Hospitals

HC Deb 14 March 1991 vol 187 cc1225-43 12.12 am

Mrs. Sylvia Heal (Mid-Staffordshire)

I am pleased to be able to air this vital issue of national health service hospitals this evening, although I could certainly have wished that the business of the House had been so organised as to enable us to have this debate at a more reasonable hour.

The debate is timely, because the national health service now faces wrecking reforms which will fundamentally distort the delivery of health care. But even before these changes are brought about, no one who has been an NHS patient recently can deny that the service is in crisis. Cuts in patient services are being made by nine out of 10 health authorities to balance their books by the end of the month. Forced to produce a clear balance sheet before the new changes, health authorities have left newly built wards unopened and have closed surgical wards, shut maternity units and made bed reductions.

Yet just a month ago the Government were willing to give those hospitals a blank cheque to treat Gulf war casualties. That proves that it is not the resources which are lacking but the political will and the commitment to public services. Thankfully, our hospitals were not inundated with the sick and injured from the Gulf, but why is the money available during that crisis not now being used to rescue hospitals from their present funding crisis? Why are those resources not being used to bring down waiting lists?

Nearly 1 million people are waiting for operations; many have been waiting for over a year. In the West Midlands region in September 1990, there were 99,306 people on waiting lists, of which 20,000 had been waiting longer than a year. The sudden resignation of John Yates and his team last month proves that cosmetic attempts to manipulate waiting lists simply will not work. Slapping a two-year deadline on waiting lists will force health authorities to abandon some treatments and to treat less urgent cases more quickly.

What is needed is more money spent on doctors and nurses committed to getting the job done within the NHS. Mr. Yates told the Government that many NHS delays may be blamed on private work. Where there are many private beds, there are also longer waiting lists for operations. However, that was not the message that the Government wanted to hear. They would not sanction research into the connection between waiting lists, consultants' private work and the work that they do for the NHS. The Government are simply too committed to propping up the private sector.

The health service is literally crumbling around our ears. Seven per cent. of hospitals were built before 1890, and a staggering 80 per cent. before 1918. Old hospitals are difficult to keep clean, but privatisation and cuts in domestics' hours must share the blame for turning United Kingdom hospitals into buildings that now justify a Government health warning. The Audit Commission report published in The Independent yesterday spoke of the need for an additional £2 billion for maintenance.

Will the health service reforms sweep away the present crisis? Not a bit of it—they will make matters worse, by creating the same destructive forces of competition that have wreaked havoc in the United States. The Americans have left the provision of health care to the market, and it has led to the most expensive, least effective, most unfair system in existence.

The reforms are a charter for bureaucrats and accountants. The cost of administering the NHS will soar. Far from solving the main problem facing the NHS—its chronic underfunding—the reforms will divert scarce resources from patient care into a costly administrative edifice. The bureaucratic nightmare will undermine and ultimately destroy the vital principles on which the current health service is based—the provision of quality care to those most in need.

The British Medical Association carried out a survey, which was published in this month's edition of its "News Review". It shows that health authorities are spending large sums of money on new administrative staff to implement the NHS review proposals. The BMA has identified new administrative posts, as advertised in the Health Service Journal, and found that administrators' salaries are likely to increase by at least £80 million this year.

In Birmingham, the district authorities and their units recruited 72 new senior managers during the six months of the survey. I want the Government to give a guarantee that the additional funding for that will not come out of the money that is needed for patient care. The reforms impose a market model on the provision of health care. Authorities are now the purchasers and the providers—with contracts to be placed, always assuming that the health authority, the purchaser, has the money. If, as in the case of one health authority within the West Midlands region, there is considerably less money—as much as £1.1 million—that means either the closing of wards, invariably surgical, or delays in the provision of care.

The South East Staffordshire community health council has told me of an elderly patient who has been waiting for a hearing aid since August. It is not a costly operation, but it would make a considerable difference to the quality of his life. He cannot receive one until April, because of spending and staffing restrictions. I am told that that situation is commonplace. The Staffordshire Association for the Deaf has withdrawn the provision of an audiology service at the Victoria hospital in Lichfield. So far, the health authority has not been able to provide its own service.

Obtaining sufficient revenue to run the new district general hospital at Tamworth is also a problem. That hospital will serve patients in the South East Staffordshire health authority area. It appears that that problem can be solved only by closing four or five of the peripheral units. However, for patients living in rural areas such as my constituency, where there is little or no public transport, even getting to a hospital can be a major problem, especially for women and pensioners who may not have access to a car.

The Mid Staffordshire health authority is currently reviewing the provision of health care in Rugeley. My constituents and GPs in Rugeley are concerned about losing access to respite care and GP beds currently available at the local hospital.

The impact of the lack of resources has an effect on patients and staff in hospitals. It is not good for a working team to have patients in different wards in a hospital. That presents problems for the medical and nursing staff. For example, if an orthopaedic patient is on an ear, nose and throat ward, the medical staff must spend time checking on patients in wards on different floors of the hospital. They may not be quite as likely to detect changes in the patient's condition as they would if they were treating all the patients on the same ward.

The nursing staff face similar problems. The staff on the ENT ward will cope with the orthopaedic patient, but not as well as staff on an orthopaedic ward would cope. The latter staff are experienced and trained in those particular skills. All that is detrimental to good practice within hospitals.

The Government talk about the increased throughput of patients, but they do not talk about the readmission rate due to the lack of appropriate home care services. Staffing levels in our hospitals are an important factor. Many patients now have a high dependency level, requiring a lot of nursing attention. A shortage of qualified stall on a ward places additional pressures on junior nursing staff. It is hardly surprising that stress and burn-out amoung nurses are increasing.

It is now often difficult for nurses to be released from the ward for professional development because of staff shortages. The market in health care is creating stress, as departments and wards are told to make income. It is no longer possible to ask a physiotherapist to show staff how to lift a patient properly. The physiotherapist must charge, because the physiotherapy department has to generate income. Therefore, the professions are trying to sell their skills, and the good will involved in sharing skills is being eroded.

It also appears that no criticism of staff shortages is allowed. In The Guardian on Monday, there was a report of a consultant haematologist in the West Midlands region who spoke of her concern about staffing levels, and who has since been made redundant.

The introduction of a pricing system in NHS hospitals was bound to create variations. The publication this week of a survey conducted by the West Midlands health service monitoring unit has revealed what can only be described as a high street price war. A hip replacement operation in Mid Staffordshire health authority will cost £1,196, but in Sandwell it would cost £7,485. A hernia operation will cost £1,125 in Mid Staffordshire, but £2,489 at a trust hospital in Rugby. To have an ingrowing toenail removed costs £283 in mid-Staffordshire but only £90 at Queen Elizabeth's hospital, Birmingham. It costs £283 at Rugby.

Inevitably, this has caused a great deal of anxiety among the fund-holding GPs. Matthew Taylor, the director of the west midlands health monitoring unit, has said: I would not like to be GP forced to decide between protecting the interests of the local general hospital and treating more patients more cheaply elsewhere. It is right to ask why there are such incredible variations.

The Parliamentary-Under Secretary of State for Health (Mr. Stephen Dorrell)

Will the hon. Lady reflect on what she has just said? If I heard her correctly, she said that she would not like to choose between protecting the local hospital and treating more patients. It seems extraordinary to say that it is difficult to choose between the interests of a hospital as an institution and those of patients as people.

Mrs. Heal

I said that the difficulty was in choosing whether to protect the local general hospital or to treat more patients more cheaply elsewhere. The GP should not have to make that choice.

I repeat my question: why are there such incredible variations? Was any guidance issued by the Department of Health on a pricing policy? Can those relatively cheap authorities cope with the number of referrals that they are likely to receive? What would be the implications for the self-governing trusts if they did not attract sufficient referrals? Would they go out of business? An opted-out hospital will survive only if it is competitive. It will have to behave like any private hospital, providing financially profitable services rather than those which are medically necessary. There will be no local representation calling them to account. They will ignore the needs of the local community, in a bid to capture the market lead for expensive treatments available for patients far and wide.

Contracts will be won on price, not quality, of health care, because no one will be in a position to measure the latter. Patient choice will fly out of the window, because patients will have to go where the cheapest block contract can be negotiated, not where the best treatment is available.

The majority of people in this country need and use the national health service and its hospitals. We cannot claim to live in a civilised society if we are not prepared for those most in need.

12.27 am

Mr. Jim Callaghan (Heywood and Middleton)

I welcome the opportunity to talk about the conditions in hospitals in the north Manchester area—an area with which you are familiar, Mr. Deputy Speaker, because, before you reached your present prestigious and exalted position, you lived in the Manchester area. I am sure that you will know the hospitals that I shall mention.

Before Christmas I had to go for an eye inspection to a hospital in the northern section of Manchester known as the Jewish hospital, which was built before the war by the donations of the Jewish community in the Cheetham Hill area of the city. After the test, the doctor said that he would like me to return in six months for a further check-up on my eyes. He wrote down that he wanted me to return to that hospital. I smiled and said, "Are you sure, doctor?" He asked why. I said, "Are you not aware that the workmen are outside now demolishing the hospital?" He said, "Oh, yes, I had forgotten." He then wrote that I should go to the Northern hospital in Manchester. I smiled again and asked him if he was sure. Again, he asked why. I said that I had it on excellent authority that that hospital was also due to close. I said, "If you are giving me an appointment in six months' time, will the hospital be open?" He smiled and said, "Yes, you have a point. The best thing that can I do is to arrange for your to go there if it is still open. If it is not, we will send you somewhere else."

There are two hospitals; one is being knocked down and the other is going to close. Earlier last year, that indefatigable worker for Blackley, my hon. Friend the Member for Manchester, Blackley (Mr. Eastham), invited me to attend a public meeting in the Moston Lane school where parents in the area were concerned about the proposed closure of the children's hospital at Booth Hall—a hospital that has had a marvellous reputation for more than 50 years, dealing with at least 100,000 children per year. The proposal is not only that that hospital but one in Salford is to close. The idea is that a glass emporium will be built on the site of St. Mary's hospital in Manchester next to the Manchester Royal infirmary.

The parents in the area are extremely angry and I assure the Minister that if the proposal is serious he will have real trouble on his hands with them. I know the hospital well because when I was a young man I was a teacher in the area. Whenever a child was injured in the school it always fell to me to be asked, "Jim, will you take this child to the clinic in Moston lane or to the children's hospital," which I preferred as I was aware of the marvellous work for children at the hospital. The idea is now to build a new glass and marble emporium in the middle of the city at a cost of £40 million. The catch is that £20 million has to be found by voluntary subscription from the general public. I cannot see that happening. There will be tremendous opposition to the scheme.

I am sure that we all send our best wishes to my hon. Friend the Member for Manchester, Central (Mr. Litherland), who is not very well and is in hospital. We all know that he fought hard to prevent the closure of yet another hospital in the north area of Manchester—Ancoats hospital. I know that hospital well because when I was a little boy I was the hospital's best patient. I was constantly in trouble, I was mischievous and I knew my way to the hospital blindfold. When I had an injury, I would go there and the doctor would look at me and say, "Not you again, Callaghan." I know the value of that hospital, but unfortunately it, too, is to close.

The isolation hospital at Monsall is set in wonderful grounds, but it is proposed that it also should close. Just over the border in south Manchester, the Withington hospital is also to close. Five hospitals are to be closed in the north, and two in the south, in Withington and in Salford, are to be closed.

Are the rumours true? I know that some of them are because the buildings are being knocked down. Will the Minister clarify the position so that people in Manchester will know that they will not have only three hospitals—one in the north, one in the centre and one in the south?

I also wish to draw the Minister's attention to the services provided at two of the hospitals which are to remain. One is the Manchester Royal infirmary. Just before Christmas, a constituent complained to me that he needed a cardiac bypass but had been told in August by the authorities at the hospital that he would have to wait until November before the operation could be completed. When he telephoned in November, he was told that he could not have it done in November. He could not go in December. He was then told to come back in January, but in January he was again told, "We are sorry, but you cannot come in January after all." He wrote to me that he still did not have a date for that very serious operation.

I wrote immediately to the general manager, Mr. Derek Hathaway and was surprised by his answer. He replied: Part of the cardiac surgery unit had to close in October because of financial restraints that is another way of saying cuts— and because of staff sickness and maternity leave. The hospital was to reopen in January with six beds and I am told that eight beds are now open. Mr. Hathaway said: It is hoped we will get back to full capacity in the very near future. The Manchester Evening News correspondent, Ian Craig, related the incident under the headline: Don't have a heart attack in Manchester. It is inconvenient. I would say that if a person is going to have a heart attack, he should be careful where he has it. I received figures showing that in north Manchester during the past year 9.2 per cent. of operations were cancelled. In Rochdale it was 9.9 per cent. and in Salford 11.1 per cent. So it is not just the hospital to which I have been referring that has been affected.

The second hospital in the north of Manchester that I am told is to remain open is the North Manchester general hospital, also known as the Crumpsall hospital. My hon. Friend the Member for Blackley—that marvellous Member of Parliament—and I have gone to that hospital every year to discuss its problems with Professor Moore

Last year, we were asked by a senior consultant if we could help to obtain the services of a second consultant who specialised in diabetes and endocrinology because there was an acute need for such a consultant in the north-west region. To prove his case he drew our attention to the report of a working party on a survey of people with diabetes.

That survey was carried out on behalf of the North Western regional health authority and the working party was chaired by Professor Stephen Tomlinson. Its report is far too long and detailed for me to quote, but basically it said that there are about 60,000 people with diabetes in the north-west region, 12,000 of whom require insulin injections and the remaining 48,000 of whom are managed by diet alone or diet and tablets. The incidence of both types of patients is, unfortunately, increasing.

All diabetics have significantly increased mortality rates compared with non-diabetics. Diabetes shortens life predominantly because of the marked increase in the incidence of coronary artery disease and because of renal failure. Diabetes is the commonest cause of blindness and foot ulcers leading to gangrene, resulting in diabetes being the commonest cause of elective lower limb amputation. Increasing evidence suggests that complications are preventable. That is why the consultant was telling us that he wanted another consultant to try to prevent such incidents.

Costing the average stay in hospital, the committee estimated that in the north-west region it would cost more than £40 million. Accordingly, the working party was asked by the regional medical officer if he would construct a strategic plan for diabetic services in the north-west region for the next 10 years. The aim was simply to identify what was available, where the gaps were in the services and what it would take in terms of capital and revenue resources to fill those gaps.

The survey was conducted not simply as an exercise in cost cutting but principally to improve services within the financial constraints which currently exist. It would have been easy simply to reiterate the recommendation made by the British Diabetic Association and the Royal College of Physicians for optimal standards for diabetes care in the health district to indicate what the ideal situation might be.

It became apparent that in every district consultants with a specialist interest in diabetes are extremely keen to provide a first-class service but lack of money—I repeat, lack of money—has often made it difficult for them to achieve the improvements that they sought. They had to build on existing resources which resulted in a quality of service and distribution of resources which varied markedly from district to district. It is widely recognised not only by health care professionals but by management that there are major defects in services for diabetics and that there is the will to improve. them. Major improvements were made in a number of districts while the survey was being undertaken. The purpose of the report was not to criticise or to judge but to identify need and establish priority as realistically as possible in the hope that health care professionals and management would find the report informative and helpful.

On physical resources, the report shows that, of 19 hospitals, 11 have no education room and eight have no system of annual reviews of patients to pick up complications early, which is necessary. Bolton and Withington meet none of the recommendations on staffing requirements. Burnley, Leigh, Tameside, Park and Wythenshawe meet one of the four recommendations. Lancaster meet two and Blackburn, Blackpool, Bury, north Manchester, Rochdale, Stockport and west Lancashire meet three.

Comparing physical resources with staffing shows that, in the main, the districts with the fewest staff have the least physical resources. In four districts—Lancashire, central Manchester, north Manchester and south Manchester—the clinic numbers are larger than expected. Interestingly, in Bolton, Bury, Rochdale and Ormskirk only one physician has been designated as having an interest in diabetes. In five districts—north Manchester, Preston, Stockport, Tameside and Trafford—only one consultant deals with a large clinic population. A district to district variation is also apparent in nurses per thousand clinic population. Blackburn, north Manchester, Stockport and Tameside fair worse than other districts. Three of those districts—north Manchester, in which I am interested, Stockport and Tameside are among the most deprived for consultant staffing, which has not been compensated by high staffing of specialist nursing.

The report recommends that particular attention be given to the needs of district hospitals in Bolton, Burnley, Tameside, Park, south Manchester, north Manchester, Rochdale and Blackburn. It says that every effort. should be made to address the priority of an additional physician with an interest in diabetes in north Manchester. That was what the consultant who contacted the hon. Member for Blackley and me was requesting.

The report said that at the appropriate time an additional consultant with an interest in diabetes should be appointed in Bolton, Wythenshawe and Preston. It recommended that a health professional should be designated to co-ordinate the development of the diabetic service in the north western region.

Having read the superb working report, my hon. Friend the Member for Blackley and I wrote to the chairman of North Western regional health authority and asked for an additional consultant for the region, based in North Manchester general hospital at Crumpsall. Needless to say, the request was refused—no doubt in the interests of cutting corners and costs. Unfortunately, the consultant who contacted the hon. Member for Blackley and has left the hospital, which is a double tragedy. The Minister must agree that if such conditions continue in the region's hospitals there will be nothing left of the NHS except its good name.

Ms. Diane Abbott (Hackney, North and Stoke Newington)

rose——

Mr. Deputy Speaker (Mr. Harold Walker)

Order. I remind the hon. Lady that, if she chooses to speak in this debate, she will not be able to speak on the subject to which she has put her name. She can speak only once tonight.

12.44 am

Ms. Harriet Harman (Peckham)

I thank my hon. Friend the Member for Mid-Staffordshire (Mrs. Heal) for raising this issue, and for the extremely important issues that have been raised by my hon. Friend the Member for Heywood and Middleton (Mr. Callaghan). They are regarded as important not just in the constituencies of my hon. Friends but throughout the country. Why, therefore, are we discussing them at a quarter to one in the morning? If they are regarded as important, they are worth discussing during the day.

It is about time that the working hours of the House of Commons were changed. The Minister seems to think that it is absolutely right and proper to organise our business in this way, but it is about time that we dragged ourselves into the 20th century and prepared ourselves for the 21st by modernising our procedures, so that issues of national importance are discussed during the day instead of in the small hours of the morning.

Mr. Dorrell

I do not want to debate the hours that the House sits with the hon. Lady, but she said that she would prefer to debate these issues in prime parliamentary time. Between 3.30 and 7 o'clock yesterday, the Opposition tabled a motion for debate, but they chose to change the subject. I should be interested to hear why they did so, in view of what she has just said.

Ms. Harman

The Minister knows that my point is that the House ought not to have to debate such an issue at this hour. He has made a cheap debating point about the subject that we chose for our Supply day debate. Some of his colleagues see the sense, as we do, of changing the way that we organise our business, which at the moment is archaic, inefficient and more suited to what happened a couple of centuries ago. The Minister aligns himself with those who look back to previous centuries rather than with those who look forward and want a modern and efficient legislature.

This is an important debate. The Government are allowing the national health service to go downhill. The cash squeeze has resulted in long waiting lists. Operations are cancelled. Hospitals are crumbling. Ambulances are no longer getting to where they are wanted on time. Even cancer patient operations are being cancelled. The Government's commitment to the national health service can only be described as lip service. NHS treatment, many people feel, is wonderful, but they cannot be sure that they will be able to get it when they need it.

The Minister will no doubt say, as he has said on many previous occasions, "Crisis—what crisis? Problems—what problems? All that the bed closures mean is that there has been a change in the way that the NHS works. It's nothing to do with budget cuts; it's just a change in procedure." I remind the House of what he said in a press statement on 14 February: Falling numbers of beds in the acute sector of the National Health Service are a reliable indicator of the improving quality of health care. I challenge the Minister to name any other organisation, inside or outside the national health service, that believes that bed cuts are a sign that patient care is improving.

The Secretary of State for Health was reported in The Independent on 9 November 1990 as saying that many bed closures were not for financial reasons but for rationalisation purposes. However, the National Association of Health Authorities and Trusts believes that total bed closures in England this year for purely financial reasons will amount to over 3,500. Bed closures will be for that reason alone, not for rationalisation, or changes in medical practice.

Bed cuts have had an effect on the services provided. My hon. Friend the Member for Mid-Staffordshire referred to cancelled operations. The Minister was forced to admit that over 300,000 NHS operations were cancelled last year. Thousands of standard letters are sent to patients telling them not to go into hospital because their operations have been cancelled. Some patients have had their operations cancelled not once but repeatedly. Each such letter that goes out causes pain and misery for the person who receives it, dashed hopes and messed up plans. It is just not good enough.

To save money, NHS managers are telling doctors to go home, not to do their full week's work, and to cancel operating lists. So operating theatres lie idle and waiting lists grow. That is not an efficient way to run the service.

Because they cannot reduce waiting lists by treating patients who need care, health authorities are looking at other ways of cutting them down. North East Thames regional health authority has come up with plans to limit the availability of some procedures on the NHS, one of which is varicose vein repair. I know how that will work: the service will be available only for clinical reasons. So postmen and milkmen will have their veins operated on, but housewives caring for small children—such women's veins throb in exactly the same way as those of the professionals whom I have mentioned—will be regarded as wanting the operation for reasons of vanity, and they will be denied it.

First it is said that bed closures are taking place for rationalisation purposes, and are a sign of good health in the NHS. The next stage is to reduce the number of people who can get on the waiting lists, as North East Thames regional health authority has done.

A letter from the acting unit general manager, Peter Burroughs, and from the chairman of the management board of Guy's hospital, outlines a package of cuts to meet the hospital's budget deadline. The final paragraph reads: Finally we must limit the number of patients being seen in out-patients"— and this despite rising demand.

We propose a 15 per cent. reduction in new attendances and a 30 per cent. cull of repeat attenders, and we would ask you to examine your clinic arrangements without delay. That means that doctors must stop patients coming, and must stop treating them.

The Government can no longer claim—I hope that the Minister will not try to do so—that the NHS is treating more patients than ever before. Bed cuts, budget deficits and frozen posts are taking their toll. The figures are beginning to show that, despite growing need for treatment, the number of patients being treated by the NHS is falling.

There is evidence of falling activity rates in the NHS. Figures that I have for Camberwell, City, and Hackney and Riverside district health authorities show that the number of patients treated this year will be smaller than that treated last year. The same is true of the Oxford regional health authority—[Interruption.] If the Minister cares to challenge that, perhaps he should ask that health authority whether it is true.

The same applies to North West Thames and North East Thames regional health authorities. They too will treat fewer patients this year than last, and there is concern about North Western health authority and Trent health authority.

The NHS is also doing a lower proportion of non-emergency work. Right-wing Tories in the "No Turning Back" group have long argued that the NHS should be a crisis service, and that non-emergency work should be shunted off to the private sector. But budget cuts have meant that, without any parliamentary debate, that is increasingly what is happening. The NHS is turning into an emergency service, with non-emergency patients pushed into private hospitals or left by the wayside.

At Lewisham hospital, a consultant told me that one patient waited from 9 am until midnight for an operation for acute appendicitis while the hospital tried to find a bed and a free operating theatre. Recently, one of the hospital's four main operating theatres was closed for two months to save money. As the hospital cannot advertise for nursing staff, because of budget restrictions, theatres are short of trained staff. So there are more cancellations.

The hospital reports that one gynaecologist has a waiting list of a year for hysterectomies. People are not referred for that operation unless they are in pain or suffering from bleeding. The operation is not undertaken lightly—yet women have to wait for a year to have it. A urinogenitary surgeon said in February that he had 50 patients to be admitted for operations to Lewisham hospital, and that 22 had had to have their operations cancelled, when some had cancer of the bladder. That is not good enough.

The Independent reported, on 21 February, the case of a 36-year-old woman who was suspected of having suffered a pulmonary embolism, a blood clot in the lungs, which could prove fatal, but for whom no bed could be found in five London hospitals. The doctor tried London, Bart's, Homerton, Whipp's Cross and St. Andrews. All refused the emergency. That shows that even emergency cases are not being treated.

I hope that the Minister will not say of cancelled operations that sometimes the patients do not turn up. He should remember that many patients rely on the ambulance service to get them to hospital; if that service is being cut and journeys are being cancelled because "no vehicles are available"—the new and growing category—patients cannot get into hospital. I draw the Minister's attention to the recent London ambulance service figures, which show that, in January this year 10,476 non-emergency journeys were cancelled because no vehicles were available. What answer does he have to that? How can he preside over a system that is letting people down so badly and over an NHS that is inefficient because patients cannot come in for their operations?

It is not as if the accident and emergency service has benefited—far from it. The Orcon standard lays down the minimum time within which ambulances should get to an emergency. Judged by that, the London ambulance service, and many others, are failing to get to accidents and emergencies on time. Part of the Orcon standard is that an ambulance in a metropolitan area should get to an accident or emergency within seven minutes in 50 per cent. of its cases in a year. In London, the average is 12 per cent. of calls being answered within seven minutes.

As my hon. Friends have said, the fabric of our hospitals is crumbling. Why should those being treated in NHS hospitals have to put up with leaky roofs, draughty corridors, torn lino? Why is it that, year after year, because of the underfunded pay awards, money is taken from maintenance budgets, with the result that important maintenance is not done? Years of the spending squeeze has resulted in a huge maintenance backlog in the hospitals, and that is not good enough.

We know that the Government have underfunded the pay awards and have not taken account of inflation. I hope that the Minister will be honest about that. It has meant that the district health authorities have had to take money from their other revenue areas to pay for these pay awards, which the Government announce with a great pat on the back for themselves. They also make assumptions about the level of inflation that are far below the true level.

The Government are not prepared to invest sufficiently in a national health service because they want fundamental changes and the commercialisation of health care, and a market economy in the health service. Therefore, pressure is put on health authorities to make them balance the figures rather than to supply the care that is needed. That is what Guy's hospital, the North-East health authority and so many others are doing.

The Government are not happy to see the waiting lists grow, because they know that they are the major recruiting sergeants of private medicine. They have already made clear their commitment to private medicine, with tax relief for health insurance for the elderly. People are desperately worried. They do not agree with what the Government are doing—opting out of hospitals, and tax relief for private health care—or with the two-tier Americanised system that the Government want. For all the Government's propaganda, they have not fooled anybody. The public know, however, that the next Labour Government will abolish the internal market. That Government will bring opted-out hospitals back into the local district health authorities, which is what the people want. They—the Labour Government—will invest in our health service so that it truly becomes a service upon which the public can rely.

12.59 am

The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell)

I begin on what should be an uncontroversial note by agreeing with the hon. Member for Mid-Staffordshire (Mrs. Heal) that debates about the national health service should proceed against the background of a shared commitment to making the NHS service into a health-care service of which we can all be proud, recognising that the vast majority of our fellow citizens—in emergencies, virtually all of them—rely on the NHS as the prime or sole source of health care. There is no division between the two sides of the House about that.

The attempts by the hon. Member for Peckham (Ms. Harman) to erect the Aunt Sally of a hidden agenda and a determination to foster a move to private medicine are unsupported by the facts. It reflects on the paucity of the arguments that the Opposition are able to muster against the Government's record on health care that they can generate steam and enthusiasm only by arguing against a policy that the Government do not espouse.

The Government believe, like the hon. Member for Mid-Staffordshire, that the NHS is one of Britain's great achievements in the post-war years, and that it is something of which we all have reason to be proud. The Government are as deeply committed to it emotionally as the Opposition. The difference between our record and that of Labour Governments is that, for a variety of reasons, we have been better able than successive Labour Governments to meet the aspirations that we set of improving the quality of health care that is available through the NHS. I shall seek to demonstrate that that is true on a number of counts.

I shall deal first with two of the issues which were raised by the hon. Member for Heywood and Middleton (Mr. Callaghan). As distinct from his hon. Friends the Members for Mid-Staffordshire and for Peckham, he talked about serious local issues and asked for specific answers.

There is a short-term and a long-term question associated with the two hospitals at Wythenshaw and Withington. There is a short-term proposal to centralise maternity care at Wythenshaw, to which the local community health council has objected. Under the normal rules of management within the NHS, the proposal—because it has been supported by the regional health authority—will come ultimately to my right hon. Friend the Secretary of State to be determined. I have said already to some of the hon. Friends of the hon. Member for Heywood and Middleton that I shall be happy to meet a delegation to discuss the matter when the proposal comes to Ministers to be decided. Assuming that the CHC maintains its objection, it will fall to my right hon. Friend to make a decision.

Mr. Callaghan

I welcome what the Minister has said about the hospitals in the south of Manchester. I said, however, that five hospitals in the north of the city are to close. Will the Minister respond to my remarks about those closures?

Mr. Dorrell

The hon. Gentleman knows that there are procedures within the management structure of the health service to determine whether such decisions are made by the local health authority or by Ministers. We can run a service that expends £30,000 million a year and employs 1 million only on the basis that management authority is delegated to local decision makers. Ministers come to make decisions on hospital closures only if the local institutions of the NHS are unable to come to an agreement on what should happen in a locality. The decision to close hospitals in the north of Manchester will come to Ministers only if the CHC maintains an objection to the proposal of the DHA. I cannot respond in detail on each of the other five hospitals in the city.

On the longer-term position of Wythenshawe and Withington, a proposal has been published to centralise acute care on the Wythenshawe site in the very much longer term. If it ever came to fruition, that would have to come to Ministers as a major investment proposal requiring approval in principle. No such application has been made, or is expected in the immediate future. Obviously there would be plenty of opportunity for representations if such a proposal were to be made by the district and endorsed by the region.

The hon. Gentleman also asked questions about the provision of diabetes care in the north-west. I shall write to him when I have had a chance to examine that in more detail.

The speeches of the hon. Members for Mid-Staffordshire and for Peckham were not as sharply focused on the specific circumstances of local health provision. The hon. Ladies were much more concerned to try to demonstrate that the health service has suffered from a crisis of underfunding of the Government's making. If I may say so, both made a good stab at arguing a virtually unarguable case. I believe that the facts on the funding of the national health service show that the Government's record is distinguished and easily stands comparison with that of their predecessor.

The revenue budget allocated to the national health service- for 1991–92 has risen by over half in real terms, compared with the revenue budget which we inherited. It is up by 52 per cent., an average growth rate in real terms over the years that the Government have been in office of 3 per cent. per annum.

That figure of 3 per cent. is an interesting statistic, because it is exactly the figure by which the Labour Government cut the revenue expenditure of the health service in real terms in 1977–78—something that the Conservative Government have never done. In 1977–78, Labour cut the revenue budget of the health service by the average amount by which it has grown in real terms since we came to power.

The 3 per cent. figure is also interesting because, on 4 June 1987, the right hon. Gentleman the Leader of the Opposition committed the Labour party in government to raising NHS expenditure by 3 per cent. above the inflation rate. That is precisely what the Government have done during the 12 years that they have been in office. It is hard for the Labour party to argue that we are underfunding the health service, when our average increase over 12 years has been precisely what the leader of the Labour party said during the last election campaign would be his commitment.

If we move from revenue funding to capital funding, the facts are even more telling. In the 12 years that we have been in office, the hospital service capital budget has risen by 63 per cent. in real terms. The capital budgets of regional health authorities next year will go up by over 116 per cent. in cash terms. There are currently 450 schemes around the country valued at over £1 million which are going ahead under the Government's capital investment programme in the national health service.

As I say, that reflects an increase in real-terms commitment to NHS capital of 62 per cent. over 12 years, compared with a real-terms cut of 16 per cent. in the capital budget of the national health service during the five years of the last Labour Government. It is hard for Labour Members to argue that we are underfunding the service when we have increased the capital budget by 62 per cent. in real terms after they had cut it in their period in office by 16 per cent. in real terms.

In arguing the case of underfunding of the health service, the hon. Ladies are confronted by other problems. The right hon. and learned Member for Monklands, East (Mr. Smith) is on record as saying that Labour's only two spending commitments ahead of the next general election relate to child benefit and pensions—neither of which has anything to do with the health service. I sympathise with the hon. Member for Peckham, because she is left to build the argument that the Government are underfunding the health service, but is prevented from committing her party to any increased expenditure by the hon. and learned Member for Monklands, East, whom she will find very much tougher still if he were ever to move into No. 11 Downing street.

Various Labour party spokesmen have used various figures in trying to measure the alleged extent to which the service is underfunded. The hon. Lady is at least modest when she seeks to substantiate that claim. On 26 November 1987, she said that the health service needed an extra £200 million—with which I suppose she thought that she could squeeze by without being picked up on that expenditure by the hon. and learned Member for Monklands, East.

The hon. Member for Livingston (Mr. Cook) was somewhat more ambitious. After a claim on 14 January 1988 that the health service was underfunded by £1.3 billion, by 20 April 1990 he was saying that the figure was £3 billion. By 22 October 1990, it was said to be a sum exceeding £4 billion.

I am sure that Labour welcomes the fact that the health service expenditure programme concluded by the then Secretary of State for Health, my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) means that next year we will increase spending by £3 billion. Only one of Labour's figures is more than the amount by which we are increasing the health service budget next year alone.

The hon. Member for Peckham also has around her neck a series of commitments about the way in which any increased health service budget will be used by an incoming Labour Government. The Opposition have committed themselves, for example, to abandoning competitive tendering—which would cost £110 million out of the vote, without one extra patient being treated.

Midland Montagu, the independent brokers, examined the way in which Labour has said that it will use additional resources, and estimated in an article published in Doctor in June 1990 that the hon. Member for Livingston would have to secure from the right hon. and learned Member for Monklands, East a total of £770 million to cover the extra administrative and other costs involved, before treating one extra patient.

Various Labour Members have sought to draw attention, quite rightly, to the pay of national health service employees. The service is the largest employer in our society, and it has an obligation to be a good employer. That is why nurses' salaries in the national health service have risen by 43.5 per cent. in real terms since 1979, compared to the 21 per cent. cut in the five years that the Labour party was in power. That is why the hospital doctor's salary has risen by 36 per cent. in real terms since 1979, compared with a 6.4 per cent. cut in real terms during the period that the Labour party was in power.

The Labour party has a record, in terms of its management of the national health service, that no party could be proud of. It has considerable difficulty in substantiating its claim that our record demonstrates anything other than full commitment to the future and to the development of the national health service.

However, there is one lesson that perhaps the Labour party has learnt—let us be grateful for small mercies. That is that the only way that one can run a free, universal, tax-funded health service—to which all the major parties in the House are committed—is by subjecting it to a cash limit. That is something to which the Labour party are as explicitly committed as the Government. If one wishes to fund health care out of tax revenues, it necessarily follows that one must cash-limit the vote, and by cash-limiting it one imposes upon the management the obligation to make disciplined choices about the way in which the resources voted into the health service are used.

That is where I take most vehement exception to the allegation of the hon. Member for Mid-Staffordshire that the Government's reforms of the national service are "wrecking reforms". They are no such thing. They reflect the Government's commitment to ensuring that there is a management system in place for the service that allows us, in a disciplined and ordered way, to make the choices that are the inevitable result of cash-limiting the vote and resources available to it

Mrs. Heal

One of the criticisms of successive Conservative Health Ministers has been about the bureaucracy of the health service. How does the Minister answer the charge that I put to him about the increased administration that his so-called "reforms" of the health service are creating?

Mr. Dorrell

I was moving to that matter. Rather than asking the hon. Lady to rely on my analysis or that of my right hon. Friend the Secretary of State, I can answer her best by asking her to rely upon the analysis of Mr. Chris Ham, who I am told is a regular contributor to the columns of Marxism Today—not a magazine that I read regularly. I am told that Mr. Ham contributes to the magazine on a rather more regular basis than either of my right hon. Friends to whom the hon. Members for Heywood and Middleton and for Mid-Staffordshire referred

Ham said in The Independent on 27 June: Only those blind to the weaknesses of the NHS deny the need for change. I would not argue that the hon. Member for Peckham and her party are so blind to the need for change that they, do not recognise that something needs to be done to restructure the management of the national health service.

The Opposition made a rather half-hearted stab at describing how they would change the management of the national health service. It has always seemed to me an absurd proposition that an organisation that spends £30,000 million and employs 1 million people will somehow run itself and that there is no need for managers. Of course we need management systems in place which will exploit the new technologies and methods used outside the health service to run large organisations, to ensure that the choices made by the service are made in full possession of the facts, and in a disciplined and ordered way. In my view, that is the only basis upon which the taxpayer can be reassured that the revenues that go into the health service are successfully used to secure high-quality health care.

Health care management is about achieving the double trick of good quality health care for the patient and good value for money for the taxpayer—that is what the investment in management is designed to achieve

Mr. Callaghan

I am interested in this theme of management efficiency. I asked the Minister earlier about the possible closure of five hospitals in north Manchester and two in the south; he is such a good manager that he could not even tell me whether those hospitals were going to close. Where is the good management there?

Mr. Dorrell

I told the hon. Gentleman that I believed that the only basis on which a large organisation could be managed effectively was the delegation of as much detailed influence as possible to the local manager. I have told the hon. Gentleman that I will write to him and give him the specific details for which he has asked.

If the hon. Gentleman really believes that it is possible to run an organisation the size of the national health service on the basis that every decision of any consequence is made by Ministers, let me remind him of the old saying about Philip II of Spain: it was said that, if people had to wait for the King of Spain's permission to die, everyone would be immortal. He over-centralised. Running a large organisation means appointing good-quality managers, and then authorising them to make decisions on the basis of the local information that is at their disposal.

Ms. Harman

Why, then, has the Secretary of State kept to himself the decision whether local hospitals should opt out? This rhetoric about giving people choice at local level simply is not matched by the system that allows central decisions by the Secretary of State about which hospitals can opt out, and does not allow ballots or a say for local people

Mr. Dorrell

This is the first time that I have heard the trust initiative presented as a centralisation of management power. The hon. Lady is shifting her ground. She is no longer interested in arguing with us about funding; she now wants to suggest that trusts constitute a centralisation of management power. They are, of course, precisely the opposite. They reflect the Government's commitment to delegated management—to enhancing the power, influence, discretion and flexibility that are available to local management, and returning to a local community the opportunity to run its own hospital. It is hard to argue that 57 individual decisions constitute gross centralisation.

The hon. Member for Heywood and Middleton obliquely mentioned acute bed spaces in his questions about Manchester hospital provision. It is important, in any assessment of the Government's record on the national health service, to look less at the number of people employed in the service and the amount spent on the service, and more at the number of patients treated by the service and the quality of care that they have received.

The hon. Member for Peckham always prefers to avoid discussion of activity levels in the health service. I am not surprised. Since 1979, the number of acute in-patient treatments has risen by 25 per cent. The hon. Lady tried to use the anecdotal evidence that she has been able to secure by ringing around a few health authorities to allege that this year may show a minor downward trend. I do not know the answer to that, because this year is not yet over. As I said during her speech, we shall wait and see what this year's figures show.

What I am absolutely confident about is that this year's figures will still show a substantial increase in health service activities over the 12 years in which the present Government have been in power. So far, the published figures—the accurately audited figures—show a 25 per cent. increase in the acute-patient activity level, and a more than doubling of the day-case activity level. Surely that undermines the hon. Lady's suggestion that our commitment to the future of the service is open to question.

Furthermore, the increase in acute patient treatments—both in-patients and day cases—as I said in the press release from which the hon. Member for Peckham quoted, is not merely a question of increased patient throughput; it is also a question of higher-quality health care. We are able to treat those patients with fewer acute beds; we require them to stay in hospital for shorter periods than was previously necessary.

This is not something that started in 1979. The suggestion that the closure of acute beds was invented by this Government is very wide of the mark. The closure of acute beds occurred before 1979 and has gone on since then, and the major reason for it is that modern medicine is less traumatic, in the technical sense, for the patient: the patient recovers faster from an operation involving minimally invasive surgery than he did from the techniques of 15 or 20 years ago. The purpose of health care is not to require people to withdraw from the community and occupy an actute bed; its purpose is to get patients out of hospital and back into the community as quickly as possible. The modern health service allows us to treat more patients with fewer acute beds.

That is welcome on two counts: first, we are able to meet more demands made upon us by the patients; secondly, we can meet them in a way that is less traumatic to the patient and therefore constitutes higher-quality, better-value health care.

Ms. Harman

Does the Minister not then accept the figure of the National Association of Health Authorities and Trusts that over 3,500 beds have been closed for purely financial reasons?

Mr. Dorrell

I certainly do not accept the proposition that one can distinguish between a bed closed for financial reasons and one closed for any other reason. As I said five minutes ago, the Labour party is as deeply committed—and rightly so—as we are to the proposition that the only basis on which the health service can be run is by cash-limiting the vote and then requiring managers to make choices.

Under the previous Government and under this Government, managers have quite rightly decided that, in using resources, it is more important for them to treat more patients than it is to keep open beds. That is a choice that managers make week by week, month by month, and not one in which it is possible to distinguish between a bed closure made for financial reasons and one made for some clinical reason.

If the hon. Lady does not understand that, I do not believe that she understands anything about managing a large organisation. Managers are there to make choices, and the choices they make are about the way in which resources are used.

I should like to move on briefly to waiting lists, another subject which came up during the speeches of both the hon. Member for Mid-Staffordshire and the hon. Member for Peckham, and which again reflects well on the record of this Government and badly on the record of our Labour predecessors. The fact about waiting lists—this is glossed over by spokesmen for the Labour party—is that the in-patient waiting list is now lower than it was in 1979, despite the fact that 25 per cent. more in-patients are being treated than in 1979.

Furthermore, there are some quite interesting statistics in the history of waiting lists. It is not only during the present period of Conservative government that we have been able to cut waiting lists. During the period of the Labour Government of 1974–79, waiting lists rose by 50 per cent. Since this Government came to power, as I reminded the House, they have been cut, as they were during the period of the previous Tory Government in 1970–74. So, since 1970, under both periods of Conservative rule, waiting lists have been cut; under the period of Labour rule, waiting lists rose by 50 per cent. It is hard for the Labour party to argue against that background that our waiting list record is somehow a measure of weak commitment to the health service.

Let me, however, give the hon. Member for Peckham the defence, lest she should have forgotten it, to the charge that her party's record on waiting lists is not as good as she might wish it to be. Waiting lists are not unimportant, especially when they rise by 50 per cent. in five years, but they are not the principal problem. It does not matter very much how many people are on the waiting list, but rather how quickly a patient gets into hospital. The statistics on that are even more telling. Half of all NHS in-patients are admitted immediately; they are not put on to a waiting list. Half the remaining half go into hospital within six weeks. The problem of long waiting lists undoubtedly exists, but it exists only within a quarter of the number of people requiring in-patient treatment. The waiting list initiative has been directed precisely at that quarter.

The hon. Member for Mid-Staffordshire referred to the record of John Yates——

Mr. Mark Fisher (Stoke-on-Trent, Central)

Why did he leave?

Mr. Dorrell

The hon. Gentleman had better ask Mr. Yates that question.

I applaud the fact that, during the period that Mr. Yates had a consultancy contract with the Department, he managed to cut waiting lists, in the worst cases, by 34 per cent. We have now recruited another consultancy to continue precisely the work that Mr. Yates was doing. We continue to be committed to the proposition that the long wait on the tail end of the waiting list is unacceptable.

Unlike the hon. Member for Mid-Staffordshire, who appeared to think that, when a consultant had accepted a person on his waiting list, it was acceptable for the wait for relatively minor routines to be spun out, we believe that a high priority must attach to reducing the worst of the waiting periods. We must remember, however, that the tail of the NHS waiting list is a relatively small part of the total number of people waiting for treatment.

I do not believe that either the hon. Member for Mid-Staffordshire or the hon. Member for Peckham made any progress in establishing that the Government are anything but deeply committed to the success of the NHS, and furthermore have a record that easily stands comparison with that of our predecessors.