Health Service and Community Care

HC Deb 17 April 1991 vol 189 cc450-522

Mr. Deputy Speaker (Mr. Harold Walker)

I have to inform the House that Mr. Speaker has selected the amendment standing in the name of the Prime Minister. He has also asked me to tell the House that he intends to impose a ten-minute limit on speeches between 7 and 9 pm.

5.23 pm

Mr. Robin Cook (Livingston)

I beg to move, That this House is disturbed that, in the past financial year, underfunding of the health service adversely affected patient care by compelling hospitals to cancel more operations and close more beds than even the previous financial crisis of 1987–88; condemns the persistence of Her Majestys' Government in forcing on the National Health Service a market driven system of health care against the opinion of the overwhelming majority of the people who work in the health service and of the people who use the National Health Service; records its concern at the growing evidence that the system of patients following contracts results in less choice for patients of where to be treated and restrictions in the treatments available to them; regrets the two year delay in the introduction of the Community Care programme which should have taken effect this month; is alarmed at the serious threat to social service provision as a result of the crisis in local government finance created by Her Majesty's Government; and calls upon Her Majesty's Government for urgent action to tackle the growing gap between income support levels and charges for residential care. Listening to the previous exchanges with the right hon. and learned Member for Rushcliffe (Mr. Clarke) I had a sense of déjà vu from our debates on this topic last year. I recall that in one of those debates I predicted that the last place the right hon. and learned Gentleman would want to be in April 1991 would be the Department of Health, where he would have to carry the can for what he had thought up. I said that he would rather be at any Ministry but Richmond terrace. I think that we can begin this debate by chalking up another accurate prediction. The right hon. and learned Gentleman is now bringing his customary tact and delicacy to the nation's classrooms. No doubt if he is ever asked about those two years in Richmond terrace he already has an answer handy: "I was never registered at that address: I stayed with a lady across the road." [Laughter]. In truth I must tell my hon. Friends that the White Paper was indeed written by a lady across the road, in Downing Street.

In the right hon. and learned Gentleman's place we have a different Secretary of State, complete with his own alibi—

Mr. Terry Lewis (Worsley)

Not for long.

Mr. Cook

My hon. Friend should be more charitable at the start of a debate.

While the changes in the NHS were germinating, the right hon. Gentleman was at the Department of the Environment, thinking up the poll tax. The claims that he is about to make for the NHS changes over which he now presides must be weighed against the wisdom that he showed in his predictions for the poll tax, including his observation that Those who argue that the poll tax is impracticable are protesting too much". I have to warn the Secretary of State that those of us who, years ago, warned that the poll tax was impractical are now warning him that these changes to the NHS will deeply damage it. And on the evidence of the poll tax we have a better track record of getting our predictions right.

We do not need to look as far as the poll tax to see how widely wrong the Government's predictions are. Two key predictions about health issues since 1987 by the Secretary of State's predecessors have proved wrong on a scale that would be comic if it were not so serious. First, there was the abolition of free eye tests. The right hon. Gentleman's predecessor simply refused to believe us when we told him that if he stopped paying for free eye tests opticians would start charging for them. He assured the House that opticians would compete against each other to do it for free. In November 1988 he said: the charge for the eye test will steadily disappear … that is my strong personal opinion."—[Official Report, 1 November 1988; Vol. 139, c. 927.] Today, almost every optician charges between £10 and £17 for an eye test.

When does the Secretary of State expect charges for the eye test steadily to disappear? I should be fascinated to hear his answer. I will happily give way to him so as to hear it. If he does not expect charges for eye tests to disappear, how can he expect us to believe the Government's predictions of what the magic of the market will do to the NHS when we know what it has done to eye tests?

The second issue on which the Government were widely wrong was that of tax relief for private medical insurance for pensioners—the first proposal in the White Paper to be put into practice. The White Paper made it clear that the purpose of granting tax relief was to encourage the take-up of private insurance by pensioners. That is one thing that tax relief has not done. With a heavy heart, I must report to the House that BUPA has made a loss on its scheme for private insurance for pensioners. It has spent £3 million gearing up for a new era of BUPA pensioners, and it did not get enough new subscribers even to cover its start-up costs. All that has happened has been a windfall gain for all who already had private insurance. Thanks to this bit of dogma, we are now spending £50 million a year for no increase in the take-up of private insurance, without an extra penny of it going into the NHS wards for pensioners. The Government amendment speaks of "improved value for money". Where is the improved value for money in this expenditure of £50 million?

Against this background of spectacular misjudgments, we come to the right hon. Gentleman's predictions about the changes that the Government are levering into place this month in the health service. There are design flaws in the new system that are already evident—most of them predicted by us. But some things have occurred that we did not predict. I have to confess that I did not predict that Lord Rayner would emerge as a self-confessed critic of the changes. After all, he is the Government's favourite business man, brought in by the previous Prime Minister to bring business common sense to the public sector. Last month he brought his common sense to bear on the changes to the NHS and he said: The whole thing to me was a total nightmare. There is no way this business"— that is, Marks and Spencer— could turn itself upside down overnight—There is no way we could do it without proper experiment and evaluation. My only regret is that Lord Rayner is such a late entrant among the critics of the scheme, but many of us criticised it as it went through the House and we made a number of predictions which are all now coming true.

We predicted that there would be less choice for patients as to where they are treated. The Government promised that money would follow patients; we predicted that patients would follow contracts. Earlier this week I received a letter from a lady who had returned from seeing her GP in Kent. She wrote to me to say that she was, "Lost for words." She has been attending Guy's hospital since 1979. Last week she was told that she must stop attending Guy's hospital—she would no longer be under the care of the consultant who had been looking after her for 12 years —and transfer to the hospital in Kent that has the contract for that condition. The Government's amendment talks about more responsiveness to people's wishes. Where is the responsiveness to the patient's wishes in that case? I ask the Secretary of State the same question that that lady asked me: Was it the intention that the NHS changes should cause my care to suffer? Yesterday was released an internal document from Wandsworth health authority. It is 18 pages of guidance on how to handle patients who want to go to different hospitals from the one where the block contracts have been placed. Outside the Conservative party's manifestos, I have never read a document of such sustained cynicism. It is blunt. It states that it will have to "reduce to the minimum" the number of patients outside block contracts. Obligingly, the document admits: Patient choice, a cornerstone of the stated benefits of the reorganisation, may be reduced … This has its implications politically with respect to … public relations. How did Wandsworth propose to handle those political implications and public relations problems? It resolved to resolve them by keeping the patient in the dark. Its advice to GPs is: "Never say no." Always "defer" or "redirect" a referral. Keep patients out of the discussion as to where they go. In most instances the patient should remain unaware of the process of the purchaser/provider discussion. How does the Secretary of State square that squalid manual with the promise that the White Paper would put the needs of patients first?

Mr. Phillip Oppenheim (Amber Valley)

I thank the hon. Gentleman for giving way and I hope that he will forgive me for intervening so early in his speech, but his answer to my question will have a bearing on the credibility of the rest of his speech. The hon. Gentleman will be aware that not so long ago the hon. Member for Derby, South (Mrs. Beckett) said that any future Labour Government would have a number of spending priorities such as pensions and child benefit. Can he tell the House whether the NHS would be one of the priorities of a future Labour Government? Will he answer yes or no?

Mr. Cook

Yes. Only yesterday my hon. Friend the Member for Derby, South (Mrs. Beckett)—[HON. MEMBERS: "Yes or no?"] I said, "Yes." There is no point in the hon. Gentleman's repeating the question after he has heard the answer. Only yesterday my hon. Friend the Member for Derby, South and I sat on the same platform when we published our policy document for this year. It contained a whole section on spending commitments on the health service. We are committed to restoring the underfunding of the health service under the present Government and fully funding pay awards—something that they have not done since 1983.

Several Hon. Members

rose—

Mr. Cook

I shall not give way, as I am answering the hon. Gentleman's question. The hon. Gentleman asked me a question. He cannot object if he does not like the answer.

Several Hon. Members

rose—

Mr. Cook

In the interests of the hon. Member for Amber Valley (Mr. Oppenheim) I must implore your assistance, Mr. Deputy Speaker, so that he gets the answer for which he has asked.

In that document we are committed to making sure that the year-on-year funding of the health service fully reflects the changes in demographic pressure that result in added claims on that health service. Our spending priorities for the health service are clearly stated. I know perfectly well why Conservative Members do not like the answer. They wanted a different answer that bears out their prejudices about our priorities rather than the reality of what we say.

Mr. Jerry Hayes (Harlow)

Will the hon. Gentleman give way?

Mr. Cook

No speech on health from this Dispatch Box is complete without an intervention from the hon. Member for Harlow (Mr. Hayes) so we might as well get it over with now.

Mr. Hayes

I am most grateful to the hon. Gentleman. I know that he wants to be helpful to my hon. Friend the Member for Amber Valley (Mr. Oppenheim). I have here the actual document on health that the Labour party published yesterday. Perhaps the House ought to hear what it says and then the hon. Gentleman can tell us a little about sustained cynicism. It states: We will invest in the modernisation of our hospitals and tackle the backlog in maintenance and repairs—although we cannot expect to put it right overnight.

Mr. Cook

After that intervention I promise to let the hon. Gentleman in a second time. Let me explain to the hon. Gentleman, who appears to be unaware of these things, that the total maintenance budget for the national health service is some £500 million per annum and the total backlog that the Government have generated in a decade is £2,300 million. It is extraordinary that the hon. Gentleman believes that even the Labour party could attempt to put right overnight a £2,300 million backlog. I assure him that it may take us more than the first night.

Mr. Anthony Coombs (Wyre Forest)

rose—

Mr. Andrew Mitchell (Gedling)

rose—

Mr. Cook

I shall not give way again. They have had two fair attempts and I have been generous to the hon. Gentlemen in pursuing their hares.

The Secretary of State for Health (Mr. William Waldegrave)

The hon. Gentleman supports the party which was responsible for the only cut in real terms in a year in the history of the health service under the Government in which the right hon. Member for Blaenau Gwent (Mr. Foot) was a Cabinet Minister. We have a right to talk about cynicism when the hon. Member for Livingston (Mr. Cook) talks about spending pledges.

Mr. Cook

If the Secretary of State wants to tweak where people were in 1975 when the White Paper was approved, he should look at the record where he will find that I voted against those cuts. The record does not lie. I am sure that my hon. Friends will agree that if those Conservative Back Benchers who now tell us that they always opposed the poll tax had had the courage to vote for what they believe in, local goverment would not now be in crisis.

We also predicted that the changes would mean that less treatment would be available on the national health service. Lo, in the first week of the new system a woman from south-east Kent was refused sterilisation because her health authority would not pay for it. Nor will she be alone. Basildon and Thurrock carried out 303 vasectomies last year, whereas this year they plan to purchase 15. What has happened to choice for the people in those health districts?

Even before the changes were in place, North East Thames RHA took a covert decision not to pay for the removal of varicose veins. The Secretary of State's response to that was that it should be a matter for clinical judgment. With respect, it is precisely these changes that have stopped it being a matter of clinical judgment. The regional district manager of the North East Thames RHA stated: Regional officers are presently preparing a list of procedures which unless there is an overriding clinical need may be deemed inappropriate to place on waiting lists". This is an appropriate moment to say that at 3.30 pm today the Secretary of State released the latest figures for health service waiting lists. They are the highest in any September since records began. Moreover, they reached that peak even before the effects of the past winter in which hospital after hospital closed its doors for routine operations. What is most embarrassing for the right hon. Gentleman in those figures is not the number of patients waiting, but the number of patients treated in those six months. Afters years during which the Government told us that what was important was not the number of patients waiting but the number being treated, today's figures show a 3 per cent. reduction in in-patient levels.

The amendment tabled by the Secretary of State invites the House to congratulate the Government on having achieved a 25 per cent. increase in in-patient activity during the past 10 years. In the light of this afternoon's figures, perhaps it will be appropriate for you, Mr. Deputy Speaker, to accept a manuscript amendment to reduce that figure to 22 per cent.

I warn my colleagues that I suspect that we are about to see a major improvement in waiting lists. I suspect that they will go the way of the unemployment statistics, not because more people are coming off those lists but because fewer will get on. Before they are magicked away —

Mr. John Butterfill (Bournemouth, West)

rose—

Mr. Cook

I am asking a question.

Ministers sold us the scheme as a basis for widening patient choice. Will they now guarantee that every patient who was on a waiting list on 31 March will be treated for the procedure for which they were waiting and at the hospital for which they were waiting? It is a simple question, which is a fair test of whether the scheme puts patient choice first. I see that all three Ministers are attempting to avoid my eye.

Mr. Butterfill

rose—

Mr. John Marshall (Hendon, South)

rose—

Mr. Cook

I will give way only to a Minister because we are entitled to an answer. Will every patient who was on a waiting list on 31 March receive treatment in the hospital of his choice? I can catch your eye, Mr. Deputy Speaker, but I have difficulty in catching the eye of any of the Ministers.

Several Hon. Members

rose—

Mr. Cook

No, I shall not give way.

I am not surprised that the Ministers do not want to rise, because there has been a change in the language used to describe the reforms. Two years ago we were assured that the reforms would mean that money would follow the patients. Overnight, the Government had found the formula to end underfunding. I sat through successive debates with successive Conservative Back Benchers who were bubbling with enthusiasm about the fact that their hospitals would be in clover because they did more work than the others. They believed that because money would follow patients, more work meant more money. Oddly, we never heard from the Back Bencher whose hospital did less work and would therefore lose money which would be gained by others.

I issue a warning to those Back Benchers, some of whom I recognise here. I do not know whether they have noticed the change in the language, but "Money following the patient" is no longer a buzz phrase. It is a little while since I heard a Minister use it. I shall listen with excitement to see whether a Minister uses it today. The change in the language has been subtle. We are now told that the benefit of the reforms is that they make explicit what the health service can afford. I shall make explicit what that means —it means a tighter system of rationing health care. Health care will now be rationed by the business men with whom the Government have stuffed the health authorities and who do not represent anyone in the local community but are charged with deciding who in that community receives care.

Mr. Butterfill

The hon. Gentleman talks about the resources available and the effect that they may have on waiting lists, but he should remember that waiting lists have been reduced by 6 per cent. under this Government but increased by 48 per cent. under the previous Labour Government.

Mr. Cook

I refer the hon. Gentleman to the Government's figures produced at 3.30 pm this afternoon. If he cares to examine the figures released for last September, he will find that there has never been a September under this Government in which waiting lists have failed to be higher than those for any September under the previous Government. Now, for the first time, Britain has a million people on waiting lists.

I make a third prediction about changes. I predict that they will make the health service less fair. If health care is put on the market, the patients who will come first will not be those most in need, but those who bring the hospital the most money. I could not have hoped for a clearer warning of that danger than the decision taken by Christie hospital in Manchester—on the eve of the changes—to sell a fast-track admission to patients from health authorities that pay more. Health authorities that pay more will get patients in within two weeks, whereas others will get patients in after six weeks. I cannot think of anything more repugnant than a two-tier standard of admissions for patients who are in an advanced stage of cancer, which strikes more thoroughly at the principle of the NHS which is that priority goes to those who are most in need of treatment, not to those who have paid the most.

In my naivety I imagined that the Secretary of State would be embarrassed by the revolution. He was not; he welcomed the scheme. However, the scheme was too much even for the Daily Express which, on the day that the changes came into effect, reported the Secretary of State as saying that this was what the new reforms of the Health Service 'are all about'. It continued: Then they are a disgrace … Maybe the Labour Party was telling the truth after all. Perhaps the NHS is unsafe in the Tories' hands. My final prediction and warning —

Mr. Simon Hughes (Southwark and Bermondsey)

So far, I agree with and support all that the hon. Gentleman has said, but I wish to amplify his expression of concern. I am the Member of Parliament for the constituency that contains Guy's hospital. It is not only people from outside the South East Thames RHA district who are becoming increasingly concerned and have been told that they could not come to that hospital for treatment. Others have been told to return equipment on which they rely and without which they cannot manage. People from within the district are also increasingly fearful that they will be kept waiting on trolleys in corridors, as the hon. Gentleman saw when he came with me to King's College hospital. They are also worried about getting home because the ambulance does not come and about waiting for treatment that they traditionally received at their hospital, but which they might not now receive because some have the advantage of buying whereas they, as local patients, are not expected to pay.

Mr. Cook

I am grateful to the hon. Gentleman for supporting my case. It is ironic that not only do I speak in this debate for the people who have supported my party and not only does the hon. Gentleman speak for the people who supported his party but between us we speak for most of the people who supported the Conservative party and who did not want these changes either.

Our final prediction is that these changes will make the health service less efficient. They have already diverted colossal resources into more managers, more clerks and more computers to run the marathon paperchase that it demands. There is a debate between the British Medical Association and the Health Service Journal on whether the number of new management jobs advertised is 300 a month or only 130 a month. It is common ground between both participants in the debate that we are pouring millions of extra pounds into administration at the very time when we are closing thousands of beds because we cannot afford to keep them open.

Of course, new managers need new salaries. Just like privatisation, opting out has released a tidal wave of gravy over top management. The chief executive of Guy's now gets £5,000 a year more to run Guy's than Duncan Nichol receives to run the whole NHS. It is common gossip in the health service that the financial package for the chief executive of Guy's includes a free car for the use of his wife. The total cost of pay and perks to senior management at Guy's is equivalent to the cost of running three wards at that hospital.

Mr. Simon Hughes

One ward was closed.

Mr. Cook

As the hon. Gentleman said, one ward was closed in the first week of the changes. Whatever happened to "improved value for money" when those salaries were negotiated?

Another type of inefficiency is starting to emerge from the changes. The theory was that we would get better value for money because health authorities would shop around for contracts while hospitals would compete with each other for business. Like all fairy tales, this would have a happy ending—competition would drive down unit costs.

Of course, real life is much more complicated. After being told to balance the books or go bankrupt, hospitals have quickly discovered that the quickest way that they can do that is to do less work for the money that they were getting before. The district general manager of Tower Hamlets health authority has complained publicly that the Royal London insists on a cut of 3 per cent. in activity for the same amount of money and he is still arguing with St. Bartholomew's hospital which wants a cut of 15 per cent. in activity. He has gone on record as saying that every London hospital except those in Bloomsbury wants to cut its work load. That is a rational response because the Secretary of State has changed the objective from meeting patient needs to balancing the books. The point of markets is not to satisfy needs but to achieve equilibrium. The problem for the Secretary of State is that some hospitals want to achieve that equilibrium at lower levels of activity.

Mr. Peter Thurnham (Bolton, North-East)

rose—

Mr. Cook

I shall not give way again. As you said, Mr. Deputy Speaker, many hon. Members wish to speak.

Is the Secretary of State prepared to measure the success of those trusts that opted out by the simple test of whether they do more or less work on NHS patients? There is, of course, a counterpoint to all the energy and all the inventions applied by those managers to the changes this month in the health service. This is also the month that was to witness the new programme of community care. In sharp contrast with the way in which Conservative Members plough ahead with the changes in the NHS, they have shelved the package of community care for two years, yet the amendment invites us to congratulate the Government on achieving it by April 1993.

Last July, the Secretary of State's predecessor said that the Government had to shelve the community care package for two years because of problems with the poll tax—another of the little impracticalities that he had overlooked. No doubt Ministers will tell us that the two-year delay is not a standstill in community care. That is right. Thanks to the poll tax, local government is in financial crisis. All over Britain, community care is not at a standstill; it is in retreat and is under pressure to make cuts.

Last month, the directors of social services published a survey on the state of social service budgets. Half those budgets ended up underfunded and in deficit. One third of those authorities expect to make reductions in their budgets this year. I have a list of cuts by one metropolitan authority that is cutting £2.5 million from its budget. Those cuts include cuts in home helps, meals on wheels, transport for the disabled and grants for voluntary agencies. The only thing going up are charges to the clients of those authorities.

Mr. Keith Mans (Wyre)

Labour authorities.

Mr. Cook

Only two weeks ago, the hon. Gentleman's colleagues in government, whom I presume he supports, imposed a poll tax cap on five social service authorities, three of them Labour and two Conservative. A third Conservative authority escaped only by making dramatic cuts the night before. These pressures are not imposed just on profligate high-spending authorities; they apply across authorities of both political colours and to local authorities that are honestly and decently trying to meet the rising tide of demand in their communities.

The authority to which I referred plans to raise £1 million more in charges from its elderly and disabled residents by doubling the charges for home helps. Most clients were exempt before; none will be exempt now. Two weeks ago, the Minister for Health said that local authorities should become much more comfortable with the idea of charging clients. I am uncomfortable with the idea of charging even the poorest pensioner for the home help whom she needs in order to stay in her home.

The worst victims of the two-year delay are the elderly who cannot stay in their home, who were encouraged by the Government to go into private residential care, who were put into private residential care by managers who could not find a place for them in hospitals and who now find that the Government will not pay for their keep. On 1 April, their income was uprated by 3 per cent.—one third of the inflation rate and less than one third of the increase in charges for residential care.

Two months ago, the National Association of Citizens Advice Bureaux published a report rich in examples of their caseloads of people who could not pay their bills and of cases showing the emotional distress, personal indignity and financial hardship caused by that trap. There is the woman of 88 who cannot buy batteries for her hearing aid because her personal allowance is swallowed up in paying charges. There is the man of 78 with Parkinson's disease and suffering incontinence who cannot buy new trousers because all his money has gone on the charges. There is the distress to the relatives of the two women pensioners on income support who, out of a weekly income of £75 between them, must find £15 a week to meet the gap in their mother's residential care charges.

There is no need for me to give more examples. Every hon. Member, on whichever side of the Chamber he or she sits, has such cases in his or her constituency. That is why, a year ago in the only Government defeat of this Parliament, the House voted to plug that shortfall. It is a shame, not just on Ministers but on the House, that we have let the Government get away with putting off that help until 1993 when many people who are now in that trap will be dead. Their relatives will not forgive the Government for what they have done to community care; nor will those who use the health service forgive them for what they are doing to the NHS.

I read last week that the Prime Minister is to launch a charity appeal for a major London hospital. The health service should not have to depend on charity. Moreover, Ministers will not prove their commitment to the NHS by promoting appeals for charities but will only confirm their lack of commitment to a properly funded system.

Mr. Thurnham

Will the hon. Gentleman give way?

Mr. Cook

No.

I find unexpected common ground with the comments made in the February 1991 edition of the Conservative Medical Society bulletin, which states: The achievement of a Conservative overall majority at the general election will be a much greater challenge than is often realised". How true. One of the reasons given is that: The National Health Service was a key issue in recent general elections and there is no reason to think that this will change. We do not intend to let that change. We shall put the NHS at the top of the agenda for the next general election and ensure that every elector understands that only if the Government are changed will the damaging changes to the health service be stopped. Only then will we get a Government who will restore the health service to a public service that treats people as equals and is accountable to electors and the local community.

6.4 pm

The Secretary of State for Health (Mr. William Waldegrave)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: congratulates the Government on the near 25 per cent. increase in the number of in-patients treated and the near 100 per cent. increase in the number of hospital day cases since 1979 and on the further recent fall in hospital waiting times; welcomes the successful introduction of the Government's reforms which are already leading to better quality services, more responsiveness to people's needs and wishes and improved value for money; notes that the reforms are being backed in 1991–92 by record increases in resources for the National Health Service and in the standard spending assessment for the personal social services; welcomes the Government's commitment to full implementation of its community care policy through local government, by April 1993; supports the Government's objective of using the National Health Service reforms to deliver real improvements in the health of the people through the development of a national health strategy; and looks forward to the forthcoming publication of a consultative document setting out the Government's proposals". Before I return to the subject of the debate, I hope that the House will forgive me if I deal with a bipartisan issue that has received wide coverage. Sometimes individuals suffer as a result of prejudice and it is necessary for the Government and the House to use their weight on the side of the individual. I refer to the case of Daniel Robinson, the seven-year-old carrier of hepatitis B who lives in Kirklees. With the full authority of the chief medical officer, may I say that there is no reason for other children to be kept from that school. Social contacts of a carrier do not need to be immunised and it is perfectly safe for the children to return to school. I fully support the local consultant in communicable disease control and the Kirklees chief education officer, and I have asked the chief medical officer or his deputy to be prepared to go to Kirklees to help to explain the facts if that would help. The misguided parents who, for no valid reason, are bringing such pressure to bear on a seven-year-old child should desist.

I welcome the opportunity to report to the House the immense achievement of those who manage our national health service and the introduction on time, at the beginning of this month, of the far-reaching reforms of NHS financing and organisation approved by Parliament last year, which they have achieved with no significant problems. The fact that the hon. Member for Livingston (Mr. Cook) could find only two problems, both of which have been reported in the newspapers and have been dealt with by my hon. Friend the Minister for Health, shows that we can be proud of them.

I am happy to be able to give an account of the start of the period of introduction of the community care programme set out originally in the White Paper, "Caring for People". It will be completed by the beginning of 1993. I shall then sketch the main directions of further policy developments that we intend to pursue and cast an eye over the Opposition's plans to see whether they have anything to offer or any substantial ideas that should detain the House, although I fear that they have not.

We now have in place in the NHS the planned separation between the strategic or purchaser function in the districts and regions and the provider or unit management function in hospitals or elsewhere. Although the plans of the hon. Member for Livingston are disguised by language, they probably accept that division, and that is helpful.

The separation of two quite distinct functions lies at the heart of our reforms and is clearly sensible. One vital job to be done is to analyse local health needs and spend money as effectively as possible to meet them. Another is to manage the clinical and other skills necessary to respond to those needs. The former task, which lies with the districts, involves the setting of public health priorities and strategies and the deployment of money to achieve them. The latter, whether in NHS trust or other hospitals, involves bidding to meet the districts' objectives most effectively with negotiations to achieve maximum benefit for patients sealed in contracts.

For the first time, districts will have a chance to buy health for their people, knowing that when they do so they are spending taxpayers' money to the best effect. As one district manager said: Now I can concentrate on making choices that can improve the population's health. In the past I became bogged down by administrative issues. Equally clear is the fact that responsibility for managing the resources of skilled people and capital, which now lies with the hospitals, is already producing a far greater source of involvement in and commitment to the task of giving the patients and their GPs what they want. As one chief executive of a hospital trust put it: The freedom Trust status offers will allow us to become closer to our patients and to the community and our involvement with GPs will be greater than ever before. Alongside the district, we now have 300 fund-holding general practices covering 3.6 million patients and spending next year about £400 million, purchasing directly on behalf of their patients from the hospitals. An editorial in Doctor magazine called this the most important development in primary care in 25 years". Professor Le Grand of Bristol rightly said: there are many including some politically unsympathetic to the present Government, who are excited by the idea". All this is now in place. District contracts are generally completed, and in those cases where final discussions are continuing I am advised that they will be completed shortly. Satisfactory arrangements are in place to ensure that patients' needs are met.

Meanwhile, the benefits that we are seeing for patients in this year's contracts include targets for the maximum wait for admission for in-patient treatment; patients getting a full week's notice of an elective admission; one in four patients being asked to complete a questionnaire asking for their views of the service provided; a two-month maximum waiting time for an out-patient appointment; all new patients to be seen by a consultant on either the first or second attendance; individual appointment times for out-patient clinics; discharge letters being provided to the patient's GP within 24 hours in 90 per cent. of cases and within three days of discharge in all cases.

The new services for patients offered by different trusts around the country include: patients being notified of appointment dates within 10 days of the receipt of their referral letter; agreement that notification of the outcome of consultations should go to GPs within five working days; patient satisfaction to be measured against a "patients' charter" jointly agreed between the trust and the local community health council; reduction of waiting time to less than four weeks for a routine out-patient appointment; changes already made to catering services in one case in response to a patient satisfaction survey.

As hoped, GP fund-holders are the pioneers of improvement. For example, a Nottingham GP fund-holding practice has agreed with a small local hospital to provide a same-day, walk-in X-ray service. Routine reports will be issued by first-class post the following morning and urgent reports will be faxed to the GP surgery. Under the old system, delays were common and reports were sent second class. The practice is now using that agreement as leverage in negotiations with a large acute unit. Incidentally it also said that it has had more hospital-based health professionals coming in to find out what was wanted since the reforms than at any time in the history of the NHS.

Oxfordshire fund-holders have requested that no patient should wait longer than one hour in out-patients, and that this should be reduced to half an hour by next year. In the North Western district, fund-holders have encouraged the drawing up of clinical protocols that GPs can follow in order to refer directly on to an in-patient list, thus reducing inconvenience to patients and pressure on out-patient departments. In Southend, the patients of one GP fund-holding practice will see consultants specialising in general medicine, surgery, gynaecology, ophthalmology and radiology at their local surgery. As one Manchester fund-holder said: For the first time we are talking to the hospital side and making them aware of our needs. We see ourselves leading a drive for better services and others will get the benefits too. Meanwhile, the new GP contract has completed its first year. I hope that we can improve it further and I have had a good discussion with the general medical services committee about that. Let us consider what it has already achieved. The incentives provided by the new target payment scheme for cervical cytology and childhood immunisation have helped to increase the uptake of the preventative services.

More than 80 per cent. of GPs have received payments for reaching targets, thereby assisting in eliminating unnecessary illness. More than 50 per cent. of GPs are being paid for providing child health surveillance services. Nearly 70 per cent. of GPs have been admitted to the minor surgery list. In the first nine months of the new contract, almost 500,000 individual surgical procedures were performed by GPs. More than 450,000 individual health promotion clinics have been held in the first nine months of the contract, covering such subjects as diabetes and giving up smoking. There has been a massive increase in expenditure on GPs' staff and premises, with more money than ever being invested. Next year's allocation of £564 million is 87 per cent. more than the £302 million spent in 1989–90. The number of nurses working with GPs has increased by 65 per cent. since 1989–90. These are formidable improvements, which we are already seeing in the development of the patient-centred NHS that we believe that the House wants and our people deserve.

Mr. John Battle (Leeds, West)

At the beginning of the procedure of switching to trusts, I asked the Secretary of State if he would publish the financial basis on which the Leeds trusts were established. He could not find it within his means to produce that information. Why is it that in the past weeks patients have been writing to me saying that they have been told that they must wait longer? Have the improvements not got through to Leeds general infirmary? Will the Secretary of State Commissioner a report to see how the improvements are working out and publish the results?

Mr. Waldegrave

I am delighted that the hon. Gentleman expects to see dramatic improvements in the first week. We shall see improvements—he should wait and see. I shall return to some of the predictions made by the hon. Member for Livingston later.

Mr. Geoffrey Lofthouse (Pontefract and Castleford)

Will the Secretary of State give way?

Mr. Waldegrave

I shall give way three times, as the hon. Member for Livingston did. This is the second one coming up.

Mr. Lofthouse

Is the Secretary of State aware that hospitals which previously showed no enthusiasm for the trusts are being encouraged by the district health authorities to take part? Is he aware that this very day nine senior staff from the Pontefract general infirmary, including five surgeons, have gone off on an eight-day junketing tour to America to study American medicine? That is an attempt to encourage them to opt out when they have not previously shown any previous enthusiasm to do so. Does the Secretary of State support that method?

Mr. Waldegrave

Although the staff may learn some lessons from clinical procedures that they may observe in America, I do not think that they will learn much about the organisation of health care in America—I agree with the hon. Gentleman on that. Whenever an application is brought to me, I have to judge the clinical support for trusts.

The achievement and sheer scale of what has been happening in the NHS may have overshadowed the fact that at the same time we have initiated the introduction of the community care reforms. Local authorities, like district health authorities, will have the duty of assessing the needs of the vulnerable groups involved in a far more rational way and directing the money available to the best and most appropriate care from the private sector, the charitable sector and their own provisions. That policy is now under way.

Mr. Tom Clarke (Monklands, West)

If that is the Government's intention, why have they infuriated the Association of County Councils and virtually every voluntary organisation involved in the subject by allowing, the week before our Easter recess, a junior Minister in another place to announce the outrageous decision that the Government intended to ignore the unanimous will of this place and not implement the remaining sections of the Disabled Persons (Services, Consultation and Representation) Act 1986? Do local authorities not consider that legislation crucial to any strategy for community care? Why did the Secretary of State not have the guts to announce that decision in this House?

Mr. Waldegrave

I do not know where the hon. Gentleman was yesterday—perhaps he was engaged elsewhere. My hon. Friend the Minister of State discussed the matter openly in the House yesterday and explained cogently why that issue was not our highest priority at present.

From 1 April, we shall introduce local authority inspection units, new complaints procedures, a new specific grant to provide services for people suffering from mental illness and a new specific grant for services to drug and alcohol misusers. All that effort to improve services in both health and community care has not been at the expense of those who need to use the services as they are now. Proof of that lies in the latest waiting list figures published today.

The figures show that good progress is being made in reducing waiting times. The number of patients waiting more than one year for in-patient and day case treatment fell by 5,100, or 2.5 per cent., in the six months to September 1990. That comes on top of a reduction of 7 per cent. in the 12 months to March 1990. Furthermore, latest provisional figures reported by regional health authorities show that the progress has not only been maintained but has gained momentum, with a 12 per cent. reduction expected in the five months to February 1991. Those significant sustained reductions demonstrate the results of continued efforts to tackle the problems.

Getting the building blocks of the reformed NHS in place has been a great achievement. I am certain that, whatever the vagaries of political fortune in the future, they will never be undone. Now we need to ensure that attention focuses increasingly on the health improvements that we want the new system to deliver. The development of the purchasing role is central to that.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

Will the Secretary of State give way?

Mr. Waldegrave

Perhaps I should take an intervention from one of the lesser parties—I give way to the hon. Gentleman.

Mr. Kennedy

Once the Minister gets past his sarcasm, perhaps he will give a serious answer to a serious question already put by the hon. Member for Livingston (Mr. Cook). Before we come to the further stage of the trusts, will the Secretary of State give a simple explanation to the House about how he will gauge the success of a self-governing hospital trust? What criteria will be used?

Mr. Waldegrave

It would be foolish to say that the success of any hospital—whether a directly managed hospital under the old system or a trust—is measured only by an increase in its activity.

A specialty may well be moved from one hospital to another, or the opening of new functions somewhere else might divert patient flows. We must base a judgment on patient satisfaction, good use of funds—the normal and common-sense tests by which we would judge the success of any hospital.

The development of the purchasing role is central to the development of the reforms. 1991–92 has seen a steady approach to the implementation of contracting, with relatively few changes in patient flows. That was necessary during such major changes in management and funding arrangements.

I have sympathy with the hon. Member for Livingston and the leader writer in today's edition of The Guardian who complains, as though surprised, that money is not yet properly following the patient. Of course, it is not—the block contracts introduced in the first year limit that process, although it is beginning to happen. I share the enthusiasm—if that is what it was—of the hon. Member for Livingston to see the reforms begin to develop as they will in the years ahead to ensure that money specifically follows the patient with far more flexibility than that offered by block contracts. We are now moving away from the so-called steady state in the introduction of the reforms.

Like the hon. Member for Livingston—if this is what he wants—I want to see further changes in the pattern of services as soon as possible to provide the maximum benefits to patients.

Mr. Robin Cook

If the Secretary of State wishes to convince the House that the new scheme is at least as flexible as the scheme that it replaced, will he answer the question that I put? It is a fair test of the extent to which the scheme meets patient choice. Will he guarantee that every patient on a waiting list at 31 March will receive the treatment for which he or she was waiting at the hospital at which he or she wishes to be treated? Can he give that assurance?

Mr. Waldegrave

The districts may now be responsible for the waiting lists of their residents. If the referor's wish remains the same, it may be granted. However, under the present system the referor could not guarantee that patients would not move from one hospital to another to find either swifter or different treatment. If the referor makes the clinical judgment that a patient should be treated at a particular hospital, that will continue.

Mr. Cook

That was not the question that I asked. I asked what would happen if a patient wished to be treated at a particular hospital. The Secretary of State's answer was that the person would be treated there if the referor decided to refer him to that hospital. Let us suppose that, irrespective of what the health authority says, the patient says, "I have been waiting to go into that hospital for a certain procedure, which I want at that hospital."

Mr. Waldegrave

The patient will have been referred there by his general practitioner. If his GP sticks to his referral and says, "That is the right clinical referral for this patient", the answer to the hon. Gentleman's question is yes. There is no difficulty about that.

Mr. Andrew Mitchell

Is it not extraordinary that the hon. Member for Livingston (Mr. Cook) should raise the waiting list issue since, as we heard earlier, when a Labour Government ran the national health service waiting lists went down by 6 per cent. but under the present Government they have gone up by 48 per cent.?

Mr. Waldegrave

I think that it may be the other way round. Waiting lists went up by 48 per cent. under the last Labour Government. It always enrages the Opposition when we remind them of what happened under their own stewardship of the NHS. It has taken them some years to regather their energy and address the problems facing the NHS.

Mr. Allen McKay (Barnsley, West and Penistone)

When I asked my local hospital whether it could guarantee that my constituents would be able to benefit from its services as they have in the past, the answer was no.

Mr. Waldegrave

If the referor's clinical judgment is that patients must go to that hospital, that will be the outcome, as I said to the hon. Member for Livingston.

As we move away from the steady state, we need to get benefits for patients from the contracts being placed. We want to get more and better quality health care for the populations represented by the health authorities. They have found this to be an exciting task. They have had to develop and discuss a local vision of what they want the reforms to achieve. They need to develop purchasing strategies, based on a fuller assessment of the health needs of the local community. They need to act together with the family health services authorities to ensure a better balance of prevention and treatment and a better integration of primary and secondary care.

The reforms are bringing about extremely exciting changes which are helping to break down the sometimes arbitrary barriers. As well as the changes being secured through the new contracts for GPs and dentists, there are major opportunities to build on team work between GPs and other health professionals to improve services further. An example of this is the development of minor surgery at GPs' premises. We need to consider whether we have gone far enough in that direction. The NHS management executive's discussion paper, "Integrating Primary and Secondary Health Care", is a clear indication of the direction of these changes and provides a useful framework for local development.

District health authorities must be open in finding out what local people want and discussing priorities. One of the only two cases that the hon. Member for Livingston gave was sterilisation treatment for a particular lady. As I said yesterday, the reforms have disclosed that in that instance the health authority had not for many years conducted sterilisations in its own hospitals. As it now has to specify openly what it does, it was found to be in breach of the guidelines from the centre about what treatment should be available. That matter has now been put right. There was no scandal in that. We want explicit health strategies which set out local priorities. Those priorities will—and, indeed, should—vary across the country, reflecting local health needs.

I have already made clear the important work that district health authorities must take forward in the area of community care. They must work closely both with local authorities and with the family health services authorities. It is right for us at the centre to contribute to that shift in attention to the production of health strategies, both local and national. We shall therefore shortly be issuing a consultative document setting out a suggested approach to the development of a health strategy for England which, if it is to contribute usefully, must go wider than the tasks of the NHS alone.

England has not developed a health strategy in a structured way before, although Wales has. We shall be learning from its experience, and from the experience of other countries. We shall proceed by publishing a consultative document, to be followed in due course —after, I hope, national debate—by a health strategy White Paper.

The House will, I hope, welcome the fact that the reforms now give us a far better chance openly to address the health needs of the nation and to direct resources to meet them. None of the progress that we want will be possible, however, unless the skills of the million or so people in the NHS are properly used.

I have three particular priorities that we shall wish to develop over the next few months. The first relates to the nursing profession. I do not believe that we are yet using the full potential of nursing skills. That is why we intend to establish a new directorate of nursing in the NHS management executive. Nurses themselves, with Government and outside support—notably King's Fund support—have developed some potentially exciting ideas on how to develop their profession. I am currently discussing with their chief nursing officer of my Department what further initiatives we can take to support them and I intend to make a further statement shortly.

My second priority is junior doctors. Steady progress is being made in the implementation of the heads of agreement on junior doctors' hours signed last December. Task forces are being established to propose solutions where local difficulties cannot easily be resolved, and 250 new career grade posts are being funded in England by the Government this year as part of the agreement. We shall play our part, but so must all the interests concerned —consultants, the royal colleges, NHS managers and junior doctors themselves. I do not believe that the juniors will easily forgive failure to make a reality of what is potentially an historic agreement.

My third priority is research and development. In post since January we have the first director of research and development for the NHS. I find it astounding that he should be the first holder of that post 43 years after the foundation of the NHS. None the less, he is now there. Professor Michael Peckham is a man of outstanding ability. As with nursing, his will be a key new directorate in the reorganised management executive. He will shortly publish his research and development strategy for the NHS. One of his vital tasks must be to spread more quickly best and most innovative practice throughout the service. Too often, bureaucratic or professional delay has hindered the spread of new ideas. The agenda is immense. The opportunity for benefit to patients is tremendous.

Labour, I have to say, has contributed virtually nothing to the national debate on health in recent years. First, it bobbed along like a dinghy in the wake of the British Medical Association campaign. How Aneurin Bevan, the patron of the right hon. Member for Blaenau Gwent (Mr. Foot), must have turned in his grave at that laying of the Labour party's sword at the feet of the BMA. Now the BMA, sensibly, is moving on. A recent British Medical Journal editorial said: As 1 April arrives, simply calling for a return of the old ways and more of the same will not do. The reforms may not address all of the problems of the NHS, but they do improve our capacity to specify the quality of services and to price improvements. So Labour's dinghy is now high and dry, stranded by the fact that the BMA is moving on.

On every important issue, Labour has cried wolf and been wrong. It campaigned —in effect, on behalf of the drug companies—against the limited drugs list, and it was wrong. It campaigned—in effect, on behalf of the then leadership of the BMA—against the new GP contract, and it was wrong. It campaigned against GP fund-holding and many of the Labour party's own supporters among GPs are telling it that, once again, it is wrong.

When it comes, as it now does, to crying wolf again —for example, about extra-contractual referrals— Labour's credibility is zero. As The Economist wrote recently: The Labour Party is paying the price for overstating the case against the reforms. Robin Cook, the Shadow Health Minister, insisted that the Tories were preparing to dismantle the NHS. Old ladies worried that hospitals would be either closed down or privatised. But on 1 April worriers will find that the NHS is still firmly in the public sector, financed from taxation, free at the point of delivery. Mr. Cook may prefer silence to eating his words". Up and down the country Labour Members of Parliament and public relations people tell local people that there will be no difficult decisions under Labour. Its members are against every rationalisation; like the Liberals, they are in favour of every lobby. But in the City of London, when the Leader of the Opposition or the right hon. and learned Member for Monklands, East (Mr. Smith) goes there to lunch, it is a very different story. Then it is, "Not a penny more for health —wait for the economic growth that Labour will produce." In other words, "Wait till the Greek kalends."

We have a right to ask how much more the right hon. and learned Member for Monklands, East would spend. He has made it clear that health is not in the privileged category with a pledge of spending behind it. If he does not intend to spend more, where is the £500 million present for the Confederation of Health Service Employees and the National Union of Public Employees to come from? Out of patient care—that is where it would come from. We have raised the share of health spending in terms of gross domestic product. In money terms we have increased it by half, after taking account of inflation. The right hon. and learned Member for Monklands, East well knows that there is not the slightest chance that Labour could do better.

Luckily, however, the hon. Member for Livingston recently rose to the challenge of clarifying his party's policies on these matters. Pressed by the New Statesman about how much more he would spend, he uttered the resounding pledge: Our policy and strategy are clear. If you give a figure, you no longer have a policy that consists of a strategy; you have a policy that consists of a figure. So now we all know where we are. Or, rather, we know where the hon. Member for Livingston is—he is up a gum tree, the only shadow Minister in the history of Oppositions so comprehensively to have lost the argument to his shadow Chancellor even before he got his feet under a real desk. Imagine what the right hon. and learned Member for Monklands, East would do to him if they ever found themselves in power. That is why it is of considerable importance to those of us who care about the health service to see that Labour never again has the chance to repeat the Healey-Ennals-Foot cuts of 1977–78, the ruthless suppression of nurses' wages which took place between 1974 and 1979, or the destruction of the NHS capital programme which occurred in those years.

The truth is that the health debate in this country is now taking place on our ground. Labour is almost wholly irrelevant to it. Today I can offer the House rather striking proof of this proposition, hot off the presses. In the latest glossy rehash of the Labour party's old policy themes "Labour's Better Way for the Nineties", one finds the following: Health care markets are out, dreadful things" — Tory things, and: Medical markets are in. I have seldom read more decisive proof of the intellectual defeat of an Opposition party. Labour's irrelevance and intellectual defeat is encapsulated in the motion before the House. I have no hesitation in asking my right hon. and hon. Friends to vote against the motion, and in favour of the amendment in my name and the names of my right hon. Friends.

6.32 pm

Mr. Peter Hain (Neath)

Entering the House after the high profile of a by-election is rather like having been head prefect in primary school, only to be plunged into the obscure anonymity of a secondary school new boy. I am confident that that fate awaits me when I sit down today.

It is an honour and a privilege to represent Neath, or Castell Nedd, whose importance dates from Roman and Norman times, and which has the cosiest town centre in Britain, surrounded by scenic valleys and majestic waterfalls, with, to the west, the a spectacular night-time view of Pontardawe's unusually tall and striking church spire.

There is a strong sense of community, an immense network of voluntary activity, and a rich culture of amateur opera, music, and male voice and ladies' choirs. On the eastern tip of the constituency is Richard Burton's home village of Pontrhydyfen. Amateur sport is widespread—football, athletics and, of course, the best rugby team in country. Recently I was introduced to a class of nine-year-old children at Godrergraig primary school. The teacher said, "Here is a very important person." One of the nine-year-olds got up and asked, "Do you play rugby for Neath?" That, I thought, was a man who had his priorities right.

I have enjoyed renewing my interests in the game at Neath's home ground, the Gnoll. In my youth, that interest involved running on rugby pitches, both as a player and, later, in another capacity, which I shall refrain from describing, as this speech is made with your indulgence, Mr. Deputy Speaker.

I am privileged in another way: I follow two Members, both survived by wives still living in Neath. Margaret Coleman is a highly respected figure in her own right in the community. Jenny Williams, now in her nineties, was a much-loved Labour party activist, and wife of D. J. Williams, who hailed from the close-knit village of Tairgwaith in the north-west of the constituency. In 1925, D. J. Williams wrote of the destructive impact of capitalism in the coal industry in terms that remain true today.

Donald Coleman's tragically premature death was not just a bitter blow to his family; it deprived Neath of a favourite son, and this House of its finest tenor. Although I will do my best to follow in his footsteps as a diligent constituency MP, I am afraid I cannot hope to match his talent for music and song. The exuberance with which he sang and preached his love for Neath reflects the intense civic pride in the town and in the villages of the Dulais, Swansea, Amman, Neath and Pelenna valleys.

But local residents cannot survive on civic pride, mutual aid and mutual co-operation alone. They take great pride in educational achievement. I have met nobody in Neath who cannot remember how many O-levels he or she has. There is a great tradition of skill and hard work in Neath and its valleys. Much has been done in the face of Government indifference and neglect, but so much more could be done if the publicly sponsored investment in industry, infrastructure and initiative for which the people of Neath and its valleys are crying out were provided.

Surely Neath is entitled to the seedcorn investment, decent training provision and long-term loan finance that only national Government or the Welsh Office is able to provide. The old Blaenant colliery site —headgear still erect as a monument to the last pit in Neath; one of over 30 to close in the constituency in the last 30 years —nestles beneath the village of Crynant in the picturesque Dulais valley. The old Aberpergwm washery and pit site is just below the little village of Cwmgwrach in the Vale of Neath. Both are prime industrial sites, yet both stand idle, black and gaunt, their potential wasting away as 11 people chase every job vacancy, training places are cut to the bone, and businesses go bust. Nobody in Neath wants a free ride. People want simply the opportunity to build a new future.

That future must include high-quality health and community care provision. With its history of mining and heavy industry, the people of Neath suffer disproportionately from ill health. With a higher than average proportion of citizens of pensionable age—22 per cent. compared to 17.7 per cent. for Great Britain —there is a particular need for a properly funded health and community care network. Yet the Welsh Office and the Treasury have still not given the go-ahead for the new hospital that Neath so desperately needs, and West Glamorgan county council has been forced, under pain of poll tax capping, to close one of its old people's homes.

Neath borough council, meanwhile, has had to spend an extra £523,000 on collecting the poll tax, compared with the cost of collecting the rates. On top of this, the borough had to install a new computer system for processsing the poll tax, at a cost of £300,000. Neath's 16,000 pensioners are entitled to question the priorities of a society and a Government that waste such colossal sums of money while hospital waiting lists grow, and responsibility for community care is unceremoniously dumped on local authorities without the necessary resources to finance it.

How can we claim to be caring for citizens in need when the iniquity of the poll tax continues to penalise them so savagely? Even after the recent £140 reduction in the poll tax, residents in the Blaenhonddan area of Neath will be paying £113.66 a head. This is £85 more, incidentally, than I pay as a resident in Resolven, a few miles up the Neath valley, even though we are paying for the same local authority services, because of the discriminatory way the Welsh Office operates the transitional relief scheme.

One resident in the Blaenhonddan area—a woman from Bryncoch—is caring for her 83-year-old mother who has Parkinson's disease. The mother has a tiny widow's pension and has to pay the full £113. Their combined household poll tax bill is £339, yet both she and her husband are on tiny incomes which are so widespread in the Neath area. The hypocrisy of preaching community care while practising such a pernicious policy is not lost on that woman or her neighbours in Neath. Conservative Members who turn a blind eye to her predicament call to mind Thomas Paine's summer soldier and sunshine patriot who in a crisis shrink from the service of their country.

How can the House claim to be safeguarding the interests of individuals such as a 72-year-old man from the village of Gwaun-cae-Gurwen, where the Welsh language is spoken with pride, whose eyesight deteriorates daily? He has waited 18 months for a cataract operation—a simple, cheap operation. Yet waiting lists for ophthalmic surgery at Singleton hospital have doubled since 1987, and there are now 1,400 local people like him awaiting in-patient treatment. Perhaps most outrageous of all, he was told that he could have the operation next week if he could go private at a cost of £3,000. He might as well have been invited to go to the moon, for that is a sum quite out of the question for someone living on the pittance that pensioners get today. He can be forgiven for noting with anger the grotesque fact that 200 people, just 0.0004 per cent. of the population, now monopolise 9.3 per cent. of the country's economic wealth—some classless society indeed.

Meanwhile, the quality of the environment and the standard of living continue to deteriorate, especially for our elderly. Local bus services in the Neath valleys have been cut ruthlessly. Fares are exorbitant. Yet who can afford a car on a basic retirement income, perhaps topped up by a miner's tiny pension? It is difficult enough for senior citizens to pay their colour television licence and the standing charges on their phone, electricity or gas. It is difficult enough for them to find the money to eat properly as food bills rise remorselessly while the real value of pensions declines compared with wage earners.

If Neath's senior citizens had free bus passes, if standing charges on basic utility services were reduced or abolished for pensioners, if those on low incomes were entitled, like their colleagues in sheltered housing, to television licences for £5 rather than £77, if Neath and Lliw borough councils were not banned by the Government from using their combined housing capital receipts of £7.6 million to build new homes and hit by cuts in housing funding from installing universal central heating and upgrading their existing housing stock, if communities like Cwmllynfell at the heads of the four main valleys in the constituency were not choked by coal dust, disruption and heavy lorry traffic from existing and threatened opencast mines—if all those vital factors were addressed, the standard and quality of life of my constituents would be dramatically improved and, with it, there would be less need to depend upon health and community care provision.

Furthermore, if the curse of "London knows best" were removed, local people would of their own volition radically recast their priorities. That is why decentralisation of power through newly invigorated local councils and an elected assembly for Wales are so vital. That is why a freedom of information Act and an elected second Chamber are so essential. The voice of the people must be heard, not smothered by anachronistic and elitist institutions of Government.

During the last 12 years especially, Britain has become an "I'm all right, Jack" society, putting instant consumption before long-term investment, selfish "mefirstism" before community care, and private greed before the public good. The result is ugly to behold: the tawdry tinsel of decadence camouflaging a society rotten at the roots.

I thank the House for its indulgence or, as we say in Neath, "Diolch Yn Fawr."

6.44 pm

Mr. Dudley Fishburn (Kensington)

I congratulate the hon. Member for Neath (Mr. Hain) on his maiden speech; a most excellent maiden speech it was. I have no doubt that, in the years ahead, the hon. Gentleman will make a substantial name for himself in the House, as he already has done outside. Being a by-election victor myself—we are rather fewer on these Benches than on the Opposition side—I have something in common with the hon. Gentleman. Not least, I congratulate him on being so quick off the mark in making his maiden speech, on the day after his introduction to the House.

The hon. Gentleman will learn, as I am afraid we have all learnt, that, in debates on the national health service, things are inclined to move at a rather predictable pace. New ideas from the Government on the restructuring of the national health service have all had the same hallmarks. They have all been radical and effective, and they have all been bitterly opposed by the Labour party.

The result is that, under the shadow Secretary of State, the hon. Member for Livingston (Mr. Cook), the Labour party, which for so many years contributed to the debate on health care not just in Britain but throughout western Europe, has boxed itself into a corner where the only contribution that it can make to the debate on the NHS is no, no, no. That has been a great disservice not just to the Labour party itself but to the general debate in Britain, in western Europe and in the United States about the way in which western democracies can seek to deliver better health care where it is needed: patient care as far away from the Government and as close to the individual as possible.

When my right hon. Friend the Secretary of State announces a new strategy for health in Britain, I fear that the debate which we shall have on the new ideas will be concentrated largely on this side of the House. I should like immediately to put two ideas into that debate and to welcome what my right hon. Friend said about setting up a new directorate for nurses. The nursing profession, which was one of the first to benefit from a radical shake-up under the Government when nurses were put on a professional career basis, is still one of the most under-utilised sections of the national health service. I congratulate my right hon. Friend on announcing at the start of his strategy that there will be a new directorate for nurses.

I hope that, in a national health service centred on patient care, one of the first things that that directorate will do will be to examine the possibility of extending to nurses the right to prescribe a limited number of specified drugs and medical products. When that happens, I hope that we will not hear, no, no, no from the Labour party, as we have heard on every other new idea.

The notion that Britain's nurses—initially the 29,000 district community nurses—should be able to prescribe certain products has been gathering intellectual respectability and popularity over the last few years. Initially it was dealt with in the Cumberlege report which recommended that nurses should be able to prescribe a limited number of products. The Select Committee on Social Services considered the matter and said the same thing. The Department of Health had its own study: in Britain, we often seem to prefer studies to action. That study, the Crown report, recommended that permitting nurses to prescribe would be a liberal, effective and humane extension of our medical services.

I gave that initiative a further kick on its way when I introduced a ten-minute Bill on the subject some time ago. I hope that the Department of Health will incorporate in its new strategy proposals to permit Britain's 29,000 district nurses to write prescriptions. That is already permitted in the United States and Canada, and it would have an immediate impact here on alleviating suffering and on bringing medical services to patients in their own homes under community care.

It is the community nurse who looks after people who are home-bound, not the doctor sitting in the surgery. The nurse knows when the patient needs to have a new product prescribed and what it should be. It is wrong that patients should have to go to surgeries to pick up prescriptions written by overworked doctors. It would be far better for prescriptions for a number of standard products to be written by nurses.

I hope that that proposal is incorporated in the strategy for health care that we develop in the next few years. The better delivery of health care, rather than a changed framework in which that care is delivered, represents the right way forward as we digest the radical reforms of the past four years. I hope that the Labour party will contribute its ideas for improving health care, as that is the way in which to provide a richer and better health service.

In the past 30 years. western society has understood that many women prefer to go to women doctors. However, we have not grasped the fact that many people from the ethnic minorities prefer to be treated by doctors who belong to their own ethnic minority. It is a great shame that so few of those belonging to the ethnic minorities, particularly those of West Indian and black origin, do not graduate from our medical schools. I represent the constituency with perhaps the largest ethnic minority of those who had the good sense to return a Conservative Member of Parliament. The problem of recruitment does not rest with the medical schools alone. The Department of Health must reach our sixth forms to encourage those from the ethnic minorities to go to medical school in the first place.

In my constituency, there are 200 practising GPs, but there is not one doctor of West Indian origin. In the next 20 years, as we attempt to have a patient-centred health service, we must try to deliver the type of services that patients want. We should consider the recruitment of ethnic minorities to train as doctors as part of that policy. The Department of Health should take a lead in that.

In the future, many ideas will be proposed for improving the health service. The Conservatives have had many ideas—all the positive ideas—on how to develop our health service. The more people who submit their ideas on the next stage the better. In the years ahead, I hope that the hon. Member for Livingston will cease to say no and will allow his colleagues to submit positive ideas to improve our health service.

6.53 pm

Mr. Charles Kennedy (Ross, Cromarty and Skye)

I do not intend to continue the arguments advanced by the hon. Member for Kensington (Mr. Fishburn), but it is important to consider what happened when we considered the National Health Service and Community Care Bill. In Committee many probing, constructive and critical amendments were moved. On some occasions such positive contribution came from Conservative Back Benchers, including the hon. Member for Harlow (Mr. Hayes). The Opposition made a positive contribution on every occasion, but the same cannot be said of the Minister. On every occasion she simply said no, no, no, or promised that it would be all right on the night. Whatever Opposition or Conservative Members sought to do, the hon. Lady assured them that that was already intended by the Government and that their commitment was good. The hon. Member for Kensington was a bit wide of the mark to suggest that there has been no constructive debate on the health service in the past. The difficulty has been trying to get a constructive response from the Government to any ideas advanced.

The Government have been in office for 12 years. Today, however, the Secretary of State outlined how much better all the changes will make the system and he described the improvements that will flow from them. One must ask what the Government have presided over in the past decade and more that led to such enormous problems that required such a drastic set of remedies.

Finance underpins the debate on the health service. The new revised trusts, operations and GP contracts mean that the planned expenditure for 1991–92 is £32 billion —a massive sum of money. That planned expenditure assumes a general inflation increase of 6 per cent., but that forecast is likely to be too low. If we spent proportionately as much on health as other western countries, the total level of expenditure would be closer to a ceiling of £38 billion.

The Secretary of State mentioned the proportion of our GDP that is devoted to health. He said that he was pleased to note that that contribution was rising. In this country it has risen to 6.1 per cent., but the average for the OECD member states is 7.5 per cent. By international comparison we still continue to lag behind.

Mr. Stephen Day (Cheadle)

Our figures do not bear comparison with international ones because they are largely misinterpreted. If one considers the levels of public expenditure on health in various countries, Britian is well up the list. The fact that other countries do better than us is due to the fact that they spend a larger amount on private health.

Mr. Kennedy

It is always the same with the Government: whatever the policy, when the figures are not as rosy as they would have us believe, it is all put down to misinterpretation. Doubtless all of us who shouted about the unemployment level in the 1980s misinterpreted the figures. We have had goodness knows how many changes to the unemployment statistics and each has led to a diminution in the level of unemployment.

We are now told that the method for calculating the rate of inflation is unacceptable and there are moves to take the mortgage interest relief out of the calculation. One wag suggested that if we wanted to improve our balance of payments it would be much fairer and more sensible not to include imports in the equation. In that way the economy would look a great deal healthier. I am somewhat sceptical when I hear Tory Back Benchers complaining about the reliability or otherwise of figures.

The resources devoted to the health service in the present financial year and the real-terms contribution to it will be eroded once again. That will happen because the health service must bear the brunt of pay review body awards that are staged and phased in such a way that they fall heavily on local health service provision. That has a great impact on all NHS funding.

I agree with the hon. Member for Livingston (Mr. Cook) about the costs of administration. We are witnessing a great disgrace in domestic policy, which has not been brought about by external events or economic circumstances—the poll tax. That policy was not inherited from another Administration, but it was conceived, delivered and botched by the present Government. The wastage of domestic expenditure on the administration of the poll tax will not be matched by the total administrative overheads of the health reforms, but, according to a recent survey conducted by the British Medical Association, those reforms are likely to add an extra £80 million on administrator salaries this year alone. That is almost six times the £14 million that the Government promised in December to cut junior doctors' hours of work. It is more than twice the £35 million that the Secretary of State for Health put towards cutting waiting lists in January. That is the reality of what this nonsense is costing us as regards the other deployment of resources that could and should be taking place.

The Secretary of State was not anxious to come clean about patients' rights under the new set-up. It is worth recalling the former Prime Minister's words. I know that that is no longer in vogue on the Conservative Benches. The wall posters along Whitehall are being taken down now that the change in leadership has taken place. In the introduction to the White Paper "Working for Patients" the right hon. Lady said: We aim to extend patient choice. Patients sometimes have strong feelings about where they want to go. They may have lost a relative or friend in a particular hospital and may find a hospital difficult to reach by public transport. A GP may think that the best specialist for a patient's condition is at a hospital some distance away.

What has been happening? General practitioners have accused the Government of lying to the public and have predicted that the issue could become as controversial as the poll tax because it became clear in the past fortnight that, apart from in exceptional circumstances, patients will be allowed to go only to hospitals with which their district health authorities have made contracts. What we are hearing about the extension of patient choice is not the case.

The Observer of 23 March quoted Dr. John Watson, chairman of Surrey's local medical committee, a GP representative committee. He was told that he can no longer refer 1,500 of his patients to his local hospital for physiotherapy and he is advising them to write to their local Member of Parliament. He said: The changes have removed my freedom of referral. The Government has misled the public over this for the last two years. The NHS will be the downfall of the Government. I have voted Conservative for the last 30 years, but I will not do so next time. That is a GP in the south of England, in true blue Conservative country, talking about his right as a general practitioner to refer patients to the hospital of his choice. It stands in stark contrast to the rubbish that we got from the Secretary of State today.

Mr. Barry Field (Isle of Wight)

I am obliged to the hon. Member for giving way and I am pleased to see that he has recovered from his illness. I trust that he will be able to confirm to the House that his excellent recovery is a result of the excellent health service that we have in this country. Could he confirm to me that he would deprecate doctors who lie to the electorate and especially those who took part in drawing up plans for the closure of hospitals when a new health service hospital was to open and who now endeavour to distance themselves from those plans because they see a few votes in it during the forthcoming elections?

Mr. Kennedy

Like every hon. Member in the House, I am never in favour of misleading, far less lying, to the electorate. It may be a local Isle of Wight problem.

Mr. Field

Very much so. I can confirm that.

Mr. Kennedy

I think that it would be helpful, especially for the Liberal Democrats, if the hon. Member for the Isle of Wight (Mr. Field), whose constituency we hope to regain at the next election, put it on record that one of his local GPs is a liar. If he would care to do so I shall happily give way.

Mr. Field

It was a member of the district health authority, appointed by the county council. He never once voted against the plans to shut local hospitals, but he has now put out a leaflet saying that he condemns those plans. He is extremely well known on the Isle of Wight, so there is no need to name him.

Mr. Kennedy

I think that we have achieved something tonight—another gain at the next election and I am grateful to the hon. Gentleman. However, we are not casting doubt on Dr Watson from Surrey, to whom I referred. That gentleman's comments speak for themselves. When we hear so much verbiage from the Dispatch Box it is worth letting the people in the health service speak for themselves. We do not often hear Government Ministers quote them.

The British Medical Association's central consultants and specialists committee recently conducted a survey of attitudes towards the changes and how people anticipated that they would work out. I shall give three quotes. The first is from the BMA's local branch in Wales, which said: Measures include—no new orders and reduction of stocks to the barest minimum. South East Thames RHA said: Completely disastrous—we have ½ million overspend on 1.4.1991 (i.e. we failed to make the level playing field). We must do 5 per cent. less work next year. So much for progress. North West Thames RHA said: Despite a savage bed closure policy, which has increased our waiting list by approximately 150 per cent., there were no financial savings recorded overall in the latest monthly figures available to us. There seems little or no prospect of any improvement after 1 April. Indeed; a worsening of the present situation, with further cuts, particularly in surgical bed numbers, seems likely. That is the reality of what is happening, not the nonsense that has been spilled out by the Secretary of State for Health.

Dame Jill Knight (Birmingham, Edgbaston)

Could the hon. Gentleman also confirm the reality of the fact that not one reform suggested by any Government, of any political persuasion from either side, has been accepted without a fight by the BMA? There has never been a reform that it has not objected to.

Mr. Kennedy

The BMA has a representative capacity on behalf of its profession to engage in on-going discussions with the Government and to put forward the interests of its members but also in the interests of what it views as decent standards of medical care. One cannot dismiss the BMA, which represents doctors up and down the land, by saying that it always takes a vested interest and does not also pay some attention to medical care overall.

I can think of a number of reforms that the BMA would not oppose—for example, lifting the charges that have been imposed for dental and optical treatment. Doctors throughout the country want that and regularly say so in our constituencies. People on low incomes have to bear the burden of prescription charges and doctors would be happy for that to change as well.

Mr. Robin Cook

What about maximum patient lists?

Mr. Kennedy

As the hon. Gentleman rightly says, there is also the question of lists. There has been constructive argument by Opposition Members in the House and in Committee about that. The BMA would be happy to see some of those changes. However, we never hear about that from Government Ministers.

The other half of this motion rightly dwells on community care and I was fascinated by the words that the Secretary of State chose to use. "Sir Humphrey" was working overtime on this one. As we know, the Government have postponed community care—of that there is no doubt. The previous Secretary of State announced it.

I wrote the Secretary of State's words down with care. He did not use the word "postponed" when talking of community care, although everyone knows that that has taken place. He said that he had "initiated the introduction" of community care. In other words the introduction is not quite with us yet, but the motive force is taking place. I prefer the word "postponement" and I also favour using one word rather than three where possible.

Given the present poll tax shambles, what will be the funding basis for local government and for the delivery of community care, which is already suffering this postponement? Now there is uncertainty about the future structure, never mind the funding, of local government. How can there be any certainty or confidence in the caring and professional services that will have to make a reality of community care against such a backdrop of uncertainty? The Government have not made the case for these reforms and the authentic voice of people in the health service, who are grappling with the problem daily, is further clinching evidence that these reforms are unnecessary, that they do not inspire public confidence and, more importantly, are not the answer to a complex problem which is rooted in the fundamental lack of political will on the Conservative side of the House, as has been proven in the past 12 years.

We shall certainly vote for the Labour motion and against the record of this Administration and their ideas for the future.

Mr. Deputy Speaker (Sir Paul Dean)

I remind the House that the 10-minute limit on speeches is now in operation. Hon. Members might find it helpful to keep an eye on the digital clocks.

7.9 pm

Mr. Stephen Day (Cheadle)

I join in the congratulations to the hon. Member for Neath (Mr. Hain) and in his tribute to his predecessor.

The hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) did not address himself to my intervention. The fact is that Britain has a marvellous record, unequalled in Europe, on public expenditure on health. It is right that that should be the case. However, other countries in Europe have a greater commitment to the concept of private health care. That is not an argument for or against private health care; it is a matter of fact. I am sorry that the hon. Gentleman did not acknowledge that.

I served on the Standing Committee that considered the National Health Service and Community Care Bill, which was a most enjoyable and interesting Committee. I was struck by the attitude of many Opposition Members towards the health service and its prospects. Almost to a man—or a woman—they never failed to cite cases of undoubted distress, which one readily accepts exist and which arouse sympathy in any human being. But they never mentioned the fact that the number of in-patients and out-patients treated has increased dramatically since the Government have been in power. There will always be individual cases which will give rise to concern and one regrets that. Indeed, the founding fathers of the NHS warned Parliament and the country that the health service would never meet demand, because demographic pressures would increase, and that we must never expect more of it than it can deliver. Those are precisely the problems that we face.

If Opposition Members accept such inherent problems and those created by technological advance, it is strange that they criticise the existing system yet resist reform. Surely reform is the only way to ensure that we have a health service in the year 2000.

The Opposition frequently do a great disservice to the NHS. They appear never to recognise, in public at least, the demographic pressures that it faces. They do not seem to appreciate or to accept publicly that our population is aging. We all hope that we will become part of that problem. The number of people as a percentage of the population who provide money for the health service through taxation is becoming smaller. That is a fact which no party of whatever political persuasion can run away from. Yet that point is never recognised by Opposition Members.

A party that simply stands back and objects to reforms that are designed to drag that service into the 1990s is the enemy of that service, not its friend. The enemies of the service say, "Stand still. Leave it as it is. Don't reform anything because it will destroy the service." The one way to destroy the service is not to reform it. How can a system that was designed to meet the needs of the 1950s meet the needs of the 1990s? We cannot run away from that reality, yet the Opposition constantly seek to do so.

I find it sickening to hear Opposition Members accuse Conservative Members of not caring about the NHS, as though they have a monopoly on caring. That is offensive. There may be differences between us about how the NHS should be run and operated, but our commitment to its existence and its future is equal to that of the Opposition. That commitment can be proved by the massive expenditure that the Government have put into the NHS —far more than any Labour Government have ever achieved and far more than any Labour Government would ever achieve.

As usual, Opposition Members say that the only way to solve the problems of the NHS is to throw more money at them. If the problems of the NHS could be solved by throwing more money at them, we would have solved them 10 times over. It is not as simple as that and the British people recognise that. They also recognise that the Opposition cannot claim, as the hon. Member for Livingston (Mr. Cook) did today, that the NHS is at the top of their list of priorities. If it is at the top of their list of priorities, it is alongside education, training and transport. The public perceive that their promises in that regard are shallow.

If the public want to protect the NHS and ensure that it is there for the future, the Government's reforms will gain their backing. During the time that I served on the Committee considering the National Health Service and Community Care Bill I, like many hon. Members, was inundated with letters from patients who were frightened by the British Medical Association's campaign, but I cannot remember the last time that I received a letter complaining about the reforms. Indeed, one practice in my constituency is complaining that it cannot introduce the changes fast enough. My hon. Friend the Minister for Health was kind enough to meet the doctor representing that practice and I am grateful for that.

The climate has changed. The Opposition may try to turn the Government's reforms into a demon, but they are the one way in which to save the NHS for the year 2000.

7.16 pm

Mr. Keith Bradley (Manchester, Withington)

I start by paying a tribute on behalf of the Labour party to my hon. Friend the Member for Neath (Mr. Hain). He delivered his maiden speech with eloquence and passion and it is clear that he will not remain anonymous on the Back Benches with some of us for much longer if that is the calibre of his contribution in the House. I congratulate him.

The Opposition motion today could have been written for the people of Manchester and in particular for my district health authority of south Manchester and my constituency. If we look at the chapter of disaster of health care there we see that Christie hospital has opted out and there is a proposal to close the maternity unit at Withington hospital and eventually to close the whole of that hospital, although the health authority has denied that, saying that it is merely relocating it. That is a novel way of allowing patients to continue to receive their health care at the same hospital. Also the plan for the Central Manchester health authority to opt out has gone through.

The Secretary of State alluded today to the wealth of GP practices in Manchester which have taken up the challenge of becoming fund-holders, but to my certain knowledge only one has gone down that road. The way Ministers have scuttled in and out of south Manchester in the past few weeks trying to boost the opt-out rate and the number of fund-holding practices shows their lack of confidence. The way in which the people of Manchester have responded to those reforms shows that they have no relevance to the future of health care in that part of Britain.

I do not want to spend the short time that I have discussing the sour taste left in the mouths of local people as a result of the opt-out of Christie hospital. My hon. Friend the Member for Livingston (Mr. Cook), in his devastating critique of Government policy earlier, referred to Christie hospital and the way in which Mrs. Kenrick did not receive treatment; the way in which, when the trust was launched, instead of looking at patient care senior management had a champagne and salmon party; and the queue-jumping proposals for people in urgent need of cancer care. Those decisions speak for themselves, and they are not lost on the people of Manchester.

As for the waiting list statistics, the Government continue to fiddle with them to make them look good. Manchester Members of Parliament recently received a letter from the chairman of the trust in central Manchester which stated that at the end of March 1991 the number of patients waiting for more than a year had reduced by 541, or 20 per cent., hailing that reduction and pointing to success in general surgery. At the same time as I received the letter, I received from a local GP on behalf of a patient a letter from the trust hospital in central Manchester stating: I do appreciate your concern for your patient and I am afraid that my good intentions to admit him in February this year for surgical correction … have been thwarted by our lack of beds. Approximately 25 per cent. of our surgical beds have been closed and this you will understand makes planned admissions extremely difficult in view of our continuing commitment to emergency services. I am afraid that until these beds are restored, treatment for patients like yours will continue to be much of a lottery. I will do my best to expedite his admission. At the same time as the trust hails the reduction in waiting lists it fiddles statistics because it is closing beds and denying referrals to the hospital.

The closure of the maternity unit and the single site hospital planned by South Manchester health authority is causing a massive public outcry. The closures have been caused by a continuing financial crisis in south Manchester which has arisen because the Government have continually underfunded pay awards and have not allowed for the true rate of inflation in the health service. They have forced the service to make efficiency savings of 1 per cent. each year, but we know that that is really a cut in service funding. They have not fully funded clinical regrading, and over the years managers have tried to manage their way out of the financial crisis by closing wards. They closed wards for the elderly on the back of the intention to introduce community care. They thought that they could get away with closing long-term beds for the elderly because people would be moved into the community. Community care has been abandoned for two years, but the beds have not been reopened because the money is not available due to the financial crisis. Many people are left in their homes without support services and without the proper supervision and health care that they need.

Recruitment has been frozen and there are longer waiting lists. That could not go on, so rationalising the service was considered. In particular, the closure of the accident and emergency department in Wythenshawe hospital and the maternity department in Withington hospital was considered. The public outcry about closing the accident and emergency department in Wythenshawe hospital, which is next to Manchester airport, was so great that the authority backed off. It has now said that there should be accident and emergency departments at both centres. That seems crazy because it now says that it will close Withington hospital.

The authority has not backed away from the proposal to close the maternity department. I am pleased to see that the Under-Secretary of State for Health is present for the debate. He has agreed to meet me before making the final decision. The community health council has objected to the plan and the Minister is aware of that. The CHC's 10-page document clearly set out counter-proposals. I hope that the Minister has that document. When the matter went to the regional health authority, the cogent and clear arguments contained in those 10 pages were reduced to four and a half lines. Members of the regional health authority did not have a full document and made their decision on that short summary.

I hope that when the Minister reviews the decision he will look at the full document and recognise the importance of maternity care in Withington. The matter is made even more important by a recent health care report by South Manchester health authority which points to the high level of infant mortality in the district. It is higher than in most parts of the country and higher than the national average. If we are to address the problem of infant mortality we need local maternity services and local ante-natal and post-natal care. That is what the people of south Manchester want.

The single site proposal was delayed until the implementation of the National Health Service and Community Care Act 1990. There were two reasons for that. The Government wanted stooges on the health authority in South Manchester to rubber stamp the authority's proposals to close the hospital. Not one of the new members of South Manchester health authority lives in that area or uses the hospital on which the authority is making a decision. The closure was the first item on the agenda of the new health authority. There was not a word of debate about the decision which went through on the nod and not one member of the new authority asked a question about the proposal. The matter was dealt with by people who have no interest in the area and who do not receive health care from the hospitals that they are closing.

One of the clear reasons for the health authority's proposal to close the hospital is the run-down in the fabric of the buildings in Withington hospital. In a financial crisis the easiest thing to go is the maintenance budget. In the 10 years from 1982–83 until now the amount spent in real terms on maintenance has been more than halved. No wonder the buildings are falling apart. That is bound to happen when the Government do not put in the resources to ensure that local hospital buildings are properly maintained.

The people of Manchester have clearly said that they want to keep their hospitals local and want access to decent health care in the communities in which they live. The "Save Withington Hospital" campaign has been magnificent and I pay tribute to those who have been involved in it, especially the campaign's chairman Tom Grimshaw and its secretary Brenda Stevenson. They have galvanised people into trying to save the local hospital. The campaign has all-party support and even local Tories are campaigning against their own Government because they recognise that the hospital must be saved.

A week last Saturday 3,000 people turned up to link hands around the hospital to say that the Government must not touch it. More than 70,000 people have signed a petition. The Government's national health changes do not address the issues of decent hospital care in Manchester. We urge the Government to intervene now and tell the regional health authority, which meets on Tuesday, that it must throw out the plan and look to decent health care in our communities. That would ensure that Manchester people received the hospital service of which they had previously been proud.

7.26 pm

Mr. Jerry Hayes (Harlow)

I congratulate the hon. Member for Livingston (Mr. Cook), who is not in his place, on his courageous speech. It was courageous because the hon. Gentleman made it absolutely clear that spending on the health service will be at the top of Labour's agenda at the next general election. I do not know whether he has spoken to his hon. Friend the shadow Chief Secretary, but I do not think that she will be pleased by his proposals.

The hon. Member for Oldham, West (Mr. Meacher), who is the shadow Social Security Minister, will not be pleased because we were told some weeks ago in a similar debate that pensions would be Labour's top priority. On 9 December 1990 the shadow Leader of the House told us that education would be Labour's top priority. The electorate and the House would like to know whether there will be so many priorities that they will be meaningless or whether the Opposition are making promises that they cannot possibly deliver.

On 20 April last year, which was my birthday, the hon. Member for Livingston pledged that a Labour Government would spend £3 billion on the national health service. What has changed, apart from the fact that in the past two years the Government have spent £6 billion on the NHS? It is therefore hardly surprising that socialist economists such as Professor Julian Le Grand, the founder of the Socialist Philosophy Group, said that the Conservative Government had promised an extra £3 billion for the next financial year. He says that it is difficult to imagine that Labour could do much better, given the other demands that Labour will undoubtedly face on taking office.

Yesterday Opposition Members heard me quoting from the Labour campaign document on health spending. They said that the problems would not be solved and that finance could not be provided overnight. I give the Opposition credit for the fact that they have made it perfectly clear in that document and in the debate today that they will spend far more than this Government on the health service. However, they will not be spending it on patient care, on the poor devils in hospital. They will be spending it on bureaucracy, because that is Labour policy.

The Labour party will give us an army of quangos, a technology inspectorate, a health quality Commissioner and a food standards agency. It is talking about regional councils to discuss the various quality controls within regional health authorities. Under the Labour party's proposals, quality will be built into contracts. I simply ask hon. Members to visit such places as Bromley, which is putting the contracts into place; they are very impressive.

The Labour party talks about value for money and quality—so why does it want to abolish the Audit Commissioner? What has that Commissioner done for health authorities during the past six months? It has given each health authority a financial profile, something almost unheard of in the history of the NHS. It has provided a number of discussion documents that show where savings can be made to improve patient care. Through the changes and procedures suggested by the Audit Commissioner, about 300,000 additional operations could be provided without any additional cost. There could be savings of £30 million just by sorting out the heating problems and another £30 million through running an efficient telephone service. There is plenty of scope for bodies such as the Audit Commissioner, which is interested in value for money and in money being spent on patient care.

I want to go into some depth on what the Labour party is promising. We have the document, which says: Labour will require health authorities and health boards to give new priority to disease prevention and health promotion. Hooray. It continues: This health strategy will set targets to be achieved over a five-year period"— hooray— such as a reduction in smoking, increased participation in exercise, and a narrowing of social inequalities of access to health care. I agree with every word, but I do so because it happens to be Conservative party policy.

What heading has the Labour party given to that policy? It is "Promoting better health". Does not that ring a bell? Was not there a White Paper called "Promoting better health", which said all those things years ago? What was my hon. Friend the Member for Derbyshire, South (Mrs. Currie) saying when she was a junior Minister at the Department of Health? It was all that the Labour party is now saying in presenting its brand-new health promotion policy.

The Labour document says that the Labour party will do even better than that. It states: The greater emphasis in our health strategy on health promotion will require new priority for primary care. That sounds new. It continues: Labour will therefore renegotiate the GPs' contract to reduce the pressure which it puts on them to seek larger patient lists. I may be wrong, but I thought that patient lists had been going down consistently over the past few years. That is certainly what general practitioners say. I am pleased to say that most of them are happy with the new contract. My right hon. Friend the Secretary of State has said that he will sit down and talk to them about any areas of difficulty. There is dialogue between the British Medical Association and the Department of Health, and the Opposition should pay attention to that. The real gripe of general practitioners during the first negotiations was the very matters that the Labour party wants to promote. General practitioners complained that they had to take on health promotion tasks, the screening of 75-year-olds, and the provision of inoculations. It is precisely the sort of contradiction that I would expect from the Opposition.

The document says: Labour will scrap the indicative drugs scheme which puts a cash budget on the drugs a GP can prescribe. Just a moment, did not the BMA and the Opposition shadow spokesman on health only late last year publicly admit that there was no cash constraint on the amount of prescribing? Have not the Audit Commissioner and a number of other independent bodies made it quite clear that we have saved more than £200 million in drug prescribing, which has gone directly to benefit patient care? Should not that be welcomed? It is certainly welcomed by general practitioners and by the BMA. However, the Labour party wants to scrap it. What will it put in its place? The document says: In its place we will encourage greater efficiency in prescribing by requiring"— that is the key word— greater use of generic prescription. If this Government introduced legislation requiring general practitioners to prescribe in a certain way, all hell would be let loose from the Opposition and the BMA.

The document also says that the Labour party will invest in the modernisation of our hospitals and tackle the backlog in maintenance and repairs—although we cannot expect to be able to put right overnight the neglect of years. That is another fudge on the finances.

We have been talking about the trade unions, and it was interesting that yesterday the Labour party said that one of its great policy planks was that there would be beer and sandwiches at No. 10. There is nothing wrong with discussion and negotiation, but there is a price for that, and that price would be a statutory minimum wage. How much would that cost the NHS? We all know—it is a matter of public record—that it will cost £500 million. Where will that money come from?

Mr. Eric Martlew (Carlisle)

Will the hon. Gentleman give way?

Mr. Hayes

I am sorry, but I have only a minute left. The document says that Labour recognises that the pay and conditions of certain health staff have worsened markedly under the Conservatives. My hon. Friends have refuted that claim. The document continues: We will halt this deterioration—and develop fairer and more rational ways of settling pay and conditions for those health service employees. It will be done in smoke-filled rooms by the paymasters of the Labour party.

It is interesting to note that the document states: In order to end the efficiency trap, budget allocations to hospitals will be flexible. Total spending must remain within cash limits but the increased funding to which we are committed will be used to create a reserve at Regional or District level which can be released in the course of the financial year to those hospitals who have outperformed their agreed targets. What financial control will be there? What financial management will be there? There will be absolutely none. That is why I say to the House that the Government have nothing to be ashamed of in their health policy, and that is why I support the Government amendment.

7.37 pm

Mr. Tom Clarke (Monklands, West)

I am delighted to join in the congratulations to my hon. Friend the Member for Neath (Mr. Hain), who made an excellent maiden speech. His constituents have every reason to be proud of him, as are we all in the Labour party. We look forward to many further speeches from him over the years.

In a remarkable response to an intervention of mine, the Secretary of State asked where I was yesterday during health questions. I was at a meeting with one of his colleagues at the Ministry of Defence—a meeting that I had been trying to obtain since the beginning of winter —about an important matter in Twechar in my constituency. I should not have thought that the few brief moments that were given to community care as a result of the accident of one question being at the top of the list represented a considered debate on the Government's remarkable decision to ditch without ceremony sections 1, 2, 3 and 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986.

The importance of community care and of that Act is all the more necessary because of what has been happening to the health service. Listening to the exchanges during this debate, one would think that it is not just a question of having a two-tier health service, although it certainly is. There are actually two health services—one is in the imaginations of Conservative Members and the other is the reality with which hon. Members deal day after day.

We know the problems. We know that my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) presented a petition organised by Health Alert to save the West Middlesex hospital. Lest it be thought that I am concentrating on important English matters, I should add that people in my constituency would not recognise the health service that the Secretary of State described this afternoon.

Mr. John Marshall

Will the hon. Gentleman give way?

Mr. Clarke

I will not give way as time is short.

My constituents are fully aware of the case of the 71-year-old woman who was refused admission to two hospitals and subsequently died. They are aware of possible closures not just of wards but of hospitals in and serving my constituency—for instance, Stobhill, where ear, nose and throat, neurology and maternity units may be closed. Patients in my constituency—and those who visit them—will then face much longer journeys to hospitals further away than necessary to find proper health provision.

My constituents are worried about debate over the future of Gartloch hospital. The Greater Glasgow health board appears to be taking decisions about psychiatric hospitals and psychiatric provision without bearing in mind the importance of community care. My constituents are also worried about the future of Stonyetts and Birdston, and they are not alone in their concern. They know that it is not enough for society to concentrate on the demands of the health service, important though they are, at the expense of the 90 per cent. of our people in the community whose rights and needs must also be respected.

This is why I am appalled—I cannot disguise my anger —at the way in which the Government have responded to the Disabled Persons (Services, Consultation and Representation) Act 1986. We were told by one Minister after another—including the former Prime Minister, the right hon. Member for Finchley (Mrs. Thatcher), and the present Prime Minister—that the Government's aim was to accept the will of both Houses and to implement that Act when resources became available. As a Minister with responsibility for the disabled, the present Prime Minister, speaking of the implementation of the Act in stages, said: This should help to make progress towards establishing such a timetable."—[Official Report, March 1987; Vol. 112, c. 157.] Until the announcement was sneaked in on the Friday before the Easter recess by a junior Minister in another place, we all accepted that that was the Government's intention. As Chief Secretary to the Treasury, the Prime Minister also said: The Act of 1986 was originally passed upon the premise that it would be brought into action over a period."—[Official Report, 29 October 1987; Vol. 121, c. 441.] This spectacular U-turn has yet to be explained by any Minister. The Minister for Health seeks to argue, and has argued elsewhere, that after the enormous amount of consultation which took place before the 1986 Act was introduced—far more consultation than the one week between the Government's White Paper on community care and the Bill that followed it—it is not necessary to implement all its sections. The consultation preceding the 1986 Act meant that sections 1, 2 and 3 provided the right of advocacy and assessment; and section 7 meant that people leaving long-stay psychiatric hospitals would be entitled to assessment and were assured that the House would attempt to reduce the number of people released from such hospitals into non-existent community care—often into cardboard cities. The approach to community care embodied in the 1986 Act, to which the House gave a great deal of credence, has been abandoned, and we cannot and will not be convinced that the community care sections of the Government's National Health Service and Community Care Act transcend what we tried to achieve in 1986—they do not and they cannot.

During the passage of the National Health Service and Community Care Act and the Children Act 1989—the latter also featured in the junior Minister's reply in another place—it was never said that the Government were planning to drop these vital sections because they were covered by those two subsequent Acts. The Government intend not just to postpone but to abandon community care until 1993. We cannot pretend that the 1986 Act was never passed.

We are told that the Government believe in citizens' rights and voluntarism and that they are prepared to listen to the views of others. Is it any surprise that the Spastics Society, Age Concern, the Royal Association for Disability and Rehabilitation, the Scottish Society for the Mentally Handicapped and many other organisations are shocked by the Government's decision and the manner in which it was announced? Is it any surprise that Sir Brian Rix of MENCAP has said that it was a disastrous decision? Grass roots members and supporters of these organisations, and the 6.5 million people with disabilities and their carers—the blind, deaf and elderly people with disabilities who cannot express their views and who believe the Government's promises of choice and independence in which advocacy plays a vital part—are equally appalled. Mary and Albert Coyle, constituents of mine, know that their son Gerard, who is 36 years old and mentally handicapped, will not now have the advocacy, representation and assessment which they thought he had been promised by the House and which they saw as crucial to the future of their child and to that of many others suffering from mental handicaps.

The House will return to these issues, but before those major debates take place—the issue will not go away—it is only right that the anger of such people should be expressed today. Millions of disabled people and their carers want the House to express its repugnance at an exercise in intellectual arrogance and abuse of temporary power by the Government which must be rejected.

7.47 pm

Mr. Alistair Burt (Bury, North)

No matter how often we debate the national health service and whatever our debates are ostensibly about—whatever reforms and new ideas may be under consideration in the motion—they always seem to resolve themselves around two arguments advanced by the Opposition. First, they say that they should be trusted with the health service because they always spend more than the Tories ever could or would want to. Secondly, they draw attention to the way in which, as they see it, the Tories have looked after the health service, claiming that that is evidence of that fact that the Tories reform plans will fail and that the Opposition would do everything better.

We can bandy statistics across the Chamber until the cows come home; we can use global statistics which people may or may not choose to believe. But by examining what happens in a local district health authority we can start to peel away some of the falsehoods and see what has actually happened. In doing so, we can see that the two arguments on which the Labour party relies are false and useless.

Let us relate the first argument, to do with Labour's expenditure, to my constituency of Bury. The only time when expenditure on the NHS in Bury has fallen was under a Labour Government. Between 1974 and 1979, it fell by 2 per cent. Bury had needed a new hospital for about 100 years. It was the only part of the north-west district that had not had a new general hospital in 100 years, but one could not be built under Labour because of reductions in capital expenditure.

Those cuts in expenditure and that way of looking after the finance of the health service was mirrored elsewhere in the country. Under the Conservative Government NHS funding as a proportion of GDP has grown twice as fast as it did under Labour. So there is no argument about finance. There has been no greater or longer lasting deceit practised on the British people than the Labour party's claim that funding is better under a Labour Government.

Labour's second argument is that the way in which the Tories look after the NHS shows just how much we care. In answer to the hon. Member for Monklands, West (Mr. Clarke), who believes that we live in a world of our imagination, I shall read out some facts about the Bury district health authority. If the hon. Gentleman thinks that they are in my imagination he can come to my constituency, talk to the consultants, ring up the district general manager and query any one of the facts that I shall spend about four minutes reading out.

The past 10 years or so have seen substantial developments in the services provided by Bury health authority. Those developments have affected almost every sphere of activity and that momentum is set to continue in the foreseeable future. There has been a massive increase in the funds made available, and at the same time the authority has been praised for the high quality of service provided.

The improvements include extra doctors in hospitals. There has been an increase of 43 per cent. in the number of doctors employed, and the additional consultant specialists appointed include those in accident and emergency, anaesthetics, paediactrics, obstetrics and gynaecology, radiology, geriatrics, psychiatry, pathology, ear, nose and throat, adult health and orthopaedics. Those people exist. They are flesh and blood. They can be met, touched and spoken to. They are not figments of my imagination.

In the past decade the number of nurses in Bury has increased from 875 to 1,181. There has been an increase of 45 per cent. in professional and technical staff such as physiotherapists and occupational therapists, from 145 to 214.

As for capital expenditure on buildings and the like, during the past 10 years or so more than £25 million has been spent on new and improved buildings. They range from new theatres, new wards and out-patient departments to all the necessary support facilities required, such as kitchens and theatre supply units. The new phase 1 development of Fairfield general hospital cost £10 million and provided new wards for the elderly, children and ear nose and throat patients. A new ante-natal clinic was provided together with a new theatre. The developments continue with a current building programme of £2.5 million which was celebrated in the local newspaper under the headline, "Health Service Cash Bonanza". That programme includes a new purpose-designed obstetric theatre which was recently opened by the Under-Secretary of State for Health, my hon. Friend the Member for Loughborough (Mr. Dorrell), upgraded maternity and gynaecology wards costing £1.1 million, upgraded wards for the mentally ill and extensions and improvements to health centres.

In the Bury health authority no beds have been lost for financial reasons. There has been an increase in the number of beds which has led to an increase in the number of people being treated. There has been an increase of 55 per cent. in the number of patients admitted to hospital and a massive increase of 160 per cent. in the number of day patients.

In 1979, the health authority's budget was £12 million, and in 1990 it had risen to £34 million which represents 19 per cent. real growth in contrast with the 2 per cent. loss in real terms which occurred under the last Labour Administration.

I shall read out some figures relating to the number of patients treated. They are all real people. In 1978–79, a total of 17,780 in-patients were treated and there were 1,575 day cases. In 1985 the number of in-patients had risen to 20,778 and day cases to 2,731. This year it is estimated that there will be 27,600 in-patients treated and 4,100 day cases. That represents a total increase in 10 years of 55 per cent. in the number of in-patients treated and 160 per cent. in the number of day cases treated.

In February 1990 there were 1,303 people on waiting lists in Bury. By February 1991 that figure had reduced by 300. The numbers waiting between one and two years in February 1990 was 104. In February 1991 that figure had decreased to seven. In 1990 the number of people waiting more than two years for treatment was 36. In 1991 that number had been reduced to zero.

I am sorry to have taken five minutes to quote all those figures to stress that no party or Government intent on destroying the health service would provide a district health authority with a record such as that. There is no evidence in my health authority to suggest the lack of care on which the Labour party based its argument. All the efforts that have produced improvements in my constituency, the ethos behind them and the competitive tendering which has produced money that has gone into patient care have been fought every step of the way by the Opposition. That is how much they care about the health service. Their attitude is to say, "Leave it as it is. It is all right. It does not matter. Trust us."

It is sad that we spend our time tossing jibes to and fro to deal with the falsities put about by Opposition Members when we know the truth. There is only one health service; it has its good parts and its bad parts. It has its problems, and it has people who wait too long for treatment. It has bad hospitals that need tidying up and people who travel too far, but, above all, it has a dedicated staff who want to improve it. There is no mileage for anybody, whether they are doctors, administrators or politicians, in making things worse. Many people put in a lot of time and effort. Those who work in the health service, whether they are GPs like my father or hospital doctors like my brother, resent the continual efforts that are made to denigrate and run down the health service. The Opposition do not appreciate that that goes home to people who are working in the health service and trying to improve it.

We should spend more time talking about matters that the community health director in Bury dealt with in his excellent annual survey. He wrote: lung cancer and coronary heart disease…are the consequence of an unhealthy lifestyle and many potential years of life are lost because of socially acceptable lifestyles committed to cigarette smoking, an over-indulgence of alcohol, promiscuity, etc. The effects of such lifestyles even threaten and prejudice during pregnancy the chances of a healthy fit baby. Whilst on the one hand we spend vast sums of money as a nation treating or subsidising the effect of these diseases we also, as consumers, spend equally vast sums of money encouraging the habits—albeit with health warnings". We should be talking more about preventive medicine and the things that really matter.

In conclusion, it is rather sad that when we have a Government with a national and local record in the health service such as I have described, and when we have the efforts that the Government have put in, we have at the same time a cynical Opposition who cannot even bring themselves to spit out through clenched teeth any acknowledgment of success and instead commit themselves to twisting the facts and pretending falsely and pathetically that under some new red dawn everything will be put right.

7.58 pm

Mr. David Hinchliffe (Wakefield)

I made the mistake of blinking during the Secretary of State's half-hour speech, and Missed his reference—which cannot have been more than one sentence—to community care. I thought that the debate was concerned with the health service and community care, and I am sorry that the Secretary of State has such contempt for the important issue of community care that he could not be bothered to refer to it in some detail.

An answer that I received from the Under-Secretary of State for Health on 24 January said: We are firmly committed to a policy of community care which enables elderly and disabled people, with appropriate support, to live in their own homes or in small homely settings in the community for as long as this is feasible and sensible." —[Official Report, 24 January 1991; Vol. 184, c. 295.] Frankly, the Government have an excellent record on words about community care, but their deeds are different. Their record on community care is shameful.

I wish to stick to the question of community care because, with the honourable exception of my hon. Friend the Member for Monklands, West (Mr. Clarke) and the Labour Front Bench, it has not so far tonight received the attention that it deserves.

During the 12 years that the Government have been in power, they have operated a programme of emptying the large psychiatric hospitals. There has been a reduction in the number of homes for children and for mentally handicapped people and in the number of geriatric wards. The Government were committed to reducing institutional care but, at the same time, there has been a distinct revival of the institutional model of care in the private sector.

During the last 10 years, there has been a 4 per cent. reduction in the number of places in local authority homes for elderly people. There has been a 316 per cent. increase in the number of places in private residential care homes. In my area of Yorkshire, there has been an increase of almost 1,000 per cent. in the number of private nursing beds. The argument is that the number of elderly people has increased but, according to the Library, the number has increased in the same period by only 9.5 per cent.

The Audit Commissioner told the Griffiths committee that a quarter of the people living in private care homes could have been accommodated in the community with the appropriate support. Only a few weeks ago, evidence was given to the Select Committee on Health by a series of directors of social services who said that, in their areas, about 50 per cent. of the people living in private care homes could and should have been accommodated in the community with the appropriate support.

The Government's record is one of placing in institutional care people who do not need and do not want to be there. They are the Government of institutions, who are in no way committed to genuine community care which involves caring for people in their own homes and neighbourhoods.

It is interesting that the Government have pursued policies geared to reducing the support available to people who wanted to live independently in the community. My hon. Friend the Member for Monklands, West referred to the appalling treatment of his much valued Disabled Persons (Services, Consultation and Representation) Act 1986. If we consider the Government's record on local authority personal and social services, it is clear that they have pulled the rug from under the feet of people who wanted to remain at home and be independent. Underfunding of the national health service means that supportive health services such as district nurses and bath attendants have been withdrawn from people who wanted to remain at home but were forced to enter into care.

There have been huge reductions in the rate support grant. I asked the Library for an estimate of the reductions in that grant during the administration of the present Government as far as they affected the personal social services. I was staggered to learn that the reductions in the budget from the 1979 level of local authority expenditure on personal social services total about £6 billion. The Government say that they are committed to community care, but they have taken from local authorities that £6 billion, which should have been spent on home help services, day care services, meals on wheels and a range of supportive services which should be available to enable people to live independently in their own homes. My area has suffered as much as any other.

There is a problem with the nonsense of the standard spending assessment. I have spoken to Conservative Members who do not understand how the SSAs are worked out. Last year, Wakefield social services spent £4.5 million above its spending assessment. If it had had to abide by it, it would have had to reduce services drastically, scrapping provision for child protection in some instances. This year, it is £3 million above its SSA. Yesterday, I asked the deputy director of social services to tell me what it would mean if the authority had to cut that £3 million. It could mean closing four homes for aged persons and two children's homes, and reducing by 10 per cent. a fundamental part of community care—the home help service.

Alongside such cuts at local authority level in community support for elderly and disabled people, the Government have pressed money hand over fist into private institutional provision, in a huge explosion following the extension of supplementary benefit payments in 1981. When I see broadcasts by the Conservative party like that last week saying, "How much does a Labour councillor cost you'?", it makes me think, "How much does a Conservative councillor cost you?" He cuts the home help service, day care centres and meals on wheels and ends up driving elderly or disabled people into private institutional day care, at a huge cost to the taxpayer. That is what a Conservative councillor costs us.

There should be a huge redirection of resources away from institutional care into independent living in the community. We must ensure that, when the new Labour Government come to power shortly, we turn on its head the central thrust of this Government's community care policy, which has been to push people into institutional private sector care.

We must transform residential care from the present warehousing provision that exists in so many private care homes. There must be more sheltered housing to give people semi-independence facilities if they need some care provision. Crucially, there must be a substantial redirection of public resources away from residential care into preventative provision within the community.

There is a need for a progressive reduction in the income support budget and the redirection of that budget to local authority community services, to voluntary organisations and to health authorities to fund a massive expansion in support and assistance within the local community.

Only today I obtained some interesting figures from the Library. I asked specifically how much money had been spent on income support to individuals going into private care homes during the past 10 years. I mentioned that the Government had removed £6 billion in personal social services funding from local authorities, thereby reducing the services available to people in their own homes and forcing them in many instances into care. The figures provided by the Library show that the amount spent on income support for people in private care homes during that period is roughly equivalent to the £6 billion spent in putting people—many of whom do not need or want to be there—into private institutional care.

Unlike the Conservative Member who accused the Labour authorities of throwing money at a solution, I believe that public resources are going in the wrong direction. The Government are spending money on the wrong things, and it should be completely redirected. I am talking not about huge additional costs, but about the appropriate use of existing resources. When talking about health or community care, we must deal above all with the human cost of the failure to enable individuals to retain self-determination, their independence and their pride.

8.8 pm

Mr. John Butterfill (Bournemouth, West)

The hon. Member for Wakefield (Mr. Hinchliffe) knows that I share his concern for community care and the provision of social services. He has perhaps done the House a disservice by suggesting that spending on social services has decreased under this Government. During the past 12 years, spending has increased by 52 per cent. and, at the same time, there has been a massive increase in expenditure through income support for those who are, sadly, resident in old people's homes. During the lifetime of the Conservative Government, that expenditure has increased from £10 million to £1 billion. There is no question but that resources are provided. It is sad that the Labour party constantly suggests that the Government do not care and do not provide money. The reality is different.

The Labour party's latest policy document suggests that a Labour Government would massively increase the resources available to the national health service. Clearly the hon. Member for Derby, South (Mrs. Beckett) does not believe that the health service is a spending priority and she is unlikely to provide the necessary money, even if Labour can find it.

No one believes that the Labour party is not sincere in wanting to improve the health service, but its record must speak for itself. When Labour was last in power, waiting lists increased by 48 per cent., the hospital building programme was suspended and in real terms doctors' pay decreased by 14 per cent. and nurses' pay by 21 per cent. The Labour party's ethos is that it cannot manage the health service efficiently; it concentrates its well-meaning efforts on the wrong items and it does not deliver the goods to the public.

The few reforms the Labour party has come up with recently—such as getting rid of competitive tendering, which will cost £135 million, and bringing in a statutory minimum wage, which will cost £500 million—will do nothing for the health service except increase costs. The money that the Labour party proposes to spend on statutory minimum wages alone would be the price of 20 district general hospitals.

I should willingly give way to the hon. Member for Birmingham, Perry Barr (Mr. Rooker) if he will say which 20 hospitals he will close to pay for his daft minimum wage proposals. Or will he create the money out of thin air? He could not create it before. The hon. Gentleman will not rise from his seat.

Mr. Hinchliffe

rose—

Mr. Butterfill

If the hon. Gentleman will excuse me, I shall not give way generally, because of the tight time limits. I should willingly give way to the hon. Member for Perry Barr, but he does not seem anxious to take up my offer.

Mr. Jeff Rooker (Birmingham, Perry Barr)

There would be one fewer speaker on the Conservative Benches.

Mr. Butterfill

Does the hon. Gentleman wish to intervene? It seems that he does not.

Expenditure increased from £8 billion under the Labour Government to £32 billion under the Conservative Government. Nowhere is that more apparent than in my constituency of Bournemouth, West. Under the last Labour Government, East Dorset health authority was starved of resources. It did not get new hospitals. A socialist chairman of Wessex health authority decided that all new hospitals would go to socialist-controlled areas —Basingstoke and Southampton, which fortunately are no longer socialist-controlled—and we got nothing. East Dorset had virtually the lowest per capita expenditure in the country.

Since then, my constituents have seen the benefits of what has happened under the Conservative Government. There is a brand new general hospital, the first phase having been completed and the second being under construction. There is a massive new extension to St. Ann's, our hospital for the mentally ill. New operating theatres have been provided for the marvellous Westbourne eye hospital in my constituency. Perhaps most important, many new facilities and new wards have been built at the psycho-geriatric hospital at Alderney. All those developments are tangible. My constituents can see them and they demonstrate more clearly than anything else could the Government's commitment to the national health service. My constituents did not see those developments under a Labour Government.

My constituency has double the average number of elderly people, creating enormous difficulties for my health authority in particular. The elderly sector is the most expensive sector to maintain in the health service. Under the last Labour Government no special consideration was given to the funding needed, but under the Conservative Government a special factor was introduced in calculating funding for areas such as mine. Because there are more over-85-year-olds in my constituency than almost anywhere else, we get far more money than we used to get for them.

The evidence can be seen in the psycho-geriatric hospital. New wards were built to bring into the hospital people who cannot cope in their homes but would like to do so. There they can be re-trained, taught to be independent and shown how they can manage for themselves. With the help of social services, which have an enormously increased budget, those people have been able to live useful lives in their homes after a limted stay at hospital. New respite care facilities have been provided in hospitals so that carers—to whom I pay tribute—can have a break from looking after their elderly dependent relatives and elderly people can be cared for better and taught how to be more independent in their homes. All that is happening in my constituency under a Conservative Government. We have nothing to be ashamed of.

One of the problems of the success that we have had with the NHS is that people are living much longer, with a corresponding increase in Alzheimer's disease. That appalling disease creates misery for the sufferers and, more particularly, their families. I believe that there has been a breakthrough. Encouraging trials are under way into a new drug to treat that awful disease. The trials seem to show that the drug will arrest the disease and improve the condition of existing sufferers. I should be grateful if my hon. Friend the Minister for Health would say something about that drug and how soon it may be generally available on the market.

8.17 pm

Mr. Geoffrey Lofthouse (Pontefract and Castleford)

I wish to raise a problem in Yorkshire which is nothing short of a scandal. Although I do not expect the Minister for Health to answer me in detail, I hope that she will assure me that she will investigate the scandal and reply later.

Earlier in the debate, I drew the attention of the Secretary of State to what happened in Yorkshire this week. Like many others, we who live in the Pontefract health authority area have problems with waiting lists, and there are many tragic cases. In 1986–87, Pontefract health authority used some of the waiting list money that it received from central Government. After the authority had decided on a scheme to take 500 patients off waiting lists, consultants at a hospital refused to operate the scheme. The authority had to transfer the money to a private hospital. Slightly over 200 operations were done, whereas 500 could have been done at the NHS hospital in Pontefract.

It came to my notice last Monday that a team of five consultants and four senior managers from the Pontefract area health authority—that means from Pontefract general infirmary—were to visit three hospitals in the United States. The health authority says that the visit is in order to gain experience in issues such as quality of health care, organisational structures, American experiences in contracting and diagnostic grouping for the costing of services—I do not know what that means. The trip is to last eight days and is funded by a separate allocation from the regional health authority. I do not know what that fund is. Perhaps it is set aside to send top health officials and surgeons to America to study medical practice.

What use can be served by consultants studying American management practice? The House will recall that, in response to my intervention, the Secretary of State for Health said that he could not see any useful clinical purpose in surgeons going to America. But they have gone.

To date, we have been unable to find out the cost of that trip or whether other health authorities in Yorkshire have also sent people on it. However much such trips cost, surely the money could be better used. I do not believe that any hon. Member would support spending money to send health service staff to America to study private medicine. We are led to believe that, because the Pontefract health authority, from senior medical staff down, has never been enthusiastic about opting out into trusts, it is now being encouraged to participate in a junketing trip so that it will change its mind and show interest in opting out. If that happens in Pontefract, it will be fought all the way.

We must consider the fact that there are still great problems with staff grading. Many nursing staff feel that they have not been graded to the extent to which they are entitled. Many workers in the health service in Pontefract are not being paid in accordance with the work they do. The money that is being spent on such trips could be spent in many other areas. The security aspect is a problem in health authorities throughout the country. Something must be done about paying more attention to security. We must not forget the tragic case in Wakefield involving two consultants.

I have visited the Pontefract general infirmary several times to visit a couple of friends there, so the information that I give the House is not a trumped-up journalist's story. I give the facts. I visited a surgical ward as recently as last Sunday. In the day room, where many elderly and middle-aged patients who had undergone surgery were hoping to watch one of the semi-finals of the Challenge Cup, the patients told me that the television had been out of order for six weeks and that they had been issued with a small one that did not work very well.

Broken chairs were piled up in the corner of that small room and I was told that they had been there for six weeks. Some of those men, who were still carrying catheters around and suffering discomfort, could not find enough chairs to sit down. In another ward I was told by patients, supported by staff, that in the evening they were unable to have a drink of tea, coffee or Horlicks because their budget did not allow them to buy enough milk. I am not making a political point but stating facts. That is happening in an authority that can send nine people off junketing to America.

I do not expect the Minister of State to answer in detail but she should investigate what is happening and say where the money has come from and why people have been sent to America. What damage will be done to the people in my area who are on waiting lists—the most recent figure that I have seen is some 2,000 people waiting for general and major surgery—when five surgeons have gone away for eight days?

Like many other hon. Members, I could relate many cases that have been put to me by constituents. I am sure that Conservative Members must receive complaints from their constituents. The other day, a constituent who came to see me was worried that his wife had been waiting for a hip operation for 14 years. She had been transferred from Pontefract to St. James's hospital—that marvellous hospital in Leeds—two years ago. [Interruption.] It is no laughing matter. That is the information that I have been given. She was then told that she must wait two years and that she would be operated on in 1991. However, she has now been told that, because of the Gulf war, she will have to wait for another 12 months.

I sincerely hope that the Minister will investigate what I believe is nothing short of a scandal if the health authority is sending people to America when money could be put to much better use.

8.28 pm

Mr. Anthony Coombs (Wyre Forest)

It is a sad reflection on the almost total bankruptcy of constructive thinking among the Opposition that we have had not only a speech by the hon. Member for Livingston (Mr. Cook) that contained not a single constructive or positive idea on the Labour party's plans for the health service, but also an unimaginative, centralist and possibly even mendacious motion put forward by the Labour party today. I agree with my hon. Friend the Member for Bury, North (Mr. Burt) that many people who work in the health service resent the talking down which their service and the high standards that they so often produce always seems to receive from the Opposition.

I believe that the public have rumbled the Labour party's old argument that it would be the one to pump more resources into the national health service, and the Conservative party has not. That is nonsense. Now the average family in Great Britain spends about £44 per week on the national health service; under the Labour Government it spent £11 per week. In real terms, the amount of resources going into the health service has risen by about 52 per cent. in the past 10 years. Under the last Labour Government it went up by 6 per cent. in four years —about one third as fast. As we have heard, one —year1977–78—saw the only cut in real resources to the health service in the past 10 years, and it was made by a Labour Government.

When I ask most consultants, they say that the facilities, such as instruments and operating theatres, with which they have to work have improved. They should have done so during the past 10 years when there has been an increase in capital expenditure of 62 per cent. in real terms under the Conservative Government. Under Labour, expenditure fell by a third in just four years.

I will translate what that increase means to my constituents. They have not only acquired a new hospital at Bewdley road in Kidderminster but, starting this autumn, there is to be a £6 million extension to our hospital, which will provide improved geriatric, obstetric and pathology facilities. I do not call such measures cuts —they represent significant investment by the Government.

The Labour party talks about beds as though the national health service were a furniture business. Beds are provided to treat patients. Under the Government 1.2 million more patients per year have been treated in hospitals than under the Labour party as well as double the number of day cases. People talk about closing beds, but last week district health authority consultants told me that the new capital investment for geriatric facilities had enabled us to close an antiquated, old fashioned Victorian building in Mill street which presently provides geriatric facilities for patients. I cannot wait for that facility to be closed. I make no pretence about it—the investment will provide a better deal for my geriatric constituents.

Nurses often have to hear their service being talked down, but there are 60,000 more of them than there were in 1979. Their average hours have dropped from 40 to 37.5 per week. They receive better training through Project 2000 and their pay has risen by 41 per cent. in real terms after taking into account price increases. Under Labour, the nurses received worse training, worked more hours and their pay dropped 25 per cent.—it bought 25 per cent. less during the last four years of the Labour Government. I do not think that Opposition Members have any lessons to teach us about managing the health service.

The hon. Member for Livingston has consistently been trumped by the Government, even when he merely asked for extra resources. I understand that last year he called for an injection of £3 billion into the national health service to make up what he regarded as lost resources. We have put in £6 billion over two years, and that investment will continue. Professor Le Grand, who has already been mentioned, is a socialist adviser to the Labour party. He said that it would be difficult to imagine that Labour could have done much better in terms of resources. If he says that, with his ideological commitment, it shows that the Labour party could not have done any better.

The most depressing factor is that the Labour party do not even seem to understand that if one tries to organise a service as big as the national health service from the top down, one is likely to make the decisions and efficiency of that service worse. That has been the case in eastern Europe. That policy makes it impossible to allocate costs properly and is likely to create greater waste and significant differences in efficiency—that has occurred between district health authorities in terms of ancilliary and administration staff.

I welcome the internal market because it will give more flexibility to local hospital managers to be able to manage properly according to local needs. It will give GPs more leverage to demand higher standards on behalf of their patients. It will identify the costs of providing treatment so that there will be a better resource allocation system than merely deciding what was spent the previous year plus a percentage. It will allow us to plan for patient needs. Therefore, it will give better patient care at any level of funding. That will be the result of the internal market and the Government's policies.

It is early days, but I shall spend a few minutes talking about GP fund-holders in my constituency. I anticipate that by the end of the year no less that 65 per cent. of my constituents will be treated by GPs operating a GP fund-holding practice. That shows the extent of the enthusiasm with which GPs have taken up the idea in my constituency. It is ironic that the three largest practices to have taken it up included the most vociferous critics of the idea when the Government mooted it last year. It has enabled them to give and demand higher standards in hospitals to and for their patients. I know that one of the GP practices already provides weight clinics, well person clinics, diabetes clinics and glaucoma clinics. As a result of being a GP fund-holder, the practices are also likely to provide further facilities for osteopathy, parentcraft and even alternative medicine.

It is not surprising that Doctor magazine states: Although it is easy to be cynical about health matters, there is no doubt that much of the health promotion now proliferating within general practice is doing a power of good. It is doing a power of good because it gives GP fund-holders and other GPs more control over their budgets and the way they do things. That is not to say that matters could not be further improved.

I should like to see the smaller GP practices with fewer than 9,000 patients given the opportunity to be fund-holders and the ability to charge hospitals for minor operations, which would take the weight off hospital casualty departments. Eventually, I should like GP practices to be given a greater control over their budgets than the 3 per cent. they currently have. But we have taken a step in the right direction because the GPs are a dynamic part of the system. They are the patients' advocates and are nearest to patient demand. That is why they will not just demand better services or just be a spur to efficiency in NHS hospitals but, most of all, they will provide a rational data base so that planning in the health service can be done on the basis of actual demand and costs of a district rather than supposed costs worked out by a bureaucrat in a regional health authority or in Whitehall.

According to the British Medical Journal and the King's Fund, as a result of the national health service reforms decisions on resources will go away from the private domain of doctors and into a more public arena. That can only be good for efficiency and the national health service. Sadly, the Labour party is too purblind to understand that the flexibility and better costing which are integral to the internal market are not a substitute for a good national health service but crucial to it. I support the Government's amendment.

8.38 pm

Mr. Jim Cousins (Newcastle upon Tyne, Central)

I add my tribute to those paid to my hon. Friend the new hon. Member for Neath (Mr. Hain) on his compelling speech. He is at that blissful stage in his parliamentary career when we all tell him that we shall hear a lot more from him. He may not realise that he will have to hear a lot more, from all of us.

One point that has been made by Conservative Members is that the Labour party does not understand management and efficiency. I have available to me the purchasing contract system of the Newcastle district health authority. I discovered that the new, more efficient, better managed system will include an unspecified number of purchasing review teaMs, at least five new professional forums—whatever they may be—five quality assurance committees and at least six different audit systems—all within the one purchasing authority of one district health authority. One of the greatest weaknesses of the new system is that, because it has not been tested, the purchasing side is far too weak. Even with all the gimcrack bureaucracy that I have just described, it will stay. People who are already in the system confess that it is weak.

I have in my hands the business plan of the North Tyneside family health services authority. It tells us that, as a contractor, it feels its position to be weak because it cannot define standards. It cannot generate competition between contractors, because it does not have sufficient authority to locate contractors. It also tells us that it has no managerial or contractual relationship with practice-based staff.

The Secretary of State has already admitted that the new system he has created will be not a true market but a managed market. I do not know whether that means that the Secretary of State is one of those people whom the right hon. Member for Chingford (Mr. Tebbit) referred to as saboteurs. If it is to be a managed market, considerable deficiencies can already be seen within my own health authority. We have discovered that the managers of self-governing trusts have already awarded themselves pay rises of between 30 and 80 per cent. and that they have announced that the true extent of that pay rise is secret and commercially confidential.

We have already discovered that a 75-year-old woman has been told that because the waiting list for cataracts is so long she cannot be added to it. She cannot even go on the list as a statistic. We have already discovered that the radiotherapy and chemotherapy departments of one general hospital have not been provided with funds for new cancer drugs and the means to deliver them, and that special arrangements have had to be made to underpin that service. We have already discovered that a dermatology service will be so reduced, under the new system, that the consultants in charge of it have been told that they can have just one office in which they may choose from time to time to put four beds. We have just discovered that no provision has been made in the dental hospital for purchasing the contracts for patient services. That is the reality of the new, so-called "managed", market.

The real damage that the Government will do to themselves under the new system was referred to by the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy). He mentioned the public health needs planning system. Not a single Opposition Member of Parliament disputes the need for a public health needs planning system, but I wonder whether Conservative Members have a clue about the information that that will produce, or of how devastating it will be.

The northern region has hardly started its public health needs planning system, but it has already discovered that 330 of the babies born in November 1989 died unnecessarily before reaching the age of one because our health performance standards are worse than the national average. It has already produced information that 40 per cent. more women die of cervical cancer in the northern region than in the nation as a whole. It has already told us that, of those women who will die unnecessarily, 10 times more come from the families of unskilled manual workers than from the families of the professional and managerial classes. The Government will have to address those devastating new needs. I doubt whether they are prepared to take on board the means that will be needed to deal with those problems.

As for the new annual report, we called years ago for such a report, but nothing was done about implementing the recommendations of the Acheson report. We are told that many more people die prematurely in the northern region, week by week, month by month, year by year, than almost anywhere else in the country, and that the best years of the lives of far more people in the northern region than anywhere else in the country are ruined by disease and disability. Neither the Secretary of State nor those Conservative Members who have spoken in the debate even hinted that they are willing to take that information on board and do something about it. I see no sign that their complacency about the new system that they have just devised has been punctured.

8.45 pm

Mr. Peter Thurnham (Bolton, North-East)

The hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) referred to a lady who had been kept waiting for a cataract operation.

Mr. Cousins

Her name had not even been put on the list.

Mr. Thurnham

She was kept waiting, yes, to be put on the list. He referred to the realities of the situation, but he seems to have forgotten that last year 92,000 cataract operations were performed, compared with 40,000 when his party was running the national health service. He should be pleased about the reforms. I am convinced that they will lead to an increase in the number of cataract operations. Now that hospitals are being asked to quote figures, we see huge variations in the costs of operations as between different hospitals. There are also wide variations in the waiting times for operations in different parts of the country. The reforms should lead to a much improved service and to a considerable increase in the number of cataract operations.

I am sorry that the hon. Member for Monklands, West (Mr. Clarke) is not here. I share his impatience. I believe that he had the sympathy of the House when he referred to the 1986 Act, which he introduced. However, he was wrong to criticise the Government for what he called a U-turn. His Act will, in time, be implemented. We should not forget that there has been a massive increase in spending on the social services under this Government. During the last 10 years it has increased by 52 per cent.

It was the speech of the hon. Member for Livingston (Mr. Cook) that disappointed me most. He said nothing about his party's proposals. He failed to give any firm commitments. He said that £2.8 billion could not be found overnight. The Government have increased spending by £3 billion during the last year. I do not know what he is offering.

The hon. Gentleman referred to NHS waiting times. The longest waiting time in the NHS is the time that we have been waiting to hear what he has to say. I sympathise with his difficulties. The Labour party is giving a low priority to the NHS. It says that child benefit, pensions and education are its top priorities, so spending on the NHS is not a top priority; therefore he cannot come forward with any proposals. His party's record is very poor. Capital spending, the proportion of gross domestic product spent on health, pay for nurses and doctors, on the increase in the number of in-patients treated each year, on waiting lists, and on NHS revenue funding—all have been far better managed under this Government than they were under the Labour Government. The hon. Gentleman is in a predicament. He cannot look back and he cannot look forward, because his party does not believe that the NHS is a top priority.

What upset me most about the hon. Gentleman's speech was his unwarranted attack on charities. Is this a new Labour party policy? Perhaps he will advise the House. It will be interesting to study what he said in Hansard. I understood him to say that he did not agree with charities giving money to the NHS. Does he suggest that when, or if, we ever have another Labour Government he would not allow charities to contribute to the NHS? My experience is that people like to give money for hospital equipment. They gain satisfaction from doing so. It is only the trade unions—the hon. Gentleman's bosses, I guess—who do not like charities. They believe that they are a threat to trade union restrictive practices.

I am disturbed by the contrast between the successful way the Government are running the NHS and the problems encountered over the delivery of social services at local level. The people in my constituency can look forward to the provision of a new hospital. The plans are coming through and work will start in the spring of 1992. The cost will be £13 million. We have been promised an increased share of North Western regional health authority revenue. For too long, Bolton has been the Cinderella. For too long, it has been at the bottom of the league table—19th in the district. Now, not only is an increased proportion of gross domestic product spent on health care, but there will be an increase in expenditure on Bolton itself.

Like other hon. Members, I welcome GP fund holders in the constituency. Two of the major practices have embraced the idea. That spirit of reform has been adopted very strongly in the area, as well as by Christie hospital, and Central Manchester hospital, which are both going for the new trust status. I welcome the extra funds that are being made available for mental handicap units. In my constituency, there are plans for such a unit. My hon. Friend the Minister for Health has been to Bolton and has heard plans discussed. I know that the health authority is working on a proposal for a new 18-bed unit to provide residential and respite care. I look forward to that coming to fruition.

I am disturbed by some failures and problems created by local authorities—too many of which are controlled by Labour—in their attempts to deliver services of a high standard. In Bolton at the moment there is much unrest among social security staff. There are threats of strikes or working to rule. It all reminds one of Labour's winter of discontent, which was the cause of so much dissatisfaction during the final year of the Labour party's last term in office.

Local authority residential homes and neighbourhood network homes involve excessive costs. There are delays in assessing the needs of the handicapped. Indeed, that applies in many local authority areas. Some local authorities, including those in Bolton and Salford, are failing to take up the mental health grant—money provided by the Government. Then there is the terrible dissatisfaction throughout the country with the way in which social workers, who are supposed to protect children, have been removing them in dawn raids from their innocent families. That has destroyed to a considerable extent the confidence that people ought to have in the way in which social services departments are run. I realise that social workers have a difficult job, but they have been given guidance in the shape of the Butler-Sloss recommendations. The situation is very disturbing. It makes one wonder whether there should not be wholesale changes in the way in which the social services are run.

A particular aspect of social services work with which I have been concerned recently is the adoption of children from Romania and other countries. I am very concerned at the attitude of the official spokesperson of the Labour party on children, the hon. Member for Eccles (Miss Lestor). I believe that in her opposition to the adoption of children from Romania and elsewhere she is quite isolated. Her attitude is in complete contrast to what was said by President Iliescu of Romania when he was here yesterday. He said that he welcomed the help given by United Kingdom couples who are willing to adopt Romanian orphans. He told us that there are still 170,000 children in institutional care in Romania, and that couples wanting to adopt are welcomed. That is contrary to advice issued by some social services departments. I hope that my hon. Friend the Minister for Health, who has been so sympathetic in encouraging couples who wish to adopt, will take note of what the Romanian President said. He hopes that British couples will not stop adopting as a result of changes occurring in Romania. I hope that my hon. Friend will be able to make that fact clear to social services departments that have been advising couples that no adoptions can be done at the moment. On the contrary, there is a great need for adoptions to continue.

I hope that my hon. Friend will find the recent formation of the British Advisory Board on Inter-Country Adoption to be of some help. That should result in the provision of very good professional advice to Government Departments, Members of Parliament and other interested people. The advisory board consists of virtually all the leading professional people concerned with the adoption of children from abroad. It has been set up under the chairmanship of Margaret Bennett of the International Bar Association, who will be involved in the forthcoming Hague convention discussions.

A few moments ago, I talked about the difficulties in social services departments. I hope that, in her winding-up speech, my hon. Friend the Minister for Health will give a little thought to whether some of the functions of the social services department might be transferred to the local health authorities. There is a difference in attitude. People employed by local authorities tend to like to work from 9 to 5, Monday to Friday, whereas many of these services are required 24 hours a day, seven days a week. I believe that these services could be provided much more sympathetically and competently by the local health authorities than by the local social services departments, many of which have demonstrated incompetence and have lost the confidence of the public.

Mr. Deputy Speaker (Mr. Harold Walker)

Order. The hon. Gentleman has run out of time.

8.56 pm

Mr. Eddie McGrady (South Down)

I am grateful for the opportunity to participate in this debate. It is 40 years since the inauguration of the health service as we knew it. Perhaps complete revitalisation, revision and overhaul are somewhat overdue, in view of the obvious changes in circumstances, in medicine and in technology. But there is one thing that never changes, and it forms the basis on which the health service was originally created—to provide equality of health care and of medicine to all citizens. In other words, citizens were to be treated equally. Let us hope that the target of a Government of any party would be care of high quality, particularly for those people who cannot care for themselves.

In January of this year, the Health and Personal Social Services (Northern Ireland) Order was passed in this House late in the evening, after a debate lasting just an hour and a half. That is the extent to which we from Northern Ireland were able to participate in the discussion of legislation affecting ourselves. No account whatsoever was taken of the differences between the manner in which services are rendered in Northern Ireland and the manner in which they are rendered in Britain. Over the years, services in Northern Ireland evolved in a slightly different direction. Communities in Northern Ireland are much more closely related, and services much more harmonised, than is the case here.

For instance, general practitioners, local hospitals and professionals involved in the provision of social services and community care have been very closely linked and identified with each other. No attempt was made to take into account that very valuable asset. With the new order, the link between one section and another went out of the window. The new structures that have been set up have diminished that facility. The order concentrated on financial restriction and administrative structures, in respect of both hospitals and doctors.

I am not in a position to make a critical analysis of medicine or of the provision of medical care, but, as a public representative, one sees what is happening. Three major areas will not be addressed adequately under the new regime. First, there is a need for greatly increased provision for the larger number of elderly and mentally disturbed elderly in the community. Secondly, the new structure does not seem to take into account the obvious necessity to provide more health care for those on lower incomes who, because of financial and other circumstances, often cannot look after themselves. Thirdly, more resources should be devoted to preventive medicine because income levels, educational ability, housing conditions and general social factors make preventive medicine more difficult in some sections of the community. In those three spheres, there will be less adequate provision under the new regime.

The new structure seems to be almost solely concerned with financial restrictions, budgetary control and so-called cost efficiency. There is an administrative nightmare in the hospital and general practitioner sectors. There is a thrust, if not a firm policy, to translate services from the public sector to the private sector as much as possible.

Budget squeezes are affecting all the boards in Northern Ireland. My area is covered by the Eastern and the Southern health and social services boards. It is evident from the new programmes and policies which they have published that the most vulnerable members of the community will suffer under the new regime. Already we have had an announcement of the closure of three homes in my constituency, in contrast to the new buildings which are planned in other constituencies, according to the contributions which I have heard in the debate. In my area, where modest hospital renewal has been planned for some 26 years, it will not be available under the new regime.

I can only draw on personal experience to comment on what is happening. The modest provision of transport for mentally handicapped children in my constituency has been withdrawn. Now they will not be transported from the rural areas of a largely rural constituency to the small towns where Gateway and other bodies provided facilities which gave some respite to their families. The elderly are suffering great deprivation from the lack of facilities which previously were available to them. All that is happening because the budgets of the boards are being squeezed beyond the point of financial efficiency to the point of financial deficiency. Unfortunately, it is the very sensitive sections of the community who are suffering.

Allied to all that in Northern Ireland has been the total abolition of local democracy in the health services. Previously we had district health committees allied roughly to our 26 district councils. They have been reduced to four health service councils. No public representative has been appointed by the Minister to any of those councils, so there is no local democracy. Every member of all four boards is a ministerial appointment. That means that the natural probing which results from local representation will be completely absent from the scrutiny of the councils.

Provision for the mentally handicapped has been reduced locally. Under the health boards in my constituency the priority areas will suffer most. Acute hospital services are being cut. There has been a reduction in residential and community care, particularly child care. That is happening under the new horizons of the structure that was supposed to lead to better care for the people. When we look back, we will see that there is no longer equality of health care and community care, or concern for the less fortunate.

I have no doubt that the weakest members of the community I represent will suffer most because of their background, income level and education. In Northern Ireland, the social deprivation suffered by some may be even worse than on the mainland because, right or wrong, their local area is designated as subject to some paramilitary influence. Those people who already suffer deprivation, however, will suffer even more because they will no longer receive reasonable health provision and care in the community.

I hope that my interpretation is wrong. I hope that we are now witnessing a new Jerusalem in terms of health and social security. I am not arguing statistics, nor do I seek to argue as an expert in medicine or administration, but my experience means that I know that the people I represent are not getting the health provision they received in the past and to which they are entitled now and in the future.

9.5 pm

Mr. John Marshall (Hendon, South)

I listened with interest to the speech of the hon. Member for Livingston (Mr. Cook), who should have come to the House to apologise for the consequences of his ill-informed campaign against reforms in the health service. His misleading campaign of disinformation and distortion caused unnecessary suffering to many elderly and ill. Was it the act of a caring man to arouse such unnecessary fears among the elderly and the sick or was it the act of an opportunist?

Typical of the distortion that has been offered by the hon. Member for Livingston and his hon. Friends is the implication that, once hospitals have become self-governing trusts and opted out of the NHS, those people must somehow pay for the treatment they will receive in those hospitals. The Opposition should accept that those hospitals are opting out of the bureaucracy of the NHS, but that they are not opting out of the principles that have underlain the NHS since 1948.

Everyone who goes to a self-governing trust hospital will still receive free treatment, but they will also find that those trusts, such as the Royal Free hospital which serves patients in my constituency, will be more responsive than in the past. It is significant that the sponsors of the trust at the Royal Free have made a commitment to reduce the hospital's waiting list.

The hon. Member for Livingston should have come to the House with a great sense of humility, because there is no doubt that he lost the battle for extra spending in the shadow Cabinet. It-is not sufficient for the hon. Gentleman to tell the House that health service spending is top of the Labour party agenda, because we know that agenda as a result of the draft Budget produced by the right hon. and learned Member for Monklands, East (Mr. Smith). Although it offered more spending on child benefit, there was not a penny more for the health service.

Yesterday, an Opposition Member spoke about a hospital closure in Liverpool, and today we heard about a hospital closure in Manchester. They claim to oppose such closures, but they should tell the House what hospitals they would close in their place.

Mr. Hinchliffe

Why?

Mr. Marshall

Because his right hon. and learned Friend the Member for Monklands, East has already said that there will not be a penny more for the NHS from a Labour Government. The draft budget made that clear, and Opposition Members should argue their case within that constraint.

The situation that would prevail under a Labour Government is even worse than one might expect. My hon. Friend the Member for Bournemouth, West (Mr. Butterfill) has already pointed out that the introduction of a minimum wage would result in an extra £500 million cost to the NHS. To meet the cost of getting rid of competitive tendering, eye and dental check charges and prescription charges, 30 general hospitals would have to be closed.

It is up to the hon. Member for Birmingham, Perry Barr (Mr. Rooker) to tell us whether one of those 30 general hospitals would be in his constituency. Would a hospital in Manchester be closed? How many hospitals in London will be closed by the Labour party? That is a policy to which it is committed.

I welcome the reforms that the Government have introduced. The Labour party is indulging in nothing less than a cynical charade. One does not have to listen to the rhetoric to understand that; one need only look at the record. The last Labour Government cut the hospital building programme by 16 per cent. They cut nurses' pay by 21 per cent. in real terms, and increased hospital waiting lists by 48 per cent. The people will look at the record of the last Labour Government, they will contrast it with the rhetoric of the hon. Member for Livingston, and they will know that the record is the guide to the future.

People can look at the record of this Government, who are treating a record number of patients with a record number of doctors and nurses. That record is in complete contrast to that of the Opposition when they were in power. The reason is that the Conservative party have created a more efficient economy. That, plus the fact that we have caring Ministers, has enabled the health service to improve dramatically in the past 10 years.

9.10 pm

Mr. Jeff Rooker (Birmingham, Perry Barr)

It was a privilege to hear the fulsome tributes by my hon. Friend the Member for Neath (Mr. Hain) in his maiden speech to our late colleague, Mr. Donald Coleman. My hon. Friend gave a graphic description of how the people in the valleys of south Wales have suffered in the past decade. He not only knows how many O-levels he has, but where his home is—and it is now clearly among the valleys. My hon. Friend will be here a lot longer than most of the Conservative Members who heard his speech, and he will be here to play a role in rectifying the neglect of the past decade.

I timed the Secretary of State's speech at about 20 minutes. Less than two minutes of it referred to community care policy, as my hon. Friends have emphasised. He then spent 10 minutes on bluster, attacking the Labour Opposition. Frankly, I am not going to take anything from the intellectual guru behind the poll tax. They can witter all they like, but part of the responsibility for their 1987 White Paper, Cmnd. 9714, was a direct result of the work of the committee chaired by the Secretary of State for Health. The poll tax has destroyed community care policy, as it will effectively destroy the Government.

The Government-imposed changes in the national health service have created a climate of fear in parts of it and among the staff in some hospitals, one of which I shall name. That hospital is so well-located, geographically, in the centre of a city that it is used by citizens in all areas of the city and outside it. Indeed, parts of north Warwickshire have such a poor public transport system under this Government that it is easier to get to the general hospital in the centre of Birmingham than to local district hospitals.

Birmingham general hospital is friendly to its users, which goes against it. It is efficient in throughput per consultant firm, much better than the Queen Elizabeth hospital, and that also goes against it. It is not a mega-hospital, and that, too, goes against it. Until the blight brought about by the Government, that hospital had a better record of nurse retention after training than the Queen Elizabeth hospital, which also goes against it.

The operating theatres have been closed deliberately to force patients elsewhere so that the figures can be manipulated. It is known that accident and emergency cases go past the hospital to get to the general hospital. Because of the climate of fear, the position is so bad that Members of Parliament cannot be seen talking to senior staff in Birmingham general hospital by administrators simply because the staff fear for their careers and for those of their colleagues. Meetings have to take place elsewhere in the city.

That is just one example and we have heard many others in the debate. We have heard horrific stories about the waste of public money, going well beyond the bounds of public probity, especially in the speech by my hon. Friend the Member for Pontefract and Castleford (Mr. Lofthouse). However, I want to concentrate on community care, as the Secretary of State did not but I presume that the Minister will.

I want to draw the attention of the House to a survey published on 9 April which claimed that 80 per cent. of all those interviewed said that they had never heard of the policy of care in the community. Those who had heard of it said that they did not really know what its implications would be for them. The survey was Commissionered by the BBC education service for a new BBC 2 series, "Who Cares?"

The survey questioned a sample of 2,000 people mainly aged over 70 from England, Scotland and Wales and 80 per cent. said that they had never heard of the community care policy. Those were elderly people who were being cared for, or thought that they would need care in the future, as well as current and future carers of elderly people. They were living in a wide range of accommoda-tion—residential care, sheltered housing, both public and private, and in their own homes. By any stretch of the imagination, it was a good cross-section, but 80 per cent. said that they had never heard of the Government's policy of care in the community. More than 50 per cent. said that they needed more information about facilities and services. That issue is constantly raised throughout the country.

I give notice now of one question that I would like answered before the end of the debate and I shall repeat and come back to it during the course of my speech.

Frankly, I should have thought that it would have been answered by the Secretary of State. It is this: will the Government tell us the cost of their policy of care in the community? The Secretary of State did not talk about delaying the policy or putting it on ice. He talked about its slow implementation—that it is under way and will come to fruition. Therefore, he must have some idea about the cost of implementation.

Last July, a delay was announced to give people more time to get ready. I want to know what the Government have done with the extra time that they have had to calculate the cost of the implementation of that policy so that they can give that figure to the House for the first time.

The details of the survey which were supplied to me by the Carers National Association revealed a blunt message —80 per cent. said that the standard of care for elderly people should not depend upon individual income. If I may use a pun, there is a health warning in this survey for the Government, and that is that two thirds of carers had heard of the policy. Most did not have great expectations of it and three quarters of those said that a political party's policy on caring for elderly people was important when voting in a general election.

It has to be fair comment to say that it was nothing less than cruel for the Government to raise false hopes for an improvement of tailor-made services and support for the elderly and disabled and then to dash them last July during a statement from the Dispatch Box. This month should have seen the implementation of the policy.

The anger among carers, some at the end of their tether, is enormous. They soldiered on not knowing that they were carers, but they got the message that there was help on the way and right at the last minute their hopes were completely dashed and the help was withdrawn. The bitterness, anger, frustration, worry and concern has to be heard and seen to be believed. I wonder how many carers and groups Ministers have met, not in the great conference halls but on a one-to-one or a family basis since they announced that cruel decision last July.

Now there is considerable doubt about whether the Government's commitment to implementing their policy stands. I say "their" policy because it is certainly not the policy of the Griffiths report. The Government just chose the bits of that that they wanted.

We want to know why there is a delay in the implementation of the policy—why, in the Secretary of State's words, there is a slow implementation, and why, in the words of others, it has been abandoned. Last year, the then Secretary of State for Health said that it was because of the poll tax. He constantly repeated that on 18 July during his statement to the House. He referred to excessive levels of community charge". Later he said that it was in the light of irresponsible behaviour by largely socialist local authorities, up and down the country, who cannot keep their policies within reasonable costs. Then he said: The policy was proceeding with a general welcome … until we reached the problem with the community charge." —[Official Report, 18 July 1990; Vol. 176, c. 1003–5.] The general consensus at the time—not from the Government—was that it would cost about £15 per head per year on the community charge to implement the policy. Since then the Government have lopped £140 per head off the community charge. Even so, last July when the decision to abandon the policy was announced the community charge was expected to be here for ever more.

It would still affect and be affected by the implementation of the policy. What was to happen in 1992 and 1993 when the poll tax was still there? Indeed, it still will be there in one shape or another if the Government remain in office.

By now the Government must know the cost of implementing the policy and they should share that knowledge with the House and the nation. Two years, even allowing for the delay, is a short time in local government planning and expenditure. After plans have been made the Government cannot keep intervening and turning everything upside down like a constant revolution. There must be planning if policies are to be effectively implemented and we want to know what use the Government have made of the extra time. The Government constantly ask local authorities and the voluntary sector what they are doing with the extra time that they have been given to make sure that policies are up and running. They throw the question back to the Government.

Are Departments talking to one another? This crucial policy is shared by several Departments—Social Security, Health and Environment. It is a cliche to say that it is everybody's distant relative and nobody's baby, but it applies strongly in this case. Even the Department of Transport must be involved.

This morning I was in the constituency of Luton, South discussing with people in sheltered housing some of the problems that they encounter. Those people are in semi-care. They have their own front door and kitchen and a minimum amount of care outside their homes. They cannot even get bus services to do their shopping. They are being forced into dependency simply because of the Government's crazy policies. They said to me, "Our MP does not visit us very often. We do not know whether he uses a bus or whether he understands the situation."

Mr. Hayes

It is disgraceful for the hon. Gentleman to say that.

Mr. Rooker

It is not disgraceful. My job is to articulate the needs of the people of this country. If those needs are not articulated by Members of Parliament, somebody else has to voice them.

The Government must have made decisions about the transfer of the social security budget from income support to local authorities so that those authorities can assess the best means of operating the care plans and mixing public, private and voluntary care as required by the individual. Decisions must have been made about the transfer of mega-billions of public expenditure. [Interruption.] We are surely talking about well over a billion for a start.

Mr. Hayes

Will the hon. Gentleman give way?

Mr. Rooker

No, I will not give way.

That amount will rise to close on £2 billion this year —and that is purely for the income support for residential care. We also want to know the community care expenditure in respect of the health service because that will have to be transferred at some time. What is the mechanism for that and what are the Government's thoughts on it? They should share with the House, local authorities and care providers the decisions that they have taken.

It is still a matter of chance as to whether a person ends up in long-stay geriatric care, nursing care or residential care, all of which levy different costs and charges. The Minister of State and the Secretary of State know that that matter must be addressed. How are they addressing it? Secrecy should not be the order of the day. The providers are not Ministers but local people, the voluntary sector, local authorities and the private sector, and they need to know the Government's thinking. The Government have made no attempt to set out the key issues since the announcement of the abandonment of the policy.

Mr. Hayes

It is not an abandonment of policy.

Mr. Rooker

It is an abandonment of policy. Until Ministers tell us what they have been doing since they announced the decision in July about planning for the future and the costings for the policy, people will not believe they are serious about fully implementing the policy. Last year's figure for income support in terms of residential care was £1.3 billion, rising by about £400 million a year. That is in a narrow sector of care, and health service provision must be added. Therefore, we are talking about several billions. That issue caused the Government to Commissioner the Griffiths report in the first place. No decisions were being made about this continuing expenditure and there was an open-ended budget commitment on income support. That was why the Government listened to the Audit Commissioner in 1986 and asked for the Griffiths report.

There was a long delay before a White Paper was published in 1989. That was followed within days with the publication of the Bill, which was quickly pushed through to Royal Assent seven months later on 29 June 1990, with implementation this April. Less than three weeks later, the whole thing was put on ice. That is not good business or good management of Government affairs. We are entitled to be told about the consequences. I know that there was disquiet at the time about the rush to implementation —

Mr. Hayes

Where from?

Mr. Rooker

From the Select Committee.

Until 17 July, the Government were adamant that the Bill should be implemented on 1 April —

Mr. Hayes

rose—

Mr. Rooker

I am not giving way as there is no time to do so. I should be taking time out of the Minister's speech.

The Select Committee had misgivings about the timing. Others also had misgivings, but the Government had no misgivings. If those misgivings had any foundation, the Government should today tell us the real reason for the delay and the real costs of the implementation of the policy. Local government needs to know.

Last July, wild allegations were made about local government and the poll tax. That was the Government's reason for delaying the implementation of the Bill —

Mr. Hayes

rose—

Mr. Rooker

Sit down—I am not giving way.

Mr. Hayes

On a point of order, Mr. Deputy Speaker. Am I right in saying that it is for the Chair to tell me when to sit down and not the hon. Gentleman, who is afraid to answer questions.

Mr. Deputy Speaker

Order. The Chair is telling the hon. Gentleman to sit down. The Minister for Health will doubtless catch my eye in a few moments, and she can reflect the views of the hon. Gentleman and his hon. Friends.

Mr. Rooker

The main reason given for the abandonment of the policy was the poll tax, not that it could not be implemented by local authorities. The former Secretary of State said that the key reason was the cost on the poll tax, not the mechanics of implementation. If, in fact, it was not the poll tax that delayed implementation, what was it? Local government has not been treated fairly. We need to know the current figures.

The Secretary of State said last year that the delay was reasonable, and we think that the Government want to put off implementation until after the election. Of course, they think that they will not lose the election. The devastating critique—and the Minister has read it because she has answered questions on it—by the King's Fund Research Institute on the causes and consequences of the delay in implementing the community care programme have not been fully answered by the Government. There has not been an opportunity in the House either in an Adjournment debate or in an all-day debate. Today, the Minister has the opportunity to answer some of the points made in that important but not lengthy report. It contained all the bald points about the consequences of the Government's decision.

The obvious and major consequence is that by delaying implementation the resources will not be available for extending care at home. We must home in on that point because finance is the key to the policy and its implementation. Local authorties know that the resources are just not there. Health authorities have been busily shifting resource costs to the social security system. My hon. Friend the Member for Manchester, Withington (Mr. Bradley) gave an example of that. Money that would have been identified as directly possible for transfer to the care in the community programme is disappearing. It is no longer available because health authorities have gone their own way. They identified a window of opportunity to shift the burden on to the social security budget, which the Government are also short changing by not funding the full care costs.

It all comes back to money. Others are involved in juggling with the Government's budget, because it is an open-ended budget commitment. Surely the Government will not say that there is to be a continuing open-ended social security budget commitment over the next two years. That budget commitment would be growing by at least £400 million a year. The problem of implementation then will be twice as bad as it would have been had they done the job properly this year. They know that. They are storing up further problems. In the meantime, thousands of our fellow citizens are being deprived of the opportunity of remaining in their own homes, with the extra costs that that entails. Nobody claims that that is a cheap option, and I do not claim that the Government said that it was.

There is not enough time to do justice to the other issue that I intended to raise which has been touched upon by Conservative Members—mental illness, for which the Secretary of State highlighted the specific grant. I do not want to go into the details, but the difficulty is that the infrastructure to deal with the problem is not in place in the community. The grant will not cope with the problem, because it will deal only with discharges, not with the people who will not be able to go into mental hospitals as they might once have done and later come out into the community. The whole policy is centred on discharges. When hospitals close, where is the procedure for making sure that their patients are picked up and helped into the care of the community in their own homes? There is no infrastructure. There is a moratorium on the care in the community policy—and that is putting it politely. There should be a similar moratorium on the closure of long-stay hospitals until the infrastructure for discharged patients in the community is put in place.

Mrs. Virginia Bottomley

That is exactly what we are doing.

Mr. Rooker

That is not what the Government are doing. If they were doing it we should not be able to see in large cities, and even in small cities, our fellow citizens wandering the streets, sleeping out at night with nowhere to live, because there is no proper effective system to take care of them. That is the difficulty that Ministers have brought upon themselves by continuing the discharge policy while abandoning the care in the community policy.

The Labour party, as you know, Mr. Deputy Speaker, is different from the Tories. I do not seek to drag you into the debate, but you know that, and so does Mr. Speaker. We shall offer a genuine partnership between Whitehall, town halls and the voluntary sector. We want authorities' social services spending on community care to be clearly identified, and the Government's contribution to be ring-fenced. The Government do not agree with that. That is why the money for community care is kept secret, and why we must press them on the costs. We will ring fence the money so that everybody knows exactly how much there is. We want a Department of Health and Community Care so that there can be no dithering about which Minister or Department is responsible for implementing policy. We shall restore fair choice as between public and private sector residential care, so that access to the massive public subsidy is on the same footing whether elderly and disabled people choose private residential care or a local authority or voluntary sector home.

We shall implement the remaining sections of the Disabled Persons (Services, Consultation and Representation) Act. We mean it when we say that users of the service have rights and we intend to see that those rights are given practical effect, which can be done only by implementing the rest of that Act. Our package will include support services for carers—the group the Government have forgotten. We shall provide care attendants to supply vital daytime and evening care, genuine and sufficient respite care to allow for breaks for carers, and a proper carers' benefit. Why should carers suffer massive financial loss as they do now? The Government are the Government and they will not tell us the cost of the policy that they are trying to implement. We will make sure that there is sanctuary provision for some of those transferred into the community who may need to be moved back to extra care temporarily due to stress. No one can deny that that problem exists.

I recently met a gentleman who is living in a nursing home in his own room on the ground floor with access to the garden after spending 41 years in a mental hospital being pumped full of drugs. We do not know why that happened. Having spent six months outside hospital, he is transformed, but a whole lifetime has disappeared for one of our fellow citizens. It is not a party political matter, but there must be hundreds if not thousands of people to whom that has happened in the past. We must take that on board and make sure that the policy is not delayed any longer than necessary. It is why we object so much not about the implementation of the specific grant but to the abandonment of the policy.

It appears that the Government are seeking not to implement the policy but to let it wither on the vine, and to let local authorities pick up the tab. That will give the Government a further excuse to complain about local authorities.

We shall set about enabling all individuals, wherever they are and wherever their home has been for however many years, to achieve as full a life as possible within the community care programme. They should have—and their advocates should invoke for them all their rights to ensure that they get—justice and fair play. Disability should not equal dependency. The only way in which we should make sure that does not happen is by fully implementing the Government's plans plus what we would add to them as we do not see eye to eye with them on these matters.

I keep hearing sedentary interventions from Conservative Members about costs. When we are in government we shall fully disclose all the costs of our policy. We shall ring-fence funds so that we can be accountable. I am asking the Government to do the same for their policies. We want services to be formed and shaped not according to the purchasing power of users as consumers through the mechanism of the marketplace, but out of respect for them as human beings and their rights as our fellow citizens.

9.37 pm

The Minister for Health (Mrs. Virginia Bottomley)

I begin by joining others in congratulating the hon. Member for Neath (Mr. Hain) on his maiden speech. He follows in the footsteps of an hon. Member who was much respected in the House and is greatly Missed. It is clear from the hon. Gentleman's speech that he will be a champion of his constituents. Members of Parliament on both sides are united in their care and commitment to their constituents and the way in which they inform their judgments about policies in the House.

We have had a debate in which many hon. Members have spoken forcefully and with feeling. Frankly, I sympathise with the shadow health team. How difficult it must be to have to admit that, in respect of their portfolio, the Conservatives do it and have done it better. Take our record over the past decade. One has only to look at the potential in our reforms. We are committed to the best health service possible for patients. My hon. Friend the Member for Harlow (Mr. Hayes) is quite right. The Opposition argue for a proliferation of Commissioners and quangos. We do not. We rely on the dedicated work force of the national health service backed by a strong economy. That is why we can say, and the Opposition know, that the numbers of doctors, nurses, dentists and midwives have increased.

I am not surprised that Opposition Members groan; they realise only too well that when we talk about statistics, facts or incontrovertible information, they have nothing in the cupboard. Their record has nothing except cuts and the destruction of the health service that my hon. Friend the Member for Hendon, South (Mr. Marshall) so clearly demonstrated.

During the previous 10 years, the numbers of in-patients, day cases and out-patients have all increased. Earlier today, my right hon. Friend the Secretary of State for Health announced the encouraging figures of the reduction in the number of people on waiting lists, especially the target group of those who have waited more than a year for treatment.

It is outrageous and deplorable for the hon. Member for Livingston (Mr. Cook) to compare the figures with those of the autumn of 1979, after the Labour Government had left office. My hon. Friends know that had he chosen to compare the figures to those of the spring of 1979, he would have found the highest figures for those on waiting lists.

Mr. Robin Cook

Let us do just that. If we compare the number of people on the waiting list in March 1979 with those announced at 3.30 pm this afternoon, we see that there are 144,000 more people on waiting lists now than there were in March 1979.

Mrs. Bottomley

indicated dissent.

Mr. Cook

The hon. Lady cannot deny it. I am citing figures from the press release issued by her Department this afternoon. If she wishes to quote figures for nurses, she should read the parliamentary answers that she signs. She would then know, from an answer that she gave to me, that in five years the previous Labour Government created twice as many nurses as this Government have done in 10 years and at four times the rate.

Mrs. Bottomley

There is not one nurse in the country who does not know perfectly well that nurses' pay has increased by more than 40 per cent. under this Government, whereas it fell by more than 20 per cent. under the previous Labour Government. In fact, only recently the Royal College of Nursing said that the main problem is not nurses' pay but their status. We recognise that, which is why nurses appreciate the practical steps taken by my right hon. Friend the Secretary of State to enhance the role of nurses, to introduce Project 2000 and to ensure that nurses are properly recognised as full members of the health care team.

Nurses can be confident under this Government. The Opposition make promises but constantly fail to deliver. We have invested in the health service and increased the number of nurses and doctors. We have provided £32 billion this year which has been highlighted by so many of my hon. Friends. People are living longer—there is an extra two years of life expectancy—and infant mortality continues to fall; about half the previous number of women now die in childbirth and fewer men under the age of 65 die of strokes and heart disease.

When did the Labour party suddenly begin to think that perhaps the NHS needed restructuring? It was only after our reforms started to capture the imagination of the people who work in the NHS. We see the enthusiasm and commitment of an increasing number of people who recognise the opportunities that are made available by our reforms to improve patient care and to make more responsive plans to meet their patients' needs. One thousand seven hundred GPs have chosen to become fund holders and there are 57 trusts now operating. There are more than 100 units queuing up to be part of the second wave.

Labour's opposition to fund holders is now perhaps a little less shrill. It will not be long before the noise about trusts also abates. Perhaps by the time they revise their policy they will adopt trusts as they have adopted the right to buy, trade union reform and multilateral disarmament. I am afraid that my hon. Friends have seen and heard it all before.

The hon. Member for Livingston fails to understand the growing support for the reforms among those who work in the NHS. Labour had to resort to threatening trust managers with their jobs to try to dampen their enthusiasm, which was disgraceful. Thankfully, Labour has stopped short of threatening GP fund holders with their jobs. It would have to face committed family doctors. Labour is playing the part of the health service Rot tweiler but without the teeth. Labour's leader—rightly—will not let his Front Bench off the leash yet. The shadow Health Secretary has been muzzled by his own leader and he and his colleagues have been forbidden to make pledges of increased funding to the health service. They can only stand on the sidelines and shout as we deliver the increased resources—£32 billion this year—[Interruption.] I am grateful to have had the opportunity to give that information.

Labour's approach is based on promises, on a scandalous disregard for the achievements of the NHS and social service staff, on Sunday surveys for Monday publicity and on sackloads of words. People in the health service and welfare services know that we are a Government with a record to be proud of who have a great deal more to do. We live in times of change and times of improvement. There is a great deal happening in the health service that we feel strongly about.

I agree that it is easy in a debate to concentrate on the exciting developments in the health service and the new treatments available, such as hip replacements and cataract treatments—treatments that push forward the frontiers of science and were not available before. Like other hon. Members, I wish to concentrate on community care aspects. Ninety-five per cent. of health care takes place in the community. Our policies for implementing community care are extremely important. Community care is vital to the nation as a whole. It potentially affects all of us as givers or receivers of care. Again, our valuable record demonstrates our commitment to enabling more vulnerable people to enjoy as full a life as possible in the community.

Spending on personal social services has increased by 53 per cent. in real terms. Labour's Sunday surveys do not seem to care for that progress. This year's standard spending figure for personal social services is £4.5 billion —a cash increase of more than 23.5 per cent. on last year and the biggest increase for 15 years in social service spending. I am afraid that Labour social service speakers are silent on that spending. Cash benefits for the disabled and the long-term sick rose from £1.8 billion in 1978–79 to £8.3 billion in 1989–90. The number of those receiving invalid care allowance rose spectacularly from 11,000 to 130,000 in just five years. That means more help for carers and for those cared for.

I hope that the issues of mental handicap and mental illness unite hon. Members. There has been a threefold increase in the number of community psychiatric nurses.

They are the key agents for effective care of the mentally ill in the community. There has been a sixfold increase in the number of mental handicap nurses. Those substantial achievements ensure that community care can be implemented successfully and effectively.

I am staggered to hear hon. Members who should know better talk about care in the community being abandoned. I suggest that each of them makes contact with his or her director of social services. I suggest that the hon. Member for Birmingham, Perry Barr (Mr. Rooker) talks to his director of social services. I met her on Tuesday this week. She has been at the forefront in implementing community care and recognising the role of carers. Like other directors of social service departments, she has seen the amount that we believe social services should spend increased by a record 23.5 per cent. this year.

Mr. Hayes

Will my hon. Friend remind the hon. Member for Birmingham, Perry Barr (Mr. Rooker) that the Social Services Select Committee warned the Government of the dangers of speeding implementation of community care?

Mrs. Bottomley

I thank my hon. Friend. One could, in justice, say that the hon. Member for Perry Barr made that point himself. There were many conflicting themes in his speech. He questioned whether anyone knew about community care and said that the carers were upset that it had not taken place. He asked why we had not gone ahead but also said that the Social Services Committee had said that we were going too fast.

I wish to talk about the aims and goals of the policy. People should enjoy the optimum quality of life and maximum independence for as long as they can. Service users should have as much say as possible in the care provided for them. Carers should be properly supported. The policy is about promoting choice and promoting dignity. It is about catering for people's needs, not providing services according to those that are available.

I wish to refer to many of the themes that were raised during the debate.

My hon. Friend the Member for Cheadle (Mr. Day) spoke forcefully and effectively about the reforms and the need for change. It is a question not simply of throwing more money at the health service but of ensuring that that money is used well. My hon. Friend the Member for Harlow also made a foreceful and clear speech and referred to that eminent academic, Professor Le Grand, and his view, which I am pleased that he drew to the attention of the House. He also identified the important work done by the Audit Commissioner to ensure, in the words of my right hon. Friend the Member for Finchley (Mrs. Thatcher), that efficiency is the ally and not the enemy of compassion. By achieving value for money we can ensure that we improve our services to the best possible effect.

My hon. Friend the Member for Bury, North (Mr. Burt), in an excellent speech, identified in practical terms the changes that have taken place in his health authority —the increases in funding, in professional staff and in care for patients. My hon. Friend the Member for Wyre Forest (Mr. Coombs) spoke about the changes, improvements and opportunities. We shall consider carefully his call for a further extension of fundholders to enable those with smaller practices to come within the scheme.

My hon. Friend the Member for Hendon, South made it only too clear that we should judge records as opposed to rhetoric when we decide which party can best be trusted with the health service. We all agree with the remarks made by my hon. Friend the Member for Bolton, North-East (Mr. Thurnham). He said that the longest waiting time in the national health service is the wait for Labour's policy. That is only too right. He raised an important issue about inter-country adoption and I shall carry it forward. I value the work that he has done to ensure that inter-country adoption, which plays an important part for many families, is properly controlled, the families are properly scrutinised and assessed, and the local authorities co-operate and undertake their work effectively. I also value his assistance in ensuring that we have an effective policy in that area.

However, the hon. Member for Manchester, Withington (Mr. Bradley) gave a biased account and a catalogue of complaints about his constituency. That is something that those in the health service find so desperately demoralising about having a Labour Member of Parliament. Unlike my hon. Friends, who look for progress, success and achievement in the health service, Labour Members go around looking for ways in which they can denigrate the achievements of those who dedicate their lives to providing health care. I feel that I owe it to those who work in the health service in the constituency of the hon. Member for Withington to point out—he is obviously not going to do so—that the number of day cases that they treated between 1982 and 1990 rose by 72.3 per cent. and the number of in-patients rose by over 10 per cent. Moreover, my hon. Friend the Parliamentary Under-Secretary, who is to meet the hon. Gentleman about some of the proposals for change in his area, recently opened a community health centre at the cost of £1.2 million. A £4.2 million development—

Mr. Bradley

Will the Minister give way?

Mrs. Bottomley

I am sorry, but I shall not give way. I feel that the work of the health service in Manchester will not be recognised if I do not put the record straight, and I shall not allow the hon. Gentleman to contaminate its excellent work again.

The new hon. Member for Neath made an excellent speech. However, I do not want him to follow in the footsteps of some of his colleagues, because there was a tendency to follow the same path. In his maiden speech he overlooked the fact that, between 1979 and 1988, the number of in-patients rose by 37 per cent., the number of out-patients rose by 37 per cent. and the number of day cases that were treated trebled in his part of the world. As a new Member, he will want the health workers in his constituency to recognise the great developments that have taken place.

My hon. Friend the Member for Kensington (Mr. Fishburn) has provided a most valuable service to the House in identifying and pushing forward the cause of nurse prescribing. We are making good headway on that issue and, as he knows, a cost-benefit analysis is under way, the results of which we hope to have by August. The Government have made it clear that, like my hon. Friend, they believe that there is more that nurses can do. They will be vital when we fully implement community care. We want to use their professional skills to the full.

I am also grateful to my hon. Friend the Member for Kensington for mentioning women doctors. They have made excellent progress. About one in eight GPs used to be women; by 1989, the figure was one in five; and this year —I hope that hon. Members will bear with me, hon. Ladies certainly will—one in four GPs will be women.

My hon. Friend also raised important points about encouraging more people from ethnic communities to come forward to train as doctors. I shall certainly follow that up.

My hon. Friend the Member for Bournemouth, West (Mr. Butterfill), who has done so much to promote the cause of community care, identified a number of important issues. We value the steps that he is taking in relation to small residential homes. He mentioned the new drug for those with Alzheimer's disease. There are some exciting developments and I can assure my hon. Friend that the drug, which is currently under trial, will, we hope, come forward for licensing. But, of course, the strict tests for licensing must include safety, quality and efficacy. There is no doubt that many people who suffer from Alzheimer's disease in this country will greatly benefit if the drug can receive a full licence.

A number of other points were raised. The hon. Member for Pontefract and Castleford (Mr. Lofthouse) spoke of consultants in his health authority visiting the United States to try to inform themselves on how to carry forward their work in the health service. I shall certainly look into that aspect, but if my investigation reveals that those consultants and managers were trying to ensure that their work was informed by best management practice, by the effective use of resources, all of us should applaud that. Of course, it is not the case that our health service, available to all and free at the point of delivery, is anything other than profoundly different in many aspects from the provision of health care in the United States.

The hon. Gentleman also mentioned the issue of the security of those working in the health service—a subject which we are addressing more carefully.

Many hon. Members have questioned the work under way to implement community care. This April, local authorities were required to have in place complaints procedures and inspection units. Increased training resources have been made available so that 140,000 staff in social service departments are this year being trained for care in the community. We have carried forward our drug and alcohol assistance for the voluntary organisations. Above all, the work done by my hon. Friend the Parliamentary Under-Secretary to ensure that the work on mental illness makes further progress is extremely important. Hon. Members have been united in their concern to ensure that the mentally ill receive the services that they require. That is why the specific grant, backed by capital assistance, was introduced to ensure that those leaving a psychiatric hospital or those in need of care in the community receive the help required.

Mr. Tom Clarke

Will the Minister of State give way?

Mrs. Bottomley

I think that the hon. Gentleman would like me to address the issue of the Disabled Persons (Services, Consultation and Representation) Act 1986. He has done as much as any hon. Member to identify the needs of the disabled. The key point is that the care in the community proposals overtake the 1986 Act and ensure the user is at the forefront of the assessment. The lion's share of the Act has already been implemented, but I shall repeat the assurance that I have already given. Should the need emerge for further elements of the Act to be implemented, we shall most certainly continue to consider that.

Mr. Clarke

On a point of order, Mr. Speaker.

Mr. Speaker

I have heard nothing out of order.

Mr. Clarke

Is it in order, Mr. Speaker, for the Minister to mislead the House by saying that the lion's share —

Mr. Speaker

Order. The Minister is not misleading the House.

Mrs. Bottomley

When he reads the record, I think that the hon. Gentleman will find that I have covered his points fairly and squarely. I should, of course, be happy to discuss the matter further with him.

May I ask the hon. Member for Perry Barr to spend a long time with his own director of social services and to continue to work with us to promote partnerships throughout the country? He mentioned regional health authorities —

Mr. Derek Foster (Bishop Auckland)

rose in his place and claimed to move, That the Question be now put.

Question, That the Question be now put, put and agreed to.

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

The House divided: Ayes 221, Noes 310.

Division No. 118]	[10 pm
AYES
Abbott, Ms Diane	Bray, Dr Jeremy
Adams, Mrs Irene (Paisley, N.)	Brown, Nicholas (Newcastle E)
Allen, Graham	Brown, Ron (Edinburgh Leith)
Alton, David	Bruce, Malcolm (Gordon)
Archer, Rt Hon Peter	Buckley, George J.
Ashley, Rt Hon Jack	Caborn, Richard
Ashton, Joe	Callaghan, Jim
Banks, Tony (Newham NW)	Campbell, Menzies (Fife NE)
Barnes, Harry (Derbyshire NE)	Campbell, Ron (Blyth Valley)
Barnes, Mrs Rosie (Greenwich)	Campbell-Savours, D. N.
Barron, Kevin	Carr, Michael
Battle, John	Cartwright, John
Beckett, Margaret	Clark, Dr David (S Shields)
Beith, A. J.	Clarke, Tom (Monklands W)
Bellotti, David	Clelland, David
Benn, Rt Hon Tony	Clwyd, Mrs Ann
Bennett, A. F. (D'nt'n & R'dish)	Cohen, Harry
Benton, Joseph	Cook, Robin (Livingston)
Bermingham, Gerald	Corbett, Robin
Bidwell, Sydney	Corbyn, Jeremy
Blair, Tony	Cousins, Jim
Blunkett, David	Crowther, Stan
Boateng, Paul	Cryer, Bob
Boyes, Roland	Cummings, John
Bradley, Keith	Cunliffe, Lawrence

Cunningham, Dr John	Macdonald, Calum A.
Dalyell, Tam	McGrady, Eddie
Darling, Alistair	McKelvey, William
Davies, Rt Hon Denzil (Llanelli)	McLeish, Henry
Davies, Ron (Caerphilly)	Maclennan, Robert
Davis, Terry (B'ham Hodge H'I)	McMaster, Gordon
Dewar, Donald	McNamara, Kevin
Dixon, Don	McWilliam, John
Dobson, Frank	Madden, Max
Douglas, Dick	Mahon, Mrs Alice
Duffy, A. E. P.	Marek, Dr John
Dunnachie, Jimmy	Marshall, David (Shettleston)
Dunwoody, Hon Mrs Gwyneth	Marshall, Jim (Leicester S)
Eadie, Alexander	Martin, Michael J. (Springburn)
Evans, John (St Helens N)	Martlew, Eric
Ewing, Mrs Margaret (Moray)	Maxton, John
Fearn, Ronald	Meacher, Michael
Field, Frank (Birkenhead)	Meale, Alan
Fisher, Mark	Michael, Alun
Flannery, Martin	Michie, Mrs Ray (Arg'l & Bute)
Flynn, Paul	Mitchell, Austin (G't Grimsby)
Foot, Rt Hon Michael	Moonie, Dr Lewis
Foster, Derek	Morgan, Rhodri
Foulkes, George	Morley, Elliot
Fraser, John	Morris, Rt Hon A. (W'shawe)
Fyfe, Maria	Morris, Rt Hon J. (Aberavon)
Galbraith, Sam	Mowlam, Marjorie
Galloway, George	Mullin, Chris
Garrett, John (Norwich South)	Murphy, Paul
Garrett, Ted (Wallsend)	Nellist, Dave
George, Bruce	Oakes, Rt Hon Gordon
Godman, Dr Norman A.	O'Brien, William
Golding, Mrs Llin	O'Hara, Edward
Gordon, Mildred	O'Neill, Martin
Gould, Bryan	Orme, Rt Hon Stanley
Graham, Thomas	Owen, Rt Hon Dr David
Grant, Bernie (Tottenham)	Parry, Robert
Griffiths, Nigel (Edinburgh S)	Patchett, Terry
Griffiths, Win (Bridgend)	Pendry, Tom
Grocott, Bruce	Pike, Peter L.
Hain, Peter	Powell, Ray (Ogmore)
Hardy, Peter	Prescott, John
Harman, Ms Harriet	Primarolo, Dawn
Hattersley, Rt Hon Roy	Quin, Ms Joyce
Haynes, Frank	Radice, Giles
Healey, Rt Hon Denis	Randall, Stuart
Henderson, Doug	Redmond, Martin
Hinchliffe, David	Rees, Rt Hon Merlyn
Hoey, Ms Kate (Vauxhall)	Reid, Dr John
Hogg, N. (C'nauld & Kilsyth)	Richardson, Jo
Home Robertson, John	Robertson, George
Howarth, George (Knowsley N)	Robinson, Geoffrey
Howells, Geraint	Rogers, Allan
Howells, Dr. Kim (Pontypridd)	Rooker, Jeff
Hughes, John (Coventry NE)	Rooney, Terence
Hughes, Roy (Newport E)	Ross, Ernie (Dundee W)
Hughes, Simon (Southwark)	Rowlands, Ted
Illsley, Eric	Ruddock, Joan
Ingram, Adam	Salmond, Alex
Janner, Greville	Sedgemore, Brian
Jones, Barry (Alyn & Deeslde)	Sheerman, Barry
Jones, Ieuan (Ynys Môn)	Sheldon, Rt Hon Robert
Jones, Martyn (Clwyd S W)	Shore, Rt Hon Peter
Kaufman, Rt Hon Gerald	Short, Clare
Kennedy, Charles	Skinner, Dennis
Kilfedder, James	Smith, Andrew (Oxford E)
Kinnock, Rt Hon Neil	Smith, C. (Isl'ton & F'bury)
Kirkwood, Archy	Smith, Rt Hon J. (Monk'ds E)
Lambie, David	Smith, J. P. (Vale of Glam)
Lamond, James	Snape, Peter
Leadbitter, Ted	Soley, Clive
Leighton, Ron	Spearing, Nigel
Lestor, Joan (Eccles)	Stott, Roger
Lewis, Terry	Strang, Gavin
Livingstone, Ken	Straw, Jack
Livsey, Richard	Taylor, Mrs Ann (Dewsbury)
Lloyd, Tony (Stretford)	Taylor, Matthew (Truro)
Lofthouse, Geoffrey	Thompson, Jack (Wansbeck)
Loyden, Eddie	Wallace, James
McAvoy, Thomas	Walley, Joan

Warded, Gareth (Gower)	Worthington, Tony
Wareing, Robert N.	Wray, Jimmy
Watson, Mike (Glasgow, C)	Young, David (Bolton SE)
Welsh, Andrew (Angus E)
Welsh, Michael (Doncaster N)	Tellers for the Ayes:
Williams, Rt Hon Alan	Mr. Ken Eastham and
Williams, Alan W. (Carm'then)	Mr. Allen McKay.
Winnick, David

NOES
Adley, Robert	Couchman, James
Aitken, Jonathan	Cran, James
Alexander, Richard	Currie, Mrs Edwina
Alison, Rt Hon Michael	Davies, Q. (Stamf'd & Spald'g)
Allason, Rupert	Davis, David (Boothferry)
Amery, Rt Hon Julian	Day, Stephen
Amess, David	Devlin, Tim
Amos, Alan	Dickens, Geoffrey
Arbuthnot, James	Dicks, Terry
Arnold, Jacques (Gravesham)	Dorrell, Stephen
Arnold, Sir Thomas	Douglas-Hamilton, Lord James
Ashby, David	Dover, Den
Aspinwall, Jack	Dunn, Bob
Atkinson, David	Durant, Sir Anthony
Baker, Rt Hon K. (Mole Valley)	Eggar, Tim
Baker, Nicholas (Dorset N)	Emery, Sir Peter
Baldry, Tony	Evans, David (Welwyn Hatf'd)
Banks, Robert (Harrogate)	Fairbairn, Sir Nicholas
Batiste, Spencer	Fallon, Michael
Beaumont-Dark, Anthony	Fenner, Dame Peggy
Bellingham, Henry	Field, Barry (Isle of Wight)
Bendall, Vivian	Finsberg, Sir Geoffrey
Bennett, Nicholas (Pembroke)	Fishburn, John Dudley
Benyon, W.	Fookes, Dame Janet
Bevan, David Gilroy	Forman, Nigel
Bitten, Rt Hon John	Forsyth, Michael (Stirling)
Blackburn, Dr John G.	Fowler, Rt Hon Sir Norman
Blaker, Rt Hon Sir Peter	Fox, Sir Marcus
Body, Sir Richard	Franks, Cecil
Bonsor, Sir Nicholas	Freeman, Roger
Boscawen, Hon Robert	French, Douglas
Boswell, Tim	Fry, Peter
Bottom ley, Peter	Gale, Roger
Bottomley, Mrs Virginia	Gill, Christopher
Bowden, Gerald (Dulwich)	Glyn, Dr Sir Alan
Bowis, John	Goodhart, Sir Philip
Boyson, Rt Hon Dr Sir Rhodes	Goodlad, Alastair
Braine, Rt Hon Sir Bernard	Goodson-Wickes, Dr Charles
Brazier, Julian	Gorman, Mrs Teresa
Bright, Graham	Gorst, John
Brown, Michael (Brigg & Cl't's)	Grant, Sir Anthony (CambsSW)
Bruce, Ian (Dorset South)	Greenway, Harry (Ealing N)
Buchanan-Smith, Rt Hon Alick	Greenway, John (Ryedale)
Buck, Sir Antony	Gregory, Conal
Budgen, Nicholas	Griffiths, Peter (Portsmouth N)
Burns, Simon	Grist, Ian
Burt, Alistair	Ground, Patrick
Butler, Chris	Grylls, Michael
Butterfill, John	Hague, William
Carlisle, John, (Luton N)	Hamilton, Hon Archie (Epsom)
Carlisle, Kenneth (Lincoln)	Hamilton, Neil (Tatton)
Carrington, Matthew	Hampson, Dr Keith
Carttiss, Michael	Hanley, Jeremy
Cash, William	Hannam, John
Chalker, Rt Hon Mrs Lynda	Hargreaves, A. (B'ham H'll Gr')
Channon, Rt Hon Paul	Hargreaves, Ken (Hyndburn)
Chapman, Sydney	Harris, David
Chope, Christopher	Haselhurst, Alan
Churchill, Mr	Hawkins, Christopher
Clark, Rt Hon Alan (Plymouth)	Hayes, Jerry
Clark, Dr Michael (Rochford)	Hayhoe, Rt Hon Sir Barney
Clark, Rt Hon Sir William	Hayward, Robert
Clarke, Rt Hon K. (Rushcliffe)	Heseltine, Rt Hon Michael
Colvin, Michael	Hicks, Mrs Maureen (Wolv NE)
Conway, Derek	Hicks, Robert (Cornwall SE)
Coombs, Anthony (Wyre F'rest)	Higgins, Rt Hon Terence L.
Coombs, Simon (Swindon)	Hill, James
Cope, Rt Hon John	Hind, Kenneth
Cormack, Patrick	Hogg, Hon Douglas (Gr'th'm)

Holt, Richard	Norris, Steve
Hordern, Sir Peter	Onslow, Rt Hon Cranley
Howard, Rt Hon Michael	Oppenheim, Phillip
Howarth, Alan (Strat'd-on-A)	Page, Richard
Howarth, G. (Cannock & B'wd)	Paice, James
Howe, Rt Hon Sir Geoffrey	Parkinson, Rt Hon Cecil
Howell, Ralph (North Norfolk)	Patnick, Irvine
Hughes, Robert G. (Harrow W)	Patten, Rt Hon Chris (Bath)
Hunt, Sir John (Ravensbourne)	Patten, Rt Hon John
Hunter, Andrew	Pattie, Rt Hon Sir Geoffrey
Irvine, Michael	Peacock, Mrs Elizabeth
Irving, Sir Charles	Porter, David (Waveney)
Jack, Michael	Portillo, Michael
Janman, Tim	Powell, William (Corby)
Jessel, Toby	Price, Sir David
Johnson Smith, Sir Geoffrey	Raison, Rt Hon Sir Timothy
Jones, Gwilym (Cardiff N)	Rhodes James, Robert
Jones, Robert B (Herts W)	Riddick, Graham
Jopling, Rt Hon Michael	Ridley, Rt Hon Nicholas
Kellett-Bowman, Dame Elaine	Rifkind, Rt Hon Malcolm
Key, Robert	Roberts, Sir Wyn (Conwy)
King, Roger (B'ham N'thfield)	Roe, Mrs Marion
King, Rt Hon Tom (Bridgwater)	Rossi, Sir Hugh
Kirkhope, Timothy	Rost, Peter
Knapman, Roger	Rumbold, Rt Hon Mrs Angela
Knight, Greg (Derby North)	Ryder, Rt Hon Richard
Knight, Dame Jill (Edgbaston)	Sainsbury, Hon Tim
Knox, David	Sayeed, Jonathan
Lamont, Rt Hon Norman	Scott, Rt Hon Nicholas
Lang, Rt Hon Ian	Shaw, David (Dover)
Latham, Michael	Shaw, Sir Giles (Pudsey)
Lawrence, Ivan	Shaw, Sir Michael (Scarb')
Lawson, Rt Hon Nigel	Shelton, Sir William
Lennox-Boyd, Hon Mark	Shephard, Mrs G. (Norfolk SW)
Lester, Jim (Broxtowe)	Shepherd, Colin (Hereford)
Lilley, Rt Hon Peter	Shepherd, Richard (Aldridge)
Lloyd, Sir Ian (Havant)	Shersby, Michael
Lloyd, Peter (Fareham)	Sims, Roger
Lord, Michael	Skeet, Sir Trevor
Luce, Rt Hon Sir Richard	Smith, Tim (Beaconsfield)
Lyell, Rt Hon Sir Nicholas	Speed, Keith
McCrindle, Sir Robert	Speller, Tony
Macfarlane, Sir Neil	Spicer, Sir Jim (Dorset W)
MacGregor, Rt Hon John	Spicer, Michael (S Worcs)
MacKay, Andrew (E Berkshire)	Squire, Robin
Maclean, David	Stanbrook, Ivor
McNair-Wilson, Sir Patrick	Stanley, Rt Hon Sir John
Major, Rt Hon John	Steen, Anthony
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)	Stokes, Sir John
Marshall, Sir Michael (Arundel)	Sumberg, David
Martin, David (Portsmouth S)	Summerson, Hugo
Mates, Michael	Tapsell, Sir Peter
Mawhinney, Dr Brian	Taylor, Ian (Esher)
Maxwell-Hyslop, Robin	Taylor, Teddy (S'end E)
Mayhew, Rt Hon Sir Patrick	Tebbit, Rt Hon Norman
Meyer, Sir Anthony	Thompson, D. (Calder Valley)
Miller, Sir Hal	Thorne, Neil
Mills, Iain	Thurnham, Peter
Miscampbell, Norman	Townend, John (Bridlington)
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	Twinn, Dr Ian
Moore, Rt Hon John	Vaughan, Sir Gerard
Morrison, Sir Charles	Viggers, Peter
Morrison, Rt Hon Sir Peter	Waldegrave, Rt Hon William
Moss, Malcolm	Walden, George
Mudd, David	Walker, Bill (T'side North)
Neale, Sir Gerrard	Walker, Rt Hon P. (W'cester)
Nelson, Anthony	Walters, Sir Dennis
Neubert, Sir Michael	Ward, John
Nicholls, Patrick	Warren, Kenneth
Nicholson, David (Taunton)	Watts, John
Nicholson, Emma (Devon West)	Wells, Bowen

Whitney, Ray	Woodcock, Dr. Mike
Wiggin, Jerry	Yeo, Tim
Wilkinson, John	Young, Sir George (Acton)
Wilshire, David	Younger, Rt Hon George
Winterton, Mrs Ann
Winterton, Nicholas	Tellers for tbe Noes:
Wolfson, Mark	Mr. David Lightbown and
Wood, Timothy	Mr. John M. Taylor.

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments), and agreed to.

MR. DEPUTY SPEAKER

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

Resolved, That this House congratulates the Government on the near 25 per cent. increase in the number of in-patients treated and the near 100 per cent. increase in the number of hospital day cases since 1979 and on the further recent fall in hospital waiting times; welcomes the successful introduction of the Government's reforms which are already leading to better quality services, more responsiveness to people's needs and wishes and improved value for money; notes that the reforms are being backed in 1991–92 by record increases in resources for the National Health Service and in the standard spending assessment for the personal social services; welcomes the Government's commitment to full implementation of its community care policy, through local government, by April 1993; supports the Government's objective of using the National Health Service reforms to deliver real improvements in the health of the people through the development of a national health strategy; and looks forward to the forthcoming publication of a consultative document setting out the Government's proposals.