Health Service and Community Care

HC Deb 14 May 1991 vol 191 cc155-207

Mr. Speaker

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

Mr. Andrew Mitchell (Gedling)

On a point of order, Mr. Speaker.

Mr. Speaker

Order. I am on my feet.

Many right hon. and hon. Members are seeking to participate. I have no authority to propose a 10-minute limit on speeches in a half-day debate, but I hope that hon. Members who are called to speak will be brief so that many of their colleagues can participate. What is the hon. Gentleman's point of order?

Mr. Mitchell

I seek your guidance, Mr. Speaker. There is a ten-minute Bill on the Order Paper in the name of a Labour Member.

Mr. Speaker

Order. I said that it is perfectly in order for an hon. Member who, for good reasons which he has explained to me cannot be present, to withdraw his motion.

Mr. Mitchell

The point on which I seek your guidance, Mr. Speaker, is that the Bill dealt with removing restrictions on immigration. It is extremely offensive to me, to many of my hon. Friends and to many of my constituents. It is, however, an important matter, and I seek your guidance as to whether it might be—

Mr. Speaker

Order. It is perfectly in order for an hon. Member who cannot be present not to move his motion, and that is what has happened today. Nothing out of order has occurred.

3.36 pm

Mr. Robin Cook (Livingston)

I beg to move, That this House records its concern at the damage to the National Health Service from the implementation of the National Health Service and Community Care Act; condemns the pressure created by the new system for a two-tier health service in which waiting time is determined not by clinical need but by commercial priorities; is disturbed that the introduction of block contracts had reduced patient choice of hospital and restricted general practitioners' freedom of referral; regrets the shortage of people representative of their local community among the businessmen appointed by Her Majesty's Government to decide local health priorities; notes with alarm the financial instability that has already become evident among hospitals that have formed self-governing trusts; deplores the decision of the Secretary of State to approve 57 health units for trust status despite advice that there were financial problems with 45 of them; and calls upon Her Majesty's Government to abandon its plans for a second wave of health units to form such trusts. It is just under four weeks since the House last debated health, yet so much has happened in those four weeks that it is almost unkind to remind Ministers of what they said in that debate.

The Secretary of State for Health took pleasure in the fact that the changes had been introduced with, as he said, "no significant problems." The Minister of State, eight days before the cuts were announced at Guy's hospital, announced to the House: It will not be long before the noise about trusts…abates."—[Official Report, 17 April 1991; Vol. 189, c. 512.] I took the precaution of checking Hansard last night in the Library in case a member of the Prime Minister's private office had been down with an errata slip.

My favourite passage was from the Secretary of State's speech in which he complimented the British Medical Association on—in his words—moving on and "becoming sensible." The Secretary of State will have followed with interest the views expressed by the new, sensible BMA over the past couple of weeks, culminating last Thursday after his meeting with it when it reported: the Secretary of State was not open to reason. That is from the very medical people who, 20 minutes ago, the Prime Minister said should take the decisions on whether a hospital should seek self-governing trust. Try telling that to the BMA.

There have been two developments since our last debate, which have given Ministers' speeches a near-comic irony which they lacked on first hearing. First, events have exposed the gulf between what Ministers promised as a result of the changes and the real effect of the changes. Last autumn, staff at Guy's were promised that the hospital would make a surplus of £1.5 million in its first year of trading. A month after the new system was introduced, the same staff at Guy's were told that the hospital was predicting a deficit of almost £7 million. At the beginning of April, the staff at Guy's received a circular from Mr. Peter Griffiths in which, under the heading "We are friendly and we are fun", he assured the staff: The management cares, really cares, about people, about their staff. At the end of April, 600 of the staff who had received that letter discovered that they might be made redundant over the next two years.

Whenever I refer to trusts as opting out, Conservative Members shout me down. I am bound to say that nothing has more convinced the public that a hospital that has formed a trust has opted out than the speed with which Ministers let it be known, when the cuts at Guy's became evident, that Guy's was on its own, that it was no responsibility of theirs, that what the board of directors did to staff jobs or patient care had nothing to do with them.

The Secretary of State cannot have it both ways. He cannot on the one hand assure us that trusts have not opted out and, on the other hand, wash his hands whenever they hit trouble. He cannot have it both ways, because his own reputation is on the line. He approved the very business plan that is now in such trouble. The Secretary of State has not been allowed by the media to ignore the crisis at Guy's.

Sir Anthony Grant (Cambridgeshire, South-West)

What trouble?

Mr. Cook

The hon. Member below the Gangway asks, "What trouble?" I do not know whether the hon. Gentleman has been out of the country for the last four weeks, but the rest of the nation knows that the trouble at Guy's is the turnround of a £1.5 million surplus, as promised in the business plan last autumn, to a £7 million deficit, with a 10 per cent. cut in staff and the dropping of whole specialties. If the hon. Gentleman does not recognise that as trouble, I do not know what he would recognise as trouble in the health service.

I was intrigued to note that the Secretary of State has now produced a novel defence of the new structure. I paraphrase his argument, but the nub of it—rehearsed several times on television and rehearsed again a few moments ago at Question Time—is that there is too much hospital capacity in London, that the advantage of the new commercial competition is not that it will strengthen the London hospital service but that it will show which London hospital should go under. On that basis, it is no doubt sensible to throw in a few high-risk cases such as Guy's.

If it is the Secretary of State's view that the problem is that there are too many hospitals in London, I cannot imagine a worse solution than throwing them all out into the market to see which sinks. We cannot plan an essential public service by waiting to see who goes bankrupt. While we wait, as the Universities Funding Council reminded us last week, we could disrupt the training of a whole generation of medical students.

I must remind the Secretary of State that the House was not sold the Government's changes on the basis that they would show which hospital should close. The Secretary of State is still comparatively new to his portfolio. He is the third Secretary of State that we have had during the process of these changes. Now that the general election is unlikely to be held until 1992, we have time for a fourth.

May I remind the right hon. Gentleman, however, that the national health service review that led to these changes was born out of the closures in the winter of 1987–88? It was presented to the House as the solution to those closures. The right hon. Gentleman's predecessor was lavish with his promises. There were promises about what would happen after the changes—that money would follow the patient. As we all know, there is never any shortage of patients. The implication was that, when money followed the patients, there would be no shortage of money, either.

I treasure in particular this passage from the speech of the right hon. Gentleman's predecessor in January 1990. Next year, he said, in April 1991, we propose to reform the NHS: the coming winter will end the last year of an entirely unreformed service. The winter of next year will not be dominated by cancelled operations, closed wards and cuts in services".—[Official Report, 11 January 1990; Vol. 164, c. 1124.] Indeed not. The net effect of the changes has been to bring the cuts and closures forward this financial year from the winter to the spring.

A whole new lexicon of cuts is being used in the Minister's Department. I saw the other week an internal Department of Health memorandum which no longer talks about closing wards but about "downsizing hospitals". I noticed last week that Guy's no longer talked about specialties but about "reprofiling services".

Mr. Kenneth Hind (Lancashire, West)

The flaw in the hon. Gentleman's argument is that the purchasers of health care in and around the environs of London have realised that they do not have to send their their patients to London teaching hospitals. They can send them down the road to the local district general hospitals. When the hon. Gentleman talks about NHS trust hospitals, he fails to look at the same time at the same problem that is being faced by those that have not yet opted out.

Mr. Cook

I have heard that argument before. I noticed with interest that Dr. Ken Grant deployed it in relation to the problems that he faces at Bart's. Hon. Members who represent districts in the inner city of London and deprived areas such as Hackney, which Bart's serves, find it incomprehensible that if, all of a sudden, there is spare capacity as a result of people from the home counties no longer coming to London, waiting lists in their areas for their constituents continue to grow.

They find it unacceptable to be told by the manager of Bart's that they will have to admit people from Essex in two weeks when they cannot admit people from Hackney within a year. If that surplus capacity is there, surely we should be using it for the people served by those hospitals.

I was recalling the new way in which cuts, which occur not just in London, are described. My hon. Friends who represent constituencies such as Bradford, Leeds and Newcastle have talked about the cuts that are now being made by trusts in their cities. Nor are just trusts in difficulty. One of the most breathtaking interviews that the Secretary of State gave in the wake of the crisis at Guy's was when he defended the trusts against criticism by pointing out that other hospitals that were not trusts were in just as big a financial hole. I congratulate the right hon. Gentleman on his candour, although I do not understand why he imagined that viewers would be reassured by the news that trusts were all right because everybody else was in the same financial boat.

From a flurry of press cuttings on closures—I should refer not to closures but to the downsizing of hospitals that are now trusts—I single out one. That is about the closure two weeks ago of a ward for elderly patients in Bath. I choose that press cutting because the report was accompanied by a charming photograph of the right hon. Member for Bath (Mr. Patten), the Chancellor of the Duchy of Lancaster, shown smiling beside a plaque recording that it was opened by him in October last year.

I could find no better illustration than that photograph of the gulf between what was promised and what has happened. It was a photograph taken the month before the right hon. Gentleman became chairman of the Tory party, showing him opening a ward. That very ward, within four weeks of the changes introduced by the Government, has been reprofiled and closed.

Mrs. Maureen Hicks (Wolverhampton, North-East)

I recall that, only a year ago, the hon. Gentleman, when making a financial assessment of the requirements of the NHS, maintained that, if we injected just £3 billion, all our problems would be solved—that no reforms or control of union power in hospitals would be necessary, and all would be magic. Since then, an extra £6 billion has been injected into the NHS. Is he aware that, if he continues to ignore the need to reform the NHS, no progress will ever be made?

I am increasingly coming to the view that the hon. Gentleman is interested only in orchestrating events to take advantage of vulnerable people who depend on the NHS—[Interruption.]—and he is playing, as he knows, into the hands of the unions.

Mr. Speaker

Order. This sounds like a good speech for later on.

Mr. Cook

Will the hon. Lady allow me to intervene? I did not produce a figure of £3 billion but quoted the estimate of the National Association of Health Authorities for the cumulative underfunding of the health service. She was right to say that, when I quoted that figure in the spring of last year, that organisation's estimate for cumulative underfunding was £3 billion. In view of the hon. Lady's complacency about the funding of the health service since then, she should know that the National Association of Health Authorities has now revised that figure to £4.5 billion.

Mr. Phillip Oppenheim (Amber Valley)

Will the hon. Gentleman give way?

Mr. Cook

I shall give way to the hon. Gentleman—

Mr. Speaker

Order. The hon. Member for Livingston (Mr. Cook) was seeking to answer a point that was put to him. It would be disruptive to have another question before he has finished answering the first.

Mr. Cook

I shall seek to give way to the hon. Gentleman when I can, as he is always worth it.

The figure of £4.5 billion is extremely interesting. The Chancellor of the Exchequer produced precisely the same figure out of a hat to deaden the political pain of the poll tax. If Conservative Members can find £4.5 billion to save their political skins, they can find it to save the national health service.

Mr. Oppenheim

While the hon. Gentleman is on the subject of funding, did not the shadow Chief Secretary originally tell the House that the only priorities under a future Labour Government would be pensions and child benefit? The hon. Member for Livingston then told the House that spending on health would also be a priority. However, the Leader of the Opposition has just told us that spending on the health service would increase only in line with economic growth. Is not the Labour party playing its old cynical game of trying to be all things to all men as usual?

Mr. Cook

I have the advantage over the hon. Gentleman, because I heard my right hon. Friend make his speech, and very well received it was, too. I know that my right hon. Friend said no such thing—[Interruption.] I merely seek to serve. My right hon. Friend the Leader of the Opposition said that the extra tax that comes from growth should be used for health and other essential services, which is entirely different from the slant being put on it by the hon. Gentleman and the Secretary of State, who imply that the Labour party was committing itself to spending no more on health than the growth of the economy. As my right hon. Friend said, that extra money will ensure that underfunding can be tackled from the start.

Sir Nicholas Bonsor (Upminster)

Will the hon. Gentleman give way?

Mr. Cook

I should like to return to my own speech at some stage, but I shall make a bargain with Conservative Members. I shall give way now to any Conservative Member who can explain to the House and to the country how the Government propose to find £30 billion to reduce the basic rate of tax, without ripping it out of the national health service.

Mr. Jerry Hayes (Harlow)

Will the hon. Gentleman give way?

Mr. Cook

Yes, I knew that the hon. Gentleman would not fail me.

Mr. Hayes

The hon. Gentleman is a man of great integrity. After all, he voted against the 48 per cent. rise in waiting lists when the Labour party was last in office. Nevertheless, he has proposed a simple challenge. There is something called the Laffer curve, and I suspect that the last Laffer will be that of the Conservative Government. Quite simply, we have reduced taxes, as opposed to the plans of the hon. Member for Livingston (Mr. Cook), who intends to increase them. In 1979, the top 5 per cent. of taxpayers were paying—[Interruption.] The hon. Gentleman should listen carefully, because he asked a question—

Mr. Speaker

The hon. Gentleman was challenged by the hon. Member for Livingston (Mr. Cook) but should come to the point, not make a speech which he might make later.

Mr. Hayes

I shall make it clear—in 1979, the top 5 per cent. of British taxpayers contributed 24 per cent. of the volume of taxes coming in to this country. Since the Conservative Government reduced taxes, the top 5 per cent. now contribute more than 31 per cent.—which means that there is more money for the health service. We are able to cut taxes and spend more money on public services, which is more than a Labour Government could ever do.

Mr. Cook

My question was about a cut in the basic rate. The hon. Gentleman referred simply to cuts in the top rate. We should welcome the insight that he has given us into what will happen if the Conservatives are re-elected—the clear sign is that they will cut the top rate. If the hon. Gentleman hopes to sell the paradox that he offers the House today, even to the good electors of Harlow, he must explain why, whenever the Government cut the rate of income tax, they have to compensate by increasing indirect taxation through VAT, which people who may well not pay income tax will have to pay when they buy their goods in the shops.

We have had good, clean, knockabout fun, which I thoroughly enjoy, but I shall now return to my speech. There is no better illustration of the gulf between what Conservative Members promised and what happened than that photograph of the Conservative party chairman. I want to leave the last word on the emptiness of the rhetoric that the Government wrapped around the reforms to Lothian health board, which has just dropped from its stationery and logos the term "Putting Patients First". That logo was dropped from all publications by the Lothian health board last week because, as its manager revealingly said on Sunday, management figures are sick of having the phrase used as a stick to beat them"— [Laughter.]—my hon. Friends have missed the punch line— every time they make cuts". There has been only one poll since the Government ran into problems with its NHS changes. Last week, a poll carried out by The Scotsman found that 58 per cent. of those replying believed that the Government changes would make the health service worse. A total of 9 per cent. believed that it would increase the health service. That response makes even the poll tax—the Secretary of State's last invention—look like a runaway success in popular support. It is not the Labour party but the voters who are currently making health the main issue of the Monmouth by-election and who will make Thursday's vote a referendum on NHS changes.

That prompts me to ask my next question of the Secretary of State. Given the overwhelming rejection by the public of those changes, how can the Secretary of State persist with his plans for a second wave of more than 100 hospitals to opt out and form trusts? Why does he not let people decide for themselves in a general election, which not even this Prime Minister can keep putting off for ever? If the Secretary of State does persist in his plans, and as the hospitals contemplate opting out, will he let the staff at those hospitals have a proper ballot?

I ask that question because the Conservative Monmouth candidate said that such a ballot would be "sensible and proper". Does the Secretary of State endorse the candidate's view? I would not ask the Secretary of State to endorse all the views of the Conservative candidate in Monmouth—I realise that that would be too painful—but will he endorse this one? It looks as though he could do with a lifeline. Or are we to take it from the Secretary of State's silence that on that point, as on so many others, the Conservative candidate for Monmouth is an embarrassment to his party?

The second development since our debate last month—

Sir Nicholas Bonsor

I am grateful to the hon. Gentleman for giving way, especially in view of the pressure of time. He should not give too much weight to what the candidates in Monmouth say—[Laughter.]

Mr. Speaker

Order. These interruptions take up a great deal of time.

Sir Nicholas Bonsor

—given that the Labour party candidate in Monmouth is putting up an appalling performance.

Does the hon. Gentleman acknowledge that efficiency in hospitals is essential in order to give patients a proper service? Does he not realise that hospitals under the NHS have been unable to account properly for the use of blankets, penicillin or anything else allowed for in their budgets? Because they have not had proper hospital accounting, they have not been able to deliver the service to patients. Is it not right to insist that hospitals have proper accountability and economic controls? Surely that is the best way of doing things.

Mr. Cook

I shall make a deal with the hon. Gentleman. I shall offer to concede that, as in any multi-million pound business—the NHS is a multi-billion pound business—there are always opportunities—[HON. MEMBERS: "Answer the question."] I am trying to use language that Conservative Members will understand. There are always opportunities for greater efficiency and greater savings; I would not deny that for one moment. But does the hon. Member for Upminister (Sir N. Bonsor) agree that the worst cases of waste that we have witnessed in the NHS have involved surgeons being paid salaries to stand idle and do no operations, operating theatres paid for and equipped but not used, and wards lying empty because hospitals cannot afford to admit patients? That is waste and inefficiency on a colossal scale, which dwarfs potential savings on blankets.

The second development since our previous debate is that events have proved how right Opposition warnings were. We warned that the new commercial system would result not only in less choice, but in a less fair health service. We warned that, if hospitals were to survive by making money from contracts, they would be quick to give priority to the contracts that made the most money. They have indeed been quick to do that. There have already been several sightings of GP fund holders securing a fast track to put their patients in front of everyone else. One of the directors of the board at Watford observed as much, when he said: the board are aware that the implication of agreeing these contracts is a two-tier service. Appropriately, that statement was made by the new marketing manager of Watford hospital.

There is a simple way to describe the new arrangements—queue-jumping. Over the past week it has been fascinating to see how Ministers have tried to defend and deny the double standards in patient care that break out on a waiting list when a market behaves like a market. On Tuesday, the Prime Minister was still trying to maintain that admissions would be made according to clinical priority—the only difference, presumably, being that, since 1 April, clinical priority has been decided by marketing managers. By Thursday, his position had been overtaken by the evidence. The Secretary of State defined a new bolthole for Ministers, drawing a distinction between urgent cases, which must be dealt with according to what he described as proper priorities, and non-urgent cases, for which it is presumably acceptable to use the improper priorities of the market.

Let us not deceive ourselves by the comfortable term "non-urgent". When we speak about non-urgent patients, we mean elderly women who are crippled and housebound because they cannot get a hip replacement operation, about middle-aged men who cannot work because of a painful hernia, and about pensioners going blind because they need a cataract operation. The right hon. Gentleman may describe such people as non-urgent patients, but they are people suffering from pain, discomfort and indignity, who want an urgent cure. How can Conservative Members justify admitting such people in order of commercial priority? How will they sell that to patients at the end of the queue?

It is not only GP fund holders who are producing the double standard on waiting lists. Last week, I published correspondence from Alderhey children's hospital in Liverpool, a hospital which formed a trust in the first wave. That letter bluntly told north-western districts that Mersey district had agreed to pay a premium for each case of child heart surgery. The letter said that, unless the north-western districts agreed to pay the same premium, It is not … possible for us to guarantee that any children currently waiting will be treated in the financial year". There is no mention there of clinical priority.

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

I am used to the stories that the hon. Gentleman puts about, which turn out on closer examination to be not quite what they seem. As he knows, for many years we have had money which is used to diminish waiting lists. All that the hon. Gentleman's story shows is that various districts were choosing from among their many priorities those to which they would apply waiting list money. Some chose to put it into a specific branch of paediatrics and others did not.

Mr. Cook

I am not making up a letter from Alderhey hospital. Not only have I seen that letter: I have seen the reply from North Manchester health authority, which properly and vigorously says that that authority has a contract with Alderhey hospital. The pricing of that contract is at less than half the premium that Alderhey now demands for each case of child heart surgery. North Manchester health authority says that Alderhey hospital must now admit those children on the basis of clinical need and priority, and not on the basis of the commercial price that Alderhey seeks.

Mr. Waldegrave

The hon. Gentleman does not understand. The hospitals told the districts that, if some of that waiting list money could be used for this specialty, extra wards could be brought back into use. There is nothing whatever wrong with that. It would not have threatened existing contracts, and more children could have been treated. I am sorry that the hon. Gentleman still does not understand that.

Mr. Cook

Apparently I am not the only one who does not understand the letter from Alderhey hospital; nor does the general manager of North Manchester health authority. He lives closer to the scene than the Secretary of State, he deals regularly with Alderhey hospital, and he has negotiated a contract with it and is therefore better placed than the Secretary of State fully to understand the meaning of the letter, which states: It is not … possible for us to guarantee that any children currently waiting will be treated in the financial year". There is only one way to understand the meaning of those words, which were addressed to districts who paid double the price. Such a double standard has no place in a public service.

Delays in children's heart surgery at Birmingham drove the Government into setting up the NHS review. Perhaps a two-tier list for children's heart surgery will finally discredit the outcome of that review and will demonstrate what happens when the national health service is run as a commercial business. Labour will scrap this market in health care and bring back into the local health service hospitals such as Alderhey which have gone it alone as trading enterprises. We will restore the NHS as a public service, as we have done before.

Before the Secretary of State tries his hand again at a historical novel and distorts the record of the last Labour Government, I shall tell him about that record. [Interruption.] I am happy to say that we do not intend to rewrite history. I shall quote from an answer received by my office on Friday from the Department of Health.

The Secretary of State will recall that, during an earlier debate on the national health service, he taxed me with the claim that, under the Labour Government, there was only one year when there was a cut in real terms in spending on health. The Opposition asked his Department to provide us with the figures on the real terms volume expenditure on the health service. As the figures came from the right hon. Gentleman's office, I think that we can be sure that they have been pored over to cure them of any Labour bias.

I have to report to the House that the figures produced on Friday in Hansard show nothing of the sort that the right hon. Gentleman asserted. Under the Labour Government, there was a steady increase every year in volume spending. There is one year, however, in which health spending in real terms fell by 1 per cent., and that was 1979, the first year of the Conservative Government's term of office.

Mr. Waldegrave

The hon. Gentleman has been misled. If that has happened as a result of an answer from my Department, I apologise to him. The figures are clear. I know exactly the mistake into which the hon. Gentleman has fallen. If the figures are taken on the basis of a calendar year, which does not include the additional moneys that are produced regularly towards the end of the year—for example, pay review bodies—the result is that which the hon. Gentleman has described. However, the year-on-year figures, which have been published for many years, show only one year in the history of the health service when there was a revenue cut, and that was 1977–78.

Mr. Cook

I accept that the right hon. Gentleman genuinely did not seek to deceive the House, and really believed in what he said. Knowing the problem that there might be in convincing him of the reality, I have brought with me the relevant edition of Hansard. It—[Interruption.] I am not surprised that the hon. Member for Esher (Mr. Taylor) is running backwards and forwards from his seat behind the Secretary of State to the Box, he being the right hon. Gentleman's Parliamentary Private Secretary.

At col. 491 on 8 May, there is an answer from the Under-Secretary of State for Health, who has been accused of misleading me. I wish to spring to his defence and to say that I have never known him deliberately to mislead. The figures are set against the years. The years are 1974–75 and 1975–76 through to 1989–90 and 1990–91. I think that the Secretary of State now has the answer in front of him. His Department provided financial year figures that do not record that which he suggested in our previous debate.

Sir Anthony Grant

Will the hon. Gentleman give way?

Mr. Cook

No; this is a private quarrel.

Mr. Waldegrave

The figures show that there was only one year, 1977–78, when there was a cut in spending.

Mr. Cook

I shall read out the figures. In the financial year 1976–77, total spending on the NHS was £18,617 million. In 1977–78, it was £18,889 million. In 1978–79 it was £19,606 million. The figures make it clear that there was no cut. There was a cut, however, in 1979–80. The Government are the people who tell us that their accounting methods are better than those that are to be found in the health service. They are the people who lecture managers that they are unable to obtain proper information and proper costings of operations in the health service. At the same time, they cannot agree on the terms of a parliamentary answer.

Mr. Waldegrave

I shall give the hon. Gentleman the gross total of NHS expenditure at 1991–92 prices. That is real prices. For 1975–76, the spending was £21,568 million. It was £21,689 million for 1976–77 and £21,155 million for 1977–78.

Several Hon. Members

rose—

Mr. Speaker

Order. May we have one at a time—and would it not be a good idea if we got on with the debate?

Mr. Waldegrave

I have been talking about the health expenditure figures. Is the hon. Member for Livingston (Mr. Cook) talking about the undivided departmental figures?

Mr. Cook

I am talking about the NHS total figure, with which column 491 of Hansard has provided me. If anyone has got the figures wrong, it is the Parliamentary Under-Secretary of State.

You kindly suggested, Mr. Speaker, that, as we had plainly won this exchange, it was now time to move on. I was interested to note—

Sir Anthony Grant

Will the hon. Gentleman give way?

Mr. Cook

No, I will not. I was interested to note that on Friday—

Sir Anthony Grant

rose—

Mr. Cook

No, I must press on.

Mr. Speaker

Order. I have already pointed out that a great many hon. Members wish to participate. This is becoming a kind of Committee stage.

Mr. Cook

On Friday—[Interruption.] I must ask my hon. Friends to allow me to proceed.

On Friday, the Secretary of State produced a new illustration of the contrast between his Government and ours. He made a speech in which he attacked me as well as the Labour party—and vulgar stuff it was; not the stuff of which he carved his intellectual reputation at All Souls. This was definitely gamma minus stuff. He said: We have dramatically increased the numbers of doctors and nurses working in the NHS. I am sorry to say that the right hon. Gentleman's ministerial colleagues have let him down again: they have produced the figures.

Throughout the 1980s, the number of doctors increased by 18 per cent. That is a comfortable increase, for which I will not deny credit to Conservative Members. During the period of the last Labour Government, however, the number of doctors increased by 25 per cent.—and that was over five years, not 10. The rate of increase was three times as fast as the annual rate under the present Government.

The right hon. Gentleman's colleagues have also been very helpful in providing the figures relating to nurses. If we take the increase in whole-time equivalents on the same basis, we find that, in the 10 years of the present Government's tenure, the number of nurses in our wards increased by 6 per cent.

Sir Nicholas Bonsor

What about the numbers?

Mr. Cook

I am talking about the numbers. Under the last Labour Government, the number increased by 14 per cent., at nearly four times the annual rate. The Secretary of State spoke of a "dramatic increase". What superlative—what hyperbole—would he find to describe the record of the last Labour Government, which is three or four times better than his Government's record?

Several Hon. Members

rose—

Mr. Cook

I will not give way.

The question for the right hon. Gentleman is this: how can he hope, at the next general election, to persuade the voters that he will do any better next time round, when sitting beside him is a Chancellor who wants to rip £30 billion out of public spending? Where will that £30 billion come from, and how much will come from the health budget?

At the next election, the electorate will have a clear choice between a Labour party that is committed to using the increase in revenue to restore the NHS and essential services, and a Conservative party that is committed to using it to pay for tax cuts. The need for that choice to be made could be seen clearly last night at King's College hospital in Camberwell. Yesterday evening, 14 people were admitted to the accident and emergency department. They had to remain lying on trolleys in the casualty room, because no beds could be found for them. Last November, the hospital closed 120 beds to meet the Secretary of State's deadline of 1 April for the elimination of the hospital's deficit. Those 14 people included an 89-year-old woman who was blind and had suffered a fall, and a 16-year-old boy who was vomiting blood. They were all lying on trolleys 9 in apart. That is the real price of underfunding of the health service. That is the real price being paid for the commercial priorities of this Government. And those are the people who cannot afford a 5p cut in the basic rate.

There is only one good consequence of the events of the past month: the Secretary of State and his changes have put the health service back in the centre of the stage. Some of his colleagues may well doubt whether that was wise, because the NHS occupies the fault line between our values and theirs. It is clear that some activities are too important to be left to the market, that there are some public services that are not just fairer but more efficient when they are planned to meet social needs and not driven by chasing market forces.

It is because, as hon. Members have just shown, they are incapable of understanding that the NHS is not safe in their hands. That is why the electorate now have a clear choice between losing their NHS under this Government or renewing it under a Labour Government.

4.20 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: welcomes the progressive implementation of the Government's reforms of the National Health Service, coupled with substantial increases in resources for the National Health Service and in the numbers of patients treated since 1979; looks forward to the benefits of these reforms being spread more widely so that services everywhere are brought up to the standards of the best, especially with the further development of National Health Service trusts and fundholding practices; notes that district health authorities and general practitioner fundholding practices will both give priority to patient's clinical needs; welcomes the determination of the new National Health Service trusts to get to grips with long-standing management problems; supports the new role of district health authorities as guardians of the public health, accountable for arranging comprehensive care for their local residents; and endorses the Government's intention to set out a new agenda for the National Health Service which concentrates more than ever on improving the health of the people. As the sound and fury of political debate declines for a moment, commentators are beginning to see that there are two issues on which the Labour party has staked out its ground. First it claims that its members would be better than we are at producing resources. Secondly, it claims that it would be better at getting those resources to where they are needed within whatever constraints are imposed. Both sides are agreed that this service will remain cash limited.

The Labour party remains in trouble about money, as usual. The anxiety of the right hon. and learned Member for Monklands, East (Mr. Smith) to appear respectable in the City has completely undermined the series of costed and uncosted, bogus and less bogus pledges made by his hon. Friend the Member for Livingston (Mr. Cook). Every lobby which writes to them gets a nod and a wink, indicating that there will be more money for its particular cause.

The pit into which the right hon. and learned Member for Monklands, East, with the able assistance of the Leader of the Opposition, has now dug the Labour party was demonstrated to listeners to "Today" yesterday, I think, when the right hon. and learned Member for Monklands, East was comprehensively carved up by my right hon. and learned Friend the Chief Secretary to the Treasury. We simply do not now know what Labour Members mean by their spending pledges, and it is increasingly clear that neither do they.

First, our record in office is better than Labour's. Labour increased spending on health by about 1.5 per cent. in real terms; we have increased it by about 3.2 per cent. in real terms. We have done better than Labour said that it would have done in 1987 had it been elected. The Labour party promised an increase of 3 per cent. in real terms in 1987 and we have provided a 3.5 per cent. increase in real terms since 1987. Both in the reality and in the promises, our word has more reason to be trusted by the electorate then Labour's.

Furthermore, as has already been pointed out, the hon. Member for Livingston has failed to achieve what many Labour Back Benchers might feel it was his duty to achieve—to place the health service among the principal priorities of the Labour party in the run-up to the next election.

Why should anyone believe that the hon. Member for Livingston would be any better in dealing with the right hon. and learned Member for Monklands, East if Labour were in power than he has been in opposition? He has not won the argument with his right hon. and learned Friend in opposition and he would not win it if Labour were in power. It is far more likely that, if the Labour party were to find itself in power, events would be just as they were last time. I stand completely firmly on the figures, which show that, in 1977–78, Labour cut spending on the health service in real terms and cut the capital spend throughout its period in office.

When I last raised that matter with the hon. Member for Livingston—it clearly distresses him to have to remember what happened when Labour was in power—he said, rather lamely, that he had voted against the 1975 White Paper. Well, his memory deceives him. He did not. He abstained. Some of the Opposition Members below the Gangway were more consistent. They voted against it all right. But the hon. Member for Livingston was not to be found in the House on that occasion. That once again shows that, when the crunch comes, and when faced with the equivalent—this is what we must and will prevent—of the right hon. Member for Leeds, East (Mr. Healey) charging about the Treasury again cutting everything to ribbons, the hon. Gentleman will not be there on the night.

Sir Anthony Grant

I wish to refer to the Labour party's record—my right hon. Friend will recall that the hon. Member for Livingston (Mr. Cook) was too nervous to give way to me in his speech on this point. Whatever the figures were, is my right hon. Friend aware that, in the last year of the Labour Government, at the famous Addenbrooke's hospital in my constituency, wards were closed, cancer operations had to be postponed, surgeons' records were taken over by militant trade unionists and many poor people were deprived of the services that they wanted by the behaviour of the Labour Government's supporters?

Mr. Waldegrave

The Labour party talks about a two-tier service, but when it left office, the Confederation of Health Service Employees and the National Union of Public Employees were deciding what was an emergency admission.

The truth is that no serious commentator outside believes—I have quoted Professor Julian Le Grand to the House before and I shall quote him again because he is such an objective commentator on these matters—that Labour would be able to do better than we have done on overall resources for health. That argument, as one of my hon. Friends said earlier during Question Time today, is dead. It is unlikely that the 3.5 per cent. growth which we have achieved would be bettered by the Labour party. It has never been bettered in the past.

As Peter Kellner—not a commentator friendly to my party—recently warned, the Labour party should be steered away from the reef of criticising our health spending record because, he thought, our spending had kept up with GDP. I can tell Peter Kellner that we have done better than that. The share of GDP spent on the NHS in the United Kingdom in 1978–79 was 4.7 per cent. It is now, in 1991, 5.7 per cent.—a full percentage point increase. We are spending on health a bigger share of a bigger national product than ever Labour would or could.

Mr. Christopher Gill (Ludlow)

Is the essential point not how much the Government spend, which is a lot more than it ever was, nor how much the Opposition promise that they will spend, but how that money is managed? Will my right hon. Friend take this opportunity to tell the Opposition that there is not one patient who cannot see a doctor or who, having been to see a doctor, has not received the drugs that he requires, and that there is not one person who, having been to hospital, has not been entirely satisfied with his treatment, service and attention?

Mr. Waldegrave

My hon. Friend is right. As there is no real argument between us on resources, we then have to concentrate on how best to get the money to the patients, and that is what I shall deal with in the latter part of my speech.

It was only because I was a little surprised that the British Medical Association seemed not to have remembered the Labour party's dreadful spending record on health that I delivered a mild rebuke to it for appearing to join in the party political debate somewhat in favour of the Opposition last week. It would have been an odd alliance, since Bevan—whose great biographer, the right hon. Member for Blaenau Gwent (Mr. Foot), is with us—described the BMA as "an organised sabotage" and "a squalid political conspiracy". Barbara Castle, in her characteristically more moderate language, said that there was a lovelessness about that bunch that made me sick. Luckily, since then, the BMA has made it clear that nothing it said was to be taken as any kind of alliance with the Labour party; it was just inadvertent that it gave its press conference the day before the local elections. Therefore, that matter can be laid to rest. There is no contest on funding. As my hon. Friend the Member for Ludlow (Mr. Gill) rightly said, the argument is about how the money is spent. For a party which is not able to commit itself to an overall increase in terms resources for health, Labour has made some extremely dangerous and irresponsible spending pledges.

For example, I calculate that at least £175 million will be needed for the minimum wage pledge, and that may be on the low side. It will be £175 million only if Labour can restrain other trade unionists from maintaining differentials and many—for example, the electricians—have made it clear that that is not on.

As no real increase will come from Labour, that £175 million will have to come from patient care—it amounts to the annual revenues of about six district hospitals. As my right hon. Friend the Prime Minister said at Question Time, Labour is choosing to throw away about £150 million-worth of savings by doing away with competitive tendering, which amounts to the annual revenues of about another five district hospitals, making 11 in total. That is what happens if one says yes to every lobby before one has secured the resources with which to pay for the pledges.

There is a long list—one might call it the nods and winks list—of all the things that Labour has said that it would do when any lobby has come to see them, although it has been careful not to cost them. That long list of things will produce cuts in patient care or it will mean that a large number of disgruntled lobbies will find that Labour's pledges meant nothing. The latter is the likeliest outcome.

Against that background of no more money, we must work out how we can get the money to where patients need it. In the past week or so, another element has been added by the Labour party, which says that not only will money go out of patient care to pay for its friends in COHSE, NUPE and the rest but it will take money out of the pockets of most of the professionals in the health service.

I am not sure whether Opposition Members are aware of this fact. We have dramatically increased doctors' and nurses' pay, as well as increasing their numbers. Instead of cutting their pay, as Labour did, we have put a considerable number of nurses into tax and national insurance brackets in which they would lose cash under Labour's proposals. Every GP and virtually every qualified doctor would lose considerable amounts. On the national insurance change alone, a top consultant would lose about £7,000 plus many thousands of pounds—

Mr. Robin Cook

With a merit award.

Mr. Waldegrave

On a merit award. I was talking about a top consultant. The tax proposals would lose the consultant many thousands more.

Mr. Tony Marlow (Northampton, North)

rose—

Mr. Waldegrave

I shall complete these remarks and then give way to my hon. Friend.

Therefore, the hon. Member for Livingston owes professionals in the health service a further commitment, which he will not be able to fund. Is he going to make good their pre-tax pay to make up for the money which his hon. Friends will take out of the pockets of those professionals? That is what he is saying to them. Virtually all senior professionals in the health service will lose money under the Labour party's proposals.

Mr. James Couchman (Gillingham)

My right hon. Friend mentioned the fact that doctors will suffer under the proposals that Labour has revealed in the past week. Is he aware also that grade H and I ward sisters, who are towards the top end of the scale in London, will lose, because they earn between £20,000 and £22,000 a year?

Mr. Waldegrave

My hon. Friend is absolutely right. Those nurses deserve that money, and I am proud that I am part of the Government who have begun to put nurses' pay on a proper and reasonable footing. I shall return to the subject of the real cuts that the Labour party made in nurses' pay during its last period in power.

Mr. Ronnie Campbell (Blyth Valley)

rose—

Mr. Waldegrave

I shall give the hon. Gentleman the information, as he seems impatient for it. Nurses' pay was cut by 21 per cent. and doctors' pay by 14 per cent. under Labour. Not only do they face the prospect of further cuts in their real pay, as that was delivered by the last Labour Government, but under the "caring party", on that lower pay they will lose large sums of money in national insurance and tax which the hon. Member for Livingston is signally failing to promise to replace by increasing their pay.

Mr. Ronnie Campbell

The Minister will be aware that the Northumberland ambulance service is now a trust. Is he further aware that the chief executive of that trust—

Mr. Dennis Skinner (Bolsover)

What, the spiv?

Mr. Campbell

Yes, the spiv and the personnel manager have given themselves 40 and 60 per cent. increases in their wages.

Mr. Waldegrave

If the management of that service deliver better patient care to the people of the neighbourhood by having more paramedics, which is what they will do, and by having better services, they will have earned that pay.

We see clearly the usual argument from Labour; it wants to get it across to the public that everything will be paid for by "the rich". When we come down to it, who are "the rich"? They are the senior staff nurses and the doctors who have just qualified. Those are the people whom Labour will hit.

The argument is not, therefore, about the overall spending of money; it is about the deployment of money. It has been easy for me to demonstrate in recent weeks that Labour has nothing to say about how to reform the systems in the health service for spending money to get services to patients better. Labour has set itself apart from modern thinking in all western European and other countries about the development and management of public services.

Throughout the western world—not just in Britain—people are seeking new ways of devolving management; that is what the NHS trusts are about. They are seeking new ways of getting cost comparisons and incentives for efficiency; that is what the whole internal market is about. Nothing in the health service is costed in the way that it will be in future. Nobody knows how best to apply the money. Labour is against that. Finally, it is against providing real power to those who will use it most directly for patients and not for the defence of vested interests. Labour is simply defending the system which was designed in the late 1940s. It is defending vested interests and it has nothing to say on how to develop our great service for the future.

The Independent got it exactly right. It wrote: Although theoretically the British public loves the NHS we all know that it has been run too much for the benefit of producers rather than consumers and too frequently cannot deliver a decent quality of service. By introducing some elements of the market into the system the Government's reform will apply real tangible pressure for greater efficiency. Labour's own ideas for reform are essentially cosmetic. That is exactly right.

More brutally, The Times put it as follows: The fear must be that in demolishing the new system Labour would be handing the service back to the tender mercies of NUPE, NALGO and the BMA. So little to say—

Mr. Nigel Spearing (Newham, South)

Leaving aside the proper interests of collective bargaining, is the right hon. Gentleman trying to say that the health service has been run for the benefit of the doctors, the nurses, the secretaries and the people who work in the service, who are notoriously underpaid? That is what he just tried to say.

Mr. Waldegrave

The hon. Gentleman knows exactly what I am saying. He knows that I believe that the service should be run for the benefit of patients and that those who simply represent the interests of the collective within it are not serving the best interests of the patients. It is that kind of argument which has led to putting off, for year after year after year, the decisions that have to be taken in London and that should be taken for the benefit of the health service throughout the country.

Labour has nothing to say itself on how to reform the structure and to make the systems more efficient. Therefore, I find myself in the happy position of defending a radical and forward-looking reform, aimed at revitalising a great public service, while Labour is left behind, carping, criticising and doing its best simply to scare people.

Mr. Marlow

On the point about scaring people, the way that the Labour party has been behaving over the past few months is reprehensible—[Interruption.] Yes, the Labour party is picking on those who understand these things least and who are most vulnerable. It is reprehensible.

I do not know whether my right hon. Friend has visited Monmouth during the by-election, but a pamphlet is being stuck through people's letter-boxes saying that the Labour party will prevent the local hospital from opting out of the national health service. As I understand it, if a hospital becomes a hospital management trust, it stays four square within the NHS. Will my right hon. Friend make that clear to the hon. Member for Livingston (Mr. Cook) so that he can get in touch with people at the printing presses tonight to put out another leaflet to let the people of Monmouth know what the reality is?

Mr. Waldegrave

Any such leaflet would be disgraceful and would contain a lie. There is no opting out of the NHS, and anybody who issues leaflets suggesting the contrary is simply misleading the public.

Mrs. Margaret Ewing (Moray)

Will the right hon. Gentleman give way?

Mr. Waldegrave

No, I have given way enough.

I want to deal now with the two main points of carping that Labour, left in our wake, has undertaken in the past two weeks. The first relates to general practitioner fund holding. We believe in giving more power to general practitioners. That is why we started the fund-holding experiment, which put general practitioners in charge of how NHS money is spent for their patients.

On this issue, the Labour party—not uncharacteristically for that party, although it is a little more characteristic of the Liberal party—is facing in two exactly contradictory directions. On the one hand, the Labour party says that it is opposed to the principle of fund holding, on the grounds that it creates what Labour calls a two-tier system. On the other hand, the Labour party is in favour of allowing non-fund-holding GPs to make greater use of extra-contractual referrals—a facility that makes it easier for GPs to shop around to secure the best treatment for their patients. In other words, the Labour party is in favour of fund holding in one case but against it in another. That is typical.

Mr. Ronnie Campbell

Will the right hon. Gentleman give way?

Mr. Waldegrave

No. We have had enough contributions from the hon. Gentleman on this occasion.

How is it that the freedoms exercised by a fund-holding GP are devices, while the freedoms exercised by a non-fund-holding GP using his extra-contractual referrals are not? On this matter, the Labour party needs to get its thinking straight. Does it, or does it not, want GPs to have greater clout on behalf of their patients? I do. I want GPs in the NHS to have the same sort of clout on behalf of their patients as do those looking after people who can afford to go for private health care.

Many of Labour's supporters are clear about what they want to see. Let me quote, for example, Dr. David Colin Thome, who stood as the Labour parliamentary candidate in Warrington, South in the 1983 election: The reason I find fund-holding attractive is not purchasing, although that is important. I am really excited because it will make us a better provider by reskilling us in clinical medicine and by developing a concept of one-stop medicine. Instead of saying that we want the best deals from hospitals, we shall soon be asking why we need to refer to the hospital in the first place. Many of Labour's most knowledgeable supporters know that Labour has got it wrong on GP fund holding. In a New Statesman interview, on 22 March, Julian Le Grand called on Labour to give fund holding more of a run. He said: There are many, including some politically unsympathetic to the present Government, who are excited by the idea, for they see it as an opportunity not only to obtain more control over other parts of the health system, but also to gain freedom to try out many of their less conventional ideas that the NHS bureaucracy has previously stifled. Exactly.

How long will it take the Labour party to recognise that it is wrong? It said, first of all, that no one would be interested in the scheme. Already, we have 1,700 general practitioners involved. Then Labour said that there would be great problems because the budgets would be insufficient. Now it has had to abandon that case. We have 7.5 per cent. of the population covered, with perfectly adequate budgets. The Labour party was wrong about that, as it was wrong about the GP contract. It was wrong also about the selective lists. Once again it was simply acting on behalf of any passing lobby that happened to write to it—in that case, the drug companies. On the question of GP fund holding, the Labour party said that there would be no benefit to patients. It said that GPs would not take on difficult patients, that patients would not like it.

On every count, the Labour party has been wrong, so now it has shifted its ground. Patients are benefiting, and the scheme is working, so the criticism has changed. The criticism now is not that the system will not work but that it does work. That is the new criticism. The experiment works very well, bringing immediate benefits to patients, so Labour is against it. When patients benefit, Labour's reaction is, "How dreadful. We must certainly stop that at once. We cannot have anybody getting better treatment."

My reaction is exactly the opposite. My question is, how can we spread this to all the other patients in the NHS? At the end of his speech, the hon. Member for Livingston offered some high rhetoric about the moral divide between our parties. What I have just said illustrates exactly the divide between our parties. We want innovation, with a view to providing better treatment for patients and spreading it to all patients; the Labour party wants to stop any innovation, lest it should work.

Mr. Robin Cook

Let us be quite clear about what the Secretary of State is saying with reference to the way in which the GP fund holding practices are working. He will recall that, last week, the Prime Minister said that patients would be admitted only on the basis of clinical priority. Is he, a week later, saying that it is acceptable to the Government that there should be a two-tier waiting list, that priority should not simply be clinical but should depend on the GP from whom the patient comes?

Mr. Waldegrave

I do not know how the hon. Gentleman thinks the present system works. There is a variety of different waiting lists at present. The hon. Gentleman referred to a case in Watford. Now, a hospital will say, "Of course, we cannot ask our clinicians to do anything they do not believe is right, so we must improve our own standards." An admission limit of a week has been set for urgent cases. That is exactly how the system should work.

Mr. Cook

What the Secretary of State just said contains an extremely clear and very important qualification. Urgent cases constitute a minority of all elective cases. Does the Prime Minister's commitment that admissions should be on the basis of clinical priority apply to all elective cases, including the great majority, which are, as the Government described then, non-urgent?

Mr. Waldegrave

It may be that the hon. Gentleman still does not understand that we are talking about bringing into use facilities not being used at present, without damaging the interests of any patient, and bringing forward treatment for other NHS patients. If the hon. Gentleman is against that, he is against progress. But that would not surprise me.

In this week's General Practitioner, a general practitioner—Dr. Hawkes—says: The argument that you have to stop improvements could be used against any pilot scheme. Dr. Hawkes is quite right. We used to be urged to cross the Floor and have experiments on everything. If experiments work, are we to be told that we must stop them? Dr. Hawkes continues: If we have proved the scheme valuable, any changes will be available to second-wave fund-holders. Any changes seen to be beneficial, especially if they are good value, could be copied by the DHAs, who will be under more pressure from non-fund-holders to do so. We will be running our own waiting-list initiatives, with money which will be divided proportionally between purchasers. We will be hiring local cottage hospital theatres, employing a surgeon and an anaesthetist to reduce the general and orthopaedic surgery waiting lists. Since this will be done using marginal costs, the scheme will be highly cost-effective, and there is no reason why the DHA purchasers should not do the same and benefit all our patients. Exactly. That is what the people who are actually doing the job say, and it is the truth.

The second matter about which there is much carping is trusts. In the last few weeks, I have heard nothing from the hon. Member for Livingston, or anybody else, to shake my belief that devolving the management to the hospitals is the right thing to do, and we shall continue to do it. The New Statesman has already pointed out to the hon. Gentleman what it calls the weakness of Labour's case. It discusses the mismatch of hospital services in London—how, often, there is not enough community care, not enough local services provided in London, and too many specialties, with people being brought too far. That is the real issue in London. The weakness of Labour's case, as the New Statesman points out, is that this has nothing to do with costs. This situation has existed for 50 or 100 years. It applies to trust hospitals and to non-trust hospitals.

Everyone with the slightest knowledge of the NHS knows that we cannot, for ever and in every hospital, have larger and larger numbers of people. The medical services must be made available where people now live. As I said at Question Time today, it will take skilful management to readjust services and, above all, teaching and research, to take account of where the population now live. But that is not an impossible task. Better management will mean redoubled efforts to avoid end-of-year crises, to have money spent on patients. It may involve looking at labour costs. That would be quite right. It is patient care that matters—not employment patterns in the historic mode.

Even in this respect, the Labour party's campaign has failed. I have had a look at the reports of some recent monitoring. The hon. Member for Livingston talked about the terrible scandal of all these trusts laying off people left and right. As a matter of fact, there are 100,000 people working in the first 57 trusts. The total planned reduction in staff is about 200 net, so I am afraid that the hon. Gentleman's fox does not run. Those are the outline plans; they are tentative plans at the beginning of the process, just as the reductions in labour are tentative plans at the beginning, when they may be necessary. They show that many trusts are expanding and some are contracting. That is surely right in the health service, which needs to change its shape and design to meet the new needs of the people.

Therefore, the great scare that trusts automatically mean redundancies is a non-runner. I hope that the trusts, including those in Bradford, will carefully examine their labour costs because there is no reason for them to employ more people than they need if they can get the money to patients more efficiently with fewer and probably better paid and better trained people.

Mr. Max Madden (Bradford, West)

rose—

Mr. Waldegrave

I shall not give way. We must move on, as it is 4.50 pm. I have already debated Bradford issues with the hon. Gentleman many times. He keeps saying that there have been 300 redundancies in Bradford, but he is wrong.

Another attack by the Labour party was on the contracting process. That is a bit thick, because Labour's line of attack on contracting is that there will be less choice—as if there was ever a Labour party interested in choice. We know from history—we have already been reminded today—what choice people had in the national health service when Labour was running it in the winter of 1978–79, when those attractive fellows were picketing hospitals and Labour was not taking decisions about clinical priority because the people who funded the Labour party were doing such things.

The hon. Member for Bradford, West says that there will be less choice, but that shows that he does not understand the contracting system. The system starts by measuring where referrals went in the past. There are discussions with general practioners who cover to the best of their ability—which will increase every year—contracts which follow the flow of patients which GPs defined in the past. If the GPs cannot fully cover that, they have the mechanism of extra-contractual referrals to deal with any further referrals which do not fall within their contracting. They will have enough money to do that, and that is how the system works.

The real purpose of contracting is that, for the first time, we have a mechanism whereby we can deliver health strategies locally and nationally. Those strategies will be worth debating in the House, unlike previously, when priorities could be set but there was no way of defining what would happen. For the first time, there will be public health authorities making agreements with hospitals, enforcing those agreements and measuring the quality, as in the Guy's and Lewisham trust where there has been access to medical audits to ensure that it is doing what it agreed with its district that it would do.

Mr. Madden

rose—

Mr. Waldegrave

By its attack, Labour wants to stop the gains—at least, I am sure that the hon. Member for Bradford, West does—to people from fund holding rather than spreading them to the rest of the people, which is my aim. Labour wants to return hospital management to distant bureaucrats and, for good measure, to put it under the control of regionally elected authorities—that would be wonderful for hospital efficiency. Labour also wants to abandon the health contracting system which, at last, can provide an open way of setting and achieving local health priorities.

There is nothing worth detaining the House in any of those criticisms. As Professor Rudolph Klein wrote in the British Medical Journal this week: Much of the reaction to the NHS reforms therefore tells us nothing for good or bad except that resistance to change is as inevitable as it is predictable. Meanwhile, I am happy to say that the NHS goes on not only building the new system but delivering improved health care.

I am happy to give the House and the hon. Member for Bradford, West the latest figures for infant mortality. Infant deaths in 1979 were 12.8 per 1,000 births. In 1989, the figure was 8.4 per 1,000 births and the latest figure for 1990, which I can announce today, is 7.9 per 1,000 births, which represents a further significant drop. The figures for perinatal fatality were 14.7 per 1,000 in 1979, 8.3 per 1,000 in 1989 and 8.1 per 1,000 in 1990—steady and useful progress.

I refer also to the work carried out yesterday by my hon. Friend the Minister of State on one of the most difficult and thorny of all problems facing the management of the health service—the problem of junior doctors' hours. I pay tribute to Stephen Hunter, the junior doctors' leader, and to Professor Margaret Turner-Warwick for the progress which is now being made steadily to produce a sensible resolution to the problem. I also pay tribute to my hon. Friend the Minister of State for the way in which she has helped to guide the discussions.

Last month, we announced the first research and development strategy for the health service. Under the sound and fury of all the nonsense of party politics about the poor old health service, there is co-operation with the general medical services committee on GP contracts, with the General Dental Council on dental contracts and with the joint consultants committee on a variety of issues.Work is being done in the regions by the deans to prepare—quite rightly—for the changes that will be needed in London. It is right that those changes should be made—let us listen to the words of Professor Rubin of the Queens medical centre in Nottingham. He wrote to The Independent on 13 May: Since its inception, this prestigious provincial teaching hospital"— he meant the Nottingham medical centre at the University hospital— has looked after more patients with less staff than London teaching hospitals and has avoided moving into debt. Do you suggest that our prize should now be to see profligacy or inefficiency elsewhere rewarded by cash injections? Surely not. One of the greatest achievements"— we should note that all the consultants signed the letter— of the original NHS was to produce a more even distribution of high quality health care around the UK, but it never went far enough, with London in particular keeping its doctors which the patients moved away. A laudible aim of the new NHS is to put money where the patients are and thereby redress still further the imbalance. This will be painful. However, pouring money into hospitals that have lost their patient base would be a triumph of short-term expediency over common sense. That is exactly what the Opposition stand for—short-term expediency over common sense.

The issues must be tackled—efficiency, the London issue, junior doctors and all the others. The test of commitment to the NHS is not whether one can shout as loudly as the hon. Member for Bradford, West but whether one tackles the underlying issues. We have heard nothing from Labout today about any of those issues. By the ruthless and irresponsible use of scare stories, Labour tries to hide its nakedness over resources and its bankruptcy on policy. The real argument is being won by the Government and I urge the House to support our amendment.

4.56 pm

Mr. Michael Foot (Blaenau Gwent)

Owing to my longevity and the constituency that I have the honour to represent, I think that I have had more exchanges with medical experts than any other hon. Member, and some of those exchanges have been of a personal character.

One of the Secretary of State's mistakes—it is difficult to select one from all the others—is that he does not take account of how the Government, in preparing their proposals, would not listen to those in the profession, whether they were the British Medical Association, the royal colleges, the nurses or the trade unions. Everyone involved in the national health service was told that they would have to wait until much later, but much later they were told that they could not have a meeting with the Prime Minister. One of the reasons why the Government are in such trouble is that they have not listened to any of the people who knew about the service.

When the proposals were first introduced, I remember going to see a consultant—I shall not say what extremity of my body he was dealing with, but I can assure the House that they are all working at the moment. I shall not identify the consultant, because I do not know how the Government would deal with him. When the proposals were made, he said that he hoped that the Government would not let British management loose on the national health service because that would be the coup de grace. Now, the same expert says that it is Mardi Gras for the accountants. That is what some of the people on the spot think of it. If the right hon. Gentleman had listened carefully to all the representations, he would have had a few different ideas.

When I had another operation, it took four hours to perform. Under the present proposals, that would be chalked up against the hospital and, no doubt, chalked up against the expert, Mr. D'Abreu from Birmingham. He happens to be the greatest expert on that subject. I should be interested in what he has to say about the Government's proposals for speeding up the operations process as one of the ways of testing what can be done.

As for what has happened to the physiotherapists, I daresay the right hon. Gentleman will produce statistics to show that there has been an increase in the number of physiotherapists. Nevertheless, I should question any statistics that he may produce. My hon. Friend the Member for Livingston (Mr. Cook) exploded a great many of those statistics in his speech. I have been very suspicious of the Government's statistics ever since the right hon. Member for Chingford (Mr. Tebbit) first got his hands upon them. I have never believed anything that the Government have had to say since then.

Anyone who talks to physiotherapists will be told what is happening. In one way or another, the number of physiotherapists in hospitals has had to be curbed. Anyone who knows anything about it knows that physiotherapists are one of the keys to providing an essential form of preventive medicine. The better the facilities for physiotherapists, the less we may have to spend on other services.

I remember a classic illustration when I was writing about the part that Aneurin Bevan played in the creation of the national health service. I went to see some of the doctors who had been most bitterly opposed to its introduction. I say this in particular to the Secretary of State, in view of his remarks today about the British Medical Association. It is true that Aneurin Bevan had arguments with the BMA, but he dealt with the whole question a good deal more sensibly than the present Government. He listened to the arguments. He also had plenty of meetings with the leaders of all the royal colleges—the very people in whose faces the door was slammed by the right hon. Gentleman's predecessor and the Prime Minister only a year or two ago. What happened illustrates a central feature of the NHS that the right hon. Gentleman and his right hon. and hon. Friends have never been able to understand.

One of those whom I went to see in 1960, soon after Aneurin Bevan's death, in order to discover what the BMA had to say about the arguments, was Dr. Roland Cockshut. He was one of those who had led the campaign against Aneurin Bevan and the establishment of the NHS. He said that we should not have a national health service and he denounced Aneurin Bevan for the way it was introduced, but when I went to see him in 1960, just after Aneurin Bevan's death, it was a different story. He said, "We didn't understand what the reality of the service was going to be; we were astounded—I am now talking as a general practitioner—to discover how wonderful it was to have introduced into our service the principle that we didn't have to care whether a person could afford to pay or not." He went on to say to me, "It was such a revelation—of course. I should have understood before. This principle is not only wonderful for patients; it is a liberation for every decent doctor in the land."

That is what the national health service was about. That is why the BMA's attitude changed—and all honour to it. It has fought persistently against what the right hon. Gentleman and his right hon. and hon. Friends have introduced. If they had had the sense to look more carefully at these matters, they might have avoided the whole of this terrible catastrophe that has befallen their Government—second only to the poll tax catastrophe. It is difficult to say which is worse. It is a tender balance.

This catastrophe for the Government goes back to the crucial decision made by the former Prime Minister, who decided to have a so-called reform of the national health service. She could not bear the idea of the continuance of a service that had as its central principle the socialist principle that no money should be charged and no market principle should dictate what was to happen to patients.

The former Prime Minister was so obsessed with opposing that principle that she would not even appoint a royal commission, or consult the royal colleges, or have conversations with any of the people working in the national health service—the trade unions, the British Medical Association, or anybody else. She said, "We are going to do it ourselves", so she set up a committee. If someone on the committee was not prepared to follow her—I am sure that the right hon. Member for Old Bexley and Sidcup (Mr. Heath) would confirm what I say, as would anybody else who has followed the details of these matters—they knew exactly what would happen. Never before had there been the proposition that a major institution in this country should be overhauled by such a method.

The former Prime Minister produced for that committee plans that have now come to fruition in an Act of Parliament. However, it had to be forced through the House of Commons by means of the guillotine. It was forced through without taking into account the protests of the few Conservative Members who had the courage to stand up against it. Worst of all, and most despicable of all, it had to be forced through the Cabinet.

One would have thought that a few members of the Cabinet—the present Secretary of State for Health at least has the distinction of not having been a member of that Cabinet, and if I were he I should continue to insist on that claim—would have stood up to the former Prime Minister. Some of the members of the Cabinet resigned on other issues, but not one of them dared to resign either over the poll tax or over the measures that were being taken to deal with the national health service. Not one member of that Cabinet of creeps dared to protest. That is why we are faced with this situation today, and most people in this country know it.

The right hon. Gentleman talked about having ballots. People in Monmouth know very well what the arguments are about. They are not being deceived by the Opposition about these matters. The argument is not that the national health service should necessarily be preserved in every detail as it was originally conceived. Nobody said more loudly than Aneurin Bevan that of course it had to be reconsidered every five, 10, 15 or 20 years to see whether it could be made into an even better service, particularly since, as he claimed, the NHS ought to be made into a democratic service. That is very different from the Government appointing managers, at high fees, to carry through any changes that they want.

We have never said that the NHS should remain exactly as it was at the beginning. We have always said, as my hon. Friend the Member for Livingston emphasised—

Mr. Waldegrave

Will the right hon. Gentleman give way?

Mr. Foot

I shall give way in a moment.

My hon. Friend the Member for Livingston properly emphasised the fact that greater resources must be allocated to the NHS. I was very glad to hear him blow out of the water all the false figures about what happened under the last Labour Government. The Government have been peddling those figures throughout the country for six or seven years, so it is good that my hon. Friend blew them out of the water. Even more, I believe that the leadership that he has given both to this House and to the country is a fine promise of what he will achieve when he becomes the new Secretary of State for Health and a fine promise of how we shall sustain the NHS and its original principles.

Mr. Waldegrave

The right hon. Gentleman has talked in his marvellous speech about resignations. Did this poem happen to pass in front of him in the Cabinet in which he served, written by the present Lord Silkin and passed to Barbara Castle: All things bright and beautiful, All projects great and small, All things wise and wonderful, The Chancellor cuts them all. At that time it was the right hon. Member for Leeds, East (Mr. Healey). He cuts the old age pension, Although he cuts by stealth, And while he looks for savings, He cuts the National Health. I do not think there were any resignations on that occasion.

Mr. Foot

If the right hon. Gentleman wants to learn some history, he should go back further still— [Interruption.] We now have the Minister learning a thing or two. If only he had listened rather earlier, the Government would not be in such a fix. He has made the great discovery that the Treasury has always been against the NHS, even in 1947–48. The Treasury was against the NHS then and we had a big fight to get the necessary funds. The Treasury has never understood the simple principle in the context of which I quoted Dr. Roland Cockshut. The Treasury has never understood the principle that one could have such a system and that if it was run on decent and humane principles it would not put profit and the market first.

The patient must come first, and that must happen genuinely. To do that genuinely, one cannot say in advance how much the service will cost. We had all those arguments way back, before the present Secretary of State was born or even thought of. The Treasury was against it then, and there must always be good Ministers of Health to stand up to the Treasury. The Labour party has an extremely good one who will take office shortly—as soon as the right hon. Gentleman and the Government dare to take the issue to the public.

5.11 pm

Sir Barney Hayhoe (Brentford and Isleworth)

It would not be appropriate for me to follow the right hon. Member for Blaenau Gwent (Mr. Foot) in his historical reminiscences, except to note that he made no response in substance to the interruption, towards the end of his remarks, by the Secretary of State.

Labour's shadow Secretary of State set the tone of the debate in his characteristically knockabout, witty but rather superficial speech. He clearly demonstrated that the debate is more about politics than patients and electioneering than health care.

I remind the House of my declared interest in health care, as set out in the Register of Members' Interests. I confess that I have not been an enthusiastic or uncritical supporter of the Government's reforms of the NHS, but Labour's antics in recent weeks have been so sickening that I am grateful for this opportunity to intervene briefly in the debate. I do so for two reasons—first, to denounce Labour's cynical attempts to exploit and mispresent particular incidents and problems in a destructive and highly partisan fashion; secondly, to express my confidence in, and support for, the Secretary of State and his team of outstanding Ministers.

It will be within the recollection of the House that Labour pounced on the recent news of possible job losses at Guy's with undisguised glee and tried to present it as a general condemnation of the whole concept of trust status hospitals. What absurd nonsense that was, and it was quickly shown to be so by the similar job losses announced for the Charing Cross and Westminster hospitals, which remain under the control of their district health authority.

Another example of Labour Members' deliberate misrepresentation has been their continual use of the phrase "opting out", with its implication that such hospitals are no longer part of the NHS. The hon. Member for Livingston (Mr. Cook) said that a Labour Government would bring hospitals back into the NHS. That is nonsense, because no hospital which goes for trust status leaves the NHS. An hon. Member whom the right hon. Member for Blaenau Gwent praised as a future able Secretary of State should not misrepresent the situation in such a monstrously outrageous fashion.

I find it appalling that the media give prominence to such phoney propositions, when responsible medical correspondents must know the truth. Labour's spokespersons—among whom I include the hon. Member for Peckham (Ms. Harman)—accuse the Government of planning to privatise or demolish the NHS. Again, what nonsense that is; and how irresponsible and uncaring of Opposition Members to generate groundless anxiety among those who do not recognise how bogus such charges are.

The NHS is a much valued national asset which is, and will remain, a crucial and essential part of the public sector, largely financed from taxation and continuing to provide services free at the point of delivery, the aspect to which the right hon. Member for Blaenau Gwent referred.

As a former Treasury and Health Minister, I congratulate the Secretary of State and the Chief Secretary on the significant real-terms increase in funding agreed for this financial year. Over £3 billion extra represents nearly 50 per cent. of the total amount allocated to the NHS in the last year in office of the last Labour Government.

As one who has long pressed, in and out of government, for additional funding, I should like to see even further increases, not least for capital projects, including much needed work to the West Middlesex University hospital in my constituency, but I recognise the very considerable additional funds that have been agreed in a difficult public expenditure year.

There has been much controversy recently about what Labour might or might not do if—it is a mightly big if—it was returned to office. Fudge and smudge seem to be the order of the day, and the hon. Member for Livingston did not shed any new light on the subject in his long speech. He talked about underfunding but made no promise or pledge of extra funds being made available by an incoming Labour Government. Opposition Members do not quote a figure, and that was significant in all the hoo-hah and shroud-waving from the hon. Member for Livingston.

Not uncharacteristically, the BMA has entered the bidding with demands for what appears to be a speedy and massive increase of between £4 billion and £6 billion—wholly unrealistic figures, as anyone with knowledge of public finance must acknowledge. Interestingly, the BMA—not the doctors' professional organisation but their trade union—which I can remember making quite a fuss about when part of the review body pay award was delayed for a few months, seems to have said nothing about Labour's new tax and national insurance proposals, which could cost senior consultants more than the whole of this year's pay award—presumably permanently and not deferred for a few months. It would certainly reduce take-home pay for the vast majority of BMA members.

No wonder the Leader of the Opposition is being so kind to the BMA in return for the kindness of its leaders, who seem to be behaving in a remarkably partisan fashion—perhaps not wholly deliberately, but at least that is how it appears in public print.

Perhaps it is appropriate to remind the BMA that the only year in which there was a real cut in NHS funding —I return to the point so clearly made by my right hon. Friend the Secretary of State—was 1977–78, under a Labour Government who also slashed the hospital building programme and remorselessly resisted reasonable pay increases for nurses. We should remember the Labour party's record when we see the nudges, winks and nods on the Opposition Front Bench.

There will always be health problems, whatever the politics or health care system, but there is a marked contrast between Labour's destructive and propaganda approach to those problems and the approach of my right hon. Friend the Secretary of State. My right hon. Friend is dealing with current problems in a sensitive and constructive fashion. For example, he and my right hon. Friend the Prime Minister have responded positively to genuine anxieties. I refer not to the assertions that the Leader of the Opposition made at Question Time, but to genuine anxieties about GP fund holders, who seek preferential arrangements for their patients.

I am glad to note the sensible comments of my right hon. Friend in the House today and in his speech to the Royal College of General Practitioners on 9 May, when he said: There may well need to be some ground rules agreed about what can and cannot be asked for by a fund holder—or a district for that matter—from a provider. It is our intention to listen, discuss and, where possible, agree. Many problems need just such an approach, such as medical education, the problem of London hospitals and junior doctors. I congratulate my hon. Friend the Minister for Health for the great progress that she has initiated and with which she is pressing forward on that score.

I hope that the Government will propose positive action for nurse prescribing. All of these and many other problems can be resolved by my right hon. Friend's patient and sensible approach. I shall support him enthusiastically in the Lobby tonight.

5.22 pm

Mr. Charles Kennedy (Ross, Cromarty and Skye)

Like the right hon. Member for Brentford and Isleworth (Sir B. Hayhoe), I shall be brief, although he will understand that the similarity between our contributions ends there. I shall speak less about the Labour party's policies than about the Government's present action, approach and philosophy on the national health service.

It strikes me that, as we last debated health issues in the House only a couple of weeks ago, the element of predictability on that occasion has been reinforced today. Hon. Members have mentioned the warnings that were given when the National Health Service and Community Care Bill was rushed through with unseemly haste and with inadequate consultation on the likely cuts. They have spoken of the reductions in services and the fact that doctors' clinical decisions would be overriden. The indifference to community aspirations and to patients' views in particularly localities was bound to be a cauldron of political controversy, and has proved to be so. However, as other hon. Members have remarked, so has the scene of the current by-election in Monmouth.

However one views the Government's position on the fiasco of the poll tax, at least they could find a scapegoat and blame local councils for some of the difficulties encountered with local government finance. The difference on this occasion is that the fault lies entirely with the Government.

During Report stage of the National Health Service and Community Care Bill, my hon. Friend the Member for Southwark and Bermondsey (Mr. Hughes) introduced what the then Secretary of State for Health, the right hon. and learned Member for Rushcliffe (Mr. Clarke), described as a mini-Adjournment debate on Guy's hospital. Many of the problems that he predicted have, unfortunately, come to pass. It was remarkable that, when the controversy about opted-out hospitals—those first flagships—hit the headlines several weeks ago, the Secretary of State suggested that he was unaware of the details of the business plan for the anticipated levels of employment.

If one went to a bank, building society or even a Government enterprise agency seeking support for a business plan and one was unable to tell the person making the decision that, within four weeks, 600 redundancies would be announced, that would be a somewhat deficient business plan. The fact that the Secretary of State did not know the details suggests either that he was not doing his job or that the managers who proposed the business plan were not sufficiently on top of their jobs. That hardly gives one confidence in the business of opting out or in the self-governing status of hospitals.

It is worth considering the management of the health service and what has happened to representatives of local communities. A survey by the British Medical Association, which the right hon. Member for Brentford and Isleworth called the doctors' trade union, showed that, of 410 non-executive members of 82 district health authorities in England and Wales, 51 are doctors and 31 are councillors. By contrast, 164 were chosen for their business and accountancy skills.

I do not say that business and accountancy skills do not have a role to play in a service as massive and complex as the national health service, but when those new appointments are so loaded in favour of those who have no direct representative role for the local community, or personal and professional involvement in health care and its delivery, something has obviously gone wrong. As we saw throughout the country at the local elections, that has caused people to conclude that the national health service is not safe with the Government.

What about the financial viability of the trusts? The management consultants, Coopers and Lybrand, whom the Secretary of State asked to prepare the business plans for the first round of NHS trusts, concluded that only 12 of the 56 so far established were financially secure. The report warned that all but 12 have "considerable financial problems". Is it sensible to send out the boat against such a background? Clearly, London hospitals will be drawn into tighter competition, with uncertain consequences.

The Coopers and Lybrand report concluded: a number of hospitals could easily find themselves in this position and to some degree it would be a matter of chance which ones would be most seriously affected. It is not obvious that any closures forced would be the most appropriate. In management consultant terminology, that is as politically clear a statement of anxiety as one is likely to get. We should not leave such questions to "matters of chance".

Moreover, the new management system does not come cheap. So far, £80 million has been spent on advertising and the cumulative costs incurred by the new appointments advertised throughout England and Wales. In health terms, that £80 million will amount to the equivalent of about 8,000 hip replacements, which is what we have forsworn as a result of the new management.

The opting-out system should stop. The second wave of opting-out hospitals should not go ahead until the Select Committee on Health has taken a further look at the business plans I know that the Select Committee has already done much work on the subject, and I pay tribute to its Chairman, the hon. Member for Macclesfield (Mr. Winterton) who is in the Chamber. The Select Committee is currently considering the business plans, and a report from the Select Committee should be discussed on the Floor of the House before we go another step further.

When the Secretary of State talks about general practitioner budget holding, I notice a curious irony. The hon. Member for Livingston (Mr. Cook) criticised the two tiers developing in the GP budget-holding system, because he said that those doctors with budgets would have a better chance of ensuring that their patients were treated where and how they wanted. I am not sure whether that criticism of the system will be the most telling one.

The political problem with budget holding is that it will prove to be, as it has already been, popular with GPs because of the clinical control that it gives them and, if the name of the game in the new system is that managers with contracts make the decisions, it means that GPs can exercise more medical freedom. As the costs and the squeeze are placed on the free-standing budget holders, Health Ministers will have to go along with the decisions made by the budget holders, because they will not want to undermine management figures who want to control the clinical decision making. That will be the political hot potato with GP budget holders.

Mr. Ian McCartney (Makerfield)

Another scenario has proved to be an increasing problem in the north-west: GPs who are not budget holders are excluded from services in their own districts. In my district, the mammograph service was paid for through public funds—£80,000 was raised by a charity. Some GPs who asked women to have a mammograph found that those women were excluded by the district health authority, which had sold its spare capacity of the publicly funded service to other health authorities at a substantially increased cost to gain income for the contract service. The GPs knew about that only when referrals were sent back by the relevant consultants stating that they could not see the women to give them a mammograph.

Mr. Kennedy

I am grateful to the hon. Gentleman, who speaks with a level of knowledge on the matter which I cannot equal. He made his point extremely well. If that is the extent to which professionals in the health service are operating in the dark, it further underlines the anxiety expressed by Opposition Members.

I now turn to the subject of funding—or, as many Opposition Members continue to argue, "underfunding"—in the health service. Earlier, I became confused as to whether we were discussing matters in relation to the financial or the calendar year. In the current year, there is a significant percentage increase in funding. However, this is likely to be an election year, and the projection beyond this year is that the level of increase will dip sharply.

There is a strong case for saying that, in the longer term, the NHS should have more security of funding and should probably enjoy a Government commitment of real annual growth of 2 per cent. above the inflation rate. I do not think that the spending cycle, in which funding tends to go up as we near polling day and then down as we move further away from an election, promotes stability in either the structure or delivery of services.

The hon. Member for Livingston rightly referred to statistics and information made available to a number of us yesterday and today on what was happening at exactly this moment—5.30 pm—in King's College hospital yesterday. He referred to a couple of examples, and I shall use another one. The individuals brought into that hospital for emergency treatment included: a man aged 80 with chronic obstructive airway disease, who spent five hours on a hospital trolley; a man aged 79 with congested cardiac failure, who spent six hours on a hospital trolley; and a lady, to whom the hon. Member for Livingston referred, who was aged 89 and was both deaf and blind, and spent nine hours on a hospital trolley waiting for treatment. We cannot be sanguine about the state of our national health service when faced with such facts about humans waiting for treatment in this city only 24 hours ago.

I find it unbelievable that one Conservative Member who, characteristically, is no longer present, said that there was no patient with a complaint about hospital treatment anywhere in the country. That hon. Member should talk to any one of the three individuals of which I spoke, or to thousands more like them up and down the land, because he would then realise that they would have no confidence in this Government's handling of the national health service. That verdict will come through clearly on Thursday in Wales and, with even greater resonance, across Scotland, England and Wales, at the next general election.

5.36 pm

Dame Jill Knight (Birmingham, Edgbaston)

I do not think that I would wish the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) to be silent on the problems of the health service, but we would all find it much more interesting if he would come off the fence and give some idea of what the Liberal Democrats intend to do about health matters. Their amendment is pathetic. Many of us would listen to the hon. Member, perhaps not with fervent interest, but with mild interest, if we had some clue what his party thinks should be done, but instead of giving us that information he simply cites cases where something obviously needs to be done.

The very fact that we are debating this ill-informed motion today shows the Labour party's total lack of understanding of the health service and its needs. The Labour party believes that reform is unnecessary, even when we are faced with massive evidence of the crying need for reform. The Labour party wants the health service left as it is. Labour's only answer to deficiencies in the health service, which we are trying to remedy, is that everything will be all right so long as we double, treble, quadruple or multiply by the number we first thought of, the money that we spend on the health service. The Labour party approaches every problem with a closed mind and an open cheque book—albeit with a cheque that is post-dated and likely to bounce. Labour's attitude towards problems is always to throw money at them unceasingly in the hope that they will be sorted out.

The other night, I had a dream. As is the way with dreams, I was transported, without realising how, to Walworth road. I could hear the banging of hammers and the sawing of wood and I saw that a great arch was being put up over the door of the Labour party headquarters. The words of the motto that the workmen were putting up were, "There is no difficulty that money will not solve—promise any amount." Of course, that is a splendid motto for catching the unwary voter.

Ms. Harriet Harman (Peckham):

Go back to sleep.

Dame Jill Knight

The hon. Lady will be sorry that I am awake.

The beauty of that motto is that the money is not Labour party money, and the beast of the motto is that the theory is a monumental mistake.

There are four excellent reasons why reforms are essential. The first reason is the enormous variations in standards of patient care that exist in the health service. The Labour party has the cheek to talk about a two-tier service developing under the reforms when five minutes research would show that there have been many tiers in the quality of service. The major reason for our reforms was to ensure that all patients, everywhere, receive the same excellent care. The Labour party either does not know or does not bother about a patient being six times more likely to get care in one area than in another, or about someone being three times more likely to get a hip operation if he lives in the south than if he lives on Merseyside. If I represented Merseyside I should be worried about that, but the Labour party does not seem to care.

Some orthopaedic surgeons in the NHS do more operations in a month than others do in six months. Some ear, nose and throat surgeons do 10 operations while others do only one. That cannot be right. Some general practitioners give a far better service than others although they have exactly the same case load—the same number of patients, the same number of the chronically sick, of elderly people, of young people, and so on. There are enormous variations in standards of care. There was always an uneasy feeling that that was the case, and we had studies done that proved it. But the Labour party does not want to know about that. Instead, it has the brass neck to claim that our reforms will bring about precisely what they will remedy. The Labour party could not recognise unfair differences when it saw them, and now it does not recognise effective reforms when they are in front of its nose.

Inefficiency in the running of the health service is a major reason why some patients are denied the treatment that they need. It is no good saying that we should throw more handfuls of money at the problem. We must realise that inefficiency is one of the greatest enemies of patient care in the health service.

The national health service was set up more than 40 years ago for patients who could not get the operations, drugs and other treatment that patients get today, many of which had not even been invented. Modern medicine, like modern business practice, has advanced out of all recognition since 1948. Last week I went into my bank to find that it has reorganised the way one is served, the way one has to wait and the way chequebooks are sent. If it is essential to bring the high street banks up to date, how much more essential it is to bring up to date and make more efficient the biggest business in Europe.

Mr. Ian Taylor (Esher)

A £30 billion operation.

Dame Jill Knight

Exactly so.

The second reason for the reforms is the need for more up-to-date management. Some of the most impressive preparation for the reforms has been made by the National Audit Office, and I take this opportunity to pay tribute to the enormous amount of work that it has done in a short time on costings, utilization, property and services. It has used its expertise to provide many examples of improvements that could be made and of money which could be obtained for patient care if only we dragged the whole system kicking and screaming into the second part of the 20th century.

Mr. Ian McCartney (Makerfield)

Will the hon. Lady give way?

Dame Jill Knight

No, I am trying to be quick. Other hon. Members wish to speak.

The National Audit Office said that efficient use of operating theatres was the key to reducing waiting lists. It said not that more money should be thrown at the problem, but that operating theatres should be managed more efficiently. Day-care surgery, the use of computers, and proper reviews and checks on waiting lists were also identified as important. It amazes me that the Labour party seems to have no conception of the message sent out loud and clear by the National Audit Office—that the reforms are essential. The enormous imortance of efficient management has nothing to do with simply allocating more money.

The third reason for the reforms has to do —with money with the need to direct funds better and reduce waste.

Mr. McCartney

rose— —

Dame Jill Knight:

No, I shall not give way.

Mr. McCartney

Give way.

Hon. Members

Sit down.

Dame Jill Knight:

The National Audit Office has said that at least 10 per cent. of the land and property owned by the health service was surplus to any possible requirements and that £300 million per year could be saved in that area.

The provision of sterile products and services in hospitals—packs and so on—is not well controlled, according to the National Audit Office, and could be carried out more reasonably and cheaply, resulting in savings. Better use could also be made of energy in the health service. The Government's reforms will cover that aspect, too. The National Audit Office also explained how £100 million per year could be saved by the more efficient use of operating theatres.

What about drugs? Everybody knows that a huge proportion of health service funds is spent on drugs. How much of that is wasted? In Yorkshire there was a campaign to call in medicines not being used. In three weeks 2.5 tonnes were handed in. What a waste of money. It was reported that in Oxfordshire when the relatives of someone who had died cleared out the house they found 4,112 Valium and 807 Mogadon tablets—somebody actually bothered to count them. No doubt the National Audit Office could tell us in a flash how much that cost the health service, but my complaint is that money was wasted which could have been spent on patients. The Government's reforms will ensure that the money is spent on them.

The Labour party merely says that more money should be spent on the health service, regardless of the fact that, as has been amply illustrated today, the Labour Government cut funding, whereas we are vastly increasing it. The Labour party does not have a leg to stand on. Our tactic is to spend as much money as the country can afford while ensuring that every pound and every penny is wisely spent and not wasted. All the savings will go straight back into patient care.

Mr. McCartney:

Will the hon. Lady give way?

Dame Jill Knight:

I have not the slightest intention of giving way. The hon. Member for Makerfield (Mr. McCartney) can save his time and his voice—and mine, too.

Mr. McCartney:

Start talking some sense, then.

Dame Jill Knight

Every word that I am saying is true, provable and relevant to the debate. I shall not take lessons from the hon. Gentleman, who has not been in the House for more than five minutes—[Interruption.]

Mr. Deputy Speaker (Mr. Harold Walker):

Order. The hon. Member for Makerfield (Mr. McCartney) must not seek to intervene from a sedentary position.

Mr. McCartney:

I was standing up, Mr. Deputy Speaker.

Dame Jill Knight:

The Labour party never says a word about ending waste—it merely castigates us when we try to do so.

The fourth and final reason for the reforms is the need to shift decision-making closer to those who best know their own situation. In campaigning to prevent hospitals from managing their own affairs, and GPs from deciding on their own expenditure, the Labour party is saying that hospital boards are not capable of making their own decisions, and that GPs are not intelligent enough to manage their own budgets. Labour can go to the country on that sort of cry if it likes, but it will not hold up. Local hospitals are far more capable of managing their own affairs.

Time and again in my political and private life, in local Government and in the House, I have seen examples which prove that those closest to the centre of any organisation are infinitely better at deciding how money should be spent and what decisions should be made in that organisation. Labour denies that, and that has something to do with its fixation that the man in Whitehall knows best and that nobody has enough sense to manage their own affairs. Perhaps Labour also clings to the belief that everything and everyone—doctors, hospitals, schools, businesses or people—should always be subject to outside control.

We forgive Labour its fixation and its outmoded beliefs, but we cannot forgive its deliberate misrepresentation that trust hospitals are opting out of the national health service. The Opposition know that that is untrue, but they keep trying to perpetuate the lie. The fact that they do not perpetuate it in today's motion is no reason for not pouring scorn and condemnation on it, as I certainly do, and no reason not to vote against it with derision.

5.50 pm

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

I should like to make two brief points. First, on Thursday at Prime Minister's Question Time, the Prime Minister spent much time quoting with approbation the words of Dr. Ken Grant about the national health service reforms. Judging by the resounding cheers from Tory Back Benchers, Dr. Grant could be the wisest guru on medical matters who has ever been born. I know rather more about Dr. Ken Grant than the Prime Minister and all the Tory Back Benchers put together. Dr. Grant might even be a friend of mine.

I was particularly surprised to hear the Prime Minister say that Dr. Grant had said that setting up an NHS trust was opting out of bureaucracy because Dr. Grant is probably the last person on earth to make such a remark. My friend Ken Grant is not a practising GP; nor does he work in a hospital as a doctor. He is a wheeling-dealing, fixing bureaucrat who, over the past three or four years has created, ordered, arranged, set up and established all the bureaucracy in the City and Hackney district health authority. All its successes are down to him, and all his criticisms, which the Prime Minister quoted so eagerly, are an indictment of himself.

What does my friend Ken intend to do now? He plans to leave the district health authority to set up a new bureaucracy, so that we shall have two bureaucracies instead of one. We shall have the district health authority and the hospital trust, which in this case will run not one hospital but several, and all the facilities of the district health authority. The Prime Minister says that that is good, but I remind the House that the last time the Conservatives reorganised the national health service, it led to an enormous increase in the number of bureaucrats. It is a racing certainty that this reorganisation of the health service will lead to bureaucrats multiplying like loaves and fishes in Judaea. We shall have more bureaucrats and fewer doctors and nurses.

About two weeks ago, I was drinking champagne in the great hall of Gray's Inn in celebration of the fact that my former pupil, Helena Kennedy, had become a QC. Over the champagne, I had an argument with Ken Grant about the NHS reforms. I put my arm around his shoulder and said, "Tell me, Ken, what is it in this life that you really believe in?" He said, "They keep changing the ground rules and that makes it difficult for me. I spend too much of my time emptying beds and closing wards to reduce our deficit." I said, "Why don't you fight for what you think is right?" He gave me a quizzical look, as if to say, "Only a politician would be stupid enough to make a suggestion like that."

When Ken dies, he will almost certainly go to hell, but, quite undeterred, he will immediately set up a consortium of the helpless, the hopeless and the hapless—as he has done with this national health service trust application —and he will start negotiating with the devil. I say to him, "Ken, don't do it. Why sup with the devil on that side of the House when you can walk with God on this side?"

The hon. Member for Birmingham, Edgbaston (Dame J. Knight) spoke about a dream. My second point is about the shattering of a 17-year-old dream about the building of a new district health authority hospital in Hackney. That dream started under the last Labour Government and a few years ago, half of that hospital at Homerton was built. But half a hospital is not enough, and it looks a bit odd. Just a year ago, the regional health authority said that we could have the other half because it had the funds and the date, and the Government had cleared the scheme. Four weeks ago, the regional health authority, backed by the Government, said that phase 2 of the Homerton hospital will not be built—today, tomorrow or ever.

We went to see a Minister about the hospital. He gave us lots of sympathy and a cup of coffee, but insisted that the money for phase 2 was not available. The mind-boggling reason given to us for not building phase 2 of a hospital first thought about 17 years ago was that the property market was such that funds would never be available.

On Thursday, the Prime Minister said that the NHS would deal with its problems on the basis of clinical need. There is much discussion about who has or has not O-levels and about who is or is not educated. It is preposterous to suggest that clinical need has something to do with the current state of the property market. Clinical need has no more to do with that than it has to do with the position of Jupiter or with the fact that the remains of the mad axeman are embedded in the concrete of the M4. That is an absurd reason for not building the second half of a hospital.

We have decided to put up a plaque on our half-hospital, giving the names of the five guilty people. They are William Waldegrave, Tory; Tim Chessels, chairman, regional health authority, Tory; Virginia Bottomley, Tory; Evan Stone, chairman, district health authority, Tory; and Stephen Dorrell, Tory. That should explain why we shall be voting against the Government.

5.57 pm

Mr. Nicholas Winterton (Macclesfield)

The hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) spoke about Dr. Ken Grant supping with the devil, and suggested that he should instead sup with God. Dr. Grant has supped with the select, in so far as he has been a distinguished adviser to the Select Committee on Social Services, the predecessor of the Select Committee on Health. As a specialist adviser, Dr. Grant contributed to a report by the Select Committee on Social Services and, in general, that report was warmly welcomed by the Opposition. Perhaps Dr. Grant has rather more ability and talent than the hon. Gentleman gave him credit for. Many of us who worked closely with Dr. Grant for a long time know that he is a distinguished and qualified community physician. He has the qualifications and the necessary skill to do the job that he is currently undertaking.

Mr. McCartney

I agree that Dr. Grant advised the Select Committee, but the hon. Gentleman should remind the House why the Opposition welcomed the Committee's report. It was because it recommended that the Government should not go ahead with trust opt-out hospitals until a pilot scheme had been conducted. The Government rejected Dr. Grant's advice, although it was accepted by the Select Committee.

Mr. Winterton

I am grateful to the hon. Gentleman for reminding the House of some of the conclusions and recommendations set out in the Select Committee's report, which I stand by to this day.

Today, the members of the Select Committee on Health visited the Bessborough clinic in the Riverside health authority here in Westminster. We also visited the West London hospital and the Queen Charlotte maternity hospital. It is important to say from the Government side of the House that there is concern among those working in the health service and those who come to it for treatment about the Government's reforms. Most of those we met today—managers, midwives, nurses, doctors and consultants—accept that the reforms are with us and that we must make them work.

I give my right hon. Friend the Secretary of State due credit for saying that, if some adjustment needs to take place or some amendment needs to be made to the reforms, he will ensure that it takes place. I know from my experience in dealing with trust applications that, if there is concern about whether applications should be put back for further consideration, my right hon. Friend is prepared to take that course so that the concern that is felt in an area in which applications are being submitted can be reconsidered and examined in the calm light of day.

It is important that the House should know that the Select Committee on Health—we have had full co-operation from my right hon. Friend the Secretary of State—will take evidence on the morning of Wednesday 22 May from Guy's and Lewisham health service trust and from the Bradford health service trust. The chief executive and the chairman of Guy's and Lewisham will give evidence. On behalf of the Bradford trust, the vice-chairman and the chief executive will give evidence.

We have already received from the Bradford trust its corporate plan and all the information we require to enable us to ask relevant and constructive questions when the vice-chairman and the chief executive come before us. I am confident that, in the near future, we shall receive a draft business and corporate plan from Guy's and Lewisham, and all the other evidence that we require, so that the Select Committee, a Committee acting on behalf of the House, can seek to clarify what has happened in the two trust areas and their hospitals, what their plans are for the future and why there have been announcements of substantial job loses. I hope that we shall be able to ascertain where the job losses are likely to fall.

There is concern in the country about trust status, but it is sensible to realise that the reforms are with us and that the trust hospitals have not opted out of the national health service. Indeed, the hospitals are still very much within it.

Only yesterday, I was asked as Chairman of the Select Committee on Health to open a new home for Anchor Housing in Gorton, Manchester. It is a sheltered accommodation project, with nursing care, that is a joint venture between the Anchor housing association and the Central Manchester health authority. I know from what the chairman of the health authority has told me that it is making it clear to the trust hospitals within central Manchester that it does not wish to see—this is the chairman's view—the development of a two-tier health service.

The initial stages of the reforms could well produce a two-tier health service. We know that from the information that has already come to us from general practitioner fund holders. It is clear that they will exercise their financial weight and influence in getting the best possible deal and contract with a hospital, and the consultants in that hospital. In guaranteeing certain time scales for the treatment of patients, it is clear that patients from non-fund-holding general practitioners are likely to be passed over.

I ask my right hon. Friend the Secretary of State to give an assurance that he will not tolerate a two-tier health service, and that he will give the most powerful and influential guidance from the Department to the national health service executive, under the chief executive, Duncan Nichol, who will transfer the guidance to the regional health authorities, district health authorities and health service trusts. It must be made clear that they must not permit a two-tier system. In any guaranteeing of the terms of a contract, they must accept their other responsibilities as national health service hospitals. That will go a long way to giving reassurance to those who are concerned about trusts and GP fund holders.

The initial implementation of the reforms will see the choice of where to refer patients being exercised powerfully by general practitioner fund holders. I think that my right hon. Friend the Secretary of State is aware of that. To build on my previous remarks, non-fundholding general practitioners will have their choice of where to refer patients limited by the block contract system.

It is theoretically possible for non-fund-holding GPs to make what are known as extra-contractual referrals to provider units where the patients' district health authority has not agreed a contract, but I believe that that will be limited by the residual funds that have been set aside by a purchasing district health authority that are not already committed to contract. I remind the House that residual funding has to cover any extra-contractual referrals by non-fund-holding GPs and the cost of tertiary referrals, as well as any liabilities arising out of the admission of a district patient to an accident and emergency department in other districts or regions.

In the short term, it is clear that a two-tier system may be in operation where one set of patients—those registered with the fund-holding GP practice—are advantaged in terms of choice over patients who are registered with non-fund-holding practices. The choice of referral will be further restricted where district health authorities have not set aside sufficient residual funds to pay for extra-contractual referrals.

I shall quote Marianne Rigge, the director of the College of Health, who wrote to the Select Committee on Health to say: most GPs and their patients are going to have less choice than in the past. I believe that that will be only in the short term. Marianne Rigge continues: No longer will it be a purely clinical decision by a consultant to whom a GP has referred a patient, that he will do that operation. There will be a new dimension—that of payment. The reasons behind the decision to operate may become financial rather than clinical. Patients may find themselves being put into a new sort of waiting list—for the money, rather than for the treatment. District health authorities that have general practitioner fund holders in their district may set priorities—this is important, and it has not been mentioned so far—that are different from those of general practitioners. That may cause problems, and no formal structure has been instituted to resolve them. The only mechanism for reconciliation is informal negotiation.

As my ministerial colleagues are aware, DHAs have little power to control general practitioner referring. Potential financial problems will be created if insufficient reserves are kept by a DHA to fund the extra referrals which I have already mentioned. The Department of Health predicted that most general practitioner fund holders would agree block contracts based on previous years' referral patterns.

That has not always happened. Some fund holders are keen to change their referral patterns this year; that means that they are seeking what I can only describe as "better deals" for their patients now, and are prepared to use their budget-holding powers to buy services from hospitals that can offer shorter waiting times, less extensive care or better-quality treatment—or a combination of all three.

According to Health Service Journal, Oxford health authority asked its GP fund holders to tie up 80 per cent. of their budgets in hospital contracts, leaving themselves 20 per cent. "to play the market". But let me present the other side of the coin: all is not necessarily rosy for fund holders. We have already received evidence that some of them are complaining that their budgets are too small to give them any clout with potential advisers. To get around that problem, some GPs are considering forming fund-holding consortia, in the hope that that will increase their purchasing power.

Let me add another caveat. If a GP spends his or her budget before the end of a financial year, the GP will play the role of "rationer of health care", and may well create a waiting list all of his—or her—own.

The implementation of the new reforms will cause problems, but, as I said at the beginning of my speech, these reforms are already with us. We on the Select Committee consider it our duty to ensure that they work, and also to ensure—with the help of the NHS professions and the Department of Health—that the Government's objectives are achieved. I entirely share those objectives, which are to provide better value for money in the delivery of health care, to make the system more patient-responsive and to ensure that a larger percentage of the total budget is spent directly on patient care and the delivery of treatment.

I believe that I speak on behalf of many other people when I suggest to the hon. Member for Livingston (Mr. Cook) that we should accept, for the moment at least, that the NHS reforms are with us. Would it not have been better for us to discuss today how those reforms could be improved to the benefit of the people, rather than merely bandying statistics and throwing political vitriol across the Floor? I personally believe that the Government are entirely sincere in their wish to achieve their laudable objectives—which, I suspect, are shared by every hon. Member, whatever his party.

Having said that, let me again ask my right hon. Friend the Secretary of State for an assurance that he will do his utmost—by means of firm guidance and encouragement from the top—to make it clear that the Government have no intention of establishing a two-tier health service. Already, the lead has been taken by a number of trust and district health authority chairmen, although not, as yet, by any regional health authority chairmen. If my right hon. Friend follows up that lead, he will carry people along with the reforms—which, after all, are already being implemented.

I am convinced that, if my right hon. Friend takes that course, we shall be able to remove the NHS from the political arena—where, today, it has been the subject of such a negative and sterile debate.

6.13 pm

Mr. Jimmy Wray (Glasgow, Provan):

Listening to today's debate, I sometimes wondered whether I was at the London Palladium. From what the Government have said, it might be imagined that there was nothing wrong with the health service. Those of us who represent constituencies that have suffered from the lack of Government expenditure know otherwise. For four years, I have been following up my ten-minute Bill asking the Government to show compassion for the thousands of women who die of cervical cancer each year. It would cost only £15 million, but the Government—to a man and to a woman—voted against my Bill. That is the kind of Government we are dealing with.

The politicians' graveyard on the Conservative Benches evokes no sympathy in me. These will soon be yesterday's men and women. For 12 years, the electorate have given them their chance, and what have they done? They introduced the poll tax, which they have now been forced to abandon. Now they have a new philosophy—health service trusts. Why do they not do something about the people who are handing out private insurance, telling the purchasers that if they take a health service bed instead of one in the private sector they will receive £100 a day? Has any Conservative Member received £100 a day from private health insurance? I think so; I know people who have received that kind of money.

My hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) has raised with the Department of Health the plight of those who, through no fault of their own, were injected with HIV. They asked, through their lawyers, whether they would be given compensation. My hon. Friend wrote to the Secretary of State on 28 February, but he has still received no reply. That is the sort of compassion that the Department is showing.

The Government say that there is nothing wrong with the health service, and that they believe that a two-tier system will work. If there is nothing wrong with the health service, why is there a waiting list of 70,000 in Scotland, and waiting lists of 50,000 and 800,000 in Wales and England respectively? Do the Government honestly think that the people will accept the closure of new hospitals because of the lack of staff and equipment?

The Government will find the answers in the ballot box. They believe in the ballot box for trade unions; they do not believe in a health service ballot box. When Guy's hospital —the Government's flagship—became a trust, was there any consultation with the workers? It is certainly clear that the Prime Minister's office is not briefing him properly. When the first Scottish hospital asked for advice about trust status, the consultants opposed the move by 87 votes to two. The Government may believe that the men and women of England and Scotland who work for the health service are ready to sell it out, but they will receive a different answer at the next general election.

I find it hard to believe that a trust set up to show the way in Britain should forecast, in its business plan, a profit of £1.5 million, and finish its first year with a deficit of £7.5 million. Who will help it out? Certainly not the present Government.

When asked about the prospect of 600 people at Guy's hospital being put on the dole, the Secretary of State said, "It is not our business; it is the board's business." I believe that, when both Scottish and English Ministers said at the Perth conference that they would not take hospitals out of the NHS, they meant it. Because of the way in which they have set up this project, the system is isolated and fragmented and ready for privatisation. That is their idea and that is what the trusts are all about—the Americanisation and privatisation of the health service. "Don't trust the trusts," is the slogan, and do not trust the Tories either.

There certainly has not been any consultation in Scotland, and if the people who asked for consultation had got it, they certainly would have said a big no to the trusts. It is nonsense to say that the people of Scotland want funded practices. Out of 1,000 practitioners, only 46 applied for advice on funded practices and only four are thinking the matter over. Nobody in the health service wants funded practices. They want decent hospitals, beds and more money invested in the service.

The health boards have done a great job for the Government, especially Lothian health board, which has already drawn up secret plans. If the health boards are really interested in dealing with the shortage of beds, why are they recommending the closure of Edinburgh Royal with 2,000 beds, one of Scotland's largest teaching hospitals, and replacing it with a new hospital with 700 fewer beds? That is the type of thing they propose. It is all about selling off assets. There will be a carrot in the form of the hospitals' assets—the beautiful buildings and greenery and the acres of land that are prime sites for building.

I hope that the people of Lothian are aware of Lothian health board's plans to close part of Eastern general hospital and of its plans for Roodlands general hospital, the Simpson memorial maternity pavilion and the Princess Alexandra eye pavilion. No doubt, the hon. Members representing constituents in that area will have something to say about it.

I shall not take up any more time, Mr. Speaker, as many hon. Members have been sitting here for hours hoping to catch your eye. I shall simply say that the people of the United Kingdom and Scotland are not interested in trusts or funded practices.

6.23 pm

Mr. David Evan (Welwyn Hatfield)

I have heard from hon. Members several instances of the national health service seeming to have failed the patient. Last night, I was out with one of my constituents, when he collapsed. He was taken to St. Thomas's where he received first-class treatment. He could not have praised more highly the efforts of the people who serve the hospital. I have heard too much from the Opposition this evening about how incompetent and inefficient some of our hospitals are. I disagree profoundly with that.

The national health service became operational on 5 July 1948. Let me put that date into perspective. Electricity generation was the task of the British Electricity Authority, the forerunner of the now defunct Central Electricity Generating Board. British Rail, established only a year earlier, was investigating technologies to replace the steam locomotive. The National Liberal party, at its June conference in 1948, voted to change its name —surprise, surprise.

The electricity industry has now been privatised. BR, which has run out of steam, is currently in the process of restructuring its organisation. The time has surely now come for the NHS to realign itself to face the challenges of the 1990s, not those of the 1940s. Demographic changes, new social aspirations and advances in medical science have all contributed to the need for a new service culture.

The Opposition, however, are happy, as we all know, to keep the NHS in a time warp. Their Front Benchers pour scorn on the Government's reforms; to a man and a woman, they fail to grasp that the NHS is in desperate need of an overhaul. All they can talk about is how much more money they would spend—a cheap commentary, without any economic foundation whatsoever.

The Opposition's shallow grasp of health economics was revealed last year, when the hon. Member for Livingston (Mr. Cook) committed the Labour party to spending some £3 billion over the lifetime of a Government to restore what he called "NHS underfunding". He failed to realise that the Government have increased spending by more than £6 billion over the last two years alone. More impressively, during their first 11 years in office, this Government increased spending by 52 per cent. There are 30,000 more patients treated every week, 16,000 more GPs, 5,000 more in the hospital service, and 60,000 more nurses and midwives.

In addition to channelling unprecedented sums into the NHS, my right hon. Friend and his ministerial team have wrestled successfully with the institutional problems that have long plagued the health service. The NHS has become what one might call a bureaucratic ghetto, with over 1 million employees, the largest employer in Europe.

The NHS trust hospitals form the vanguard of the Government's latest reforms. On 1 April, 57 were created, and 130 others hope to join them by next year. They have an ongoing restructural process which will drag the national health service into the 21st century. Hospitals are now able to release themselves from the pervasive bureaucracy that has stifled local initiative for so long—a malaise which is particularly relevant to the North-West Thames regional health authority, which administers the funding of hospitals in my constituency.

My local authority, East Hertfordshire, has been the victim of gross mismanagement dished out by the North-West Thames regional health authority. The six shire authorities have had to stand by and witness their prudent fiscal policies being translated into cuts, while funds have been redirected into free-spending inner-London health authorities. The results are absurd. The shire authorities, which have 43 per cent. of the region's population, receive only 31 per cent. of the cash. In other words, where £1 is spent in Brent, only 75p is spent in Welwyn Hatfield.

A comparison of staffing ratios in East Hertfordshire as against the Riverside health authority produces even more laughable results. East Hertfordshire has 19 occupational therapists compared with Riverside's 120; a derisory 18 physiotherapists compared to inner London's 119; and 17 district nurses compared to 179—and this is for the same number of people in Riverside as in East Hertfordshire.

The most graphic example of this towering ineptitude is seen in the history of the Westminster and Chelsea hospital project. The cost of that scheme started off at £78 million. It then went up to £130 million. It is now over £200 million, and every capital project in the shire district has had to be shelved for three years. That is due to the incompetence of the North West Thames regional health authority and its chairman. Hospital trusts will offer an escape from that quagmire. They are an imaginative, far-sighted response to the archaic thinking prevalent in the old organisational structure.

I come now to the caring Labour party and an article in The Times in 1978 with the headline "Hospital is to turn away patients with cancer". It says: '"Patients with breast, lung and other cancers and abortion cases are to be turned away from the Kingston hospital, Surrey, because of industrial action by national health services workers and supervisors', the hospital said yesterday. From midnight next Tuesday even known cancer cases will be denied admission and lives immediately threatened. Investigative surgery, even where there is strong suspicion of the life-threatening condition, will not take place. On 21 October 1978,The Times said: Talks aimed at ending the dispute involving hospital engineers and work supervisors broke down last night after union leaders rejected an appeal from Mr. David Ennals, Secretary of State for Social Services, for a return to work, because, he said, patients were dying Mr. Ennals, who had been touring the West Norwich hospital where services had been badly affected by the dispute said: 'I appeal to those who are taking industrial action. For God's sake suspend it. For God's sake go back to work and stop playing around with people's lives. They can no longer take it out on patients. There is no doubt that some people have already died. Every day and week that goes by, the danger is there.' Far from the medical garden of Eden, hon. Members will see an institution ravaged by union militancy and retarded by poor leadership mirrored in the Labour party. If the Labour party gets in at the next general election, God help us.

6.31 pm

Mrs. Margaret Ewing (Moray)

I must of necessity compress my remarks, but I have a local issue that I wish to raise.

My constituency is also covered by what is known as West unit within the Grampian health board. West unit has recently applied for additional information on trust status. During the past few weeks, many of my constituents—not only those who work in the health service—have made clear their genuine concerns and fears about the situation.

I start from the basic principle that the NHS is not a business to be organised by managers. People are at the heart of the service. We are the providers of the health service and we must understand the profound affection that people throughout the country have for it. Some of my constituents' concerns are based on the Government's record in the preparation for the changes to the NHS.

I refer in particular to what was said not by the Secretary of State's predecessor but by his predecessor's predecessor—the golden boy of the Conservative party, the right hon. Member for Croydon, Central (Mr. Moore) —who was charged with bringing forward fund-holding practices and trust status. In an address to the Young Conservatives, he said: I foresee a substantial increase in private medical care with the NHS remaining as a safety net. Against that kind of background, is it any surprise to the Government that people should be suspicious? Why should any Minister refer to the NHS as a safety net unless the Government intend to implement a two-tier system?

The Government were asked by the royal colleges, the British Medical Association and the Select Committee to implement pilot schemes. Instead, 57 trusts were established and it is already clear from their record that not all is well. We have seen what has happened in three of them and we are deeply concerned that the Government are continuing to push trust status against that background. At the very least, they should consider abandoning the prospect of further trusts until we can analyse and evaluate further what is happening in those already established.

My constituents are also worried about what is meant by the consultation process. In theory, there is consultation before trust status is agreed to, but it is essentially a meaningless exercise because, even where the medical profession and the public have made clear their antagonism towards the idea of a trust, it has still gone ahead.

Those who are charged with delivering the health service—in our area, the Grampian health board—say that they are required to take a view on any trust application and are well placed to advise on the likely impact of the proposal on the local provision and the quality of health care. Those people are not from the medical profession—they are business men and Tory appointees. In addition, within the Grampian health board area, the health councils have been reduced from five to one. In my constituency, the most northerly part of the Grampian region, we have only three representatives on the health council. Democracy appears to have gone out of the window.

Against that background, given the exigencies of time, I make a plea to the Government to endorse the view being so clearly expressed everywhere that there must be no further trusts until there has been a clear evaluation and analysis of the existing ones.

6.36 pm

Ms. Harriet Harman (Peckham)

Tonight the Secretary of State stood before the House of Commons as a man in whom the public have not a shred of confidence. No one believes the Government's promises on the NHS any more. No one trusts the Government because they have broken every promise that has been wrung from them. Above all, they have broken their promise that we can keep our national health service. Instead, we have seen hospitals opting out, NHS queue-jumping and a relentless drive towards a United States-style, two-tier health service.

No one believes the Government's promise that they are really committed to the NHS, and why should we? We were told that the opted-out hospitals were to give people a say at local level, to devolve decision-making down to local communities, but then we learned that there were to be no ballots, so people at local level were not to have a say about whether their hospital should opt out. Despite the overwhelming opposition of people at local level, the Government were clearly determined to ride roughshod over local opinion. How can that be giving people a say at local level when they cannot even have a say in whether their hospital should opt out?

We were told that opting out would not mean job losses and all that we said was supposedly scaremongering. The gap between rhetoric and reality is well illustrated in a little booklet entitled "Guy's Hospital Gazette", which says: We are friendly and fun. This is a great place to work … The management cares, really cares about people … Having fun is considered as legitimate! That is the Guy's self-governing trust. Just as that document was being circulated to the staff, we were told that 600 jobs were to go. We were then told that those job losses would not hit services, but then a leaked memorandum from Guy's hospital told us that there would be inevitable reductions in direct patient care services. So the job losses that we were told would not happen will indeed hit patient care services, although the Government tried to conceal the truth from the people who depend on those services.

We were told that opted-out hospitals would not be cut loose from the national health service, but as the scale of the cuts became clear at Guy's and then in Bradford, the Secretary of State said, "It's nothing to do with me—I am only the Secretary of State. Guy's has opted out, as has Bradford, so why don't you ask the chief executives of opted-out hospitals?" The Secretary of State has a choice: he can either accept responsibility for cuts in services or he can admit that hospitals have opted out of the NHS. He cannot have it both ways.

We were told that opted-out hospitals would still be open and accountable, but in the 200-page application for Guy's opt-out nothing was said about the swingeing and immediate cuts in jobs and services. We have never been allowed to see the secret business plan that the trust submitted to the Government. Why should we trust the Government when they will not show us documents that trusts have submitted to them? The Government are supposed to be running the national health service, but they are operating it like the secret service.

The Government denied that the internal market would produce a two-tier national health service—

Mr. Andrew Smith (Oxford, East)

As regards the two-tier service, does my hon. Friend share my deep concern about the report to the Oxfordshire community health council this week to the effect that a contract is being concluded with Swindon district health authority giving patients from that authority a guarantee of a scan on the marvellous magnetic resonance imager at the John Radcliffe hospital within two weeks, when the average waiting time for Oxfordshire patients is three months? Does that not show that it is the ability to fix financial deals and not medical need which determines access to treatment?

Ms. Harman

Moreover, because all those people will have priority in queue-jumping, everyone else will have to wait even longer. Within weeks of the establishment of an internal market, queue-jumping has been institutionalised in the NHS, and the Secretary of State knows it. It happened first in Watford. Let us be absolutely clear what we are talking about. Two GP fund-holding practices have 10 per cent. of the patients in the district and 90 per cent. are with other GPs. As a result of priority admission being arranged for the patients of the two fund-holding practices, the other 90 per cent. of patients will have to wait longer.

The same arrangement was made in Bart's, and now an arrangement is being negotiated with Guy's whereby not only will some GP patients have priority admission, and therefore everyone else will have to wait longer, but some people will get priority when it comes to who performs the operation and whom they see. Advantage will be negotiated. Some patients will see consultants and senior registrars and everyone else will be relegated, irrespective of clinical need to more junior members of staff. That is the logic of the internal market, and it will hit not only Watford, Bart's and Guy's, but all hospitals in due course.

When a person is treated will depend not on how urgent the clinical condition is, but on whether the GP is a budget-holder and whether the district health authority has been able to fix a preferential deal. As a result, there will be patients in adjacent beds for hip operations, one having waited 18 months in pain and agony and the other having waited only two weeks. I shall be interested to know whether Conservative Members would defend that situation. If that is not a two-tier health service, I do not know what is.

Inconsistencies have started to appear in the stories from different members of the Government, as always happens with people who are up to no good. The Prime Minister is saying quite clearly: Operations are done on the basis of clinical need and again: I shall repeat that in case he did not fully hear it first time: operations are done on the basis of clinical need."—[Official Report, 7 May 1991; Vol. 190, c. 620.] Yet the Secretary of State has admitted tonight that queue-jumping arrangements will be negotiated, so it will be contracts and wheeling and dealing between GP budget-holders, hospitals and district health authorities that will determine priorities rather than clinical need. No wonder, to use the words of Dr. Ken Grant, district general manager of the City and Hackney health authority, in a letter to consultants: This does mean that the question of equity has gone out of the window"— I should like to know whether the Secretary of State accepts that— but this is the reality of GPs holding their own practice budgets for elective work. Another promise that the Government have broken is that people will have a choice about where they go for treatment. Choice is being taken away from the patient in consultation with the GP.

Mr. Hind

They never had it before.

Ms. Harman

Yes, they did—[interruption.] If hon. Members will give me one—[Interruption.] Take maternity services, where there has been a long tradition—

Mr. Speaker

Order. I think that it would be better if the hon. Lady directed her speech through me.

Ms. Harman

If we take maternity services, there has been a long tradition, which we should encourage, of women choosing where to have their babies on the basis of what was convenient for them, what sort of care they wanted and the style of delivery that they wanted. That was described as cross-boundary flow and operated under the last Labour Government and until now. However, the decision about which hospital she will go to will not now be taken by a woman in consultation with her GP but by the district health authority manager, who will place block bookings for maternity services for the district. If a woman wants to have a baby in a hospital other than the one where the contract has been placed, she will have to apply for access to the extra-contractual referral fund and go through the procedure. There is simply not enough money in the contingency funds to safeguard choice, tertiary referrals, and so forth.

If the Government were honest, they would admit that choice has gone out of the window with the internal market. They also ought to be honest and admit that they are promoting private health care. They have allowed waiting lists to grow so that more and more people have been driven to paying for private health care. The Government have been giving tax relief for private health care for the elderly. Now the private sector is stalking further into the NHS, with private contractors for cleaning and laboratory services and private deals for private hospitals on NHS sites.

Perhaps the Minister in her winding-up speech will take the opportunity to stop in its track the secret deal that AMI Healthcare is negotiating to build a private hospital on the site of the QEII hospital in Welwyn Garden City to lure NHS consultants and nurses away from their patients to do private work and to make everyone else wait longer.

We remain steadfast in our straightforward opposition to the internal market, where doctors have to put cash before care, where profits come before patients. We shall abolish the internal market and we shall remain steadfast in our opposition to opting out. We shall bring opted-out hospitals back within the NHS. The Government can no longer carry on riding roughshod over public opinion. They are wildly out of step with the mood of the public. They must admit—as they did with the poll tax—that they have got it wrong.

6.48 pm

The Minister for Health (Mrs. Virginia Bottomley)

We are becoming accustomed to a litany of carping hysteria, negative stories and misleading information. I shall focus on some of the elementary points. "Take maternity services," said the hon. Member for Peckham (Ms. Harman). Well, let us take maternity services. What has happened? My right hon. Friend the Secretary of State informed the House that perinatal mortality has never been lower. In the past 10 years, we have halved the number of babies dying in childbirth and in the past 15 years we have halved the number of women dying in childbirth. That is what I call "taking maternity services". More than that, in 10 years we have gained one third more midwives. We are profoundly and sincerely committed to concentrating on the improvement of the identifiable and measurable health care indicators.

As for waiting lists, the last Labour Government, like every Labour Government, left power with waiting lists increased; there was a 48 per cent. increase in waiting lists during their term of office. Waiting lists have come down 7 per cent. under the Conservative Government. We want to do better, and we will do better. If ever there was encouragement for the private sector, it was the fact of the Labour party being in power. As has been said clearly in the debate, the clinical judgment and the priority which operated when the Labour party was in power were exercised by the COHSE official at the gate. We understand that. With one third of the parliamentary Labour party sponsored by one of the health unions, we understand where Labour's loyalties lie.

Our commitment is clear: it is to continue to improve the health care of our people. No, we do not want to argue with the AMI initiative at Welwyn Hatfield. If the private sector can flourish and develop, that does not offend us, because we are concentrating on improving the functioning, the management and the care provided by our national health service.

None of us is prepared to listen to lectures from the Labour party about commitment, investment and plans for the health service because the Government have invested in the service and increased the number of doctors and nurses. I do not know how the hon. Member for Livingston (Mr. Cook) dared to talk about the record of staff in the face of the cuts in pay that health care staff suffered under Labour.

There has been discussion today about a two-tier service. I want to give an example of what I think would have created a two-tier service. Hon. Members are well advised to recall the debates on the introduction of the general practitioner contract. Almost all now agree that the contract has been a major force for good. Children are immunised and women are screened. It is becoming a health service, not a disease service. There is more health promotion.

What was the line of the Labour party? According to Labour, it was too much to expect GPs in inner-city areas to meet the targets that the rest of the country had to meet. The Labour line was that targest should be lowered in inner-city areas. That is what I call a two-tier health service. Our approach was not to lower the targets for some groups in the community but to make sure that those GPs in inner-city areas received additional deprivation payments. We want to make sure that all parts of the community receive the best possible patient care.

I am grateful to my hon. Friend the Member for Macclesfield (Mr. Winterton) for his contribution and for his recognition that the health reforms are here to stay. We want to improve the health care of all. Yes, trusts are at the forefront of changes. GP fund holders can use their purchasing power. They have the control and autonomy to do what a good GP has always done, which is to advise patients on how to get the best deal from the various hospitals and provisions. That is the role of the GP. The GP is the advocate for the patient. We want GPs to push forward the frontiers, but we want the districts, which have much greater purchasing muscle than GP fund holders, to make sure that they seek the same quality improvements so that they can get the same results in waiting times.

Again, what is the approach of the Labour party? It is equal misery for all, levelling down, and the lowest common denominator. Labour thinks that it would be wrong for some people to make progress because others might be left out. Our approach is to have the best possible health care for all the people. If trusts can move forward improvements in quality and if GP fund holders can use their leverage to improve health care, we will welcome and endorse that.

I should like to address some of the speeches made in the debate. The right hon. Member for Blaenau Gwent (Mr. Foot) spoke with feeling about BMA opposition to the health service. He quoted it as saying, "We didn't understand what the reality of the service would be." We know how that feels. We are absolutely confident that, as the reforms bed in and as we move forward, the BMA and many others will understand precisely what they mean for the health service.

The right hon. Gentleman seemed in his splendid oratory, which all of us much enjoyed, to overlook the fact that it was his party that introduced cash limits for the health service. On a precise point, he mentioned the role of physiotherapists. I endorse the point that it is often the professions allied to medicine which can make a major contribution to improving patient care. I can inform the right hon. Gentleman that there has been a 35 per cent. increase in professions allied to medicine over the past 10 years. Certainly physiotherapists have an important part to play.

I thank my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe), who has particular knowledge of and expertise in the health service. I am grateful for his recognition of what is being done about junior doctors. Much of the work in which I have been involved in that respect has been built on his work in achieving a balance. That was very much the model that was put to me when there was talk about having a ministerially led team to tackle an outdated, unacceptable way of training our juniors. How pleased I am that the consultants and the juniors have found a way through the hurdle. We are setting up regional task forces and guidance will be produced shortly. We are determined to bring to an end an unacceptable way of training doctors.

Mr. Dickens

Does my hon. Friend agree that the NHS trust within the national health service has the opportunity to reintroduce matrons into hospitals? One hospital has already done that. New managements could make similar decisions. Most people would welcome that approach.

Mrs. Bottomley

It is always worth while giving way to my hon. Friend. He has made a point that meets with great support. Indeed, he has made two important points. First, the culture around the matron was that she was a person who knew what was going on. The matron understood how the hospital was organised. That is part of our emphasis on better management. We have to tackle the problem. We cannot allow the health service to run on in the way that it has worked traditionally. We need people to take responsibility.

Secondly, my hon. Friend was right to identify the role of nurses. My right hon. Friend the Secretary of State has carried forward the cause of nurses by putting the chief nursing officer on the policy board. We introduced Project 2000, a much more appropriate way of training nurses, who are now much better paid.

Coming back to my right hon. Friend the Member for Brentford and Isleworth, who spoke about nurse prescribing, we want progress as quickly as possible. It is a dreary feature of Government that we need to make sure that the list and the cost benefit are correct and that liaison with other professionals has been properly addressed.

Mr. Hind

Will my hon. Friend make it clear that the problems that we have discussed in the debate relating to London hospitals are essentially London problems? Will she make that clear before the Labour party carries its nasty propaganda to the north of England and frightens many constituents in other parts of the country with its suggestions about NHS trusts?

Mrs. Bottomley

Indeed, my hon. Friend is so right. Of course, the Labour party has total amnesia. Not only did Labour introduce cash limiting on the health service and prescription charges, but it set up the resource allocation working party, identifying then the dilemma which we face about the provision of consultants and beds in inner cities, based on historic provision, at a time when there has been enormous expansion outside London. The reforms will help us better to plan services and to improve the care that we provide.

We have no doubt that these reforms will build a better health service. We have a right to have pride in our record. We have invested in an unprecedented way. We have worked with the service, and for the service, for patients. Above all, putting patients first is the focus of our work. I hope that all hon. Members will reject the Labour party's motion. The Labour party has no right to speak for the health service. Its only loyalty is, of course, to the health service unions. Ours is the record, ours is the policy, and we shall see a stronger, healthier and more effective health service as a result of these reforms.

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

The House divided: Ayes 184, Noes 296.

Division No. 142]	[7.00 pm
AYES
Abbott, Ms Diane	Darling, Alistair
Adams, Mrs Irene (Paisley, N.)	Davies, Rt Hon Denzil (Llanelli)
Allen, Graham	Davis, Terry (B'ham Hodge H'l)
Archer, Rt Hon Peter	Dewar, Donald
Armstrong, Hilary	Dixon, Don
Ashdown, Rt Hon Paddy	Dobson, Frank
Ashley, Rt Hon Jack	Doran, Frank
Ashton, Joe	Douglas, Dick
Banks, Tony (Newham NW)	Duffy, A. E. P.
Barnes, Harry (Derbyshire NE)	Dunwoody, Hon Mrs Gwyneth
Barnes, Mrs Rosie (Greenwich)	Eadie, Alexander
Barron, Kevin	Eastham, Ken
Battle, John	Ewing, Mrs Margaret (Moray)
Beckett, Margaret	Fatchett, Derek
Beith, A. J.	Fearn, Ronald
Bell, Stuart	Flannery, Martin
Bellotti, David	Flynn, Paul
Benn, Rt Hon Tony	Foot, Rt Hon Michael
Bennett, A. F. (D'nt'n & R'dish)	Foster, Derek
Bermingham, Gerald	Foulkes, George
Blair, Tony	Fraser, John
Blunkett, David	Fyfe, Maria
Boateng, Paul	Galbraith, Sam
Boyes, Roland	Galloway, George
Bray, Dr Jeremy	Garrett, John (Norwich South)
Brown, Nicholas (Newcastle E)	Garrett, Ted (Wallsend)
Brown, Ron (Edinburgh Leith)	George, Bruce
Buckley, George J.	Godman, Dr Norman A.
Caborn, Richard	Golding, Mrs Llin
Callaghan, Jim	Gordon, Mildred
Campbell, Menzies (Fife NE)	Gould, Bryan
Campbell, Ron (Blyth Valley)	Graham, Thomas
Campbell-Savours, D. N.	Griffiths, Nigel (Edinburgh S)
Carlile, Alex (Mont'g)	Griffiths, Win (Bridgend)
Carr, Michael	Grocott, Bruce
Cartwright, John	Hardy, Peter
Clark, Dr David (S Shields)	Harman, Ms Harriet
Clarke, Tom (Monklands W)	Haynes, Frank
Clwyd, Mrs Ann	Heal, Mrs Sylvia
Cohen, Harry	Henderson, Doug
Cook, Robin (Livingston)	Hinchliffe, David
Corbett, Robin	Hogg, N. (C'nauld & Kilsyth)
Cousins, Jim	Home Robertson, John
Cryer, Bob	Hood, Jimmy
Cummings, John	Howell, Rt Hon D. (S'heath)
Cunliffe, Lawrence	Howells, Geraint
Dalyell, Tam	Howells, Dr. Kim (Pontypridd)

Hughes, Robert (Aberdeen N)	Powell, Ray (Ogmore)
Illsley, Eric	Prescott, John
Ingram, Adam	Radice, Giles
Janner, Greville	Randall, Stuart
Kaufman, Rt Hon Gerald	Redmond, Martin
Kennedy, Charles	Rees, Rt Hon Merlyn
Lamond, James	Reid, Dr John
Leighton, Ron	Richardson, Jo
Lestor, Joan (Eccles)	Robinson, Geoffrey
Lewis, Terry	Rogers, Allan
Litherland, Robert	Rooker, Jeff
Livingstone, Ken	Rooney, Terence
Lofthouse, Geoffrey	Ross, Ernie (Dundee W)
Loyden, Eddie	Ruddock, Joan
McAllion, John	Salmond, Alex
McCartney, Ian	Sedgemore, Brian
Macdonald, Calum A.	Sheerman, Barry
McFall, John	Sheldon, Rt Hon Robert
McKay, Allen (Barnsley West)	Shore, Rt Hon Peter
McKelvey, William	Short, Clare
McLeish, Henry	Sillars, Jim
McMaster, Gordon	Skinner, Dennis
McNamara, Kevin	Smith, Andrew (Oxford E)
McWilliam, John	Smith, C. (Isl'ton & F'bury)
Madden, Max	Smith, Rt Hon J. (Monk'ds E)
Mahon, Mrs Alice	Soley, Clive
Marek, Dr John	Spearing, Nigel
Marshall, David (Shettleston)	Steel, Rt Hon Sir David
Marshall, Jim (Leicester S)	Steinberg, Gerry
Martin, Michael J. (Springburn)	Straw, Jack
Martlew, Eric	Taylor, Mrs Ann (Dewsbury)
Maxton, John	Taylor, Matthew (Truro)
Meacher, Michael	Thompson, Jack (Wansbeck)
Michie, Bill (Sheffield Heeley)	Vaz, Keith
Michie, Mrs Ray (Arg'l & Bute)	Walley, Joan
Morley, Elliot	Wardell, Gareth (Gower)
Morris, Rt Hon A. (W'shawe)	Welsh, Andrew (Angus E)
Morris, Rt Hon J. (Aberavon)	Wigley, Dafydd
Mowlam, Marjorie	Wilson, Brian
Mullin, Chris	Winnick, David
Nellist, Dave	Wise, Mrs Audrey
Oakes, Rt Hon Gordon	Worthington, Tony
O'Brien, William	Wray, Jimmy
Owen, Rt Hon Dr David
Patchett, Terry	Tellers for the Ayes:
Pendry, Tom	Mr. Jimmy Dunachie and Mr. Thomas McAvoy.
Pike, Peter L.

NOES
Adley, Robert	Brazier, Julian
Aitken, Jonathan	Bright, Graham
Alexander, Richard	Brown, Michael (Brigg & Cl't's)
Amery, Rt Hon Julian	Browne, John (Winchester)
Amess, David	Buchanan-Smith, Rt Hon Alick
Amos, Alan	Buck, Sir Antony
Arbuthnot, James	Budgen, Nicholas
Aspinwall, Jack	Burns, Simon
Atkins, Robert	Burt, Alistair
Baker, Rt Hon K. (Mole Valley)	Butler, Chris
Baker, Nicholas (Dorset N)	Butterfill, John
Batiste, Spencer	Carrington, Matthew
Beaumont-Dark, Anthony	Carttiss, Michael
Bendall, Vivian	Cash, William
Bennett, Nicholas (Pembroke)	Chalker, Rt Hon Mrs Lynda
Benyon, W.	Channon, Rt Hon Paul
Bevan, David Gilroy	Chapman, Sydney
Blackburn, Dr John G.	Chope, Christopher
Blaker, Rt Hon Sir Peter	Churchill, Mr
Body, Sir Richard	Clark, Dr Michael (Rochford)
Bonsor, Sir Nicholas	Clark, Rt Hon Sir William
Boscawen, Hon Robert	Clarke, Rt Hon K. (Rushcliffe)
Boswell, Tim	Colvin, Michael
Bottomley, Peter	Conway, Derek
Bottomley, Mrs Virginia	Coombs, Anthony (Wyre F'rest)
Bowden, A. (Brighton K'pto'n)	Coombs, Simon (Swindon)
Bowden, Gerald (Dulwich)	Couchman, James
Bowis, John	Cran, James
Boyson, Rt Hon Dr Sir Rhodes	Currie, Mrs Edwina
Braine, Rt Hon Sir Bernard	Curry, David
Brandon-Bravo, Martin	Davies, Q. (Stamf'd & Spald'g)

Davis, David (Boothferry)	Key, Robert
Day, Stephen	King, Roger (B'ham N'thfield)
Devlin, Tim	Kirkhope, Timothy
Dickens, Geoffrey	Knapman, Roger
Dicks, Terry	Knight, Greg (Derby North)
Dorrell, Stephen	Knight, Dame Jill (Edgbaston)
Douglas-Hamilton, Lord James	Knowles, Michael
Dover, Den	Knox, David
Dunn, Bob	Lamont, Rt Hon Norman
Durant, Sir Anthony	Lang, Rt Hon Ian
Dykes, Hugh	Latham, Michael
Eggar, Tim	Lawson, Rt Hon Nigel
Emery, Sir Peter	Lee, John (Pendle)
Evans, David (Welwyn Hatf'd)	Leigh, Edward (Gainsbor'gh)
Evennett, David	Lennox-Boyd, Hon Mark
Fairbairn, Sir Nicholas	Lilley, Rt Hon Peter
Fallon, Michael	Lloyd, Sir Ian (Havant)
Favell, Tony	Lloyd, Peter (Fareham)
Field, Barry (Isle of Wight)	Lord, Michael
Fishburn, John Dudley	Luce, Rt Hon Sir Richard
Forman, Nigel	Lyell, Rt Hon Sir Nicholas
Forsyth, Michael (Stirling)	McCrindle, Sir Robert
Forth, Eric	Macfarlane, Sir Neil
Fox, Sir Marcus	MacGregor, Rt Hon John
Franks, Cecil	Maclean, David
Freeman, Roger	McLoughlin, Patrick
French, Douglas	McNair-Wilson, Sir Michael
Fry, Peter	McNair-Wilson, Sir Patrick
Gardiner, Sir George	Madel, David
Gill, Christopher	Major, Rt Hon John
Gilmour, Rt Hon Sir Ian	Malins, Humfrey
Glyn, Dr Sir Alan	Mans, Keith
Goodhart, Sir Philip	Maples, John
Goodlad, Alastair	Marland, Paul
Goodson-Wickes, Dr Charles	Marlow, Tony
Gorman, Mrs Teresa	Marshall, Sir Michael (Arundel)
Gorst, John	Martin, David (Portsmouth S)
Grant, Sir Anthony (CambsSW)	Mates, Michael
Greenway, Harry (Ealing N)	Maude, Hon Francis
Gregory, Conal	Mayhew, Rt Hon Sir Patrick
Griffiths, Sir Eldon (Bury St E')	Mellor, Rt Hon David
Griffiths, Peter (Portsmouth N)	Meyer, Sir Anthony
Ground, Patrick	Miller, Sir Hal
Grylls, Michael	Mills, Iain
Gummer, Rt Hon John Selwyn	Miscampbell, Norman
Hague, William	Mitchell, Andrew (Gedling)
Hamilton, Hon Archie (Epsom)	Mitchell, Sir David
Hamilton, Neil (Tatton)	Moate, Roger
Hannam, John	Monro, Sir Hector
Hargreaves, A. (B'ham H'll Gr')	Montgomery, Sir Fergus
Hargreaves, Ken (Hyndburn)	Moore, Rt Hon John
Harris, David	Morrison, Sir Charles
Haselhurst, Alan	Moss, Malcolm
Hayes, Jerry	Moynihan, Hon Colin
Hayhoe, Rt Hon Sir Barney	Mudd, David
Hayward, Robert	Neale, Sir Gerrard
Heath, Rt Hon Edward	Nelson, Anthony
Heathcoat-Amory, David	Neubert, Sir Michael
Hicks, Mrs Maureen (Wolv' NE)	Nicholls, Patrick
Hicks, Robert (Cornwall SE)	Nicholson, David (Taunton)
Higgins, Rt Hon Terence L.	Nicholson, Emma (Devon West)
Hind, Kenneth	Norris, Steve
Hogg, Hon Douglas (Gr'th'm)	Oppenheim, Phillip
Holt, Richard	Page, Richard
Howard, Rt Hon Michael	Paice, James
Howarth, Alan (Strat'd-on-A)	Parkinson, Rt Hon Cecil
Howarth, G. (Cannock & B'wd)	Patnick, Irvine
Howe, Rt Hon Sir Geoffrey	Patten, Rt Hon John
Howell, Rt Hon David (G'dford)	Pawsey, James
Howell, Ralph (North Norfolk)	Peacock, Mrs Elizabeth
Hughes, Robert G. (Harrow W)	Porter, David (Waveney)
Hunt, Sir John (Ravensbourne)	Powell, William (Corby)
Hunter, Andrew	Price, Sir David
Irvine, Michael	Raffan, Keith
Irving, Sir Charles	Raison, Rt Hon Sir Timothy
Jack, Michael	Rathbone, Tim
Janman, Tim	Redwood, John
Johnson Smith, Sir Geoffrey	Rhodes James, Robert
Jones, Robert B (Herts W)	Riddick, Graham
Kellett-Bowman, Dame Elaine	Ridley, Rt Hon Nicholas

Ridsdale, Sir Julian	Thompson, D. (Calder Valley)
Rifkind, Rt Hon Malcolm	Thompson, Patrick (Norwich N)
Roberts, Sir Wyn (Conwy)	Thornton, Malcolm
Roe, Mrs Marion	Thurnham, Peter
Rossi, Sir Hugh	Townend, John (Bridlington)
Rost, Peter	Townsend, Cyril D. (B'heath)
Rumbold, Rt Hon Mrs Angela	Tracey, Richard
Ryder, Rt Hon Richard	Tredinnick, David
Sainsbury, Hon Tim	Trippier, David
Sayeed, Jonathan	Trotter, Neville
Scott, Rt Hon Nicholas	Twinn, Dr Ian
Shaw, David (Dover)	Vaughan, Sir Gerard
Shaw, Sir Giles (Pudsey)	Viggers, Peter
Shaw, Sir Michael (Scarb')	Wakeham, Rt Hon John
Shelton, Sir William	Waldegrave, Rt Hon William
Shephard, Mrs G. (Norfolk SW)	Walden, George
Shepherd, Richard (Aldridge)	Walker, Bill (T'side North)
Shersby, Michael	Walker, Rt Hon P. (W'cester)
Sims, Roger	Waller, Gary
Skeet, Sir Trevor	Walters, Sir Dennis
Smith, Tim (Beaconsfield)	Ward, John
Speed, Keith	Wardle, Charles (Bexhill)
Speller, Tony	Watts, John
Spicer, Michael (S Worcs)	Wells, Bowen
Squire, Robin	Whitney, Ray
Stanbrook, Ivor	Widdecombe, Ann
Stanley, Rt Hon Sir John	Wiggin, Jerry
Steen, Anthony	Wilkinson, John
Stevens, Lewis	Wilshire, David
Stewart, Allan (Eastwood)	Winterton, Mrs Ann
Stewart, Andy (Sherwood)	Winterton, Nicholas
Stewart, Rt Hon Ian (Herts N)	Wolfson, Mark
Sumberg, David	Wood, Timothy
Summerson, Hugo	Yeo, Tim
Tapsell, Sir Peter	Young, Sir George (Acton)
Taylor, Ian (Esher)
Taylor, Teddy (S'end E)	Tellers for the Noes:
Tebbit, Rt Hon Norman	Mr. David Lightbown and Mr. John M. Taylor.
Temple-Morris, Peter

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

Resolved, That this House welcomes the progressive implementation of the Government's reforms of the National Health Service, coupled with substantial increases in resources for the National Health Service and in the numbers of patients treated since 1979; looks forward to the benefits of these reforms being spread more widely so that services everywhere are brought up to the standards of the best, especially with the further development of National Health Service trusts and fundholding practices; notes that district health authorities and general practitioner fundholding practices will both give priority to patient's clinical needs; welcomes the determination of the new National Health Service trusts to get to grips with long-standing management problems; supports the new role of district health authorities as guardians of the public health, accountable for arranging comprehensive care for their local residents; and endorses the Government's intention to set out a new agenda for the National Health Service which concentrates more than ever on improving the health of the people.