§ Order for Second Reading read.
§ Madam Speaker
Before I call the Secretary of State, I must inform the House that I have selected the amendment in the name of the Leader of the Opposition.
§ The Secretary of State for Health (Mrs. Virginia Bottomley)
I beg to move, That the Bill be now read a Second time.
The Bill represents the final steps in the programme of national health service reform that began with the National Health Service and Community Care Act 1990. When we embarked on those reforms, there was a clear consensus that the NHS needed to change. Despite the substantial extra funds that the Government had committed—increases unprecedented in its history—the service was still often inefficient, inflexible and unresponsive to the needs of patients.
Management was exercised through a cumbersome, command-and-control bureaucracy; staff were trapped in a system over which they had little or no control; the vested interests, whether they be the trade unions or the Sir Lancelot Spratts of this world, had too much power. The patient had little say, and even less choice.
The background to the Bill is four years in which—
§ Mrs. Bottomley
I am sure that the hon. Gentleman wants to share reminiscences with me, as someone who was a member of the Standing Committee that debated the National Health Service and Community Care Act 1990 five years ago. However, I must make progress.
The background to the Bill is four years in which the balance of power in the NHS has changed. We have effected a fundamental and irreversible shift in favour of the patient. Before I outline the detailed provisions of the Bill, let me remind the House of some of that progress.
We said that we would devolve power and responsibility to the local level, so that decisions would be taken as close to the patients as possible. We have done that by establishing NHS trusts, by creating a new and distinct role for local health authorities, and by giving family doctors more power through fundholding.
The hon. Member for Livingston (Mr. Cook), whose dodgy predictions we always enjoy on these occasions, foretold that the trust movement would be like a bicycle with a flat tyre. Well—some bicycle, some tyre. Not 30 per cent., not 50 per cent., not 70 per cent., but 96 per cent. of hospitals and community health services are now run locally as trusts.
I am delighted to be able to inform the House that I have approved a further 13 applications from hospitals and ambulance services wishing to become trusts from next April. That will mean that not 96 but 98 per cent. of services will be in trust hands.
§ Mr. O'Brien
Will the Secretary of State comment on the proposals for the Yorkshire and Northern regional 633 health executive, which covers an area equal to that of Scotland but which will have fewer than 140 people to administer it and ensure fair treatment in hospitals? Will she consider allowing the existing Yorkshire regional health authority boundaries to remain in place, which would mean a better service for the people of the region?
§ Mrs. Bottomley
That is evidence of the Opposition's hypocrisy when they claim that they wish to reduce bureaucratic layers of management. We can achieve savings by reducing the number of regional health authorities and, what is more, because of the nature of the responsibilities devolved to the districts, we do not need the large command-and-control regional health authorities. The Opposition are always hankering after regional government, tiers of government and layers of officials. That is their idea of paradise, but it is not the right way forward for the health service today.
I cannot finish with the subject of trusts without offering the right hon. Member for Derby, South (Mrs. Beckett) one last opportunity to clarify her party's policy on NHS trusts. Would they stay or would they go under Labour? Will she say yes or will she say no? She recently had breakfast with David Frost, and she made a proper meal of it. I have the transcript of the programme here.
The right hon. Lady was asked whether she would keep the trusts, and she replied:You can't simply tear the plan up and start again".That seems perfectly clear, but, two pages further on in the transcript, she has changed her mind—By the way"—she added as an afterthought—we're not talking about keeping the Trust hospitals".She is after all thinking of tearing up the plan and starting again.
I know that, in her defence, the right hon. Lady will say that she is consulting. She told Mr. Frost that a Labour Government's first dramatic act in respect of trusts would be to do even more consulting. To be fair to her, she also said that she would "consult fast", but that is not good enough. Labour has a third health spokesman, but the party is still consulting.
I doubt that the right hon. Lady could tell us the day of the week without gathering views from the length and breadth of the Labour movement and issuing a discussion document. It has to be said that the right hon. Lady is the author of the biggest waiting time scandal in the national health service—the length of time that the public have been kept waiting for the Labour party's health policy.
I was referring to the progress made in implementing the Government's health reforms which form the backdrop to the Bill. As part of the reforms, we promised more consultants to reduce waiting times, to improve the quality of services and to cut long hours. In those three years, more than 1,000 new consultant posts were created. Thirteen thousand on-call rotas of 83 hours for junior doctors were eliminated, and in the past six months there has been a 46 per cent. reduction in the number of on-call rotas of more than 72 hours. That is real progress, which will lead to benefits for patients as well as staff.
§ Mrs. Jane Kennedy (Liverpool, Broadgreen)
Is one of the 13 national health service trusts that the Secretary of State is announcing today the proposed new trust which 634 is a merger between the Broadgreen hospital trust and the Royal Liverpool university hospital trust? The two NHS trusts are struggling financially, but the proposed merger offers no solution to their financial problems.
The people of Liverpool have waited a long time for a decision. They have been "consulted"—according to the Secretary of State's understanding of the word—and we are now waiting for her announcement. Will she clarify the situation?
§ Mrs. Bottomley
I confirm that that trust is one to which I have been able to give approval today. It will join the other trusts in providing excellent quality of care for patients. The hon. Member is particularly fortunate to live in a part of the country which, under the leadership of Sir Donald Wilson, has delivered waiting time achievements which are the envy of the country. Most of my hon. Friends think that the people of Mersey are extremely fortunate to have their health care controlled by the health service rather than by political appointments and local councils which have not had the same achievements or praise. But I do not intend to provoke Labour Members, as I have to make a great deal of progress, and I know that they want to make their own speeches.
We said that general practitioner practices would be allowed to manage their own budgets. Fundholding has proved to be one of the biggest reform success stories. Fundholders are expanding services and shaping the services that others provide in order to respond to patients' needs. They are cutting waiting times, improving the quality of services and showing others the way.
The House does not need to take only my word, or that of my hon. Friends, for it: hon. Members should consult the report released last week by the National Audit Office. It states:There is evidence that the direct involvement of general practitioners in health care purchasing has led to improvements in the services provided for their patients and made fundholders more aware of the cost implications of their spending decisions.By being good stewards of available resources, GPs have been able to make the resources go further and work harder for the benefit of all patients.
The report, like the independent evaluation of fundholding by Howard Glennerster before it, is further evidence that fundholding works. The report recommends that the benefits of GP involvement in purchasing should be extended to all patients. That is our policy, and it is why I recently announced a radical extension of fundholding.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
Is there not a problem with the right hon. Lady's argument? The National Audit Office report also says that, at the time of the field work, none of the regions it visited was able to compare directly the funds allocated to fundholders and the resources available to districts to purchase equivalent services for the patients of non-fundholders. In other words, the NAO says that direct comparison is not possible.
§ Mrs. Bottomley
It is quite clear that the methodology behind setting budgets and the details of the reforms' implementation are improving all the time.
§ Mrs. Bottomley
It is comparing like with like. The report says that there is scope for improving the 635 methodology behind the allocation of the budget. It also says that, as we move to capitation funding for GP fundholding, it will be more possible to make tight comparisons. There is overwhelming evidence of the benefits of GP fundholding in independent report after independent report. It is also evidenced by the number of people who are seeking to become GP fundholders, and recent Government announcements have made that even more possible.
§ Mr. Tim Smith (Beaconsfield)
Is it not extraordinary that the Opposition will not accept the National Audit Office's genuinely objective and independent assessment of the situation? It has completely vindicated the decision to establish fundholders, as well as making the more general point about pushing down decision making in the health service as far as possible.
§ Mrs. Bottomley
I thank my hon. Friend for his comments. Characteristically, the Labour party has a lowest common denominator approach to everything. Labour Members dislike excellence and innovation. They think that any change must be a change for the worse, and that is a tragedy. GP fundholding has been commended by the Organisation for Economic Co-operation and Development report, by Professor Glennerster's report, and now by the National Audit Office. Labour Members are deaf and blinkered; bad news is the only news they favour.
The Government have achieved the objectives which we set out in the National Health Service and Community Care Act 1990. Trusts are here to stay, and fundholders are leading the drive towards our goal of a primary care-led health service. The power to take decisions has been put in the hands of those closest to patients.
But in one vital respect, we want to go further than was envisaged in our original reforms. The principle purpose of the Bill is the abolition of regional health authorities. The RHAs played a necessary role in the old NHS. That fact has been recognised by many of my colleagues, not least by the late Lord Joseph, to whom I pay a very warm tribute. He was a most distinguished predecessor in this office and a major contributor to the well-being of this country.
In the first stages of the reforms, regional health authorities assisted the successful development of trusts, of fundholders and of district health authorities in their new purchasing role. I express my appreciation, and that of other Ministers, of the work of regional chairmen over the years. I am pleased to say that they will have a continuing and important role as regional members of the policy board.
The successful devolution of responsibility to local level inevitably meant that the role of RHAs would reduce. To put it slightly more bluntly: they were the last bastion of the old command and control system from which we have now escaped. By abolishing RHAs, the Government will sweep away an unnecessary tier of NHS management. The Bill is part of our concerted move to streamline management, to eliminate unnecessary duplication and bureaucracy, and to save money on administration which we can then spend on patients.
We estimate that the savings from the Bill will total £150 million every year in England, and at least £3 million a year in Wales— substantial savings, which will result in even better patient care. Those savings will result from the abolition of RHAs and from bringing together 636 and halving the number of DHAS and family health services authorities. In Wales, 17 health authorities will be reduced to five. A further £50 million will be saved from reductions in the size of the Department of Health. We are determined to ensure that we set an example from the centre, and we expect streamlining to take place throughout the service.
§ Mr. Kevin Hughes (Doncaster, North)
If the Secretary of State's Government are leading the fight against bureaucracy and are streamlining management, why has bureaucracy in Doncaster increased by 48 per cent since the changes were introduced? Spending on bureaucracy has increased from £4 million to £6 million—and that is only in Doncaster. Where is the Secretary of State's streamlining there?
§ Mrs. Bottomley
A less than worthy characteristic of the Labour party is its knee-jerk attacks on NHS managers at every possible opportunity. People who go into NHS management are committed to the national health service and to the improvement of service provision to patients.
The Government's achievements have included strengthening management in NHS trusts and health authorities; ensuring that there is better financial control, so that health authorities do not run out of money nine months into the year; and, above all, managing waiting lists so that progress can be made on waiting times. The hon. Member for Doncaster, North should realise that, because of the Government's reforms, his region has received a further £139 million this year for the benefit of patients. Those are the achievements that really matter.
In line with our manifesto commitments, substantial efficiency savings, amounting to £200 million, will be spent to improve the quality of services further. Thanks in part to this Bill, we will be able to make even further cuts in hospital waiting times.
§ Mr. Alex Carlile (Montgomery)
On the question of NHS administrators, does the Secretary of State agree or disagree with the views expressed on that subject by her hon. Friend the Under-Secretary of State for Wales?
§ Mrs. Bottomley
I certainly agree with the Under-Secretary of State for Wales, my hon. Friend the Member for Clwyd, North-West (Mr. Richards), who makes a very important contribution to the decision-making process. It is a great asset to have a colleague in the territorial Departments who takes a close and detailed interest in the matter, and I am delighted to see that he is in the Chamber today.
§ Mr. Robert Banks (Harrogate)
I am especially glad that my right hon. Friend has paid tribute to the work of employees in the regional health authorities. Will she, however, give full recognition to the talent, expertise and knowledge of the work force during the reorganisation? In particular, will she consider carefully before moving the headquarters from Harrogate, which has one of the best possible offices? If the headquarters was retained, the pool of expertise could continue its valuable work in the enlarged area.
§ Mrs. Bottomley
I know what a great champion of that cause my hon. Friend is. I have visited the headquarters to which he refers, and his local trust hospital. I have seen some excellent mental health project developments there. Detailed consideration is, of course, given before final 637 decisions are made. The region under consideration is large, so it is important to have the headquarters somewhere that is accessible not only for the area my hon. Friend represents, but for those in the north and the east of the region.
§ Mrs. Bottomley
I will not give way now, because many hon. Members may be fortunate enough to catch your eye later, Mr. Deputy Speaker.
In short, the changes will ensure that we have a local service which is locally accountable to health authorities and trusts providing the service, and not the great command-and-control, hierarchical, bureaucratic service of the past. It is because of that change that the service is so much more flexible and so much more responsive to local circumstances than it would be with a command-and-control system.
It is not a coincidence, of course, that Labour Members belong to the party that produced that great document, the national plan, in 1965. That is how Labour Members would like to run the health service. They would like one document in the centre—
§ Mrs. Bottomley
Exactly—a Stalinist approach to these matters. The hon. Gentleman has helped me with the word. We believe in devolution and flexibility.
§ Mrs. Bottomley
No. The hon. Gentleman will be able to address the House on his Stalinist ideas at great length later. He will understand that I must now make progress—[Interruption.] I will not be tempted on the matter now.
The Opposition's amendment refers to cancer services. Thanks in part to the Bill, we shall be able to make further progress on that front as well. We shall build on the excellent cervical and breast screening programme that we established. I again place on record my commitment to take forward the principles set out in the report on cancer by the chief medical officer's expert advisory group. I want to see them sensibly implemented throughout the service. Facing changes, as we do in the Bill, will enable us to do precisely that.
This is the difference between the Government and the Opposition. Labour's policies are in turmoil, and its policies threaten turmoil for the national health service. We have introduced this sensible measure, which will improve the management of the NHS, improve its efficiency and improve services for patients. Let no one be in any doubt that, if the Opposition vote against the Bill tonight, they will be voting for bureaucracy and inefficiency, and voting to put patients last.
I turn now to the detailed provisions of the Bill. It is essentially a straightforward measure, with one major provision in clause 1, which will abolish regional health authorities. It will also remove the existing district and family health services authorities and replace them with a single body—the health authority.
It is a further measure of the success of the reforms that the merger of DHAs and FHSAs now seems an obvious and inevitable step. Many DHAs and FHSAs already work in an integrated way under a single chief executive. 638 Those joint health commissions eagerly await formal merger and other authorities are not far behind. It has become clear that the whole NHS will be ready for this change by 1 April 1996. We have decided, therefore, to establish all the new health authorities on the same date. That will make it absolutely clear where we stand and where the future lies.
As all hon. Members are probably aware from their constituency mail, many people outside the health service cannot tell the difference between DHAs, FHSAs and RHAs. I am pleased to tell them that they will not have to bother in future. From 1 April 1996, there will be just one health authority at local level, and the system will be simple, clear and accessible. The new merged authorities with their wide span of responsibility will have real influence at local level.
§ Mrs. Bottomley
I am delighted that the hon. Gentleman is prepared to offer advice to the Government on these matters. I know that he will vigorously support the legislation when it is in Committee. My hon. Friend the Minister for Health has noted the hon. Gentleman's enthusiastic support; he may be able to help to move some of the amendments.
The local authorities will have real influence and a vital role. They will be the single authority responsible for ensuring that the entire health needs of their populations are met. For the first time, their job will to be to ensure that the hospital, the community and the family doctor services are planned together in a coherent and co-ordinated way. I expect the new health authorities to work especially closely with the family doctors in their areas—fundholders and non-fundholders alike.
General practitioners, as my hon. Friends are well aware, have always had a crucial role as the gatekeepers of the national health service. Their position is a hallmark of our health service and is recognised, at home and abroad, as one of its great strengths. Our reforms have, rightly, enhanced the role of family doctors. We have given them new powers and new authority to shape services according to the needs of patients. The Bill will build on that.
The Bill will ensure that family doctors are even more at the heart of the new NHS. The new health authorities will be better placed to support GPs in the move towards more primary care-led health care, and they will ensure that family doctors, as the National Audit Office report again suggested, are fully involved in the crucial task of purchasing secondary care.
Schedule 1 makes the consequential changes required to reallocate functions. The new health authorities will bring together responsibility for both primary and secondary care—[HON. MEMBERS: "And dentists."] Indeed, as hon. Members say, dentists will also be included. As a result, the new authorities will be able to take on some of the roles previously carried out at regional level.
We shall be able, for example, to pass down to local level functions such as purchasing specialist services, public health, midwifery supervision and some aspects of education and training. Where tasks need a wider perspective than a single health authority, several will be able to work together, supported as necessary by regional offices. I know that this is a point of concern to many of 639 my hon. Friends. The new system will retain the necessary overview to ensure that the health service continues to deliver its objectives efficiently, effectively and coherently.
We have today published a guide to the operation of the new system, which sets out some of the issues in more detail. It builds on good practice and experience so far. Among other things, it describes the role of the new regional offices. The proper implementation of key national policies, such as our objectives in "The Health of the Nation", the reduction of junior doctors' hours, teaching and research, and the development of regional and supra-regional specialty services, requires strategic direction. The NHS executive, operating through its regional offices, will discharge that role. It will support the development of local policies and, where necessary, ensure effective co-operation across service, education and research.
§ Mr. Hugh Bayley (York)
The Secretary of State referred to the Yorkshire regional health authority office in Harrogate. Will she undertake to publish the full and detailed option appraisal on whether the new regional offices should be based in Harrogate, York or Durham, so that hon. Members within the new region can express opinions on the merits of each case and so that the public can be consulted? Or does she intend that the new decentralised health service should deny the public the opportunity to express views on the health service? Will decisions simply be taken behind closed doors in the NHS executive?
§ Mrs. Bottomley
I regret having given way to the hon. Gentleman. It is the case that decisions about the delivery of services are open to public consultation, and the papers are made available. For decisions about the organisation of NHS staff and people in the Department of Health, that is not the process followed. Our duty is to ensure that the taxpayer's money is used as effectively and efficiently as possible for patient services.
I regret giving way to the hon. Member for York (Mr. Bayley). I thought that he might have something interesting to say about the role of the regional office and that vital aspect of delivering a local service but also managing to pursue a number of national priorities. We believe that we have got that balance right in this important Bill—through detailed consultations and consideration within the service.
§ Mrs. Bottomley
I have lost patience. I was so disappointed with the comments of the hon. Member for York that I am not prepared to give way. I am afraid that my patience has withered away. I shall try to be more forgiving in due course, but now I have lost patience.
§ Mrs. Bottomley
I am deeply in awe of my hon. Friend, and will follow her instructions.
What matters is to establish a more effective, streamlined management, so that the executive can better fulfil its role. That will ensure that we continue to deliver national policies by getting the best out of the local flexibilities that are at the heart of the new NHS.
640 The regional offices will not be RHAs by another name, however. They will be considerably smaller, and totally different in outlook. Two years ago, the regions employed around 3,900 staff. Today they employ 2,600. The new regional offices will employ no more than 1,100, which is less than a third of that original size.
Their work will focus on the key functions that have to be exercised at regional level. There will be no unnecessary duplication of functions between the regions and the centre, or between the regions and NHS trusts and health authorities. The executive will give proper strategic management to ensure accountability of health authorities, fundholders and trusts. The simplified structure means that information and advice can flow more freely between the NHS executive and local level. There will be a clear line of accountability from the NHS in the field through to Ministers.
The new system will further promote freedoms at a local level. It recognises the importance of innovation and will nurture it. We utterly reject the Labour party's model of a health service—rigid, monolithic and crawling along at the pace of the slowest. We believe in the rest learning from the best and in levelling up, not levelling down. That is the culture that the Bill will reinforce.
I do not need to take the House through the functions in schedule 1 in detail, as most of them are straightforward consequential amendments, but I must highlight two areas, not least because they are of direct relevance to the Labour party's amendments. They are the role of professionals and the future of education and research.
On the latter, we are committed to maintaining and improving the essential partnership between the universities and the NHS. I have already had productive discussions with the Committee of Vice-Chancellors and Principals, and we will monitor progress carefully during and after the reorganisation.
§ Dame Elaine Kellett-Bowman
I trust that my right hon. Friend is not referring only to universities, as there is a very good Project 2000 in St. Martin's college in my constituency, which is not a university, although it is as good as most, or better.
§ Mrs. Bottomley
Again, my hon. Friend has the right of it. She will know that that revolution in the training of nurses is one of the changes since the introduction of the reforms. The Project 2000 course is now available throughout the country. As my hon. Friend rightly says, we are leading in that area. The courses are especially good for training nurses to work in the community as well as in a hospital setting. I thank my hon. Friend for drawing that fact to the attention of the House.
As I think that my hon. Friend the Member for Lancaster (Dame E. Kellet-Bowman) will agree, the training of doctors and dentists has certain special aspects—the long training, the rotations and the links with research. Because of the importance of maintaining those contacts, I asked the eight regional policy board members to take special responsibility there.
Some of the changes that the Bill introduces are to enable consortia of health authorities and trusts to work more closely together in informing the purchasing of education and training over time and, in due course, taking on some purchasing themselves. That will no doubt apply to the college to which my hon. Friend referred. That change will take place within a national framework, which will be carefully overseen by the NHS executive.
641 Similarly, because medical research in this country is, frankly, outstanding—some of our centres receive commendations from around the world—it is important that we have the right balance between local and national input. Many of my hon. Friends will be aware of the important work undertaken by Professor Michael Peckham, the first ever director of research and development for the NHS.
I was recently able to underline the Government's commitment to teaching and research by announcing an additional £40 million support in the coming year. In passing, it is only possible to make such announcements for the health service because the Government are taking such good care of the economy that we have such sums to invest.
Following the publication of the detailed document "R&D in the New NHS" and of the important Culyer report, we have been holding discussions with the research and academic communities, with a view to introducing a new single stream of funding for NHS research. I am pleased that, so far, that has been welcomed. I shall be able to make more announcements shortly.
Finally, when we make regulations on the membership of the new health authorities, we will require them, where they have a medical or dental school in their area, to have a university member on the board. In doing so, we shall continue the present arrangements, which recognise how vital is the partnership between universities, medical schools and the NHS.
On health authority membership, when our changes created district health authorities, with their new and distinct role, we paid special attention to who should sit on their boards. Frankly, I regret the fact that so many of the non-executive members have had to face the vituperation of the Opposition, who constantly denigrate their contribution, regardless of the way in which appointments to health authorities were made by the Labour party when it was in power, and of the arbitrary way in which 32 health authority chairmen were dismissed at one stroke by a former Labour Secretary of State for Health because he did not like their political colour.
More important than the non-executive appointments, however, we brought in executives for the first time. It was absurd that, under the old system, the agenda was often dominated by overtly political interests, such as the prospective local Labour party candidates in Greenwich who sat on the board of the health authority, while those who had to do the work had to sit on the sidelines. In the new health authorities, we propose that the executive members will include a director of public health. The Labour party's amendment—characteristically missing the point—mentions regional public health directors.
Of course, the new local health authorities should be the focus of action in a decentralised system. The public health function should properly reside there, closer to the public whose health is the key issue. That is why, in an important advance on the old system, we will establish for the first time as a statutory requirement an executive director of public health at the local level.
Health authorities will continue to be unified boards, bringing together executive and non-executive members working towards a common purpose. It is important that 642 they comprise the best people locally to give them the balance of skills that they need. People should be selected for the personal qualities they bring to the boards, and not to represent sectional interests. As the House will know, we are opening up our appointments procedures so that both health authorities and trusts have access to an even wider range of skills and experience.
I have asked the right hon. Member for Derby, South before to take her embargo off the trusts and to encourage people to serve on them, instead of putting them in the appalling position in which, if they serve on trusts, they are apparently supposed to be working for her to bring them to an end.
§ Mrs. Margaret Beckett (Derby, South)
I must have told the right hon. Lady at least three times that there is no such embargo. Will she cease making such a silly point?
§ Mrs. Bottomley
I am to some extent reassured by the right hon. Lady's comments, but members of her party have been worried about taking on such appointments, when approached to do so by Ministers, because of their fears of offending the party they support. If that happens again, I shall refer the details to the right hon. Lady.
The Bill will build on the practice that we have already established with district health authorities, so that the new boards have the best people to help them to discharge their vital role.
We expect that a growing number of both health authority and trust members will have backgrounds in nursing, medicine or any other relevant profession, and we are already seeing examples of that.
The hon. Member for Wakefield (Mr. Hinchliffe) and I served on the Standing Committee on the National Health Service and Community Care Act a long time ago—[Interruption.] We were all young then. The hon. Gentleman, and my hon. Friends who served on the Committee, will be aware that the president of the Royal College of Physicians at that time was Dame Margaret Turner-Warwick. I am pleased to report to the House that she has for some time contributed her considerable talent as chairman of the Royal Devon and Exeter trust.
I am delighted to be able to announce today that the then chairman of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting, Dame Audrey Emerton, is now to take up her post as chairman of the Brighton hospitals trust. I think that that is very good news indeed.
Sitting on boards is not the only way for professionals to be involved, nor is it sufficient. I commend to the House the views of Professor Cyril Chantler, who is principal of the United Medical and Dental Schools of Guy's and St Thomas's, and is a policy board member. He described the old medical advisory committees asfunctioning as a sort of Greek chorus, commenting on what was going on the stage but not taking part in the play.He says that doctors need to contribute tothe strategic and operational management of the service, in hospital, in the community and in practice, and in the commissioning role at district and central level, rather than doctors simply seeing themselves as there to give advice.I strongly agree, although I would extend the analysis to nurses, dentists, pharmacists and the full range of health professionals.
As Professor Chantler suggests, the existing professional advisory structure is not firmly integrated into the work of regional and district health authorities. It 643 is peripheral, and that is why we will not be incorporating it into the new structure. We want professional advice to be integral in the new structure, and we want professional advice to become professional involvement. We require the new health authorities to promote a constructive partnership between health professionals and managers, as many of the best DHAs and family health service authorities are doing.
Teamwork is vital to the NHS, and I have been at great pains to point that out during my tour of the regions during the past six months. The Bill will make teamwork easier by removing some of the organisational boundaries, and enabling us to build on the considerable progress which has been made during the past four years.
The House will want me to address the question of accountability. There will be a full and accountable partnership between health authorities and the public on whose behalf they act. The Bill marks an important boost for accountability by cementing the devolution of decision-making to local level. The closer to patients that decisions are taken the more accountable the service will be to them. Health authorities are beginning to work much harder at explaining to the public what they do, and asking how they could do better.
I believe that they could be doing better still, and I shall insist that they do so. In the new structure, the public will have access to a single body which will be responsible for securing health care for them. The new authorities must work even more closely with the public—consulting, communicating and involving them in key decisions.
§ Mr. Campbell-Savours
As a Member who is sponsored by Unison—the union pays me personally nothing, in case the Secretary of State wishes to misrepresent that fact—may I press her on the question raised by my hon. Friend the Member for York (Mr. Bayley) about a very important issue for the northern region? Why cannot we, and the health service workers and administrators throughout the region, have access to the appraisal documents which were produced in conjunction with departmental officials upon which the decision to move the regional headquarters has been taken?
Is it not significant that, when the hon. Member for Harrogate (Mr. Banks) intervened, he did not ask that pertinent question? He asked a safe question, which he knew the Secretary of State could answer.
§ Mrs. Bottomley
My hon. Friend may wish to raise that point in his own speech. I have made the position clear. There is a requirement for consultation when there is a proposal to change services for patients. As many hon. Members will know, that consultation can be extremely lengthy and often delays necessary change, but it is important in terms of changing services for patients. Ministers have a duty to make sure that taxpayers' money is effectively used, and the streamlining outlined in the changes will result in better patient care. The hon. Member for Workington (Mr. Campbell-Savours) will know that another £139 million will go to his region in the year ahead. The changes will mean that we can do even more.
I was talking about the important role of the new health authorities in making sure that they involve local people in decisions. Authorities must consult and encourage local visibility. We are making much more information about the organisation of the service available to the public than 644 ever before through annual reports, public meetings and the important NHS performance tables. None of that information was ever made available to the public when the Labour party was in power.
That is the accountability that matters to patients—information which enables them, or their advocates, the GPs, to exercise informed choices. We shall back all that up through clear lines of accountability between the NHS at local level and Ministers. Those lines will be reinforced by such measures as our codes of conduct of accountability and openness.
Let me briefly mention clause 3 and schedule 2, which provide for the transition to the new structure. Clause 3 gives health authorities wide powers to work together, so that, by 1 April 1996, they can be completely ready for merger. We are taking steps to manage the process effectively to minimise any disruption to services. The significant degree of joint working which is already in place will help, and some of my hon. Friends have referred to that.
Schedule 2 provides for the effective reallocation of the staff, property, rights and liabilities of the authorities which are being abolished. We will do all we can to minimise the distress to health authority staff. I take the points made by my hon. Friend the Member for Harrogate and by the hon. Member for Workington—[Interruption.] The hon. Member for Workington, having made his intervention, is no longer interested. He talks about being interested in staff, but when I talk about minimising the disruption to staff, he cannot even be bothered to listen. [Interruption.]
§ Mrs. Beckett
Is it not rather bad parliamentary manners for the Secretary of State to chide my hon. Friend for not listening when the hon. Member for Harrogate—to whom she referred—is not even in the Chamber?
§ Mrs. Bottomley
The hon. Member for Workington was talking through my speech. That is a great discourtesy, particularly when the hon. Gentleman protests his interest in health service staff. But that will not surprise any of my hon. Friends at all, and I only regret giving way to the hon. Gentleman.
§ Mrs. Bottomley
My hon. Friend did not intervene during my speech. The hon. Gentleman persistently made attempts to intervene, and he has proceeded to have his own conversation while I am discussing what we are doing for health service staff. I shall move on, as clearly we will have some fascinating speeches from Opposition Members, and certainly my hon. Friends are longing to get in.
I began by setting out the background to the Bill, and the enormous progress which has been made in a short time in implementing the health reforms. What is truly remarkable is that, throughout the period of substantial organisational change, the NHS has not only maintained its services to patients, but improved and enhanced them.
For every 100 patients treated in 1990-91—the last year before the reforms—118 were treated in 1993-94. [Interruption.] I find it extraordinary that Opposition Members cannot be bothered to listen to the staggering achievements of Health Service staff during the process of transition. I suppose—as ever—that the news is so 645 good they cannot bear it. In 1994, we expect the number of patients treated to rise to 122 for every 100 treated before the reforms.
Whereas, before the reforms, 170,000 patients were waiting for more than one year, today that figure is just 60,000, and it is coming down. The figures which have been published only today show that, in the past five years, the number of hip replacement operations has risen by nearly one quarter, the number of cataract operations by 44 per cent., and the number of heart operations by 65 per cent. Those are impressive figures, and they mean an improved quality of life for many thousands of people.
While the implementation of the reforms has been a substantial management success, the changes should only ever be seen as a means to an end, and not an end in themselves. The real challenge lies in realising the full potential of the new NHS at a time when it must respond to profound changes in clinical practice, the aging of the population and the rising expectations of patients. Those changes have been recognised not least by the medical profession in its recent welcome statement on core values.
The measures contained in the Bill will draw our organisational changes to a successful conclusion. They are based on our experience so far, and on evolving practice. They reflect widespread consideration and discussion within the service and beyond. They provide the basis for a period of stability and constructive partnership. They will streamline and improve management; cut bureaucracy and costs; and ensure that even more power and responsibility is passed down to where it belongs—to those closest to the interests of patients.
The independent evidence that our reforms are working is mounting up. The OECD, the Audit Commission, the National Audit Office, the British social attitudes survey, and independent experts of all persuasions and none, say that the Government are getting it right.
The Bill is important and timely, and a good one. It confirms our commitment to a comprehensive, high-quality health service, which responds to the needs of patients and is true to its founding principles. It puts in place the final building block to create the first-class health service we need, fit for the 21st century. I commend the Bill to the House.
§ Mrs. Margaret Beckett (Derby, South)
I beg to move, To leave out from 'That' to the end of the Question, and to add instead thereof:this House declines to give a second reading to the Health Authorities Bill; notes widespread concern over future provision of cancer screening services, the independence of regional public health directors and the delivery of medical education for doctors; fears that claims for reduced bureaucracy and savings to public funds will prove ill-founded; and believes that far from completing the NHS reforms the Bill fails to address the problems of hospital closures, waiting lists over one million, commercialisation of trusts, a two tier service with general practitioner fundholding and the fragmentation of a National Health Service into hundreds of health businesses.I salute the extraordinary efforts of the staff of the national health service to maintain the level of that service in the face of the Government's enthusiasm for the anarchy of the internal market, the fragmentation of the service and the commercialisation of health provision. I 646 make that point deliberately at the outset of my speech because I have observed from previous debates that if the Opposition do not mention what a wonderful job the staff of the NHS are doing the Secretary of State accuses us of attacking them and not appreciating their work in the public service.
Let it be clearly on record that the Labour party believes that the ancillary workers, nurses, dentists, physiotherapists, dieticians, cleaners, radiographers, radiologists, doctors, anaesthetists, consultants, clerical workers, managers and physicists—to name but some of the categories of staff—are unstinting in their loyalty to the health service and to the notion of public service.
§ Mrs. Beckett
No, definitely not the Ministers.
Let our admiration for the level of patient care that is still provided in the health service be clearly and explicitly on the record. And let it be accompanied by an equally explicit and clear statement that it is, remains and always will be our view that the NHS is a public service which should not be—and by the Labour party never will be—regarded as a business.
It should not be necessary to detain the House by making such relatively simple statements about our support either for staff or for patients. I do so only because the Secretary of State has developed a rather tedious habit: if the Opposition fail to mention the staff of the health service, the right hon. Lady accuses us of attacking them and not appreciating their work. Yet if we mention them, she accuses us of being in the pockets of the trade unions. That is scarcely a sophisticated debating technique, and it has become deeply boring; as we are discussing a new Bill, I urge the right hon. Lady to turn over a new leaf and just drop it.
§ Mr. Streeter
Will the right hon. Lady make one further thing clear today? Would the Labour party abolish NHS trusts—yes or no?
§ Mrs. Beckett
We have made it clear repeatedly that we certainly do not intend to work with the current structure of NHS trusts, but we are exploring how to knit those trusts—
§ Mrs. Beckett
What does the hon. Gentleman mean by "abolish"? Those trusts exist, and the hospitals and services that they run exist; of course we do not want to get rid of those services—no one does. If the hon. Gentleman is asking me whether we intend to continue with the structure of those individual health businesses, as set up by the Government, the answer is most certainly not—everyone is aware of that.
What causes huge resentment in the House and widely outside is the Government's attempt to outlaw the questioning and criticism of their policies towards the health service by insisting that anyone who attacks those policies is attacking the service itself. Let me, once again, put it clearly on the record that the Opposition are not attacking the health service, whether that means the staff, the patients or anyone else involved in its efficient 647 operation. We are, however, attacking what the Government are doing to the health service and we have not the slightest intention of being deflected from that attack.
Part of the problem is that the health service is under attack—from the Government. In particular, all the staff who work in the health service, at every level, are under attack because the Government are attacking them. They are under attack by threats that their pay will be linked to their individual performance. They are also under attack because that performance will obviously be measured, at least partly, against the yardstick of loyalty to the organisation and the extent to which staff are prepared, as they were recently urged by one of the Secretary of State's most loyal supporters, to put the interests of the organisation before the interests of the patient.
They are under attack because, should they dare to speak out about their concerns and anxieties in relation to patient care, their very livelihood is threatened by the new gagging contracts issued by so many of the trusts which have been set up by the Government's legislative changes. Finally, and perhaps most insidiously of all, staff feel themselves to be under attack when they hear people like Professor Caines say that the very notion of public service is at an end, when it was exactly to engage in the service of the public that most of them joined the health service in the first place, and they still take pride in that concept.
The Secretary of State is seeking wide powers in the Bill—in many cases, wider powers than those available to previous Secretaries of State through earlier legislation under Governments of every political shade. Much of the detail of what is intended to be done with those powers is left unstated in the Bill. Yet again, we are witnessing sweeping enabling legislation from the Government, with an immense amount of the detail and execution of it left to regulations which, of course, cannot be amended. We are greatly concerned about that aspect of the Bill and we shall seek to explore it in Committee.
One thing that is clear from the Bill and the schedules to it is that, apart from taking substantial powers, the Secretary of State seems potentially to be removing from the arena others who might possibly have a different point of view or a different perspective to express. For instance, I was surprised as well as dismayed to see that the Government intend to abolish local advisory committees. According to another proposal in the Bill—exactly the type that will cause public concern—in future when a local hospital is thinking of applying for trust status, consultation—which in the past had been compulsory—will be carried out only if the Secretary of State thinks that is necessary, and then under terms that the right hon. Lady will decide sometime between now and when the regulations are published. The Bill contains no suggestion as to what those criteria might be.
One thing that I should have thought that everyone in the House had learnt, at least from the experience of the workings of the Child Support Agency, is just how dangerous it is to leave all the detail—the framework of proposals—to regulations rather than just matters such as exact figures or precise dates, which have always been properly matters for regulation.
I listened with care to what the Secretary of State eventually said about the Bill. There are elements in it to which we can offer support—in particular, the proposal that district health authorities and family health services authorities should be merged. As my hon. Friends pointed 648 out in sedentary interventions, the Labour party has long advocated that. Like the Government, we believe that such a merger could and should lead to more efficient management of resources, better planning and ultimately a better service for patients. We shall look forward to exploring in Committee the detailed implementation of that proposal.
That proposal, however, sits alongside the proposed abolition of regional health authorities. The removal of some functions from regional level and the apparent intention to devolve them to local level is a matter of concern not only to the Opposition but to people throughout the health service. We shall want to explore that issue, too.
As I am sure that the Secretary of State must be aware, widespread anxiety has been expressed about the loss from regional level of the maintenance of cancer registries or the handling of national confidential inquiries. However, the main matter that I shall first discuss is the Secretary of State's claim that those proposals and that aspect of the Bill are not merely part of the Government's so-called reforms of the health service, but a necessary part of completing the process of reorganisation.
It seems to us that that specific proposal is neither necessary nor desirable, and it leads us to have grave doubts about the real intentions behind that part of the Bill. We treat with considerable cynicism the Secretary of State's assertion that the changes that she proposes will automatically lead to improvements in patient care.
The Government appear to be managing the operation of the national health service with the same level of competence that they apply to managing the Conservative party. Indeed, if the Government were a privatised trust and not a publicly financed, publicly accountable, publicly run Administration they would definitely be in severe difficulty. Their public relations consultant, Mr. John Maples, has just advised them that the British electorate are unwilling to renew their contracts and that they, the Conservatives, can never win on that issue. In consequence, he advises:The best result for the next 12 months would be zero media coverage of the National Health Service"—not the best result for the national health service, but the best result for the interests of the Conservative party, to which alone the Government's concern appears to be directed.
§ Mrs. Beckett
I am delighted to give way to the Secretary of State on the subject of the interests of the Conservative party.
§ Mrs. Bottomley
The right hon. Lady's account is bizarre. As I told the House this afternoon, in five years there has been a 65 per cent. increase in heart operations, a 44 per cent. increase in cataract operations and a 24 per cent. increase in hip operations. Those are dramatic achievements. The number of patients being treated now—
§ Mrs. Bottomley
I can tell the hon. Gentleman that the increase in activity during the 1970s, when the Labour party was in power, was about 1 per cent. a year. The 649 increase in activity throughout the 1980s was about 2.5 per cent. a year. Since our reforms, the NHS has been increasing the number of patients treated by about 5 per cent. a year. It is a much better, more efficient service, delivering much better quality.
§ Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)
Order. I address these remarks not just to the Secretary of State but to everyone in the House. This afternoon it seems that the interventions have been speeches and not to the point. In future, let us have interventions to the point and on the subject in question. [Interruption.] Order. I was directing my remarks not only to the Secretary of State but to everyone in the House.
§ Mrs. Beckett
The Secretary of State tells us, as she did in her speech, about some of the achievements of the national health service. However, she was selective in the figures that she gave, quoting areas in which new technology is coming into play as well as changes in the manner of treatment. It is not at all clear to me that the figures that she gave my hon. Friend the Member for Cardiff, West (Mr. Morgan) were for a comparable area of health care, but never mind—we are used to Ministers not giving accurate figures in the House or, indeed, anywhere else.
Although the Secretary of State highlights some of the genuine achievements of the staff of the health service and the development of health care, not only Labour Members but people throughout the country resent the Government claiming credit for those improvements, as though they all flow from the Government's reforms and changes. In fact, they have absolutely nothing to do with the Government's reforms and changes. Indeed, in many cases, those changes have seriously impeded the development of better health care, as everyone in the country recognises, except those on the Conservative Benches.
The Conservatives are seeking to avoid media coverage for the national health service, and if they were an organisation like a national health service trust they would be in serious trouble. Their professional team cannot be relied on any longer. As a result of a revolt last week by junior members of the team, senior board members found themselves unable to raise the finance necessary to run the business of Government. No private company worth its salt would survive in the marketplace after such a debacle. I suppose that, if the Government were not a public undertaking—if they had been privatised—we would expect them to do what Mr. Cedric Brown did recently and choose the moment of the lowest public esteem to award themselves a 75 per cent. pay increase, or at least something substantial.
The Secretary of State says that the Bill will complete the reforms that were begun in 1990. The phrase has a neat, tidy and finished feel, as though she were a ship's steward, conscientiously dashing about, reordering and rearranging the deckchairs on—no, not the Titanic on this occasion, but perhaps the Achille Lauro. The impression created by the Secretary of State's public statement, which she sought to reinforce in her intervention a few moments ago, is that soon everything will be satisfactorily completed and after her spate of demented and feverish 650 activity she will be able to sit back and relax in her deckchair as the national health service liner continues on its voyage.
The reality, of course, is quite different. Like the Achille Lauro, the national health service has sunk—and public confidence in the Secretary of State's captaincy at the Department of Health has gone down with it, just as public confidence in the Government has descended to the depths. Contrary to the cheery picture that the Secretary of State tries to paint of the tidy, scrubbed deck of a floating national health service, all that we see are survivors trying to cope in the 485 separate leaky lifeboats of the individual health businesses that are the real result of the Secretary of State's reforms.
The Secretary of State asked why we were criticising the performance of the health service under her administration, and talked about all the improvements that she detects and the figures that she gives for specific operations. One of the reasons why we take what the Secretary of State says not with a pinch but with a bag of salt is that scarcely a day goes by without an NHS survivor contacting my office and the offices of my Opposition colleagues, alerting us to yet further deterioration in the service as they experience it.
§ Mrs. Beckett
The hon. Gentleman is exactly right. That is exactly what they say on every occasion—"The health service is nothing like it was. Our health service is disappearing before our very eyes and we bitterly resent the speeches of Conservative Members who do not seem to understand what is happening in our health service." That is what they all say.
§ Mrs. Beckett
I can only tell the hon. Gentleman that none of the people who have telephoned my office so far have been aged less than 18. They are all people who experienced the national health service and were treated by the national health service in the days that the hon. Gentleman is talking about. They all say what everyone except the Conservative party says—that the NHS is worse than it used to be, and that they are deeply upset and worried about the way that it is disappearing before their eyes.
§ Mr. Campbell-Savours
As my right hon. Friend knows, I have been in hospital for some fairly long periods in the past couple of years, and it is interesting that, every time that I have been in hospital—sometimes for as long as three weeks—nurses, doctors, consultants and administrators have always come to my bed when they learned that I was a Member of Parliament, to tell me how worried they were about developments in the national health service. How can the Government possibly deny it?
§ Mrs. Beckett
My hon. Friend is entirely right, and he knows that his experience is shared by every Opposition Member. I find it extremely difficult to believe that people avoid saying the things to Conservative Members that they say to every Opposition Member.
651 I will give some further examples of reasons why we express anxiety—to which the Secretary of State seems to take such exception—about the service that is provided. Three thousand seven hundred operations were cancelled on or after the day of admission in the three months between July and September in London and the south-east alone. Recently, the surgical directorate at Whittington hospital in London decided to cancel all—yes, all—non-urgent surgery except for patients of GP fundholders. In Staffordshire last week, eight out of 11 consultants cast a vote of no confidence in the chief executive at the Foundation trust. A study carried out in Britain, France, Canada and the United States showed that British doctors were the most overworked, half of them wanted to practise abroad and one third wished that they had chosen another career.
Senior hospital doctors recently made a statement about the "disintegration" of the health service—their word, not mine—and drew attention to what they saw as the distortion of clinical priorities. They said that, although patients should, as the public expect, be treated on the grounds of clinical need and priorities and their sickness, rather than the finances of the trust, that was ceasing to happen. They alleged that patients of fundholders were being treated preferentially and that non-urgent patients were taken from long waiting lists at the expense of urgent patients, who then had to wait longer. That was all being done for financial reasons—to keep hospitals solvent—rather than for reasons of medical priority. In addition, it was being done at the direction of managers because of financial concerns rather than on the basis of clinical decisions made by the medical profession.
§ Mr. John Gunnell (Morley and Leeds, South)
I thank my right hon. Friend for giving way. I will illustrate the point that she has just made. One of my constituents had his operation stopped after he had received the anaesthetic and was waiting outside the theatre. It turned out that the operation had been stopped on the direction of the hospital administration because of the overtime that would be involved if it were completed.
§ Mrs. Beckett
I just do not believe that no Conservative Members are told similar stories or are aware of similar concerns.
§ Lady Olga Maitland
Surely it is time to balance the debate. Is the right hon. Lady aware that whenever I meet constituents they tell me how much they appreciate the treatment that they receive in our local NHS hospital trust of St. Helier? They say how much they appreciate the dedication of the doctors and nurses, and the speed of delivery of treatment. Does the right hon. Lady agree that, as a result of health service reforms, 3,000 more patients a day are treated than before? Surely that is something of which to be proud.
§ Mrs. Beckett
First, that is not the result of the health service reforms. Secondly, as the hon. Lady must be well aware, those figures are nonsense. We are talking about finished consultant episodes, not people. All that the British public care about is when people are treated, the length of time that they have to wait and how their concerns are handled. Of course we are well aware of the 652 dedication of national health service staff. In the hope of preventing questions such as those asked by the hon. Lady, I went out of my way at the outset to make it plain that we do not question that dedication.
I was speaking about the concern of senior hospital doctors at some of the changes they see. I am sure that the Government and Conservative Members must be well aware that it is not only those doctors who are concerned, but every patient who uses the health service and who objects to the outcome of care being determined not by the medical profession on grounds of clinical need, but as a result of Government policies. As well as the more general reports of what is happening, my office is contacted daily by people expressing fear and anxiety as a result of their personal experience of how the health service works today.
§ The Minister for Health (Mr. Gerald Malone)
My right hon. Friend the Secretary of State is the only person in the debate so far to have given statistics about what is happening in the service and improved patient care. The right hon. Member for Derby, South (Mrs. Beckett) has relied on nothing other than anecdote. When will she provide facts? When will she make anything other than general assertions that the facts that we are providing about the health service and improved care are wrong? When will she say, in detail, why they are wrong, rather than simply making allegations? It would be extremely helpful to the debate if we could have no more anecdotes and a few facts.
§ Mrs. Beckett
I do not know what all that was about. The Secretary of State gives statistics about details of operations. What is the Minister of State asking for—alternative statistics? He knows perfectly well that there is widespread concern about the validity of the Government's statistics—everyone knows that. At the last Department of Health Question Time a Minister admitted that the Government's figures do not count people, but episodes of treatment.
§ Mrs. Beckett
The Minister of State says that we all know that. I rest my case and propose to go on with my speech.
§ Mr. Malone
There is no point in the right hon. Lady trying to be astonished about things that are well known facts. Of course such statistics are counted in completed consultant episodes—that has been the basis on which treatments have been considered for some time. On that basis, it has been shown that treatments have increased by a record number. The right hon. Lady cannot get away with trying to say that that is an astonishing revelation—it is well known.
§ Mrs. Beckett
I am delighted that the Minister of State has put that even more firmly on the record. It is certainly the Opposition's understanding that for a considerable time Ministers have sought to cloud the issue. When the hon. Member for Sutton and Cheam (Lady Olga Maitland) spoke a few moments ago, she talked of people being treated and said that the number of people who had been treated had increased. But the figures that she was quoting did not relate to people, but to finished consultant episodes. We are pleased to have it on record that those 653 are well known facts. I hope that Ministers will not trot out such statistics as proof of how many people have been treated in future.
The Minister of State mentioned levels of throughput. We are seeing changes in the method of delivery of health care, including new technology—everyone recognises that. But not one jot or tittle of the credit for any of that belongs to the Conservatives. It belongs to staff in the national health service and developments in medical technology. The attempts of Conservative Members to take the credit for it offends not only the Opposition but the general public.
The conflict between managers and clinicians is growing. There are increasingly regular reports of clinicians declaring their lack of confidence in the chief executive of their trust. Nothing in the Bill changes those concerns. On the contrary, it further centralises bureaucracy in the health service and further concentrates power in the hands of the Secretary of State. Waiting lists are still at record levels. Hospital in-patient waiting lists still stand at more than 1 million. We all know—I hope that this, too, will soon become an uncontested fact—about the many people who are not on waiting lists as they are yet to have their first out-patient appointment, but who are none the less waiting for treatment. Nothing in the Bill will assist them in their plight. Instead, the Bill's effect will be to withhold still further information from the public as regional staff become civil servants, bound by the Official Secrets Act and responsible only to the Secretary of State.
There is nothing in the Bill to address the number of complaints about the NHS. The Minister of State asked how we could raise certain issues without giving statistics, so I will give him this one: complaints about the health service rose by 57 per cent. between 1991 and 1993—so much for the Conservative party's contention that everyone is perfectly content with the progress of the service. The Bill does not respond to any of the issues. It responds to a different set of demands and a different agenda. We have seen the commercialisation and fragmentation of the health service and are now seeing the drive to introduce competition at all costs when it is co-operation in the provision of a public service that the public and staff wish to see.
There was an interesting report in the Health Service Journal at the end of last week suggesting that guidelines to be issued soon by the NHS executive would take a harder line. It said Ministers would take a harder line on the internal market and seek toclamp down on 'anti-competitive developments' such as hospital mergers.The article continued:Contrary to the softer official line adopted in recent months, the guidelines reassert the efficiency gains which can be generated by competition".In fairness, the article also stated thatMinimum intervention to protect the interests of patients" might occur from time to time. But the public want co-operation in the provision of health care.It seems that the ultimate agenda is the privatisation of the national health service in so far as it can be said that that has not already taken place. We are seeing its removal as a public service, and we are not the only ones to say that: the chairman of the British Medical Association also 654 did so when he spoke on behalf of that organisation at its conference. He expressed surprise at the Prime Minister's lack of understanding of the fact that the health service is already being privatised. We are witnessing the virtual floating off of the national health service executive from the Department of Health.
If the changes contained in this Bill are laid alongside the structural changes taking place in the Department, it seems to me that the provision of health care is slowly being transferred to a quango. The NHS executive has been given responsibility for policy development in health care, a responsibility that surely ought to rest with Ministers and the Department. If they are not paid to set policy, what are they paid for? By further detaching functions from the Department and placing them under the NHS executive, the Secretary of State is in effect floating a separate arm of the health care business.
The danger, we believe, is that the same loss of parliamentary and public accountability will occur as occurred with the other Government Departments from which major functions were devolved. As a result of the creation of the Benefits Agency, hon. Members now have to take up queries and complaints not with the Secretary of State, who takes no responsibility for the service as it is provided, but with the chief executive of the agency.
One of the knock-on effects of that change was that information that had been given in parliamentary answers and published in Hansard—and thus been available to all hon. Members and the public, not just the person raising the query—was, for a long time, given only by letter to the hon. Member making the complaint or raising the query. It took a long campaign by my hon. Friend the Member for Newport, West (Mr. Flynn) before Parliament and public again gained access to this valuable information.
What the Secretary of State is doing by means of this Bill cannot be reconciled with what has been said here today. She is not devolving power. Far from it: she is just shifting the centre of power, floating service delivery off into separate businesses and thereby creating opportunities for privatisation. Shifting the centre of power in this way serves the second item on the Secretary of State's agenda. Rendering power and responsibility more diffuse shifts blame and disperses responsibility. There is nothing the Secretary of State would like better than to shift blame and responsibility elsewhere, so that they do not rest with Ministers.
Today the Secretary of State argued that organisational changes, particularly incorporating regional health authorities in her Department as offices of the NHS executive, would lead to more effective streamlining, to greater efficiency in the treatment of patients and to greater savings. She has tried to convince us that she is abolishing one tier of bureaucracy. All she is doing, however, is replacing one statutory tier of bureaucracy by another, more centralised bureaucracy. She is not even abolishing an entire tier. The Bill reveals that mental health review tribunals are to stay, on the basis of the existing regions. That is just one example of the fact that some regional functions are to continue, although it is not altogether clear how they will be managed, or what will happen to some of the other functions.
The substitution of the existing tier by another will create a bureaucracy that is to be more secretive. Staff will now be bound by the Official Secrets Act. They will be more tied to the Secretary of State's patronage and thus 655 more tightly controlled by the centre. In other words, under the powers granted by the Bill, far from removing bureaucracy the Secretary of State is giving herself the opportunity, through patronage, to create a more pliant and amenable bureaucracy—all of which ties in with the Maples memorandum which issued instructions to stop up the leaks and silence any criticism of the service.
While the Secretary of State increases centralised control over the allocation of resources direct to health authorities, through a new formula, there will be top slicing of money for strategic development, research and development, and education and training. It is not clear what the new formula will be; it is not clear what the degree of top slicing will be. All those decisions rest in the hands of the Secretary of State, who is taking substantial enabling powers in clause after clause.
There are references in the Bill to the orders that the Secretary of State will lay. We shall want to explore and debate the possible contents of each order very carefully.
There is a real question as to whether this recycled organisational tier—recycled, not abolished—will do what the Secretary of State promises and will slim down the burgeoning bureaucracy of the health service. There is a growing belief, which I am coming to share, that there may be an increase in bureaucracy at the lower levels of the health service, because regionally based services will now have to be run by smaller units. The British Medical Association has argued that removing the strategic planning tier will mean that hundreds of trusts and authorities will have to acquire the skills to agree on regional specialties, public health policy and a host of other issues previously dealt with by the regions.
Local authorities will have to do this with a loss of economies of scale, and will have to combine with the contracting process inherent in the internal market. We believe that that too is bound to generate more bureaucracy. That would be entirely in line with current trends under the reforms, which show that the number of senior and general managers in England has shot up since 1986, from 5,000 to more than 20,000; and that total bureaucratic costs since 1987-88 have more than doubled.
Despite these unhelpful precedents, the Secretary of State said today that there will be savings. None of them were properly costed here today, and we have some doubts about them—partly because of the context of the overall effects of the Secretary of State's reforms, which have cost the British taxpayer will over £1 billion. We also doubt them because there is a planned reduction of staff of about 1,500, and we doubt whether the savings that have been identified could come just from those staff reductions.
We also doubt the savings because of the Secretary of State's remark—or so I thought—and the idea in the Bill that possibly as much as £150 million could be saved. A press release issued after the publication of the Bill contained a revised figure of nearer £60 million. The notes on clauses and the Bill itself actually make it clear that provision has been made for an increase in the short term in the money spent by Parliament as these changes are made.
It is just over two years since hundreds of civil servants were moved at considerable cost, not to mention disruption to them and their families, to Leeds. Now 200 of them are to be made redundant, thereby creating a great deal more cost and difficulties for their families. How can it be that only two years ago these people were so needed 656 by the NHS that it was prepared to go to great lengths and considerable cost to move them all to Leeds, yet now, out of the blue, they are no longer needed? It is either gross incompetence or part of a different agenda.
Will the end result be that regional functions—for instance, advice on information technology, currently carried out a regional level—that will still be necessary will be contracted out? Is that the Government's secret agenda? If the functions cannot be performed owing to staff losses, will that be an opportunity for contracts in the private sector? There is certainly a widening circle of waste of public money—public money spent to take staff to Leeds, then spent to make them redundant and then, almost certainly, spent on the contracted out functions that could have been performed by those staff had they not been made redundant.
We question why the Government have proceeded with the changes in this Bill. Is it just that a further fragmentation of the health service will make it easier to privatise, as well as making it easier to bring private companies into the operations of the service? Certainly, if the Secretary of State's record is anything to go by, it is neither to slim down the bureaucracy nor to save money. She has been catastrophically bad at both.
We expect the changes in the Bill to lead to growth in bureaucracy at the expense of patients and of clinical care, but there are also wider concerns. We shall be looking closely at the allocation of responsibilities and functions as between health authorities and the regional offices. The Bill abolishes the local advisory committees, and any replacement will be dealt with by regulations. Here and elsewhere in the Bill it seems ever more clear that what the Government have in mind is dispensing with much of the expert advice that they currently receive. We do not believe that clinicians should be given excessive power to veto changes and improvements in the health service, but we do not believe either that it is advisable for management on the ground to do without the advice of experts in health policy and practice.
Who, under the terms of the Bill, will hold the contracts of junior doctors? Who will monitor the cancer screening service? Who will oversee the vocational training of GPs? Who will deal with complaints about trusts? It seems to be suggested that functions such as the oversight of communicable diseases and the handling of national confidential inquiries will mostly, or perhaps completely, be dealt with by the new, more local health authorities. However, there is deep disquiet as to whether that is the right place for them to be handled and whether such authorities will be able to or should deal with such matters.
There is alarm at what seems to be the loss of independence of the regional director of public health. The Secretary of State expressed surprise that we had drawn attention to that in our motion, although I notice that she did not go so far as to suggest that what we said was incorrect. It is an honourable part of the history and tradition of Britain that the holders of posts such as that of director of public health are whistleblowers in the interests of the general public. But in this new regional structure anybody at that level who blows a whistle will find himself on the street. There is widespread concern not only about what that will mean for the structure of the public health service below the level of regional director, but about to what extent the public will get the degree of oversight to which they have become accustomed.
657 As I said earlier, throughout the Bill the approach seems to be to discard in-house expertise whose impartial advice should be needed when judging the quality of information or advice which might be bought in from outside. That is only one example of ways in which long-standing and successful partnerships seem to be at risk. Despite what she said, the Secretary of State must know that the deeply held view of those in medical education, whether at undergraduate or postgraduate level, is that the combination of academic and clinical roles is an essential prerequisite of the training that has been provided hitherto. That view is held by the universities and by the health service.
Despite what the Secretary of State said about the consultations that have been held, she must be aware that that structure is perceived by people, including the Committee of Vice-Chancellors and Principals, to be put at risk by the changes. She must also be aware that there is real anxiety about the nature and scale of future medical education not only in the medical profession but in ancillary professions. Despite the impression given by the Secretary of State, that anxiety has not been dispelled.
The most professionally anarchic proposal of all is the Government's aim to devolve pay to local level. If anything will lead to increased costs and bureaucracy, it is that ill-thought-out policy. The time of managers will be used up in lengthy local negotiations on pay and conditions. Doctors, nurses and other staff will find themselves neglecting patients because they will be expected to attend to their own pay negotiations. The National Association of Health Authorities and Trusts has already said that the administration of local pay schemes alone will cost an extra £40 million.
The Secretary of State talked about people wanting to reduce matters to the lowest common denominator. No Opposition Member wants to do that, but that is what local pay is all about and that is what the Government are trying to achieve. They are trying to create a scenario in which pay and conditions can be cut, although where scarce skills are needed competition between trusts to attract and retain professional staff seems likely to lead to options for those specialties in which more than 480 different bargaining units will have to engage in competitive bids.
We do not intend to let the Government or the public forget what is already occurring in the structure for which the Government make such claims. An example of such an occurrence is to be found, I believe, at the Royal Marsden hospital, where a circulated memorandum suggested that someone should be hired not merely because he was the best in his clinical field but because removing him from another hospital would destabilise a competitor. Competition rather than co-operation will be further enhanced by local pay, which will also distort clinical priorities.
Skilled clinicians will no longer move from hospital to hospital for professional development reasons alone. Hospitals with research teams and research facilities will no longer seek to attract people primarily because they are innovators at the frontiers of scientific development: they will also depend on the pay that the chief executive can offer.
658 Some trusts will not be able to enter that competition. The director of personnel at the Havering Trust has already announced that he has to save £3 million in the next three years. How will that trust be able to attract or retain scarce skills during that period with the anarchy of purely local pay bargaining? How will patient care be delivered in that locality in those circumstances?
The Secretary of State expressed surprise that we wished to move a reasoned amendment rather than simply supporting the Bill. As we have made plain, we did so because we oppose the abolition of the NHS regions in their present form, although we welcome some of the Bill's other proposals.
§ Mrs. Beckett
I do not know why the hon. Gentleman says that; I made our position clear at the outset, but perhaps he was not here at that time.
Above all, oppose the way in which the functions of the regions will be dispersed and broken up. We oppose further fragmentation of the health service and we believe that behind the Bill lies the hidden agenda of breaking up and floating off different NHS functions and making them ripe for picking by commercial interests. As Mr. Maples advised, the intention is to silence the staff while that is happening.
At best, the Bill fails to address the real problems of health care in Britain. At worst, it exacerbates the problems that Government reorganisation has created. The Secretary of State repeated phrases that she has used in every speech that I have so far heard and read. There is the suggestion that under what she calls the old NHS there was a command and control structure, which she attacked. A command and control structure of a kind that no previous Secretary of State has enjoyed is precisely what the Bill introduces to the health service. For the sake of our national health service, that process, like the Government, must soon be brought to a halt.
§ 6.6 pm
§ Mr. Colin Shepherd (Hereford)
I am pleased to be called to speak so early in the debate. Those of us who take an interest across the spectrum of activities in our constituencies have to address the issue of health service delivery against the background and the experience of our constituencies. The changes that have been made in Herefordshire over the past few years, and especially the change in the make-up of the county's health authority and the bringing in of executives with particular expertise, have been beneficial. Therefore, the Bill is a logical next step and I have no quarrel with it in principle. I shall certainly support it in the Lobby.
I support the Bill's concept of endorsing local decision making in the NHS. That is very much at the core of the admittedly constituency interest that I wish to put before the Secretary of State and the Minister of State. We are greatly worried about how health services in Herefordshire could be affected if there is unsympathetic implementation of the Bill's proposed changes. I emphasise that the reforms must make sense to people if they are to be supported and understood.
My worries are about the imminent decisions that will be made by West Midlands regional health authority in its dying days. That authority has been charged with the 659 responsibility of predicating the shape and number of health authorities in what is currently the west midlands region.
My Herefordshire health authority—I take the proprietorial "my" on behalf of my constituents—is already the smallest in the country, with the exception of that for the Isle of Wight. It is working fairly well and is consistently meeting all the national targets. It is financially sound, it is at the top of the efficiency index in the west midlands, its management costs are well below the average for equivalent-sized authorities, and it has taken more steps to identify further reductions in those costs. This year, it knocked £200,000 from its management costs.
What is worrying is that, on this coming Thursday, 15 December, the regional health authority will decide its policy for the counties of Hereford and Worcester. It is anticipated that the recommendation will be that there should be just one new health authority covering the two counties.
The authority has arrived at its recommendation—although I think that "decision" would be nearer the mark—without very much consultation, and certainly not without its own walls. Its own statement says that consultation islimited at this stage primarily to Health Authorities".I inquired where the consultation had taken place and discovered that there had been little in Herefordshire. Indeed, I am not entirely sure who has been consulted.
The two county Members of Parliament—myself and my hon. Friend the Member for Leominster (Mr. Temple-Morris)—had a meeting with the health authority chairman and the director of performance management, at our request. It was certainly not a consultation because we were making representations. I understand that the chairmen of the health authorities were not even consulted. The general managers of the four health authorities concerned were summoned to the regional chief executive and told what was to be the case.
What the matter boils down to is that, without much consultation, the regional management executive has determined what is to be the case and, presumably, will go out to consultation. What will be the value of that consultation if, as I perceive, decisions have already been made and written on tablets of stone?
I am not alone in feeling great hostility towards the proposed move. Everything in me shrieks against it. I do not believe that it is necessarily in the best interests of my constituents in Herefordshire. I am not alone in that view—the general practitioners and their council in Herefordshire are unanimous in their opposition to that particular shape for the health service. The clinicians, the consultants, the joint operation of clinicians and general practitioners, the Hereford medical forum and everybody else involved in the medical sector are unanimous in their opposition.
The foundation for that opposition comes from 20 years of local government experience. It shows that where Herefordshire has been linked to the larger population base of Worcestershire there has been an inexorable suction effect away from Herefordshire and into the heavier weight of Worcestershire. A classic example of that is the eight years of the Hereford and Worcester area health authority between 1974 and 1983. It was like trying 660 to get hold of a cotton wool cloud. We could not get hold of the authority; it simply was not there in tangible form—it was too busy sitting in committees.
I am told that circumstances have changed and we have moved on, that I must not lock myself into 1974-type thinking and that I must adjust myself to today. However, our experience over the past 20 years is that, whenever small Herefordshire has been linked to large Worcestershire, because the demographic weight of population is to the east of the county, we have not benefited.
We actually made progress from 1983 onwards when we were given our own health authority. It was identifiable and small. At the time, we were told that it would be too small, but we said, "Let it run." It has been very successful and it has made progress. From my point of view as a Member of Parliament dealing with constituents and the health authority, I have found the lines of communication both short and effective. There have been good results in sorting out problems and unscrambling messes when they have occurred.
In Wolverhampton on 26 October, my right hon. Friend the Secretary of State told the chairmen of health authorities and trusts in the west midlands region that the new health authorities would be the stewards of the local community. The question being asked in my part of the world is: how local is local? The west midlands—. Birmingham—is light years away. I must inform my right hon. and hon. Friends that Worcester is also light years away. That might seem very parochial, but our area is sparse and large distances are involved. There is a range of hills in between. We are not the same. Over the years, we have tried to work in many different forums on a Hereford and Worcester basis, but none has been effective in its operation.
Where is the sensitivity to local needs? We need reassurance on that point from my hon. Friend the Minister. Herefordshire has a high elderly population, a low ethnic population and an old town. Redditch, on the other side of the joint county arrangement, has a high young population and a new town. Worcester has an old town and a high ethnic population. If the weight of population is to the east, how will sensitivity to the west be recognised?
In terms of finance, we are worried that the loss of sensitivity to the Herefordshire population profile will leave us at a disadvantage. We are very worried about the potential lack of sensitivity to the more rural parts of Herefordshire and beyond. My hon. Friend the Minister with responsibility for health matters in Wales knows full well how far into Wales runs the catchment area for Hereford, which is looked to as the centre for the provision of acute hospital care.
I am aware that my right hon. Friend said that we must not look for sectional interests on the area health authority, but unless there are people who come from the Herefordshire side of the hills there cannot be a recognition of what Herefordshire needs. I am not making sectional interest pleading; I am asking how Herefordshire's needs will be understood. It is not all number crunching. It might look very tidy from the inside looking out, but from the outside looking in it is not quite so tidy and comfortable.
All our experience suggests a shift of services to the centre of gravity of the combined area. Our worry is that that would be detrimental to the range of hospital facilities 661 that will be available in Hereford—not immediately, as these things take time—and that over the years there will be a migration of services as people rationalise and strategic decisions are taken about what is done where and how. In 10 years' time we could find ourselves not with the present acute hospital unit providing a broad range of clinical services, but with a hospital providing an accident and emergency service and the ancillaries that go with that. That worry must be laid to rest.
I am glad to see my hon. Friend the Under-Secretary in his place. When I explained my fears to him, I am afraid that his reply merely underlined them. My fears reflect those expressed to me by my constituents. I very much hope that my hon. Friend will be able to reassure us.
The regional health authority will put a paper before the meeting on Thursday. The reasons given in that paper for its decision seem to me to be self-justificatory bull.
§ Mr. Shepherd
Definitely not Herefordshire bull—Birmingham bull.
It appears to me that the authority's attitude is that a decision has been taken, so it must make everything fit it. I am told that the new authority will operate best againsta sensibly sized strategic canvas"—marvellous; furthermore:Local sensitivity will be assured by Primary Care-led purchasing, and the extensive development of GP Fundholdingcovering 87 per cent. of the population. I wonder what the sensibly sized strategic canvas will be. I was told that Hereford is too small to support both a strategically focused health authority and an extended range of GP-focused purchasing. When I met the regional health authority chairman and his colleague, I was told about the "theology of numbers" for a successful operation, which is somewhere between 300,000 and 500,000 residents.
When the Herefordshire health authority started, we were told that the population was too small at 140,000. I pleaded with the then Minister and he accepted my arguments, and we have a successful health authority as a consequence. It covers 160,000 people, and the mid-Wales dimension takes the figure to 250,000—not far short of the bottom limit of the theology of numbers. However, having pursued that matter with my hon. Friend the Minister, I understand that there is no bottom limit but that it is a matter of what makes sense. The regional health authority seems to be making rules to suit itself. What is the foundation for that theology of numbers?
It is suggested that a single health authority would attract high-quality staff and administrative savings of £1.5 million, which would be available, if it materialised, for reinvestment in local health services. I understand that the Price Waterhouse report is distinctly suspect and that if there were a single commissioning authority or health authority for Worcestershire and one for Herefordshire, the savings would be not £1.5 million but £500,000.
I am worried about the numbers that will be put before the regional health authority on Thursday. The regional chief executive's report dated 21 July stated that the situation in Hereford and Worcester is much more complex and that local ownership and accountability within any arrangement is more important than financial considerations. That is intriguing, because it implies two lines of thought.
662 We have marvellous clinicians in Hereford. They like working there and do not wish to leave, and there is no reason for them to do so. The quality of life in Herefordshire is darn good, and they do a good job.
The third argument is a wonderful piece of jargon. It is that NHS providers in particular will find it easier to shape their future against a clearer purchasing and commissioning strategy. That is true whether the authority is large or small. The argument is also made that the functional clinical links developing between providers across the county make a clear purchasing view all the more important and urgent. Those links will be made whether there are one or two authorities because they make sense. That is not a reason but a reflection of something that will happen as a matter of logic.
It is said that the business cases for the Hereford and Worcester hospitals are nearing completion, and that the Hereford scheme in particular should have its outline case approved by the regional office by the end of December.
I have been pursuing the establishment of a hospital since 1974. Hereford has three clapped-out building sites, one of which has finally been identified as a site for redevelopment. It is expensive, maintenance is bad, and it is difficult to see how services could logically be provided. In addition, the site is dangerous. A cardiac arrest on the operating theatre in the general hospital would necessitate an ambulance run to the county hospital's intensive care unit, which is unacceptable. I urge my hon. Friend the Minister to press for the completion of that hospital at the earliest possible moment.
Although the business case was presented in Birmingham today, I received from Mr. Brian Baker, chairman of the regional health authority, a note saying, "Hold on a second. We cannot go now on the shape of the Hereford hospital—not until such time as we know what is to happen in Worcester." That emphasises my worst fears. The two are interdependent, but decisions are being taken before we are ready.
I support the Bill's principles because they are right, but I urge my hon. Friends on the Front Bench to make a sensible arrangement for my part of the world, because it is different by virtue of its geography and demography. The reforms must make sense for people if they are to secure support.
What message are the Government sending my constituents? At 9.30 am on Thursday morning, the Local Government Commission will make an announcement, which I would bet heavy money will say that there should be a unitary authority for Herefordshire. It will recognise that the connection with Worcestershire over the past 20 years has not been to Hereford's advantage, and that its people think that they can do better. At 10.30 am, the regional health authority will say, "We are taking away Hereford's independence and will tag it on to Worcester to make a big merged health authority."
Although Hereford's health authority is small, it is good. It could be nicely merged with a family health services authority to form a new authority that is responsive to the needs of the people and understands them. The logical way for my hon. Friend the Minister to progress is to say, "I hear you, Herefordshire, and your worries. You will have a health authority in your own right." He can enter the caveat that, if that does not work, he will exercise the Bill's inbuilt powers to put Hereford together with another health authority, possibly 663 Worcester. He can do that if, in the light of experience, shortcomings are identified, and the individual authority is perceived not to make sense. I urge my hon. Friends on the Front Bench, as I support them tonight, to listen to us in Herefordshire.
§ Mr. John Heppell (Nottingham, East)
The Secretary of State said that the Bill exists to take account of Government reforms, but all those made so far have been utter failures. I see no reason why the Bill should not also be a complete failure.
The Secretary of State asked for facts and statistics. Government health reforms so far have cost £1.2 billion, which has meant that the cost of NHS bureaucracy has risen from £1.44 billion to £3.02 billion—an increase of 110 per cent. or £1.5 billion, which could have been spent on patients rather than on administration.
The right hon. Lady spoke about streamlining management. In 1986-87, the national health service had 500 managers. In 1989, it had 4,600 and by 1993, it had 20,010. That is an increase of 1,800 per cent.—not quite as large as the increase in prescription charges, but almost. In 1987, management costs were £25.7 million. Today, they are £49.8 million. That is what the Government's reforms have meant; those are the statistics for which my right hon. Friend the Member for Derby, South (Mrs. Beckett) was asked.
The Government say that they want to introduce further reforms that will save more money and make the NHS more efficient and effective. Does any Conservative Member seriously believe that we seriously believe what the Government say? They say that they plan to remove a tier of the health service, but when we examine the small print we find that they do not really mean that. They plan to remove regional health authorities—the section of the service that secures accountability at regional level.
It is no use for the Secretary of State, and other Conservative Members, to talk about the way in which people are appointed to trusts or regional health authorities. Every hon. Member—and, I suspect, everyone in the country—now knows that one overriding criterion ensures appointment to trusts, district health authorities and regional health authorities: allegiance to the Conservative party. More than half the 240 health authority chairs come from businesses, consultancies or financial institutions. They are directors and employers in firms that donate money to the Conservative party. Only 15 of those 240 have any medical background, but more than 120 have financial backgrounds.
If the appointees are not directors or other members of firms that give money to the Conservative party, they are members of the party. I know from experience—as, I am sure, do other hon. Members—that prominent members of Conservative associations are repeatedly appointed to trusts and health authorities. The same applies to Conservative candidates, both national and local. They are usually failed candidates, but what does that matter now? If a candidate cannot persuade the country to let him put his ideas across by means of the ballot box—if he cannot secure the changes that he wants democratically—it does not matter. As long as he has an allegiance to the Tory party, the Government will appoint him to a quango, such as a trust or health authority.
664 Not only those people themselves but their wives, brothers and brothers-in-law may be appointed. They have this in common: they are all yes-men, or yes-women, in relation to what the Tories want to do. In fact, regional health authorities do not pose much of a threat to the Government; they produce little opposition to the Government's proposed changes. Every now and again, however—not very often—we see a bit of independence and initiative, and hear a few murmurs of discontent and disagreement. For that reason, RHAs will have to go. The Bill is not about removing a tier of the NHS; it is about removing accountability.
Are the Secretary of State, the Minister and other Conservative Members trying to tell me that nothing needs to be done at regional level any more? I have taken time to read research paper 94/124, produced by the Library. A section beginning on page 11 asks:Who will do what in the new NHS?I have highlighted the instances in which it is still necessary for the region to act, and almost every part of the section has been highlighted as a result.
The regional officers will still set the local research agenda within a national research and development strategy developed by headquarters, and will manage research and development projects. When the revenue allocations are made directly to health authorities, surely the NHS executive will use its regional tier to establish what those allocations should be. When the responsibility for public health functions goes to local health authorities, regional offices will ensurethat effective arrangements have been put in place".When the professional advisory machinery is at local or multi-district level, the current sub-committees—the specialty sub-committees—at regional level will retain their responsibilities:regional offices will be responsible for performance management of health authorities and for monitoring Trusts".After that, they will have new responsibilities for GP fundholding. The regional tier will still have to do a great deal of work.
I find it hard to accept that the changes at regional level will save £150 million. How can 1,500 jobs disappear when all that work will still have to be done—unless, as my right hon. Friend the Member for Derby, South suggested, the plan is to contract the work out to private companies which are probably making large donations to the Conservative party? In any event, why are the RHAs being targeted in connection with bureaucracy? Bureaucracy has not increased in the RHAs.
Between 1992 and 1993, regional staff numbers fell from 7,845 to 3,905—a massive drop, as everyone would surely agree. Moreover, in the following year the numbers fell to 2,613. Meanwhile, bureaucracy has increased in the trusts, in the FHSAs and at district level, but predominantly in the trusts. If bureaucracy is to be tackled, they should be tackled. It is nonsense to abolish the tier in which bureaucracy has been slimmed down—the tier that has been made lean and mean—and preserve organisations in which bureaucracy continues to flourish.
A limit of 135 staff has been set for each region. Can anyone tell me how that number was arrived at? Is there no difference in the size of the regions? Is not the regional authority represented by the hon. Member for Hereford (Mr. Shepherd) smaller than some others? If the size indeed varies, will not differing staff numbers be required?
665 The truth is that the figure was plucked out of the air—and, even if it is met in the short term, I am certain that it will not stay the same in the medium and long term. As I have said, the work that needs to be done at regional level will continue. I guarantee that no future assessment of the number of staff required will produce a figure of 135, if it is done correctly.
Although I agree in principle with the amalgamation of the district health authorities and the family health service authorities, I have very strong reservations about whether the Government will carry it out efficiently and effectively. I have evidence that in some areas it is not being carried out efficiently and effectively.
§ Mr. Malone
It would be a little presumptuous if it were being carried out wholesale while the Bill has not yet received a Second Reading. There are a number of co-operative arrangements in place, which is very different from sorting out the amalgamation once the House has sanctioned the Bill. Surely the hon. Gentleman understands that.
§ Mr. Heppell
I understand it, but it seems that the Secretary of State does not. My hon. Friend the Member for Sherwood (Mr. Tipping) wrote to her pointing out that the Nottinghamshire FHSA and the Nottinghamshire health authority had combined—informally—to form a health commission and had proceeded to pick a new chief executive who is already in post and being paid. The chief executive of the Nottinghamshire FHSA has been sent home on what is described as "gardening leave". That person is on a salary of perhaps £50,000 or £60,000 but has been sent home before Parliament has even debated the necessary legislation because someone else has been given the job of taking over the new amalgamated health authority, which the Minister says should not yet be in place.
Perhaps the Minister will tell me that he proposes to take action against members of the health authority or the FHSA or against the chief executives of both bodies for proceeding without parliamentary approval. The Minister shakes his head. He clearly accepts that inefficiency has been engendered by the attempted amalgamation of two bodies without there first being in place a proper structure and without there first being a proper debate with the medical profession and members of other services involved. I am sure that the Minister will therefore accept that I am bound to have some reservations about the Government carrying out the reforms and achieving the savings they seek.
The Bill will be a failure because of what is not in the Bill as much as for what is in it. It does not tackle the real problems in the NHS. It does not deal with the fact that there are now 1 million people on the waiting list and that there is a secondary list of 1 million people waiting for out-patient appointments. The Bill does not tackle the fact that, since 1979, 147,790 beds have disappeared from the health service and that some people are now finding it impossible to get a bed.
The Bill does not deal with the fact that, in 1993 alone, 10,637 beds disappeared from the health service or that since 1979, 538 hospitals—or one in five—have closed. It does not deal with the patients charter. We learned only this week that the charter's targets are not being met. Nor 666 does the Bill tackle the problems of increased prescription or dental charges or the cost of eye tests. It does not tackle the fact that we now have fewer nurses than ever—in 1989, there were 397,650 nurses but by 1992 the number had dropped to 361,460.
The Bill does not solve the problem of perks going to the most well paid people in the NHS or the excessive pay rises that some people award themselves. Last year, the average pay claim by chief executives was 8.5 per cent. although some awarded themselves 33 per cent. even while the Government were telling public sector workers that their pay should not rise by more than 1.5 per cent. How can the Government in all honesty say that to ordinary NHS workers while some chief executives award themselves 33 per cent.?
The Bill does not deal with complaints which have increased by 57 per cent. to 58,000 a year and nor does it tackle staff morale. My right hon. Friend the Member for Derby, South mentioned the fact that the Government were trying to introduce locally negotiated pay. Only today I had a visit from a member of the British Medical Association, Dr. Gill, who is on the local negotiating committee. I am sure that he will not mind my mentioning that he told me that locally negotiated pay would be disastrous. It would mean that, in addition to their management and administration duties, hundreds if not thousands of doctors would have to attend one or two meetings a week to negotiate pay, whereas, at the moment, it is negotiated nationally and effectively and no one has complained.
The Bill gives the impression that it will cut bureaucracy but it will not; it gives the impression that this is the end of the NHS reforms but it is not; and it gives the impression that it will help the NHS but in reality it is a collection of bogus measures which are, if anything, simply a public relations exercise for the Government. The Bill's provisions are a smokescreen for the NHS reforms that have already taken place, and for the Government's betrayal of the service.
§ Mr. John Whittingdale (Colchester, South and Maldon)
I hope that the hon. Member for Nottingham, East (Mr. Heppell) will forgive me if I do not agree with him entirely. I find extraordinary the Opposition's constant desire to denigrate dedicated individuals who are trying to improve health care in their communities and especially strange is the idea that anyone who has had any association with Conservative politics—or who happens to be related to anyone in Conservative politics—should not be allowed to serve on a regional or district health board.
I shall not take up too much of the House's time because, despite the speeches that have been made so far, I do not think that the Bill is especially controversial. It is quite narrowly defined and technical, although that might not be immediately apparent—I note that schedule 1 will require 45 Acts to be amended, including the Polish Resettlement Act 1947, the Dartford-Thurrock Crossing Act 1988 and the House of Commons Disqualification Act 1975. Despite the wide-ranging nature of the Bill, I do not think that it is controversial, and it has received wide support, especially outside the House.
667 I agree entirely with my right hon. Friend the Secretary of State that the Bill is the logical consequence of our national health service reforms which were undoubtedly the most radical change to the structure of the NHS since it was created. Much of the attention since then has been given to the establishment of NHS trusts, and I was pleased to hear my right hon. Friend announce today that the coverage of the trusts is to be extended further to take in, I believe, 98 per cent. of patients. Attention has also been given to GP fundholders whose numbers have been growing steadily, but the biggest NHS reform was the creation of the internal market and the separation of purchasers and providers.
The Bill reforms the structure of the purchasing side of the national health service, which I have always believed is at the core of the NHS. I do not take the ideological, rigid view that the NHS should use only publicly owned providers. I am happy to see it use privately or publicly owned providers, as long as they deliver the best possible treatment to patients. The core of the NHS is its purchasing function, and the Bill concentrates upon that.
Three and a half years on, we can now begin to make a judgment about the results of the NHS reforms. Despite what the right hon. Member for Derby, South (Mrs. Beckett) said in her speech, I have absolutely no doubt that the reforms have worked. NHS trusts have been an unqualified success. General practitioner fundholders are providing better care to patients and, as a result, the number of patients being treated has increased and the quality of care has improved.
A couple of weeks ago, The Guardian stated that the NHS reforms had achieved "considerable success" in helping to restore confidence in the NHS. I take it that that was not written by the KGB.
Inevitably, when reforms as great as the NHS reforms are introduced there will be some problems. I accept that one such problem is the number of layers of management created and the amount of money spent on administration. I do not accept the more simplistic charge that the reforms have simply created layers of management. An organisation the size of the NHS must have strong management. It spends the equivalent of a small country's gross national product, and it must have properly qualified, good managers to ensure that we receive maximum value for money.
One of the reforms' main intentions was to devolve responsibility downwards—to give real decision-making power to those who are involved in running hospitals and to the GPs who have chosen to become fundholders. Devolution of responsibility has led NHS trusts, quite correctly, to recruit more management staff. The problem is that that increase has not been matched by a corresponding reduction in the number of administrative staff employed elsewhere within the NHS. The recruitment of more managers in NHS trusts should mean that many managers are no longer needed at the upper level of the health service. The Bill is designed to address that problem.
The disappearance of regional health authorities will require one or two of their tasks to be performed elsewhere. A traditional responsibility of the regions was the allocation of funds within a region using a weighted capitation formula.
668 The House has heard me talk previously about the consequences of that funding allocation in the North Thames region. I do not wish to go over familiar ground in detail, but I repeat that there has been a problem. Although there is a national formula to distribute funds between regions, when a region such as mine adopts a different formula for the allocation of resources within a region it leads to unfairness, particularly in my district of North Essex.
Because the national formula does not take full account of the social deprivation factors which the region uses to distribute funds within North Thames, North Essex has been doubly penalised. I have raised the problem with the Minister previously, so I do not wish to spend too much time on it tonight. However, as a result of the changes introduced by the Bill, I hope that the Department will implement a single national formula to allocate funds between districts. That will remove the present unfairness and ensure that all districts are treated equally.
The regional monitoring role must continue to be performed. It has been suggested that part of the role can be performed by the new health authorities— in particular, that they will be responsible for monitoring GP fundholders. As the British Medical Association has pointed out, the new authorities will also be competing purchasers. It concerns me that they will be not only competing with GP fundholders, but given responsibility for them. Will the Minister explain how the system is intended to operate?
At district level, I believe it must make sense for a single body to be responsible for ensuring that patients receive the proper degree of health care. The division between primary and secondary care has always been pretty artificial; it is now breaking down even further.
More and more treatments can be performed in a GP's surgery and no longer require a visit to hospital. When hospital treatment is needed, it is often performed on a day-case basis and no longer requires an overnight stay. In some cases, GPs will come into hospitals and use their facilities to treat patients and, as a result, consultants and registrars do not need to be involved.
These changes—many the result of technological change within the health service—will inevitably alter the profile of the health service. In future many people will not need to go anywhere near hospitals; their local GPs' surgeries will become mini-hospitals. Judging the performance of the health service, as the hon. Member for Nottingham, East did, on the basis of the number of beds available or the number of operations performed will become increasingly irrelevant.
I congratulate the Secretary of State on the speech that she made earlier this year—I think it was to the National Association of Health Authorities and Trusts conference—in which she drew attention to the changes that will take place in the health service. She highlighted the report by the United Kingdom chief nursing officers, who predicted that in future 60 per cent. of operations are likely to be performed on a day-case basis, 40 per cent. of specialist consultations will take place outside hospital and, as a result, 40 per cent. fewer beds will be needed.
The figures caused great uproar when they were first published, but it is an inevitable consequence of the technological change which is taking place in health 669 care. It is important that we should recognise it and debate now the consequences for the shape of the health service in the future.
Separation of the body responsible for the purchase of secondary care—in other words, the district health authority—from the body responsible for primary care is becoming increasingly daft. Many areas have recognised that already: commissioning agencies have been formed, with close co-operation between the two bodies.
In North Essex relations between the family health services authorities and the two DHAs are very good. Following my right hon. Friend's statement earlier in the year, the FHSA and the two DHAs talked about the structure of future health provision in the county. Clearly, the main question was whether future health authorities should be divided into two or three different bodies, or whether a single body should have jurisdiction over the whole county.
As well as engaging in wide consultation, the FHSA and the DHAs commissioned the King's Fund to investigate and make recommendations on that point. I was sorry to hear about the experience of my hon. Friend the Member for Hereford (Mr. Shepherd), who did not feel that sufficient consultation had taken place in his constituency.
Very wide consultation has taken place in Essex and, as a result, there is almost universal agreement that the most sensible structure is to divide the county along existing district health authority boundaries and to have two health authorities in future. I congratulate the three chairmen—Major-General Robert Wall of the FHSA, Alec Sexton of the North Essex health authority, and David Micklem of the South Essex health authority—on the way in which they conducted the investigations into future health provision in Essex. I think that their recommendations will enjoy widespread support and prove a great success.
I will touch upon one or two concerns that have been raised already in the debate. The first concerns accountability within the health service. I agree entirely that it is essential that the public have confidence and feel that they are fully involved in decisions affecting patient health care. The Bill is not entirely clear about the membership of the new health authorities—although I welcome the Secretary of State's clarification in her speech. I hope that members of the future health authorities' boards will be widely drawn from within the local community.
Clearly, the membership should include medical professionals. I especially welcome the announcement that the director of public health will be a mandatory executive on the health board, but I believe that a wide range of individuals who have specific skills to bring to bear should also be involved. I especially hope that there will be full involvement of the primary care sector. It is important that the new authorities should not be based mainly on the existing DHAs and that they should properly reflect the responsibilities of both the DHAs and the FHSAs.
As I have said, it is essential to try to increase public involvement in the provision of health care. North Essex health authority has been extremely good at trying to involve the public. I cite the public consultation 670 exercises that the authority has carried out on the provision of cancer services in the county which has recently led to the recommendation that there should be a new cancer centre in my town of Colchester. I also cite the consultation exercise on the provision of orthopaedic services. The original proposals for orthopaedic services to be centred on a single site in Broomfield were dropped as a result of the consultation exercise and new proposals have now been introduced for two centres, one in Chelmsford and one in Colchester.
I also cite the exercise in determining public priorities for medical treatment within the county. Many consultative documents were issued by the health authority, but, unfortunately, there was a lack of response to the documentation. I know that the director of public health was rather disappointed by the number of responses he received. One parish council in my constituency complained about the number of consultative documents it received and said that it was unreasonable for it to spend so much time answering them. That is a problem. I hope that consultation exercises will be phrased in simple language so that they will generate a proper response from those who wish to participate.
One of the interesting results of the recent visit by members of the Select Committee on Health to Oregon, where a wide-ranging consultation exercise has been carried out, was the discovery that the people who came along to the public meetings were not members of the public at all. They were health professionals. There must be the danger that a limited response to a public consultation exercise may not properly reflect public opinion in the locality.
I commend the fairly novel approach of Alec Sexton, who is the chairman of North Essex, one of the health authorities. He has started to hold public surgeries and he invites members of the public to raise with him any concerns they have about the provision of health care. That is an extremely welcome innovation and I hope that his example can be followed widely by the new health authorities.
Another problem has arisen in my area which the new authorities will need to consider—the growing number of patients who are being removed from GP lists. In Essex, there has been a slow but steady rise in the number of removals, from 977 in 1991 to 1,154 in 1993. I entirely accept that the figure still represents only seven out of every 10,000 patients, but I believe that it is a cause for concern.
It has been claimed that the increase is the result of fundholding practices seeking to remove patients who will be costly to their budgets. There is no evidence to support that claim. Indeed, the evidence in Essex proves precisely the reverse. In my mid-Essex area, there are fewer removals by fundholders than by non-fundholding practices. I accept that a doctor must have the right not to have on his list a patient with whom his relationship has broken down, but it is not acceptable for a doctor arbitrarily to remove a patient from his list, especially if no proper explanation is given to that patient. In rural areas such as mine, real problems can be created if the nearest alternative practice is many miles away. I should like there to be a requirement for doctors to justify the removal of a patient from their list and, 671 perhaps, for an arbitration scheme to be established to try to prevent the problem where possible. I hope that my hon. Friend the Minister will consider that point.
I now turn to the responsibility of the new health authorities for long-term care. As the House is aware, lead responsibility for the provision of community care rests with the local authorities. However, the availability of social care is, obviously, a paramount consideration in determining whether a patient is to be discharged from hospital. If adequate social care does not exist, patients will have to be kept in hospital, thereby putting additional strain on the health authority's budget and occupying badly needed beds. Essex county council, in common with a number of other Labour and Liberal Democrat-controlled authorities, has announced that its community care budget is close to exhaustion. That will cause real difficulties for the health authority.
It has been claimed that, in Essex, community care has been inadequately funded. That simply is not true. The amount available to spend on social services this year stands at £175 million, which is an increase of 22 per cent. on last year's figure and 7 per cent. more than the national average. The change in the distribution of the special transitional grant, which some local authority social services departments claim has penalised them, has benefited Essex by a further £21 million. The principal reasons why Essex county council social services department is now in that position are simply mismanagement and the council's failure properly to plan its budget in advance.
§ Mr. Hinchliffe
I have listened with interest to the hon. Gentleman's comments about community care. The subject does not have a great deal to do with the. Bill, but it is important to make one point. Does the hon. Gentleman recall, that in the first year of the care changes, the Association of County Councils made the point that community care was underfunded? At that time, the association was controlled by the Conservative party.
§ Mr. Whittingdale
I simply do not accept that community care has been underfunded. The hon. Gentleman will find that this area of local government responsibility has received better funding than almost any other and that the funding has been steadily increased since the changes were introduced. There is no justification for local authorities to claim that their budgets have been exhausted. Such claims have aroused fears among some of the most vulnerable people in society, which is a disgrace.
Essex county council's reserves stand at about £25 million. The council should simply transfer some of that money to make up any shortfall and it should take immediate action to ensure that such a situation cannot be repeated. I can see that you are looking at me, Madam Deputy Speaker; I am conscious that I have strayed a little from the Bill. I thank you for your indulgence.
I have no doubt that the Bill will result in a more efficient and streamlined structure for the NHS. It will consequently result in real benefits for patients.
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. Before I call the next hon. Member to speak, I 672 must point out that, so far, no Back-Bench speaker has managed to make a speech in less than 20 minutes. If that trend continues, there will be some disappointed Members who will not have made a speech at all. I hope that I make the point clear.
§ 7.8 pm
§ Mr. Alex Carlile (Montgomery)
I cannot resist starting with a reference to the strong plea that the hon. Member for Hereford (Mr. Shepherd) made on behalf of the Herefordshire health authority. I have a lawyerly connection with Hereford and, as a Member of Parliament for mid-Wales, I am well aware of the number of patients, especially from the south of the county of Powys, who go to Hereford for the very good hospital treatment in that ancient city. The hon. Gentleman's argument was sound and not merely on a local basis relating to his constituency, although that stands too.
I am glad to see the Under-Secretary of State for Wales, the hon. Member for Clwyd, North-West (Mr. Richards), in his place. In his presence, I ask the Government to ensure that, during the reorganisation, close attention is paid to ensuring that patients who seek treatment, or are sent for it, across the Welsh border will continue to be able to receive it efficiently.
The consideration that the hon. Member for Hereford mentioned applies equally to constituents in Brecon and Radnor; and to my constituents, who go to Shrewsbury for much of their treatment. Indeed, it applies in particular to the Minister's constituents in Clwyd, many of whom gravitate towards Chester for treatment. Cross-border availability is an important issue. There has certainly been a feeling in my constituency that the Shropshire health authority has tended to look east, to the neglect of the western part of its catchment area. The reorganisation should not allow that trend to continue.
I have a feeling that, while drafting the Bill, the parliamentary draftsman was reading the Maples memorandum. We have four pages of Bill and 50 pages of schedules. I suspect that the instructions might have been to make it so dull that it would introduce legislative anaesthesia and possibly euthanasia of the Standing Committee—Oregon was mentioned a few minutes ago—so that the politics of the Bill, or indeed the whole Bill, would be forgotten.
Beneath that textual exactitude, which the draftsman so skilfully incorporated—especially in schedule 1—lies a breathtaking transfer of power. Breathtaking powers are to be placed in the hands of the Secretary of State and of unelected and extremely large public bodies. Of course no one objects to reorganisation if it improves the quality of service, unless one takes a dogmatic view as to whether all health care should be provided by the public or the private sector, which I do not. I hope that we will gain an assurance from the Minister in his reply, especially in answer to the hon. Member for Hereford, that it is improving the quality of service that drives this reform and not some organisational ethos, which is what crept into that remarkable jargon that the hon. Member for Hereford read to us earlier.
Reorganisation is unacceptable if the quality of service is not improved. We must bear in mind the fact that those extraordinarily large and totally unelected public bodies will take decisions that will affect the fundament of people's lives. They are the organisations that will decide—as some have decided not to—whether to pay for 673 extra coronary operations, above the number of operative treatments for which they have contracted. Like the existing Powys health authority, which is responsible for my constituents, they are the authorities that will produce proposals that may mean emergency ambulances only in a large and sparse rural area. No one could imagine a decision—based on financial stringencies, of course—that could be less calculated to serve the large, local, elderly population.
Those are the authorities that make arbitrary judgments—again like Powys—such as the decision that, as a matter of policy which I believe to be unlawful and capable of judicial review, childless couples will in no circumstances be able to gain fertility treatment on the national health service. Such decisions should never be taken, but the lack of any sort of democratic accountability, whether in the old or the new authorities, renders them more likely.
Beyond those general considerations, I must deal briefly with six specific issues. The first has already been mentioned—predictably so—and concerns how members of the authorities will be appointed. Will there be yet more epidemic and centralised patronage? I want to be fair. The Labour Government's record on epidemic patronage before 1979 was every bit as bad as that of Conservative Governments since. There is no reason for it to be so. For example, why will the Department of Health and the Welsh Office not advertise for possible non-executive members of the authorities? Why trawl among the great and the good and those with whom they happen to go to cocktail parties, rather than advertising every one of the posts in the regional press, so that the trawl can be made from the widest range of possibilities?
§ The Parliamentary Under-Secretary of State for Wales (Mr. Rod Richards)
May I enlighten the hon. and learned Gentleman by telling him unequivocally that my right hon. Friend the Secretary of State for Wales will soon be advertising the posts of chairmen of the new health authorities in Wales?
§ Mr. Carlile
That is a small step for mankind and it is right that the trawl should happen in that way, but why not in England, too?
§ Mr. Carlile
I will give way in a moment. I seem to be drawing a chorus. Like two choirboys, singing seasonally, the Ministers come to their feet. Perhaps the Minister of State will tell us why every non-executive post on those health authorities should not be advertised.
§ Mr. Malone
The hon. and learned Gentleman should be aware that that is increasingly the practice. The availability of posts is advertised. The widest possible representation is sought among applicants, to enable the appointments to be made. That already happens in some 674 regions, especially in the south and the west, which I represent. It is an excellent practice, it is being encouraged and it will be expanded.
§ Mr. Carlile
I feel a little like a swordsman rather successfully drawing blood. Perhaps I should keep on this tack and in another 10 minutes we might have an announcement that all the posts will be advertised.
§ Mr. Carlile
I am sorry, but I must get on.
Will the Minister of State assure us in his reply that each authority will have representatives of the executive and medical, nursing and midwifery staff on its board, as well as consumer representatives, who might best be drawn from the community health councils that have been serving the public so well?
On consultation, will the Minister of State be able to assure the House that the authorities will be statutorily required to consult with community health councils? We face the threat of some health councils being taken out of existence as a result of the changes. The Bill requires at least one community health council for every health authority area. One suspects that that may mean that, in some areas, there will be only one community health council for that health authority area. I hope that community health councils will be consulted, and that we can expect to see very few reductions in the number of community health councils.
I was encouraged to hear what the Secretary of State had to say about universities. Eloquent representations have been made by the vice-chancellors, and in particular by the principal of St. George's medical school, Sir William Asscher. He has made the point that the regional authorities will, in effect, be replaced by regional outposts, which could mean that the influence of the universities will be reduced. All the research which universities do and the facilities they provide at the clinical frontier may also be reduced.
I hope that the Minister will be able to confirm that we will not simply have a token university representative in each enlarged region, but that the proportion of university representatives will be maintained in the new structure so that the extremely valuable quantum of their influence is not lost.
The next point I wish to make briefly relates to public health. Representations were made on that issue by Labour Members earlier in the debate, particularly by the right hon. Member for Derby, South (Mrs. Beckett). Public health doctors are concerned at the way in which the independence and discretion of members of the medical profession will be affected by the changes. Will they be able to speak freely on public health issues within the range of their responsibility, or will they always have to seek authority from the region—or possibly even from the Department of Health—before they speak on public health issues?
It is extremely important that consultants in public health medicine should have the liberty to express their medical opinion. There is a danger otherwise that the Government may naturally wish to play down a particular issue because of its political consequences, whereas public health specialists might wish to speak out to make the public aware of the medical consequences.
675 One way of dealing with the issue might be to require in the statute that each health authority should produce an annual report on the state of public health within its region, so that the public would at least be able to see the authority offering to make itself accountable on public health issues.
Midwifery has been subject to statutory supervision, which has ensured high clinical standards. At present, the regional health authority is the local supervising authority. The Royal College of Midwives has called for supervision to be retained on a statutory basis, and I hope that the Government will support and accept that call.
I suggest that the local supervising authority should be at purchaser level, so as to ensure the effectiveness and directness of supervision. In that context, will the Minister also tell the House whether the Government will retain maternity service liaison committees, which have served midwives and patients well?
I shall make a brief, but important, point about student nurses. It is right that nurse training has been improved, and that has been beneficial, but the Royal College of Nursing produced a survey within the last fortnight which showed clearly that many student nurses are simply not able to survive without working elsewhere during their courses. In many areas, it is extremely difficult for student nurses to obtain other work. The result is that student nurses—who work long hours and are gaining more and better professional qualifications—are being forced beneath the breadline. I do not think that we should be training nurses in that atmosphere.
Finally, I wish to mention the future of district general hospitals, and to do so I return to the speech of the hon. Member for Hereford. Hereford is a good example of a city with a district general hospital service—I shall leave the buildings out of it at present—which is extremely good. It does not provide the entire range of medical services, but the broad sweep is catered for by a competent group of clinicians.
The trend now, which one can understand, is towards emphasising centres of excellence, or specialist treatment centres—it does not matter whether they are in the public or the private sector—which provide good-value treatment in particular specialties. Those centres do, of course, have a role to play.
The Welsh Office Minister who is present tonight gave evidence to the Welsh Select Committee recently in connection with specialist treatment centres. In that evidence, he made the point that the percentage of treatment within the given specialty which the treatment centres in Wales provide is still very limited. I accept that that evidence is right, but the centres are a burgeoning trend.
There is a feeling in the national health service that the growth of centres of excellence may prove to be a threat to district general hospitals in cities such as Hereford. Ministers must watch closely as the situation develops. If district general hospital services are significantly reduced, we will inevitably see the closure of a large number of district general hospitals and, by that token, a reduction in services to the community. I hope that the Government accept that around every accident and emergency service there exists the need for a wide range of services which are best provided in a district general hospital.
During what I hope has not been too long a speech—I am the only hon. Member speaking for my party in the debate, Madam Deputy Speaker—I have sought to 676 highlight six specific points of concern to me and to my colleagues. I have studied both the Bill and the notes on clauses, and not a great deal of light has been shed upon the clauses as a result of that study. Some light may be shed upon those real live doctor-patient issues by the Minister in Committee. Just a little chink of light when the Minister comes to sum up the debate tonight would be much appreciated.
§ Mr. Peter Atkinson (Hexham)
The lack of passion from Opposition Members during a debate on a matter that I always thought they claimed as their subject has been remarkable. Indeed, if one looks around the House tonight, one can see three Labour Back Benchers and three Opposition Front-Bench Members in their seats. That is extraordinary from a party that always says that it makes the running on health.
The reason for the lack of passion is that the Opposition are concerned where to step, because they know perfectly well that they have no real policy on the subject. They also know that the Labour party is moving slowly, steadily and inexorably towards an acceptance of the Government's health service reforms. It cannot do anything else, because—despite the blustering of one or two Opposition Members—it knows that our health reforms are working and that the health service has improved out of all recognition from when the Labour party was last in office.
Why should not the Opposition accept our recommendations? After all, in recent months they have accepted a great deal of what the Government have done in their period of office. The Opposition appear to have accepted competitive tendering, privatisation and even educational league tables. Some Labour Members even accept the idea of opted-out schools. It is inevitable that the Opposition will slowly move towards an understanding that our reforms have been a success.
On a more serious note, however, if one digs deeper into the Opposition's lack of policy, the makings of a policy can be found. A clue to it can be found in the Opposition amendment, which refers to "regional public health directors" and their document, "Health 2000", published in February, which spoke about a possible regional form of health service.
We know that the Opposition are seeking to break up the United Kingdom. We have heard about a parliament for Scotland and what is called an assembly for Wales.
§ Madam Deputy Speaker
Order. I am not clear how those points relate to the Second Reading of a Bill.
§ Mr. Atkinson
If you will bear with me for a moment, Madam Deputy Speaker, I will prove how they do.
Just as the Opposition want regional assemblies for England, so they propose their form of regional health authorities. That proposal would re-politicise the health service, when the Government have successfully de-politicised it. Such a shift is extremely important.
I served on a district health authority for some years in the bad old days, when the DHAs were dominated by local councillors or the placemen of local councils. I must admit to being one of those placemen, because a local authority put me on a health authority board.
677 At the time, I had scant knowledge about the health service, but I am pleased that it is now run by professionals rather than those who were appointed to DHAs to politicise that service. That politicisation option had been proposed many years ago, but it had been rejected by the then Labour spokesman, Nye Bevan.
The result of the politicisation of the health authorities was quite appalling for patients, especially in regions dominated by the Labour party. Those Labour DHA members had at heart not the best interests of patients, but those of the unions and union members. Labour councils also appointed health workers from one DHA area to sit on the DHA of another. They were not interested in looking after the interests of patients; what mattered to them was looking after the interests of their fellow professionals by adopting a "make work, improve conditions" attitude.
Those DHAs resisted the closure of redundant 19th-century hospitals which should have been closed down years ago. They also opposed root and branch any form of contractorisation or tendering for hospital services. I remember that, when my local DHA eventually succeeded in privatising the cleaning services for one hospital, we were amazed to discover that that hospital worked on a 30 per cent. daily absentee rate. The contracting out of services revealed such arrangements.
In those days, we had to work with COHSE, the health service union. A greater misnomer for a union one could not find, because that union continually reduced hospitals and their patients to misery through regular strikes at hospital laundries. That action was one of the union's favourite tactics. That union now represents itself as a new union, Unison, but I am sure that its agenda is the same as that pursued in the old days.
One of the purposes of the RHAs was to sort out the mess caused when local authority boundaries and health authority boundaries were coterminous. That problem arose because of early reforms to the NHS in the 1970s. In those days, patients did not travel within their local authority boundary for treatment but continually crossed to where their doctors wanted to give them treatment, or where those patients wanted to be treated. The RHAs therefore had to have enormous financial departments to sort out the mess caused by such cross-boundary treatment.
All those problems have been resolved through our creation of hospital trusts. That is why it is perfectly timely for the top layer of bureaucracy in the health service to be abolished. I must commend, however, what RHAs have managed to achieve in recent years.
If I may be parochial for a moment, I am pleased that the headquarters of the Northern RHA will be relocated in Durham, rather than in Harrogate, as has been argued for today by some hon. Members. Durham 678 is the convenient choice, because it is in centre of the region. That RHA has offered an innovative solution to a problem involving my district general hospital.
§ Mr. Bayley
Without becoming too parochial, is the hon. Gentleman suggesting that Durham is equidistant between Newcastle and Grimsby, which will be within the same RHA?
§ Mr. Atkinson
Given that the new authority will include Northumberland, Cumberland, Durham and parts of North Yorkshire, I believe that Durham is conveniently close to the centre of that region and has good road links.
My local RHA offered an imaginative solution to the problem posed by Hexham district general hospital. The solution may interest the hon. and learned Member for Montgomery (Mr. Carlile), who might be faced with a similar problem in his constituency.
The small district general hospital at Hexham is rather archaic—it was built as a temporary hospital during the war—but it serves a large rural area, and is loved and appreciated by local people. The difficulty was that the hospital could not provide the wide range of services, expertise and specialties that are available in major teaching hospitals and major city centre hospitals. The RHA's solution was most effective, because it welded Hexham general hospital into a joint trust with the Royal Victoria infirmary of Newcastle, which is one of the leading teaching hospitals.
As a result of Government reforms, consultants from the Royal Victoria infirmary are now able to travel out to the district hospital to carry out operations. That change will bring the expertise of that major teaching hospital to the district hospital. I hope that the Under-Secretary of State for Wales, who is on the Front Bench now, will pass on to his colleagues at the Department of Health our optimistic hope that a new district hospital will be built on the existing site in the centre of Hexham.
The RHAs have run their time. They served a necessary and useful purpose, because, in recent years, they have been helpful in establishing the reorganisation of the NHS. The final reform proposed in the Bill will ensure proper independence for the trusts, better financial savings and a better service to patients.
§ Mr. Hugh Bayley (York)
So far, hon. Members have addressed the issues of bureaucracy and accountability. I accept that they are important and central to the Bill, but the most important issue is whether the abolition of RHAs and the merger of FHSAs and DHAs will improve the health of the people.
The most fundamental principle of the NHS is that of equity—that patients, irrespective of where they live, should be treated on the basis of need and on their ability to benefit from health care. That is the absolute hallmark of a public-sector, tax-based health system—a system into which we all pay and from which we can all draw health care, when we need it, on the basis of need.
Under the Conservative Government, however, evidence has grown of stark, widening inequalities in health, both between different regions in the country and between different social classes—inequality in terms of access to health care and in terms of people's state of health.
679 Evidence of that appeared many years ago in the Black report, which was commissioned by the then Labour Government, but buried after the 1979 election by a Conservative Health Minister. The Select Committee on Health has also taken evidence of health inequalities. For instance, in our recent study of dental services, we learned that five-year-old children in Scotland, Wales and the North Western RHA had twice as many decayed, missing or filled teeth as children in the West Midlands, South West Thames or Wessex RHAs. What is more, the average number of decayed, missing and filled teeth is actually increasing in the poorest regions of the country, whereas it is decreasing in the richest region of the country.
There are disparities not simply between regions, but between social classes. In the Health Select Committee, we were told that adults in social classes IV and V, unskilled and semi-skilled manual workers, when compared with those in social classes I, II and IIIa, white collar workers, had more missing teeth and more than twice as many decayed teeth, but fewer filled teeth, showing a lower level of treatment.
Quite recently, in April 1994, an article by Peter Phillimore and others in the British Medical Journal identified the health inequalities in the Northern region. They found that adults aged less than 65 in the more depressed parts of the region, such as St. Hilda's ward in Middlesbrough or West City ward in Newcastle, were four times more likely to die—they had four times the standardised mortality ratio—than people living in more prosperous parts of the region such as Wylam ward in Tynedale or Whalron ward in Castle Morpeth. In other words, health inequalities are literally a matter of life and death.
The problem of regional inequalities was first tackled in 1976 by the last Labour Government by introducing the resource allocation working party, which funded regional health authorities on the basis of the populations in the regions weighted by death rates in those regions. That basis of funding the national health service has continued ever since.
However, the abolition of regional health authorities as a result of the Bill means that a new funding formula would be needed, because one can no longer fund on the basis of regions. Therefore, last year, the Department of Health commissioned research from a group of health economists at the university of York, to develop a new formula to fund district health authorities.
The researchers found that the current formula underestimates the need for health are in deprived areas, principally in the north of the country and in inner cities, because it takes no account of the health implications of social deprivation. They found that indicators such as unemployment, the proportion of the population who are lone parents, the proportion of elderly people living alone with no carer, and the proportion of ethnic minorities, were good indicators of the amount of health need and the resources required to meet it.
The York research team published its findings in the British Medical Journal on 22 October 1994. It estimated that, using its formula, the Northern regional health authority should receive 2.8 per cent. more in relation to acute care to meet the health needs of the population in the Northern region, compared with the health needs of populations elsewhere in the country. By contrast, the 680 team found that, as far as acute care is concerned, the Oxford regional health authority received 4.8 per cent. more than its entitlement on a needs-based assessment.
The team also produced a formula for the provision of services for mentally ill people. It found that the North East Thames region received 15.4 per cent. less than its entitlement for psychiatric services, and that the Wessex region received 17.5 per cent. more than its entitlement when the health needs of the population in the region were taken into account.
The day before the researchers published their results—perhaps the timing was co-ordinated—the Department of Health issued a letter to all finance directors in the national health service in England, departmental letter FDL (94)68, which accepted the main thrust of the York researchers' argument and said that it would apply the York formula to the majority of the NHS budget. The Department made some modifications, but it chose the York formula as a basis for the new allocations to health authorities.
It therefore shocked me to find out last week, from a Department of Health press release, that next year's resource allocation to the health service provides exactly the same 4.4 per cent. increase for each regional health authority, irrespective of the health needs of the population in the region. That will perpetuate the health inequalities I mentioned earlier, and will undermine the principle of the NHS as a national health service, meeting the needs of patients equally, whether they live in Newcastle or Bournemouth.
The difference that funding on a straight percentage basis for each regional health authority in the country makes, amounts to very big money. With the help of some of the York health economists, I have calculated over the weekend the target allocations for each regional health authority if the York formula, which the Government have said they will accept, was implemented on the modified basis that the Government laid out in their letter to our health service finance chiefs.
Compared with the actual allocations that the Secretary of State announced last week, the new combined Northern and Yorkshire region will receive £128 million less than its target, according to the formula that the Government say they will apply. The North Thames region will receive £103 million less than its entitlement under the formula that the Government commissioned, and which the Government say that they will introduce.
By contrast, the South and West region will receive £40 million more than its entitlement based on the health needs of the population in that part of the country, and the Anglia and Oxford region will receive a massive £286 million more than its entitlement based on the health needs of the population in that area.
I do not argue for swingeing cuts in the health service in the south. However, if the Government wish to provide a comprehensive health service which provides equal access to treatment for people throughout the country, they should be moving towards the allocation of resources based on health needs. They need a strategy for gradually correcting the imbalance in resource allocation that favours the south at the expense of the north, and this year they had the opportunity to do it.
The press release last week, announcing the Department of Health's allocation for this year, said that the allocation amounts to a 0.85 per cent. increase in 681 addition to the rate of inflation. Significant new money is going into the health service, and that new money could and should be targeted on the regions that are underfunded at present.
If one draws a line across the country from the Severn to the Wash, according to the formula that the Government themselves commissioned, north of that line the national health service receives £235 million less than its entitlement based on the population and the needs of a population; and south of that line the NHS receives £235 million more than its entitlement based on the needs of the population.
That is unfair; it is unjust. It is unacceptable to meet the health needs of people in the south by cutting the health care budget for people in the north. If we are to continue to have a national health service, health resources must be allocated on the basis of patient need for care, rather than party political geographical allocation, which benefits people living in Conservative parts of the country.
§ Mr. Bernard Jenkin (Colchester, North)
Following the hon. Member for York (Mr. Bayley), I am intrigued by his discussion of formulae and allocation. I have not studied the York formula, and perhaps he served warning on me, as a representative of a constituency south of the line that he drew from the Severn to the Wash, that I should study it, and with care, but I am bound to say that study of those formulae rarely repays the effort as much as one hopes.
We in the North-East Thames region have, for some considerable time, perhaps been over-provided as a region. The resource allocation working party set up by the last Labour Government in 1975 started to move resources for a fairer allocation across the country.
Within the North-East Thames region we have had lengthy arguments about the allocation of resources between the various districts. The most salient point to come out of the discussion about formula is the distorting nature of the regional health authorities. They have not just distorted the allocation of resources across the country—doubtless that argument will continue—but have distorted the allocation of resources within regional health authorities.
They have done so to such an extent that the national formula used by the Government to distribute resources across the regions is discarded by the regions, which use their own formula. That formula is perhaps closer to the York formula, which reflects social deprivation and other such factors. North-east Essex has thereby suffered a double whammy. We are losing money as a result of the resource allocation working party and the trend towards allocating resources out of the London area. We have been losing money again as a result of finances being concentrated in the London parts of the North-East Thames region.
Thankfully, the NHS reforms have, over the years, begun to resolve that problem. There was a wide differential between the amount of funding per head allocated to my constituents in north-east Essex and north Colchester compared with those in south Suffolk. As a result of the NHS reforms, that gap has gradually closed, and we are today much closer to attaining parity.
682 It is important that bureaucrats, whether in the districts or in the regions, are having less and less influence over the allocation of resources. As we see the growth of GP fundholders, as fundholders attract resources on the basis of their patient lists and their characteristics, and use that purchasing power—not just within the district where the district purchaser has purchasing power, but anywhere—we see developing an NHS that allocates resources more intelligently according to the natural signals developing in terms of the internal market. Resources are used more effectively and carefully by the GPs acting as advocates for their patients and allocating resources accordingly.
It is no surprise that the Labour party, for all its modernising tendencies, should oppose the Bill. It has opposed every one of our NHS reforms when we have produced them. We no longer hear the scare stories about NHS trusts leaving the NHS. The Labour party is no longer able to make that charge, because it is ridiculous. No doubt the Labour party will make ridiculous and equally fallacious charges about the Bill. As my hon. Friend the Member for Hexham (Mr. Atkinson) said, perhaps the Labour party will eventually come to the same view on the Bill as it did about education league tables and grant-maintained schools. We expect the argument to continue to advance in our direction.
The achievements in my constituency as a result of the NHS reforms have been considerable. All our provider units, to use the jargon—most people still call them hospitals—have moved towards NHS trust status. As a result, our acute unit has been able to expand and use its resources more efficiently. We have opened a day surgery centre and new surgical wards. It was recently announced that the unit's facilities will be further expanded to include a day surgery.
That is not to say that those who work in Essex Rivers Healthcare do not have to work extremely hard, often under adverse conditions. We ensure that the money goes as far as it can. I pay tribute to all who work in Essex Rivers Healthcare and give them my moral support. We must not ceaselessly take advantage of the good will of those who work in the health service.
Perhaps one of the benefits of the continuing devolution of decision-making power in the NHS is that one day we shall get rid of the old Whitley council arrangements for negotiating terms and conditions. We could then apply much more modern terms and conditions, with better pay for those who most deserve it, rather than being hidebound by the existing bureaucratic pay and negotiating structures.
Essex Rivers Healthcare has to cope with discharge policy in the face of what my hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) mentioned—the failure of Essex county council's policy on community care. Despite there having been a 66 per cent. real-terms increase since 1991 in the funding of community care in Essex county council, the Labour party has cocked it up—not to put too fine a point on it.
That just shows that, for all the caring good will—I am sure that those involved are nice people who care—they are incapable of delivering the policies that people expect and on which the most vulnerable in society depend. That inability has a knock-on effect in the NHS, and ultimately places a strain on the good people who work in the Essex Rivers Healthcare who have to make decisions about discharging patients. It is rich for the Opposition endlessly to say that they would look after the health service better 683 than we do. That is another example of Labour policies, even in county councils, having a detrimental effect on the NHS.
The mental health services in Essex took on NHS trust status soon after the NHS trusts were first announced. We have a trust called New Possibilities, for people with learning disabilities. All the NHS trusts have become innovative examples of what can be achieved. The New Possibilities trust has started an employment agency specifically for people leaving the old-fashioned system of care under the health service. It moves people into the community and ensures that they find a job. That is an example of innovation that we should surely support.
We also have large numbers of GP fundholding practices that greatly benefit patients in the district. My constituency contains the first single GP fundholder. I urge the Government not to dismiss such innovation. In the initial study, single GP fundholding practices were found not to be cost-effective, but that was because they were given the same start-up funding as multi-GP fundholding practices.
Although I am certain that the money may have been put to good use, surely a single GP setting up as a fundholder does not need the same start-up money as a multiple GP practice. That must have had a detrimental effect on the cost-benefit analysis of the study. I urge Ministers to continue to study single practice GP fundholders—a good innovation that works extremely well in my constituency. I wish that we had more of them.
The abolition of the regions is a natural consequence of the NHS reforms. The existing regional structures have done good work over the years, but are part of the old command and control system—the Stalinist system, as my right hon. Friend the Secretary of State called it. That is no longer necessary, as so many decisions on the allocation of resources at local level are now taken at local level.
Opposition Members often criticise the rise in bureaucracy in the NHS, but the new policy gets rid of bureaucracy, and it is entirely natural that we should have moved some of the bureaucrats out of the regions and districts and into the hospitals and GP fundholding practices where the decisions are made. It naturally follows that we need to cut out the bureaucracy that has now become obsolete.
It is only natural that people sitting behind rows of desks in large office blocks feel that they are doing useful jobs; perhaps they are, but they are not as useful as they used to be, and they are certainly less important now.
I confess that, on my one visit to the headquarters of the North East Thames regional health authority, I was staggered by the size of the building. I lusted after the time when we would have NHS trusts all over Essex taking the decisions, and we would be able to get that distant London-based bureaucracy out of our hair. That has now happened, and we are better off as a result. We do not need regional interference in local policies of the type from which we used to suffer. The job of the regions is obsolete now that we have the trusts.
The development of specialist services is no longer planned by the regions in the way envisaged when the RHAs were first established. The Opposition amendment obliquely mentions cancer services. Decisions about cancer provision and anti-cancer strategy are being made now by the London implementation group, which is 684 taking a more keen look at the general provision of cancer services across the regions—a view that a single region could never enjoy on its own. A much more co-ordinated approach is needed. We are moving towards a health service that takes the day-to-day decisions at a level ever closer to the patient; and strategic decisions are planned unashamedly strategically.
Although this may raise bogus fears about accountability, the only accountability that really matters is to the patient, when he or she gets the treatment required. As a party, we are happy to remain accountable to the British people. If they are not satisfied with the service, no doubt they will say something about it at the general election.
All the evidence shows that patient satisfaction has improved. Of course, Opposition Members go on talking up what usually prove to be false fears about the state of the health service, but more patients are being treated and are satisfied with that treatment. If one asks an ordinary person what he thinks about the state of the health service, he will pick up the adverse vibrations sent out to him by—usually—an Opposition Member. If one asks him, however, about his own doctor or hospital, he will say what marvellous treatment he has received at their hands.
Accountability brings me to the membership of health authorities. I am very pleased that, once again, Ministers have made it clear that we are not going back to the argy-bargy political meetings held by the old-fashioned health authorities at a time when people were appointed to them as part of the process of handing out the political spoils of office to councillors. People used to end up arguing about the PLO and many other things that had nothing to do with the health service. The real decisions were not made, and if they were made, they were made far too late.
§ Mr. Jenkin
I am not giving way.
The internal market in today's health service provides the information that is needed to make decisions in the service which allocates the resources. This Bill is a natural consequence of the continuing and successful reform of the NHS, and I commend it to the House.
§ 8.3 pm
§ Mr. John Gunnell (Morley and Leeds, South)
I am one of the few Opposition Members to have served as a member of one of the new health authorities. I should like to assure my hon. Friend the Member for Nottingham, East (Mr. Heppell) that I was not appointed because of my support for the Tory party.
My second relevant experience lies in the fact that I, like those who work for the RHAs, was once abolished. I used to be the leader of a metropolitan county council, but then I was abolished, and the father of the hon. Member for Colchester, North (Mr. Jenkin) had a hand in that.
My third relevant experience—the most important one—has come during the past two and a half years of handling queries from constituents. Conservative Members may say that constituents are always complimentary about the nursing care that they receive and so on, but hon. Members are also brought a great many cases of real difficulty. I know of a whole series of such cases, of which perhaps the worst was the one that I 685 cited earlier—the person whose operation was stopped after he had been anaesthetised. Such cases lead me to comment on this Bill.
I oppose the abolition of the regional health authorities, not from dogma but because I think that abolition will bring to the health service two things that we could do without: centralisation and fragmentation. One result of abolition will be that the strategic planning of the service moves from tie region to the centre. My hon. Friend the Member for Nottingham, East pointed to the number of functions that the regional offices will continue to carry out.
The difference between the regional offices and RHAs is that the former are accountable upwards, to the NHS executive and to the Secretary of State, but they contain no members who are accountable to other bodies. The current RHAs may have been accountable only in a limited way, but at least there was more downward accountability. That means that strategic decisions will henceforth be taken out of the public eye, because they will be made exclusively in regional offices.
This, too, is very like the abolition of the metropolitan counties. A whole range of decisions previously taken by those democratically elected bodies moved away to regional offices and were taken by regional civil servants.
There will also be less coherence of service within a given region—that is where the fragmentation comes in. At present, RHAs at least consider the context of a region generally. With a series of separate authorities, there will be fragmentation, making it even harder to achieve an equitable distribution around a region. My hon. Friend the Member for York (Mr. Bayley) has already pointed out the inequity of that distribution.
Furthermore, some services will be dumped when the RHAs disappear. They will disappear without trace—another striking parallel with what happened when the metropolitan counties were abolished. Some services, such as the Crown Prosecution Service, were immediately centralised; some remained in a recognisably accountable form. But the powers of such bodies—the joint boards for police, fire and public transport—were gradually whittled away, and smaller, specialised services were lost. That happened not because the powers to promote, say, an archaeology service disappeared, but because the authorities responsible for such services had no money with which to perform them.
The greatest loss, however, was the loss of accountability.
§ Mr. Michael Trend (Windsor and Maidenhead)
The hon. Gentleman has made the rather serious allegation that some services might be dumped as a result of the Bill. Would he care to give us an example?
§ Mr. Gunnell
I shall shortly be offering a quotation precisely with that in mind.
I should like first to deal with the money that it is claimed will be saved. There is not much evidence that the £150 million savings have been thought through. The abolition of the metropolitan counties was based on the idea that enormous savings would accrue. Research showed that there would be no savings before or after abolition. The savings argument was bogus. We shall be surprised if any savings as a result of abolition go to the care of patients.
686 The region is not being entirely discounted. Under the process of accountability each region will be represented by one person, a respected local figure, and he will somehow be responsible for that region. How can one person take that on and be a respected local figure in the whole of the Yorkshire and the northern region? It is facile to say that such appointments will not be political because the eight people who will represent the regions will be on the policy forum at the centre and will inevitably be members of the Conservative party.
My experience of being appointed to an authority as a Labour party member was interesting. I was invited to meet the chief executive of the health authority and he asked whether I would be willing to serve on it. He knew my background and where I stood politically. I had many commitments at the time so I said that I had doubts about serving. I had been asked to serve because I was a member of Leeds city council and I suggested that another member of the council might be willing to serve. I was told that only three members of Leeds city council were acceptable. I am not sure what that made me.
One of the three was already on the regional health authority and another was on St. James's hospital trust. That left me and I was told that if I did not take the job there would be no representation from the city council. I discussed it with the leader of the council and we agreed that it would make sense for me to become a member of the health authority and chairman of the social services committee. It was clearly seen as a political appointment, and it is facile to pretend that such appointments are not. That is not to say that they are all political appointments, but the eight people who will be regional bosses will be the ears of the Secretary of State, and those ears will be very sensitive to the policies of the Conservative party.
There are non-political appointments to health authorities. I was one, and it is the job of people on such authorities to make them work. The new health authorities are probably not as bad as we say and not as good as the Government make out. One specific achievement by Leeds health authority which was brought about by the reforms is that before the reforms it was almost impossible to get an abortion in Leeds. As soon as the providers found out that there was income to be had from abortions, they became available in Leeds, and that was a welcome change.
A fellow member of Leeds health care was a non-political appointee. He is David Hunter of the Nuffield Institute for Health at the University of Leeds. In the research paper provided by the Library, Mr. Hunter states what would be lost when the regional health authorities were abolished as:arbitrating in local disputes; providing a challenge to local myopia in service development and commissioning; encouraging innovation and new ways of doing things; and promoting health strategy development, community care and priority services, research and development, and health alliances. In theory, purchasers and providers ought to be able to inherit such an agenda. In practice some will but many more won't.I have two questions about the changes and the merger between Leeds and Yorkshire. Why Durham? No contracts have been let because a site has not yet been chosen. However, £2 million has been spent on the centre in Harrogate to bring it to a high standard. Was that taken into account when the issue was discussed and studied?
Under the Minister's proposals, Quarry house in Leeds will lose 200 employees, which is, I think, 21 per cent. of its staff. A tremendous amount has been spent on Quarry 687 house and if 200 staff are going there must be space for 135 from the new regional health authority without having to build anything extra. Have the Government considered the costings and found that it is cheaper to construct a new building in Durham than to use the space that they have created in Leeds by partly emptying Quarry house? The sums do not add up.
We oppose the abolition but look somewhat favourably at the merger of the district health authority and the family health services authority. As the chairman of the social services committee in Leeds I have worked with both authorities and to me it makes a great deal of sense to put responsibility for primary and secondary care together.
Why will fundholders be more directly linked to the regional offices than to the new authority? The authority should be responsible for fundholders as well because if it is not that will perpetuate the current inequity. Conservative Members have not answered our questions on purchasing. As the numbers of fundholders increase, the purchasing role of health authorities will decrease. By acquiring primary care they have obviously increased their purchasing powers a great deal. Will health authorities still have a real role in that context?
§ Mr. Michael Trend (Windsor and Maidenhead)
I welcome the Bill and the overall progress of the Government's health reforms. I recently had the honour to attend an international conference at one of the royal colleges at which people from health services all over the world were gathered. It was clear that our health reforms were in the international league and that other countries were looking to us with our experience. Not all of them had done what we have done, and the United States was on a completely different tack.
Fundamentally, the reforms are held together internationally by the purchaser-provider split, which was pioneered in this country and has made a real contribution to creating an excellent health service that the country can afford.
The Secretary of State spoke about the OECD report. It states:The command and control system of the NHS lacks flexibility, incentives for efficiency, financial information and hence accountability and choice of providers of secondary care.The health reforms have been widely praised and I also commend them. We began by addressing the trusts and fundholders. That is evidence of the Government's desire to have a more locally based national health system. Had any Government wished to create a centralised system they would have started by reforming or strengthening the centre. That was not what happened. First, more local systems in hospital and primary care were set up, and that shows the emphasis of the Government's reforms.
While that was going on, some people thought that the purchasing side of the equation was in danger of being left behind. Purchasing is central to the NHS. We have heard much about the so-called centralisation of the NHS through these reforms. Does the Bill centralise? I do not think that it does. It removes a vestige of the command and control system. It is extremely important that we understand that the new NHS will be based, and will be accountable, locally.
What about accountability? The present system is working well in both trusts and fundholding. It is part of the evidence that we need to examine to ensure that 688 accountability is secure. As many of my hon. Friends have already said, we do not want to politicise the NHS, its management or its accountability. We must not forget community health councils, which are the voice of local people. I understand that their position remains unaffected by the Bill.
I am not at all sure about Labour's regional plans. The right hon. Member for Derby, South (Mrs. Beckett) did not clarify its plans for regional health services. I suspect that she is trapped in the difficult logic of Labour's proposed governmental reforms—perhaps having tiers of regional government throughout the country—and she may want some conterminous boundaries between regional government and regional health authorities.
This is a debate about health services in the regions. However, I advise the Labour party to think carefully about its general plans for rearranging local government, or even central Government, on a regional basis. I do not think that the people of England would have any fondness for an end to their traditional national form of Government in favour of the imposition of new regional forms. It is a big can of worms for the Opposition. From the West Lothian question down to the English regions, it will provide a big headache for them in the months and years ahead.
I want to say a few words about the formal relationships outlined in the Bill. First, when the new health authorities come into being, they must respond to what Ministers want in the development of the NHS. There will be a conduit of organisation coming down from Richmond house through Leeds to the new outposts, to trusts and on into the primary system. The means to achieve that must exist.
Secondly, the new authorities must be effective. They must be able to do well the job that they have been given to do. They must be efficient and economical and able to direct scarce resources to the areas where they are most needed. Thirdly, they must be responsive to the local environment. It is extremely difficult to legislate for that, so I shall instead comment on the informal relationship that the Bill will establish.
Health authorities have not always been responsive, but that is not the same as saying that they have not been accountable. The lack of responsiveness has arisen out of the old command and control structure. There needs to be a culture shift within health authorities. I shall give an example from my constituency. A distinguished local hospital—the Edward Windsor belongs, together with two other hospitals, to the local community trust. Last year, satisfactory plans for its future were proposed by the East Berkshire health authority. Shortly after that, the East Berkshire and West Berkshire health authorities amalgamated to make one Berkshire health authority.
The new authority had different priorities and plans for health care provision in my part of the county. The new plans were not nearly as satisfactory as the ones that they replaced. One proposal was to remove the world-famous Prince Charles eye unit from the Windsor hospital. Another proposal was not to proceed with a number of elderly rehabilitation beds, which had formed part of the original plan.
There was a vigorous local campaign. I took part in it, as did the local newspapers. A large petition was presented to Parliament. Doctors, consultants and many other local people raised their voices. The significant factor was that no one appeared to be in favour of the 689 health authority's new plans. No voices were raised in its support. The negotiations that took place, which were chiefly between myself and the health authority, were protracted. I was learning as we went along, and I felt that the health authority was also learning. The current position is more satisfactory because the eye unit has been saved and there are to be new and expanded clinical services. However, we have not reached any agreement with the health authority about rehabilitation beds for the elderly and it has now postponed a decision.
My argument with the health authority was not a local argument in the sense that I was saying that we had to have that unit for Windsor, that it must not go anywhere else and that I was sticking up for my people. Of course there was an element of that—there always is. My argument was that the provision of care for the elderly, especially rehabilitation care, would be more appropriately placed in local community hospitals rather than in acute hospitals at some distance—sometimes a great distance—from people who wanted to visit their elderly and frail relations.
We took advice from the King's Fund and others on current thinking and conventional wisdom. However, an impasse was reached because the health authority held one view sincerely and deeply and we held another—based on professional advice, not just narrow local considerations. In such circumstances and where all the local voices are ranged on one side, it is important that a health authority responds sensitively to the concerns of local people.
The new health authorities, whatever they be—regional or district, of whatever type or composition—must listen more to local voices. I thought I heard that message clearly in the opening remarks of my right hon. Friend the Secretary of State. She said that there needed to be more flexibility—I think that she used the word "visibility". The health authority should be more visible. For example, we heard earlier about the chairman of a health authority who holds local surgeries where he is available for local people to meet him.
We also heard today about public meetings on health matters—I have been to some—where almost everyone in the room is a health professional of some sort or another. The health authority calls the meeting and it sends a lot of people to it. Nurses and doctors attend, as do local Members of Parliament and local councillors. However, to get the general public involved, even through the CHC, is extremely difficult. It is only when a specific case arises, such as the Edward VII hospital, that the public have an understanding of the issues involved. Therefore, there must be far more "visibility" by the health authorities. They must work with local people because they are working for local people.
We want a locally based NHS and I believe that the Government are delivering that through their reforms. We want that locally based NHS to be responsive quickly and with the minimum bureaucracy and waste. The Bill will help to bring about that desirable aim. However, if we go too far or too fast and do not take public opinion with us, and if the health authorities are not responsive to local voices, we will risk many of the benefits of our reforms coming undone.
690 It is most important that the public's confidence in the national health service is maintained at the highest level. Recent research shows that public confidence in the NHS is higher and growing. The Opposition say, on the one hand, that the health service is falling to pieces, but, on the other, that it is excellent. A constituent of mine, who I suspect is a member of the Labour party, also holds both views at once. He tells me that the health service is falling to bits, there is no care, and people are struggling in the streets and dropping like flies. He then writes to the local paper saying that he has been in hospital for a certain procedure and cannot not speak too highly of the doctors and nurses and the care that he received, and that he felt considerably better. I wrote to him and pointed out that that was excellent news and perhaps he would take a less jaundiced view about the health service in future.
Confidence must be kept high. It is important to ensure that our health authorities in both their formal structure, which makes them locally based, and the informal advice and encouragement which we give them to listen to local voices, are the way forward. None the less, this is a good Bill. It will be good for patients and the national health service, and I hope that it receives a Second Reading tonight.
§ Dr. Tony Wright (Cannock and Burntwood)
This strange Bill is both short and long. Its substance covers but four pages, while its schedules cover some 50 pages. That shows that it is a framework Bill that takes powers. In this case, it takes powers to the centre where they can then be used in a variety of ways, to be spelled out later in secondary legislation. That is the kind of Bill which the Government favour. If the Bill is a culmination, as we have heard, it is a culmination of a whole way of legislating, in which one takes framework powers in a Bill like this and then backs them up with a battery of further powers in which the meat and substance are filled out.
In some ways, this is a fairly uncontentious and perhaps even sensible Bill. For many years we have discussed whether it is sensible to have regional health authorities, whether their function could be defended or whether the time had come to remove them. It is possible to discuss that sensibly. The problem is that it becomes a more apocalyptic story about a process of health service reforms, of which the Bill is said to be a culmination.
I shall ask three questions about that process of health service reforms. First, will it improve the quality of the service? I understand that that question is fundamental when we sweep aside some of the possible arguments. Secondly, will it improve the accountability of the service? Thirdly and more specifically, although it is important, will it enable people better to complain about the service if things go wrong?
On my first question, I hope that the Bill will improve the quality of the service, because, for a long time, many of us have thought that the way to improve the commissioning—we prefer to use the word "commissioning" than "purchasing"—of health care locally is to amalgamate FHSAs and district health authorities. We felt that the division was artificial and made local health planning much more difficult. The fact that that amalgamation is taking place is, prima facie, an argument for the ability to drive quality upward as a result. However, I put it in terms only of potential rather than achievement because a huge job remains to be done.
691 If the Government say that the health agenda is complete in that respect, I argue that it has only just begun. A range of issues to do with the quality of health care are untouched. It is only the precondition for a concerted assault on issues of health quality. I refer particularly to primary care, where FHSAs, or their predecessors, family practitioner committees, have had the sole function of paying cheques to doctors. They have had no effective function in monitoring the quality of primary health care and seeking to drive up its quality.
I hope that a consequence of that amalgamation will be to provide the armoury whereby that can now take place because there is a huge gap in our ability to achieve health quality. For example, in the past year alone an extremely good report has been issued by the director of public health for the South Staffordshire health authority. It identified for my area, Cannock Chase, a number of appalling and worrying developments. It showed that we had the largest number of single-handed practitioners, the longest lists in the district and the highest number of referrals from Gps to hospitals, which usually indicates problems in the quality of primary care.
I took those problems to the Staffordshire FHSA. The analysis was linked to other evidence, which said that the area had the most health needs. As we have more ill people in the area, we have a mismatch: the poorest quality of provision and the worst health. The FHSA is the notional provider of primary health care, so I presented the evidence to it and asked what it could do about it. The answer, essentially, was that it could do nothing. It could have conversations with doctors and watch, but nothing more. That is wholly unacceptable. We must work towards a position where those who pay for or commission primary health care have far more ability to watch, monitor and drive up the quality of that care. That presents a huge agenda, and I hope that it will be grasped.
On the issue of hospitals, the Government must grasp the problem in relation to clinical outcomes, audit and performance, which is a hugely neglected area. Many of the matters to which we have devoted so much energy over the years are of minor significance compared with those hard indicators of the quality of care—not what goes into the system but what comes out of it.
§ Mr. Malone
I am tempted to invite the hon. Gentleman to come and join us because he is pointing out that the new system can tackle those agendas in a way that the old one could not. It is particularly important that he realises that the ability of GP fundholders to respond instantly to the patient need which he has identified is one of the great benefits of the reforms that are now in place. I am sure that the hon. Gentleman will acknowledge that.
§ Dr. Wright
I am extremely grateful for the Minister's invitation, which is the best that I have had all day. Nevertheless, he rose a little prematurely, because I was about to add that, if that is common ground, as it should be, what should also be common ground is a serious attempt to look at inequities in health care. If that is not common ground, I simply ask the Minister to look at the evidence presented in last week's British Medical Journal, which brings together much of the contemporary evidence on inequalities in health care.
The professor who wrote the overview referred to the way in which "The Health of the Nation" devoted only one page to variations, not inequalities, in health among socio-economic groups, which are said to be the result of 692 complex factors. The British Medical Journal stated that it is inconceivable that changes in the genetic make-up of different socio-economic groups have occurred over the past 15 years to produce the increases and differences in mortality in Britain. That is an appalling and devastating commentary on 15 years of social and economic policies that have produced a massive deterioration in health equality.
We use terms such as "life chances" in a glib and easy way, but here we are literally talking about life chances, which have deteriorated in the past 15 years as the result of a so-called trickle-down policy that was supposed to make everything come good. It not only failed to come good but came bad in a big way.
Surely we could at least agree on health policy aims to reduce inequalities in health, then apply our minds to achieving those aims. Instead, we have failed to agree and the position has grown substantially worse. There is a huge agenda to tackle.
Will accountability be improved? Is the Bill a decentralist or a centralist measure? Regional health authorities play a role in protecting and sponsoring health authorities and now trusts. They perform a variety of useful functions, and one must question what will happen to some of those roles when regions are abolished.
Only last week, almost all the consultants at the Foundation Mental Health Trust in Stafford passed a vote of no confidence in its chief executive. That was a fairly dramatic occurrence and, by implication, a vote of no confidence in a rather ineffectual trust board. Those consultants were immediately able to seek the advice and guidance of the region, which acts as a buffer between the centre and the localities. When regional offices are no longer statutory offices with a status and integrity of their own but simply regional outposts, the relationship 'will change and roles will alter.
Reference was made to problems in relation to the regional director of public health. The service needs every independent voice that it can get, and the Bill will reduce rather than increase independence. As the former chairman of a community health council, I regret that CHC statutory rights in relation to proposed trusts are removed by the Bill. We should strengthen the role of CHCs, users and consumers—not weaken them further. Every time that I hear the statistical arguments that were made earlier, the more I become convinced that the NHS desperately needs an independent inspectorate that can produce reliable information of a kind that does not exist at present.
The most crucial aspect of accountability is the composition of the new health authorities. I return to the nature of the Bill, with its few clauses and vast number of schedules. It is extraordinary that a Health Authorities Bill should fail to answer the fundamental question of who will serve on the new authorities. Schedule 1 on page 19 of the Bill states only that there will be new health authorities, whose members will be appointed by the Secretary of State. Earlier, the Secretary of State told the House that they will be the best people. I have evidence of the best people who have been appointed to such bodies in the past, but Conservative Members might find it embarrassing if I presented it now.
The new bodies will be the key commissioning organisations for health care in local communities, but the Bill does not say who will serve on them. Recently, the House considered the composition of police authorities. 693 It would not dream of allowing those authorities to be established by a Bill without any indication of their composition, yet it is doing so in respect of this legislation.
Recently, the chairman of the Conservative party said that one could not have serving on health bodies people who were not in favour of the Government's reforms. That is preposterous. One wants people who are committed to the health service. It seems that to be passionately in favour of or passionately against reforms is cause for disqualification. One wants people with an acute sense of public interest, who will defend it and the NHS at all costs. The Conservative party chairman has stumbled into a miasma of patronage, without thinking of the implications of his remarks.
There is now a test of whether the Government are prepared to roll back their public appointments process. Of course we need an open system and a commission publicly to advertise such appointments so that anyone who has something to contribute can apply, and normal civil service criteria could be used for selection. Such appointments must be taken out of the orbit of ministerial patronage and put in the arena of public interest. No wonder that Professor Chris Ham and Professor Hunter in Leeds both concluded that the Bill looks more like a centralising than a decentralising measure.
The complaints issue, which surfaced briefly in the debate, is dealt with by the Bill only in terms of transitional arrangements, yet it is the Bill's biggest lacuna. On any reckoning, the present complaints system is a total mess. Sir Alan Wilson and his committee were asked to investigate that aspect as a matter of urgency a year ago. The committee reported in May and consultation ended in August. We were promised speedy action, but Professor Wilson is now expressing regret and disappointment that there has been none.
§ Mr. Malone
There will be action. We shall bring forward proposals once we have considered what must be done.
§ Dr. Wright
That is good to know, but I can only go on the present delay. There was a clear expectation that there would be such legislation as was required in the present Session. The present complaints system has been called chaotic by everyone who examines it—the health service ombudsman, Sir Alan Wilson, the National Consumer Council and the National Association of Health Authorities and Trusts. A report on the matter was welcomed and broadly endorsed by every relevant party.
The present complaints system undermines the most fundamental principles of the citizens charter in terms of speed, effectiveness and independence. It cries out for reform. This is a health Bill, but one that signally fails to take up the one option that would bring direct and immediate benefit to users of the service.
There is now a certain ambivalence in people's attitude to the health service, as hon. Members—including the hon. Member for Windsor and Maidenhead (Mr. Trend)— have pointed out. Why do they feel passionately well disposed towards the service, yet passionately ill disposed towards aspects of the way in which it is run? I believe—this is meant, in a way, to be helpful to the Government—that something approaching a crisis of legitimacy is currently evident.
694 My theory—it is no more than that—is that the recent explosion of complaints about the service is not simply due to the fact that there is more to complain about; that is an easy point to make. I think that at one time people were not inclined to complain, because they felt that it was "their service"—or rather, "our service". Now they feel that it has truly become "their" service. A real test of legitimacy must be applied to the Government's proposals, and I do not think that the Bill meets it.
§ Lady Olga Maitland (Sutton and Cheam)
Throughout the debate, Opposition Members have carped and jeered at the NHS. I entirely endorse what my hon. Friend the Member for Colchester, North (Mr. Jenkin) said about people's responses to his questions about their experience of the services. I receive the same responses on doorsteps in my constituency. People tell me that they are worried about the health service, but when I ask them about their personal experiences, they always express gratitude for the care and support that they have received. When I ask, "Then why do you feel as you do?", they reply, "It is what they say on television; it is what those Labour party politicians say." I am sick and tired of hearing a litany of disaster. I thought that it might be helpful if I quoted from the response to a questionnaire sent out by a GP fundholders' practice in my constituency, the Cheam family practice. That response is very revealing: 111 patients responded, 97 per cent. of whom said, interestingly, that they were entirely satisfied with the care that they had received. That is completely at variance with what the Opposition are trying to tell us.
§ Lady Olga Maitland
I am delighted to hear it. I could take up hon. Members' time by going through the rest of the questionnaire, which contains many points that you now beg me to mention. [HON. MEMBERS: "No."] You do not want to hear the truth.
§ Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)
Order. The hon. Lady must not keep using the word "you"; the Chair has nothing to do with this discussion.
§ Lady Olga Maitland
I stand corrected, Mr. Deputy Speaker, but there are times when I feel somewhat goaded.
It might be beneficial and educational for Opposition Members to hear a little more about the questionnaire, although originally I did not intend to impose it on the House. To the questionOn entering the ward were you made to feel welcome?",86 per cent. of patients replied, "Absolutely." When asked,Were your family/friends made to feel welcome?",98 per cent. said yes. When asked,Did staff respond quickly to requests for assistance?",82 per cent. said yes. When asked, "Were you given privacy?", 100 per cent. said yes. Again, 100 per cent. said yes to the question, "Was your linen clean?". There must be some sense of reality about the kind of patient care that is actually being delivered.
I welcome the Bill. At first sight, it might strike many patients as no more than an accountancy exercise; but many patients will benefit from it. Any GP's eyes will 695 light up when he sees how his practice will benefit. Let me focus for a few minutes on how the Bill will affect patients in my constituency. I see them as the VIPs who are at centre stage in the whole scenario; the Bill, after all, is designed to improve facilities in their daily lives.
My regional health authority, South Thames, is scheduled to disappear as a result of the reforms. I shed no tears, because my constituents will be better served without it. The RHA's staffing level will drop from 400 to 135: that number will form the NHS local executive branch. It does not take much imagination to see how local medicine could benefit from the value of 375 salaries.
Moreover, it is plain common sense to merge Sutton, Merton and Wandsworth district health authority with the family health services authority. It strikes me as perfectly normal for GPs to work in ever closer partnership with the district health authority, and from the same building. In this instance all parties will operate from Wilson's hospital in Merton: as a result they will be not a telephone call or fax away from each other, but literally just a step from each other's offices. Daily, regular contact to discuss mutual problems—particularly when the GP is playing an increasingly important role in managing patient care—can only benefit all of us. In short, we shall have a one-stop shop.
The new chief executive of the combined health authority will be Mr. George Gibson. He is enthusiastic about making the GP the key link in the whole health-care system—the gatekeeper, as it were, who will determine who gets what and where. His input will ensure personal involvement as well. In his health authority alone, as a result of the Bill, Mr. Gibson will have the means to allocate £1.5 million more resources to front-line patient care—for instance, X-rays for lung cancer, tests for breast and cervical cancer, the delivery of effective drug rehabilitation care, health promotion such as anti-smoking campaigns, especially among schoolchildren, and more community health centres, especially on low-income housing estates. Indeed, why should there not be more district nurses?
In the same mode, Mr. Gibson wants to provide more mental health care to help families who must care for relatives suffering from schizophrenia, Alzheimer's disease or deep depression. All those conditions impose great strain on carers, who badly need psychiatric nurses to be on hand. I hope that his "wish list" will bring on stream child and adolescent psychiatric services: such services, sadly, are needed more than ever as children suffer from the pressures of broken families and drugs.
GPs, in turn, would have more resources to earmark for primary care. There would be help for children with special educational needs, crucial speech therapy and more physiotherapists. Surely he should have the power to employ a full-time carer or nurse if that means keeping a patient at home rather than in hospital, which is costly and not always necessary.
I cite the example of a local case involving four people suffering from sickle cell anaemia, which is a painful and miserable illness. Between them they were in and out of hospital 800 days a year, and pain management was the main problem. It was common sense to employ a full-time nurse to look after them and to help them cope with the pain and provide the support that they needed. They were able to stay at home in familiar surroundings and hospital 696 beds were released for expensive acute care for others. I trust that the Bill will mean that more resources are made available to expand such services.
It must be right that a GP should have a direct say in all aspects of patient care. More important, he should be encouraged to take a more proactive role, even if that means attending refresher courses. He should also be coaxed into offering more services in his surgery and given the necessary resources to be able to do so. That should apply whether or not he is a fundholder, but, clearly, the GP who is a fundholder will have more say in how his patients receive the appropriate care and, in addition, will receive the benefit of the extra resources made available as a result of the Bill.
There are a number of enthusiastic GP fundholders in Sutton. However, there is anxiety to ensure that resources earmarked for primary care are ring fenced. That would certainly introduce the necessary discipline, especially where there is a temptation for a district health authority to become so immersed in its own spending plans that, despite the well-aired aims, GPs end up being sidelined.
My fundholding GP told me what the extra resources would mean to him. He would like to improve his premises so that he can deliver more surgical care. It is nonsense to suggest that patients should have to put up with what I experienced years ago when I had to attend out-patients at Bart's to have a boil lanced on my thumb. It should have been done by my GP in proper surroundings. In future, a GP should be able to deal with all manner of minor surgery from skin lumps and bumps and the removal of cysts to joint injections.
I know a GP fundholder who is also a fellow of the Royal College of Surgeons. Once a week he carries out a minor surgery list which could include the treatment of hernias. Much routine work could be delegated in this way. With the extra resources, a fundholder should be able to employ physiotherapists, dieticians and counsellors and social workers should be brought in to work closely with patients who need extra care and support.
If we were to stretch a point, we could follow the example of the general practice in Aviemore in Scotland which was visited by a GP whom I know and his teenage daughter. She had broken her arm while walking on the moors, but the fundholding practice had a 24-hour casualty service. The girl was X-rayed and made comfortable and only then allowed to go to a hospital in Inverness for an operation. Had she had a clean break, all the services would have been available in the plaster room for her to have been fixed up without having to go elsewhere. Would it not be marvellous if resources released for primary health care as a result of the Bill could provide such services? I have no doubt that rural areas in particular would benefit.
GP fundholders should have the power to insist that their patients are placed in single-sex wards in general hospitals if that has been requested. I welcome the written reply that I received today from the Minister in this regard, but I am not certain that the patients charter standards to be issued next year, which will require hospitals to inform patients in advance when they will be accommodated on a mixed ward for non-urgent treatment, will be entirely satisfactory. The reply does not make it clear what patients can do if they find the arrangements unacceptable.
697 Is the onus on the health service to comply with the patient's requirements if a single-sex ward is not available immediately? I hope that, when establishing their contract with local hospitals, fundholding GPs will make it a condition that patients's concerns will be top priority and that they will not be exposed to embarrassment and forced on to a mixed-sex ward. There has already been some publicity about the issue, but it is not only women who are worried—I am told that men, too, are not always keen to be on a mixed ward.
I heartily welcome the Bill. It may not hit the headlines, but the result will be that patients, at their most vulnerable, will benefit most. It is disappointing that the Opposition cannot bring themselves to support it wholeheartedly. The Labour party's proposals will rebuild overloaded bureaucratic structures, and pressure groups will have their say at patients' expense. Throughout the debate Labour Members have demonstrated their obsession with political appointments. Under a Labour Government, the health service would go back to the bad old days.
I am delighted that the Bill deals with the real world. It will become law and provide improved services which patients need so badly, while Opposition Members bicker about how they will increase NHS bureaucracy. I doubt that patients will thank the Labour party for putting jobs for the boys first.
§ 9.5 pm
§ Mr. Kevin Hughes (Doncaster, North)
Contrary to what the Secretary of State for Health and her colleagues have said in the debate, the Health Authorities Bill represents yet another blow against accountability, which has been attacked consistently throughout the Government's reform of the health service. Accountability must play a part in the provision of health services. However, with this Bill the Government are running away from accountability yet again and making the system less responsive to people's needs.
Accountability is essential because it is the only way to ensure that patients' interests come first. As a result of the internal market process, emphasis on cost cutting is defining priorities far more than the wishes of patients. Services are being planned by accountants and business managers whose priorities are financial and have nothing to do with the caring professions or with patients.
Under the Tories, business has taken over from service in the national health service. Patients have become "consultant episodes" rather than people. Applications for new equipment have become "business cases" to be negotiated with the private sector. In meetings, local health service managers talk about "strategic directions", "over-performance", "under-performance", "outturns" and "contract monitoring". They have figures and tables for everything—although most of them are designed so that no one, apart from the author and a chosen few insiders, can understand them. Bureaucracy has gone mad under the Tory Government.
In the current dispute over local pay, doctors are putting in about an extra 14 hours per week performing management tasks, including preparing invoices on patient charges, drawing up contracts, assessing prices and talking to managers. The public can ask legitimately: why are doctors not treating patients in that extra time?
698 Yes, patients are suffering. Last week, one of my constituents was told that he would have to wait for months just to obtain a consultant's appointment. He was also told that he would have to wait about two years to have a very painful cyst removed, even though the doctors knew that the man's employers had threatened to sack him if he did not receive treatment, because he could not continue to do his job in his present state. However, my constituent was told that if he could pay for the consultation—if he could find £50—he would be seen by the same consultant almost immediately. That is privatisation by the back door, and the Government know it.
The Bill further undermines the role of doctors and nurses in the decision-making process. It drops the duty to recognise local advisory committees of clinicians. It gives no details of any seats on health authorities that will be designated for medical staff. How will their expertise become part of the decision-making and oversight process? I know from my experience in social services that finding out about the practical problems and taking a practical approach to their resolution is essential if management are to be effective in securing improvements in services at the point of delivery.
Staff are a part of the accountability equation. Some months ago, a report by the health advisory service on mental health services in Doncaster was published. One of the problems clearly identified was the lack of consultation of staff and the lack of weight given to their opinions by management. If there are no clear lines of accountability in the NHS, that situation will be duplicated throughout it, with the inevitable consequences for planning, for the efficient use of resources and for patient care which flow from such failures. The report also found that a number of service users and their groups felt that the consultation was superficial. Clearly, people who matter are being excluded from the decision-making process.
The Bill is yet another example of how the Tories treat the NHS as just another business venture. Maples was right. The Tories will never win on the NHS because they will never learn that co-operative, collective action works and that people are central to success. They can only understand competition, selfishness and market forces. They do not understand that the NHS is staffed by people, that the services are delivered by people and that the patients who are treated are people. We are not dealing with machines making goods. We are dealing with people treating people and with the need to get the very best from the highly trained and skilled people in the NHS. The Government's approach, which undermines the rights of staff and patients, will not achieve that.
The Secretary of State says that a light touch is needed. That can only mean limited co-ordination and a lack of accountability which will prove damaging in the long term. The new regional executive offices should not be centralising bodies which consider themselves to be responsible to the centre. If that happens, there will be a lack of oversight and the loss of a strategic, regional, co-ordinated approach. We shall be left with an even more fragmented health service than we have now. The Government have put in place a system of mini-health businesses which are run by their sycophants at local level. Locally negotiated pay will take us further down 699 that road. As the Government move to complete their reforms with the Bill, fragmentation of the service and privatisation by the back door will continue.
The Government now propose that the health care function of the Department of Health should be run by the NHS executive, which will take full responsibility for the NHS. The executive will thoughtfully help Ministers with parliamentary accountability. Presumably the executive will give them their lines to read at the Dispatch Box, as usual.
Another aspect of the proposals which suggests that someone in the Department of Health has a healthy sense of irony is the announcement that the Bill will reduce the costs of management in the NHS, a view parroted by the Secretary of State today. Surely that is a joke too far. Since the introduction of the reforms, in Doncaster alone administration costs have risen from £4 million to £6 million, a rise of 48 per cent.—[Laughter.] Conservative Members may think that that is funny; I certainly do not. Patients are entitled to know why that money is being spent on administration in Doncaster.
That figure is completely separate from the 300 per cent. rise in managerial costs locally. Yet the Government expect £150 million to be released for patient care as a result of the changes. They are living in cloud cuckoo land. How can the Secretary of State, who has presided over such a massive explosion in NHS bureaucracy, tell the House with a straight face about the merits of reducing costs to plough money back into patient care?
The Government do not—and, I suspect, dare not—say how they arrived at that £150 million, which is perhaps why they seem confused about how much, if anything, will be saved. If the changes follow in the tradition of the remainder of the Government's reforms, we can expect a vast increase in costs and bureaucracy. We shall find that health authorities have to take on some of the region's functions, but they will do so less effectively because of their lack of expertise. There will be local duplication of some of the work previously done by regional health authorities, and costs will undoubtedly increase as a result.
Frankly, I do not believe the Government's claims about the national health service. They perversely attacked it for inefficiency and waste, but then created a new system which put incredible bureaucracy and waste in its place. Their claims about bureaucracy are not credible, just as their claims about waiting lists are not credible and were exposed earlier in the debate.
The Government's business-oriented and competitive approach to the national health service is fundamentally flawed because their ideology is wrong. I look forward to kicking them out of Government so that we can build a national health service based on socialist principles, which mean that people come first.
§ Mr. Nicholas Brown (Newcastle upon Tyne, East)
The Bill was presented to the House as bringing to a natural conclusion the Government's health care reform agenda. The end result is supposed to represent the Conservative party's vision of a national health service safe in their hands. In opening the debate, the Secretary of State described it as the "final building block" in a national health service that will survive while the Prime Minister lives and breathes.
700 The Bill is not an impressive conclusion or summation of Mrs. Thatcher's vision when first embarking on the project. What started—indeed, what swept in—in the mid-1980s like Boadicea's chariot, and caused almost as much chaos, is ending in farce and confusion, as if Boadicea had been replaced by Mr. Bean. Heralded as a streamlining measure, it attracts bureaucracy and leaves unanswered more questions than it deals with.
Perhaps I may put this question to the Minister: if the Bill is supposed to save money, why is it followed by a money resolution? I suppose that the Minister will answer that it will save money later but may require expenditure of funds immediately. It certainly looks that way.
There is, and always was, a case for merging district health authorities and family health services authorities in England and Wales, but it follows logically that the opportunity should have been taken to provide the national health service with coherent boundaries at local level, to parallel the well understood community boundaries used by local government. There is no case for a separate, geographically incoherent map solely for the national health service, which continues to be disfigured by demarcation disputes with local authorities about community care provision. The Bill could have dealt with that structural issue, but it did not, and the present situation will be allowed to continue. Whatever else the Bill may be, it cannot be described as the completed reform agenda of which the Government boast.
The Government's second and more controversial structural reform is to convert the eight remaining regional health authorities in England to eight regional outposts of the NHS executive. The claim for that agenda is that it will abolish a layer of bureaucracy. As my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell) and others correctly pointed out, the Bill dloes nothing of the sort; it merely transfers the regional tier from the national health service to the civil service. 'The new structure makes the regional tier directly responsible to the Secretary of State.
As civil servants, staff will be subject to the terms of the Official Secrets Act 1911 and their first duty will be not to the NHS or to patients but to care for the Secretary of State in the community. It is perfectly possible—
§ Mr. Brown
I would have given way, but I am beginning to share the Prime Minister's opinion of the hon. Gentleman, who did not give way to me, so I will not give way now.
It is perfectly possible that the agenda will increase rather than decrease the number of administrators needed. With the new joint arrangements between the different health authorities, it is quite possible that we shall put in place a new tier of administration, and do so in an ad hoc manner.
In any event, the changes must be set in the context of the rest of the Government's health care reforms. Before doing that, I should refer to the first-rate speech by my hon. Friend the Member for York (Mr. Bayley), who spoke of the injustices of the Government's current method of allocating resources, with specific reference to the absolute nonsense of merging the Yorkshire and Northern regions.
The Northern region alone is the size of Wales, and the entire new region of Yorkshire and the North is the same size as Scotland; yet we are told that the resources 701 allocated to its regional office will be broadly similar to those allocated to smaller regions. It is difficult to conclude that that is anything other than a political decision. The Government are advantaging areas where there are Conservative seats at the expense of areas where there are predominantly Labour seats.
The broader context is well known, but it will not hurt to remind the House of it. Since 1988, the number of NHS managers has increased by an astonishing 1,538.3 per cent. In 1993 alone, the number of managers employed by the NHS increased by 13.5 per cent.—this from a Government who claim to be committed to cutting bureaucracy. Since 1987, total costs throughout the NHS have risen from £1.44 billion to £3.02 billion, with an increase of 110 per cent. in administration costs alone.
The proportion of the total NHS budget spent on administration, clerical and management costs rose from 8.77 per cent. in 1987£1988 to 10.8 per cent. in 1992£1993. It used to be a source of pride that administrative costs in the NHS were lower than elsewhere in the developed world, but the Government have thrown that advantage away with their new structure without demonstrating the corresponding benefits from the new system.
We shall want to examine in more detail in Committee the allocation of responsibilities and functions between the health authorities and regional offices, but a number of important questions ought to be raised now. Who will hold the contracts of junior doctors? Who will maintain and monitor cancer screening services? That question was put directly to the Secretary of State, who responded by praising the services. I join her wholeheartedly in so doing—that is not an issue of contention between the parties—but she did not say who will maintain and monitor the cancer screening services.
Who will be responsible for the vocational training of general practitioners? What provision has been made for a national overview of nurses' training? How will day-to-day responsibility for GP fundholders be managed, given that that responsibility is now passing directly to the Secretary of State even though the resources are to come from the local health authorities? It is a bit much for the Secretary of State to say that an incoming Labour Government would be centralising and totalitarian—she refers to us as Stalinist—when she is centralising significant powers theoretically in her own hands. When she said that a Labour Government would have authoritarian powers, she was perhaps referring to the structures that she will hand over to the incoming Labour Government.
The training of nurses is an important matter. Training is being devolved, as I understand it—I am willing to be corrected if I am wrong—to local consortia of NHS trusts. As I have said, those consortia—they have yet to come into being—could create a whole new tier of administration. The structure is bound to make the planning of nurses' training more problematic, and it may result increasingly in shortages of trained nursing staff.
The failure to address obvious long-term planning issues has been accompanied by a failure to invest in nursing training and the long-term future of the NHS. The Secretary of State seemed to recognise that problem, because, in what I took to be an effective adjustment of the contents of the Bill, she said that regional directors 702 would be invited to take a special interest in that matter. That suggests that the case for a regional tier is almost being rebuilt as the details of the Bill are examined by the House.
My hon. Friend the Member for Nottingham, East (Mr. Heppell) rightly pointed out that public confidence in the proposed arrangements has been further undermined by the lack of any democratic accountability. The public interest will be represented on those new structures by the usual Conservative business men or close relatives or friends of Conservative Members. The public find that quangosity wholly unconvincing and they are fed up with it.
A legitimate debate may be held about exactly where and how the lay interest of health service consumers should be represented in the NHS. I do not believe that there is any one absolutely correct method of representing local public interest, but it should surely be represented by people chosen by the public and it should specifically not be undertaken by those whom the Secretary of State has chosen—especially since they all seem to be drawn from the ranks of the supporters of the right hon. Lady's party and their relatives. [Interruption.] I am happy to give way to the right hon. Lady, who is muttering; perhaps she has thought of someone whom the public would accept.
§ Mrs. Virginia Bottomley
I am surprised that the hon. Gentleman has no recollection of Helene Hayman, among many others.
§ Mrs. Bottomley
If the hon. Gentleman would like a great list of names, I would be prepared to discuss them with him. He should bear in mind, however, that a great many people in the Labour party are becoming progressively more embarrassed by the need to identify them. They wish that the Opposition would turn round and say that they support trusts and the progress made in health authorities and stopped putting the frighteners on their own people.
§ Mr. Brown
We have always made it perfectly clear that we do not support the trusts that the Secretary of State has established, but we want to participate in the democratic mechanisms of the NHS. A statement—now several years old—from the national executive of the Labour party authorised members of the party to become members of a trust if invited to do so. It is a lie spread by Conservative Members that members of my party would be under some disciplinary injunction if they participated in the work of a trust. That is wrong and untrue.
I suspect that the reason why there are not more Labour party members on trusts is that they are not chosen by the Secretary of State and those who advise her. In fairness to the chairman of the Conservative party, he made it 703 perfectly clear that he wants to choose people who support the Conservative party to work on trusts and not supporters of its political opponents.
I took what the Secretary of State said to be an invitation for more Labour names to be proposed to try to give some respectability to institutions of whose very structures the Labour party is deeply critical. It would be easier to put such names forward were it not for the fact that the exact composition of health authority boards is unclear. It is astounding that we are having this debate when we do not know from precisely which areas those who are to serve on the new committees will be drawn.
We understand that the chairs will be appointed by the Secretary of State. As my hon. Friends have already said, in practice that will undoubtedly mean that those people will be political appointees of the Conservative party. The Secretary of State implies that I might be surprised. I am ready to be surprised, but I do not think that I shall be. The remaining five executive members and the five non-executive members will be left for the regulations to determine.
I have to say to the Minister for Health, who is presumably to steer the Bill through Committee, that we shall expect to have the details before the Bill leaves Committee. The Secretary of State has said that there will be a role for senior figures from the world of public health, that there will be a role for the medical dean or equivalent figure from the world of dentistry, and that for the other posts she will seek in her appointments—for they are indeed her appointments—people with health backgrounds, a full range of health professionals. What that will mean in practice remains to be spelt out in regulations; it is not obvious from the structure of the Bill. The House is entitled to a full explanation of what it is expected to be legislating for before we legislate, not afterwards.
The abolition of the regional health authorities removes the statutory position of universities and medical schools under the National Health Service and Community Care Act 1990. As I am sure the Minister recalls, that enables them to participate in regional planning and decision making. It is not obvious what arrangements will now be in place for their participation in strategic decision making, and the Bill does not guarantee a role for health care user groups in the decision-making process of health authorities.
As the Secretary of State contended in her introduction to the debate, one way of proving that everyone is content with everything is not to provide i unified system for processing complaints. My hon. Friend the Member for Cannock and Burntwood (Dr. Wright) referred to the work of Professor Alan Wilson, vice-chancellor of the university of Leeds, who chaired a committee to consider that subject and made some important recommendations, which the Secretary of State appears to have ignored. He recommended a single system, with similar features, for handling all complaints about NHS care and services. I took careful note of the Minister's intervention to my hon. Friend, but an intervention promising action in future is not the same as tackling the issue where it should be tackled: in a Bill that is intended to be the final building block in the Government's health care reform, although according to the Minister some cement is still to come—we shall see.
704 I should be happier if we were able to discuss Professor Wilson's recommendations in Committee. He recommended that the complaints procedure should be separate from the disciplinary systems. He recommended a three-level complaints procedure, including an independent panel chaired by a lay person and with a lay majority; he did not say anything about the Secretary of State appointing them all. He also made recommendations to widen the role of the Health Service Commissioner—another subject on which the Secretary of State has been silent. The Bill is intended to complete the Government's health reform agenda; yet the subject of complaints is not tackled.
Although the Bill sets out to draw several new boundaries, the one boundary that has been overlooked appears to be the most glaring omission—the case for a strategic authority for London. Health care in London has a range of problems; yet they are all tackled in an episodic and piecemeal way. There is no London wide health authority or health care strategy and no London wide review of the condition of accident and emergency services. There is chronic underfunding of London health care. High levels of special need, caused by social deprivation in London, remain unmet. Indeed, there is a specific threat to units such as the North Thames region ethnic minorities unit because the passage of the Bill may leave no one to finance it.
It is right to consider the other serious problems caused by earlier Government health care reforms which remain unsolved by the Bill: massive hospital in-patient waiting lists; a two-tier system of health care, of which the Conservatives are so proud, with GP fundholders able to fast-track their patients; hospital trusts which act like independent businesses and are almost impossible to call to account; and competition between hospitals resulting from the internal market and leading to inefficient duplication in some sectors and neglect of others.
Local variations in service provision seem to many to be politically driven. There are continuing bed and ward closure programmes. In 1993 alone, the service lost 10,637 beds. There has been a relentless encroachment on public services by private medical interests and an astonishing growth in maladministration and even corruption, as identified by the recent reports of the Public Accounts Committee. Now there is an absurd, expensive and inefficient row about performance-related pay and local rather than national pay bargaining.
We are told that all of this is the final, triumphant conclusion to the Government's health care reform agenda and the Government confidently ask the British people to judge them on the result. On that, we can all agree: I, too, hope that the British people will judge the present Government on what they have done to the national health service.
§ The Minister for Health (Mr. Gerald Malone)
We have now heard from the hon. Member for Newcastle upon Tyne, East (Mr. Brown) that he and his party are against trusts. That is not quite what the right hon. Member for Derby, South (Mrs. Beckett) said earlier. I am pleased that we have at last managed to get the admission from them.
§ Mrs. Beckett
This is deeply boring as well as extremely stupid. The Minister and his colleagues have 705 repeatedly been told by the Opposition that we are of course against the existence of national health service trusts. Had we come to power in 1992, we would have got rid of them. There are so many of them that all the individual hospitals are likely to be trusts. We are looking for a new way to re-knit individual health businesses into a co-ordinated structure. The fact that we are against health service trusts has never been in doubt, and it never will be, because they are destroying the national health service.
§ Mr. Malone
The right hon. Lady has now adopted an even more interesting position—I hope that she has cleared it with her shadow Cabinet colleagues. She is against trusts which are destroying the health service, but her party is going to do nothing about it as there are too many of them and they have succeeded—that is an extraordinary position. In fact, the pass was sold by the hon. Member for Wakefield (Mr. Hinchliffe) at the beginning of the debate when he helpfully said, from a sedentary position, that he and his party were the first ones to think of the reforms contained in the Bill, which were an extremely good idea.
§ Mr. Malone
I shall be delighted to give way to the hon. Gentleman so that he can expand on his position at greater length.
§ Mr. Hinchliffe
I do not think that the Minister was around in 1989 when what became the National Health Service and Community Care Act 1990 was going through Standing Committee. The Secretary of State was, and she will recall that the Labour position was that we would bring together the district health authorities and the family health services authorities, which is now the Government's position. Why have the Government taken so long to come round to Labour's policies?
§ Mr. Malone
As the hon. Gentleman said, I was temporarily displaced at that time, but I continued to take a great interest in the affairs of the House. I am delighted that the hon. Gentleman has intervened in the debate and confirmed that he thinks that the Bill's principles are sensible. I am sure that that view is shared by his Front-Bench colleagues and by others.
The right hon. Member for Derby, South did not know whether she was coming or going when she opened the debate. At one moment she argued 'that the Bill would ensure that the service was fragmented, split up and spread around the country so that there was, ultimately, no NHS, which would be the end of life as we know it. We then heard her say that she objected to the Bill because it would centralise everything. According to her, it is a centralising Bill and a fragmenting Bill at the same time, as well as being a privatising Bill. I am not sure which of the strands she intended to follow, but her arguments were entirely contradictory.
What the Bill does, and what my right hon. Friend the Secretary of State set out to say that it does, is to put the final touches to a structure that is now firmly in place. It is a logical and reasonable Bill to conclude that process and is widely accepted by the country. At heart, the point of it is recognised by Opposition Members who, 706 throughout the debate, have argued and given their views on the health service, but have not done much to criticise the essence of the Bill.
The right hon. Member for Derby, South said that the executive was being floated off by the Secretary of State. Nothing could be further from the truth. The NHS executive is part of the organisation, accountable to Ministers just like the rest of the Department of Health, and it will remain so. It is informed by internal market guidance, just as the whole service will be. There are clear and practical ground rules for judging the balance between local purchasers and national responsibilities. Local freedoms and responsibilities must be kept in balance, and there is a simple set of principles further to improve the efficiency and quality of responsiveness of the service to the needs of patients. That is what the internal market guidance is for, and it largely answers the points raised by the right hon. Lady.
The right hon. Lady also made the point that consultation on trusts would no longer be compulsory. I assure the House that there is no intention of abolishing consultation, which will be carried out by the Secretary of State or by the trusts themselves. It makes sense to cover the range of possible circumstances when consultation will be needed in regulations, so that we may adjust as necessary. That is better than rigid provisions that would entail primary legislation when circumstances changed. It is surely right to build in such flexibility.
The right hon. Lady also discussed the abolition of professional advisory committees. Frankly, I do not believe that they were much loved. They were widely criticised and were ineffective. We shall be looking to health authorities to demonstrate that professional input is far more integrated in their work—input not just by the professions but across the professions. The integration of such advice is important; there are many models in the best health authorities of nurses and doctors either in executive posts or being consulted in other ways. They participate in constructive discussions between clinicians, purchasers and trusts, and the help of outside experts is also called upon. This puts the consultation process well beyond the formality that it sometimes became. It was often ignored and left on the sidelines: we are giving it real life.
The right hon. Member for Derby, South also mentioned the independence of public health officials. District public health officers will report on the health of their local populations and will be free to comment on it. The regional role will become different under the new structure. It will be to carry out functions on behalf of the executive. No longer will there be a regional report on the health of a region's population. The experience of the whole service has been that, as care has devolved ever closer to the patient, it has become more important to identify local need. That is why public health functions, when devolved to district level, will be more effective at identifying trends and putting in place policies to deal with them.
A couple of ancillary, and sedentary, points were raised at the start of the debate in connection with the Northern and Yorkshire regional office site appraisal. Of course the Public Accounts Committee can call for full documentation. Some Members of Parliament, including one who raised the issue, have already asked for, and received, a summary of what has been proposed. The only details left out are estimates of prices, which must be left 707 out as the district health authorities still hope to obtain better prices than have thus far been submitted. The whole process has been effected according to Treasury rules. There is nothing to hide; indeed, I am surprised that hon. Members brought up the subject at all.
My hon. Friend the Member for Hereford (Mr. Shepherd) made a powerful constituency speech. I can reassure him that we have no preconceptions about the size of the authorities, about the organisation of the services that they will provide, or about whether local authority boundaries should coincide. I assure my hon. Friend that there will be consultation as the process continues, when provisional recommendations are drawn up by the regions. His powerful points of today will certainly be borne in mind. We adopted the same approach to the new regional health authorities, but that did not stop us changing boundaries in response to compelling local representations.
My hon. Friend also made a couple of points about the provision of services. Of course the Secretary of State has a duty, clearly set out in primary legislation, to provide the whole population in England with a comprehensive health service. I hope that he will understand that, when authorities of whatever sort are shaping their services, they will have to bear that in mind.
The hon. Member for Nottingham, East (Mr. Heppell) spoke about joint executives of district health authorities and family health services authorities. He underpinned the fact that those authorities are beginning to coalesce naturally and sensibly. I hope that he welcomes that. It has happened in my constituency and it has been very effective. The legislation recognises the coming together of structures.
§ Mr. Malone
I hope that the hon. Gentleman will forgive me if I do not give way. I listened to his speech and I wish to answer some of the other points that were raised in the debate.
My hon. Friend the Member for Colchester, North (Mr. Jenkin) was courteous enough to tell me that he could not be in his place for my winding-up speech because he has a constituency engagement. He spoke about weighted capitation, as did other hon. Members. Work is in hand to develop a new approach to resource allocation. It is a complex issue which needs a great deal of careful thought, but the Government remain committed to allocation by a formula which will demonstrate a clear need to devolve spending according to local need. That demonstrates our clear commitment to the principle of access to health care within and between regions in a properly informed way.
My hon. Friend the Member for Colchester, North also spoke about health authorities competing with general practice fundholders. They are in partnership, not competition. The GP fundholding accountability framework, which has been published for consultation, should help to clarify that relationship in the best possible way. I hope that my hon. Friend understands that.
The hon. Member for York (Mr. Bayley) spoke at length about inequalities and resource allocation. I wholly refute his allegation that the north has been treated unfairly in resource allocations for 1995–96. Allocations to regional health authorities are not the real issue. The real issue is the allocation to district health authorities. Regional health authorities will take into account the 708 directions in the new calculations when they make next year's allocations to DHAs. There is no sense in making major changes to regional health authority allocations for the final year when there is only one year to run.
Regional health authorities can be expected to manage changes to the DHA allocations at a sensible pace. I was glad to hear the hon. Gentleman acknowledge that it would be pointless if it caused substantial dislocation. As we move towards a new formula and its total implementation, we must move evenly so that dislocations do not occur.
§ Mr. Malone
I apologise to the hon. Gentleman. I said earlier that I did not intend to give way and my usual bonhomie in giving way must not be demonstrated now, as there are many matters to which I must respond.
The hon. and learned Member for Montgomery (Mr. Carlile) spoke about the public health function and the future of services. His fear that public health doctors will be gagged is entirely unfounded. Health authorities will be required to have medical directors of public health and to publish annual reports. That, not the regional level, is the right level for such reports. They will be crucial in determining the future of local services, and it will be for health authorities to decide which services are needed locally and which will be needed in specialist units.
The hon. and learned Gentleman asked what voices would be heard on the new authorities. I reiterate what my right hon. Friend the Secretary of State said in her speech—that it is important that the boards comprise the best people locally to provide the balance of skills that are needed. We expect that a growing number of members in executive or non-executive positions will have backgrounds in nursing or medicine or in other professions. That is a growing trend throughout the health service and I welcome it.
The hon. and learned Gentleman asked about consultation with community health councils. He will be glad to know that there will be no change in the requirement on health authorities to consult CHCs, nor is there is any intention of changing their number. He spoke about the local accountability of health authorities. I entirely agree that new health authorities should be clearly accountable to local populations. That can be done in a number of ways—for example, by establishing a single local body. The Bill simplifies local accountability arrangements, and that means that, demonstrably, the public will be able to know who is providing the service and who is purchasing it on their behalf and they will have a far clearer input to it. Health authorities will continue to be required to transact all important business in public, to publish accounts, reports and strategic plans and to consult widely on all key proposals.
The hon. and learned Gentleman's final point was about the supervision of midwifery. The responsibly for that will shift from regional health authorities to the new health authorities. That is as the hon. and learned Gentleman wishes it to be, so I hope that he is reassured.
The hon. Member for Morley and Leeds, South (Mr. Gunnell) asked why the Northern and Yorkshire regional office is to be located in Durham. The decision on relocation follows an extensive appraisal of a wide range of options. My right hon. Friend the Secretary of State has authorised the regional health authority to pursue locations in Durham, subject to a strict cost calculation.
709 The hon. Gentleman also raised a point about policy board members not being representative of regions. We are not suggesting that they should formally represent regions. The argument goes to the core of what Labour Members think—that throughout the health service people should be representatives of sectional interests. That is not the way that we see it. We want them to represent the interests of the service and of the patients. We want them to be drawn from the widest possible constituency.
The hon. Member for Cannock and Burntwood (Dr. Wright) made an interesting speech, with which I obviously agreed at exactly the right moment because he then went on to disagree with everything that the Government are doing. He said that the Bill centralises too much, but he was one of the centralisers. He also said that the Bill gives too many regulation-making powers to the Secretary of State.
I find it difficult to recognise the Bill that the hon. Gentleman described. It is always sensible to put in regulations the detailed provisions that may need to be adjusted from time to time. The majority of the enabling powers in the Bill already exist in relation to district health authorities—for example, provisions on membership and on joint working between authorities. There are already matters for secondary legislation. The hon. Gentleman may think that it would be far better to have a 700-clause Bill on these issues, but I do not. The future of the NHS is much better served by a flexible structural framework.
§ Mr. Nicholas Brown
I understand what the Minister means when he says that some matters are better dealt with in regulations than in primary legislation, and on that point of principle there is no quarrel. However, on some of the key issues, we want to see what will be in the regulations before we let the Bill come out of Committee.
§ Mr. Malone
The hon. Gentleman makes a Committee point, which he and I can explore some time in the new year. My point is sensible and straightforward. The issues that will be subject to regulation are no different from those that have been subject to regulation in the past. Throughout the debate, the Opposition have suggested that something novel is involved— [Interruption.] If the hon. Member for Cardiff, West (Mr. Morgan) would remain silent for a second, his hon. Friend the Member for Newcastle upon Tyne, East might hear what I am saying. There is nothing novel, in dealing with arrangements by regulation. Of course the Committee will explore the Government's intentions. I shall be glad to do so.
The hon. Member for Cannock and Burntwood asked about the remaining statutory right for community health councils to be consulted. I have dealt with that point, but I repeat that we remain committed to consultation. They will be among the bodies specified in the regulations to be consulted on the establishment of new trusts.
The hon. Gentleman also said that membership should be specified in the Bill. As I said, it would not be sensible to do that. It is far better to have wide powers and the ability to seek talent where we can and in the widest possible way than to follow the representative route wanted by Labour Members.
710 My hon. Friend the Member for Windsor and Maidenhead (Mr. Trend) made a constituency speech and raised a specific point about the Edward VII hospital. He asked what we could do about appropriate accommodation for the elderly. Suitable accommodation for elderly people is already available within a reasonable distance of the hospital. I have heard what he said and hope that he will take the opportunity either to write to me on that issue or to come and meet me, when I shall be happy to discuss the matter with him further.
The Bill is the last building block of the reforms that we introduced in 1990. I am sorry that, yet again during the debate, we have heard from Opposition Members, including the right hon. Member for Derby, South, appalling slurs against all those who serve on trust boards and health authority boards, in terms of their selection and interest. I challenge the right hon. Lady to give a single instance of misconduct. If Opposition Members have evidence that they have acted against the interests of the trust boards on which they serve, I invite them, with the protection of the House, to give a few instances instead of those vague slurs against people who give voluntary service in the best tradition of British public life.
§ Mrs. Beckett
I am not sure which debate the Minister attended, but as I said nothing about members of trust boards, I do not know what he is talking about.
§ Mr. Malone
The right hon. Lady and her hon. Friends forever talk about Tory placemen on boards. Nothing of the sort exists. If one wishes to discuss the position of people on authorities, one need look no further than the Labour party to see what instructions are given. I was fascinated by an Opposition Member's Freudian slip when he said that, at some point, the Labour party had "authorised" its members to serve on those boards. They get the authority from Walworth road, but it goes beyond simple authority. Not only is their appointment to boards authorised but they are given instructions. I quote from the "Guidance on participation" issued by the Labour party's national executive committee.
§ Mr. Malone
No. I shall give way to the hon. Gentleman once I have read out the instructions issued by his party. The "Guidance on participation" says:Labour party members may take up places on non-elected authorities and use them as a platform for our campaigning".Labour Members are not in the least interested in serving the board—they are interested only in serving their party. That is not all. The guidance goes on:Party members who are appointed to non-elected boards must discuss ways of reporting back to their local constituencies and other constituencies … Consideration should be given to ways of liaising with Labour Party representatives in other capacities ….Members accepting appointments of this kind should inform Walworth Road so that the relevant Shadow spokespeople and Head Office policy officers can maintain a network of contacts".The instructions given by the Labour party to its representatives on boards are more detailed than those the KGB ever gave Richard Gott of The Guardian. I do not know how they are delivered—whether it is by dead letter boxes in Islington or tete-a-tetes in the Gay Hussar—but instructions are clearly given to make it absolutely certain that Labour members turn to party interests when they are meant to be serving on boards in the public interest.
711 The Bill puts in place important reforms at the end of a series of reforms that now deliver better health care at a better cost than ever before. The health service is now recognised for its excellence not only in this country but abroad. Opposition Members should look at the OECD report and British attitude surveys that are now being published on the excellence which people now consider the health service delivers. As I asked the right hon. Member for Derby, South to do, I ask them to look at the figures on this matter. They should look at the number of operations, the treatment that is given and the services which the NHS can deliver in primary health care, which it was unable to deliver before.
That improvement across a system that is delivering better health care, better value for the taxpayer and increased volume of health care is something of which we can be proud. The Opposition have not made their case against the Bill. They tabled a token reasoned amendment but did not speak to it. I have every confidence in supporting the Bill before the House tonight, and I invite my right hon. and hon. Friends and Opposition Members who support the reforms to join me in the Lobby.
§ Question put, That the amendment be made:—
The House divided: Ayes 267, Noes 308.715
|Division No. 18]||[22.00 pm|
|Abbott, Ms Diane||Chisholm, Malcolm|
|Adams, Mrs Irene||Church, Judith|
|Ainger, Nick||Clapham, Michael|
|Ainsworth, Robert (Cov'try NE)||Clark, Dr David (South Shields)|
|Allen, Graham||Clarke, Eric (Midlothian)|
|Alton, David||Clarke, Tom (Monklands W)|
|Anderson, Donald (Swansea E)||Clelland, David|
|Anderson, Ms Janet (Ros'dale)||Clwyd, Mrs Ann|
|Armstrong, Hilary||Coffey, Ann|
|Ashdown, Rt Hon Paddy||Cohen, Harry|
|Ashton, Joe||Connarty, Michael|
|Austin-Walker, John||Cook, Frank (Stockton N)|
|Banks, Tony (Newham NW)||Cook, Robin (Livingston)|
|Barnes, Harry||Corbett. Robin|
|Barron, Kevin||Corbyn, Jeremy|
|Battle, John||Corston, Jean|
|Bayley, Hugh||Cousins, Jim|
|Beckett. Rt Hon Margaret||Cox, Tom|
|Beith, Rt Hon A J||Cummings, John|
|Benn, Rt Hon Tony||Cunliffe, Lawrence|
|Bennett, Andrew F||Cunningham, Jim (Covy SE)|
|Benton, Joe||Cunningham, Rt Hon Dr John|
|Bermingham, Gerald||Dalyell, Tam|
|Berry, Roger||Darling, Alistair|
|Betts, Clive||Davidson, Ian|
|Blunkett, David||Davies, Bryan (Oldham C'tral)|
|Boateng, Paul||Davies, Ron (Caerphilly)|
|Boyes, Roland||Davies, Rt Hon Denzil (Llanelli)|
|Bradley, Keith||Davis, Terry (B'ham, H'dge H'I)|
|Bray, Dr Jeremy||Denham, John|
|Brown, Gordon (Dunfermline E)||Dewar, Donald|
|Brown, N (N'c'tle upon Tyne E)||Dixon, Don|
|Bruce, Malcolm (Gordon)||Dobson, Frank|
|Burden, Richard||Donohoe, Brian H|
|Caborn, Richard||Dowd, Jim|
|Callaghan, Jim||Dunnachie, Jimmy|
|Campbell, Menzies (Fife NE)||Dunwoody, Mrs Gwyneth|
|Campbell, Mrs Anne (C'bridge)||Eagle, Ms Angela|
|Campbell, Ronnie (Blyth V)||Eastham, Ken|
|Campbell-Savours, D N||Enright, Derek|
|Canavan, Dennis||Etherington, Bill|
|Cann, Jamie||Evans, John (St Helens N)|
|Carlile, Alexander (Montgomry)||Fatchett, Derek|
|Chidgey, David||Field, Frank (Birkenhead)|
|Fisher, Mark||Mandelson, Peter|
|Flynn, Paul||Marek, Dr John|
|Foster, Don (Bath)||Marshall, David (Shettleston)|
|Foster, Rt Hon Derek||Martin, Michael J (Springburn)|
|Foulkes, George||Martlew, Eric|
|Fraser, John||Maxton, John|
|Fyfe, Maria||McAllion, John|
|Galloway, George||McAvoy, Thomas|
|Gapes, Mike||McCartney, Ian|
|Garret, John||McFall, John|
|George, Bruce||McKelvey, William|
|Gerrard, Neil||McLeish, Henry|
|Gilbert, Hon Dr John||McMaster, Gordon|
|Godsiff, Roger||McNamara, Kevin|
|Golding, Mrs Llin||McWilliam, John|
|Gordon, Mildred||Meacher, Michael|
|Grant, Bernie (Tottenham)||Meale, Alan|
|Griffiths, Nigel (Edinburgh S)||Michael, Alun|
|Griffiths, Win (Bridgend)||Michie, Bill (Sheffield Heeley)|
|Grocott, Bruce||Michie, Mrs Ray (Argyll & Bute)|
|Gunnell, John||Milburn, Alan|
|Hain, Peter||Miller, Andrew|
|Hall, Mike||Mitchell, Austin (Gt Grimsby)|
|Hanson, David||Moonie, Dr Lewis|
|Harman, Ms Harriet||Morgan, Rhodri|
|Harvey, Nick||Morley, Elliot|
|Hattersley, Rt Hon Roy||Morris, Estelle (B'ham Yardley)|
|Henderson, Doug||Morris, Rt Hon Alfred (Wy'nshawe)|
|Heppell, John||Mowlam, Marjorie|
|Hill, Keith (Streatham)||Mudie, George|
|Hinchliffe, David||Mullin, Chris|
|Hodge, Margaret||O'Brien, Bill (Normanton)|
|Hoey, Kate||O'Brien, Mike (N W'kshire)|
|Hogg, Norman (Cumbernauld)||O'Hara, Edward|
|Home Robertson, John||O'Neill, Martin|
|Howarth, George (Knowsley N)||Oakes, Rt Hon Gordon|
|Howells, Dr. Kim (Pontypridd)||Olner, Bill|
|Hoyle, Doug||Orme, Rt Hon Stanley|
|Hughes, Kevin (Doncaster N)||Parry, Robert|
|Hughes, Robert (Aberdeen N)||Pendry, Tom|
|Hughes, Roy (Newport E)||Pickthall, Colin|
|Hughes, Simon (Southmark)||Pike, Peter L|
|Hutton, John||Pope, Greg|
|Illsley, Eric||Powell, Ray (Ogmore)|
|Jackson, Glenda (H'stead)||Prentice, Bridget (Lew'm E)|
|Jackson, Helen (Shef'ld, H)||Prentice, Gordon (Pendle)|
|Jamieson, David||Prescott, Rt Hon John|
|Janner, Greville||Primarolo, Dawn|
|Jones, Barry (Alyn and D'side)||Purchase, Ken|
|Jones, Ieuan Wyn (Ynys Mon)||Quin, Ms Joyce|
|Jones, Jon Owen (Cardiff C)||Radice, Giles|
|Jones, Lynne (B'ham S O)||Randall, Stuart|
|Jones, Martyn (Clwyd, SW)||Raynsford, Nick|
|Jones, Nigel (Cheltenham)||Reid, Dr John|
|Jowell, Tessa||Rendel, David|
|Kaufman, Rt Hon Gerald||Robertson, George (Hamilton)|
|Keen, Alan||Roche, Mrs Barbara|
|Kennedy, Charles (Ross,C&S)||Rogers, Alan|
|Kennedy, Jane (Lpool Brdgn)||Ross, Ernie (Dundee W)|
|Khabra, Piara S||Rowlands, Ted|
|Kilfoyle, Peter||Ruddock, Joan|
|Kinnock, Rt Hon Neil (Islwyn)||Sheerman, Barry|
|Kirkwood, Archy||Sheldon, Rt Hon Robert|
|Lestor, Joan (Eccles)||Shore, Rt Hon Peter|
|Lewis, Terry||Short, Clare|
|Liddell, Mrs Helen||Simpson, Alan|
|Litherland, Robert||Skinner, Dennis|
|Livingstone, Ken||Smith, Andrew (Oxford E)|
|Llwyd, Elfyn||Smith, Chris (Isl'ton S & F'sbury)|
|Loyden, Eddie||Smith, Dew (Blaenau Gwent)|
|Macdonald, Calum||Soley, Clive|
|Mackinlay, Andrew||Spearing, Nigel|
|MacShane, Denis||Spellar, John|
|Madden, Max||Squire, Rachel (Dunfermline W)|
|Maddock, Diana||Steel, Rt Hon Sir David|
|Mahon, Alice||Steinberg, Gerry|
|Stevenson, George||Wareing, Robert N|
|Stott, Roger||Watson, Mike|
|Strang, Dr. Gavin||Wicks, Malcolm|
|Straw, Jack||Wigley, Dafydd|
|Sutcliffe, Gerry||Williams, Alan W (Carmarthen)|
|Taylor, Matthew (Truro)||Williams, Rt Hon Alan (Sw'n W)|
|Taylor, Mrs Ann (Dewsbury)||Wilson, Brian|
|Thompson, Jack (Wansbeck)||Winnick, David|
|Timms, Stephen||Wray, Jimmy|
|Tipping, Paddy||Wright, Dr Tony|
|Turner, Dennis||Young, David (Bolton SE)|
|Walker, Rt Hon Sir Harold||Teller for the Ayes:|
|Walley, Joan||Mr. Stephen Byers and|
|Wardell, Gareth (Gower)||Mr. Geoffrey Hoon.|
|Ainsworth, Peter (East Surrey)||Congdon, David|
|Aitken, Rt Hon Jonathan||Conway, Derek|
|Alexander, Richard||Coombs, Simon (Swindon)|
|Alison, Rt Hon Michael (Selby)||Cope, Rt Hon Sir John|
|Allason, Rupert (Torbay)||Cormack, Patrick|
|Amess, David||Couchman, James|
|Arbuthnot, James||Cran, James|
|Arnold, Jacques (Gravesham)||Currie, Mrs Edwina (S D'by'ire)|
|Arnold, Sir Thomas (Hazel Grv)||Davies, Quentin (Stamford)|
|Ashby, David||Day, Stephen|
|Aspinwall, Jack||Deva, Nirj Joseph|
|Atkins, Robert||Devlin, Tim|
|Atkinson, David (Bour'mouth E)||Dicks, Terry|
|Atkinson, Peter (Hexham)||Dorrell, Rt Hon Stephen|
|Baker, Nicholas (Dorset North)||Douglas-Hamilton, Lord James|
|Baker, Rt Hon K (Mole Valley)||Dover, Den|
|Baldry, Tony||Duncan Smith, Iain|
|Banks, Matthew (Southport)||Duncan, Alan|
|Banks, Robert (Harrogate)||Dunn, Bob|
|Bates, Michael||Durant, Sir Anthony|
|Batiste, Spencer||Dykes, Hugh|
|Bellingham, Henry||Eggar, Tim|
|Bendall, Vivian||Emery, Rt Hon Sir Peter|
|Beresford, Sir Paul||Evans, David (Welwyn Hatfield)|
|Biffen, Rt Hon John||Evans, Jonathan (Brecon)|
|Bonsor, Sir Nicholas||Evans, Nigel (Ribble Valley)|
|Booth, Hartley||Evans, Roger (Monmouth)|
|Boswell, Tim||Evennett, David|
|Bottomley, Peter (Eltham)||Faber, David|
|Bottomley, Rt Hon Virgina||Fabricant, Michael|
|Bowden, Sir Andrew||Fenner, Dame Peggy|
|Bowis, John||Field, Barry (Isle of Wight)|
|Boyson, Rt Hon Sir Rhodes||Fishburn, Dudley|
|Brandreth, Gyles||Forman, Nigel|
|Brazier, Julian||Forsyth, Michael (Stirling)|
|Bright, Sir Graham||Forth, Eric|
|Brooke, Rt Hon Peter||Fowler, Rt Hon Sir Norman|
|Brown, M (Brigg & Cl'thorpes)||Fox, Dr Liam (Woodspring)|
|Browning, Mrs. Angela||Fox, Sir Marcus (Shipley)|
|Bruce, Ian (Dorset)||Freeman, Rt Hon Roger|
|Budgen, Nicholas||French, Douglas|
|Burns, Simon||Fry, Sir Peter|
|Burt, Alistair||Gale, Roger|
|Butcher, John||Gallie, Phil|
|Butler, Peter||Gardiner, Sir George|
|Butterfill, John||Garel-Jones, Rt Hon Tristan|
|Carlisle, John (Luton North)||Garnier, Edward|
|Carlisle, Sir Kenneth (Lincoln)||Gill, Christopher|
|Carrington, Matthew||Gillan, Cheryl|
|Cash, William||Goodson-Wickes, Dr Charles|
|Channon, Rt Hon Paul||Gorman, Mrs Teresa|
|Churchill, Mr||Gorst, Sir John|
|Clappison, James||Grant, Sir A (Cambs SW)|
|Clark, Dr Michael (Rochford)||Greenway, Harry (Ealing N)|
|Clarke, Rt Hon Kenneth (Ru'clif)||Greenway, John (Ryedale)|
|Clifton-Brown, Geoffrey||Griffiths, Peter (Portsmouth, N)|
|Coe, Sebastian||Grylls, Sir Michael|
|Colvin, Michael||Gummer, Rt Hon John Selwyn|
|Hague, William||McLoughlin, Patrick|
|Hamilton, Neil (Tatton)||McNair-Wilson, Sir Patrick|
|Hamilton, Rt Hon Sir Archibeld||Mellor, Rt Hon David|
|Hampson, Dr Keith||Merchant, Piers|
|Hanley, Rt Hon Jeremy||Mills, Iain|
|Hannam, Sir John||Mitchell, Andrew (Gedling)|
|Hargreaves, Andrew||Mitchell, Sir David (Hants NW)|
|Harris, David||Moate, Sir Roger|
|Haselhurst, Alan||Molyneaux, Rt Hon James|
|Hawkins, Nick||Montgomery, Sir Fergus|
|Hawksley, Warren||Needham, Rt Hon Richard|
|Hayes, Jerry||Nelson, Anthony|
|Heald, Oliver||Neubert, Sir Michael|
|Heathcoat-Amory, David||Newton, Rt Hon Tony|
|Hendry, Charles||Nicholson, David (Taunton)|
|Heseltine, Rt Hon Michael||Nicholson, Emma (Devon West)|
|Hicks, Robert||Norris, Steve|
|Higgins, Rt Hon Sir Terence||Onslow, Rt Hon Sir Cranley|
|Hill, James (Southampton Test)||Oppenheim, Phillip|
|Hogg, Rt Hon Douglas (G'tham)||Ottaway, Richard|
|Horam, John||Page, Richard|
|Hordern, Rt Hon Sir Peter||Paice, James|
|Howard, Rt Hon Michael||Patnick, Sir Irvine|
|Howarth, Alan (Strat'rd-on-A)||Patten, Rt Hon John|
|Howell, Rt Hon David (G'dford)||Pattie, Rt Hon Sir Geoffrey|
|Howell, Sir Ralph (N Norfolk)||Pawsey, James|
|Hughes, Robert G (Harrow W)||Peacock, Mrs Elizabeth|
|Hunt, Rt Hon David (Wirral W)||Pickles, Eric|
|Hunt, Sir John (Ravensbourne)||Porter, Barry (Wirral S)|
|Hunter, Andrew||Porter, David (Waveney)|
|Hurd, Rt Hon Douglas||Portillo, Rt Hon Michael|
|Jack, Michael||Powell, William (Corby)|
|Jackson, Robert (Wantage)||Rathbone, Tim|
|Jenkin, Bernard||Redwood, Rt Hon John|
|Jessel, Toby||Renton, Rt Hon Tim|
|Johnson Smith, Sir Geoffrey||Richards, Rod|
|Jones, Gwilym (Cardiff N)||Riddick, Graham|
|Jones, Robert B (W Hertfdshr)||Rifkind, Rt Hon Malcolm|
|Jopling, Rt Hon Michael||Robathan, Andrew|
|Kellett-Bowman, Dame Elaine||Roberts, Rt Hon Sir Wyn|
|Key, Robert||Robertson, Raymond (Ab'd'n S)|
|King, Rt Hon Tom||Robinson, Mark (Somerton)|
|Knapman, Roger||Roe, Mrs Marion (Broxbourne)|
|Knight, Dame Jill (Bir'm E'st'n)||Rowe, Andrew (Mid Kent)|
|Knight, Greg (Derby N)||Rumbold, Rt Hon Dame Angela|
|Knight, Mrs Angela (Erewash)||Ryder, Rt Hon Richard|
|Knox, Sir David||Sackville, Tom|
|Kynoch, George (Kincardine)||Sainsbury, Rt Hon Tim|
|Lait, Mrs Jacqui||Scott, Rt Hon Nicholas|
|Lamont, Rt Hon Norman||Shaw, David (Dover)|
|Lang, Rt Hon Ian||Shaw, Sir Giles (Pudsey)|
|Lawrence, Sir Ivan||Shephard, Rt Hon Gillian|
|Legg, Barry||Shepherd, Colin (Hereford)|
|Leigh, Edward||Shepherd, Richard (Aldridge)|
|Lennox-Boyd, Sir Mark||Shersby, Michael|
|Lester, Jim (Broxtowe)||Sims, Roger|
|Lidington, David||Skeet, Sir Trevor|
|Lightbown, David||Smith, Sir Dudley (Warwick)|
|Lilley, Rt Hon Peter||Smith, Tim (Beaconsfield)|
|Lloyd, Rt Hon Peter (Fareham)||Smyth, Rev Martin (Belfast S)|
|Lord, Michael||Soames, Nicholas|
|Luff, Peter||Speed, Sir Keith|
|Lyell, Rt Hon Sir Nicholas||Spencer, Sir Derek|
|MacGregor, Rt Hon John||Spicer, Michael (S Worcs)|
|MacKay, Andrew||Spicer, Sir James (W Dorset)|
|Maclean, David||Spink, Dr Robert|
|Madel, Sir David||Spring, Richard|
|Maitland, Lady Olga||Sproat, Iain|
|Malone, Gerald||Squire, Robin (Hornchurch)|
|Mans, Keith||Stanley, Rt Hon Sir John|
|Marland, Paul||Steen, Anthony|
|Marshal, John (Hendon S)||Stephen, Michael|
|Marshal, Sir Michael (Arundel)||Stern, Michael|
|Martin, David (Portsmouth S)||Stewart, Allan|
|Mates, Michael||Streeter, Gary|
|Mawhinney, Rt Hon Dr Brian||Sumberg, David|
|Sweeney, Walter||Walker, Bill (N Tayside)|
|Sykes, John||Waller, Gary|
|Tapsell, Sir Peter||Wardle, Charles (Bexhill)|
|Taylor, Ian (Esher)||Waterson, Nigel|
|Taylor, John M (Solihull)||Watts, John|
|Taylor, Sir Teddy (Southend, E)||Wells, Bowen|
|Temple-Morris, Peter||Whitney, Ray|
|Thomason, Roy||Whittingdale, John|
|Thompson, Patrick (Norwich N)||Widdecombe, Ann|
|Thompson, Sir Donald (C'er V)||Wiggin, Sir Jerry|
|Thornton, Sir Malcolm||Willetts, David|
|Thurnham, Peter||Wilshire, David|
|Townend, John (Bridlington)||Winterton, Mrs Ann (Congleton)|
|Townsend, Cyrll D (Bexl'yh'th)||Winterton, Nicholas(Macc'f'ld)|
|Tracey, Richard||Wolfson, Mark|
|Tredinnick, David||Wood, Timothy|
|Trend, Michael||Yeo, Tim|
|Trotter, Neville||Young, Rt Hon Sir George|
|Twinn, Dr Ian|
|Vaughan, Sir Gerard||Tellers for the Noes:|
|Viggers, Peter||Mr. Sydney Chapman and|
|Walden, George||Mr. Timothy Kirkhope.|
§ Question accordingly negatived.
Main Question put forthwith, pursuant to Standing Order No. 60 (Amendment on Second or Third Reading), and agreed to.
Bill read a Second time, and committed to a Standing Committee, pursuant to Standing Order No. 61 (Committal of Bills).