The National Health Service

HC Deb 25 October 1994 vol 248 cc775-865

Madam Speaker

I have selected the amendment in the name of the Prime Minister.

4.28 pm

Mrs. Margaret Beckett (Derby, South)

I beg to move, That this House shares the public alarm at the creeping privatisation of the National Health Service, accompanied as it is by lower accountability to the public, and a diversion of resources into increasing bureaucracy at the expense of patient care.

The national health service holds a unique place in the life and affections of the people of Britain. There could be no more eloquent testimony to its uniqueness and importance than the lip service paid even by the former Prime Minister, Lady Thatcher—to whom the socialist principles on which the health service are based were and are anathema—or the caution shown by her successor, who claimed only a few days ago in Bournemouth that the health service will not be damaged or privatised not while I live and breathe.

Fine words, which we are told express good intentions—but we, like the people of Britain, do not give that for the Prime Minister's intentions. Of concern to us is the calamitous effect of his policies, which are producing a two-tier health service with an increasing role for ability to pay, driving us stealthily but steadily towards a privatised health service with diminished public accountability for huge sums of public money, and causing an enormous increase in bureaucracy.

At the outset, I pay tribute to those people who continue, despite the obstacles placed in their way by the Government's gross incompetence, to make, our health service work and who strive daily to deliver high standards of patient care. I refer to the staff of the national health service. The Secretary of State, like her Government colleagues, has adopted the dishonest practice of attempting to pretend that any criticism of her or of Government policy is criticism of the health service itself or of its staff. Let us get that out of the, way for a start. The staff of the health service are wonderful—the Government are appalling.

The health service remains a service with huge achievements to its credit. It is one within which public servants struggle to do the job for which they were trained, no matter how difficult the Government make it. Those achievements are maintained despite Government policy, not because of it.

The Secretary of State continues to insist that her so-called reforms are delivering the goods. I remind her of the words of the chair of the British Medical Association at its conference in July: There is no longer one national health service.

That is despite the promises that the Government have repeatedly made to the British people. The chair continued: There are 100 purchasing consortia and 400 provider units, each with its own self-serving view of its best interests.

Despite the Secretary of State's claimed confidence in the changes that she has brought about, she has been deeply reluctant to debate them in the House. The Government last initiated a health service debate in November 1991, when the right hon. Lady's predecessor was in charge. The current Secretary of State for Health, who has held that office since the last general election, has never once volunteered to discuss her relentlessly continual reforms—her permanent revolution—with right hon. and hon. Members.

Not only has there been little debate, but there has been no independent evaluation or research into the impact of Government reforms. Ministers are often pleased to quote the OECD report published earlier this year, but even they have admitted that it relies on assumptions and figures supplied by the Department of Health and can in no way be described as independent. We await with interest the Audit Commission report due next year. Meanwhile, the Secretary of State is charging ahead with further changes and initiatives well before that report appears.

Major transformation in the nation's health service is taking place without proper consideration and debate in the House, and without full and proper evaluation even of changes made so far, let alone with full prior consideration of the latest ideas being floated—the application of performance-related pay or local pay bargaining. We are also kept ignorant of the real costs.

In March 1993, we were told that the cost of changes up to that time was –1.2 billion. That was enough, had it been differently spent, to fund up to 1,000 new health centres across Britain or almost to clear the health service's waiting lists. But, since March 1993, there has been silence from the Secretary of State on the cost to the health service of this "permanent revolution". We have managed to squeeze out the news that some —37 million, in total, has been spent on minor consequences of change; such matters as logos, changing note paper and so on. Although that much smaller sum has been spent on the minor consequences of change, it is, of course, the kind of sum that the Government have found for attacking the waiting lists, which are of so much more value to patients.

The first effect of the Government's changes, whatever their cost, is the commercialisation of the health service—the slippery slope to overall privatisation—and not only that commercialisation, but the stealthy increase in private provision itself. I am a[...]vare that the Conservative party dislikes the use of the word "privatisation" in the context of the national health service, although it seems to revel it in everywhere else. I am even more aware that, in the course of the debate, some Conservative Members may chide me for daring to use the word in the light of the Prime Minister's assurance that the health service will not be privatised while he lives and breathes. Let me, for the fullness of information, quote what the chairman of the British Medical Association said last week at a meeting of the Caledonian Society. He said: I was delighted by the Prime Minister's assurance in his Party Conference speech that the Government is not going to privatise the NHS…I am, nevertheless, somewhat bewildered because the fact is that the NHS is already being privatised. He goes on to give the example of the first privatisation of clinical support services in the Lister laboratories. That privatisation is causing serious alarm across the health service because it means the privatisation of pathology services, which are so crucial to the provision of a universal national health service. By the way, I would not like the House to miss the fact that this passage about privatisation—again, I am quoting the words of the head of the BMA—concluded: I am driven to the sad conclusion, therefore, that the Prime Minister does not know what is going on or that he is not in control of the situation. Is the Secretary of State—I wonder—in control of the situation? If she tells us that the health service is not being privatised, she, too, will be subject to the charge that she does not know what is going on.

The number of private beds has risen by two thirds since 1980, while national health service beds have been reduced by a third. That is not a question only of changes in medical techniques, which, I know, is the usual excuse that the Government trot out when we talk about the reduction in the number of beds; it is a shift in the pattern of provision in which the number of national health service beds is being reduced and the number of private beds is increasing. One hundred thousand private patients are now seen in the national health service, mostly in private bed units in trust hospitals—an increase of 12 per cent. over one year. Laings review of private health care makes it plain that almost 19 per cent. of all United Kingdom hospital-based health care is now provided by private hospitals and nursing homes, whereas in 1984 only 7.5 per cent. of hospital-based health care was so provided.

Dr. Charles Goodson-Wickes (Wimbledon)

Does the right hon. Lady accept that the number of beds in the national health service has gone down at a rate of—roughly–10 per cent. over the past 10 years, which merely reflects different patterns of treatment and more surgery being done on a day-case basis? Is not it dangerous for her and her colleagues to put out an alarmist story about beds disappearing when, in fact, that is totally inconsistent with today's medical needs?

Mrs. Beckett

I know that the hon. Gentleman has made that intervention in previous debates and I am afraid that I think that he might—if I may say so with deep respect—have been on automatic pilot. If he had listened carefully, he would have heard me saying that my point was not simply that there had been a reduction in health service beds, because I recognise, despite the fact that we would argue with him to what extent that has been part of the problem, that there have been changes in medical care—the point that he was making. I was making a different point, not one with which he is quite so familiar, which is that while the number of national health service beds is decreasing, for whatever reason, the number of private sector beds is going up.

A survey carried out by The Observer newspaper and Denplan, a private dental scheme, shows that, in dentistry, 77 per cent. of those dentists surveyed thought that within five years they would treat no national health service patients.

I hear the Minister of State muttering, "Here we go again: we have heard that before." Yes, we have heard it before. I receive complaints at my advice bureaux—I should think that the Minister receives them at his; if not, I hope that people will listen and then turn up—from people who are very worried because they do not think that they will be able to get NHS treatment for their dental needs in the future. They find that very alarming and they do not like the fact that the Government are presiding over such a reduction in health service care.

Perhaps most telling of all, within the private sector the share provided by charitable hospitals has fallen from 57 per cent. to 37 per cent. since 1980, while the share provided by hospitals run for profit—run explicitly as businesses to make money—has grown from 42.5 per cent. to 63 per cent.

In August this year, Peter Griffiths, an advocate of the Government's so-called reforms—a former deputy director of the NHS executive, I believe—was more forthcoming than some Ministers have been about the future as they see it. He made it clear that, in his view, the move by many of our existing institutions from state trust status to, in effect, the status of private health care providers was an inexorable development of existing policy.

Then there is the evidence leaked to The Sunday Times in August, and not so far refuted—although perhaps it will be refuted during the debate—that American health care companies are engaged in secret talks with the Government with the aim of taking over parts of the national health service. The Minister of State, I believe, has confirmed to The Sunday Times that several American concerns are trying to secure a foothold in Britain, and doctors and academics have already expressed the fear that the managers of the world's most expensive medical system may end up dictating the price of health treatment in Britain.

The hospitals that—it is suggested—have been targeted are the Royal Marsden in London, with its worldwide reputation for cancer treatment, and the Christie in Manchester, which is similarly famous and valued. As I have said, despite those strong rumours we have as yet heard no denial from the Government that such talks are taking place and I see no evidence that anyone is volunteering to give me such a denial today.

Across the board in the health service, we are seeing the commercialisation of a great public service. As research commissioned recently by the GMB union shows, there is no clearer evidence of that commercialisation than the composition of the trust boards appointed by, or in concert with, the Secretary of State. A study of the expertise and backgrounds of those appointed to the boards shows that they are overwhelmingly representative of Conservative interests. One third are directors of private companies—or 25 per cent. in some cases. Others are solicitors and accountants; only a tiny percentage have medical expertise, or expertise in the national health service.

Moreover—as was mentioned here earlier today–66 of the trusts are chaired either by a Conservative or by someone connected with a company that has made a donation to the Conservative party. The party, and Tory front organisations, have been given nearly £2 million by companies whose directors were appointed by the Secretary of State and now sit on NHS trusts. Some trusts, for example, are tarred with the brush of a company—Tarmac—whose interests and expertise have nothing to do with health, but are in construction and road building; although, by coincidence, it is the company which gave £413,500 to the Conservative party between 1979 and 1992.

Tarmac is well represented on the NHS trusts. Brian Baker, chairman of a trust in the west midlands, was the managing director of the company until last year; Lord Stafford, from another division of Tarmac, is a director of the mental health foundation of the mid-Staffordshire trust.

I must concede that Sun Alliance has an interest in people's growing insecurity about the future of our health service, and in its disintegration. Its former chief executive, a Mr. Addison, is a director of Croydon community trust. Sun Alliance has given a total of £478,000 to the Conservative party. George Kennedy, a director of Kent and Canterbury hospitals trust, was chairman of a division of Smiths Industries. It has donated more than £100,000 to the Tory party. The largest corporate donor to that party, United Biscuits, is represented on the board of the Great Ormond Street hospital for sick children by its chairman, Sir Robert Clarke.

Hon. Members who have retired from the House or from the European Parliament, or who may be active in the House of Lords, can often be assured of a place on one of the Secretary of State's NHS trusts. The beneficiaries of her patronage include Sir Timothy Raison, Sir Robert McCrindle, Lord Jenkin—a former Conservative Health Secretary—Lord Hayhoe, Baroness Cox, Maureen Hicks, Tony Favell and Lord Wade. Only yesterday, I heard that the former Member of the European Parliament for Lancashire, Central—a Mr. Michael Welsh, who presumably lost his seat as recently as June—is now to chair the Chorley and South Ribble NHS trust.

Mr. Andrew Rowe (Mid-Kent)

Will the right hon. Lady give way?

Mrs. Beckett

I shall be pleased to give way to the hon. Gentleman.

Mr. Rowe

I thank the right hon. Lady. The tenor of her arguments suggests—

Mr. Terry Lewis (Worsley)

Only a tenner? You are cheap!

Mr. Rowe

I understand the attraction of apparent illiteracy to certain hon. Members, but it is a pity that they do not understand plain English.

The right hon. Lady's argument suggests that, were she or any of her Front-Bench colleagues to lose their seats at an election, they should not be given any jobs in which their expertise and experience could conceivably be of any public value. Is that really what she means?

Mrs. Beckett

I do not intend to be drawn into that argument. Let me merely observe that I have lost my seat in the past, and no member of the Conservative Government offered me anything. The hon. Gentleman's assumption that we apply the same standards as the Government is not borne out, certainly by my experience.

The hon. Gentleman made a similar point the last time these issues were debated, and I understand from what he has said that his wife has health service expertise, I have no quarrel with people whose political persuasions are different from my own—people across the board, indeed—who have expertise, knowledge and experience that could be valuable to the health service, and who are given positions on NHS trusts. I must tell the hon. Gentleman, however, that anyone who scrutinises the information that has been dragged out of the Government piece by piece will not get the impression that the community, in its broadest sense, could conceivably be said to be represented.

The Secretary of State for Health (Mrs. Virginia Bottomley)

If the right hon. Lady really wants more of her supporters to join NHS trusts, the best thing that she can do is say that she supports those trusts. Will she take the opportunity today to acknowledge that trusts are working and are good for patients? Will she encourage her supporters, and congratulate them on the good work that they are doing in the trusts?

Mrs. Beckett

That was an interesting intervention. I know that the Secretary of State has made that point repeatedly in the past. She knows that we oppose NHS trusts; nevertheless, while they exist we want them to work in the way that gives the best value to the community.

I am interested to note that the Secretary of State's definition of a person who is fit to serve on the boards of trusts is someone who agrees with her. That is apparent in their membership. Our information is inevitably somewhat anecdotal, because the Government do not publish proper information about the qualifications of those on the bodies concerned. However, I know of many Conservatives with years of experience, much expertise and a record of serious service to the NHS, all of whom have been swept out of sight in those bodies because their devotion to the NHS might outweigh their devotion to the Conservative party, and because they will not do precisely what the Secretary of State says.

What the right hon. Lady has said is very revealing. Yes, making the trusts broadly publicly representative will mean including members of other parties, but it should also mean including people of different shades of opinion from the Secretary of State, who tell the truth about what is happening in the NHS rather than slavishly repeating whatever she says.

The hon. Member for Mid-Kent (Mr. Rowe) has a particular interest in these matters, but the spouses of other Conservative Members have been given positions on hospital trusts. They include the husband of the Secretary of State for Education, the wife of the hon. Member for Southend, East (Sir T. Taylor), the wife of the right hon. Member for Woking (Sir C. Onslow), the wife of the hon. Member for Dartford (Mr. Dunn) and the wife of the hon. Member for Reigate (Sir G. Gardiner). As I have said, that is just the information that is available to us now.

Sir Teddy Taylor (Southend, East)

Is not it grotesquely unfair for the Opposition repeatedly to attack my wife for being appointed to a trust when she has spent all her life working in the health service and did a great deal of service for no payment in the Southend health authority and whom I met when I was taken to Westminster hospital as one of her patients? Is the right hon. Lady aware of anything inadequate about her qualifications for chairing a trust? Is she aware of anything inadequate in the record of the Southend community care trust? Is not it dirty and unfair to mention my wife's name repeatedly when she has had no job other than working in the health service as a fully qualified person?

Mrs. Beckett

I am not attacking the hon. Gentleman's wife as an individual or her expertise. I did not know her background, but now I do. I named her because she is one of a string of known Conservative party members and supporters appointed to boards. It is an indication of the way in which the structure of the health service is being packed with people who, whatever their other expertise and experience, are Conservative party supporters. The hon. Member for Southend, East must be well aware that the vast majority of them have no experience in the health service.

The Minister for Health (Mr. Gerald Malone)

Will the right hon. Lady give way?

Mrs. Beckett

No, I have not finished.

There would be nothing wrong with people such as the hon. Gentleman's wife having a place on these trusts were they balanced by people of similar experience from right across the community. There would be nothing wrong if people who had that knowledge, expertise and understanding were much more widely represented on the boards. If the hon. Gentleman's wife has any sort of medical or health service background, she is one of a tiny percentage—between 4 and 6 per cent. We are attacking not the individuals but the nature and overall composition of the boards and the Secretary of State's decisions about the people she puts on them.

Mr. Malone

The right hon. Lady cannot have her argument two ways. She refers consistently to the wives of hon. Members and then concedes that they are perfectly well qualified to serve on boards. Will she undertake to the House that she will stop referring to them in the future? That would be the decent thing to do.

Mrs. Beckett

The Minister is missing the point, no doubt deliberately. My point is not that these are people with or without expertise in the health service. My point is that the only people appointed to serve on these boards have a known political allegiance or have no knowledge or understanding of the health service.

Mr. Malone

The only people?

Mrs. Beckett

Not the only people but the vast bulk of them. There is a tiny number of people of a different political persuasion. There is a sprinkling of Liberal Democrats and a slightly larger sprinkling of members whose political orientation is towards the Labour party. The Minister knows perfectly well that what we are saying is true. He knows, too, that this information has had to be dragged out of the Government inch by squealing inch. He knows that the boards are packed with people who can be relied upon to do the Secretary of State's bidding. If the Government have so little to hide why have not they been prepared to publish these lists until we dragged the information out of them?

Sir Teddy Taylor

rose—

Mrs. Beckett

With respect to the hon. Gentleman, I want to go on to a different point. I have sympathy for him, but he has made his point.

Sir Teddy Taylor

rose—

Madam Deputy Speaker (Dame Janet Fookes)

Order. If the right hon. Lady is not giving way, the hon. Gentleman must resume his seat.

Mrs. Beckett

I would give way to the hon. Gentleman if I had not already done so.

As my hon. Friend the Member for Darlington (Mr. Milburn) has revealed in a survey, almost £20 million a year is being spent by the national health service on payments for these chairmen and non-executive directors of trusts. This morning on the "Today" programme the Secretary of State was sniffy about our concern over these issues. If I recall correctly she said that they were receiving "insubstantial sums". Well, I recognise that for people in the position of some of the directors involved, the sums they receive—£15,000 or £20,000 for the chairman of a trust—may not be regarded as substantial. I remind the Secretary of State that although a non-executive director on a trust can hope to earn £12 an hour for an eight-hour week working for that trust, a nurse on the middle range of pay can expect to earn £5.79 an hour for a long 40-hour week.

Although it is claimed that everything about the appointments has been open and above board, we all recognise that that is not the case. If declarations of interest were made initially, they were certainly unpublished and had to be dragged out of the Government by my hon. Friends who preceded me in this post. Now that they are being published, we see how little experience of and contact with the NHS some board members have had and we are starting to see some more direct conflicts of interest. The chair of Trent regional health authority, which covers the area that I represent, is a board member of a company called Takare plc, the business of which is nursing homes. Therefore, it has a direct financial interest in reducing the role of the national health service.

My predecessor wrote to the Secretary of State, who was too busy to reply. One of her junior Ministers replied, shrugging off the concern. The Minister offered not his own view about whether there was a conflict of interest but said that Mr. Ackroyd believes that there is very little risk of any conflict of interest arising between his position as Chairman of Trent Regional Health Authority and as a Director of Takare". He would say that, wouldn't he? I have heard that before.

In that context, the Government's announcement that they will finally respond to demands from the Opposition and set up some sort of independent body to review and monitor standards in public life is welcome, but it remains too little, too late. It is not clear to me that it will address, or that there are other steps to address, the questions that I put to the Secretary of State this morning. We want to hear from her whether the Government propose to establish a central register of quangos so that we know of all the bodies that exist. We want to know whether the Government propose to establish a register of the names of every board member of each quango and the qualifications of those members for board membership. We want to Know whether the Government intend that the same standards as apply to surcharge and other safeguards in local government will apply to quangos, because, even more than local government, these bodies are involved in the use of public money and it is right that they should be dealt with in the same way.

The Secretary of State sometimes seems to imply that because, by the standards of those involved, the money is so slight, it does not matter that it goes overwhelmingly to people involved with the Conservative party. Although she tries to pretend that there is no real problem, the Government have already made some changes in the way that the matter is handled by insisting that interests are declared. Today, it appears that perhaps they are making more. The concern that is reflected in those changes is felt much more widely outside the ranks of the Government than they sometimes recognise. The Conservative leader of Wandsworth council, in putting forward a proposal opposing the closure of Queen Mary's hospital in Roehampton said that health care decisions are too important to be left to unelected quangos. I did not think that I would ever agree with the Conservative leader of Wandsworth council. Clearly, today is a first.

Apart from the accountability of public money, we are concerned about its use. We want to see the money used in the front line to provide the maximum and best possible patient care. Under the Government's waiting list initiative, trusts are being encouraged to use the private. sector even though the cost of treating patients there is, on average, £1,552, which is more than five times the cost in the NHS. For a high level of psychiatric care the national health service cost is on average £46,000 a year whereas, according to the National Schizophrenia Fellowship, some private hospitals are charging£70,000 or £80,000 a year for similar care.

Of course, those are rough and ready approximations. However, there seem to be some strange exceptions to the pattern. For example, the Health Care International hospital in Clydebank has received £40 million of public money, which has doubled from an initial estimate of £20 million, and that was enough, to treat patients from beyond these shores and, it was claimed at the time, create 4,000 jobs into the bargain. That project, however, has employed only 400 people. I understand that, far from treating patients from overseas, as was intended, the hospital is treating patients from Birmingham and Manchester on a cut-price deal basis. I shall refrain from wondering whether the geographical origin of someone in Clyclebank is a matter of concern. What really worries Opposition Members is the widespread rumour that such sums of public money have already been spent on a hospital that everyone in the locality concerned with health care said was an unnecessary investment and that the Government are coming under pressure to put in further public money to rescue a collapsed private sector initiative.

The Secretary of State keeps telling us how open, honest and transparent the Government are in their NHS policy, so I am sure that it is an aberration that the eight questions tabled by my hon. Friend the Member for Glasgow, Maryhill (Mrs. Fyfe) came back to her yesterday without a substantive reply on what is happening in relation to the hospital or the Government's intentions.

Mr. Dennis Turner (Wolverhampton, South-East)

The Secretary of State is not listening.

Mrs. Beckett

I am sure that she does not wish to take heed of the question that I am directly putting to her. I hope that she will tell us that the Government have no intention of putting further public money into a purse that has already had far too much of it.

The Secretary of State says that she has declared war on bureaucracy. It is obviously serious because she has taken on thousands of bureaucrats to help her fight it. There has been a 57 per cent. increase in the number of practice managers, but the number of general practitioners has decreased. The number of health managers has tripled, so we have a huge standing army of non-medical staff being paid large sums of money to think up new ways of saving money.

I can provide the Secretary of State with one new way of saving money without any difficulty. The Government should abolish tax relief on private health insurance. If they did that, £85 million could be available at a stroke. That would go a long way to restoring free eye and dental checks, which would be of far greater value to most of the British public.

In 1989, there were 4,540 managers in England, whereas in 1993 there were 20,000. Manager numbers are rising by 13 per cent. a year, but the number of nurses is falling by 1 per cent. a year. Department of Health expenditure on management consultants totalled £20 million in the days before this permanent revolution, but it was £66 million in the last reported year of 1993. It is being suggested that the cost of local pay bargaining that is under consideration could run to an extra £40 million in new bureaucracy. The Secretary of State's permanent revolution has led to an explosion of bureaucracy and waste, which is associated most directly with trust management and with GP fundholding.

I see the Secretary of State, presiding as she does over this permanent revolution, as the Madame Mao of the health service. She attacks the authority of medical staff. She banishes or sacks people who disagree with her. Parliament and the public have to seek information through a system of Chinese whispers. She turns for support to the now highly politicised managers of the health service—a group of involuntary Red Guards who are obliged blindly to follow the dogma of the internal market. Increasingly paranoid, she and her Ministers treat the medical profession as conspirators and as harbingers of counterrevolutionary values, rejecting their advice and tossing aside their experience and judgment.

Despite what the Secretary of State said at health questions, it is known that gagging clauses are widespread in contracts issued by health service trusts and that people who dare to speak out risk disciplinary action. Evidence has been found of telephone bugging. All hon. Members hope that that was an exception. As Dr. Brian Boughton, a senior consultant of the South Birmingham health authority has observed, there is now a climate of fear among staff in the health service and especially among those staff who are critical of the effects of Government policy on patients. In a rather sinister phrase, he told The Birmingham Post that these people are being removed from the scene. That was certainly the experience of Ian Mahady, the clinical director of obstetrics at Burnley general hospital. He is a highly respected and experienced senior consultant who happens to be critical of the Government's reforms. He was sacked and asked to clear his desk within three hours.

The proposal for performance-related, locally determined pay is another step in the permanent revolution, which, against this background, can be guaranteed only further to weaken morale. We hear that Ministers have had to put those plans on ice because the national health service trusts announced that they were not ready for the move. It is clear yet again, and particularly clear if that was the reaction of the trusts, that the proposal has been bandied about without thought or consideration, let alone debate.

The chairman of the Federation of National Health Service Trusts, Rodney Walker, has said that managers are confused and uncertain and that it is one thing for Government to set the agenda and say there you are then, but it is a quite another to embark individually from scratch on such a profound course. That was yet another criticism from someone who was trying to make the Secretary of State's changes work and an example of what is happening in practice.

Perhaps the most succinct critique of the Secretary of State's role came from the Daily Express, normally a slavish supporter of the Government. An editorial written during the Conservative party conference deplored the brutality with which the Secretary of State was destroying our health service. It stated: We don't want our centres of excellence, our Guy's and Bart's hospitals, chopped up and sown together again under some new name which satisfied the demands of Virginia's managers on tightening up resources … Imagine the uproar if she were to become Education Secretary and decide to do away with Oxford and Cambridge." [Interruption.] No heckling please. The editorial continues: The NHS is not about numbers. It's about people and people don't want managers to decide where and when they are going to have their hip operations. They want doctors and nurses and hospitals near to where they live, where staff are not too tired and over-worked to give them the treatment they deserve. We want the outcome of the debate to be that the Secretary of State and her colleagues stop tinkering with our health service and start listening. They should stop repeating bogus statistics about the number of people treated, like some demented mantra, believing that, if chanted long enough, it will ward off evil reality. The Secretary of State knows that episodes of consultant care are distorted by patients going for an operation from one ward, coming back from it to another and being counted twice. The figures mean nothing and the Secretary of State is aware of that.

Opposition Members ask the Government to start listening to passionate words like those of Dr. Macara of the British Medical Association. The Government must hear these things, but they seem to go in one ear and straight out the other. Speaking about our health service last July, Dr. Macara said: There is despair in the air today. There is despair about the mood of alienation and demoralisation in the NHS.

He goes on to say: Co-operation has been supplanted by commercial competition. There is an uncontrolled ill-managed internal market pitting purchaser against provider, fund-holding GP against non-fund holding GP, GP against consultant, junior against senior, hospital against hospital, and all to serve a perverse philosophy of winners and losers … Money does not follow the patient"— the Government's justification for the changes— the patient has no choice but to follow the money until it runs out. Later in his remarks, he says that we must all face the facts. Government must acknowledge that their 'huge national experiment', as the new Chief Executive of the NHS has described it, has failed them and failed the nation. Opposition Members oppose both the commercialisation and the fragmentation of our health service. Since the NHS trusts and GP fundholdings are agencies of fragmentation, we oppose them and wish to see them replaced. Like the British people, we reject the drift towards privatisation and we are appalled at the attitudes that it is already engendering—attitudes such as that revealed in July concerning the business plan for Charing Cross hospital. When that hospital decided to try to poach the leading consultant from the Royal Marsden, Mr. Nicholas Breach, one of the criteria taken into account was that that act would

assist in destabilising a competitor. What kind of attitude is that in a health service that is supposed to be providing patient care? I will tell the Secretary of State—it is an attitude fostered by everything that the Government have done by introducing their reforms.

We are engaged in the process that the Government have shirked; a process of thorough and lengthy consultation, which includes representatives of patients and staff at every level. When our consultations are complete, we will come forward with proposals to re-establish a health service that can provide access to treatment on the basis of medical need rather than ability to pay. We will reestablish a health service that is available in every part of Britain because that is what the British people expect of our national health service and what this Government have put at risk.

We in the Labour party created the NHS and that is why we can be trusted to modernise it, but only a new Labour Government can give Britain the new health service that it needs.

5.10 pm

The Secretary of State for Health (Mrs. Virginia Bottomley)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof: 'notes that since the introduction of the Government's health reforms the number of patients treated has risen, waiting times fallen and quality of care improved; welcomes independent support for the reforms from sources such as OECD; and calls upon Her Majesty's Government to continue policies which uphold the values and ethos of the NHS, further reduce administrative duplication and waste and deliver a flexible service able to respond to the changing needs of patients.'.

I warmly welcome the right hon. Member for Derby, South (Mrs. Beckett) to her new responsibilities. I must say that the literature does not bulge with her previous utterances on health. The best that can be said of her speech today is that she was making up for lost time. The second best thing that can be said is that she has been given her new job as an essential political sweetener, as Barbara Castle might have described it, for the trade unions.

True to form, as Opposition Members will soon realise, the right hon. Lady, sponsored by her trade union, spoke at length about staff, but spoke not once about patients. That is always the case with Opposition Members who are sponsored by people who work in the railways or in the health service. Those hon. Members are blinkered to the needs and interests of patients.

Ms Hilary Armstrong (Durham, North-West)

Will the right hon. Lady give way?

Mrs. Bottomley

I should like to make some progress, but I shall then happily give way.

I had hoped that today might have proved third time lucky, because as long as I have been at the Department of Health there have been three Labour party spokesmen on health. I kept hoping that the Opposition might offer a policy, but from what we have heard today they are off consulting again. It is a great tragedy, however, that the right hon. Member for Derby, South did not take the opportunity here and now to say that she supports trusts and recognises their work and the fact that they are doing good for patients. It was her predecessor but two, the hon. Member for Livingston (Mr. Cook), who said that he did not believe that trusts would treat more patients. That was the test that he set at that time and they have passed it, because they are treating more patients than the numbers treated under the old system. Let me give the right hon. Lady a small piece of advice: she should take the opportunity to modernise the health service, accept the world in which we live and support the trusts and the work that they are doing.

The right hon. Lady began by challenging the Government's commitment to the NHS. Perhaps I could remind her of some facts. Under the Government, NHS spending has risen from £7 billion to £37 billion, a 64 per cent. increase. That is a remarkable figure. More than that, a new multi-million pound hospital project has been completed, on average, once every eight days.

The right hon. Lady wondered how anyone with any experience of the construction industry could have any part to play in a trust. Let me tell her the answer. Because we have one of the largest capital and building programmes of any organisation, we certainly need people with skill and expertise in the construction industry.

Ms Armstrong

On that specific point, is the right hon. Lady aware that patients and prospective patients in my constituency are now facing the worst of all worlds with the rundown of their hospital at Shotley Bridge? Now her Government have delayed the building of a new hospital, which, in any event, is 14 miles away, because they have said that private companies must make a successful bid to plan, build and manage all but the core services of that new hospital. That will inevitably lead to a delay of at least a year and, in the meantime, the trust has said that services at Shotley Bridge must continue to be wound down. Is that looking after patients and their needs?

Mrs. Bottomley

I regret that I gave way to the hon. Lady at that moment, because I shall address later that precise issue of the private finance initiative and the importance of considering that option. It would be better to deal with it at that stage in my speech rather than at this particular moment.

Mr. Keith Mans (Wyre)

The hon. Member for Durham, North-West (Ms Armstrong) will have to sit there and wait.

Mrs. Bottomley

Indeed.

I must ask the right hon. Member for Derby, South to consult her sources again because in the past 10 years alone 8,000 more hospital doctors and dentists have been employed as well as 3,000 more general practitioners—a dramatic increase in their number—and 18,000 more qualified nurses. Let me remind her that while her party cut the pay of nurses and doctors, we have paid nurses 65 per cent. more in real terms and doctors 35 per cent. more. We are proud of our record because it contrasts and compares extremely well with that of any other previous Government.

Above all, I remind the right hon. Lady that that investment has been generously repaid by results. Our policies have delivered a handsome dividend of better health, longer life and higher quality care. Since 1979, life expectancy has gone up by more than two years. In the past 10 years, the number of children dying at birth or within the first year of life has fallen by two fifths and the number of people dying under the age of 65 has fallen by one fifth. Those are dramatic achievements.

Mrs. Barbara Roche (Hornsey and Wood Green)

Does the right hon. Lady agree that that handsome dividend has been paid just to the private sector? In my local health authority, New River, to date more than £500,000 has been paid to the private sector because there are not enough beds for mental health in-patients in the NHS. As a result, 79 of those patients have been sent far away from their homes. The beneficiaries have been, once again, those in the private sector.

Mrs. Bottomley

What we see from the Opposition is their virulent loathing of the private sector. For all the eau de nil, the modern Labour party style and the Opposition's apparent belief in a mixed economy and working with the private sector, they are obsessed with the ownership of the means of production. That is the only issue that matters. It is the clause IV mentality. It is not a coincidence that Unison sponsored the health debate at the Labour party conference and that Unison voted to support clause IV. It is no coincidence that the right hon. Member for Derby, South is sponsored by a union that wants to retain clause IV. At heart, that is the issue for the Labour party, but the issue that we mind passionately about is benefits for patients. We are proud of all that we have achieved for patients. We are proud that the average waiting time has halved—

Mr. Paul Boateng (Brent, South)

rose—

Mrs. Bottomley

I am still replying to the hon. Member for Hornsey and Wood Green (Mrs. Roche), but I would be happy to give way to the hon. Member in a moment.

We are proud of the increase in the number of community psychiatric nurses. We are proud of the improvements in services that are now taking place. Today is a good day for the NHS, because new figures from the Government's statistical service show that in the past year alone—

Mr. Tom Clarke (Monklands, West)

Will the right hon. Lady give way?

Mrs. Bottomley

If the hon. Member will allow me to complete my sentence, I shall then give way.

Only today, new figures from the Government's statistical service show that in the past year alone, NHS hospitals treated an extra 455,000 patients. That is a 4.7 per cent. increase. It is twice the annual average achieved in the 1980s and five times the annual average increase achieved under the Labour Government. It represents a dramatic increase in the quality of care received.

Mr. Tom Clarke

The right hon. Lady touched on community care by referring to the number of psychiatric health visitors. How many persons are in prison in England and Wales, and what advice has she had from the medical units in those prisons?

Mrs. Bottomley

The hon. Gentleman will know that I cannot instantly tell him the number of people in prisons. However, I can tell him very strongly that, for more than two years, I have been saying that we should target resources and care on the severely mentally ill. I have also been saying that we need supervision registers, which are really mental health priority lists, to ensure that, with the great expansion in services for the mentally ill—that is a priority for the Department but also a personal priority—we shall ensure that those resources are focused on the most severely mentally ill. In co-ordinating the improvements and tightening up care in the community wherever possible, it is extremely important to co-operate closely with social services and the Home Office.

Mr. Boateng

On benefits to patients, is the right hon. Lady aware that in the Central Middlesex hospital trust, which is not alone, matters are now so bad that the trust charges patients and nurses for using the car park? The only people exempt from those charges are the managers, who have their own spaces. Is not that typical of the level to which she has now reduced the national health service—a service that cares only about money and managers?

Mrs. Bottomley

When the right hon. Member for Derby, South considers other health services, she will realise that the NHS is remarkable in its lack of charges. We have no charge to go to a GP or to hospital and few charges for prescriptions, and we have £100 million more than when the Labour party was in power. It is sometimes appropriate to charge for car parking, not least because many people use hospital car parks for a great number of purposes. Where that can result in further developments and improvements in health care, it makes a sensible contribution. I cannot confirm the precise arrangements at the hospital mentioned by the hon. Member for Brent, South (Mr. Boateng), but I should be surprised if managers uniquely had free car parking spaces. That would not have my support.

Mr. Rowe

In the long distant mists of time when there was a Labour Government and I was a civil servant working for them in Scotland, there was a hospital called Ninewells hospital, Dundee. In the absence of someone on the board who understood construction, it overran its costs by well over three times. When it was opened, all the consultants insisted on having named spaces in the car park. Those were removed after two months because they simply revealed how seldom they were there.

Mrs. Bottomley

My hon. Friend is absolutely right. My excellent Minister of State, who has experience north of the border, well remembers the example that he gives. It makes the precise point about why many of the appointments in the health service help us to develop our skills in sectors where, frankly, we have not always been as good as we should have been. We have first-rate doctors and nurses, but in many other sectors the NHS has not had the quality and calibre of expertise that we should have in an organisation that spends well over £100 million a day.

It may surprise the right hon. Member for Derby, South to know that the Conservative Members judge the NHS not by who is appointed to it but by the results. We take great pride in those results, which have come about following the reforms that we have introduced. We appoint people to health authorities and trusts for their ability to get the job done, whether they are the wife of the my hon. Friend the Member for Southend, East (Sir T. Taylor) or any other member of society. We want to get the job done and to improve the efficiency of the service and the quality of care to make services more responsive to patients'needs. Our excellent non-executives are helping the health service build on its already formidable record of efficiency.

Mr. Richard Burden (Birmingham, Northfield)

As the Secretary of State is interested in results, does she consider it an acceptable result of the health service reforms that in Birmingham, at a time when hospital wards are being shut and beds being closed, heart patients are being asked to travel 300 miles to a private hospital in Glasgow, Health Care International? Do not people have the right to be treated in their own communities where their families can visit them?

Mrs. Bottomley

Once again, the hon. Gentleman has singularly failed to identify what really matters to patients, which is how long they wait. Patients want to be treated as soon as possible. Before the reforms, 200,000 patients were waiting for more than a year. That number is now down to 60,000. We said that we would bring an end to the two-year waiters; we did so. We then said that we would bring an end to the 18-month waiters for hip, knee and cataract operations; we have done so. Moreover, we have extended that 18-month guarantee across the board from next year. In the area where the hon. Gentleman lives, the health authority is going for a commitment of a maximum of nine months' waiting. I should have thought that he would pay credit to all those people who are leading the country and delivering a nine-month guarantee for new patients. Those patients are being offered an opportunity to have their heart operations sooner. If they do not want that, they need not do so. If I lived in that area, I would much rather take the opportunity of being treated than linger so that the hon. Gentleman could satisfy some ideological dogma.

Dame Elaine Kellett-Bowman (Lancaster)

My constituents like not only a short waiting list but, if possible, a short stay in hospital. That applies particularly to women, as long stays in hospital disrupt their domestic arrangements. If they can go to a day hospital, they are absolutely delighted.

Mrs. Bottomley

My hon. Friend is absolutely right. I commend to my hon. Friend and the right hon. Member for Derby, South a recent article in theBritish Medical Journal about the dramatic change in health care, not just in this country but in every country in the world. The rapid advance of micro-invasive techniques, endoscopy, new scanning techniques and new medical treatments mean that people need not automatically put on their pyjamas when they go into hospital but can be treated on a day basis and return home.

Dame Elaine Kellett-Bowman

As they are in Lancaster.

Mrs. Bottomley

As they are in Lancaster, as my hon. Friend says.

However, we must have a service that is forward looking, responsive and flexible—

Mrs. Maria Fyfe (Glasgow, Maryhill)

Will the Secretary of State give way?

Mrs. Bottomley

I shall try to make some headway now. I have already given way twice as much as the right hon. Member for Derby, South did, and I shall try to come back to the hon. Lady in a moment.

The NHS is world renowned for its quality of care, teaching and research. That is important and we intend to build on it. We are recognised internationally as having taken a lead in preventive health with "The Health of the Nation" White Paper, which was commended by Sandy Macara at the BMA conference. I was surprised at the element of the speech which the right hon. Member for Derby, South quoted. It seems to have slipped her mind that he said how much he commended "The Health of the Nation" and that we should make progress. He emphasised the importance of doctors in management, and we agree. He emphasised the importance of looking at effectiveness and outcomes, and we agree. He emphasised the importance of looking at health needs, not only health demands, and we agree. We agree on those and many other sectors, and that agreement and working together have characterised our relationship with the professions in recent years.

It is important that we recognise all that has been achieved, but also that we build on it and seek further improvements. Our family doctor service is seen across the world as a model of its kind. That is important and we shall build on it. The NHS is facing a medical and technological revolution that will dwarf the management changes that have taken place. New techniques, new drugs, an aging population and rising expectations all place immense pressure on the service. They will dictate new patterns of care, new challenges and new ways in which we view the health service and its achievements.

We need a flexible service, able to respond to those challenges—not clinging on to the past, but moving to the future. We need to liberate the innovators; to release the talents from our doctors and nurses, our technicians and scientists. That is the aim of our reforms, and that is the dividend for patients that we have been delivering.

Dr. Lynne Jones (Birmingham, Selly Oak)

rose—

Mrs. Bottomley

I am tempted, but I shall not give way. I must make headway.

Dr. Jones

I want to make an important point.

Mrs. Bottomley

If I do not make headway, other hon. Members will not be able to speak and I shall be severely rebuked later.

I give the right hon. Member for Derby, South credit. She is at least conscious of her limited grasp of what has been happening in the NHS. When asked by Matthew Parris on BBC "Breakfast News" this summer whether she would keep any elements of the Government's health reforms, she replied: Yes that's a good question Matthew. I am trying hard to think whether there are any I would wish to preserve. I can't call one to mind at the moment, but don't hold me to that because I might realise afterwards that there was something that they have done that has been beneficial. Conservative Members would be glad to help the right hon. Lady out of her difficulty. Scores of changes to the health service are beneficial to patients. We shall let pass no opportunity to tell her about them.

The right hon. Lady has been given an onerous brief by the Leader of the Opposition—to modernise her party's policies, to make them more positive and to bring them up to date with the reality of the new NHS. Oh dear; no wonder we are told that she is so miserable, and no wonder she has had such difficulty today.

The right hon. Lady's predecessor, the hon. Member for Sheffield, Brightside (Mr. Blunkett), spent two and a half years deciding what he opposed and fudging what he supported. He opposed GP fundholding. I wonder whether the right hon. Lady will hold that opinion. Seventy-four per cent. of patients in the area where she lives already have the benefit of GP fundholding. There is only another 25 per cent. to go and they will all have a top-tier service—but no, I suppose that it has to be equal misery for all in the right hon. Lady's book.

The right hon. Lady's predecessor opposed competitive tendering. He opposed pay beds in spite of the new modern Labour party. Then he went to Blackpool, boasting at the Labour party conference that a Labour Government would abolish trusts. He lapped up applause from union delegates. He basked in their admiration for his dogged refusal to accept the Tories' agenda. What was his reward for that ideological triumph? Two weeks later, he came fourth from bottom in the shadow Cabinet poll and was sacked from the position of shadow Health Secretary by the Leader of the Opposition.

Oh dear. It falls awkwardly to the right hon. Lady, who scarcely has a reputation as a moderniser of her party, to pick up the pieces, but she has frankly inherited a time capsule. While all around her is going forward, she looks backwards to the old days. In the meantime, independent commentators, such as the Organisation for Economic Co-peration and Development, recognise that Britain, whose NHS has long been the envy of the world, is now setting the pace in health care reform. The Labour party wants to go back to the oppressive, centralising state control that has been rejected, not simply here, but throughout the world.

The challenge is to seize the reforms and to build for the future. I suggest the following to the right hon. Lady: Central planning was not a conspicuous success in the health service; decentralised sources of information close to local needs, like GP fundholders, may provide a better base for long-term decisions than a centralised planning agency. Those are not my words, but those of Professor Julian Le Grand, the founder of the Socialist Health Group and one of the foremost advocates of our reforms.

The right hon. Lady will have to decide whether she will abolish 419 trusts when almost every hospital is now a trust, and doctors, nurses and managers are using the freedoms of trust status to innovate and to improve benefits for patients. Is she serious about abolishing fundholding? Does she believe, for example, in decentralisation, or is she more interested in the doctrinaire pursuit of uniformity over diversity? Is she really committed to patient power and patient choice—there has been no evidence of that today—or is she simply a poodle of the trade union movement?

I challenge the right hon. Lady: if her commitment to patients is genuine, she should renounce her sponsorship by the Transport and General Workers Union, so that we may be sure in whose interest she is speaking. Does she want to? No; there is silence.

The right hon. Lady resorted to the old scares and smears about privatisation. She produced no new evidence—simply peddled more of what my right hon. Friend the Prime Minister described as the most insidious lie in politics. That privatisation scare story, which she regurgitated today, discredits the Labour party and dishonours the truth. Labour Members have been running it for years; they paid the electoral price for it in 1992 and they will pay the price again.

Mrs. Fyfe

The right hon. Lady claims that Opposition Members are wrong to say that the health service is being privatised. What else does she call it when the Secretary of State for Scotland gives £30 million and more to a private hospital that is allegedly built to take overseas patients and, when it fails to succeed in that objective, survives by moving in patients from Manchester, Birmingham and anywhere else that it cares to dip into when it cannot obtain patients of its own from overseas? How can one plan for a national health service and national health service care of patients when that is allowed to happen?

Mrs. Bottomley

I think that the hon. Lady knows that there is everlastingly a call for inward investment in Scotland, and it was in that context that the Secretary of State made that decision. It was not money that came from the health budget, but the hospital is providing health care for many NHS patients, and I care about patients. The Labour party's real agenda is not about patients; it is not about the so-called public alarm. It is about trade union power; it is about the old clause IV preoccupation.

Let me make it clear, as the Prime Minister did at Bournemouth, that the Government will not deviate one dot or comma from the fundamental underlying principle of the NHS. Care is provided for everyone on the basis of clinical need, regardless of ability to pay. However, where there are benefits to be gained for patients from working more closely with the independent sector, we will pursue those benefits. Where there is scope for innovation, flexibility and choice, we will let those qualities have their head. When we can secure additional investment in the NHS through private finance, we will seek to reap those opportunities soon.

We spoke during health questions about the importance of the private finance initiative. We welcome the extra resources that result from that initiative. We want a modern service for patients. We also welcome the £1 billion of efficiency savings that have been secured as a result of market testing.

Ms Armstrong

Will the right hon. Lady give way?

Mrs. Bottomley

I have already given way to the hon. Lady, and it was not very rewarding.

The Labour party would deny NHS patients that money and the benefits from it. The price tag of that is all for the Labour party's blinkered dogma; another little sweetener promised to the unions. The Labour party must make up its mind. Who was it, as I said earlier, who said that the Government had to ensure that the public and private sector worked together? I may have given the hon. Member for Newcastle upon Tyne, East (Mr. Brown) the credit, but I was quoting the Leader of the Opposition. I hope that the hon. Gentleman will understand if I have promoted him in that short space of time—not before time.

Mr. Nicholas Brown (Newcastle upon Tyne, East)

It happens all the time.

Mr. Hugh Bayley (York)

The Secretary of State was reaffirming the Government's commitment to equity—to equal access to care. Would the Secretary of State care to say why there are such wide differences in health among people from different social classes in different parts of the country, why those health inequalities are widening, and what the Government intend to do to narrow them?

Mrs. Bottomley

The hon. Gentleman needs only to look at "The Health of the Nation" strategy. That is designed precisely to ensure that we consider variations in health, so that we can make progress. I do not accept the view almost espoused by the Labour party that somehow it is so distressing for the healthier to become more healthy faster that one would rather hold them back than see progress throughout the range.

There have been major improvements in maternal and child health for all social groups, for all income groups and throughout the country. That is the significance of the distinction between the purchaser and the provider—that the health authority is tasked with assessing health need and setting priorities. It is one of the many reasons why we would never turn the clock back to a monolithic, bureaucratic health service, as espoused by the Labour party. It does not allow the flexibility for local strategies and approaches to tackle the specific health needs of different parts of the country.

When looking at its agenda, the Labour party will have to come to terms with fundholding. I have already said that in the region of the right hon. Member for Derby, South, 74 per cent. of patients benefit from a GP fund-holder. We recently announced that we shall extend the scheme—lower the list entry size, widen the range of services available and introduce new community fundholding schemes—to give even more practices the chance to experience its benefits. We have pledged to level up and extend the benefits. We will deliver that pledge to the patients of this country so that they see similar improvements.

I would commend to the right hon. Lady the new, independent evaluation of fundholding by professor Howard Glennerster. A first-wave fundholder states: For the first time, we had managed to get to talk to consultants about the standard of care they were giving our patients". That is the essence of the scheme—clinicians talking to clinicians about patient care.

Fundholding is rewriting the rules in the patients' favour. That marks, as Professor Glennerster states, a shift in the balance of power back to general practice for the first time this century". General practitioners like it, patients like it and we like it.

Mr. Malone

Labour Members do not like it.

Mrs. Bottomley

They do not like it.

Nowhere is the Government's commitment to patients more obvious. Nowhere is it having a more dramatic practical effect. The Labour party takes a vindicative approach and always wants to level down, not up.

Mr. Kevin Hughes (Doncaster, North)

I am grateful to the right hon. Lady and want to pick up something that she said earlier when talking about the constituency of my right hon. Friend the Member for Derby, South (Mrs. Beckett). The Secretary of State said that 74 per cent. of my right hon. Friend's constituents came under GP fund-holders and that soon all of them would have a top-tier service. Will she explain what that means? Does it mean that other people do not receive a top-tier service?

Mrs. Bottomley

The key point about GP fundholding is that when the GP is in control and autonomous, and has control over the budget, he is able to secure improvements and has a flexibility and responsiveness which, with the best will in the world, is almost impossible to achieve unless he is in the driving seat. GP fundholding is a voluntary scheme, but we have made it as simple as possible for more GPs to join.

I simply commend again Professor Howard Glennerster's book in which he talks time and again about the commitment of GPs who come into fundholding and the benefits that they have been achieving, not just for their own patients, but for all patients in primary care. Their relationship with the hospital has also benefited.

The hon. Member for Doncaster, North (Mr. Hughes) should talk to Dr. David Colin Thomé in Runcorn who fought as a Labour candidate in a previous election. He is a champion of fundholding and has pioneered changes and improvements for patients. Were the hon. Gentleman to spend time talking to that doctor it would be difficult for the hon. Gentleman to come away with any other view than that the future lay in fundholding and all GPs should pursue that option.

Dame Elaine Kellett-Bowman

I recall calling to my right hon. Friend's attention the fact that in my district the hospital fundholders had carefully husbanded their resources. When the trust was beginning to run out of funds at the end of the year, the patients of the fundholders were still able to be admitted. My right hon. Friend was good enough to give the hospital another£250,000 to catch up, but it was because the fundholders had carefully spread their resources over the year that their patients benefited.

Mrs. Bottomley

My hon. Friend has it. With that, I will try not to take any more interventions.

The important subject that we have been debating today is that of accountability. The Labour party has failed to grasp the fact that, under the old system, accountability went by the board. There was little information, less transparency and an opaque and impenetrable bureaucracy where no one knew what was happening or what anything cost, and few people even bothered to ask. Decisions were taken, not just behind closed doors, but behind closed doors tens or even hundreds of miles away. There has been a dramatic change—health authorities and trusts have clear and separate roles and identities.

The patients charter sets out for the first time patients' rights in the NHS and their means of redress if things go wrong. We have opened up the service to independent, external scrutiny through the Audit Commission. We have thrown the light on the health service. We have dramatically improved openness and the information available throughout the service.

Mr. Denis MacShane (Rotherham)

rose—

Mrs. Bottomley

We have reinforced our deep and abiding commitment to the values and ethos that underpin public service in the NHS. We expect from the service the highest standards of both personal and corporate conduct. That is why when Sir Adrian Cadbury first published his report, I invited him to meet me and a number of leaders in the health service to discuss the principles of corporate governance. I believed that they were appropriate to the NHS and took steps to introduce them. In April this year, after widespread consultation, I issued codes of conduct and accountability for trust boards and their members that closely followed the Cadbury principles. They represent a landmark for the health service.

For the first time, we have set out the need for audit and remuneration commitments to ensure the proper stewardship of the vast resources at the disposal of the health service. For the first time, we have required members' relevant interests to be declared and established in registers of those interests. Throughout the years of health appointments, which have changed little since 1948, we have never before had registers of interests and proper codes of accountability and conduct. Those codes have been widely welcomed by Sir Adrian Cadbury, the Audit Commission, the Public Accounts Committee and, not least, the right hon. Member for Ashton-under-Lyne (Mr. Sheldon), who chairs that Committee.

The Labour party talks a lot about accountability in a sort of Islington dinner party way. But when it comes to the accountability that really matters to patients, it changes its tune. We have increased accountability by bringing decision making closer to patients through local health authorities and trusts. The Labour party resisted it. We have set in hand an information revolution throughout the service—through annual reports, annual accounts, access to medical records and other means. The Labour party carped and criticised. We published the information that patients and the public want about their local hospital in performance tables. The Labour party poured scorn on that initiative. Time and again when we make information available the Labour party does not seem interested in what the patient wants to hear.

The right hon. Member for Derby, South made a number of disparaging remarks about appointments to health authority trusts. I am sorry that she comes to the job so encumbered by that prejudice. I am sorry that she finds it necessary to attack non-executives with business back-grounds in the same way as she goes for knee-jerk attacks on managers. We need the skills of a great range of people to deliver the improvements in patient care.

When we consider the number of patients being treated now, we have to pay tribute to all those whose different talents, skills and expertise have made that possible. Sir Adrian Cadbury took a similar view; his report welcomed the role of strong non-executives who bring the insight of an outsider into the NHS. We endorse his view. Anyone who knows anything about running a service that spends £100 million a day would endorse that view.

If the right hon. Lady wonders why she can identify fewer of her supporters on NHS trusts, I have already today made the reason only too clear. If she constantly denigrates and attacks the non-executives on NHS trusts, what encouragement is that to members of the Labour party who want to undertake that sort of public service? Can the lack of supporters on NHS trusts be anything to do with the Labour party's history of putting the frighteners on its members who seek to serve on trusts—as we saw before the last election? Is it any wonder that the hon. Lady cannot succeed in getting Labour members onto trusts when she pledges to abolish trusts given half the chance?

The right hon. Lady and the Labour party politicise trusts by making them part of the party political debate. Everywhere else they are part of the landscape, not part of the debate. Unlike the Labour party, we appreciate the talent that is brought to the trusts by non-executives and leaders of the profession such as Dame Margaret Turner Warwick, a former president of the Royal College of Physicians and now chairman of the Royal Devon and Exeter trust.

My challenge to the right hon. Lady is to turn the clock forward and to recognise that trusts are good for patients and staff. She must recognise that there is a place on health boards for people of genuine merit who will bring to them their skills, experience, energy and commitment. She must accept that serving on a trust is like being a magistrate—it is something in which people of all political parties should be engaged as a form of public service. That is not a party political statement: it is a statement of fact.

Let me now reveal some of the Labour party's hypocrisy. The policy of appointing chairmen has changed very little since 1948. We have reduced, and are reducing, the number of appointments as we streamline authorities and boards and make them decision-making groups. Does the right hon. Lady know which party, before our reforms, nominated three disqualified Lambeth Labour councillors to the West Lambeth health authority? Which party put forward its three prospective parliamentary candidates as its nominees for the Greenwich health authority?

Mr. Nick Raynsford (Greenwich)

rose—

Mrs. Bottomley

Which Secretary of State sacked—

Mr. Raynsford

On a point of order, Madam Deputy Speaker. Is it in order for the Secretary of State to decline to give way to me when naming for the second time today an hon. Member of this House?

Madam Deputy Speaker

It is entirely a matter for whoever has the Floor to decide whether to give way.

Mr. Raynsford

She is frit.

Mrs. Bottomley

No; she has given way much more often than she ought to have—

Mr.Raynsford

rose—

Mrs. Bottomley

However, in the interests of neighbourliness to my husband, I shall give way.

Mr. Raynsford

Does the Secretary of State think it right that people who have been proposed perfectly legitimately by a local authority, and who have a deep concern for that authority, should be replaced, for health authority membership, by double glazing salesmen—because that is what her party did? Does she think it right that the Greenwich health authority subsequently reduced the health situation there to chaos—so much so that when her appointee in the region visited recently he had to recognise that the whole system was not working, and the chair and chief executive of the local healthcare trust have had to be replaced? Is the right hon. Lady proud of that record?

Mrs. Bottomley

The hon. Gentleman is being extremely mischievous. He must know that Rosie Barnes, a former Liberal Member of Parliament, serves in his part of the world. He may also like to know that two Labour councillors serve on the Leeds community and mental health trust. Of course there are times in particular hospitals when certain management issues need to be tackled and some key people need to be replaced—that has nothing to do with the system of appointments—[Interruption.]

Madam Deputy Speaker

Order. The House will be aware of my views on seated interventions. The hon. Member for Greenwich (Mr. Raynsford) has been allowed to intervene; I do not expect sedentary interventions to follow.

Mrs. Bottomley

I had expected the hon. Gentleman to deny that the Greenwich authority proposed three prospective parliamentary candidates as its nominees for the health authority. I wonder what their agenda would be? David Ennals, a former holder of my office, sacked 32 health authority chairmen purely and simply because they did not support the Labour party. Where is the integrity, the accountability or even the common sense in that?

We believe that the service benefits greatly from its non-executives, whatever their party. That is why we are establishing an even more transparent and accessible system. We are widening the pool of candidates, drawing in people from an even broader range of backgrounds and expertise. We have already greatly increased the number of women on trusts and in health authorities, and we have encouraged people from black and ethnic minorities. We are advertising widely for applicants, and independent panels of trust and authority members will sift and scrutinise applicants to ensure that the best people continue to be selected.

I share the Prime Minister's absolute commitment to the highest possible standards in public life, and we shall participate fully in the committee that he has announced today, but I believe that it will be found that the systems that we have set in hand in the health service are models to follow. If they need modifying in any way we shall not hesitate to modify them. Already, we have embraced the Cadbury principles, we have opened up our system of finding people to serve as non-executives, and we have made enormous progress. We need only one thing more—we need the Labour party to take the frighteners off the people who serve on the trusts and to support them.

The real dilemma that the right hon. Member for Derby, South faces is how to tackle the feud raging in the Labour party over who should run the health service. She should act now to stop that feuding. She must say what her policy is. Does she seek to re-open the 1948 debate? Does she favour a local authority takeover of the NHS? Such a takeover would be deeply unpopular. Who believes that Derek Hatton running Merseyside would have had anything like the success of Sir Donald Wilson? Perhaps the right hon. Lady has a lingering affection for David Bookbinder in Derbyshire? We believe that the task of the health service is to serve patients, not to get tangled up with local authority control and involvement.

This was the old battle that Nye Bevan fought with Herbert Morrison, and it would be a great shame if the Labour party reopened the feud—but that is the problem that the right hon. Lady will have to deal with urgently in her party. Her predecessor was clearly moving in that direction, and we wait for the uncertainty to be resolved.

The Royal College of Nursing has said that it believes that equity, one of the founding principles of the health service, would be undermined by local authority control of health services. If the right hon. Lady will not take my word on the issue, let her listen to Christine Hancock, who has said that such a proposal would at best block progress towards achieving the highest standards of care and equity throughout the service and at worst be the end of a national health service.

So if the right hon. Lady wants to reopen the wounds that were patched up in her party 40 years ago, let her say so—but let her also recognise the massive increase in bureaucracy that such policies would bring about. Let her confirm that, while the Government are abolishing regional health authorities, a Labour Government would bring them back. Let her come clean about her party's proposals for regional government; bureaucratic tentacles would then be wrapped around the health service. Let her admit that by abolishing trusts the Labour party would be reinventing the old command and control bureaucracies that we have swept away.

We will take no lessons from the champions of bureaucracy in the Labour party. They are committed to cumbersome regional bureaucracies; we want to sweep them away. We have cut the number of health authorities by 70. We shall reduce their numbers further by enabling family health services authorities and DHAs to merge. We have also reduced the number of regions, before their abolition.

Over the past year alone, administrative savings at regional and district level have led to an extra £34 million being invested in patient care. During the summer, I visited every region and spoke to every trust and every health authority chairman, and I heard about the savings that are already being secured: £4.7 million in Northern and Yorkshire, £6 million in South West, £15 million in the two Thames regions—all by streamlining.

I have already mentioned Sir Donald Wilson in the north-west saving £8 million by streamlining and investing the money in better primary care in Liverpool's most deprived area. I cannot remember when Liverpool last saved £8 million for anyone.

All trusts must be accountable for what they spend on management and for how they spend it. That is why I announced that all trusts will publish their management costs in their annual reports so that the public can see and compare the figures. They will be published alongside the performance tables so that people can see the added value that management is bringing to the NHS. That is better than indulging in knee-jerk attacks on managers.

All I ask is that we are judged by our results. The achievement of the reforms has been to put the right structures in place for a flexible and responsive service. The reforms have been tried and tested in practice and endorsed by independent evaluation, by the OECD and by experts and commentators. All over Britain, NHS staff have worked hard for those changes. They take pride in their work and want to realise the full benefits. The last thing that they want is the Labour party's recipe for a return to a centralised and inefficient bureaucracy.

Our policies are delivering results by which we shall be judged. We are prepared to be judged by the 3,000 more patients being treated every day in trusts, by the growth in childhood immunisation, by the improvement in the health of the nation, by the innovations in quality care which are to be seen in our health centres and hospitals. We are also prepared to be judged on our record in reducing waiting times, junior doctors' hours and the size of GP lists.

We offer progress for patients. Our policies present a chance to tackle the problems which remain and to rise to the challenges and pressures that lie ahead. Labour is backward and inward looking. It looks back to the failed structures of the past and inward to its own vested interests. It is the old Labour party with old, failed and discredited policies. We have created a new national health service for a modern world, and I commend it to the House.

6 pm

Mr. Stephen Timms (Newham, North-East)

Many facets of the health service worry hon. Members, and some of those worries have been mentioned in the debate. Since my election in June, I have had the opportunity to talk to many people who work in the health service in Newham and to patients who depend on it, and I have discovered enormous unhappiness about the state of the service. People are worried about the unexplained and steady rise in emergency hospital admissions. They are worried about the falling number of visits to dentists and opticians, because that means that problems which would have been found in check-ups now go undetected until they are far more serious. People are worried about proposed changes to the rules for pharmacies, because it is widely felt that they will drive many local chemists to the wall. Health officials are frustrated by restrictive rules on new medical premises, which are delaying improvements to primary care in London.

Above all, people feel that enormous decisions are being made by an invisible and anonymous bureaucracy which could not care less about what people think. The Prime Minister's pledge a couple of weeks ago that the health service would never be privatised has been mentioned in the debate. Will the Secretary of State stop the bureaucrats behaving as if the health service has already been privatised?

People want the Government to listen. The August King's Fund report hit the nail on the head about the effect of the changes in London. Dealing with the Government's policies, it stated: The effect on public confidence has been severe. Patients have a confidence in their nurses and their doctors that they do not have in the managers and politicians. With tense negotiations continuing behind closed doors, most staff simply do not know where they stand. Public confidence has plummeted.

Just after I was elected, I contacted the local health care trust to inquire about the delay in carrying out an operation for an elderly constituent. The reply took some time, and when it came it was just an apology that the trust could not tell me anything. The operation was contracted out to a different health care trust, and although the patient had seen the consultant in our local hospital and was, as far as he was aware, a patient there, it could provide no information at all about when the operation would be carried out. People inside the service do not understand what has happened, let alone the patients.

A much more serious issue has arisen in east London about the future organisation of community health services. The City and East London family and community health services, or CELFACS, was set up to manage community health services in the short term after their separation from the new acute trusts, and to review the longterm options for their management. Nobody was too surprised when, no doubt after due and careful consideration, CELFACS recommended that the best option was for it to run the services.

The proposal went out to consultation and overwhelmingly, those who were consulted preferred an alternative structure with locally based trusts for Newham, Hackney and the City and Tower Hamlets. Their experience was that the CELFACS organisation was an unresponsive, top-heavy bureaucracy and which adopted a narrow and inflexible approach to services, which has failed to reflect the different needs in the different areas of east London. In the view of those involved, it is not an appropriate body to run community health services for so large an area.

I know that, in Newham, staff put in enormous effort on top of their existing heavy work loads to develop the local trust proposal, and the same happened in Hackney and the City. However, it was clear that, despite local strength of feeling, CELFACS had, quite properly, strong support from a small number of senior health managers, which, of course, included those who were running CELFACS.

The issue went to the district health authority, which voted narrowly for the locally based trusts. The voting was four to three, all the non-executive members of the authority supporting the locally-based trusts while all the managers, the executive members, favoured CELFACS. One might have expected that that would be that, but the matter then appeared on the agenda of the executive committee of the regional health authority, comprising only authority managers. Predictably, they overruled the district view and recommended the CELFACS option. We gather that that has been forwarded to the Secretary of State as the final recommendation.

The Secretary of State alleged that Opposition Members denigrate non-executives. I do not denigrate them at all, and in the instance that I have cited, they were certainly carrying out their task conscientiously. But they were overruled by managers who are a step higher in the bureaucracy, and who have forwarded a different view to the Secretary of State.

I hope against hope that the Government will not simply rubber-stamp the view of the regional executive, because that would unleash a tidal wave of cynicism among the practitioners on which the services depend. It cannot be right to impose on those who will deliver the services the views of a small group of managers for what, as far as I or anyone else can establish, is no good reason.

Is it not time that the Government adopted the motto, "Front Line First", not just for defence but for other public services? Constantly consulting the front-line providers and then ignoring them, preferring instead the views of managers, is terribly damaging to the services. That process is not the right way to make decisions about our vital public services. It is not so much the decision that is the problem as the transparently unacceptable way that it has been arrived at.

At the start of my speech, I asked what the Secretary of State proposed to do about managers behaving as if the health service were already a private corporation. I hope that, at least in this instance, she will overrule them.

Finally, I should like to address the issue of decision-making on the allocation of resources. I welcome the publication last week of the long-awaited York university report, with its recognition at last of the need for adequate funding for deprived areas, reversing the recent trend to take resources away from them. Earlier this year, my hon. Friend the Member for Bristol, South (Ms Primarolo) asked the Secretary of State which were the top 10 deprived health areas in London. My hon. Friend was told that my borough of Newham is the most deprived.

All the key indicators show that the severity of health problems in Newham justifies additional resources. Those problems relate to perinatal mortality and infant mortality rates, the standardised fertility ratio, the hospitalisation rate, the rate of HIV infection affecting children and families, income levels, and simply the need to provide translators to communicate with many people in the borough who can speak no English.

Government figures show that Newham has the most severe deprivation in the country, but its capitation has been cut, while capitation to other parts of the same region with much better starting points in terms of quality service provision has been raised. I have no problems about raising the funding for other areas, but it should not be done at the expense of areas that are acutely struggling. In publishing its research, York university rightly commented that the old formula produced in the early 1990s has resulted in a shift of resources away from poorer and sicker areas. Our family health services authority, the City and East London authority, has the highest level of deprivation in the country, but the FHSA spending per head in Newham was less than in Dorset, Cornwall, the Isle of Wight or Lincolnshire. Our services have far greater needs to contend with, yet they have been allocated fewer resources. That problem has been made worse since 1990. Again, that cannot be right.

I am delighted that the research by York university has vindicated what we have been saying for a long time. Can the Secretary of State now assure us that the findings of the York research will be implemented in full, allocating additional resources to the inner city areas where they are needed? Will she refute reports that efforts are being made to find ways of avoiding the implementation of the York university recommendations?

What will be done to put right the distribution of resources for primary care? Precisely the same problem exists there, with poorer and sicker parts of the community receiving inadequate resources. Is that problem now to be addressed?

People must be able to see who is making the decisions that affect their health service and to know the reasons for decisions that affect their lives and their futures. Inexplicable decisions cannot be allowed to continue descending anonymously from invisible layers of bureaucracy—a faceless, bureaucratic brick wall.

The country desperately needs the Minister to go some way to dispel the tide of cynicism and despair which, as anybody who speaks to those involved will report, is engulfing the health service; to acknowledge there are real problems to overcome instead of simply continually telling us that there is not really a problem at all; to make it clear that the Government are listening to what people are saying, not simply dismissing it; and to announce that the Government are prepared to change their mind where plainly they have been wrong.

6.11 pm

Mrs. Marion Roe (Broxbourne)

I am grateful for the opportunity to speak in today's important debate. We live in a country with a health service which is the envy of the world, where care is universally available and provided economically, where standards are improving and waiting times are falling, as measured by every available parameter.

Yet Opposition Members do nothing but criticise and demean, destroying morale in the service and damaging the confidence of the public. Today, we are seeing a new tactic, calculated insidiously to undermine the jewel in the crown of world health care: criticism of the innovative ways in which the health service is seeking further to increase the funding available for patient care, and criticism about accountability and management and its costs.

My right hon. Friend the Secretary of State has already clearly explained in national terms the misrepresentations in the Labour party's assertions, but I should like to explore and answer those issues using a local example.

My constituents use the services of East Hertfordshire NHS trust, a second wave whole-district trust which, since its creation in April 1992, has offered high-quality care economically and efficiently. It has innovatively developed its facilities, and has expanded the capital available to it by partnership with the independent sector.

For example, the trust required a magnetic resonance imaging scanner, the latest technology for visualising internal body structures. A partnership was established with a private company, and a new unit was built in the grounds of the Queen Elizabeth II hospital. Scans are now rapidly available to health service patients more cheaply than the trust could otherwise have obtained them.

The company involved is contracted to provide the latest upgrades in equipment at no cost to the trust, and the trust receives a share of the proceeds of the work that is undertaken. For health service patients, therefore, the huge benefits of rapid access are obvious, while for the trust there is the availability of a major clinical resource that it would not otherwise have. That is not the creeping privatisation which the right hon. Member for Derby, South (Mrs. Beckett) presages, but a valuable symbiotic relationship for mutual benefit and better patient care.

Opposition Members should never forget that the health service exists to provide care for the people of Britain, not to act as a sounding board for those who would use alarmist statements for political ends.

The Opposition parties claim that, in some way, the trusts and general practitioner fundholders are not accountable. Such an accusation is entirely without foundation. The trusts and fundholders are accountable, both to the populations they serve and to the principles of ethical activity that govern all business behaviour.

Mr. Gerry Steinberg (City of Durham)

How?

Mrs. Roe

I shall explain.

Trusts are monitored by regional health authorities, and their activities are examined in great detail by both internal and external auditors. The chairman and non-executive directors of the trusts, who are local residents, monitor executive activities and decisions. Trusts must publish an annual report, and the public have access to the senior management teams at a statutory, publicised annual public meeting, where they can question the report and ask about any other issues of interest and concern.

Mr. Steinberg

If, at one of the meetings, the general public, after seeing the information, decide that they do not like the membership of the trust or the way in which the trust is being worked, can they get rid of the members of the trust?

Mrs. Roe

I fear that the hon. Gentleman has never attended one of those meetings. The people who attend them in my area find that they get satisfactory answers, and that the queries they raise are investigated. Furthermore, patients who have any cause for anxiety can write directly to the chief executive of the trust, who has the responsibility for investigating and personally responding to any complaints or worries.

As for fundholders, they are accountable to their family health services authority and to the regional health authority, they undergo statutory regular examination of their financial activities by auditors and, most importantly, they are accountable to their patients with whom they work all day and every day.

Such public sector accountability is comprehensive and effective, and compares favourably with the accountability, for example, of many trade union organisations, which work furtively, espousing individual rights on the one hand while stoically maintaining secret block voting and decision-making on the other.

In addition, the trusts and health authorities work within the codes of conduct expected of the most ethical businesses. Public organisations must be open and accountable, and everything they do must stand the test of public scrutiny.

The Government recognised that requirement and are to be congratulated on their vision and determination to introduce the principles of Cadbury into the medical services. The code of conduct and accountability, which was published last spring, defined the information for the annual report, outlined the decisions to be taken at board level, reviewed the mechanism for financial and performance reporting, and introduced a declaration and register of interests.

For the Opposition to declare that there is anything less than openness and full accountability within the health service is to fail to understand the high and ethical standards demanded of and received from the trusts, the fund-holders and the health authorities.

A business with a £37 billion turnover needs effective management. My right hon. Friend the Secretary of State has already informed the House how that has been achieved nationally and how the Labour party propaganda has been used in an attempt to disseminate misinformation about management costs.

I am in accord with the former shadow spokesman for health, the hon. Member for Sheffield, Brightside (Mr. Blunkett), when he stated in the Health Service Journal earlier this year: Managers—at whatever level—are not the enemy but the lubricant of the service". They administer and deliver the service economically and more effectively than anywhere else in the world.

Again, I can cite the East Hertfordshire NHS trust used by my constituents. Its team of senior managers account for only 2 per cent. of the pay bill. Using the much broader definition of "management" as described by the Audit Commission, the trust has recently been examined and found to have total management costs of 5.9 per cent.

That figure—among the lowest in the North Thames region—compares with an average figure of between 7 and 8 per cent. for trusts and, using the same criteria, an average figure of about 14 per cent. for an industry with an equivalent turnover. Therefore, since the introduction of the reforms, there has been a doubling of the increase in the number of patients treated in the secondary care sector, in the face of management costs about half that of industry. Surely that is a truly remarkable success story.

Our excellent health service is not in decline, not over-managed, not unaccountable, not subject to insidious privatisation; it is developing, expanding, introducing innovative and exciting ideas, and working with the independent sector to expand further the facilities available for the population.

It is doing all that in an open and accountable way, with management costs that are modest by any standard and on which there is continued pressure for reductions to ensure that an ever greater proportion of national health service funding goes into clinical care. There is no public alarm about the health service, just a genuine belief among the overwhelming majority of the population that the care they are receiving is continuing to improve.

To fail to consider the care and treatment of patients and to use tactics designed to alarm and confuse is a cheap trick by the Labour party. Let Opposition Members whinge and whine, bereft of genuine cause for criticism or complaint. For me, the health service is a source of great pride; for my constituents, a service which is ever better; and for the country, a universal provider of care that is second to none.

6.22 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

I do not think that the hon. Member for Broxbourne (Mrs. Roe) is right in her assessment of the changes in the national health service. However, I do not think that she is wholly wrong, either. She was right to say that some benefits have resulted from the administrative changes over the past few years. She was certainly right to say that the issue is not the involvement of the private sector, provided that the treatment for the patient is free at the point of delivery. That is the important factor. Nor is it bad to separate the purchasing and providing provisions. That is a sensible change which can be built upon.

The hon. Lady takes a keen interest in those matters and does a sterling job in her role on the Select Committee on Health. However, I am sure that, in the quietness of her own thoughts, she would accept that the implementation of some of the changes could be improved—and, in some cases, improved significantly. The Government were wrong to try to achieve their targets within the time scale that they set themselves. The computerisation programme and the introduction of new technology, which I support, were done at a speed that anyone with an understanding of the implementation of some of the systems knows was wholly unrealistic. Because of that, some of the aspects of implementation have been more chaotic than they should have been. The Government should have made greater use of a system of pilot schemes. Different parts of the country could have tried different things in different ways.

I hope that I carry the hon. Lady with me in saying that not every part of the country is necessarily always best served by trusts. Some elements of the centralised system have a coherence that the local delivery of services through trusts may not yet have. The jury is still very much out on that. If the hon. Lady is to be confident in her assertion that the new system is serving the interests of local people best, local people should have been given an opportunity to say whether they wanted to try it.

I am not aware of any of the consultation processes, which are part of the statutory legislation, ever succeeding in persuading a trust applicant that it was wrong. I know that from my local experience— [Interruption.] The Minister may want to put me right on that when he replies. If there has been a public consultation on whether a trust should be implemented, which then showed that that trust was not wanted by the local community, which then resulted in the trust application being abandoned, I should be pleased to hear about it. I am not aware of the consultation process resulting in such an outcome. I know that the Minister takes a keen interest in the Borders because he is always visiting his weekend cottage in God's own country in Roxburghshire. He is very welcome when he comes.

Mr. Tom Clarke

The Minister did not make the same mistake as the hon. Member for Harwich (Mr. Sproat).

Mr. Kirkwood

I shall not be tempted down that road.

The Minister knows that the Borders health board is going through a process of public consultation on whether there should be twin trusts to provide health care in southeast Scotland. I have to tell the hon. Member for Broxbourne—her writ on the Select Committee does not run north of the border—that there is widespread fear that the implementation of twin trusts would not improve, local health care. We have a very high quality of health care, mainly because of the standard of care produced by the professionals who work in the service. The health council carried out widespread consultation and there was a unanimous view that local people did not want any change.

The hon. Lady is a fair person. The health council is an objective body with no Labour party axe to grind. If the result of its consultation is that local people want, their local health provision left alone, surely she accepts that it should be left alone. If a case cannot be made and if the public cannot be carried, they are entitled to keep the existing system and not have it replaced by the trust system. Otherwise, she would be sentencing every part of the country, whether it likes it or not, to the implementation of the new machinery. That would be wrong.

The Government may well have a case on the provision of trusts and they may, in certain circumstances, improve health care—that might be true in inner-city centres—but I am not convinced that they are necessarily good for every part of the country. The local people should be allowed to have their say on that.

The hon. Lady's investigations as part of the Select Committee are important in these matters. She will know that there is at least a question mark over the state of morale among nurses, doctors and health care professionals generally. The pace at which the reforms were implemented may have been responsible for some of that. I do not have a Labour party axe to grind— [Interruption.] The hon. Member for Monklands, West (Mr. Clarke) will have to wait for a long time before I do. I do not have any ideological hang-ups, but I believe that there are considerable concerns among health care professionals and that their morale is low.

The Government's attempt to measure procedures, episodes and treatments by volume is a mistake. Of course, it is an important indicator, which must be taken into account, but the quality of outcome is also an essential part of the process of trying to evaluate whether the system is working. We tend to forget that aspect. We have just been trading statistics about the number of staff in place and the number of patients treated. I accept that there have been signal improvements in some areas, particularly waiting lists, which were far too long to start with.

The argument about private versus public is sterile. We are spending far too much time looking at the mechanism when we should be spending more time looking at the quality of health care and the way in which it is being delivered. The debate is obsessed with structures. My final point to the hon. Lady for consideration in a quiet moment is that she is wrong to say that power has been devolved from central command all the way down to patients. Power has been devolved down the line and is now in the hands of providers, but they are not necessarily the same as patients. We have a long way to go to persuade people that, just because there is more empowerment at the level of provider, we can be confident that that meets with the accords, wishes and needs of local people. I am sure that outside the confrontational atmosphere of the Chamber, the hon. Lady will acknowledge that there is some truth in some of the things that I have said in response to her interesting speech.

I declare an interest. I am a member of the Royal College of Nursing panel and have been for a number of years. It is one of the more fulfilling aspects of my work in this place. I get to meet real people who work at the front line of the NHS, a contact from which I benefit. I am also grateful for the expertise and briefings from which members of the panel from both sides of the House benefit.

The Royal College of Nursing rightly identifies the future of long-term care for older people as being one of the issues that comes into the category, or could come into the category—I know that such loose language annoys Ministers—of creeping privatisation. There is much confusion at present about who should pay for continuing care for the elderly. We all know that in recent years there has been a dramatic reduction in the number of NHS continuing care beds and, as a result, a rapid growth in private nursing homes.

There has been an absence of any sensible, coherent and orchestrated debate at the hands of the Government. That is a dereliction of duty. I do not run away from the fact that tough decisions have to be made. They may involve getting the community at large to face up to family responsibilities more rigorously than happens at the moment. Those are not easy questions, but the Government have introduced the changes by stealth. That is not in the interests of arriving at a national consensus on how to cope with such matters.

The Government are sloughing off responsibility and increasingly local authorities are expected to take responsibility for continuing care. As a direct result, more patients previously funded by the NHS are now to be means-tested and needs-assessed before they have any guarantee of continuing care.

The lack of clarity in the past few months about who should fund continuing care is causing much anxiety, particularly for elderly and disabled people and their relatives. Those anxieties were fuelled by the draft guidance that was published in August 1994 by the Department. It proposes that local authorities and health authorities should, between them, decide which elderly people are eligible for state-funded continuing care and which are not. That is an abdication of responsibility.

The Government should give a much clearer steer on what they expect to happen in such circumstances and what the future will bring. The RCN's particular worry is that continuing care, if it consists of anything, consists of intensive nursing. It is right to say that that should be the clear responsibility of the NHS. The draft guidance, in describing the elements of continuing care, talks about the NHS focusing only on medical needs in future. It fails to acknowledge the crucial contribution of nursing to the continuing care process. The Minister may not have time to deal with that question tonight, but I hope that he will address it seriously. It is a legitimate question, which is not being properly tackled.

I welcome the right hon. Member for Derby, South (Mrs. Beckett) to her new position. The health portfolio can in no way be described as middle-ranking. Health is a crucial issue and the right hon. Lady is an experienced parliamentarian. I have enjoyed doing business with her in the past and I look forward to continuing that relationship in future. The Secretary of State was a bit churlish in her welcome to the right hon. Lady, but that is a matter for her.

The right hon. Lady made some important points about the need for more accountability in trusts. I was interested in the experience of the hon. Member for Broxbourne, who has for some time had a trust in her constituency, an experience which I do not share. Leaving aside the party political arguments which are valid and will continue, urgent efforts need to be made to satisfy the public that there is genuine accountability in some of those bodies.

There is a wider concern. There are ways in which the need for accountability could be addressed by creating more user groups and voluntary organisations and in which the independent sector could take a more direct interest in trusts. More than anything else, greater accountability could and should be achieved by making trust meetings more accessible. They should always be held in public. I cannot for the life of me understand why health boards, trusts and so on are allowed to meet in private. That is a dereliction of duty on their part and an abdication of democracy.

Annual reports and annual meetings are valuable and welcome, but the trusts should make far more effort to achieve a much more open style of management. It is up to them. Unless the Minister tells me that they are precluded in some way from adopting an open style of management, they have the power to do so. They have a responsibility not just to feed information up and to be accountable to the Secretary of State but to reach out and contact the public whom they seek to serve. People with more direct experience of trusts in the constituency can put me right if I am wrong, but I see no evidence of that.

The right hon. Member for Derby, South referred to the increase in bureaucracy. To a certain extent, that is inevitable. If there are purchasers and providers, there are now two sets of management where previously there was one, so there must be an increase in management. The right hon. Lady contrasted the 2 per cent. drop between 1992 and 1993 in the number of nurses and midwives with the 13 per cent. increase in senior managers during the same period.

I was disappointed that the Government did not do more to encourage health care professionals to go into those management roles. If more doctors and senior nurses had gone into trusts as managers, many of the public fears that we are now experiencing and with which we are having to cope would have been substantially allayed. Bureaucracy is a matter which should be addressed.

I fear that the climate of fear, to which reference has been made, is creeping into the national health service in a way that I would never previously have thought possible. Members of staff are beginning to say that they would like to come to my public meetings and say what they think, but they have their jobs to consider. Such a suggestion would have been strange, foreign and unheard of 10 years ago. However, such people now fear for their jobs and that is a bad thing.

Finally, I make a plea to the Minister, who I am glad to see is making assiduous notes. I am also pleased to see his colleague, the Under-Secretary of State for Scotland, the hon. Member for Edinburgh, West (Lord James Douglas-Hamilton). I have a completely lunatic situation in my constituency. Recently, the Borders health board entered into an arrangement with a bona fide, non-profit-making partnership to run a nursing home, using an NHS hospital at Drumlanrig in Hawick that looked after old people. The Minister knows what I am talking about. The board signed a contract with the non-profit-making organisation to deliver residential care in that NHS hospital, which, apart from a couple of acute beds, was denied to the health service.

As part of that contract, the organisation undertook to build a 36-bed residential unit costing millions of pounds. It was to be a state-of-the-art and most welcome addition to the town's residential care needs. The week that it opened, the health board announced that it was beginning consultations on a number of options, the preferred one being to turn that residential home into a community hospital.

However one explains the management processes, from St. Andrew's house to the health board and local care in Hawick, that development makes no sense. The town has waited years for that brand new home, providing 36 places and state-of-the-art care, yet the week that facility opened, the health board said that it wanted to turn the home into a cottage hospital.

The Minister of State has not been in his job long, but I know that he has close connections with health care professionals and meets them most weekends, if he gets home at weekends these days. One does not need to be an expert to know the difference between a cottage hospital and a residential home. It is scandalous to suggest such a proposal, and that a town the size of Hawick, with 18,000 souls in the immediate vicinity, should be denied a custom-built primary care cottage hospital for the future. If Ministers are to be believed, primary care is the aspect that will be enhanced and developed in future. To provide a town the size of Hawick with a cobbled-together arrangement, with a residential unit being converted the week that it is opened, makes no sense.

I hope that Ministers from the Scottish Office—and I note that the Under-Secretary of State for Scotland is taking an interest—will investigate that matter and can give an assurance that the Borders health board will be given the opportunity, facilities and capital consents that it may require to ensure that Hawick will have both the residential care unit and the cottage hospital that it needs in the years ahead.

6.42 pm

Mr. Edward Garnier (Harborough)

The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) made a thoughtful speech, and I will take up his point about guidance relating to long-stay patients. I had a similar problem in my constituency.

Leicester has seen the closing of the Carlton Hayes and the Towers long-stay mental hospitals. Members of the Carlton Hayes action group visited my surgery to express their concern about the future for long-stay elderly patients and about the Department's so-called guidance. Their fears were allayed because the health authority's chief executive displayed sensitivity, met patients and their families, and was able to interpret the rules in a way that neither offended the patients' long-term hopes nor breached the guidance, to reach a compromise that was entirely within the rules.

The hon. Member for Roxburgh and Berwickshire said that there should be openness and contact between health authority managers and patients and their relatives. That point was well made, and was well satisfied in the case that I cited. I commend to my hon. Friend the Minister the sensible handling of that problem by the chief executive of Leicestershire's health authority. That problem was solved thanks to sensitive and sensible behaviour by all parties. I am grateful to the Government for providing rules that allow for flexibility.

It is the duty of all who comment on the Government's behaviour and reforms to consider what has been achieved rather than to put up Aunt Sallies. I will outline some of the good developments that have occurred over the past few years thanks to the reforms. National health trusts treat 3,000 more patients every day than before the reforms were introduced. Since April 1991, the number of hospital in-patients has risen by 1.3 million a year, and out-patient attendances have increased by 2.1 million. The population of Leicester is about 650,000, which gives some idea of the scale of the increase in in-patients.

Since the reforms, the number of people waiting for hospital treatment longer than one year has fallen from 170,000 to fewer than 65,000, and the average waiting time has been cut by half. A survey by the National Association of Health Authorities and Trusts in June showed that nine out of 10 patients who had attended hospital the previous year had found the service very good, good or average, and three out of four had found it to be very good or good.

I conducted a similar survey in m\y own constituency, by having questionnaires delivered to every household—and I have approximately 79,500 electors. There was a large number of replies, and the proportion of respondents saying that they were pleased with the performance of the NHS was even higher than nine out of 10. I hope that it is accepted by the House that patients are happy with the conduct of the health service. Members of the public and others nationally and internationally have also commented favourably.

My right hon. Friend the Secretary of State referred to the comments of the Organisation for Economic Co-operation and Development. I will quote a short passage from page 65 of its July report: The command and control system of the NHS lacked flexibility, incentives for efficiency, financial information (and hence accountability) and choice of providers of secondary care … Consultants with lifetime positions in hospitals had little incentive to run a service more effectively. There was little incentive to use buildings economically as they had always been paid for by the Government … reliable per unit capital costs were generally absent. It added that the reforms opened up possibilities to overcome some of the weaknesses of the old NHS and highlighted the improvements introduced by NHS trusts and GP fundholders, who do seem to have done a better job of purchasing than district health authorities. It reported also that recent national attitude surveys suggest some increase in satisfaction with the way in which the NHS is run, both among recent users of the service and among the population as a whole". That is confirmed by my local survey.

My right hon. Friend mentioned also the remarks of the founder of the Socialist Philosophy Group, Professor Le Grand, who made this clear: Central planning was not a conspicuous success in the old health service; decentralised sources of information close to local needs, like GP fund-holders, may provide a better base for long-term decisions than a centralised planning agency. I could not agree more. Professor Le Grand thinks also that "many, perhaps most" health policy analysts believe that the reforms have been a success. That view was attributed to him by The Times on 6 April.

I suggest that the general picture is one of satisfaction and approval of the way in which the national health service reforms are delivering care to patients. The Government spend huge sums of money on the national health service on the taxpayers' behalf—£100 million a day. That is why a strong management is required to improve efficiency and services for patients. Some £1.5 billion in cumulative efficiency savings has been realised since the mid-1980s, when the Government began strengthening NHS management.

The Government have taken tough action and will continue, I trust, to eliminate unnecessary administrative duplication and waste in the national health service. I trust that before very long we shall see the abolition of regional health authorities and the merger of many district and family health services authorities. I am pleased to note that already the number of regions has fallen from 14 to eight, and when eight regional offices replace the regions, they will employ a total of 1,080 people, as compared with the 3,900 employed in 14 regions two years ago. In the past two years, the number of district health authorities has been reduced by 70 to 111. That has meant that administrative savings at regional and district level have released a total of £34 million to date. That money, instead of being spent on teacups, trolleys and filing cabinets, can be spent on direct patient care.

Earlier this month, my right hon. Friend announced that NHS trusts will publish in their annual reports how much they spend on management. To enable the public to see and compare those figures, they will be published alongside NHS performance tables.

A further improvement is that general and senior managers now account for only 2.6 of the NHS work force and 3 per cent. of the wages bill. The vast proportion of the NHS wages budget now goes on staff who provide care directly to patients. For your information, Mr. Deputy Speaker, the proportion of NHS staff who provide care directly to patients has increased from 60 per cent. in 1981 to almost 66 per cent. now.

One further improvement is that, earlier in the year, the Government published codes of conduct and accountability for NHS boards and other members, covering such areas as remuneration and declaration of interest. All trusts and health authorities have been requested to incorporate those matters in their standing orders.

The whole flavour of the national health service reforms and the whole purpose behind them is to increase the priority of the patient as opposed to the providers of the service. We now have 419 NHS trusts in operation and there are good examples of those trusts in my own area of Leicester. We have the Leicester Royal Infirmary trust, the Leicester General Hospital trust and the Glen-field trust. The three major acute hospitals are now all under trust management. Furthermore, the Fosse trust covers the community hospitals and many of the GP practices. The system is working and it is seen to be working, but the ultimate test of the success of the new arrangements is whether they have increased the quality and the quantity of patient care. I would suggest that that is precisely what they have done.

Since April 1991, when the trusts began, the number of hospital in-patients has risen by 1.3 million a year and the number of out-patient attendances by 2.1 million—figures which I mentioned at the start of my remarks. In daily terms, that means that 3,000 more patients are treated every day. If that is not a benefit of the reforms, I do not know what is. Since April 1991, the number of patients waiting over one year for hospital treatment has more than halved, to under 65,000. That means that, since March 1988, the average waiting time for all patients has been cut by half—to 4.6 months in March 1994. Waits of more than two years have been all but eliminated, as I am sure my hon. Friend the Minister will be able to confirm later. No one now has to wait for longer than 18 months for a hip or knee replacement or a cataract operation and 80 per cent. of patients are seen within 30 minutes of their appointment time, as set out in the patients charter. I can confirm that national figure from my visits to my local major hospitals, where one can see that the waiting times have been vastly reduced in the past few years. One can now go to hospital and expect to be seen at the time at which one is booked in to be seen—and that is under a national health system, not a private BUPA system.

At the party conference earlier this month, my right hon. Friend announced that a new expanded patients charter will offer an even greater dividend for patients, with a new national standard for out-patient appointments and a maximum 18-month waiting time for every operation. Already, half the total number of patients are seen immediately; half the remainder are seen within five weeks; almost 75 per cent. are seen within three months; and 98 per cent. are seen within a year.

Those improvements are a direct consequence of the Government's reforms. They flow from the reforms because the new system involves the devolution of decision-making power to local level: they give doctors and NHS managers living in the community the freedom to innovate and to improve patient services. The whole system is driven by the district health authorities and the GPs at local level—those who control the money that the trusts receive. They are developing ways in which to respond more closely than ever to the needs and wishes of the communities that they serve. The GP fundholding initiative in particular has involved a devolution of power to those closest to the patients.

Mr. Iain Duncan Smith (Chingford)

Does my hon. Friend agree that often when criticisms are made—and there may be some legitimate criticisms of some of the changes—it is also said that everything was perfect in the past? For example, people say that access to information was excellent and that identifying who was responsible for what was very easy, when in fact quite the reverse was true? In many senses, breaking everything down and devolving it has made it much easier to identify who is responsible for the treatment and—now that the accounts are published—where the money is flowing. Does not my hon. Friend agree that that has been a massive improvement?

Mr. Garnier

Yes, I do agree, and I am most grateful to my hon. Friend for that intervention. The responses to my survey in my constituency underline the point that my hon. Friend has just made.

I wish also to commend the Government for providing better accountability in the national health service. That subject has been mentioned also by Labour Members, who have complained that that is not the case. I beg to differ from them and will seek to persuade the House that there is better accountability. The NHS reforms have already led to significant strengthening of the accountability of the health service to the patients whom it serves. That is the whole point of the national health service. It is there for the patients. It is not a job provider; it is a patient carer.

The patients charter sets out in black and white the rights enjoyed by patients and the means of redress when things go wrong. The split between the providers of health care and the health care commissioners, to whom hospitals are accountable and whose role it is to promote the interests of patients, means that the service is now largely patient driven. Again, I have seen that in my constituency. I see it at my advice surgeries, where people thank me—quite unnecessarily, because I have not done anything— for the good work of the national health service in our local hospitals. [HON. MEMBERS: "Come on."] Hon. Members may scoff, but that is a fact. I am not in the business of misleading the House. Constituents of mine have come into my surgery time after time to commend the work of the national health service. It is fair to say that even the Opposition nowadays agree—the hon. Member for Roxburgh and Berwickshire certainly agrees—that there is a case to be made for, and even a case for accepting, the need for a split between purchasers and providers of care.

Hospitals are now much more accountable for the use of taxpayers' money through their contracts with health authorities and GP fundholders. Under the old system, few hospitals knew what individual treatments cost, as my hon. Friend the Member for Chingford (Mr. Duncan Smith) has just pointed out. Few felt the need to know because they were not held properly accountable. Most people simply did not know how to find out information; there was a great black wall of bureaucracy which they could not penetrate.

Mr. Turner

Talking of bureaucracy, the hon. Gentleman will have heard this week of the record pay-out in respect of a very serious accident that happened to a young man in Wolverhampton. Some £2 million of compensation has had to be paid or is to be paid. It has taken 14 years of bureaucracy for that case to be heard and settled. Is that the accountability in the health service and the lack of bureaucracy about which the hon. Gentleman is telling us? It has taken 14 long years—a scandal—for that case to be heard and dealt with. Where is the justice, accountability or lack of bureaucracy in that case?

Mr. Garnier

With respect, I think that the hon. Gentleman must be taking part in a different debate. What is more, 11 of the 13 years to which he referred—or however many it was—were pre-reform. But I digress: I will not be diverted by the hon. Gentleman. I have no doubt that, if he has a sensible point to make, he will try to catch your eye in due course, Mr. Deputy Speaker.

I see that the hon. Gentleman is now leaving the Chamber. No, he has returned, and is approaching the Front Bench. I am delighted that his intervention has led to instant promotion; I trust that he will go further.

Decision making has been devolved to levels much closer to the patient, particularly—as I suggested a moment ago—to GPs, through fundholding. As I was saying before I was interrupted, those making the decisions are better able to assess patients' needs. More information is available to patients and the public than ever before, enabling them to make more important decisions.

The Government's NHS reforms allow the Government and NHS managers to listen to the needs of the public. They have listened to those needs, as is clear from the example that I gave the hon. Member for Roxburgh and Berwickshire. I have no doubt that Ministers have that at the forefront of their minds. I am much fortified by the assurance given by my right hon. Friend the Prime Minister at the Conservative party conference that the national health service was safe for as long as he was alive and breathing: he is a young man, and I wish him a long stay in office.

I am certain that, when the time comes, the national health service will be available to me in my old age. I trust that the Minister will continue his good work, and ensure that the public still have the confidence in the NHS that my constituents have shown—as I have no doubt they will.

7.1 pm

Mr. Gerry Steinberg (City of Durham)

The gigantic programme of change brought about by the health service reforms will have implications for nearly every patient and member of staff. In Durham, the merger of the district health authorities, the abolition of the regional health authority and the plans for a new district general hospital represent an era of change unprecedented since the formation of the national health service.

I am delighted that there is to be a new hospital in the city of Durham, and that the new regional office will be sited there as well: that will create many welcome jobs. But what is going on behind the scenes of these changes? Will these major developments enhance the range and quality of hospital services locally available to the people of Durham?

The changes are market led, not customer led. The internal market is rapidly reshaping the health service, fundamentally changing the nature and quality of services and undermining the ideals that underpin the NHS—that health care is available to all, that money does not buy better or quicker treatment and that patients are treated locally if that is what suits them best.

Let me refer specifically to the proposed new Durham hospital. I hope that the Minister will take careful note of what I am going to say. I am disgusted and outraged by the latest decision on how the hospital is to be funded.

Soon after I was first elected to Parliament in 1987, plans for a new district general hospital were discussed—although the hospital had been proposed even earlier. Capital expenditure in Durham district health authority had been miserly over the years in comparison with that of other district health authorities in the region. For example, Durham was among the bottom six of 16 districts, with a spend of less than £15 million in 1989; only £2.5 million extra was spent between 1982 and 1989. In contrast, Newcastle district health authority was allowed to spend nearly £59 million in 1989, £9 million extra being spent between 1982 and 1989.

Even if we add the capital expenditure of North-West Durham district health authority—which is now part of the new Durham authority, and which was bottom of the table with a total spend of only £3.8 million in 1989, with virtually no increase since 1982—it is clear that both authorities have been allowed very little capital expenditure over the years.

Until a few weeks ago, it seemed that at last—after seven years—the hospital was ready to be built. Detailed business plans were drawn up and it was a case of looking to the Government for the capital expenditure. However, the Government have dashed hopes that funds for the proposed North Durham hospital would be approved by the end of the year. They are now insisting that a private sector bid for planning, building and running all but the core medical services must be included with the business plan. That is completely contrary to what the authorities had already been told; the decision, which is now expected to delay the bid for over a year, has ruined the plans for the hospital and delayed them even further.

The business plan had been prepared at a cost of about £500,000. It had forecast the start of building work by 1996, with patients being admitted by 1999. Not only have the plans been delayed, however; they have been forced down the road to privatisation. The hospital managers of North Durham acute hospital trust hoped to receive the plans for go-ahead this year and hoped that the first phase, costing approximately £44 million—building next to the existing hospital—would start even before 1996. For the hospital authorities now to be told that their plans have been dashed, and that a new financing system is to be introduced, is a scandal and a disgrace, and has set the hospital back further.

Not only has the new hospital been delayed; all the money spent on plans—including the business plan—has been a complete waste. For the Government to insist that private money builds a hospital is nothing more than privatisation of that hospital, and privatisation of the health service in Durham. Whichever way we look at it, if the private sector builds the hospital the private sector will expect to profit from it after it is built. That means that the private sector will run the hospital, and that therefore the hospital will run on a basis of profit rather than health care.

If the hospital is not making a profit in certain areas, its owners will insist that the managers drop the service concerned and dictate where profitable services may be found. That could lead to a cut in non-profitable services, such as care for the elderly, and to decisions on medical care being taken not by doctors and consultants but by property developers and business men. If that is not privatisation, I do not know what is.

So much for the Prime Minister's statement at the Tory party conference that the national health service would never be privatised while he lived and breathed. The proposed new North Durham district hospital is being used as a guinea pig for new financing arrangements, and my constituents will have to suffer—now and later. I ask the Minister to meet me, along with other hon. Members, in the Durham area, to discuss the new proposals; I should be grateful if he would give me some indication of his response this evening.

Mr. Malone

I should be delighted.

Mr. Steinberg

The speed of the Minister's response has taken my breath away, but I am glad that he has acceded to my request.

Under the new regional structure, the NHS executive's new regional offices will be responsible for purchasers and providers of primary and secondary care. The executive, with its single structure of regional offices—each with no more than 135 staff—will take on responsibility for all policy development in relation to the NHS. At local level, health authorities will evaluate health care needs. Major objectives will be delivered through corporate contracts between health authorities and the NHS executive.

Trusts are primarily accountable to purchasers for the delivery of care through NHS contracts. They will be held to account by the provider arm of the NHS executive regional offices for meeting their statutory financial duties: in other words, there will no longer be any democratic accountability in local health care provision. There will be limited direct monitoring by regional offices of certain non-financial aspects of trusts' performance which cannot be pursued through NHS contracts, including national policy initiatives such as Opportunity 2000 and junior doctors' hours.

Once regional health authorities are abolished, all appointments to district health authorities, family health services authorities, new health authorities and trusts will be formally made by the Secretary of State. Far from localising decisions, we will see a considerable move of power to the centre and political domination by the Secretary of State.

With the abolition of RHAs, the emphasis will shift from a regional picture to the performance of individual health authorities and trusts which are unaccountable. National health service executive headquarters will establish an accountability framework for the NHS to be set out in a statement of responsibilities and accountabilities. Chief executives of health authorities and trusts are to be designated as accountable officers who will be accountable to Parliament for the use of all funds in their charge. Purchasers will provide information to those interested in their activities, including Members of Parliament, the public and the press. By any stretch of the imagination, that cannot be a democratic or acceptable system of accountability.

Undoubtedly, a hospital trust has the financial interest of the hospital ahead of the health needs of patients and the pay and conditions of staff. There is already a trend towards low-paid, casual work and job insecurity. The cost-cutting measures of the market depress pay levels and by that means providers can offer cheaper services to purchasers through being more competitive.

The rosy picture of staff morale in Durham hospitals painted by the Secretary of State is not familiar to me. Recently, we saw the regional health authority attempt to buy off nurses in a grading dispute. The health authority offered a blanket £700 to each claimant in exchange for dropping the claim. It is nothing more than a cash-oriented scam. Many of the nurses waited years for a fair hearing at a grading appeal to recognise their additional responsibilities. In today's health service, there appears to be little scope for fairness. The health authority did its sums and pressed nurses to drop their claims in an unprincipled attempt to cut its losses. The nurses were given a deadline to accept the offer and were advised that refusal could result in a two-year wait for their grading appeal to be heard. Many nurses accepted the cash offered rather than face a further delay. Almost 2,000 of the nurses had already been waiting for five years.

That action is further evidence of the abandonment of long-established public service traditions in favour of the "money talks" philosophy that we see in the health service under this Government.

One of the first staff-related decisions made by the acute hospital trust in Durham was to replace skilled staff with cheaper and fewer staff. Staff are being treated as disposable units and are being used to make savings by reducing wage costs and job security. Auxiliaries, ward clerks and ward aids were replaced by what are called team assistants. The team assistants are to be recruited from jobcentres and are not required to have any previous experience in the health service. They will receive in-house training, but the complete training course lasts only 11 months or even less for successful students.

The new post will be more qualified than an auxiliary but less qualified than an enrolled nurse and most post holders will have no previous experience in the health service. The new post holders will not be offered Whitley council employment and service conditions. Their conditions will be imposed upon them. For example, they will have only seven weeks holiday a year, including time off for sickness. Any further absences after seven weeks will mean a loss of pay. Given the nature of the work and the stress involved, that is an erosion of the rights that they have enjoyed for years. I do not see that as progress through reforms.

A further erosion of their rights is that the 37-hour working week will be stretched to six days instead of five. Although that means shorter shifts, it means that an extra working day will be imposed for the same money. There is to be an overall pay decrease and special duty payments have been scrapped for night and weekend work. There will be no pay structure except at the whim of management with increments being awarded on merit. A bribe will be offered to the present work force with a one-off payment if they sign away their Whitley conditions.

A system of internal rotation has been introduced where nurses who previously worked only night shifts must now work day duty and vice versa. That is all at the whim of the sister in charge of the ward. To make matters worse, nurses who did two complete night shifts are now being forced to do five nights with four hour shifts, finishing at one o'clock in the morning. That means that nurses have to return home alone in the early hours of the morning. That is unsafe and has been forced upon them. The nurses who gave me this information pleaded with me not to reveal my source because they believed that they would be sacked.

At a meeting, the chairman of the hospital trust indicated that workers' rights were important. However, it seems that the new system is being imposed without real negotiation and will be implemented regardless of trade union opinion. The guarantees given to me seem worthless. I wonder whether the guarantee that he gave about not sacking anybody who spoke to me rings true. I would not dare take a chance and reveal any source of my information.

Secrecy surrounds the appointment of board members to the newly formed health trusts in county Durham. I was notified of the trust membership of the community health service, acute hospitals unit and the ambulance service. I was not objecting to individual appointments, but I inquired about the process of selection. I was particularly interested in the full list of nominations that had been received for trust membership so that I would be able to judge the criteria upon which the successful board members had been appointed. I was astounded to be told by the management of each service that the list of nominations was privileged information and could not be released. That is disgraceful.

Those boards will run the vast majority of health services for the people of Durham, yet I am told that secrecy surrounds who was considered and how the appointments were made. That contrasts dreadfully with local government, where councillors are selected by the people and all nominations are open to public scrutiny. The chair of the ambulance trust in Durham is a very nice lady. I have met her and I got on very well with her. However, she is a failed Tory candidate for local government. How and on what grounds was she appointed? What are her qualifications? We do not know because they will not tell us. Her qualification is that she is a supporter of the Tory party and she was appointed on that basis. That is scandalous.

In my constituency, there has not been a single Tory elected to the district council, which consists of 49 councillors, or to Durham county council. However, two of the ambulance trust members are Tory party members. That is a slap in the face for the people of Durham, who consistently vote against Tory representation. They do not want the Tories, but they are lumbered with them.

Mr. Michael Carttiss (Great Yarmouth)

Is the hon. Gentleman suggesting that in an area where one party is dominant, such as in Durham and in some parts of the country where, until recently, the Conservative party might have been dominant, nobody with a different political affiliation should be appointed to hospital trusts or any other body responsible for the health service? Is he saying that because the people in Durham are silly enough to vote Labour, no Conservative should be appointed there, even though some people in Durham do vote Conservative?

Mr. Steinberg

The people who vote Conservative in Durham could probably be counted on one hand. I am saying that it seems strange that in an area that predominantly votes Labour, two Tories are placed on the board of the ambulance trust and one is made its chairperson. I am not against those individuals. In fact, I get on well with them. One was the leader of the Tories in Durham. My point is that when I asked for information about how and why those people had been elected, I was told basically to mind my own business. I can assume only that they were appointed because they were Tories. I would have been satisfied if I had received an explanation of why they had been appointed or if I had been given their credentials for serving on boards. The system as it stands, however, is non-democratic and unaccountable and, therefore, it must change. It is perceived that the appointments of those people are a political favour. I am sure that Conservative Members cannot be happy with such a position.

Mr. Rowe

I have a lot of sympathy for what the hon. Gentleman says. There is great deal to be said for being entirely open about trust appointments. In the early stages of the trusts, there is bound to be a presupposition that people who approve of trusts rather than those who do not will be appointed.

Mr. Steinberg

That is a fair point. I was asked by the chairman of the regional health authority whether I would be prepared to propose nominees for the trust board. I duly nominated a number of Labour party members who would like to serve on trust boards. That was the last that I heard of the matter. No reason was given as to why they were not picked or why the Tories were. That must lead to suspicion.

Mr. Duncan Smith

May I press the hon. Gentleman on this point? He said that he nominated a number of Labour party people. When he nominated them, did it occur to him whether those people would do an efficient job?

Mr. Steinberg

I assure the hon. Gentleman that one of the members who I nominated was the former vice-chairman of the district health authority. He had been removed by the Secretary of State when the new district health authority was set up.

Mr. Bayley

Purged is the word.

Mr. Steinberg

Sorry, he had been purged. I nominated someone with a tremendous amount of experience.

My relationship with the trusts is excellent. I work well with them, but they are not accountable. We do not know why the appointees were chosen and we do not know what their qualifications are for holding their positions. That is an unhealthy state of affairs. It can be put right only by a more accountable system in which trust members are elected by the people whom they serve. They should riot chosen by the Secretary of State for Health purely on the basis of the political party that they support—in this case, the Tory party. I do not wish my views to be taken as a personal slur on any trust appointees, but I believe, as a matter of principle, that greater public accountability is needed in this process.

Patients do not have the freedom to attend a hospital of their choice. General practitioners cannot refer them to the consultant of their choice. I should like to give an example of an appalling problem that occurred in my constituency. A 70-year-old lady had a heart attack and she had to bussed to the next county to receive emergency treatment. When she became ill at midnight, she was attended by what I call a night-shift doctor from the GP's practice who was unable to obtain her admission to the local hospital. It refused her admission because it did not have a bed for an old lady who was having a heart attack.

Her husband's wish to accompany her to an accessible hospital led to an inquiry in the next county, but that was also refused. Eventually, the ambulance took her to a different hospital in the county unaccompanied by her husband. Ambulancemen told the old gentleman that if he went with his wife at 1 o'clock in the morning, they could not get him back home. He had to wait at home while his wife was shipped off to the end of the county. That is an outrageous and intolerable position. An elderly man was left grief stricken while his wife was shipped off to the other end of the county.

Unfortunately, that is likely to be regular occurrence now that the hospital has been granted trust status. That is the sort of health care that the reforms have brought. Durham's hospitals should care for the people of Durham. The Government have wasted millions of pounds on expensive management studies and bureaucratic procedures in the health service, yet they have got the basic things wrong. Why should elderly people be treated like second-class citizens? Things are going from bad to worse.

There is little distinction between private and national health care. No patient can be accepted by a trust hospital unless someone pays the bill. We are assured that the health service will not be privatised, but few people believe it.

7.24 pm

Dr. Charles Goodson-Wickes (Wimbledon)

Durham is a long way from my constituency, but I note that my hon. Friend the Minister, whom I welcome to his new post, has already acknowledged the points that have been raised and shown his willingness, and that of his colleagues, to listen to them. That is the new listening national health service, if I can call it that.

A distinguished medical colleague said to me recently that treating patients is a great deal easier than running the national health service. As a physician, I acknowledge the difficulties addressed by my right hon. Friend the Secretary of State for Health.

When I became a medical student 30 years ago, I could not possibly have imagined the nature and pace of change, either professionally or administratively, especially in the past few years, but changes there had to be. For far too long, the NHS thought itself immune from challenge. Indeed, any challenge precipitated the wheeling out of Nye Bevan and was portrayed emotionally as a betrayal of the ethos of those people who set up the NHS.

Those of us who worked in the NHS knew otherwise. Paternalism, from consultants downwards, had too often turned into a patronising attitude. Patients were led to believe that they should be grateful to be treated at all. Often, scant attention was paid to the timing of their appointments and admissions and they were often treated less well as people than one would expect. If that sounds over-critical, I should balance it by saying that those same patients received some of the best medical, nursing and ancillary treatment in the world.

The publication of the White Paper "Working for Patients" was the watershed. New thinking had to be applied to a service which, as everyone had come to recognise, was subject to unlimited demands and that, paradoxically, increased in line with further medical and surgical sophistication.

As new treatments became available, waiting lists inevitably increased. General practitioners felt frustrated and hospitals were overstretched. Hospitals often found themselves in the wrong place because of demographic movements and changes in catchment areas. Rationalisation, particularly in London, was long overdue. Therefore, the Government, introduced new concepts, initially perhaps rather tentatively, which soon gathered a momentum of their own.

The achievements are worth restating. NHS trusts forced the introduction of proper management techniques and accountability. No longer were investigations ordered without regard to cost and usefulness. No longer were waste and poor stock-keeping tolerated. Attention was at last paid to the cost of stays in hospitals, which was linked appropriately to the development of day surgery, a theme that I have developed in the House before. Lastly, compulsory competitive tendering, introduced by the Government, promoted efficiency and ensured that the maximum resources were available for patient treatment.

GP fundholders were another great innovation. I remember attending highly charged meetings in my constituency with GPs who were apprehensive about having to manage their own affairs and about making use of the purchaser-provider split in the internal market. I understood their concerns and you, Mr. Deputy Speaker, would also have understood them. Like them, I had grown up in the NHS, of which it really was true to say that doctors tended to know the value of everything and the cost of nothing. They certainly knew the value of all sorts of human and scientific factors but few of us knew the cost of anything, whether of a day's stay in hospital, of drugs that we prescribed, of dressings that were applied by staff or of investigations for which we daily wrote forms.

Hon. Members know that the waves of NHS trust applications gathered a momentum of their own. I welcome the announcement of my right hon. Friend the Secretary of State for Health at the party conference that, in response to demand, the threshold for GP fundholders would be lowered to 5,000 patients on a list. Those changes truly represent market forces at work as doctors and, more importantly, patients see the benefits of the reforms. I can speak personally of those benefits because I and all four members of my family have been in-patients under the NHS at Bart's hospital during the Government's term of office.

Who did nothing but carp and criticise? The Labour party and, I am ashamed to say, my union, the British Medical Association. The classic socialist arguments were trotted out. The changes were described as creating a two-tier service as though all those benefiting from fundholding practices should be deprived simply because if everyone cannot benefit, no one should benefit. I suspect that that type of egalitarian thinking will survive in the Labour party long after any cosmetic surgery has been carried out on clause IV. The hon. Member for Newcastle upon Tyne, East (Mr. Brown) appears to be nodding in agreement.

Mr. Nicholas Brown

Our argument is that everyone should be treated the same.

Dr. Goodson-Wickes

That is our aspiration as well. The hon. Member was obviously not listening to what I said. The Labour party has always maintained that one cannot have a two-tier service during a transition that provides a one-tier levelling up. Over the years, socialism, on the contrary, has persistently been all about levelling down.

Mr. Tom Clarke

I must say that what the hon. Gentleman said did not sound like that to me. When he talked earlier about the difference between value and price, which was more important to him?

Dr. Goodson-Wickes

I know that the hon. Gentleman was listening attentively, so he will know that I was talking about human values as opposed to financial costs.

It is interesting to consider the attitude of the BMA in this saga. On Saturday 6 August, the British Medical Journal published a leader entitled: Where now for the NHS reforms? I suppose that as the BMA is producing its own magazine, it is not at the mercy of anyone else and its staff can write the sub-headings to any articles. The sub-heading to that leader was: Making them up as they go along. If that sub-heading does not make that leader a political tract at first sight, I wonder what it does. The article stated: For many managers and professionals in the NHS, this has meant a period of learning by doing in which the importance of GP fund-holding, NHS trusts, and similar initiatives have been discovered in the process of making the reforms work. Where these changes will take the NHS is unclear even (or perhaps especially) to those at the heart of government … To this extent, the changes introduced by Working for Patients are out of control, with development; being driven from the bottom up not from the top down. And yet. Despite the overwhelming evidence of confusion and inconsistency at the centre of the NHS, there are those who argue that the reforms are guided by a master plan". That is a load of gobbledegook, unworthy of the usual stringent editing of the BMJ. The BMA cannot have it both ways—it cannot criticise reforms instigated from the bottom up while, on the other hand, accusing the Secretary of State by implication of imposing some master plan from above.

The article in the BMJ asked What should be done? Firstly, Ministers should assess the founding principles of the NHS for their relevance today. I do not know how good the right hon. Member for Derby, South (Mrs. Beckett) is at her history, but I did a bit of research and found out that one of the main criticisms levelled by the Labour party has been directed at the Government's theme of money following the patient. I challenge any of the health intellectuals on the Opposition Benches to give me the provenance of that phrase. I am met with a lot of blank faces, so let me educate those hon. Members. That phrase came straight from Nye Bevan, who, when speaking about local hospitals, said: the endowment of that local hospital follows the patient"—[Official Report, 26 July 1946; Vol.426, c.470.] I recommend that phrase to the Opposition and I hope that the concept of money following the patient will no longer be criticised as a Conservative philosophy.

Mr. Bayley

When Nye Bevan was speaking, the money did follow the patient because the doctor could refer the patient to any hospital. The funding that that hospital received depended on the number of patients that it had. Now, of course, money does not follow the patient. The doctor sets a contract with various providers and the patient cannot exercise choice by going to whichever hospital he believes is the best—that is the nature of the internal market.

Dr. Goodson-Wickes

The hon. Member is obviously not an expert because he knows nothing about extra-contractual referrals.

We have heard cries from the Opposition about creeping privatisation and commercialisation, despite the categorical assurances of my right hon. Friend the Prime Minister that the Government have no intention of privatising the NHS. My health interests are registered in the Register of Members' Interests, about which we have to be so careful nowadays, and I am proud to be associated with a public company that is working closely with local authorities to deliver an excellent standard of community care. It allows patients to be treated with dignity in the best possible environment. I also greatly welcome the fact that the company is competing not only with other companies but with in-house services.

The new-look Labour party may admit to synergy between the public and private sectors in the NHS, as it does in other sectors. I challenge the Opposition to come clean. What do they really believe about co-operation between the private and public sectors?

I do not know whether the right hon. Member for Derby, South believes that there is a place for the private sector in the NHS. However, I recently found out that her predecessor, now disposed of, the hon. Member for Sheffield, Brightside (Mr. Blunkett) did not seem to have any qualms about such co-operation. Dental Practice reported that, last year, the hon. Member opened a dental practice called Shiregreen, in Sheffield, within the largest public housing scheme in Europe. The magazine described how a private patient suite and private office were located on the first floor of that practice. I hope that when the right hon. Member for Derby, South replies to the debate she will clarify her party's views on such co-operation.

Mrs. Beckett

I opened the debate; I will not be winding it up.

Dr. Goodson-Wickes

Perhaps she will clarify her party's views in due course.

What I find most frustrating in any debate on the NHS—we have all heard the interminable debates that have gone on—is the lack of good news that is described as such. In my constituency I have several good examples of such news. The St. Helier NHS trust, together with St. George's Hospital trust and the Kingston Hospital NHS trust, is responsible for the care of my constituents. It is an extremely successful trust and it is proposing possible new plans under the private sector finance initiative to transform the delivery of health care in south-west London. That is excellent news in itself and it may involve other hospitals, but it would be wrong of me to mention those in other hon. Members' constituencies.

Atkinson Morley's hospital in my constituency is recognised as a centre of excellence throughout the world and it is quite possible that it may find its eventual home within the new set-up pioneered by the St. Helier hospital trust. I commend that trust for the work that it is doing on that project. Nelson hospital in my constituency is a small, old-fashioned hospital which is held in enormous affection by my constituents. Its obituary notice has been written prematurely many times. At last, there is a proposal before the local council for that hospital to benefit from an entirely new build. I submit that there could hardly be a better index of faith in its future.

The new plans incorporate increasing the number of out-patient consulting rooms from seven to 10 and the number of places for day treatment for the elderly from 20 to 30, and doubling the operating theatres from one to two. Moreover, my constituents will benefit from locally available physiotherapy, occupational therapy and x-ray facilities.

Mr. MacShane

I can cite examples in Rotherham of an increasing number of beds and positive work accomplished in the NHS. What concerns me and should concern the Minister of State who will wind up, as he is a former journalist and Scottish editor of The Sunday Times, is the fact that when consultants, physicians and nursing staff in Rotherham district general hospital tell me things and I say that we shall discuss them publicly, they say that we cannot. That is a gagging of discussion inside the NHS by a Government who talk about decentralisation and improving information flow but who will not allow the people who know about those matters to express their views in the public domain. I am happy to represent the staff of Rotherham hospital, but I should prefer the Government to lift the gagging and allow consultants, doctors and nurses to speak for themselves in public debate.

Dr. Goodson-Wickes

I cannot speak for the hon. Gentleman's constituency of Rotherham. I can simply say that once the plans servicing my constituency are worked out, they will go to full and very public consultation. I imagine that that pattern is reproduced elsewhere.

A recent MORI poll shows that doctors are the most trusted profession. At the other end of the table, politicians are the least trusted. I believe that politicians are now on a par with journalists and, in the light of recent events, I am not certain whether the position at the bottom of the table has changed. Those of us who are both physicians and politicians must be somewhat schizophrenic. Speaking as a doctor and a politician, I welcome the reforms, knowing them to be for the benefit of the only person who matters in all our deliberations—the patient.

7.41 pm

Ms Tessa Jowell (Dulwich)

I, too, am pleased to take part in this debate and should like to record my interest as an adviser to the Royal College of Nursing. Like the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), who spoke earlier, I am a member of its parliamentary panel.

Such is the collapse of public confidence in the Government's management of the health service that every week my constituents come to my advice services or write to me to express their fear and fury about what is happening. The Secretary of State prefers press conferences to Parliament and a mantra of statistics and jargonese that causes bewilderment to even the most hardened bureaucrat or journalist. Recently, when she appeared before the Health Select Committee and was challenged about where support came from for her health reforms, she conceded that some members of the public may be "counter intuitive" to the changes. However, she went on to say that trust chairmen were always telling her how wonderful the NHS reforms were. Too right, as she appointed them and rescued many of them from oblivion after a general election defeat.

It is because the NHS now seems to be run by a deadly combination of the Secretary of State's fantasy and a new breed of bureaucrat that patients and the public—that means all of us—are so alarmed. If public confidence in the national health service is as high as Conservative Members would have us believe, why has there been such a sharp increase in the number of people taking out private health insurance?

Another major aspect of our debate today is the increase in bureaucracy. My hon. Friend the Member for Newham, North-East (Mr. Timms) has already referred to CELFACS. A constituent of mine recently sent me a list of vacancies within the corporate services for CELFACS. Anybody who believes that the patient is still at the heart of our national health service should take a look at the 31 job descriptions, which include the assistant director of financial management; the assistant director of financial services; the financial accountant; the finance manager; the contracting systems and development accountant; the debtors' cash management accountant; the assistant management accountant; the public relations manager; and the press and public relations assistant. CELFACS has advertised 31 jobs, not one of which refers to patients in its job description.

Mr. Malone

That is a pretty stupid point to make. Advertisements for jobs for clinicians appear in another source called the British Medical Journal. If the hon. Lady is talking about over-management in the service, does she accept the fact that only 2.6 per cent. of those employed in the service are in management? That is a pretty small figure for a service that runs at a rate of £32 billion a year.

Ms Jowell

Given that the Health Ministers claim the NHS to have the patient at its heart, the fact that City and East London Family and Community Health Services has produced 31 job descriptions, none of which refers to patients, makes my point.

I recently received a letter from a local GP practice that serves many of my constituents. It said: On Monday evening the 10th of October 1994 at about 6.00 p.m. one GP trying to get an emergency admission for an elderly patient was told by the Registrar on call that there were no available beds at King's or Dulwich and that some eighteen patients were currently waiting on trolleys. Our patient was admitted to a ward at Dulwich at 5.00 a.m. on Tuesday the 11th of October. This practice of holding people for hours on trolleys in A&E seems to be commonplace and acceptable to the hospital but we do not believe that ill, elderly or vulnerable or distressed people should ever be treated in this manner.

Another reality that the Government systematically avoid is the well-documented crisis facing London's mental health services. During the summer, we heard from the Royal College of Psychiatrists that bed occupancy is running at a staggering 130 per cent. I pay tribute to the excellent work of the Mental Health Foundation in systematically analysing and providing data on the scale of the crisis facing the mental health services in London, with which all my hon. Friends who represent London constituencies deal daily.

A constituent of mine who is a mental health worker wrote to me recently: The bed situation in London is terrible. Our patients are frequently referred to private hospitals where they are known as 'outliers'. I understand that the bed in the private sector costs £500 a night which is more expensive than an NHS bed and the NHS has to pay for the bed. However, all our patients who go to these hospitals complain that the care they receive is poor. Their medication needs are just about met but they are excluded from group and occupational activities and the staffing ratios are poorer than in the NHS. More importantly they are patients we know well who have been treated by a team they do not know and over whom we"— the people who know them— have no control.

In south-east London, more than 43 per cent. of spending on medium secure beds is now in the private sector. Often, beds are more than 100 miles away, making a mockery of community-based care. A private bed costs between £80,000 and £87,000 a year and a national[health service bed in a medium secure unit about £70,000 a year, but with a much wider range of support services. The situation in south-east London is critical, with four times the national average number of people suffering from serious mental illness.

I shall happily give way if the Minister will now give an undertaking that the bid by the Southwark, Lambeth and Lewisham health commission for an additional 45 medium secure beds for south-east London will be funded when the bid is considered by South Thames regional health authority. I see that he is not rising to his feet to give the people of south-east London that assurance.

For those who doubt the oppressive hand of bureaucracy, I shall quote the words of a local general practitioner: In the inner city most of us do not have the premises to promote the Government Policy, and where the premises are available the time factor is still a problem. We are having to spend more and more of our time in form-filling and every week we are bombarded with new forms and charters. Instead of treating patients we are subjected to magazines from Health Authorities and Hospitals who are fighting for our custom with pretty pictures of their staff. All this bureaucracy costs money, but obviously the patient … is the least person to be considered. Waiting lists for treatment are lengthening. If I take again the example of my area, that covered by the Lambeth, Southwark and Lewisham health authority, as the number of available beds decreased between 1991–92 and the present by nearly 400, so waiting lists increased by 1,700, with an especially marked increase in the number of patients waiting up to one year.

That illustrates another piece of illogicality in the Government's policy about which they have chosen to do nothing—the problem created by the substantial increase in the number of emergency admissions. It is a national problem, which is biting especially hard in London. where hospitals are reporting as much as a 17 per cent. increase in emergency admissions.

A constituent who contacted me earlier this year had his hernia operation cancelled five times. He was suffering increasing pain. The explanation that he was offered by King's went as follows: Mr. D. was placed on the waiting list on the 9th of November 1993 and was first offered a date in December for his operation which unfortunately had to be cancelled as did two subsequent admissions planned for early February 1994 due to the extreme pressure on beds caused by very high numbers of emergency admissions and continuing problems caused by beds occupied by patients awaiting assessment by social services unable to be discharged. As the proportion of emergency admissions increases and the proportion of elective admissions decreases, hospitals need more beds to deal with the fluctuation in demand that is an inevitable part of handling pressures arising from emergencies.

In south-east London, bed occupancy regularly runs at between 96 and 98 per cent. That places an intolerable burden on the hospitals, which is evidenced by long trolley waits and the cancellation of patients' operations. By general consent, 85 per cent. bed occupancy is regarded as a manageable target.

Such a situation completely disrupts clinical priorities. Increasingly, patients will be referred as emergencies, because that is felt by GPs and patients alike to be the only sure way of getting into hospital, even if it involves the prospect of a long wait in casualty. It means that elective patients will wait longer, as evidenced by the figures provided to me by my local health authority.

The prospect is that there will be two routes whereby patients will be treated electively. They will be treated if they hit the 18-month wait that requires them to be admitted by the patients charter, or if they suffer from a condition that can be treated by day surgery, which is cheap and offers high-volume turnover. Patients are therefore confronted by the absurdity that their bunions may be treated—because they can be operated on on a day surgery basis—but they may have little prospect of getting their hysterectomy done on an elective basis until they become an emergency, or until they have waited for 18 months.

Long waits are tackled only at the expense of patients who have waited for a shorter time. That is a complete abandonment of the principle that patients should be treated according to their clinical need. It is not even as if the hospitals do not have the capacity to treat the patients. The problem arises only because their capacity is determined artificially by the purchasers and the contracts that they negotiate, not by the length of the waiting lists or the number of patients who need to be treated.

Even where it is shown that hospitals could produce another 10 to 12 per cent. in activity, which would make a substantial inroad into increasing the number of patients treated and therefore taken off the waiting list, and even though the hospitals have the capacity, they are prevented from treating those patients, even where they could do so at marginal cost. So a hospital that is "over-performing" by, for example, 10 per cent., but overspending by a fifth of that—which is increased productivity even by the Government's standard—is forced into the madness of closing wards to reduce expenditure instead of opening them to deal effectively with the increased demand. Why? The answer is, because the purchasers have no more money. such is the public apprehension and fear that nothing is now safe from the Government's arbitrary hand, that the Government have succeeded in turning "save our" into the two most potent words in the nation's political vocabulary.

Guy's, just the other side of the Thames, is a world-class hospital and pivotal local hospital, yet for the past eight months it has been blighted by the prospect of its accident and emergency department and acute services being stripped away. Philip Harris House, with its state-of-the-art facilities, is confronted by the prospect of never opening for the purposes for which £140 million of public and charitable money was raised. Dulwich hospital, a much-loved local hospital used by my constituents, is threatened with closure at the same time as people wait on trolleys at King's along the road because there are no beds to which to admit them.

This debate is yet another opportunity to ask Ministers to listen; to ask them to venture out of their world of fantasy to accept the reality that confronts patients and staff every day.

Let me finish with an especially brutal piece of reality, which recently came to me in a letter from another GP who serves many of my constituents. He said: I was in H.M. Forces when the National Health Service commenced and could not wait for demobilisation to join, I wished to be part of this brave new world. Sadly, in August"— this year— I was glad to leave the National Health Service disillusioned and demoralised at what the present Government has done to my dream.

7.58 pm

Mr. Andrew Rowe (Mid-Kent)

I am somewhat between a rock and a hard place. If I do not make it absolutely clear that I am married to a non-executive director of a health trust I shall rightly be castigated for having concealed that material fact from the House. If I make that fact clear, I shall be given hell when I get home because my wife—who has spent most of her professional career working in the national health service, who currently holds a senior position in the Centre for International Child Health, who has made her way in the health service entirely due to her own efforts and who has earned a considerable reputation therein—will tell me that I have no business dragging her name into a debate on the health service as though she were some sort of appendage of mine.

My wife is a non-executive director who obtained her position entirely on her own merits in a trust that has behaved in an exemplary way, which should be widespread throughout the nation. The trust advertised for non-executive directors and had a thoroughly open selection procedure as a result. That is the right way to proceed and I hope that it will become a widespread practice. As trusts become established, the public interest in them grows and popular support for them grows. We can expect good people to apply for positions on trusts.

As always, I listened with great attention and care to the hon. Member for Dulwich (Ms Jowell), who made an eloquent and telling appeal for her constituents. Her speech suffered from only one weakness in that it had no historical perception. I used to live in the constituency that the hon. Lady currently graces. I vividly remember that a number of people whom I knew, including my daughter, went to local hospitals and found them in considerable difficulties—one of them was not particularly clean—which meant that visiting them was not a happy experience.

The idea that financial constraints leading to the closure of beds or wards is a new phenomenon resulting from the reforms is a joke. Of course it is true that, in a health service the size of ours, which has growing difficulties for a variety of reasons—the instability of family life, the growing violence on the streets, the enormous increase in the use of drugs—inner city areas come under immense pressure. Far from blaming the shortcomings on the reforms, we should realise that the reforms present the only way of meeting the vastly difficult challenges that have not been satisfactorily met under the old system.

Ms Jowell

I have to correct the hon. Gentleman. Both King's College hospital and Dulwich hospital have beds that are closed only because the purchasers do not have the money to fund their being open.

Mr. Rowe

I understand that perfectly. I am saying that that phenomenon is not a direct consequence of the reforms, but existed long before the reforms. The demands on the national health service have always out-stripped supply and always will. At some stage, some form of rationing, however it is done, has to be introduced. One method that used to be used across the nation was to close wards and make doctors and others useless. If that still happens in some parts of the country, I very much regret it, but it has diminished considerably and is not nearly as common in my part of the country as it used to be, largely as a result of the reforms.

I approve of the reforms for many well-rehearsed reasons. They have enormously increased the transparency of the costings. We have a much clearer idea of where the costs lie in the national health service. It is not enough emotionally to suggest that because we know where the costs lie we are somehow uncaring. In the old days, because one did not know where the costs lay, it was a matter of pot luck whether a health authority spent money on one thing or another. At least now it is possible to make rational decisions about the likely demand for services and to go for as good a deal for the national health service as possible.

I approve of the reforms and believe that we have a much tighter management as a result. I can give one small but telling example. Before the reforms were introduced, beds tended to belong to a specialty. If there were empty beds in one part of a hospital, there was a complicated system of negotiations about whether some other specialty could use those beds. It is now accepted that the beds belong to the trust and, as a consequence, there is much better and more effective use of them. In the trusts that I know well, there is infinitely greater co-operation between the various clinical directorates than there was under the old system, where many consultants were prima donnas for whom bed ownership was one of their status symbols.

In many parts of the country—certainly in my constituency—there is now better co-operation between the social services and the trusts. The hon. Member for Dulwich may have an added problem because her local social services are not adequately managed and have not forged the sort of links with the hospitals that make it easy for patients to move satisfactorily from hospital into community care.

Ms Jowell

The hon. Gentleman is well versed in the working of the community care reforms, so he will understand the particular problems that the London borough of Southwark has in two respects. First, it has among the smallest proportion of long-stay beds for elderly people, whether in the private or voluntary sector, of any authority in the country. Secondly, the Government's stricture that 85 per cent. of special transitional grant be spent in the independent sector discriminates heavily against inner city authorities such as mine, which has virtually no private domiciliary provision. People stay in hospital simply because there is not adequate support for them when they go home.

Mr. Rowe

I accept what the hon. Lady says about her constituency. I wonder whether some of the difficulty of obtaining private sector provision within the local authority stems from the endemic hostility to the private sector that characterises boroughs such as hers. One aspect that is not a direct consequence of the reforms but has enormously helped the reforms in Kent, has been the evolution of doctors' co-operatives such as Meddoc and Maiddoc for the provision of out-of-hours service. That has not only enormously improved the provision of out-of-hours service, with tremendous public acceptability, but has meant that GPs have become accustomed to working together. In my part of the world we are seeing some exciting developments as a direct consequence of the GPs' growing confidence and trust in one another.

The hon. Member for Wolverhampton, North-East (Mr. Purchase), who is not in his place now, but has been here for most of the debate, spoke in Question Time about nurses being forced to undertake medical procedures that were putting them under stress. I have no doubt that that is a stressful business for some nurses, but for many more nurses it provides an opportunity to put into practice their professional skills at a level from which they were hitherto barred due to the unwillingness of the medical profession to trust them. The upgrading of the nurses' job and the growing trust in their capacity to do a range of tasks frees doctors to do other things that only they can do.

I believe that the royal colleges should accept this sort of development and should have much more confidence in a more flexible approach to new ways of guaranteeing quality. Sometimes in the past, their ways have been too rigid. For instance, the ratio between the number of consultants and the number of those in grades below consultant needs to be reviewed. Trusts could often make much better use of their facilities if we did away with a rigidly handed down formula for that ratio. A flexible formula would help the reforms to drive forward.

In a smaller and perhaps less significant way, the NHS reforms have been vindicated by the sharp falling off in the number of complaints about the NHS which I, as a constituency Member, receive. Complaints against GPs in Kent have remained remarkably static, although there has been a slight increase this year. I believe that the trusts have responded much more swiftly and effectively to patient complaints than did their predecessors.

One of the troubles with our parliamentary system is the built-in need for the Opposition to see the glass as half empty and for the Government to see it as half full. In the complicated, difficult and challenging environment of the NHS, the Opposition should be much more generous about what is going well and we, perhaps, should be even tougher on what is going wrong.

I am encouraged to discover that the proportion of staff delivering direct care rose from 60 per cent. in 1981 to 66 per cent. this year. The right hon. Member for Derby, South (Mrs. Beckett) went on and on about the number of managers in the service, but she failed to say whether clinical directors are to be regarded as managers, or whether nurses who have taken on the management of their peers are to be regarded as managers. I think that practice managers in general practices often take a tremendous load off doctors, leaving the latter free to do what they want to. I do not therefore regard such management statistics as either valuable or threatening.

As for Doctor Macara's anxiety, it is interesting to note that although Bevan, the architect of the NHS in legislative form, felt that he had been held over a barrel by the consultants, at this moment it happens to suit the Labour party to take up that same vested interest and support it to the hilt whenever it wants to complain about how the reforms are working.

An Opposition Member—I forget which one—made a great song and dance about some of his patients having to travel 14 miles. I have spent most of my time in Parliament pressing for the reform of NHS hospitals in London, because constituents of mine, far from having to travel 14 miles, need to go as far as 55 miles for care because of the gross over-provision in London of many services that could easily be delivered locally. Thanks to the reforms, we are at last getting a better deal for Kent than ever before.

On the whole, I think that fundholding is good for patients. There has been a remarkable diversification and generous provision of a variety of services for patients. This has been good for GPs, who have suddenly discovered that they really have a say in the purchase of health care—but I urge the Minister to be careful. It is a wonying fact that the number of GP trainees in Kent has fallen and that, from being top choice, the job of GP has moved well down the ladder. That is partly because of the general upheaval in the service, but it may also have something to do with how fundholding is perceived. We need to take a careful look at that.

We need also to take care lest some of those who are considered for fundholding in the next wave prove not to be up to the standards required to run their own show that we would expect. It would be a grave disservice to the fundholding initiative if, in our enthusiasm for spreading what has been widely accepted by the first wave, we find ourselves rushing into the next wave too quickly.

I have one final anxiety about fundholding. I get the impression that the Government have been slightly surprised by the enormous popularity of fundholding and the drive to increase the number of fundholders. The consequences for trusts and for purchasing authorities have not been completely thought through. Some of my local trusts have been operating extremely well with relatively slim budgetary surpluses. Just as a roll-on roll-off ferry does not need much side-slip to go over, if one of the big co-operatives of fundholders suddenly decided to take its services elsewhere, that could cause quite a severe list in the ferry, or trust. I am whole-heartedly behind the national health service reforms and I am entirely in favour of fundholding, but I hope that the Minister can reassure me that he will watch carefully to see that well-managed and effective trusts are not suddenly blown off course by a shift in GP fundholding purchasing.

8.17 pm

Mr. Bill Etherington (Sunderland, North)

I am pleased to be able to take part in this debate, especially after the long recess. I feel rather sad and a little angry about the somewhat sanctimonious contribution by the Secretary of State today. In many ways, it was not worthy of such an important subject.

Several speakers in the debate have shown great expertise. We have heard from GPs and from people with backgrounds in nursing and social services. I do not pretend to have that sort of expertise. What I can do, however, is to bring some of the concerns expressed by my constituents to this Chamber.

Of all the subjects that are causing concern at the moment, the plight, or fate, of the NHS is uppermost in most people's minds in my constituency. My constituency and the adjoining one, Easington—I see my hon. Friend the Member for Easington (Mr. Cummings) in his place—were classified in a study carried out not long ago as two of the five worst areas in Britain for long-term illness. Taking 100 as an average, the Easington area was allocated 191.24 and the Sunderland area 154.61. That is the paramount factor in people's perceptions of the sort of service that they are getting. It may not seem too bad when bed cuts are prophesied for areas where standards of health and of living are reasonably high. But that is not the case in Sunderland or anywhere in the north-east.

We all know that the regional health authorities and hospital trusts have become much more oriented towards public relations exercises than they are towards service to the public. That is most noticeable in my part of the world. There is a plethora of glossy magazines, and rather poor stories are gilded as much as possible, but the health authorities and the trusts are signally failing to persuade the public that what is proposed is for their benefit.

People's suspicions have reached great heights in the north-east. Fairly recently a petition carrying 11,000 signatures of people opposing the regional health authority's proposals was presented to Sunderland health authority. That petition speaks for itself. The signatures were obtained not by people going from door to door but by people standing in a marketplace on a Saturday, talking to people at random and explaining the situation.

Following consultation, there was a public meeting on 29 September. I had the good fortune—or the misfortune, depending on how it is viewed—to attend that meeting, and I was rather sad to learn that, in essence, the public consultation exercise had been a total sham. The House may be interested to know the sort of people who supported Sunderland health authority's proposal to do away with 200 hospital beds. It was supported by Sunderland university, which is a quango; by the Cumbria ambulance trust, another quango; by the Freeman hospital at Newcastle, which is also a quango; by Priority health care, Wearside, which is one of its customers; by South Tyneside health care trust, a quango; by City hospitals trust, Sunderland, another customer; by Durham health commission; by Easington joint commissioning board, which is another quango; and by the South of Tyne health commission, which is yet another quango.

All the other bodies that were consulted objected to the proposal, but no one has taken the slightest notice of them. As the business plan was being proposed at the meeting of Sunderland health authority on 29 September—I call it a business plan because that is what the health authority calls it, with no mention of patients—the general practitioners' representative, Dr. Pam Wortley, said that GPs were concerned that if the 200 beds were phased out, there would be no practical alternative but to improve primary health care facilities.

One of the rather worrying factors mentioned by Dr. Wortley was that many more GPs would be needed to deal with the increased need for primary health care. In principle, that is excellent—no one would dispute that—but in Sunderland recently there were 30 vacancies for GPs and only 14 were filled. Many members of the public who attended the meeting were shocked by what Dr. Wortley said.

The basis of public disquiet is that there do not seem to be any good alternative proposals. Prime Minister Herbert Henry Asquith used the immortal term, "Wait and see", and that is what Sunderland health authority is telling Sunderland's citizens. That is not good enough and it is unacceptable.

All sections of the public were vehemently opposed to the authority's proposals, but the impression is that bodies of people, whether they form hospital trusts, regional health authorities or local commissions, have been appointed to carry out the instructions of the appointer. That is what it is all about and it does not matter what political party the appointees belong to or how admirable or knowledgeable they are: they are placed there to do as they are told.

In the north-east, the various quangos are staffed by a pool of interchangeable people, some of whom sit on more than one quango. Someone can be a member of a hospital trust and of a regional TEC or a member of Tyne and Wear development corporation and the chairman of a hospital trust. The Secretary of State spoke about Islington dinner parties. I do not know about those, but I know a clique when I see one, and that is what this business is all about. People recognise that and they find it totally unacceptable. Political ramifications have nothing to do with it: I am talking about people who congregate to form a clique that is undemocratic and answerable to no one in the locality. Generally, they are fairly well paid for their services. I agree that the idea of public service is admirable, but in this case such service is also paid for, and that sweetens things a little.

Mr. John Cummings (Easington)

I am grateful to my hon. Friend for giving way because it is difficult to take part in a debate while carrying out the duties of a Whip. My hon. Friend mentioned Easington joint commissioning board. Perhaps I could relate an incident that occurred some months ago, and which has not yet been resolved. An infirm lady of 77 was discharged from Ryhope general hospital into the community. Twice a week, she has to take a taxi costing £2 to a private residential home, where she pays £3 for a bath. She is then turned out into the street and has to take a £2 taxi ride back to her home. The matter has been raised with the joint commissioning board but we are no further forward. Of course the board has established working parties between itself and social services—

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse)

Order. I am feeling fairly tolerant, but the hon. Gentleman is going on a bit. Interventions are supposed to be brief.

Mr. Cummings

Those are the problems that we encounter when dealing with quangos, joint commissioning boards and other bureaucrats who take no notice whatever of elected representatives.

Mr. Etherington

I appreciate the intervention of my hon. Friend the Member for Easington because people in his constituency make full use of the facilities in Sunderland that I have mentioned. I am pleased that you exercised tolerance, Mr. Deputy Speaker, although I have no doubt that it will shorten my speaking time. The story told by my hon. Friend is but one of many gruesome tales. People perceive what is happening because of the bureaucrats, the great and the good, who are appointed by the Secretary of State for Health.

I should like to read a short extract from a letter by Dr. R. N. Ford, the chairman of Sunderland local medical committee. He is almost a model of moderation and his letter was published in the Sunderland Echo on 7 October. That letter states: I can assure you that local GPs have been very active indeed. We decided to pursue a policy of quiet but firm diplomacy in our negotiations with Sunderland Health Commission and the Sunderland Hospitals Trust management in the hope that this would prove to be in the best interest of the patients under our care. Unfortunately, we now believe that this has been unsuccessful, and our views have gone essentially unheeded … now we have the issue of bed closures looming. For your information, GPs are overwhelmingly opposed to the business plan proposed by City Hospitals, and in particular to the savage cuts in bed numbers. For the benefit of Conservative Members, I should say that Dr. Ford is not some unreconstructed Marxist but a general practitioner in a responsible position looking after other GPs and the interests of patients whom they serve.

I know that time is short and that two of my hon. Friends wish to speak, but I should draw attention to one important factor that came to light recently. When the local hospital trusts were trying to point out how little they spent on bureaucracy, they cited two figures that made it appear that very little was being spent on management and administration. However, one can work out from the numbers employed that it costs £24,000 to employ a member of the nursing staff, with all the services that such staff provide, and £38,000 for the provision of one member of staff in management. That throws a different light on matters.

We have a contrived market which hides the fact that Britain does not spend enough on health care. We spend far less than many of our European Union competitors and about half what is spent in the United States. Of course, if money is well spent, what matters is not always how much is available but how the sum is used, and, by and large, the national health service has been successful. No one would suggest that we should never look for improvements, but we should not do so by contriving an artificial market, by creating more management jobs and well-paid jobs in hospital trusts and by setting up a bureaucratic unaccountable quango.

Having followed developments in Sunderland fairly carefully, I have reached the conclusion that hospital trusts are behaving like asset strippers by closing down premises and moving everything into one unit. Sunderland general hospital has tremendous parking problems. There are many complaints from people who live locally who cannot get into their homes during hospital visiting hours. That has not been helped by the fact that the quango has decided to charge people who visit the hospital for the pleasure of using the car park. Yet the trust is considering extending the premises and putting more hospitals on the same site. That makes no sense whatever and is causing public disquiet among those who live in the area and those who have the misfortune to travel there by motor car. The reason given for charging for. parking was to improve security. That has not been successful. My hon. Friend the Member for Jarrow (Mr. Dixon) was told today that his wife's car has been stolen from the car park where security is costing so much money.

We are dealing with a business where patient care is very much secondary.

Mr. Chris Mullin (Sunderland, South)

Before my hon. Friend leaves the subject, does he agree that one of the main concerns about the radical changes taking place in Sunderland hospitals stems from a feeling that there are not the facilities at the general hospital to deal with the greatly increased demand and also that there are not the facilities or resources to provide the community care that will be necessary if those extremely radical plans are carried out?

Mr. Etherington

I agree with my hon. Friend the Member for Sunderland, South (Mr. Mullin), who has been very active on the subject, as have other neighbouring Members. I can do no better than to quote to my hon. Friend what Councillor Louise Bramfitt, who is chair of the social services committee of Sunderland city council, said recently. She asked whether the money to be saved from the bed closures would be handed over to the social services department. We all know the answer to that: probably most of the money will find its way back to the Treasury. That is also causing concern.

I will finish off with one personal matter. Recently, an old uncle of mine who is 84 years old had the misfortune to be knocked over. He was taken to Sunderland general hospital, where both the treatment he was given and the way in which I was received when I visited him in casualty were absolutely superb. I can pay no greater tribute than to say that no person on earth does a better job than someone who looks after the health of others and protects their lives. It was magnificent.

I was not so pleased when it was time for my uncle to come out. I did the reasonable and civilised thing and offered to take him home. The sister on the ward was only too pleased to accept my offer, but I still had to pay to park to save the trust a little bit of money. That was deplorable and should not be tolerated in civilised society. There are many poor people in Sunderland as there is high unemployment. People have enough problems paying for transport to visit their loved ones in hospital without the added burden of having to pay for parking. If the Secretary of State has any heart at all, she will take some action. I hope that she will.

When the Minister meets my hon. Friend the Member for City of Durham (Mr. Steinberg), who happens to be my constituency Member, I hope that he will also meet me, along with my hon. Friends the Members for Sunderland, South, for Easington, for Houghton and Washington (Mr. Boyes) and for Jarrow, and everyone else who is concerned about the abysmal situation in Sunderland.

8.34 pm

Mr. Michael Carttiss (Great Yarmouth)

I was intending to make a fairly gentle contribution to this important debate, but I am emboldened by my hon. Friend the Member for Mid-Kent (Mr. Rowe), who said that we should be tougher about what has gone wrong.

My hon. Friends the Under-Secretary of State and the Chief Whip know that last November, at the beginning of this parliamentary year, I advised them both that I could not support the Government in any health service debate for the rest of this Parliament, and I shall explain why later on in my observations.

Tonight, I have no hesitation in coming to the Chamber not only to support the Government's amendment, but actually to speak in its favour. I do so though I have much sympathy with some of the comments that I have heard from Opposition Members, particularly the hon. Member for City of Durham (Mr. Steinberg), who is not here momentarily and who allowed me to interrupt his speech.

I cannot comment on what the hon. Member for Sunderland, North (Mr. Etherington) said about Sunderland, but I certainly share some of his concern about the method of appointment to the hospital trusts and the cliques to which he referred in Sunderland. I am sure that Sunderland is not alone in that experience.

The one feature of the debate that causes me to run fast and furious into the Government Lobby tonight is the reference in the motion tabled by the right hon. Gentleman the Leader of the Opposition and his right hon. and hon. Friends, which talks of public alarm at the creeping privatisation of the National Health Service".

I would not like it to be thought by anyone who cares to read or listen to what I say that, by being silent in this debate and keeping out of the Government Lobby, as I have in every health service debate since last November for reasons that I shall explain later, I could in any way be associated with the claim by the Opposition that there is any such thing as a "creeping privatisation" of the national health service.

My right hon. Friend the Prime Minister, in his speech at the Conservative party conference, explained and reiterated his commitment to the national health service, which he explained at the party conference and throughout television, as it was reported widely on the various channels in the late news.

Speaking from personal experience, my right hon. Friend the Prime Minister said: Believing, as I do, that the greatest nightmare for millions is that one day they might be old, sick, poor, and uncared for, is it really likely that I would take away from people the security of mind that was such a comfort to my own parents? I can tell you—not while I live and breathe".

I am pleased to echo and quote the words of my right hon. Friend the Prime Minister in once again nailing the lie that is promoted up and down the land and has been repeated here. I believe that Opposition Members who sometimes repeat it genuinely believe it. Most of them are not making speeches for the sake of party politics. I believe that the vast majority of Opposition Members who have spoken in this and other debates are committed to the health service.

They believe that the Government have a hidden agenda. I reject that assertion, even though I understand that some of them sincerely believe it. Of course, others know that it is not true; they make their comments for party political reasons after they have posted their cheques to some private health care scheme or paid their subscriptions to their unions, which in turn take out private health care for their members.

My right hon. Friend the Prime Minister was speaking from his personal experience and that of his elderly parents. If my mother were alive today, she would be up in the Gallery thinking, "How on earth did I breed someone who is mixing it with all these people? Why doesn't he get himself a decent job?" Of course, my mother is not there. She was not there when I made my maiden speech in 1983. She was not there when, at the age of five, I went to Filby village primary school. She died of tuberculosis in Norwich when I was three years old, before the national health service existed.

I lost my mother when I was three without ever really knowing her, because in those days tuberculosis was a deadly disease. I was taken away from her and brought up by my grandfather because they were afraid that I would catch tuberculosis, which was an horrendous disease. Of course, if someone had money he did not die—in fact, he did not catch it. [AN HON. MEMBER: "It is the same."] It is not the same.

I am convinced that, if my mother had caught tuberculosis in her late 30s—by which time there was a national health service—rather than in her late 20s, she would have been treated and she would be here today. I apologise to hon. Members for wearying them with a personal story, which does not require any sympathy. I state it merely as a similar experience to that of my right hon. Friend the Prime Minister. It explains my commitment, which I believe is shared by the vast majority of Conservatives, to a national health service free at the point of delivery.

Many of the reforms that my right hon. Friend the Secretary of State and her team have introduced have been to the benefit of patients. My hon. Friend the Member for Wimbledon (Dr. Goodson-Wickes) concluded his speech by saying, "I speak as a doctor, and I speak as a politician." I speak as a patient and as someone whose uncles and aunts—brothers and sisters of my late mother—have benefited from the national health service. I speak as someone who would not dream on principle of taking out a private health care scheme. I do not believe in them, but equally I do not believe that we should stop them.

I believe in a society in which those who, rather than buying a new car, want to take out additional personal health care insurance, are encouraged to do so. That happens with Labour Members as well as Conservatives. However, that is not for me. My national health service hospital is good enough for me, it is good enough for my constituents, and it is doing a great job.

I recently had a letter from a constituent in which he voiced his concern about the Government moving towards privatisation of the NHS. There is a fear throughout the country that we have that agenda. He was concerned because he had read an advertisement for a private health care scheme that said, "Don't wait in the queue. Avoid long waiting lists." He interpreted that as meaning that private health care patients were taking a higher place on the waiting list at our local hospital, with the result that he was having to wait longer.

In fact, the James Paget hospital, which serves the Great Yarmouth, Waveney and Mid-Norfolk constituencies, has just six private beds. It is a large hospital, which my hon. Friend the Under-Secretary has visited at least twice during the past three years. He knows that it is a great hospital. Those six private beds are not available to the NHS, but they do not keep NHS patients out of hospital. Instead, they bring a profit of £250,000 to my constituents who use NHS facilities at that hospital.

I wish that we made more of the fact that private health care is something for those who want it. We should not say that, because many of us cannot afford it, no one should have it. Those six beds bring in a profit of £250,000—

Mr. Bayley

Can the hon. Gentleman tell us how much it costs to treat patients in those private beds? I ask that because the Government are unable to give figures for the cost of treating NHS patients. How can the hon. Gentleman tell whether that £250,000 is a profit or a loss when set against costs?

Mr. Carttiss

I cannot answer the hon. Gentleman's question now, but I will find out the answer and let him know, because it is an interesting point.

I am quoting the figure given in a letter from the chief executive of the James Paget hospital. He specifically refers to £250,000 in the hospital's budget that is profit from the use of private facilities at the hospital. That sum is then reinvested in direct patient care services. He writes: This is another way of saying that if we did not have that sum then the services at the James Paget Hospital would have to be cut by that same amount.

Marrying the private and public sectors is a recipe for success, which I believe is to the advantage of everybody. That is certainly true in my constituency, as can be seen from that example. However, in supporting that, hon. Members should not assume that the Government are intent on privatising the NHS, as the Opposition's motion suggests.

I said earlier that I had some sympathy with the comments of the hon. Member for City of Durham. I also picked up one or two points made by the hon. Member for Sunderland, North about hospital trusts. I welcome the Government's statement that they will continue to appoint the best possible people to trusts. There is a great deal of nonsense about whether they are Conservative or Labour. There must be some political balance, but the important factor is to get the right people.

I was sure—the hon. Member for City of Durham more or less admitted it—that the hon. Gentleman had a good relationship with the two Conservatives on his local ambulance trust. He acknowledged that they were very good. I have a good relationship with the Labour members of my local hospital trust, who do a good job.

The local Labour party opposed setting up the trust, but, the next thing I knew, the wife of the chairman of the British Medical Association's local branch—a Labour councillor and a former nurse—was one of the first people in the Labour party to accept an appointment to the trust. We welcome one sinner who is converted rather than 99 already on our side.

Mr. Bayley

Let her speak for herself.

Mr. Carttiss

That lady did not have to accept the appointment if she was so solidly opposed to the trust. I am trying to make the point that it is good that there are Labour members serving on the trust. She was selected by the other trust members not because she was a Labour councillor, not because her husband was chairman of the local BMA branch, but because she was identified as a young woman who could contribute to the hospital trust. I welcome that. I wish that we heard more speeches from the Opposition of the kind made by the hon. Member for City of Durham, who paid tribute to the fact that some people were doing a good job, and that his objection was to the way in which they were appointed rather than to who they were. That is an objection which I share.

The Department of Health is drawing up new guidelines with a view to implementing them across all regions next year. The system will be transparent and the procedures clear to potential candidates for membership of NHS trusts. It will be accessible to people from a wide range of backgrounds. I understand that there will be advertisements at regional and local level to allow access to vacancies. I hope that the hon. Member for York (Mr. Bayley) will pursue that point further.

There is much to be done about NHS trusts. A man has just been appointed to the Anglian Harbours NHS trust in Great Yarmouth and Waveney, replacing the Tory chairman, who was a county councillor. That is an example of the Government dispensing with the services of a first-class Tory councillor and producing someone from goodness knows where. No one in Yarmouth and Waveney, including the two Members of Parliament, has ever heard of him. I was sent his name and asked for my comments. I said that I did not know him, and therefore did not think that he was suitable, and asked what was wrong with the existing chairman.

The chairman of the Anglia and Oxford regional health authority—we have a huge region looking after my constituency, based in Oxford—decided that that man was the right one for the job. He may well be, but that is not good enough for me. [Interruption.]

I see the Whip indicating something, but I will ignore him, because I have not made the point that I came here to make. That is that, having dispensed with the nonsense in the Opposition's motion about creeping privatisation, which brings me back on side with the Government tonight, I come now to another phrase with which I do have some sympathy—lack of accountability.

Everyone in Great Yarmouth and Waveney was consulted about the proposal to merge half the Great Yarmouth and Waveney health authority with the Norwich health authority in order to complete the new purchasing body. Waveney, which had been united with Yarmouth as one health authority or grouped hospital administration unit ever since the NHS was set up, was taken away from the Great Yarmouth and Waveney health authority, and placed with Suffolk health authority. That was interpreted locally as meaning that hospital services for people in Lowestoft, represented by my hon. Friend the Member for Waveney (Mr. Porter), would have to go to Ipswich. That was never a reality. Repeated reassurances on that point were given, but 90 per cent. of the bodies and people consulted last year came down in favour of the Yarmouth and Waveney health district continuing. As a secondary fallback position, those people were prepared to accept, as part of the general reorganisation of district health services, the merger with Norwich.

In October, I brought to the Under-Secretary of State, my hon. Friend the Member for Bolton, West (Mr. Sackville) a deputation of doctors and clinicians and other people, to present the virtually unanimous view that merger was okay, but that there should be no separation. My hon. Friend rejected that. On 8 December, in an Adjournment debate, we repeated our claim.

On 3 March 1994, with my hon. Friend the Member for Waveney, I brought another deputation from Great Yarmouth and Waveney, and pleaded with my hon. Friend the Under-Secretary to reconsider his decision. One reason for that decision had been the need to relate the health service purchasers to the providers of social services. The argument was that the boundaries of the health authorities had to be related to the social service providers, Suffolk and Norfolk county councils.

I told my hon. Friend that the Local Government Commission was coming to Norfolk and Suffolk to review the future of local government, and that there was a strong possibility that it would recommend the merger of the Great Yarmouth borough council and the Waveney district council as a single-tier authority and a social services provider. We asked the Government to wait for the Local Government Commission's report and the response to it.

In July, the Local Government Commission recommended five unitary authorities in Norfolk, one of which was to be the Great Yarmouth and Waveney authority, crossing the county boundary. There we had the possibility, if the Local Government Commission's original recommendation was accepted, of a new social services provider, knocking on the head one of the arguments that my hon. Friend the Under-Secretary had advanced for separating the two. That is the sort of nonsense that gets the Government a bad name and which underlines the lack of accountability of the decision makers.

If the population, the chambers of commerce and the district bodies had been split half and half in favour of the Minister's proposals, or even 40 per cent. in favour and 60 per cent. against, my hon. Friend could have said that the 60 per cent. were people who did not know what they were talking about. But in Waveney and Yarmouth the decision was almost unanimous, that the authority should continue to be one district, albeit merged with Norwich. My hon. Friend rejected that.

Where is the public accountability in that? Where is the public accountability in the appointments that my hon. Friend has made to the East Norfolk health commission? Where is the public accountability in sacking the first-class chairman of the Anglian Harbours NHS trust, who happens to be a Conservative county councillor, and replacing her with someone who is completely unknown?

I fear the same debacle that we had when a complete unknown was appointed to be chairman of the James Paget hospital trust. He was a man resident in the constituency of the Parliamentary Secretary to the Treasury, my right hon. Friend the Member for Mid-Norfolk (Mr. Ryder). No one in Yarmouth or Waveney knew him. What did he do? He gathered together all his friends, none of whom lived in Great Yarmouth or Waveney and only about two of whom had any connection with the catchment area of the health service provision at the James Paget hospital.

Within a few weeks, the then Minister for Health, who is now my right hon. Friend the Secretary of State for Transport, wanted to sack him. Eventually, happily, the man resigned, in much the same voluntary way as. my hon. Friend the Member for Tatton (Mr. Hamilton) did today.

We are getting more accountability, but not enough. Therefore, I welcome the statement made my right hon. Friend the Prime Minister this afternoon about examining all these matters. Why on earth is there such a fuss about a published list? My right hon. Friend stood at the Dispatch Box and announced half a dozen members of the Labour party. Opposition Members asked how we know that they are Labour members. The answer is obvious.

Why not have a full list? What is so secret about the people who sit on quangos? I do not take the view that they should be elected, or that they ought to be in local authority service. After all, the Crossman reforms, which the Conservative party implemented, established area health authorities based on counties, and district bodies within them—which took from the county council of which I was a member responsibility for all sorts of health matters that were previously the remit of elected councillors.

I do not need any lectures from Opposition Members on elected bodies, because the Labour party's Richard Crossman was the father of previous health service reforms that took some health service responsibilities from local authorities.

Nevertheless, I hope that my hon. Friend the Minister will devise a more effective and transparent method of appointing people to health service trusts, with chairmen and existing trust members having some involvement—rather than waft a name out of a hat and telling me, "We've taken note of your comments but we will appoint this man willy-nilly."

Let there be public consultation. If 90 per cent. of the local population, doctors and others working in the service are against a regional health authority proposal and Members of Parliament, irrespective of their party, urge my hon. Friend the Minister not to abandon his plans but to leave them for a year—to see what the Local Government Commission produces before making a decision—and he still ignores us, he will have to unscramble everything again if a Great Yarmouth and Waveney social services provider emerges from the current review.

I want to continue speaking, but other hon. Members wish to contribute—and my Whips are nodding me down because they do not like anything that remotely resembles the truth. The real test of friendship and loyalty is to tell one's friends when one knows that they have gone wrong. On this particular issue, my hon. Friends know that they have gone wrong—but I will be happy to enter the Government Lobby, knowing that Opposition Members are more wrong than we are.

9.1 pm

Mr. Tom Clarke (Monklands, West)

I do not regret having been in the House since 2.30 pm this afternoon so that I could make the point that both the motion in the names of my right hon. and hon. Friends and the Government amendment refer to patient care and the needs of patients. I do not see how we can accomplish those objectives if we do not, before the end of the debate, address ourselves to the enormous problems of care in the community, which are staring us in the face, and which did not invite even one word from the Secretary of State for Health.

Many years ago, we were told by the National Audit Office that community care was in a state of chaos. That led the former Prime Minister, Lady Thatcher, to establish the Griffiths committee, which confirmed that view and reported that the one option that was not tenable was to do nothing. Not only are the Government saying nothing, as we have seen today, but they are doing nothing—and that is entirely unacceptable.

To throw community care to market forces, which seems to be the Government's approach, is to destroy the concept of community care, is absolutely repugnant and is a great disservice to the people of our country. It is not as though the Government lack information. The letters that right hon. and hon. Members receive from constituents and representations made at surgeries show grave concern. Individual, family and community experience is something that the House cannot ignore.

Recently, I received a letter about the morale of consultants at Monklands district hospital, which serves my constituency. Having listened carefully to the Minister's reply this afternoon to my hon. Friend the Member for Wallasey (Ms Eagle) and to the excellent speech of my hon. Friend the Member for City of Durham (Mr. Steinberg), I am reluctant to reveal the names of those who wrote to me. They are enormously respected in my community—[Interruption.] Much more so than the Minister of State, who interrupts from a sedentary position. I should be happy to give way if the Minister wishes to challenge my evidence. The evidence is that consultants in Monklands district hospital, in common with their colleagues in district hospitals all over the country, are experiencing a decline in their morale and greater and greater demands, which they are unable to meet. They reject utterly the Government's approach to performance related pay and it being imposed on them while those increasing demands continue. I say to the Government—

Mr. Malone

rose—

Mr. Clarke

I shall give way to the Minister in a second because, given the late hour, I want to go on to deal with the issue of care in the community. The Government may ignore the points that are being made in this debate, but the British people will not.

Mr. Malone

If the consultants in the hon. Gentleman's constituency are against any form of local pay arrangements that perhaps allow different levels of pay to be introduced, can he confirm that they are also against the merit awards system, which consultants elsewhere in Britain seem to back?

Mr. Clarke

I said very clearly that the consultants in the Monklands district hospital, which serves my constituency, are overwhelmingly opposed to performance-related pay. If the Minister, in his reply, can tell us how one can relate performance-related pay to accident and emergency units, or to the time that consultants in psychiatric units have to give to their patients, and one can make some kind of division between them and other departments, I would be very interested to hear his view. But I must tell the Minister that there is not a consultant in the country who would believe a word that he would say.

My hon. Friend the Member for Wakefield (Mr. Hinchliffe) has established a very distinguished tradition in the House of bringing to the Floor of the House and to its Committees the realities of what is happening outside. The Royal College of Psychiatrists has twice warned the Government about care in the community. I am delighted to see the Secretary of State for Health—she no doubt came in when she saw my name on the annunciator and realised that it was not the Chancellor of the Exchequer who was speaking—so that I may repeat that the Royal College of Psychiatrists has warned twice that the present system of community care simply is not working.

Let us look at the evidence, not only that of our mailbags and what we see in our communities, but of the fact that, in three years, there have been 34 murders by patients who have been involved in psychiatric care in the preceding 12 months. We know of cases, such as that of Jonathan Zito—

Mrs. Virginia Bottomley

rose—

Mr. Clarke

Would the hon. Lady wait for a second, as I would like to finish the point? There have been cases such as that of Jonathan Zito, who was a musician in the London underground. Those circumstances were followed by a report by Jean Ritchie QC, in which we saw that Jonathan Zito's death—it could have been avoided—clearly took place because proper assessment of the person who had killed him had not been acted on and that tragedy occurred.

Mrs. Bottomley

Does the hon. Gentleman agree that it is important not to inflame unduly anxiety about care in the community? The Royal College of Psychiatrists has not in any way suggested that there has been an increase in the number of homicides proportionately from severely mentally ill people. Every homicide is serious in itself, but there is no suggestion that there is an increasing trend. Does he agree that the Ritchie inquiry about Zito suggested that we needed better co-ordination and a more assertive approach to the supervision of mentally ill people in the community? That is exactly what the supervision registers and the guidance on discharge from hospital are doing and that is precisely the intention of supervised discharge, which we hope to introduce at a later date.

Mr. Clarke

I agree entirely that the recommendations of the Ritchie report ought to be taken seriously. However, I must say bluntly to the hon. Lady that I see no comparison between those recommendations and the policy that she is pursuing. I want to continue to cite other cases because the right hon. Lady appears at the Dispatch Box, and on the "Today" programme, I think, every second morning—almost as often as the God squad—and the tragedy is that she does not relate what she is saying to the real world. We have case after case in our constituencies such as, for example, that of Ben Silcock and Tony Sarumi, who found themselves in the lions' cage at London zoo clearly because assessments were being made and nobody was acting on them. As I did the Secretary of State the courtesy of listening to her intervention, she might just listen to a word or two of the remainder of my speech. I am appalled by the Government's complacency, which is personified by the Secretary of State and made even worse by the Minister. In September, the Government—not the Opposition—appointed a mental health task force, and received its report. The task force said that services in London were overstretched, and that vulnerable patients were being discharged.

In a leader entitled "Care Beyond the Cages", The Guardian said: The problem is not confined to London. Every major conurbation is facing the same challenge: Manchester, Birmingham, Liverpool, Glasgow We all know that to be true. Even The Sunday Telegraph—which does not rush in to support the Labour party or the trade unions that the Secretary of State derided, ignoring the fact that hundreds of thousands of their members are keeping the NHS afloat at this very hour—said, in a moving account of the story of Mary Batchelor and Graham, her schizophrenic son: There is a big gap between what the Government says is happening and what they see is happening. That is what this debate ought to be about.

Earlier, I asked the Secretary of State a clear question. I asked her to tell us the number of people who are mentally ill and in prison in England and Wales. She said that she did not know. I am very glad that my hon. Friend the Member for Lewisham, Deptford (Ms Ruddock) takes her duties more seriously: she does know, because she put a question to the Government which was answered on 18 October. The answer stated that 19.2 per cent. of the sentenced population had some form of psychiatric disorder.

What does that mean? It tells us what is happening in Britain today—in England and Wales, that is; it ignores the problems that we are having in Scotland. I welcome the presence of the Under-Secretary of State for Scotland, the hon. Member for Edinburgh, West (Lord James Douglas-Hamilton), who is much more civilised than those whose company he currently keeps. I say to Ministers that for the Secretary of State to ignore the fact that 6,800 mentally ill people are in prison because the courts simply cannot find anywhere else to put them is an absolute disgrace, which cannot be excused even by her Mary Poppins-style sweetness and light on the "Today" programme.

The current position contrasts starkly with promises given during health debates. I recall the Secretary of State's contribution to some of those debates, as a junior Minister. What was said when we debated the National Health and Community Care Act 1990, and even when we debated the Children Act 1989, and the glossy documents produced by the Government could not be more different from what we are seeing now. There was, for instance, the crucial issue of assessment, followed by the provision of services; the Secretary of State does not seem to have taken that on board.

There is no excuse. The Secretary of State will recall being visited in Richmond house by some of my hon. Friends, and members of another place who are interested in these matters. I went along with Brian Rix—now Lord Rix—Lord Ashley, my right hon. Friend the Member for Manchester, Wythenshawe (Mr. Morris) and the hon. Member for Exeter (Sir J. Hannam), to support the Disabled Persons (Services, Consultation and Representation) Act 1986. As the right hon. Lady will recall, we argued then that the legislation that the Government were producing was no substitute for sections 1 and 2 of that Act, which meant that there would be real representation, and that the patient of the advocate concerned would have a say in what happened to him. We have heard nothing of that theme from a single Conservative Member today.

The Government talk about voluntaryism, but ignore the views of the voluntary organisations. As recently as yesterday, Enable, which was recently called the Scottish Society for the Mentally Handicapped, and Scope, which was until recently the Spastics Society, reinforced strongly the arguments that still hold for the implementation of sections 1 and 2 of the 1986 Act. I will explain why. In spite of the slogans that we have heard from the Government, there are those who are committed to the rights of citizens regardless of whether a charter exists. Why are not patients having a say? Why is there no real advocacy? In the limited time available, I shall relate one important story about advocacy.

When I was involved with many others in trying to get the 1986 Act on to the statute book, I visited one of the most excellent community care pròjects in Glasgow. I met two ladies who had once worked in the shipyards but who had spent 15 or 20 years in a hospital which was described as a hospital for the mentally ill. By that time, they were living in nice flats with privacy when they wanted it but support when they needed it. When I asked them what difference they saw between the hospital in which they had spent many years—I concede that it was a Victorian building—and where they were living now, one of the ladies said, "They dinnae gie ye jags." To interpret that for the benefit of non-Scottish Members, it means that they were not given injections. People are entitled to know what medication they are being given. People or their advocates are entitled to know what is happening and why. Yet, time after time, the Government give the impression that they support the principle while they do not provide the resources necessary to put those principles in operation.

Following the Government's legislation, the balance of NHS and community care has shifted away from institutional care. We have seen closure after closure. However, we have not seen provision within the community of the support that is necessary if community care is to work. Some 85 per cent. of people with learning difficulties are living in the community and increasing numbers of elderly parents are looking after younger people with learning difficulties.

What of assessments? I plead with the Minister to take on board not just my view but the view of the Carers National Association, which has already told us that, although assessments are taking place, there is no action in response to the needs that are being assessed. We find young people with learning difficulties leaving school at 19 and being placed beside much older people. We find local authorities trying to deal with discharged patients and councils, which are themselves under financial seige, are cutting back on facilities such as day care services and respite care and having to introduce charges which are repugnant to them.

We are seeing a mockery of care in the community and joint planning. It will not be helped in Scotland by the fact that when the local authority boundaries are introduced in January 1996 they will not even be coterminous with the boundaries of local authorities. That is unacceptable. When Griffiths was asked to report and to respond to the views of the National Audit Office, he confirmed that care in the community was in chaos. That tells us something. This is a problem about people, families, communities and individuals. I want to conclude by quoting not statistics but the moving views of Jonathan Zito's widow, Jayne, in that excellent television documentary that we saw a few months ago. She talked about the death on the London underground of her husband, a musician. She talked with courage, conviction and compassion. She was not bitter. She was not negative. All she asked for was better community provision, and that is all we ask for.

9.19 pm

Mr. Nicholas Brown (Newcastle upon Tyne, East)

It is a great pleasure to follow the moving speech of my hon. Friend the Member for Monklands, West (Mr. Clarke), who brings an enormous amount of expertise and experience to this important debate.

At the beginning of the debate, my right hon. Friend the Member for Derby, South (Mrs. Beckett) said that the national health service had a special place in the nation's affections. The enduring twin achievements of the postwar Labour Government are the provision of universal education and the provision of universal health care. All institutions change over time, responding to changing needs, demography, technological advancement and even economic factors. If that were all that was happening to the NHS, the Conservative party would be able to mount some sort of defence in this debate, but that is not all that is happening.

As my hon. Friend the Member for City of Durham (Mr. Steinberg) said, the driving engine of Conservative party health service reform is political philosophy, not practical experience, common sense or even managerial efficiency. The imposition of a blinkered ideology that is wrong anyway on an organisation like the NHS is bound to lead to nothing but harm. Worse, when theory comes to practice, that ideology sinks into a quagmire of, at best, expediency and, at worst, corruption. Replacing a flawed and old-fashioned framework with a more fundamentally flawed one makes the delivery of the service difficult, unworkable in places and increasingly unfair.

A legitimate case exists for devolved responsibility and accountability. Public resources are not infinite. They have to be managed and prioritised. That is not what Conservative health care reform is about. Under the previous Prime Minister, the Conservative party had clear objectives. She had a clear vision of the future of the NHS. She was the avowed enemy of public expenditure, yet her Conservative party authorised substantial extra expenditure on NHS managers, administrators and accountants.

To use the Government's own figures and taking the period 1988 to 1993, the number of people employed in nursing and midwifery fell by 4.2 per cent. Over the same period, the number of people employed as general or senior managers has risen by 1538.3 per cent., a substantial increase. The Conservative party will say two things about those figures: first, that some of the figures are the result of reclassification; and, secondly, that the health service was undermanaged anyway and there was a case for appointing more managers. Both arguments have some substance.

Mr. Malone

I am grateful to the hon. Gentleman for giving way. I should not like his argument to be incomplete. He is making two important points, but there is a third: Project 2000 nurses are no longer included in the figures and there are a substantial number of them. I hope that I am helping to bolster his argument.

Mr. Brown

That goes to prove that one can be too generous in wind-up speeches. I said that reclassification accounted for part of the figure involved in this argument. Only 45 per cent. of the total, however, can be accounted for by reclassification. The transition has taken place over four years yet, last year, the number of managers employed in the NHS increased by 13.5 per cent. The Government are still at it.

The reforms are not driven by managerial efficiency alone. The Secretary of State for Health boasted about cutting bureaucracy, but the 1538.3 per cent. increase in bureaucrats is hardly evidence of that. The real purpose of the purchaser-provider split is to put a price tag on individual transactions. If the state is paying the bill, surely there is less need to have everything individually priced. But of course the original objective of the Conservative party was to alter the structure so that payment by state entitlement could sit alongside payment by private medical insurance or even by direct private purchase. Why should the British citizen want to purchase medical care privately if he is entitled to provision free at the point of need? The answer can only be because private provision will be made better than the state's; will be given more quickly; or, worst of all, will be the only method of getting treatment because the state will no longer provide it. In summary, that is what the Conservatives are trying to do to the NHS.

On BBC radio, in one of her frequent and much-loved appearances, the Secretary of State—[HON. MEMBERS: "What?"] Well, I enjoy waking up to the Secretary of State on the "Today" programme—frankly, I think myself lucky that that is where she is. On 24 August 1994, the Secretary of State said that she had "no views" about whether service should be delivered by the public or the private sector. She is supposed to be in charge of it, but she has no views about the delivery of services. I must tell the House that the author of the NHS reforms, Mark Thatcher's mother, had views. According to her, it should be private, so that she could, as she famously said, have what she wanted, when she wanted it. Other patients would like the same. That right hon. Lady told us that the health service, like the Saudi arms contract, was supposed to be safe in her hands.

Is the NHS safe in the Government's hands? Not according to the Public Accounts Committee, which has produced an important report on the proper conduct of public business. The NHS features prominently in that report. We learn from the PAC that the director of regionally managed services of the West Midlands regional health authority left on redundancy terms, after five years' service with the authority, and was given an immediate pension of £6,462 a year and lump sums totalling £81,837. Some might think that that is all well and fine, but the PAC report goes on to say: The Authority and the NHS Management Executive told us that he should have been dismissed not made redundant. Wessex regional health authority managed to waste £20 million of public money in attempting to implement its regional information systems plan, which it abandoned in 1990. The PAC reports uncompromisingly that the money should have been spent on health care for sick people.

It also levelled other criticisms at West Midlands regional health authority.

Mr. Tony Worthington (Clydebank and Milngavie)

May I suggest that the PAC should also investigate Health Care International at Clydebank? Up to £40 million of public money has been given to a private international hospital, but. within three months of being opened by the Secretary of State for Scotland, it faces financial collapse. It was funded to provide for overseas patients. I tabled a parliamentary question to find out how many overseas patients it has, but, I was told that information about non-NHS patients is commercially confidential to the company. We put £40 million into that hospital; it promised not to deal with British patients, but just last week 100 patients were moved from Birmingham to Clydebank. Should not that—

Mr. Deputy Speaker

Order. That was a very long intervention.

Mr. Brown

Nevertheless, it was a very important one. My hon. Friend is quite right that that deplorable scandal should be investigated by the PAC. The Secretary of State for Scotland opened the hospital in June and said that it was an important investment opportunity, which would provide 1,800 jobs. So far, the hospital has employed 400 people, but it has had a maximum occupancy of just 20 patients. That is scandalous and represents a substantial waste of public money. It looks as though the Government will waste more public money digging themselves out of a privatised nightmare that they have created for themselves. That is precisely the sort of thing that the PAC would denounce.

Mr. Malone

Will the hon. Gentleman give way?

Mr. Brown

The Minister has not yet been denounced by the PAC, but he is no doubt anticipating it. Of course I shall give way.

Mr. Malone

I am grateful to the hon. Gentleman for giving me an opportunity to clear up this matter now. First, it was £30 million that was invested under the aegis of Locate in Scotland. [Interruption.] It is important to have put those £10 million more accurately into the argument. Secondly, this is not a health service budget commitment but a commitment by Locate in Scotland, designed specifically to attract jobs to Scotland. When I represented another constituency in a different capacity, Scottish Labour Members were keen to ensure that they devoted a maximum amount of money to projects that would attract jobs.

Mr. Brown

In her opening speech, the Secretary of State tried to gloss over that whole appalling affair as if it were attracting inward investment into Scotland. The Minister of State says that the Government have wasted only £30 million so far and the figure of £40 million is what they are planning to waste to get them out of it. If he thinks that that acquits him of the charges that we are making, his view is unlikely to find a hearing from an impartial audience.

Mr. Burden

Will my hon. Friend comment on my concern that the Minister suddenly seems to know a great deal about this issue whereas, in answer to a parliamentary question that I tabled last week about the cost to the NHS of transferring patients from Birmingham to Glasgow, the Under-Secretary of State answered that that was a local matter and that I should contact Mr. Brian Baker, chairman of the West Midlands health authority. Does my hon. Friend believe that it is acceptable for Ministers to say one minute that they have no knowledge and the next that they have such knowledge? Should not they know how much the national health service is wasting in that way?

Mr. Brown

My hon. Friend has clearly caught the Minister out, as the investigatory authorities will no doubt do in due course.

The Public Accounts Committee has been hard at work in the Department of Health. On Wessex regional health authority, for example, it says: the Authority acknowledged that a fundamental conflict between their interests and those of Wessex Integrated Systems Limited arose when the Authority appointed a Director of that company, with whom the Regional Health Authority had a contract to supply computer services, to act as Regional Information Systems Manager. It goes on to point out: The Authority also allowed a secondee from IBM to advise them on the purchase, without competition, of — guess what?— an IBM computer for £3.3 million, at a time when it could have been purchased for £0.5 million to £1 million less. The Conservatives tell us that their new structures prevent such things from happening. It is perfectly clear from evidence produced by the PAC that that is not so.

Let us look at some of the other absurdities. The number of administrative staff in general practice has risen dramatically, yet it has not eased the burden on GPs. Since 1989, GPs are doing a third more administrative work, despite—or perhaps because of—a 40 per cent. growth in administrative staff. Interestingly, Oxford Research shows that GPs who are fundholders cost four times as much as other GPs for health authorities to administer.

My hon. Friend the Member for Dulwich (Ms Jowell) spoke about front-line services for community care and other reasons. The money is going on administration, not on front-line services. Adminstrative costs at the Department of Health have risen by 108 per cent. since 1987. The hospitality budget for the Department of Health has risen by 74 per cent., and that is only between 1990–91 and 1992–93. I am concerned not about whether it is spent or underspent but about the fact that it has risen by 74 per cent. in one financial year.

The South-East Thames region managed to beat even that. The administrative costs in its family health service rose by 403 per cent. between 1989–90 and 1992–93. It is a gruesome fact that, this year, 143 health service trusts managed to spend £37 million between them on logos and image-building. The national health service management executive has managed to spend £620,000 of taxpayers' money on writing and distributing pamphlets to other health service managers. To pay for all that, prescription charges have increased 16 times since the Conservatives came to power. Dental charges will, apparently, increase from 80 per cent. to 100 per cent., further undermining the provision of dentistry in the national health service.

My hon. Friend the Member for Newham, North-East (Mr. Timms), in an excellent contribution, asked what is wrong with "front line first" as an objective for the health service? If the Government care about front-line services for the Ministry of Defence, why not have front-line services for the Department of Health as well?

However, I must not give the impression that all is doom and gloom, because it is not. According to an Income Data Studies survey in November 1993, the remuneration—I know that the whole House will be reassured to hear it—of chief executives has "escalated rapidly". In one year, the average increase was 8.9 per cent. and the largest pay increase has been at the Guy's and Lewisham NHS trust, where the chief executive received a 33 per cent. pay increase.

Halton health authority in Cheshire paid £228,000 to relocate its new district general manager, and the House will be reassured to learn that only half those payments were deemed to be unlawful by the district auditor. The House will also be relieved to learn that the North Cheshire health authority is trying to recover some of the money. The National Audit Office told us last September that more than £3 million had been wasted in potentially unlawful pay-offs and removal expenses.

The Department of Health has spent more than £1 million on sending national health managers on image-building courses, which it calls "executive coaching".

I know that the House will be interested to learn of the excellent expenditure of public resources at Quarry house, the new management executive headquarters at Leeds. It cost £55 million; it has a swimming pool; it has a £30,000 gym and a £15,000 hand-woven rug, which, I am reliably assured, is not an executive toupee but a £l5,000 rug. Thirty thousand pounds a year is being paid on first-class rail tickets between London and Leeds, yet the former Department of Health offices in Elephant and Castle are being kept empty at a cumulative cost of £5 million per year between 1991 and 1997.

My hon. Friend the Member for Monklands, West: said that the patients did not get the jags. It may be true in the Secretary of State's health service that the patients do not get the Jags, but the chief administrators certainly do—or at least a decent Ford. The amount spent on company cars by the national health service has increased to about £70 million in 1992–93. It is an increase of 31 per cent. on the previous year. The amount spent by trusts on cars, as opposed to patients, has increased by nearly £19 million—from £5.3 million to £24 million.

Those are substantial sums of money. There may be some defence for some of the expenditure, but that is a startlingly dramatic increase.

I must draw my remarks to a close, because I shall no doubt want to intervene on the speech of the Minister, as he has intervened on mine. He will ask what the Labour party would do. Oh—the Government are silent. The Labour party believes in the ethos of public service, based on respect for professionalism, admiration for ethics, even a belief in altruism. We need to renew the methods by which public service is delivered. Management systems must emphasise management, not simply administration. We shall expect managers to take responsibility in the public interest, for the public interest.

Good people can make a bad system work after a fashion. As Conservative health bosses are showing, ill-motivated people can wreck the most carefully structured institution.

I conclude by echoing my hon. Friend the Member for Sunderland, North (Mr. Etherington). The national health service should not be about markets, purchasers or providers. It is an institution rooted in an earlier, less complex, more innocent, age. It is about collectivism. It is a socialist creation, and a socialist institution to the core of its being. The Labour party built it; it is our creation. We intend to keep it safe and we intend to keep it safe in our hands.

9.39 pm

The Minister for Health (Mr. Gerald Malone)

I am grateful to enter the debate at this stage when we are suddenly hearing that the great, new-look modern Labour party is going to go back to the start of the health service in the 1940s to instruct us on how it should be run in the 1990s and beyond. Of course, the health service is about a public ethos; of course, it is a health service that is in the nation's custody. Those aspects were all underpinned by my right hon. Friend the Prime Minister at our recent party conference in Bournemouth. The national health service is not about the sort of collectivist activity to which the hon. Member for Newcastle upon Tyne, East (Mr. Brown) referred. He made an astonishing admission about his agenda and that of his right hon. Friend the Member for Derby, South (Mrs. Beckett) for the future of the health service.

Although the Labour party may have been responsible for setting up the health service in the late 1940s, it has been under the custody of a Conservative Government for far longer than it has been in the hands of a Labour Government. In the hands of a Conservative Government, it has prospered, new practices have been introduced to make it more efficient and more patient care is being delivered. More importantly—this was conceded by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood)—many of the reforms are widely accepted. I understand that the hon. Member for Roxburgh and Berwickshire differs from the Government on some of them.

Many of the reforms are accepted, not just by the hon. Member for Roxburgh and Berwickshire, but throughout the country and the medical profession, as being essential and desirable. They are clearly accepted in the constituency of the right hon. Member for Derby, South, where 79 per cent. of residents are covered by GP fundholders. The right hon. Lady made an astonishing pledge—one of the only new policies that she revealed to the House today—when she declared that she would say to that 79 per cent. of people, "I am going to abolish fundholding." That is one of the right hon. Lady's declared policies.

Mr. Nicholas Brown

If the reforms are widely accepted by the medical profession, as the Minister says, I should draw his attention to the publication, "Senior Doctor", which contains an exclusive survey of consultants and describes the national health service as being on the "verge of collapse". That does not sound like the sort of acquiescence that the Minister was describing to the House.

Mr. Malone

That is yet another exclusive survey that probably relates to a tiny minority of the people involved. We are used to exclusive surveys of a selected 200 or 300 people done by organisations such as the British Medical Association which clearly have an interest in the result. Across the House, the purchaser-provider relationship is accepted as a sensible principle in the provision of care in the health service. It was resisted root and branch by the Opposition when it was first introduced.

I had better warn the hon. Member for Newcastle upon Tyne, East that GP fundholding is widely accepted in the community and regarded as something of great importance by all those who have taken it up. They see that it is not only a challenge, but a method of delivering far better patient care than has ever been delivered before.

Mr. Burden

Will the Minister comment on the case of Sandwell Healthplan—an independent consortium of GP fundholders—which has gone bust? It rented its premises from the chair of the Sandwell family health services authority—for £19,000 in one case and £35,000 in another. That has been the subject of an internal audit report. Does the Minister think that that is a good advertisement for fundholding?

Mr. Malone

The hon. Gentleman should ask all those involved, who have declared their determination to remain fundholders, whether they wish to remain committed to the general fundholding principle. The answer is that they do.

I shall now address some of the specific issues raised in the debate.

The right hon. Member for Derby, South alleged that the pathology services at Lister hospital were being privatised. The point is that those services were properly market-tested and bidders included an in-house team and another NHS trust as well as a private contractor. When there is proper market testing, as in this case, it is good for the health care of the whole community that the bid which will deliver the best health care for the best value for money should be the one accepted.

I cannot understand the continued refusal by the Labour party to acknowledge that there is nothing wrong with introducing the private sector when it can provide certain services more competitively. What really counts is that NHS patients can be treated at a time nearer their choosing and be given a better service. I am surprised that the right hon. Lady should still be sunk in the old Labour party ideology.

My hon. Friend the Member for Broxbourne (Mrs. Roe) touched on accountability. There are three threads of accountability running through the service; it is important to note that these things never existed before. The first is the code of conduct, which lays down explicit standards of conduct that are expected of NHS boards. It introduces new measures to help boards fulfil their responsibilities for effective stewardship and financial control—[Interruption.] Thank goodness the hon. Member for Maker-field (Mr. McCartney) seems to have relinquished his former post. From a sedentary position, he calls this a sleaze charter, even though Sir Adrian Cadbury has commended the code. The hon. Gentleman should think again before making such ill-considered remarks. The code reaffirms the public service values of openness, probity and accountability—they are all extremely important.

The code of practice on openness clearly states that the NHS will provide information unless there are good reasons for not doing so; the reasons are then defined. The code ensures that the public have access to the information that they want and need.

As for appointments, new procedures will open the system to far more scrutiny and provide greater transparency than ever before. We intend to reach people from a far wider range of backgrounds. Everyone is eligible to apply. As my right hon. Friend the Secretary of State said, if the Labour party will encourage its supporters to apply for these posts, perhaps even more of them will apply and be appointed. [Laughter.] I am surprised that the hon. Member for Newcastle upon Tyne, East should mock. It is important that people of all parties be represented on trusts and boards. They should all be allowed to make their public contribution, and I am astonished that the hon. Gentleman should make light of that.

All will be interviewed by panels against agreed criteria. There is no suggestion that there should be any cronyism about it. I welcome what my hon. Friend the Member for Broxbourne had to say about that. Standards of accountability throughout the service are far higher now than ever before.

Mr. David Jamieson (Plymouth, Devonport)

While the Minister is on the subject of accountability, he will be aware of the case of Plymouth hospitals trust and Sister Pat Cooksley, who served 17 years as a sister in Derriford hospital and was highly regarded by patients, professionals and workers alike. She objected to a lowering of standards on her ward and was sacked on the slightest pretext. I am sure the Minister will be pleased to know that she has been reinstated by the hospital trust. Does he agree that such outrages would not happen if the trusts were more accountable to local communities?

Mr. Malone

The hon. Gentleman totally misrepresents the facts. The lady has been reinstated and retrained—[Interruption.] The hon. Gentleman is quite wrong, and if he takes the trouble to find out the facts, he will learn that he is wrong.

The hon. Member for Roxburgh and Berwickshire asked whether any trust applications had been turned down after consultation. I think that he feared that only lip service was paid to such a principle. A number of applications were turned down after consultation. Surrey Heartlands hospital and Manchester children's hospital both had earlier applications for trust status rejected. I hope that that reassures the hon. Gentleman. [Interruption.] I have given two examples and I do not wish to occupy the rest of the time that is available to me in giving all the examples that are available.

The hon. Gentleman also spoke about a place that I know, Drumlanrig. As he knows, it provides respite care in the Borders region. There is already considerable capacity for respite care in the area and the health board sees no case for a new purpose-built facility.

I should like to deal with the two points raised by the hon. Member for City of Durham (Mr. Steinberg). I happily reiterate my offer of a meeting with him at the earliest possible opportunity to discuss the matter that is of great constituency interest to him. I hope we can arrange that as quickly as possible. The hon. Gentleman spoke about the use of low-grade auxiliaries in place of nurses. The modern health service needs a skill mix that perhaps it did not have in the past. Boundaries are breaking down between professions—for example, between consultants and general practitioners. Consultants often practise minor surgery in the premises of GPs, and that has never happened before.

There is a similar situation in secondary care. The hon. Gentleman will find when he enters an accident and emergency unit that the first person to greet him is a qualified nurse instead of someone who clerks patients in rather than assesses them. The breakdown of those boundaries ensures that the nursing profession in particular is able to exercise its professional skills at higher levels rather than carrying out mundane tasks. That is extremely important.

My hon. Friend the Member for Wimbledon (Dr. Goodson-Wickes) highlighted culture changes in the health service. He was right to say that Labour would ignore anything that gets better and would oppose any attempt to introduce an assessment of cost in the health service. But cost is important if one is to improve the quality of patient care while being careful about the spending of public money. I completely fail to understand how Labour can continue to ignore that. Opposition Members seem to be stuck in old arguments that have no place in a modern health service.

The hon. Member for Dulwich (Ms Jowell) criticised the number of cancelled operations and said that she had experience of such cancellations in her constituency. Since 1 April 1994, national standards on cancelled operations have improved substantially. Patients must now be admitted for treatment after only one cancellation on the day of admission. The original standard was two cancellations. I cannot comment specifically on the case that she mentioned, but it seems to have grossly exceeded the previous standard. As I say, a higher standard has been set and we view most seriously any failure to implement such standards.

The hon. Member for Sunderland, North (Mr. Etherington) spoke about Sunderland City hospitals trust. I was rather astonished that he did not mention a 377-bed ward block that was recently opened by the Princess Royal. We can also point to a new dedicated two-theatre day case unit, which opened in March. There is good news in the constituencies and I wish that Opposition Members would sometimes mention that rather than indulging in dirges that give only half the picture. In the hon. Gentleman's constituency, there has been a 6.5 per cent. increase in in-patient and day cases over the past three years, and there are 25 per cent. more consultants than there were in 1988.

I worry that the only response from the Opposition is that those are mere statistics. I was on the "Today" programme on one of the few mornings that my right hon. Friend the Secretary of State was not. I was told by someone representing the opposite case, "That is all very well for you to say, Mr. Malone. These are simply facts and figures. What do they mean?" Let me say to the hon. Member for Sunderland, North and all other hon. Members who do not think that the facts and figures about improved health care mean very much, that they mean a tremendous amount. In particular, I am delighted to announce that in his constituency no one has been waiting for more than 12 months. I hope that he will recognise that point.

My hon. Friend the Member for Great Yarmouth (Mr. Carttiss) made an interesting speech. I returned to the Chamber to hear the second half and I understand that the first half was as interesting as the second. He raised a number of genuine concerns and I should particularly like to address one of them. He was concerned that chairmen and non-executive members appointed to health authorities should be local and locally known. I do not think for one second that the home address of a potential non-executive member is absolutely crucial to whether he should serve on a trust or a board. A whole range of factors is quite properly taken into account. They include local links with the area and any local work or business connections that the person has had in the area.

Our prime concern is, and will continue to be, to ensure that the NHS benefits from the best possible leadership from the best possible pool of talent. On that point, we believe that best practice should be followed. Best practice is often to advertise. I have said before that we wish to extend that to all posts. It is very important indeed that there is a pool of talent available to occupy such important public positions. We can move forward from the best practice which is already in place in my own area—the South and West region—and which I hope can be spread throughout the country.

The debate was not terribly surprising for Conservative Members. We heard the same old arguments from the new team. I am interested to see that on their first outing they do not appear to be allowed out on their own. They are flanked by their predecessors, presumably to ensure that they get the line right. The hon. Member for Makerfield has made a longer and more comprehensive speech from a sedentary position than many who have spoken from the Front Bench this evening.

We were told to expect that on this first outing of the new model Labour party on an Opposition day debate we should be hearing new things. I thought that the new model Labour party was in favour of a mixed economy—but not for health. The new model Labour party is not interested in beggar-my-neighbour policies which ensure that no additional funds from the private sector are to be available for additional health care over and above public spending. Labour is interested only in hiding behind slogans; there is no substance to any of its policies. However, I will move on to the substance of one or two of the policies that we heard.

We hear simply slogans. I suppose that there will be one for the health service. I should not be surprised to learn that it was, "Tough on illness, tough on the causes of illness," and when it came to spending, "Fair spending, not high spending." The veneer has been stripped away in the debate this evening. At bottom, we know that the Labour party is precisely the same Labour party that it has always been, the same Labour party which defends public sector interests and the trade union interests in the health service; it is not in the least bit interested in making any progress.

The right hon. Member for Derby, South gave an interesting message on health policy. Labour's one declared policy is to strip pensioners of their tax benefit for private health care. It is the first time that on a first outing a Labour party spokesman has made a direct attack on pensioners as a specific aspect of policy. The whole point of the debate, according to the right hon. Lady, is that the health service is shrouded in secrecy, that we are afraid to disclose details of those who serve on boards and that it is all a great dark secret and a conspiracy. Let me refer to her own constituency. I have here what she would consider to be a secret document, which means that nothing is available to her and that she can obtain no information about who serves on trusts. The secret document is the Derby Evening Telegraph. There it is—the new team, The team you can trust". I can tell the right hon. Lady that there is no such secrecy. Everything is above board and right. The best talent is recruited to run our health service. It is a health service of which we are proud and when it comes to the team that can be trusted, it is not that team over there; it is this team over here.

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

The House divided: Ayes 263, Noes 297.

Division No. 313]	[10.00 pm
AYES
Abbott, Ms Diane	Clapham, Michael
Adams, Mrs Irene	Clark, Dr David (South Shields)
Ainger, Nick	Clarke, Eric (Midlothian)
Ainsworth, Robert (Cov'try NE)	Clarke, Tom (Monklands W)
Allen, Graham	Clelland, David
Alton, David	Clwyd, Mrs Ann
Anderson, Donald (Swansea E)	Coffey, Ann
Anderson, Ms Janet	Cohen, Harry
Armstrong, Hilary	Connarty, Michael
Ashton, Joe	Cook, Frank (Stockton N)
Austin-Walker, John	Corbett, Robin
Banks, Tony (Newham NW)	Corbyn, Jeremy
Barnes, Harry	Cousins, Jim
Barron, Kevin	Cox, Tom
Battle, John	Cummings, John
Bayley, Hugh	Cunliffe, Lawrence
Beckett, Rt Hon Margaret	Cunningham, Jim (Covy SE)
Beith, Rt Hon A. J.	Cunningham, Rt Hon Dr John
Bell, Stuart	Dalyell, Tam
Benn, Rt Hon Tony	Darling, Alistair
Bennett, Andrew F.	Davidson, Ian
Benton, Joe	Davies, Bryan (Oldham C'tral)
Bermingham, Gerald	Davies, Ron (Caerphilly)
Berry, Roger	Davies, Rt Hon Denzil (Llanelli)
Betts, Clive	Davis, Terry (B'ham, H'dge H'I)
Blair, Tony	Denham, John
Blunkett, David	Dewar, Donald
Boateng, Paul	Dixon, Don
Boyes, Roland	Donohoe, Brian H.
Bradley, Keith	Dowd, Jim
Bray, Dr Jeremy	Dunnachie, Jimmy
Brown, Gordon (Dunfermline E)	Dunwoody, Mrs Gwyneth
Brown, N. (N'c'tle upon Tyne E)	Eagle, Ms Angela
Burden, Richard	Eastham, Ken
Byers, Stephen	Enright, Derek
Caborn, Richard	Etherington, Bill
Callaghan, Jim	Evans, John (St Helens N)
Campbell, Menzies (Fife NE)	Fatchett, Derek
Campbell, Mrs Anne (C'bridge)	Field, Frank (Birkenhead)
Campbell, Ronnie (Blyth V)	Fisher, Mark
Canavan, Dennis	Flynn, Paul
Cann, Jamie	Foster, Don (Bath)
Carlile, Alexander (Montgomry)	Foster, Rt Hon Derek
Chidgey, David	Foulkes, George
Chisholm, Malcolm	Fraser, John
Church, Judith	Fyfe, Maria

Galbraith, Sam	McCartney, Ian
Gapes, Mike	McFall, John
Garrett, John	McKelvey, William
George, Bruce	McLeish, Henry
Gerrard, Neil	McMaster, Gordon
Gilbert, Rt Hon Dr John	McNamara, Kevin
Godman, Dr Norman A.	McWilliam, John
Godsiff, Roger	Meacher, Michael
Golding, Mrs Llin	Meale, Alan
Gordon, Mildred	Michael, Alun
Graham, Thomas	Michie, Bill (Sheffield Healey)
Grant, Bemie (Tottenham)	Michie, Mrs Ray (Argyll Bute)
Griffiths, Nigel (Edinburgh S)	Milburn, Alan
Griffiths, Win (Bridgend)	Miller, Andrew
Grocott, Bruce	Mitchell, Austin (Gt Grimsby)
Gunnell, John	Moonie, Dr Lewis
Hain, Peter	Morris, Estelle (B'ham Yardley)
Hall, Mike	Morris, Rt H[...]n A. (Wy'nshawe)
Hanson, David	Morris, Rt Hon J. (Aberavon)
Hardy, Peter	Mowlam, Marjorie
Harman, Ms Harriet	Mudie, George
Harvey, Nick	Mullin, Chris
Hattersley, Rt Hon Roy	Murphy, Paul
Henderson, Doug	O'Brien, Michael (N W'kshire)
Heppell, John	O'Brien, William (Normanton)
Hill, Keith (Streatham)	O'Hara, Edward
Hinchliffe, David	O'Neill, Martin
Hodge, Margaret	Oakes, Rt Hon Gordon
Hoey, Kate	Olner, William
Hogg, Norman (Cumbernauld)	Orme, Rt Hon Stanley
Home Robertson, John	Patchett, Terry
Hoon, Geoffrey	Pike, Peter L.
Howarth, George (Knowsley N)	Pope, Greg
Howells, Dr. Kim (Pontypridd)	Powell, Ray (Ogmore)
Hoyle, Doug	Prentice, Bridget (Lew'm E)
Hughes, Kevin (Doncaster N)	Prentice, Gordon (Pendle)
Hughes, Robert (Aberdeen N)	Prescott, John
Hutton, John	Primarolo, Dawn
Ingram, Adam	Purchase, Ken
Jackson, Glenda (H'stead)	Quin, Ms Joyce
Jackson, Helen (Shef'ld, H)	Randall, Stuart
Jamieson, David	Raynsford, Nick
Janner, Greville	Reid, Dr John
Johnston, Sir Russell	Rendel, David
Jones, Barry (Alyn and D'side)	Robertson, George (Hamilton)
Jones, Ieuan Wyn (Ynys Mofln)	Robinson, Geoffrey (Co'try NW)
Jones, Lynne (B'ham S 0)	Roche, Mrs. Barbara
Jones, Martyn (Clwyd, SW)	Rogers, Allan
Jowell, Tessa	Rooker, Jeff
Kaufman, Rt Hon Gerald	Rooney, Terry
Keen, Alan	Ross, Ernie (Dundee W)
Kennedy, Jane (Lpool Brdgn)	Rowlands, Ted
Khabra, Piara S.	Ruddock, Joan
Kilfoyle, Peter	Salmond, Alex
Kirkwood, Archy	Sedgemore, Brian
Lestor, Joan (Eccles)	Sheerman, Barry
Lewis, Terry	Sheldon, Rt Hon Robert
Liddell, Mrs Helen	Shore, Rt Hon Peter
Litherland, Robert	Short, Clare
Livingstone, Ken	Simpson, Alan
Lloyd, Tony (Stretford)	Skinner, Dennis
Lwyd, Elfyn	Smith, Andrew (Oxford E)
Loyden, Eddie	Smith, C. (Isl'ton S & F'sbury)
Lynne, Ms Liz	Smith, Llew (Blaenau Gwent)
Macdonald, Calum	Soley, Clive
Mackinlay, Andrew	Spearing, Nigel
MacShane, Denis	Squire, Rachel (Dunfermline W)
Madden, Max	Steinberg, Gerry
Maddock, Diana	Stott, Roger
Mandelson, Peter	Strang, Dr. Gavin
Marshall, David (Shettleston)	Straw, Jack
Marshall, Jim (Leicester, S)	Sutcliffe, Gerry
Martlew, Eric	Taylor, Mrs Ann (Dewsbury)
Maxton, John	Thompson, Jack (Wansbeck)
McAllion, John	Timms, Stephen
McAvoy, Thomas	Tipping, Paddy

Turner, Dennis	Williams, Rt Hon Alan (Sw'n W)
Tyler, Paul	Wilson, Brian
Vaz, Keith	Winnick, David
Walker, Rt Hon Sir Harold	Wise, Audrey
Wallace, James	Worthington, Tony
Walley, Joan	Wray, Jimmy
Wardell, Gareth (Gower)	Wright, Dr Tony
Wareing, Robert N	Young, David (Bolton SE)
Welsh, Andrew	Tellers for the Ayes:
Wicks, Malcolm	Mr. Eric Illsley and
Williams, Alan W (Carmarthen)	Mr. John Speller

NOES
Ainsworth, Peter (East Surrey)	Currie, Mrs Edwina (S D'by'ire)
Aitken, Rt Hon Jonathan	Curry, David (Skipton & Ripon)
Alison, Rt Hon Michael (Selby)	Davies, Quentin (Stamford)
Allason, Rupert (Torbay)	Davis, David (Boothferry)
Amess, David	Day, Stephen
Ancram, Michael	Deva, Nirj Joseph
Arbuthnot, James	Devlin, Tim
Arnold, Sir Thomas (Hazel Grv)	Dicks, Terry
Ashby, David	Dorrell, Rt Hon Stephen
Atkins, Robert	Douglas-Hamilton, Lord James
Atkinson, Peter (Hexham)	Dover, Den
Baker, Nicholas (Dorset North)	Duncan, Alan
Baldry, Tony	Duncan-Smith, Iain
Banks, Matthew (Southport)	Dunn, Bob
Banks, Robert (Harrogate)	Durant, Sir Anthony
Bates, Michael	Dykes, Hugh
Batiste, Spencer	Eggar, Tim
Bellingham, Henry	Elletson, Harold
Bendall, Vivian	Emery, Rt Hon Sir Peter
Beresford, Sir Paul	Evans, David (Welwyn Hatfield)
Biffen, Rt Hon John	Evans, Jonathan (Brecon)
Body, Sir Richard	Evans, Nigel (Ribble Valley)
Bonsor, Sir Nicholas	Evans, Roger (Monmouth)
Booth, Hartley	Evennett, David
Boswell, Tim	Faber, David
Bottomley, Peter (Eltham)	Fabricant, Michael
Bottomley, Rt Hon Virginia	Fenner, Dame peggy
Bowden, Sir Andrew	Field, Barry (Isle of Wight)
Bowis, John	Fishburn, Dudley
Boyson, Rt Hon Sir Rhodes	Forman, Nigel
Brandreth, Gyles	Forsyth, Michael (Stirling)
Brazier, Julian	Forth, Eric
Bright, Sir Graham	Fox, Dr Liam (Woodspring)
Brooke, Rt Hon Peter	Fox, Sir Marcus (Shipley)
Brown, M. (Brigg & Cl'thorpes)	Freeman, Rt Hon Roger
Browning, Mrs. Angela	French, Douglas
Bruce, Ian (S Dorset)	Fry, Sir Peter
Budgen, Nicholas	Gale, Roger
Burns, Simon	Gardiner, Sir George
Butcher, John	Garnier, Edward
Butler, Peter	Gillan, Cheryl
Butterfill, John	Goodlad, Rt Hon Alastair
Carlisle, John (Luton North)	Goodson-Wickes, Dr Charles
Carlisle, Sir Kenneth (Lincoln)	Gorman, Mrs Teresa
Carrington, Matthew	Gorst, Sir John
Carttiss, Michael	Grant, Sir A. (Cambs SW)
Cash, William	Greenway, Harry (Ealing N)
Channon, Rt Hon Paul	Greenway, John (Ryedale)
Churchill, Mr	Griffiths, Peter (Portsmouth, N)
Clappison, James	Grylls, Sir Michael
Clark, Dr Michael (Rochford)	Gummer, Rt Hon John Selwyn
Clarke, Rt Hon Kenneth (Ru'clif)	Hague, William
Clifton-Brown, Geoffrey	Hamilton, Neil (Tatton)
Coe, Sebastian	Hamilton, Rt Hon Sir Archie
Colvin, Michael	Hampson, Dr Keith
Congdon, David	Hannam, Sir John
Conway, Derek	Hargreaves, Andrew
Coombs, Anthony (Wyre For'st)	Harris, David
Coombs, Simon (Swindon)	Haselhurst, Alan
Cope, Rt Hon Sir John	Hawkins, Nick
Couchman, James	Hawksley, Warren
Cran, James	Hayes, Jerry

Heald, Oliver	Onslow, Rt Hon Sir Cranley
Heathcoat-Amory, David	Oppenheim, Phillip
Hendry, Charles	Ottaway, Richard
Heseltine, Rt Hon Michael	Page, Richard
Higgins, Rt Hon Sir Terence	Paice, James
Hill, James (Southampton Test)	Patnick, Sir Irvine
Horam, John	Patten, Rt Hon John
Howard, Rt Hon Michael	Pattie, Rt Hon Sir Geoffrey
Howarth, Alan (Strat'rd-on-A)	Pawsey, James
Howell, Rt Hon David (G'dford)	Peacock, Mrs Elizabeth
Howell, Sir Ralph (N Norfolk)	Pickles, Eric
Hughes Robert G. (Harrow W)	Porter, Barry (Wirral S)
Hunt, Rt Hon David (Wirral W)	Porter, David (Waveney)
Hunt, Sir John (Ravensbourne)	Portillo, Rt Hon Michael
Hunter, Andrew	Powell, William (Corby)
Hurd, Rt Hon Douglas	Rathbone, Tim
Jack, Michael	Redwood, Rt Hon John
Jackson, Robert (Wantage)	Renton, Rt Hon Tim
Jenkin, Bernard	Richards, Rod
Jessel, Toby	Riddick, Graham
Johnson Smith, Sir Geoffrey	Rifkind, Rt Hon. Malcolm
Jones, Gwilym (Cardiff N)	Robathan, Andrew
Jones, Robert B. (W Hertfdshr)	Roberts, Rt Hon Sir Wyn
Jopling, Rt Hon Michael	Robertson, Raymond (Ab'd'n S)
Kellett-Bowman, Dame Elaine	Robinson, Mark (Somerton)
Key, Robert	Roe, Mrs Marion (Broxbourne)
Kilfedder, Sir James	Rowe, Andrew (Mid Kent)
King, Rt Hon Tom	Rumbold, Rt Hon Dame Angela
Kirkhope, Timothy	Ryder, Rt Hon Richard
Knight, Dame Jill (Bir'm E'st'n)	Sackville, Tom
Knight, Greg (Derby N)	Sainsbury, Rt Hon Tim
Knight, Mrs Angela (Erewash)	Scott, Rt Hon Nicholas
Knox, Sir David	Shaw, David (Dover)
Kynoch, George (Kincardine)	Shaw, Sir Giles (Pudsey)
Lait, Mrs Jacqui	Shephard, Rt Hon Gillian
Lamont, Rt Hon Norman	Shepherd, Colin (Hereford)
Lang, Rt Hon Ian	Shepherd, Richard (Aldridge)
Lawrence, Sir Ivan	Shersby, Michael
Legg, Barry	Sims, Roger
Leigh, Edward	Skeet, Sir Trevor
Lennox-Boyd, Sir Mark	Smith, Sir Dudley (Warwick)
Lester, Jim (Broxtowe)	Smith, Tim (Beaconsfield)
Lidington, David	Soames, Nicholas
Lilley, Rt Hon Peter	Spencer, Sir Derek
Lloyd, Rt Hon Peter (Fareham)	Spicer, Michael (S Worcs)
Lord, Michael	Spicer, Sir James (W Dorset)
Luff, Peter	Spink, Dr Robert
MacGregor, Rt Hon John	Spring, Richard
MacKay, Andrew	Sproat, Iain
Maclean, David	Squire, Robin (Hornchurch)
Madel, Sir David	Stanley, Rt Hon Sir John
Maitland, Lady Olga	Steen, Anthony
Malone, Gerald	Stephen, Michael
Mans, Keith	Stern, Michael
Marland, Paul	Stewart, Allan
Marlow, Tony	Streeter, Gary
Marshall, John (Hendon S)	Sumberg, David
Marshall, Sir Michael (Arundel)	Sweeney, Walter
Martin, David (Portsmouth S)	Sykes, John
Mates, Michael	Tapsell, Sir Peter
Mawhinney, Rt Hon Dr Brian	Taylor, Ian (Esher)
McLoughlin, Patrick	Taylor, John M. (Solihull)
McNair-Wilson, Sir Patrick	Taylor, Sir Teddy (Southend, E)
Mellor, Rt Hon David	Temple-Morris, Peter
Merchant, Piers	Thomason, Roy
Mills, Iain	Thompson, Patrick (Norwich N)
Mitchell, Andrew (Gedling)	Thompson, Sir Donald (C'er V)
Mitchell, Sir David (Hants NW)	Thornton, Sir Malcolm
Moate, Sir Roger	Thurnham, Peter
Monro, Sir Hector	Townend, John (Bridlington)
Montgomery, Sir Fergus	Townsend, Cyril D. (Bexl'yh'th)
Nelson, Anthony	Tracey, Richard
Neubert, Sir Michael	Tredinnick, David
Newton, Rt Hon Tony	Trend, Michael
Nicholson, David (Taunton)	Twinn, Dr Ian
Nicholson, Emma (Devon West)	Vaughan, Sir Gerard

Viggers, Peter	Widdecombe, Ann
Walden, George	Wilkinson, John
Walker, Bill (N Tayside)	Willetts, David
Waller, Gary	Wilshire, David
Ward, John	Winterton, Nicholas (Macc'f'ld)
Wardle, Charles (Bexhill)	Wolfson, Mark
Waterson, Nigel	Wood, Timothy
Watts, John	Yeo, Tim
Wells, Bowen	Young, Rt Hon Sir George
Wheeler, Rt Hon Sir John	Tellers for the Noes:
Whitney, Ray	Mr. David Lightbown and
Whittingdale, John	Mr. Sydney Chapman.

Question accordingly negatived.

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

The House divided: Ayes 292, Noes 259.

Division No. 314]	[10.15 pm
AYES
Ainsworth, Peter (East Surrey)	Clappison, James
Alison, Rt Hon Michael (Selby)	Clark, Dr Michael (Rochford)
Allason, Rupert (Torbay)	Clarke, Rt Hon Kenneth (Ru'clif)
Amess, David	Clifton-Brown, Geoffrey
Ancram, Michael	Coe, Sebastian
Arbuthnot, James	Colvin, Michael
Arnold, Sir Thomas (Hazel Grv)	Congdon, David
Ashby, David	Conway, Derek
Atkins, Robert	Coombs, Anthony
Atkinson, Peter (Hexham)	Coombs, Simon
Baker, Nicholas (Dorset North)	Cope, Rt Hon Sir John
Baldry, Tony	Couchman, James
Banks, Matthew (Southport)	Cran, James
Banks, Robert (Harrogate)	Currie, Mrs Edwina (S D'by'ire)
Bates, Michael	Curry, David (Skipton & Ripon)
Batiste, Spencer	Davies, Quentin (Stamford)
Bellingham, Henry	Davis, David (Boothferry)
Bendall, Vivian	Day, Stephen
Beresford, Sir Paul	Deva, Nirj Joseph
Biffen, Rt Hon John	Devlin, Tim
Body, Sir Richard	Dicks, Terry
Bonsor, Sir Nicholas	Dorrell, Rt Hon Stephen
Booth, Hartley	Douglas-Hamilton, Lord James
Boswell, Tim	Dover, Den
Bottomley, Peter (Eltham)	Duncan, Alan
Bottomley, Rt Hon Virginia	Duncan-Smith, Iain
Bowden, Sir Andrew	Dunn, Bob
Bowis, John	Durant, Sir Anthony
Boyson, Rt Hon Sir Rhodes	Dykes, Hugh
Brandreth, Gyles	Eggar, Tim
Brazier, Julian	Elletson, Harold
Bright, Sir Graham	Emery, Rt Hon Sir Peter
Brooke, Rt Hon Peter	Evans, David (Welwyn Hatfield)
Brown, M. (Brigg & Cl'thorpes)	Evans, Jonathan (Brecon)
Browning, Mrs. Angela	Evans, Nigel (Ribble Valley)
Bruce, Ian (S Dorset)	Evans, Roger (Monmouth)
Budgen, Nicholas	Evennett, David
Burns, Simon	Faber, David
Burt, Alistair	Fabricant, Michael
Butcher, John	Fenner, Dame Peggy
Butler, Peter	Field, Barry (Isle of Wight)
Butterfill, John	Fishburn, Dudley
Caborn, Richard	Forman, Nigel
Carlisle, John (Luton North)	Forsyth, Michael (Stirling)
Carlisle, Sir Kenneth (Lincoln)	Forth, Eric
Carrington, Matthew	Fox, Dr Liam (Woodspring)
Carttiss, Michael	Fox, Sir Marcus (Shipley)
Cash, William	Freeman, Rt Hon Roger
Channon, Rt Hon Paul	French, Douglas
Churchill, Mr	Fry, Sir Peter

Gale, Roger	Marland, Paul
Gardiner, Sir George	Marlow, Tony
Garnier, Edward	Marshall, John (Hendon S)
Gillan, Cheryl	Martin, David (Portsmouth S)
Goodlad, Rt Hon Alastair	Mates, Michael
Goodson-Wickes, Dr Charles	Mawhinney, Rt Hon Dr Brian
Gorman, Mrs Teresa	McLoughlin, Patrick
Gorst, Sir John	McNair-Wilson, Sir Patrick
Grant, Sir A. (Cambs SW)	Mellor, Rt Hon David
Greenway, Harry (Ealing N)	Merchant, Piers
Greenway, John (Ryedale)	Mills, Iain
Griffiths, Peter (Portsmouth, N)	Mitchell, Andrew (Gedling)
Grylls, Sir Michael	Mitchell, Sir David (Hants NW)
Gummer, Rt Hon John Selwyn	Moate, Sir Roger
Hague, William	Monro, Sir Hector
Hamilton, Neil (Tatton)	Montgomery, Sir Fergus
Hamilton, Rt Hon Sir Archie	Nelson, Anthony
Hampson, Dr Keith	Neubert, Sir Michael
Hargreaves, Andrew	Newton, Rt Hon Tony
Harris, David	Nicholson, David (Taunton)
Haselhurst, Alan	Nicholson, Emma (Devon West)
Hawkins, Nick	Onslow, Rt Hon Sir Cranley
Hawksley, Warren	Oppenheim, Phillip
Hayes, Jerry	Ottaway, Richard
Heald, Oliver	Page, Richard
Heathcoat-Amory, David	Paice, James
Hendry, Charles	Patnick, Sir Irvine
Heseltine, Rt Hon Michael	Patten, Rt Hon John
Higgins, Rt Hon Sir Terence	Pattie, Rt Hon Sir Geoffrey
Hill, James (Southampton Test)	Pawsey, James
Horam, John	Peacock, Mrs Elizabeth
Howard, Rt Hon Michael	Pickles, Eric
Howarth, Alan (Strat'rd-on-A)	Porter, Barry (Wirral S)
Howell, Sir Ralph (N Norfolk)	Porter, David (Waveney)
Hughes, Robert G.	Portillo, Rt Hon Michael
Howell, Rt Hon David (G'dford)	Powell, William (Corby)
Hunt, Rt Hon David (Wirral W)	Rathbone, Tim
Hunt, Sir John (Ravensbourne)	Redwood, Rt Hon John
Hurd, Rt Hon Douglas	Renton, Rt Hon Tim
Jack, Michael	Richards, Rod
Jackson, Robert (Wantage)	Riddick, Graham
Jenkin, Bernard	Rifkind, Rt Hon. Malcolm
Jessel, Toby	Robathan, Andrew
Johnson Smith, Sir Geoffrey	Roberts, Rt Hon Sir Wyn
Jones, Gwilym (Cardiff N)	Robertson, Raymond (Ab'd'n S)
Jones, Robert B. (W Hertfdshr)	Robinson, Mark (Somerton)
Jopling, Rt Hon Michael	Roe, Mrs Marion (Broxbourne)
Kellett-Bowman, Dame Elaine	Rowe, Andrew (Mid Kent)
Key, Robert	Rumbold, Rt Hon Dame Angela
Kilfedder, Sir James	Ryder, Rt Hon Richard
King, Rt Hon Tom	Sackville, Tom
Knight, Dame Jill (Bir'm E'st'n)	Sainsbury, Rt Hon Tim
Knight, Greg (Derby N)	Scott, Rt Hon Nicholas
Knight, Mrs Angela (Erewash)	Shaw, David (Dover)
Knox, Sir David	Shaw, Sir Giles (Pudsey)
Kynoch, George (Kincardine)	Shepherd, Colin (Hereford)
Lait, Mrs Jacqui	Shepherd, Richard (Aldridge)
Lamont, Rt Hon Norman	Shersby, Michael
Lang, Rt Hon Ian	Sims, Roger
Lawrence, Sir Ivan	Skeet, Sir Trevor
Legg, Barry	Smith, Sir Dudley (Warwick)
Leigh, Edward	Smith, Tim (Beaconsfield)
Lennox-Boyd, Sir Mark	Soames, Nicholas
Lester, Jim (Broxtowe)	Spencer, Sir Derek
Lidington, David	Spicer, Michael (S Worcs)
Lightbown, David	Spicer, Sir James (W Dorset)
Lloyd, Rt Hon Peter (Fareham)	Spink, Dr Robert
Lord, Michael	Spring, Richard
Luff, Peter	Sproat, Iain
MacGregor, Rt Hon John	Squire, Robin (Hornchurch)
MacKay, Andrew	Stanley, Rt Hon Sir John
Maclean, David	Steen, Anthony
Madel, Sir David	Stephen, Michael
Maitland, Lady Olga	Stern, Michael
Malone, Gerald	Stewart, Allan
Mans, Keith	Streeter, Gary

Sumberg, David	Walker, Bill (N Tayside)
Sweeney, Walter	Waller, Gary
Sykes, John	Ward, John
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	Wheeler, Rt Hon Sir John
Thomason, Roy	Whittingdale, John
Thompson, Patrick (Norwich N)	Widdecombe, Ann
Thompson, Sir Donald (C'er V)	Wilkinson, John
Thornton, Sir Malcolm	Willetts, David
Thurnham, Peter	Wilshire, David
Townend, John (Bridlington)	Winterton, Nicholas (Macc'fld)
Townsend, Cyril D. (Bexl'yh'th)	Wolfson, Mark
Tracey, Richard	Wood, Timothy
Tredinnick, David	Yeo, Tim
Trend, Michael	Young, Rt Hon Sir George
Twinn, Dr Ian
Vaughan, Sir Gerard	Tellers for the Ayes:
Viggers, Peter	Mr. Sydney Chapman and
Walden, George	Mr. Timothy Kirkhope

NOES
Abbott, Ms Diane	Coffey, Ann
Adams, Mrs Irene	Cohen, Harry
Ainger, Nick	Connarty, Michael
Ainsworth, Robert (Cov'try NE)	Cook, Frank (Stockton N)
Allen, Graham	Corbett, Robin
Alton, David	Corbyn, Jeremy
Anderson, Donald (Swansea E)	Cousins, Jim
Anderson, Ms Janet	Cox, Tom
(Ros'dale)	Cummings, John
Armstrong, Hilary	Cunliffe, Lawrence
Ashton, Joe	Cunningham, Jim (Covy SE)
Austin-Walker, John	Dalyell, Tam
Banks, Tony (Newham NW)	Darling, Alistair
Barnes, Harry	Davidson, Ian
Barron, Kevin	Davies, Bryan (Oldham C'tral)
Battle, John	Davies, Rt Hon Denzil (Llanelli)
Bayley, Hugh	Davis, David (Boothferry)
Beckett, Rt Hon Margaret	Davis, Terry (B'ham, H'dge H'I)
Beith, Rt Hon A. J.	Denham, John
Bell, Stuart	Dewar, Donald
Bann, Rt Hon Tony	Dixon, Don
Bennett, Andrew F.	Donohoe, Brian H.
Benton, Joe	Dowd, Jim
Bermingham, Gerald	Dunnachie, Jimmy
Berry, Roger	Dunwoody, Mrs Gwyneth
Betts, Clive	Eagle, Ms Angela
Blunkett, David	Eastham, Ken
Boateng, Paul	Enright, Derek
Boyes, Roland	Etherington, Bill
Bradley, Keith	Evans, John (St Helens N)
Bray, Dr Jeremy	Fatchett, Derek
Brown, Gordon (Dunfermline E)	Field, Frank (Birkenhead)
Brown, N. (N'c'tle upon Tyne E)	Fisher, Mark
Burden, Richard	Flynn, Paul
Byers, Stephen	Foster, Don (Bath)
Caborn, Richard	Foulkes, George
Callaghan, Jim	Fraser, John
Campbell, Menzies (Fife NE)	Fyfe, Maria
Campbell, Mrs Anne (C'bridge)	Galbraith, Sam
Campbell, Ronnie (Blyth V)	Gapes, Mike
Canavan, Dennis	Garrett, John
Cann, Jamie	George, Bruce
Carlile, Alexander (Montgomry)	Gerrard, Neil
Chidgey, David	Gilbert, Rt Hon Dr John
Chisholm, Malcolm	Godman, Dr Norman A.
Church, Judith	Godsiff, Roger
Clapham, Michael	Golding, Mrs Llin
Clark, Dr David (South Shields)	Gordon, Mildred
Clarke, Eric (Midlothian)	Graham, Thomas
Clarke, Tom (Monklands W)	Grant, Bernie (Tottenham)
Clelland, David	Griffiths, Nigel (Edinburgh S)
Clwyd, Mrs Ann	Griffiths, Win (Bridgend)

Grocott, Bruce	Mitchell, Austin (Gt Grimsby)
Gunnell, John	Moonie, Dr Lewis
Hain, Peter	Morris, Estelle (B'ham Yardley)
Hall, Mike	Morris, Rt Hon A. (Wy'nshawe)
Hanson, David	Morris, Rt Hon J. (Aberavon)
Hardy, Peter	Mowlam, Marjorie
Harman, Ms Harriet	Mudie, George
Harvey, Nick	Mullin, Chris
Hattersley, Rt Hon Roy	Murphy, Paul
Henderson, Doug	O'Brien, Michael (N W'kshire)
Heppell, John	O'Brien, William (Normanton)
Hill, Keith (Streatham)	O'Hara, Edward
Hinchliffe, David	O'Neill, Martin
Hodge, Margaret	Oakes, Rt Hon Gordon
Hoey, Kate	Olner, William
Hogg, Norman (Cumbernauld)	Orme, Rt Hon Stanley
Home Robertson, John	Patchett, Terry
Hoon, Geoffrey	Pike, Peter L.
Howarth, George (Knowsley N)	Powell, Ray (Ogmore)
Howells, Dr. Kim (Pontypridd)	Prentice, Bridget (Lew'm E)
Hoyle, Doug	Prentice, Gordon (Pendle)
Hughes, Kevin (Doncaster N)	Prescott, John
Hughes, Robert (Aberdeen N)	Primarolo, Dawn
Hughes, Simon (Southwark)	Purchase, Ken
Hutton, John	Quin, Ms Joyce
Ingram, Adam	Randall, Stuart
Jackson, Glenda (H'stead)	Raynsford, Nick
Jackson, Helen (Shef'ld, H)	Reid, Dr John
Jamieson, David	Rendel, David
Janner, Greville	Robertson, George (Hamilton)
Johnston, Sir Russell	Robinson, Geoffrey (Co'try NW)
Jones, Barry (Alyn and D'side)	Roche, Mrs. Barbara
Jones, Ieuan Wyn (Ynys Mofln)	Rogers, Allan
Jones, Lynne (B'ham S 0)	Rooker, Jeff
Jones, Martyn (Clwyd, SW)	Rooney, Terry
Jowell, Tessa	Ross, Ernie (Dundee W)
Kaufman, Rt Hon Gerald	Rowlands, Ted
Keen, Alan	Ruddock, Joan
Kennedy, Jane (Lpool Brdgn)	Salmond, Alex
Khabra, Piara S.	Sedgemore, Brian
Kirkwood, Archy	Sheerman, Barry
Lestor, Joan (Eccles)	Sheldon, Rt Hon Robert
Lewis, Terry	Shore, Rt Hon Peter
Liddell, Mrs Helen	Short, Clare
Litherland, Robert	Simpson, Alan
Livingstone, Ken	Skinner, Dennis
Lloyd, Tony (Stretford)	Smith, Andrew (Oxford E)
Llwyd, Elfyn	Smith, C. (Isl'ton S & F'sbury)
Loyden, Eddie	Smith, Llew (Blaenau Gwent)
Lynne, Ms Liz	Soley, Clive
Macdonald, Calum	Spearing, Nigel
Mackinlay, Andrew	Squire, Rachel (Dunfermline W)
MacShane, Denis	Steinberg, Gerry
Madden, Max	Stott, Roger
Maddock, Diana	Strang, Dr. Gavin
Mandelson, Peter	Straw, Jack
Marshall, David (Shettleston)	Sutcliffe, Gerry
Marshall, Jim (Leicester, S)	Taylor, Mrs Ann (Dewsbury)
Martlew, Eric	Thompson, Jack (Wansbeck)
Maxton, John	Timms, Stephen
McAllion, John	Tipping, Paddy
McAvoy, Thomas	Turner, Dennis
McCartney, Ian	Tyler, Paul
McFall, John	Vaz, Keith
McKelvey, William	Walker, Rt Hon Sir Harold
McLeish, Henry	Wallace, James
McMaster, Gordon	Walley, Joan
McNamara, Kevin	Wardell, Gareth (Gower)
McWilliam, John	Wareing, Robert N
Meacher, Michael	Welsh, Andrew
Meale, Alan	Wicks, Malcolm
Michael, Alun	Williams, Alan W (Carmarthen)
Michie, Bill (Sheffield Heeley)	Williams, Rt Hon Alan (Sw'n W)
Michie, Mrs Ray (Argyll Bute)	Wilson, Brian
Milburn, Alan
Miller, Andrew

Winnick, David	Young, David (Bolton SE)
Wise, Audrey
Worthington, Tony	Tellers for the Noes:
Wray, Jimmy	Mr. John Spellar and
Wright, Dr Tony	Mr. Eric Illsley

Question accordingly agreed to.

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

Resolved, That this House notes that since the introduction of the Government's health reforms the number of patients treated has risen, waiting times fallen and quality of care improved; welcomes independent support for the reforms from sources such as OECD; and calls upon Her Majesty's Government to continue policies which uphold the values and ethos of the NHS, further reduce administrative duplication and waste and deliver a flexible service able to respond to the changing needs of patients.