only hope that they will join us in the Division Lobby tonight. But the battle will go on beyond that. It must go on because we are committed to keeping, improving and expanding the National Health Service as Nye Bevan saw it. We wish to introduce real community care supported by the community, not based on the "community couldn't care less" attitude and the prospect of community neglect which we find unacceptable.

There is another aspect to that difference of philosophy. The Prime Minister has said: Let our children grow tall—and some grow taller than others. The Bill is a continuation of that logic. It is the catechism of inequality—let our people grow old and some will be better cared for than others; let our people go sick and some will have better provision than others; let people develop disabilities and some will be supported and some not; let people care for their elderly or sick relatives and we shall ignore them.

We are sending to another place a Bill which has been inadequately debated and the subject of the minimum consultation which amounted to a sham. It is a mean-minded Bill which is fatally flawed, unworthy of the House, and repugnant to the vast mass of the British people. In asking the House to oppose Third Reading, the Opposition send a clear signal to all the people of Britain that the forthcoming Labour Government will remove this shabby measure from the statute book with the speed and urgency that its miserable contents invite.

7.12 pm
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

The Bill was introduced into the House on 7 December last year by my right hon. and learned Friend the Secretary of State for Health. It has had some three and a half months of detailed debate and scrutiny. On behalf of the Government, I thank all hon. Members from both sides of the House who have made constructive comments during the passage of the Bill. I particularly thank my hon. Friends the Members for Newbury (Sir M. McNair-Wilson), for Stamford and Spalding (Mr. Davies) and for Gainsborough and Horncastle (Mr. Leigh) for their powerful speeches in support of the Bill on Third Reading.

The Bill is based on five key principles. It might be helpful to run over them. First, it is based above all on the need to provide better patient care. The patient comes first and last. [HON. MEMBERS: "Last."] No, the patient comes first and last.

Secondly, the NHS will continue to be financed under the Conservative Government by the taxpayer and it will he largely free at the point of delivery. It will remain a universal Health Service. The myth repeated again tonight by the hon. Members for Wakefield (Mr. Hinchliffe) and for Pontypridd (Dr. Howells) that there is a hidden agenda and that we intend to privatise the Health Service is not true. The Health Service will remain a national service, financed from public funds and available to all. The public do not want the NHS to be privatised and they will not be given a privatised NHS.

We have heard nonsense about hospitals opting out of the NHS for three and a half months. It is not true. We are delegating greater authority to hospitals, and hospitals to be known as NHS trusts—indeed, units other than hospitals—will have greater freedom to operate but will remain in the NHS.

My hon. Friend the Member for Northampton, South (Mr. Morris), who is here, made a powerful speech on Second Reading and again tonight. We all respect his views. He is in a minority. (HON. MEMBERS: "Is he?"] We shall see whether he is in a minority. His argument that the family practitioner service is to be cash-limited is simply not true. My right hon. and learned Friend the Secretary of State and I have given him an assurance on many occasions that the drug service will not be cash-limited, neither at doctor, family practitioner, regional nor national level. I repeat that assurance.

In 1990–91 the family practitioner service is forecast to grow in cash terms by almost 13 per cent. That reflects the fact that there are pressures each year for more and better drugs, which cost more in real terms. It is not our intention to cut the drug budget in real terms—it will continue to grow. But we intend to bring downward pressure on the rate of growth of the drug budget. I believe that many doctors will agree that clinical responsibility can and should march side by side with doctors accepting financial responsibility. It is no longer reasonable to argue that, whether they work in general practice or the hospital service, doctors should have no account of the costs of the service. It is unrealistic.

Mr. Alfred Morris (Manchester, Wythenshawe)

Will the Minister give way?

Mr. Freeman

I hope that the right hon. Gentleman will be brief, because of the limitation on time.

Mr. Morris

I am conscious of the limitation on time. Before this Bill leaves the House of Commons and, therefore, before the Minister concludes his speech, can we have a definitive statement of the Government's attitude to the plight of poor, vulnerable and elderly people in residential homes who face eviction? The Minister will recall that new clause 1 on that subject was carried with all-party support. Can he at least, before concluding the debate, give an assurance that there will be no evictions? Can he also make a statement on the Government's attitude to the whole issue?

Mr. Freeman

I understand the right hon. Gentleman's position. The House has voted and declared its position clearly on the matter. He will know that it is a prime responsibility of my right hon. Friend the Secretary of State for Social Security. He said clearly at the Dispatch Box that he understood the feelings of the House. In due course and at the right time and place he will lay before the House and develop the thoughts that he outlined during that debate.

My hon. Friend the Member for Newbury was absolutely right about the third principle behind the Bill, which is better value for money. In response to a seated intervention from the hon. Member for Sheffield. Hillsborough (Mr. Flannery), he said that improving the quality of the NHS is not only about more money. The Government have provided more money. It is about managing resources better. [HON. MEMBERS: "Oh, no."] Hon. Members may groan but it is absolutely true. Many countries around the world envy the National Health Service because it provides good value for money—it is an excellent service—but we are interested in and admire the steps that we are taking to get even better value for money.

The hon. Member for Glasgow, Cathcart (Mr. Maxton) said that the National Health Service "is not inefficient". I hope that he is not burying his head in the sand and saying that no measures to improve the efficiency of the National Health Service are appropriate; of course they are. We need to get better value for money from the £30 billion of resources that we put in, as my hon. Friend the Member for Gainsborough and Horncastle said.

The fourth principle is that we need to provide—and will provide—greater choice for patients, not only in the selection of their general practitioners but in elective surgery and in the hospital to which they go which may not be their own local hospital. The agreement and approval of the patient is required before he travels to another hospital, but it is humane and sensible to offer him the chance to do so because that will reduce waiting times for others at hospitals which are not so fortunate. That is a sensible measure, which will improve the quality of care.

Moreover, we are offering choice for the elderly—real choice this time. That is something about which the hon. Member for Wakefield and my hon. Friend the Member for Eastleigh (Sir D. Price) have expressed concern. I shall come later to my hon. Friend's point about ring-fencing. We shall be offering real choice to the frail elderly rather than simply the choice of going into residential care. We intend them to have a real choice between staying at home with proper domiciliary care and going into residential care.

My hon. Friend the Member for Eastleigh raised an important point about ring fencing, which was not addressed at length in the debate. He raised the matter on Second Reading and my right hon. and learned Friend the Secretary of State and my ministerial colleagues carefully considered his arguments. In fairness, there are two important arguments against ring fencing in relation to the care of the frail elderly and the mentally handicapped that my hon. Friend did not address. First, there is no evidence that personal social services depts are in any way faring badly in relation to other local government departments in terms of the relative share of resources that is available to them. There is no evidence that money is being diverted into other activities.

Secondly, if we pursued my hon. Friend's argument to its logical conclusion, all aspects of expenditure by social services departments would have to be ring-fenced. That would be a complete denial of the responsibility and flexibility that we have awarded to local authorities.

Sir David Price


Mr. Freeman

My hon. Friend will forgive me if I do not give way; I am just about to conclude my remarks.

We believe strongly that flexibility in local authorities should be preserved.

The fifth and last general principle concerns the delegation of authority in the National Health Service. That is what lies behind our proposals. We are talking about delegation not to, but from, the Secretary of State—to the National Health Service trusts, to general practice fund holders and to smaller, more businesslike district health authorities. We have great confidence in the staff who work in the Health Service, of whom there are almost I million. That is why we propose to delegate greater authority to them.

We have heard almost no constructive suggestions from the Opposition about reforming the National Health Service. The solution of the hon. Member for Livingston (Mr. Cook) is simply to throw more cash at it. The only two commitments that I can find in the Labour party's election manifesto are to the abolition of compulsory competitive tendering, which would cost £100 million, and to steps that would lead inevitably to the abolition of private medicine and income generation in the Health Service, which would cost a further £100 million. The first consequence of the hon. Gentleman's appointment as Secretary of State for Health—which will not happen—would be the loss of £200 million, or £1 million on average per district health authority. As for the suggestion of the hon. Member for Peckham (Ms. Harman) that we should have activity budgets, it is not well thought out. The Labour party has not explained where the money is coming from to fund greater activity in hospitals. But our proposals for money to follow patients are well thought out.

We are confident that at the next general election, the only poll that counts, the public will realise that our reforms—-which will have been in place for two years in the case of the general contract and one year in the case of the reforms themselves—have worked and are beneficial. Not only is the National Health Service safe in our hands; it will become a better National Health Service in our hands. I invite the whole House, especially my hon. Friends, to support the Bill.

7.25 pm
Mr. Alfred Morris (Manchester, Wythenshawe)

There is scant time left, but the House ought to have a definitive statement from the Government about their attitude to an amendment—new clause 1—that was supported on both sides of the House, the case for which was brilliantly argued by my hon. Friend the Member for Livingston (Mr. Cook). The proposal had all-party support. Before the conclusion of the debate, can we at least have the plain assurance that no elderly person will be evicted from residential care simply because he or she lacks money?

It being three hours after the commencement of proceedings, MR. DEPUTY SPEAKER put forthwith the Question already proposed from the Chair, pursuant to the resolution [14 March].

The House divided: Ayes 293, Noes 215.

Division No. 131] [7. 26 pm
Adley, Robert Dorrell, Stephen
Aitken, Jonathan Douglas-Hamilton, Lord James
Alexander, Richard Dover, Den
Alison, Rt Hon Michael Dunn, Bob
Allason, Rupert Durant, Tony
Amery, Rt Hon Julian Eggar, Tim
Amess, David Emery, Sir Peter
Amos, Alan Evans, David (Welwyn Hatf'd)
Arbuthnot, James Evennett, David
Arnold, Jacques (Gravesham) Fallon, Michael
Arnold, Tom (Hazel Grove) Farr, Sir John
Baker, Nicholas (Dorset N) Favell, Tony
Baldry, Tony Fenner, Dame Peggy
Banks, Robert (Harrogate) Field, Barry (Isle of Wight)
Batiste, Spencer Fishburn, John Dudley
Bellingham, Henry Forman, Nigel
Bendall, Vivian Forsyth, Michael (Stirling)
Bennett, Nicholas (Pembroke) Forth, Eric
Benyon, W. Fowler, Rt Hon Sir Norman
Blaker, Rt Hon Sir Peter Freeman, Roger
Body, Sir Richard French, Douglas
Bonsor, Sir Nicholas Gale, Roger
Boscawen, Hon Robert Garel-Jones, Tristan
Boswell, Tim Gill, Christopher
Bottomley, Mrs Virginia Glyn, Dr Sir Alan
Bowden, A (Brighton K'pto'n) Goodhart, Sir Philip
Bowden, Gerald (Dulwich) Goodlad, Alastair
Bowis, John Goodson-Wickes, Dr Charles
Boyson, Rt Hon Dr Sir Rhodes Gorman, Mrs Teresa
Braine, Rt Hon Sir Bernard Gorst, John
Brandon-Bravo, Martin Grant, Sir Anthony (CambsSW)
Brazier, Julian Greenway, Harry (Ealing N)
Bright, Graham Greenway, John (Ryedale)
Brooke, Rt Hon Peter Gregory, Conal
Brown, Michael (Brigg & Cl't's) Griffiths, Peter (Portsmouth N)
Bruce, Ian (Dorset South) Grist, Ian
Buck, Sir Antony Ground, Patrick
Budgen, Nicholas Grylls, Michael
Burns, Simon Hague, William
Butler, Chris Hamilton, Hon Archie (Epsom)
Butterfill, John Hanley, Jeremy
Carlisle, John, (Luton N) Hannam, John
Carlisle, Kenneth (Lincoln) Hargreaves, A. (B'ham H'll Gr')
Carrington, Matthew Hargreaves, Ken (Hyndburn)
Carttiss, Michael Harris, David
Cash, William Haselhurst, Alan
Chalker, Rt Hon Mrs Lynda Hayes, Jerry
Channon, Rt Hon Paul Hayward, Robert
Chapman, Sydney Heathcoat-Amory, David
Churchill, Mr Hicks, Mrs Maureen (Wolv' NE)
Clark, Hon Alan (Plym'th S'n) Higgins, Rt Hon Terence L.
Clark, Dr Michael (Rochford) Hill, James
Clark, Sir W. (Croydon S) Hind, Kenneth
Clarke, Rt Hon K. (Rushcliffe) Hogg, Hon Douglas (Gr'th'm)
Colvin, Michael Holt, Richard
Conway, Derek Hordern, Sir Peter
Coombs, Anthony (Wyre F'rest) Howard, Rt Hon Michael
Cope, Rt Hon John Howell, Rt Hon David (G'dford)
Couchman, James Howell, Ralph (North Norfolk)
Cran, James Hughes, Robert G. (Harrow W)
Critchley, Julian Hunt, David (Wirral W)
Currie, Mrs Edwina Hunt, Sir John (Ravensbourne)
Curry, David Hunter, Andrew
Davies, Q. (Stamf'd & Spald'g) Hurd, Rt Hon Douglas
Davis, David (Boothferry) Irvine, Michael
Day, Stephen Irving, Sir Charles
Devlin, Tim Jack, Michael
Jackson, Robert Peacock, Mrs Elizabeth
Janman, Tim Porter, David (Waveney)
Jessel, Toby Portillo, Michael
Johnson Smith, Sir Geoffrey Powell, William (Corby)
Jones, Gwilym (Cardiff N) Price, Sir David
Jones, Robert B (Herts W) Raffan, Keith
Jopling, Rt Hon Michael Raison, Rt Hon Timothy
Kellett-Bowman, Dame Elaine Rathbone, Tim
Key, Robert Renton, Rt Hon Tim
King, Roger (B'ham N'thfield) Riddick, Graham
King, Rt Hon Tom (Bridgwater) Ridsdale, Sir Julian
Kirkhope, Timothy Roberts, Wyn (Conwy)
Knapman, Roger Rossi, Sir Hugh
Knight, Greg (Derby North) Rost, Peter
Knight, Dame Jill (Edgbaston) Rowe, Andrew
Knowles, Michael Rumbold, Mrs Angela
Knox, David Ryder, Richard
Lamont, Rt Hon Norman Sackville, Hon Tom
Lang, Ian Sayeed, Jonathan
Latham, Michael Scott, Rt Hon Nicholas
Lawrence, Ivan Shaw, David (Dover)
Lawson, Rt Hon Nigel Shaw, Sir Giles (Pudsey)
Lee, John (Pendle) Shaw, Sir Michael (Scarb')
Leigh, Edward (Gainsbor'gh) Shelton, Sir William
Lennox-Boyd, Hon Mark Shephard, Mrs G. (Norfolk SW)
Lester, Jim (Broxtowe) Shepherd, Colin (Hereford)
Lilley, Peter Sims, Roger
Lloyd, Sir Ian (Havant) Skeet, Sir Trevor
Lord, Michael Smith, Sir Dudley (Warwick)
Luce, Rt Hon Richard Smith, Tim (Beaconsfield)
Lyell, Rt Hon Sir Nicholas Soames, Hon Nicholas
Macfarlane, Sir Neil Speed, Keith
MacGregor, Rt Hon John Speller, Tony
Maclean, David Spicer, Sir Jim (Dorset W)
McLoughlin, Patrick Spicer, Michael (S Worcs)
McNair-Wilson, Sir Michael Squire, Robin
McNair-Wilson, Sir Patrick Stanbrook, Ivor
Madel, David Stanley, Rt Hon Sir John
Malins, Humfrey Stern, Michael
Mans, Keith Stevens, Lewis
Maples, John Stewart, Allan (Eastwood)
Marland, Paul Stewart, Andy (Sherwood)
Marlow, Tony Stewart, Rt Hon Ian (Herts N)
Marshall, John (Hendon S) Stradling Thomas, Sir John
Marshall, Michael (Arundel) Summerson, Hugo
Martin, David (Portsmouth S) Taylor, Ian (Esher)
Maude, Hon Francis Taylor, John M (Solihull)
Mawhinney, Dr Brian Taylor, Teddy (S'end E)
Maxwell-Hyslop, Robin Tebbit, Rt Hon Norman
Mayhew, Rt Hon Sir Patrick Temple-Morris, Peter
Mellor, David Thompson, D. (Calder Valley)
Meyer, Sir Anthony Thompson, Patrick (Norwich N)
Miller, Sir Hal Thorne, Neil
Mills, Iain Thornton, Malcolm
Miscampbell, Norman Thurnham, Peter
Mitchell, Andrew (Gedling) Townsend, Cyril D. (B'heath)
Mitchell, Sir David Tracey, Richard
Moate, Roger Tredinnick, David
Monro, Sir Hector Trippier, David
Montgomery, Sir Fergus Trotter, Neville
Moore, Rt Hon John Twinn, Dr Ian
Moss, Malcolm Waddington, Rt Hon David
Neale, Gerrard Wakeham, Rt Hon John
Nelson, Anthony Waldegrave, Rt Hon William
Neubert, Michael Walden, George
Newton, Rt Hon Tony Walker, Bill (T'side North)
Nicholls, Patrick Walker, Rt Hon P. (W'cester)
Nicholson, David (Taunton) Waller, Gary
Nicholson, Emma (Devon West) Walters, Sir Dennis
Norris, Steve Ward, John
Onslow, Rt Hon Cranley Wells, Bowen
Oppenheim, Phillip Wheeler, Sir John
Page, Richard Widdecombe, Ann
Paice, James Wilkinson, John
Parkinson, Rt Hon Cecil Wilshire, David
Patten, Rt Hon Chris (Bath) Wolfson, Mark
Patten, Rt Hon John Wood, Timothy
Pawsey, James Woodcock, Dr. Mike
Yeo, Tim Tellers for the Ayes:
Young, Sir George (Acton) Mr. David Lightbown and Mr. Irvine Patnick.
Younger, Rt Hon George
Abbott, Ms Diane Garrett, John (Norwich South)
Adams, Allen (Paisley N) Garrett, Ted (Wallsend)
Allen, Graham George, Bruce
Alton, David Gilbert, Rt Hon Dr John
Anderson, Donald Godman, Dr Norman A.
Archer, Rt Hon Peter Golding, Mrs Llin
Armstrong, Hilary Gordon, Mildred
Ashdown, Rt Hon Paddy Gould, Bryan
Banks, Tony (Newham NW) Graham, Thomas
Barnes, Harry (Derbyshire NE) Grant, Bernie (Tottenham)
Barnes, Mrs Rosie (Greenwich) Griffiths, Nigel (Edinburgh S)
Barron, Kevin Griffiths, Win (Bridgend)
Battle, John Harman, Ms Harriet
Beckett, Margaret Healey, Rt Hon Denis
Beith, A. J. Heffer, Eric S.
Bell, Stuart Henderson, Doug
Benn, Rt Hon Tony Hinchliffe, David
Bennett, A. F. (D'nt'n & R'dish) Hoey, Ms Kate (Vauxhall)
Bermingham, Gerald Hogg, N. (C'nauld & Kilsyth)
Boateng, Paul Home Robertson, John
Boyes, Roland Hood, Jimmy
Bradley, Keith Howarth, George (Knowsley N)
Brown, Nicholas (Newcastle E) Howells, Dr. Kim (Pontypridd)
Brown, Ron (Edinburgh Leith) Hoyle, Doug
Bruce, Malcolm (Gordon) Hughes, John (Coventry NE)
Buchan, Norman Hughes, Robert (Aberdeen N)
Buckley, George J. Hughes, Roy (Newport E)
Caborn, Richard Hughes, Simon (Southwark)
Campbell, Menzies (Fife NE) Illsley, Eric
Campbell, Ron (Blyth Valley) Ingram, Adam
Campbell-Savours, D. N. Janner, Greville
Carlile, Alex (Mont'g) Johnston, Sir Russell
Cartwright, John Jones, Barry (Alyn & Deeside)
Clark, Dr David (S Shields) Jones, Ieuan (Ynys Môn)
Clarke, Tom (Monklands W) Jones, Martyn (Clwyd S W)
Clay, Bob Kennedy, Charles
Clelland, David Kilfedder, James
Clwyd, Mrs Ann Kirkwood, Archy
Cohen, Harry Lamond, James
Coleman, Donald Leadbitter, Ted
Cook, Frank (Stockton N) Leighton, Ron
Cook, Robin (Livingston) Lestor, Joan (Eccles)
Corbett, Robin Lewis, Terry
Cousins, Jim Livingstone, Ken
Cox, Tom Livsey, Richard
Crowther, Stan Lloyd, Tony (Stretford)
Cryer, Bob Lofthouse, Geoffrey
Cummings, John Loyden, Eddie
Cunningham, Dr John McAllion, John
Darling, Alistair McAvoy, Thomas
Davies, Rt Hon Denzil (Llanelli) McCartney, Ian
Davies, Ron (Caerphilly) Macdonald, Calum A.
Davis, Terry (B'ham Hodge H'l) McFall, John
Dewar, Donald McKay, Allen (Barnsley West)
Dixon, Don McKelvey, William
Dobson, Frank McLeish, Henry
Doran, Frank Maclennan, Robert
Duffy, A. E. P. McNamara, Kevin
Dunnachie, Jimmy Madden, Max
Eadie, Alexander Mahon, Mrs Alice
Fatchett, Derek Marek, Dr John
Faulds, Andrew Marshall, Jim (Leicester S)
Fearn, Ronald Martin, Michael J. (Springburn)
Field, Frank (Birkenhead) Martlew, Eric
Fields, Terry (L'pool B G'n) Maxton, John
Fisher, Mark Meale, Alan
Flannery, Martin Michael, Alun
Flynn, Paul Michie, Bill (Sheffield Heeley)
Foot, Rt Hon Michael Michie, Mrs Ray (Arg'l & Bute)
Foster, Derek Mitchell, Austin (G't Grimsby)
Foulkes, George Molyneaux, Rt Hon James
Fraser, John Moonie, Dr Lewis
Fyfe, Maria Morgan, Rhodri
Galloway, George Morley, Elliot
Morris, Rt Hon A. (W'shawe) Skinner, Dennis
Morris, Rt Hon J. (Aberavon) Smith, Andrew (Oxford E)
Morris, M (N'hampton S) Smith, Rt Hon J. (Monk'ds E)
Mullin, Chris Smith, J. P. (Vale of Glam)
Murphy, Paul Soley, Clive
Nellist, Dave Spearing, Nigel
Oakes, Rt Hon Gordon Steel, Rt Hon Sir David
O'Brien, William Steinberg, Gerry
Orme, Rt Hon Stanley Stott, Roger
Owen, Rt Hon Dr David Strang, Gavin
Patchett, Terry Taylor, Mrs Ann (Dewsbury)
Pendry, Tom Taylor, Matthew (Truro)
Pike, Peter L. Thomas, Dr Dafydd Elis
Powell, Ray (Ogmore) Thompson, Jack (Wansbeck)
Prescott, John Turner, Dennis
Primarolo, Dawn Wallace, James
Quin, Ms Joyce Walley, Joan
Radice, Giles Wardell, Gareth (Gower)
Randall, Stuart Wareing, Robert N.
Redmond, Martin Watson, Mike (Glasgow, C)
Rees, Rt Hon Merlyn Welsh, Andrew (Angus E)
Reid, Dr John Welsh, Michael (Doncaster N)
Richardson, Jo Wigley, Dafydd
Robertson, George Williams, Rt Hon Alan
Robinson, Geoffrey Williams, Alan W. (Carm'then)
Rogers, Allan Wilson, Brian
Ross, Ernie (Dundee W) Winnick, David
Rowlands, Ted Winterton, Nicholas
Ruddock, Joan Wise, Mrs Audrey
Salmond, Alex Worthington, Tony
Sedgemore, Brian Young, David (Bolton SE)
Sheerman, Barry
Sheldon, Rt Hon Robert Tellers for the Noes:
Shore, Rt Hon Peter Mr. Frank Haynes and Mr. Ken Eastham.
Short, Clare
Sillars, Jim

Question accordingly agreed to.

Bill read the Third time, and passed.