§ Mr. Morgan
I beg to move amendment No. 5, in page 6, line 27, at end insert—'(2) The Secretary of State shall be under a duty to give directions to such Health Authorities as may be established in Wales, requiring them to act so as to secure—I am pleased to be able to speak to an amendment that deals specifically with some of the problems pertaining to the application of the Bill in Wales. When one thinks of past major political figures from Wales such as Lloyd George and Aneurin Bevan and the contributions which they made to the development of the NHS, it is right that we should have a debate on Wales. No doubt The Sunday Times will run a story next week alleging that Lloyd George and Aneurin Bevan were Soviet agents with the code names of "Snow White" and "Taffy", or some such invention in which it specialises.
- (a) the promotion of common standards in the purchasing of equipment for, and design of capital works by, those authorities,
- (b) the publication from time to time of such information, including annual performance targets and details of defective or deficient work by contractors, as is necessary to enable progress towards the achievement of such common standards to be evaluated, and
- (c) the organisation of clinical and non-clinical services on an all-Wales basis where that represents the most efficient and cost-effective means of providing such services.'.
There are areas where we are somewhat dissatisfied with the application of the Bill to Wales. The Bill should probably have solved more problems than it does. It comes forward with a raft of measures which try to bridge the long-standing gap between the purchasing of secondary and primary health care. It tries to reflect in statute the equalisation of status between GPs and the primary health care which they represent on the one hand, and the consultants and hospitals on the other—the historic prima donna-shopkeeper split within the medical profession—by merging the health authorities and the family health service authorities. That is okay as far as it goes.
The Bill gives power to the Secretary of State to come back later and to merge those authorities geographically as well, and that is also okay as far as it goes. It would have been better to have some way of debating that now. The amendment attempts to tie down the duties of the Secretary of State further, because there is a plain failure in the way in which the Bill has been drafted, to cover a lot of things which would have been covered had this been proper, competent and timely legislation.
There should have been coverage of a unified complaints authority, and we try to deal with some aspects of that in the amendment. There should have been some reference to the future of the two special health authorities in Wales. Either merging them or doing whatever it is that the Secretary of State intends to do would at least mean 215 that we could debate the authorities. We have also covered that issue in the amendment in the best way we can to ensure that there is some form of debate on the issue.
Finally, we need to clarify the role of the newly merged health authorities in relation to GP fundholders and other providers, hospital providers and the Welsh Office. It is an eternal triangle between the Department allocating the budget, the GP fundholders and health authorities as purchasers and finally the provider units such as trusts or directly managed hospital and community health care units. Those involved in that eternal triangle—in which the Secretary of State is the hypotenuse—must work out their relationship in an entirely new ball game.
We have attempted to clarify that matter by giving the Secretary of State a set of duties. The Bill gives the Secretary of State all of the fun, and none of the duties. The fun is that he can decide without much debate after the Bill has reached the statute book how many health authorities there will be in Wales and what their function should be. Of course, he can announce the annual allocation of the budget, but he will not have any duties. We have injected duties into the amendment, so that the Secretary of State can impose duties on the purchasers and providers in the new health care system.
The Bill, as has been often emphasised by Ministers, is a part of the final piece in the jigsaw of the health care reforms of 1990 and the establishment of trusts and GP fundholders. The effect of all that has been to break up the NHS in Wales into some 200 small businesses, which can buy their own equipment and services and manage their cash flow and capital expenditure, and which are able to save money by more astute purchasing. We have to decide—as taxpayers—what leeway those units will have to deal with that money.
The Secretary of State must decide how much leeway he wants those 200 small businesses to have in how they spend their money, particularly when they can squeeze some cost savings out of the providers of health care and not spend all of the money that they been given through their capping formula. It is a difficult area for hon. Members. We are responsible to the taxpayers for the way in which the money has been raised, but we must assure taxpayers back in our constituencies that we are sure what has happened to their money.
The breaking up of the NHS in Wales has led to the creation of 200 small businesses. If we apply that across Britain, we would be talking about several thousand small businesses. We cannot be sure what is happening to all of the money, and that is why we are trying to establish a set of duties for the Secretary of State to try to co-ordinate a system after the Government have broken the NHS into pieces.
I shall give a simple example of the duties which we want to establish. The Welsh Office has produced documents relating to the general practitioner fundholders steering committee—there is an oxymoron if ever I heard one. The whole purpose of fundholding is to break up the system and allow GPs to do their best to buy health care with their own money; but, as soon as they set up as fundholders, they almost immediately form a steering committee to bring them back together again and to tell them what they ought to be doing.
From the documents it is obvious that, in the coming financial year, GP fundholders are expected to make savings of some £10 million, and that will be free money for them. If we gross that up for the whole of Great 216 Britain, we are talking about £200 million of free money for GP fundholders to spend in ways which we cannot account for. That is why fundholders buying equipment should do so under a direction from the Secretary of State.
If GP fundholders next year—when they will only be responsible for some 40 per cent. of the patients in Wales—have £10 million to spare, they will have made what is known as efficiency savings, although I do not think the word "efficiency" is used. That is free money, available to GPs to spend as they wish on capital equipment. They can extend their surgeries or buy additional physiotherapy or chiropody equipment. We have no way of registering the equipment, or of telling them that some forms of capital expenditure may benefit their pensions. When a GP retires at 65 or 70 and sells out his share of a practice, his pension may be enhanced by taxpayers' money.
We need control over the process by which money which we have approved as taxpayers becomes eligible for savings simply by prescribing cheaper drugs or by forcing a harder bargain out of providers. We all want them to try to do that, but not necessarily in such a way that benefits their pension when they, as GPs and self-employed contractors to the health service, retire and sell out to a younger partner. If the practice has been extended three or four times, it will be worth a lot more when the GP sells up at 65 than it would have been if the taxpayer had not enabled him to have the ability to spend on capital equipment.
The fact that the matter has perplexed the Government is shown in the general practitioners steering group documents. The matter is obviously causing the Government considerable problems in terms of the accountability of GP fundholders for the money that they draw out of the system by extracting "savings". Strangely, non-fundholders make the same savings but do not have the right to spend the money as they want on improved services. That money still belongs to the family health services authorities and is part of the traditional allocation from taxpayers' money. If it is not spent, it returns to the Treasury; if it is spent, the same amount plus an allowance for inflation is allocated the following year.
The difference in treatment of fundholders and non-fundholders is not logical as there is no evidence that GP fundholders gain more in efficiency than GP non-fundholders. But they are given the benefit of spending taxpayers' money as though it were their own. I admit that they must spend it on patient care but it can be spent in a way that makes a considerable capital gain throughout a GP's career.
Given that, next year, "free money" will amount to £10 million in Wales and £200 million in Great Britain, we must know what the Minister has to say about it, particularly in the light of all the questions that have been asked in the general practitioners steering group, which was set up by the Welsh Office to try to restore order to the chaos that it created. It is totally bewildering that the Government never foresaw that problem when they proudly set up the GP fundholders scheme in 1990 and announced the creation of those wild cards, which would float freely and be able to negotiate their own bargains.
The amendment also seeks to provide that, as well as enabling powers that determine how many authorities we need, health authorities should have annual performance targets for themselves and suppliers of equipment, buildings or whatever. That links with the point about the 217 need for health professionals to be involved, through local medical committees, in advising on the purchase of X-ray equipment, sterilisers and various aspects of the health services' purchasing functions. There should be a professional input, and we hope that annual performance targets will help.
In that process, a function exists for at least one all-Wales special health authority. We have tried to frame the amendment to fit in with the enabling pattern of the Bill. Sub-section (c) implies that, ultimately, the Secretary of State has discretion in that matter. It would be nice to have the whole Bill before us so that we could see the detail of all the practical implications. The enabling style of legislation that is becoming increasingly common makes debate at this stage far more difficult than in the past.
The amendment seeks to oblige the Secretary of State to set out clearly for those in the health service what the performance of an all-Wales health authority should be. There are two such authorities at the moment, but we do not say whether there should be one or two. We say that, where the benefit of having an all-Wales health authority is evident, the Secretary of State should not be held back by a dogmatic aversion to an all-Wales health authority such as we have now. At present, dogma seems to drive the exercise.
At the last Welsh Grand Committee but one in June last year, the Secretary of State told the Committee that he did not like the structure of the Welsh Health Common Services Authority, which has clinical and non-clinical aspects. At that time, 1,000 people worked in the non-clinical part at the new headquarters building at Cardiff bay. The Secretary of State said that he would market test the non-clinical part of that outfit.
Market testing is Government policy, and the Government do not require the House's authority to carry it out. But having announced that he would market-test the authority, the Secretary of State engaged not in market testing but in his own version of market testing—a game of "heads I win, tails you lose". The aspects of the authority which he wants offered up to the private sector are not allowed to compete against the private sector. People in those jobs have been told that it is not market testing in the usual sense. It is a new phoney version of market testing in which they are not allowed to make an in-house bid.
The staff are extremely upset about that, because they were led to believe that the authority would be market-tested. A subsequent ministerial instruction appears to have been given to the Welsh Health Common Services Authority that there can be no in-house bids. That has not happened with the authority of this House. We have not come across that framework or any legislative backing for a "market testing exercise"—those are not my words but the words of the Secretary of State in the Welsh Grand Committee last year when that policy was announced—but it has subsequently been introduced by the actions of the Secretary of State, who says that his version of market testing involves no in-house bids.
The staff are wondering what they should do. Should they simply resign and just give up? They have suggested that, if they cannot engage in a classic in-house bid, as 218 would normally be the case in market testing, they could try to privatise themselves so that they could bid for their jobs against outside contractors. But they have been told that they can have no assistance for doing that.
Normally, the civil service and public agencies are allowed to employ accountants and legal advisers, but in this case they are being denied assistance and have been told that it will be strictly private contractors bidding for their jobs. That could result in no more than 100 people working at the Welsh Health Common Services Authority in 18 months' time. Indeed, I am told that that is the Government's estimate.
Another oddity that I should draw to the attention of the House, as it is relevant to subsection (c), is that among the people who have inquired about bidding for a large part of the Welsh Health Common Services Authority is W.S. Atkins and Partners, a company that is on a cautionary list published by the Department. The Welsh Office has told the authority that, except in exception circumstances for small jobs, it cannot use the company for hospital design work because it is responsible for the two major hospital design disasters of the modern Welsh health service, in Gwynedd and, before that, at the University Hospital of Wales, and it was required to make out-of-court settlements to the Welsh Health Common Services Authority with respect to those design disasters. Although it is on a cautionary list, sent on the Department's instructions to the authority, it is allowed to make an inquiry into buying the whole service and could take over hospital design services. That is the height of absurdity.
As we said earlier, we need a clear list of the minimum standards required within the health service. Contractors are used by health authorities throughout Wales, and they must abide by a minimum standard set by the Department. Nowhere is the need for standards more clearly illustrated than by the appalling case of the stillborn baby who was transported from Wrexham Maelor hospital to the University Hospital of Wales in Cardiff for pathological examination. It took sixteen and a half hours to travel by private courier from Wrexham to Cardiff. The firm did not say how long it would take to reach Cardiff or whether it would go direct, and the package containing the stillborn baby appeared to have been left outside in the rain. That is why the package partly broke open when it arrived in Cardiff.
How can it take 16 and a half hours for a package of that sensitivity to travel a journey that most of us know takes only four hours these days? That courier firm should not be on any private contractor list for any health trust, hospital or health authority anywhere in Wales. We need common standards and we need a clear complaints and public inquiry procedure to ensure that those matters are brought out into the open and not squashed.
§ Dr. John Marek (Wrexham)
My hon. Friend referred to the incident concerning the stillborn baby in Wrexham. The health authority produced a good report, in which it admitted that it was at fault, but of course it did not explain the length of time that it took for the baby to reach Cardiff, how it went and the instructions that were given to the private courier firm. However, the health authority has said that it will not use private courier firms in future, which is a good thing.
219 I asked the Welsh Office whether it would issue guidelines and at the time it said that it would not. Will the Minister reconsider that? If there is a case for issuing guidelines to hospitals in Wales, that surely must be it, and it is also a recommendation for amendment No. 5.
§ Mr. Morgan
I am grateful to my hon. Friend the Member for Wrexham (Dr. Marek) for using that argument, as the hospital is in his constituency and he has drawn attention to the need to set minimum guidelines. When one has an awful story of that type—
§ Mr. Richards
I wish to clear up that matter, as it obviously was a ghastly incident, which I am sure everyone in the House regrets. The trust has prepared a report about that unfortunate incident. That report is with my Department and we are examining it carefully. If anything can or should he done or needs to be done, obviously we will do it. I do not think that we want to go much further on that point.
§ Mr. Morgan
Obviously, something must be done; but it is not adequate for the Minister to say that he is considering it in the Department to discover whether anything needs to be done. Obviously something must be done; it is merely a matter of trying to decide exactly what it is.
From the point of view of amendment No. 5, it is obvious that it is now up to the Welsh Office to set minimum standards and not simply to leave the setting of standards to each hospital. As my hon. Friend the Member for Wrexham said, the Wrexham Maelor trust itself prepared a report. It was an internal report, but it has been placed in the Library of the House and we have been able to read it. It is evident that the report tends to skip the critical facts—the exact way in which the package got rained on and the exact way in which a package of that sensitivity could possibly be transported to Cardiff in such a way that it took sixteen and a half hours to do a four-hour journey.
§ Mr. Allan Rogers (Rhondda)
I accept that the issue is extremely important, but I caution my hon. Friend not to labour the Welsh Office with tackling issues that would perhaps best be tackled at trust level. As long as the trusts exist, I should have thought that we should say to them, "Carry out your job properly."
I would hate to think that in future the Welsh Office, which has great difficulties in coping with its job at present, a fact of which we are manifestly aware, will start laying down standards for everything. That is one of the big problems that we should consider as regards the distribution of effort throughout Wales and the level at which it is carried out.
§ Mr. Morgan
That is the most backhanded compliment to the Welsh Office that I have heard in my time.
We have mentioned the question of the way that one provides a form of health service in Wales in which we try to give people incentives to improve their efficiency but not necessarily resulting in those people doing much better out of it financially than before. The Government have converted people into quasi small businesses in a quasi-market. We are not happy with that.
I think that some sort of warning system is being given to me, but I am not quite sure how it has been worked out. A new form of mathematics is being used in the timing mechanism here.
220 The contrast could not be wider than on the issue of the blood transfusion service in Wales—an all-Wales service, which is run by the Welsh Health Common Services Authority. Uncertainty remains as to what will happen to it. The Secretary of State has said that, for the time being, it will remain under the care of the Welsh Health Common Services Authority, but when we are engaged in the process of primary legislation of that type, we do not want references to what the Secretary of State will do for the time being; we want to know what the Secretary of State will do.
The donor donates free of charge to the blood transfusion service. The costs that arise are simply the on-costs of the blood transfusion service itself, which governs what happens when the blood is passed on and processed or otherwise for use in operations. However, it is a free service. That is in total contrast with the increasing business and quasi market climate that the Government have created—a broken-up health service with everyone acting as their own business managers in a way that contrasts starkly with the ideas that Lloyd George and Aneurin Bevan originally had when they made a great contribution to the social system of the country by setting up the national health service.
That is why people in Wales feel especially strongly that the health service should remain a unified national health service, and that is why we have tabled the amendment. I commend it to the House.
§ Mr. Richards
First, I should like to reply to one or two of the arguments of the hon. Member for Cardiff, West (Mr. Morgan). The Bill does not deal with special health authorities, as those are established by order and are not affected by the measure that we are discussing.
§ Mr. Rowlands
As we are in Committee, would it not be a better idea for the Minister to listen to the debate first and listen to an expansion of the case by my hon. Friend the Member for Cardiff, West (Mr. Morgan) before trying to reply to it?
§ Mr. Richards
No; we are on Report. If I feel that I need to speak after the hon. Member for Cardiff, West makes a unique contribution to the Bill, I shall decide to do so at that time if it is appropriate.
Fresh powers are not needed to deal with the special health authorities, the Welsh Health Common Services Authority or the Health Promotion Authority for Wales. Indeed, I am fascinated that the hon. Member for Cardiff, West, who has a distaste for quangos, should wish to create what would, in effect, be a super health quango for Wales. It is not in keeping with his general distaste for health authorities.
§ Mr. Morgan
Can the Minister confirm that it would result in the saving of one quango, with all the board expenses that that involves?
§ Mr. Richards
It would not at all result in the saving of one quango. It would create a quango at least three times as large as the quango that we have already.
The proposals on the relationship between health authorities and GP fundholders will be worked up in the next few months in consultations among those involved. 221 That work will consider accountability issues in detail, and the general practitioners steering group, to which the hon. Member for Cardiff, West referred, is part of that process.
The amendment is unnecessary to achieve the efficient and effective delivery of services. In the case of capital works, it would, in any event, not secure what the hon. Member for Cardiff, West seeks, as it does not acknowledge that the Welsh Health Common Services Authority, which is a special health authority, and NHS trusts have the key roles in contracts on capital works. In the case of capital works, it would add to the activities of health authorities and create a further tier of responsibilities, with additional bureaucratic costs cutting across the functions of NHS trusts. The design and implementation of capital works are subject to the law governing contracts between the NHS organisation concerned and the firm carrying out the work.
Standards for the design of health buildings are published by NHS Estates and the Welsh Office and are common to England and Wales. Those include health building notes, health technical memoranda and health facility notes, which are used by designers, whether in the public or the private sector.
§ Mr. Rogers
With the health trusts themselves being responsible for the placing of contracts for capital works, is the Minister now saying that they are bound to stick to the designs and specifications as laid down in the standards that he has just said are appropriate for Wales and England?
§ Mr. Richards
The hon. Gentleman clearly did not listen to my first sentence. Standards are published by NHS Estates and the Welsh Office and are common to England and Wales. They include health building notes, health technical memoranda and health facility notes.
§ 8 pm
§ Mr. Richards
No, I will not give way to the hon. Gentleman; I think that I have made that point perfectly clear.
The documents are all available through Her Majesty's Stationery Office. If the hon. Gentleman wishes to study them, he is welcome to do so. Each development is project managed carefully. An evaluation is required for all capital projects which should identify important lessons in the planning, design, cost control and procurement of schemes, as well as in the use of the facilities.
The private sector undertook 30 per cent. of the contracts placed for design over the past five years. The vast majority comply with all conditions and, where performance of contractors is considered unsatisfactory, any failures are pursued in line with the contract in the first instance; that would include action to remedy defective or deficient work by contractors.
The Welsh Office is made aware of the conclusions of evaluations of all projects. That will continue whatever the outcome of the review of the EstateCare Group within 222 the Welsh Health Common Services Authority. What the amendment seeks to achieve is already undertaken and, therefore, it is unnecessary.
§ Mr. Morgan
I think that the Minister has covered only hospital works. The departmental GP fundholders steering group refers in its document to the savings that GP fundholders can make. In paragraph 16, it says:Savings must be used for the benefit of the patients of the practice. This statutory requirement allows the purchase of equipment and improvement of practice premises.The question of what happens to the "free money" that GP fundholders have—it was £4.7 million in the last financial year, it is about £7 million this year and it will be about £10 million next year, and it can be spent on premises—applies also but, unfortunately, it is not covered by what the Minister has said.
§ Mr. Richards
I am astonished that the hon. Gentleman should speak in that way about savings that can be, and are, made by GP fundholders. He has said that any savings made—considerable savings can be made—should be used for the benefit of patients. Surely the hon. Gentleman welcomes any development whereby more resources are made available to patients. I know how the hon. Gentleman will reply; but before he says that premises should or should not be included, I remind him that even the development of premises can be beneficial to patients—particularly if it means that consultants can visit GP fundholding practices to consult patients.
§ Mr. Morgan
I am grateful to the Minister for giving way again. The amendment covers the way in which general practitioners extend their practices with the "free money". Unfortunately, there is nothing to oblige them to use the "free money". The departmental GP fundholders steering group document says:Holding large cash balances is seen by some as an unproductive use of resources".They are the words of the Welsh Office. The document continues:Is this the case and, if so, is there a risk that if this continues it will lead to criticism because it denies patients treatment?They are not my words; they are the words of the GP fundholders steering group.
§ Mr. Richards
With respect to the hon. Gentleman—I do not intend to pursue the point any further with him—I believe that that was a rhetorical question within the steering group document; it was not a statement.
The Welsh Office is currently consulting on proposals for the future management of three clinical services—the blood transfusion service, the artificial limb and appliance service and Breast Test Wales—currently managed by the Welsh Health Common Services Authority. The consultation document makes it clear that the proposals are aimed at ensuring that the services develop in response to patients' needs, and that improvements in efficiency are reinvested in patient care.
They also indicate that long-term programmes such as Breast Test Wales's contribution to the UK evaluation programme of screening as a means of treating cancer will be fully protected and that Wales will continue to co-operate with sister organisations elsewhere in the UK, for example, the blood transfusion service with the National Blood Authority. Assurances have been given about the continuing all-Wales requirements of the artificial limb and appliance service.
223 No final decisions have been taken on the proposals or the detailed issues which are out for consultation. We will take final decisions in the light of comments received. A reasonable period has been allowed for consultation and comments have been invited by 23 February. I reject the suggestion from some quarters that, because it took some months to work up proposals, a similar amount of time must be spent on consultation.
I do not wish to anticipate decisions on the three clinical services delivered by the common services authority. Clearly there is merit in placing them in NHS organisations with relevant clinical expertise, although we do not propose any change in the current arrangement for the blood transfusion service for the time being. As the House is aware, their location within the common services authority is for management purposes only.
Finally, it might be helpful if I set out the approach to the provision of clinical and non-clinical services generally. In the case of clinical services, decisions will be taken with a view to securing the most efficient and cost-effective results. Health authorities will commission services on that basis, and where it is appropriate for more than one to purchase together for a particular service, they will do so. With only five authorities in place from April 1996, subject to the passing of the Bill it will be possible for them to establish an all-Wales consortia to do so if that is appropriate.
I am glad to say that progress is being made on the work which has been under way within the common services authority to bring about market testing and the possible privatisation of non-clinical services. I wish to bring matters to a conclusion, and I am grateful for the support of the hon. Member for Cardiff, West, so that NHS trusts have the opportunity to purchase support services—information technology, supplies, estate design and maintenance—in the most cost-effective manner.
The establishment of NHS trusts means that decisions should be taken at the hospital level. Where it can be shown that there is an essential need to deliver services on an all-Wales basis, one option would be for authorities and trusts to create consortia. The common services authority accumulated a number of services before trusts were established and, therefore, there is no criticism intended of the staff concerned. We are now placing responsibility on trusts to obtain their services in a cost-effective manner.
Options for handling IT, supplies, estates design and maintenance will be ready for consideration in the next two months or so and, following that, tenders will be invited, as appropriate, for elements of activity. Until those exercises are completed, I cannot speculate on the outcome. However, I can assure the House that the whole exercise will be completed in the next financial year. The common services authority has already told its staff that my right hon. Friend wishes to have a small organisation in place by April 1997.
The hon. Gentleman was quite wrong when he said that my Department had sent instructions to the common services authority to say that in-house bids would not be entertained. That is quite untrue: in-house bids will be allowed. I must stress that the April 1997 date has been set to allow for all detailed implementation arrangements to be carried through.
§ Mr. Morgan
Will the Minister clarify what kind of in-house hid he means? I illustrated two kinds in my 224 remarks. Is he referring to the conventional kind of market-testing approach, whereby an in-house bid from within the civil service or a public agency is allowed; or does he mean a situation where the in-house team is allowed to buy itself out in a management-employee buy-out? If that is so, why has it not been given the legal and accountancy assistance which is normal in those circumstances to permit it to make a viable in-house bid outside involving the same people?
§ Mr. Richards
I was responding to the hon. Gentleman's comments because he asserted that the people already working within the common services authority would be excluded from making any form of bid. Without prescribing one form or another, they will not be excluded in the way that the hon. Gentleman implied.
There may be a need to consider with health authorities and NHS trusts how consortia can be established to run some of the services now located within the common services authority, and I would not wish at this stage to give an indication of the ultimate size of that organisation.
I share many of the points made by the hon. Gentleman. In particular, I was delighted that at the start of his remarks he welcomed the principle of the Bill of merging the district health authorities and the family health services authorities in Wales. There is agreement between us that delivering services in an efficient and cost-effective way is of paramount importance. I have outlined how we intend to achieve that for the reasons I stated. It is not necessary, however, to include such provision in the Bill, and I urge the House to reject the amendment.
§ Mr. Rogers
I shall be brief. The Minister ended his speech on a note of critical importance to any part of the reorganisation that is to take place, with his reference to efficiency and cost-effectiveness. The Opposition accept that that is necessary, but quality standards and clinical effectiveness are also necessary in a national health service. A drive simply for efficiency and cost-effectiveness by a group of accountants, politicians or bureaucrats is losing sight of what the national health service is all about. Quality standards and clinical effectiveness are equally important. I am glad to see that the Secretary of State has arrived to hear my pearls of wisdom this evening. [Interruption.] As my hon. Friend the Member for Bridgend (Mr. Griffiths) says, she came back especially to listen to me.
I have a little problem with the amendment moved by my hon. Friend the Member for Cardiff, West, in that I am always concerned about over-centralisation. As I said earlier, the Welsh Office has great difficulty in coping with its functions and on occasions it appears to be breaking down. I hesitate to transfer willy-nilly all sorts of functions to the Welsh Office.
If there is to be a centrally imposed direction on the trusts, whether it be at health authority level or from the Welsh Office, it ought to be consistent, coherent and agreed generally with those who have to provide the services to the patients. The measure is not about good order in the Welsh Office, in health authorities or in the management of trusts, but about delivering services to patients.
Lastly, in addition to being consistent, coherent and generally agreed, decisions must be made swiftly. One of the problems that practitioners face now, particularly in 225 relation to standards being set across the board, is that the time taken to set those standards and implement them is quite inordinate.
There is no doubt at all that all-Wales services are appropriate—for instance, in genetics and national screening programmes. Breast Test Wales is a classic example of where it is necessary to carry out comparative epidemiological examinations of the facilities that are provided. Of course we have a special point—as I am sure the hon. Member for Ynys Môn (Mr. Jones) is aware—in carrying out certain clinical facilities, but north Wales is often far better served from Mersey, the north-west and the west midlands.
I would hate us to continue talking about all-Wales provision of services on a nationalistic basis when services would be better provided from across the border in a much more efficient and coherent way. Perhaps the hon. Member for Ynys Môn has a different perspective on the delivery of national services as such, but I am quite sure that the patients in north Wales, who are more crucial than any artificial boundaries, would appreciate the maintenance of the high-quality service often given by hospitals in Liverpool and Manchester to north-east Wales.
My hon. Friend was right to have tabled the amendment because there is enormous concern among health service providers in Wales about the size of the common services authority. I was pleased to hear the Minister saying that he was seeking to make sophisticated or to streamline the functions of that organisation. We have witnessed central management costs spiralling upwards, while at the same time there has been much pressure on reducing management costs in the NHS in Wales.
I have been given to understand that there has been little consultation with NHS Wales on the future of the common services authority, but I take hope from what the Minister has said. If he carries out what he has promised, I am sure that some of the present fears will be overcome.
I said a little earlier that the problem of long time scales—for instance, in respect of the design of capital works by the CSA—could be resolved if there were proper dispersion of work to the appropriate level. There is evidence that the private sector could reduce those time scales without necessarily reducing the quality or the standard of the work, but I am concerned that certain standards are set.
I tried to intervene during the Minister's speech when he spoke about the standards that are evidently relevant for England and Wales in respect of designs and specifications. If he made those standards mandatory on trusts, as they will be drawing up the designs and contracting out capital works, that is the best level at which to implement them; on the other hand, if a trust feels that it can aim for a lower standard and lower specifications simply to save money, we shall again reduce the service to patients.
§ Mr. Gareth Wardell (Gower)
I can think of no better example of his point than the siting of the Prince Phillip hospital in Llanelli, which was built on the site of two 226 former coal shafts. As a consequence, it cost the trust and/or the Welsh Office some £800,000 to ensure that the site was safe before the hospital could be built.
§ Mr. Rogers
As an engineer and geologist by profession, when I had a proper job, I fully appreciate the problems that the designer might have had. I am still waiting for the Dungeness power station to fall down.
My hon. Friend is absolutely right. Unless standards are given and specifications followed, once they are diluted or are brought down to the level of health trusts, the in-house design capability will be inadequate to ensure that problems such as the incident that my hon. Friend has outlined do not take place.
§ Mr. Wardell
Does my hon. Friend agree that, because the Government have taken some rather stupid decisions—such as the transfer of all the coal records from south Wales to Bretby—when hospital trusts or any other trusts wish to establish new buildings, the cost of finding those records and seeing what they say adds enormously to the costs and poses difficulties, not only to the health service in Wales but, indeed, to everyone else?
§ Mr. Rogers
I entirely agree. That is why I hesitate to support the offloading of functions to the Welsh Office. The present Minister, of course, is faultless; but before he entered his post, some very dubious decisions were made.
We may talk of cost, efficiency, effectiveness, structures and the specification of contracts, but ultimately those who use the national health service will be affected by our decisions. We have a duty to deliver the best possible service. If that can be done better at Welsh Office level, fine, but it would be better still for it to be done at trust level. I have serious doubts about the advisability of establishing too many decision makers: one may end up simply passing the buck to the others.
I shall support the amendment, but I consider it deficient in some respects. It refers, for instance, toa duty to give directions to such Health Authorities as may be established".Will those health authorities have common standards, or will they decide individually on different standards, thus creating a patchwork quilt of provision in Wales?
§ Mr. Rogers
If that is so, and order will be maintained, I shall be quite happy; but if direction is to be centrally imposed, it must be consistent, coherent and generally agreed, and decisions must be made swiftly.
§ Mr. Ieuan Wyn Jones (Ynys Môn)
I am pleased to be able to speak in a debate that gives us a rare opportunity to consider some aspects of the health service in Wales. I am grateful to the hon. Member for Cardiff, West (Mr. Morgan) for drawing our attention to a number of important issues.
I am also grateful to the hon. Member for Rhondda (Mr. Rogers) for giving me an opportunity to respond to some of the points that he made. He seemed to suggest that I would not welcome cross-border co-operation; it may come as a nice surprise to him that I have always welcomed the fact that many of my constituents—and, indeed, members of my family—have benefited from the specialty services that exist in Merseyside—at the Clatterbridge centre, the Christie hospital and elsewhere. Long may that continue.
227 The hon. Gentleman may also be interested to learn that my wife received an excellent training at the royal infirmary in Liverpool. I have no problem with the idea of cross-border movements, in terms of either specialties or staff. Let me go a little further than the hon. Member for Rhondda, and suggest that we need to adopt a strategic approach to both clinical and non-clinical health matters in Wales.
The decision of the Welsh Office to market-test the Welsh Health Common Services Authority has caused great problems in Gwynedd. In preparation for the market-testing exercise, the authority decided to provide the Welsh Office with some examples of ways in which it could cut costs. It suggested, for instance, that the stores provision at Ysbyty Gwynedd should be closed, and that medical and other supplies should be provided from a store in Denbigh in the Vale of Clwyd. I have no problems with that; I know the area well, having lived there for many years, and my wife's family originated there.
§ Mr. Jones
And since she went to Liverpool. I hope that the hon. Gentleman realises that I support his amendment. If he wants me to attack it, however, he is going the right way about it—particularly if he says some nasty things about my better half.
If medical and other supplies are transferred from Ysbyty Gwynedd in Bangor to Denbigh, it will not be possible to provide the same standard of service or to do so more efficiently. When Ysbyty Gwynedd was built in 1970, the stores were built alongside it. That meant that the wards were built without sufficient capacity to take on-site medical supplies. If the move takes place, there will not be enough space in the wards at Ysbyty Gwynedd to maintain sufficient supplies from time to time. Supplies will have to be transferred from the Vale of Clwyd by road, which will mean increased road traffic and increased costs.
That is the sort of decision that the Welsh Health Common Services Authority has already made, in an attempt to demonstrate to the Welsh Office that it can save money. But what will be the cost to the people of Gwynedd, who need a health service that is properly resourced and has sufficient capacity within the county to deliver medical and other supplies?
During the summer months in particular, it may be difficult for supplies to be brought quickly from the Vale of Clwyd to Bangor and other Gwynedd hospitals at times of emergency. We disapprove of the kind of decisions that are now being made, but if the amendment were accepted we could deal with the position, because the Welsh Office would have to give the authority guidelines on how it should discharge its responsibilities.
It is, after all, the responsibility of Government to ensure that medical and other supplies are available to hospitals when they need them. What will happen under market testing? If a private firm says that it will provide the services that the common health services authority currently operates, what comeback will there be if it proves unable to deliver those services?
The Minister said that the Government were currently considering only market testing of non-clinical supplies, and I accept that; but this is a first step towards further developments. Despite what some hon. Members have said, I will support the amendment, and urge the 228 Government to do the same. From time to time, strategic decisions will have to be made that can be taken only at an all-Wales level.
§ Mr. Nick Ainger (Pembroke)
The possibility of establishing fewer health authorities in Wales is one of the main aspects of the amendment. My constituency contains what is probably the smallest health authority currently operating in Wales—if not in England and Wales—and I am extremely concerned about the impact that the Bill may have not only on my constituency but on those of my hon. Friend the Member for Carmarthen (Mr. Williams), my right hon. Friend the Member for Llanelli (Mr. Davies) and the hon. Member for Ceredigion and Pembroke, North (Mr. Dafis).
This year's announcement of funds for the Pembrokeshire health authority was linked with the announcement relating to East Dyfed. In effect, a Dyfed health authority has already been created. But the indications are that Dyfed and Powys—the old, soon to be the former counties—will be united in a huge health authority, which would cover more than 50 per cent. of the service in Wales. Hon. Members who do not know Wales may find it interesting that it would be far quicker for me to travel from the extremity of my constituency to this place, than to travel from one extremity of the proposed health authority to the other side. It would probably take me twice as long to get from the far west of Dyfed to the far east of Powys than to travel to this place.
The objection to the Bill involves the lack of accountability inherent in it. In relation to local government in Wales and England, the Government are saying that small is beautiful and that local authorities should be getting closer to their electorate and to the people they represent. Unitary authorities will be in place in Wales from April 1996. It is remarkable that, in relation to the provision of health care, the Welsh Office may be saying the complete opposite: that big is beautiful, and that being further away from patients and people who need care is a far better system. That is extremely worrying.
Many hon. Members on both sides of the House objected to the possibility of a reduction in the number of police authorities in Wales because of the lack of accountability, and because of the extremely effective performance of the smaller, in particular, rural police authorities. I would be worried if, because of the Bill, the Secretary of State for Wales could create extremely large health authorities.
§ Mr. Gareth Wardell
Does my hon. Friend agree that, as the Government are proposing to reduce the number of health authorities in Wales from 17 to five, it is vital to realise that some hospital trusts in Wales are relatively small, and that it would be helpful if some of them were amalgamated? Their delivery of services could then be improved, and the sort of duplication that occurs in some of them would not arise.
§ Mr. Ainger
I agree. I welcome the amalgamation of district health authorities with family health services authorities. I am concerned, however, that combining those authorities will create large organisations, which will in effect, because of the enormous areas involved, become extremely remote and difficult to organise. That 229 is certainly the case with Dyfed-Powys, which I am concerned about. If the Secretary of State goes down the road of combining FHSAs with district health authorities, that will obviously cause administrative problems. Those two organisations have different roles.
§ Mr. Rogers
I am sure that my hon. Friend is right in some of what he is saying, but we should remember that we are seeking to amend the awful system that was created by a Tory Government in 1973. Before that, far more effective and closer delivery of health services took place. There were, for instance, hospital management committees, which were much more appropriate for some areas. The false structure set up by the Conservatives in 1973 has been so inefficient and so bad that it must be amended. It was amended once, and it is still being amended now. I still would not want large authorities to operate to the detriment of small units, with a personal delivery at hospital level.
§ Mr. Ainger
I agree. We must remember that the Bill is relevant only to health authorities—the purchasing authorities—and not to the running of hospitals. They must be sensitive to patient needs, because they are the ones that will be purchasing health care from the various trusts and from directly managed units. I do not want to be accused of making an awful pun, but they must obviously have their fingers on the pulse of what is required in their areas.
It is important to remember that it is only a couple of years since reorganisation. In Pembrokeshire, we saw the disastrous effects of that reorganisation, which followed the establishment of the Pembrokeshire NHS trust and of the purchaser-provider split.
In September 1993, Pembrokeshire NHS trust and Pembrokeshire health authority, prompted behind the scenes by the Welsh Office, called in independent advisers to sort out the problem where they could not agree a contract between themselves. They had to approach the chief executive of Clwyd health authority, Mr. Brian Jones, and the finance director of the Wrexham Maelor hospital trust, Mr. David Galley, to consider what had happened since the establishment of the trust and, effectively, the emasculation of the then Pembrokeshire health authority.
It was an interesting report. Those two men spent three months in Pembrokeshire considering in great detail what had happened immediately before and immediately after the establishment of the trust. Their report makes interesting reading. It is certainly worth quoting. This is what those two experts in health care had to say about that reorganisation:the residents of Pembrokeshire did not receive any increase in the level of services provided, although increased levels of expenditure were taking place.Pembrokeshire health authority lost virtually all its members of staff, bar two, to the new trust, because of the way in which purchasing staff had been transferred to the trust from the authority.
The report continues:a minimum of £750,000 has been diverted from purchasing health care for the Pembrokeshire population into additional purchasing management costs.The money went into administration, not health care.
230 We should not forget that the report was written by people who had spent virtually all of their working lives in the NHS and who were senior individuals. They went:there appears to have been a significant increase in the cost of employing a number of senior managers within the trust during its first year of operation.Basically, that related to one particular individual, the then chief executive of Pembrokeshire NHS trust. Before the establishment of the trust, he had been general manager of the Pembrokeshire health authority, where he had received a salary of approximately £50,000. At the end of the first year of the operation of the trust, that individual, as chief executive of the trust, received a salary of £73,000—an increase of £23,000 in 12 months. By the end of the second year of the operation of the trust, he was receiving not £73,000, but £87,000. That is why we need to be careful, to establish a properly accountable system of health delivery, and to be sure that we do not make a mess of further reorganisations.
That individual has retired from the Pembrokeshire NHS trust under interesting circumstances. I am told that the chairman of the NHS trust was informed by the chief executive in December 1993 that he had completed virtually 30 years in the NHS, and that he was looking for pastures new. He joined the NHS from school and, even after completing 30 years of service, he was only 47.
§ Mr. Rogers
My hon. Friend is being extremely unkind. He does not realise—I am sure that the Minister will advise him later—that executives of health trusts are in enormous demand within industry and management outside the health service, as well as in America and Europe. They need to have their salaries doubled year after year so that they can be retained in the health service. I am sure that the Minister will put my hon. Friend right.
§ Mr. Ainger
I am not being unkind. I understand that the individual is now running an antique shop. His successor, who in my opinion had greater experience of running large organisations at senior level, was employed on a new contract. His total emolument is not £87,000, but £64,000. That is a significant saving. In the meetings that I have had with Mr. Stuart Fletcher, the new chief executive of the Pembrokeshire NHS trust, I have been extremely impressed with the quality of his performance and experience.
It is interesting that Mr. Brian Davis told his chairman in December 1993 that he would like to leave the NHS trust to go to pastures new.
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. The hon. Gentleman is going into considerable detail. I hope that he can relate his comments more closely to the amendment under discussion. If not, it seems more like a general history.
§ Mr. Ainger
The essence is the lack of accountability within the current organisation in Wales. I am trying to enforce the point that we need an accountable system of administration in Wales in order to stop the abuse—I use that term advisedly—that has happened in the past.
We must never allow individual managers to assume certain powers, often because of the weakness and ineffectiveness of other members of the board who improperly control the way in which salaries escalate, allegedly under performance-related pay. It is worth referring to that, because the Jones Galley report said that, while that individual's salary was increasing in the two 231 years that he was chief executive, the performance was going down, and the £750,000 was spent on administration, not on health care.
It is vital that, if and when the new reorganisation takes place, it must maintain the true connection with our local communities, particularly in rural Wales. Large organisations find that difficult to do. It is important to ensure that, when we appoint new people to the boards, they know that they have a responsibility to ensure that the reorganisation is done smoothly, effectively and efficiently, and to ensure that we do not see a massive escalation in salaries.
§ Mr. Gareth Wardell
Does my hon. Friend agree that it is hoped that the Government will advertise all the posts that will become available on the new health authorities, including the role of chief executive, so that we can have open competition? Does he agree that no job that currently exists should be protected, but that they should all be open to anyone, whether executive or non-executive, so that we have the best people running the health authorities? Perhaps early retirement packages could be looked at soon, so that those who are reaching the stage at which they need to think about retirement can be assisted in that direction.
§ Mr. Ainger
I could not agree more. To illustrate my hon. Friend's point, it is interesting that, when the post of chief executive of the NHS trust in Pembrokeshire was first advertised, it referred to requiring somebody with business acumen. It did not mention health care or patients. That advertisement failed to lead to an appointment. After my intervention to point out the omissions, the post was readvertised, and included references to health care and requiring somebody with experience in the NHS. The excellent Mr. Stuart Fletcher was then appointed.
§ Mr. Richards
The hon. Member for Rhondda (Mr. Rogers) made the best speech that I have ever heard him make. He spoilt it by supporting the amendment at the end. I agree with his first point—
§ Mr. Rogers
I wish my hon. Friend would not take the words out of my mouth. I am in such a sensitive position with my parliamentary majority that any compliments from the Minister can only put me in jeopardy.
§ Mr. Richards
The hon. Member for Rhondda spoke about clinical effectiveness. The Government share his view, and attach a high priority to that. There are on-going trials. The Government also agree with the hon. Gentleman's point about centralisation. I am sure that he will agree that the health service reforms have devolved power and decision making to local people. His comments about the size of the Welsh Health Common Services Authority reflect the Government's view.
The hon. Gentleman referred to standards of design. The current standards and the need to maintain standards will remain, and a capacity will be needed at the centre, either within the Welsh Health Common Services Authority or within the Welsh Office, to monitor the 232 projects. That will need a fairly small team, and the Welsh office will receive and consider all evaluations undertaken by trusts.
The hon. Member for Ynys Môn (Mr. Jones) gave one or two anecdotal examples of what I would call micro-level savings that might be made in Gwynedd. What we are doing with the Welsh Health Common Services Authority is on rather more of a macro-level. We are looking for greater efficiency and a better service. The hon. Gentleman made a serious point about the guarantee and continuity of supplies. It is for the customer—the trust or whoever—to ensure that continuity of supplies is maintained.
The hon. Member for Pembroke (Mr. Ainger) raised the small versus large issue. The Bill is not the end of the road, but is very much the beginning. We envisage that, over time, the purchasing role will shift more and more to GP fundholders. Decisions will therefore he made much closer to the patient than he fears would be the case with rather larger health authorities than he would wish. With regard to his point about salaries and so on, the my right hon. Friend the Secretary of State has made it clear that management costs must and should be kept under control, and, indeed, they include the salaries of senior executives within the trusts.
§ Mr. Morgan
I rise briefly to explain why I shall seek leave to withdraw the amendment.
The Minister mentioned, perhaps unwisely, the fact that Opposition Members supported one of the principles behind the Bill, but I do not think that he made any attempt to understand our objections. The idea of crossing the boundary between primary and secondary health care, in purchasing and commissioning—the new word, as the Government have a taboo about using the word "planning"—is one that the Minister does not seem to understand. We agree with crossing that boundary. We agree with merging family health service authorities and district health authorities, but the Government have demerged at the same time as they have merged.
They are demerging GP fundholders, who represent an ever-increasing proportion. The figure is expected to be 40 per cent. in Wales—it may be higher in England, but it is certainly less in Scotland—from April. They are being demerged from the merger. That is the problem that the Minister has not understood and which causes us difficulties. Indeed, we know from the documents that we have from his Department that it is causing the Welsh Office considerable difficulties.
How does one, having broken up Humpty-Dumpty, put him back together, when one has one created all these new animals that make their own purchasing and commissioning decisions? People have described the difficulty as one of herding cats in a thunder storm, but it was not me who said that, of course. When these alleged savings are created—I do not think that the Minister has dealt with this problem—what do we do with them?
The savings are known as "do-it-yourself top slicing". If anybody under the age of 15 is listening, it is not something that I would advise them to do at home. The Minister top-slices sums to release into waiting list initiatives or whatever, but GPs are now able to do that themselves. They can reserve money—it looks as though the figure will he £10 million in Wales and probably £200 233 million throughout Britain—to spend as they want, in the same way that Ministers have the right to top-slice for special ministerial initiatives.
My hon. Friend the Member for Rhondda (Mr. Rogers) attempted to solve the fundamental problem of the health service: how does one have local initiative and national guidelines? I made the point earlier about the Wrexham Maelor to Cardiff stillborn baby scandal—perhaps the Minister will refer to it with respect to the Glan Clwyd baby theft issue. We all want a local inquiry to try to solve the problem and for the Minister to say, "What lessons have we learnt from the local inquiry? Do we need national guidelines?" Perhaps he should have been a bit clearer about what lessons could be learned at an all-Wales level from those individual incidents, which teach all of us a lesson. That is the way in which one bridges the gap between the need for decisions to be taken locally, but with the right to establish national guidelines for minimum standards when required.
§ Mr. Rogers
Surely the lessons are immediately apparent. When the Government issue instructions to health trusts to go outside to private contractors, they must impose particular standards. That is self-evident. We do not need a massive inquiry involving hundreds of thousands of pounds. Something should be done at a local level. It is all about controlling private contractors.
§ Mr. Morgan
I entirely appreciate that; otherwise those scandals occur, and our functions as politicians is to slam the stable door shut with as much panache as we can, finding a new locksmith and so on, while trying to persuade the public to forget that the horses have been stolen in the first place. We are concerned that the Government are not good at listening when, if they have to listen, it cuts across the dogma.
The Minister said that he was happy with the consultation on the artificial limb and appliance service in Wales and that he will preserve necessary all-Wales services, but he will have seen the scathing letter from the British Limbless Ex-Servicemen's Association about the break-up of that service. I hope that he will reconsider the matter.
I apologise to the hon. Member for Ynys Môn (Mr. Jones) for any misunderstandings between him and me, as we are undoubtedly on the same side of the issue tonight. I am sure that we will be able to agree on any remarks that I made but which he may have misheard.
I want to know whether we received a genuine concession from the Minister on in-house bids for the Welsh Health Common Services Authority. He told me that I was wrong and that in-house bids would be allowed. I have to tell him that at a face-to-face meeting with the chairman, the chief executive, two union officials—one lay, one full-time—and several senior officials, the chairman told me that he had been instructed by the Welsh Office not to allow any in-house bids. I cannot do better than that. That is the information that I was given.
§ Mr. Richards
Let me make it clear to the hon. Gentleman, so that there is no misunderstanding, that no 234 instruction has gone from my Department to the Welsh Health Common Services Authority to exclude in-house bids.
§ Mr. Morgan
The authority seems to have developed the opposite impression. Perhaps I should try to clarify that, and perhaps the Minister will as well.
My hon. Friend the Member for Pembroke (Mr. Ainger) made some extremely important points about the accountability of the health service, particularly of some of the rip-roaring practices that have occurred in the pay of chief executives, their perks and early retirement. In Pembroke, what is known as Bennett's folly occurred when one of my hon. Friend's predecessors, just before an election, formed a trust because the Government were determined to have a trust in place before the election.
When the chief executive took early sick leave—I understand that he had been driving a Porsche, which had been paid for by the health authority, and he developed backache, because Porsches tend to have that effect—it is believed locally that he wrote on the application the reason for his illness as "Munchausen's syndrome by Porsche". The lesson for everybody is not to go for flashy cars if one is in a senior position in the health service.
That was symptomatic of what was going wrong with Ministers exceeding their powers, or letting their vision of a new dogmatic health service overtake sensible planning of what the people of Wales wanted. It was also one of Bennett's follies to send the Welsh Health Common Services Authority to a new, expensive skyscraper office block, which has now become the target of the next Secretary of State's desire to eliminate bureaucrats in the health service. The Minister's predecessor has two black marks against him for the problems that he has created for people working in the health service.
The predecessor before that was the Secretary of State who, of course, had all the wonderful pleasures that the present Secretary of State wants by virtue of this Bill, to decide how many health authorities there should be. His predecessor but one, Lord Crickhowell, decided that he wanted a local health authority for Pembroke and set up an additional health authority but the present Secretary of State wants to rationalise health authorities.
It must be wonderful for Secretaries of State to be able to decide how many health authorities they can have, while the House does not have a great deal of opportunity to establish proper criteria to determine how many we need in Wales. If we are really to decide how many health authorities there should be in Wales, the job should possibly be left to a Welsh Assembly after the next election.
§ Amendment, by leave, withdrawn.
§ Mr. Gunnell
I beg to move amendment No. 4, in page 21, line 5, at end insert— 235'5.—(1) No appointment shall be made under paragraph 1(a) or (b) above unless the Secretary of State has first procured and considered independent advice as to the suitability of the respective candidate.(2) "Independent advice" in subparagraph (1) above means advice from a person or persons with relevant local knowledge or experience, with particular reference to the provision of health services, but who is, or who are, not—
- (a) employed in any capacity by, or in any commercial or contractual relationship with, any Health Authority or NHS trust,
- (b) employed by the Crown,
- (c) the holder or holders of any public elected office, or
- (d) affiliated to, or publicly identified with, any political party or cause.(3) "Suitability" in subparagraph (1) above means personal qualifications or aptitude, irrespective of political affiliations, for discharging the functions of the post to which the appointment is to be made.'.It was said earlier that we had been through some issues a number of times, and this is one such issue. We have discussed many times, and at length, the appointment of health authority members. The hon. Member for Milton Keynes, North-East (Mr. Butler) thinks that we have spent an unduly long time on such matters, and I notice that, in support of his plea, the digital clocks have broken down. It is the first time that I have seen them out of action, and it means that we cannot check whether we are talking for too long. However, it is an important issue, and it is necessary to emphasise one or two points in the context of amendment No.4.
The amendment seeks to change the procedure for the appointment of non-executive members and chairmen of health authorities and other health bodies. The Government have already accepted that their record in this respect has been very poor. They have made grossly biased political appointments and because they now feel some guilt in the past month the Secretary of State issued a paper on the appointment of chairmen and non-executive directors to NHS authorities and trusts.
Much of the procedure is contained in the statement but not in the Bill. The Bill gives an outline but not the detail of how the appointments are to be made. The amendment seeks to add that detail to the Bill and to ensure that the system of appointments is more independent than that which the Secretary of State, to judge from her guidance notes, is trying to introduce.
From a statistical point of view, appointments made since the NHS reforms have involved those with affiliations to the Conservative party. Analysis after analysis has made that bias clear. In fact, it is unusual for that bias to be denied, and only in the Standing Committee debating the Bill have I heard vigorous denials that there were political appointments. Even in Committee, evidence was produced to show that appointments were structured to favour Conservative party members. I stress that the barrier to changing the political bias in appointments is in the guidance notes produced by the Secretary of State.
Our experience in Yorkshire shows the political nature of such appointments and, although I raised this matter in Committee, I shall do so again. I was a political appointee, albeit a Labour political one, to Leeds health authority. It might be argued that I was appointed as a member of the council, but I was appointed as a Labour member of a Labour-controlled council. Leeds Health Care, the health 236 authority that I joined, is, in many ways, a very good health authority. Four of its six members were clearly political appointees, if I count myself among them.
The chairman, who I believe to be a good and effective chairman, was the chairman of Yorkshire area Conservative group. One member was the ex-leader of the then Conservative-controlled city council and another was a noted Conservative business man who had previously been the chairman of one of the two Leeds health authorities when they were divided. That makes three political appointments out of four, and there were two appointments that I regarded as neutral. A university appointee became vice-chair of Leeds Health Care and a second university appointee was director of the Nuffield centre for health service studies. That meant that there were two people who may have been generally politically neutral.
The health authority made its decisions on the basis of what it considered to be best for health care in the city as a whole. I do not think that decisions were made on a political basis. The appointments were political, but the decisions were, on the whole, sensible. It was intended to reach consensus on the way in which Leeds Health Care worked.
There are still some malfunctions in the way in which our authorities work, as shown by the case concerning long-term care to which I have already referred. The health commissioner found Leeds health authority at fault, yet the case was never reported to health authority members. Although the authority was strongly criticised by the health commissioner, none of the non-executive members of Leeds Health Care—those who were privy only to what went on in board meetings—were aware of the case. I do not think that the chair of the authority was aware of it, either. With a case that gained such notoriety, it was a reflection on the way in which we were organised that a decision that strongly upset the health commissioner was never, either before or after it was seen to be a difficult case, referred to the board. That matter needs to be looked at.
In Yorkshire, although there were a number of Labour appointees, the then chair of the regional health authority made it clear to me that he was regarded as having appointed enough Labour members. When it was suggested that he might appoint another to another authority, he said that he felt that he was already somewhat suspect because most of the authorities in Yorkshire appeared to have a Labour member. As he told me, that was a contrast with what happened in other areas. If we look at the statistics as a whole, we see that the pattern in Yorkshire was not a normal pattern.
What concerns me about the pattern established for the future is that we shall continue to have political appointments despite the fact that the wording suggests otherwise. The position is made clear in the draft guidance, which says:The aim of this guidance is to establish a national framework within which Regional Policy Board Members … can implement new procedures for the appointment of non-executive directors and chairmen to NHS authorities and trusts.The guidance continues:RPBMs are responsible for the integrity and effectiveness of the arrangements in their region and for making recommendations on appointments to Ministers.237 As we run through the guidance, it is clear, again and again, that the decision rests with the regional policy board member. The guidance says that there will be a sifting processconducted by a panel consisting of at least three local chairmen or non-executives … The panel may also include an independent member".When one gets to the end of the section on procedure, it is made clear that the appointment referred to is the appointment of a regional policy board member.
The RPBM will be able to use this information"—information about people's performance and information that has come from the independent panel—when making his/her decision whether to recommend re-appointment to the Minister. RPBMs will retain the right to over-ride the preferences of any individual board chairmen when making recommendations.The guidance continues:RPBMs should consult with all local MPs on those candidates intended for nominations to Ministers as chairmen.That is a means of ensuring that the appointments remain in the hands of the Conservative party. The regional policy board members who were appointed under the old appointment procedure—not under the guidance issued by the Secretary of State—were hand-picked members of the Conservative party, whose judgment could safely be relied on. I am sure that the Minister would tell me if he were not absolutely convinced that each appointee was a card-carrying member.
Nothing is said, of course, about what the judgment of the regional policy board members will be based on. I have already mentioned a letter that I received from a regional policy board member of the Northern and Yorkshire regional health authority. That board member attempted to consult hon. Members about an appointment to St. James's hospital trust—a critical appointment at a very important hospital. The Minister knows that it was a contentious appointment because the acting chairman, who was a Labour councillor, had extensive experience of the health service.
In telling us about the appointment, Mr. Greetham says:David"—that is the name of the person appointed, whom I have never met, so I am totally neutral—has very wide management experience both in industry and in his distinguished career with the Territorial Army. I am certain that this will place him in a very strong position to lead the Trust through the challenging and changing times ahead, and I hope you will be supportive of this appointment.We are contrasting a person with distinguished service in the Territorial Army and experience in industry with someone acting as a chair of social services, who played an active role when the widespread issue of child abuse first came to public attention and who has been a member of the health service trust since it was established at St. James's seven years ago. The latter candidate also had experience of being acting chairman for over a year.
238 I do not discount experience in industry, but I wonder what the Territorial Army has in common with the national health service. I have no doubt that some of my colleagues would be able to suggest a reason.
§ Mr. Gunnell
I forgot that. I know that the Territorial Army is pretty hierarchical, too.
We need a process that ensures much more genuine independence. The amendment suggests that independent advice should not be given by people who are holding office in the health authority, who are employed by Her Majesty's Government or who are the holders of any publicly elected office. They should not be political people. [Interruption.] We are suggesting that those people should not be identified with any political party. We are not suggesting that none of the appointees should have political affiliations, but we are suggesting that the independence of advice on suitability of candidates should be more genuinely independent than is suggested in the Bill or in the regulations.
§ Ms Coffey
I want to add a few comments to those made by my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell), who gave a fairly comprehensive analysis of the problems. He described how the amendment would achieve some credibility in terms of the public's perception of objective criteria being used in relation to the appointments.
I would be interested to know the size of the new health authorities which will comprise the old health authorities and the FHSAs. Obviously the size of the new authorities will vary according to the existing membership. However, there will have to be a process in some areas whereby existing members will not be reappointed to the new health authorities because there will be too many members when the members of the FHSAs are added to the members of the old health authorities.
As there is no transparent system to show how the members of those authorities were appointed in the first place, I should be interested in the explanation of why some members are not going to be reappointed to the new health authorities.
I was a member of an old district health authority. I did not sit on that authority after 1990 as elected political nominees were thrown off it. Of course, I was not a political appointee, but I was a representative of a political party. That was regarded as positive, because places were reserved for members of political parties.
I sat beside other members of the district health authority who were clearly appointed because places were reserved for particular specialities. Others were appointed by mysterious routes. The problem about appointments is not recent; it has existed for some years.
The difference between appointments to the old district health authority and the new appointments is that, in those days, no one was paid to be a member of the district health authority. People made a contribution because they were public spirited. They did that work voluntarily. With the new trusts and health authorities, there are executive and non-executive directors. That model is taken directly from private business and all the appointees are paid.
239 Some of the members of those authorities do not really know how they came to be appointed. One person told me that he had received a telephone call from someone who said, "You're a local business man. Would you be interested in being on this trust?" That man said, "Yes," so he knows something about his process of appointment.
People who have been appointed in that way have not answered an advertisement. They have simply been approached informally. They know that somehow they have been appointed by the Government because telephone calls from people inquiring whether they wanted to be members of trusts or health authorities clearly came from people who have the power to make such appointments. Ultimately, the appointments are made by the Government, so everyone assumes that they are Government appointments.
The problem for people appointed in that way is that they are not aware of the criteria for what they have to do. They do not know the criteria by which they were appointed. The appointments are short-term contracts. Presumably, members do not know whether they are going to be reappointed. The trouble is that that makes them less than independent. I am sure that some of them must think, ''Well, if we create too much trouble, we are not going to be reappointed by this mysterious process which appointed us in the first place. We are not here to be troublemakers."
That attitude impinges on the members' ability to be independent, particularly if they are paid. A voluntary member might think that if he was not reappointed, he could do something else, but when it is a paid occupation, the matter must be given some consideration. That may affect their attitudes and perceptions about what is happening.
The Government's view on appointments to trust boards is that trust boards—as the phrase implies—are business organisations. It is clear that they want to encourage people with business interests on to boards because they see the management of trusts essentially as a business enterprise. My hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell) pointed out other difficulties, as there have not just been business appointments. I do not find it acceptable to say that a trust board is a business, and therefore we need people with business experience. But I suppose it is the logical view, if nothing else. A problem is that some appointments have been made for party political reasons.
In Committee I told the Minister that the Conservative Member who lost the Stockport seat in 1992 materialised as the chair of the Tameside trust some months later. The Minister would find it hard to convince me that that man was appointed because of his experience. I think—as do other members of the public—that it was a pay-off to him for having lost his seat. That sort of appointment brings the whole system into disrepute and makes it difficult for us to take seriously the notion of objective criteria.
Appointments to health authorities will be important because the Government cannot argue that those are business enterprises. Health authorities have a clear health commissioning role on behalf of the local population. If the Government's view is that health authorities should be responsive to local people, the people who sit on the authorities will be crucial. My experience in Stockport is that, almost without exception, the trust members came from outside the town. We shall be relying on those members of the health authority in Stockport to justify the idea of a locally responsive health service.
240 The attitudes and beliefs of the people who are appointed will be important. As the authority's purchasing role diminishes with the increase in GP fundholding, the strategic role which it performs will be absolutely crucial in the provision of care for the mentally ill, the mentally handicapped, the elderly and other specialities. It is important that the people on the health authority have the experience needed, and are local people. It is more important that they are seen to be appointed by a transparent system in which people can see what the criteria are and what the appointees are being asked to do, and that appointments have been made on the grounds of experience.
If we cannot get on to the authority people who can do the best job for the people of Stockport, and who are seen to be the ones who can do that, it will not only bring into disrepute the whole system but will be a great loss to Stockport. That view can be duplicated for all health authorities around the country.
It is not enough for the Minister to say that he believes that appointments should be made among people with the best experience. He should bring forward clear guidelines, and show how those guidelines are to be systematically adhered to and properly monitored. If he does not do that, there will be continual criticism that people get on to health authorities not because of experience, but because of who they know. Ultimately, that is to the good of neither the health authority nor the people it serves.
§ Mr. Kevin Hughes
Everybody knows that the system is based purely on patronage. The Government have tried to defuse that criticism by changing the procedure for appointments. The new system, however, is also a closed process and the changes represent little more than a sham—a con trick to make people think that things have changed.
The Government are not interested in real change or proper accountability and do not want people to see what is happening in the national health service. They do not want to be held accountable for the problems that exist in some parts of the NHS. They want to cover them up and keep them quiet. In short, they would be happy to take the advice of John Maples to have zero media coverage and keep the whole mess under wraps.
The amendment seeks to encourage the Government to introduce a truly independent element into the process, for example, community health councils. The Government's attempt at change—the new guidelines which they announced on 14 February—is no great leap for accountability, openness or democracy. The new sifting panel will consist of chairs of trusts appointed under the old system, and the regional chair will have the final say. Those people, who were all appointed under the old system, will control who enters the national health service and Ministers will still have the final say on chairs of NHS trusts. That is what we in Doncaster call the "Old Pals Act", section 1, paragraph 1.
One reason for our amendment is the fact that local people will have no opportunity to have a say. Five of the eight regional chairs are Tory supporters. A recent survey by The Independent showed that two thirds of the trust chairs examined had links with the Conservative party. That fact speaks for itself. Among them were spouses of Members of Parliament, former Tory politicians and party workers.
241 We need a more open and democratic system. Philip Hunt, director of the National Association of Health Authorities and Trusts, recognised that the changes made by the Government will not be enough to restore public confidence in the system. Lord Nolan seems to share that view. The amendment seeks to introduce an independent element into the system and ensure that people who are neither politicians nor civil servants, nor in health quangos, will have a say. The Secretary of State will be forced to seek advice to ensure that the candidate is the best possible person for the job.
Needless to say, when the Government decided to reform the appointments guidelines they missed the opportunity to introduce an independent element. In response to their announcement last week, Lord Nolan pointed out that an independent involvement could give the Government an opportunityto dispel the widely held perception that so many are Conservative appointments.The changes are an admission that the appointments system is neither fair nor open. The fact that the Government have made such a trifling change shows that they are not prepared to open up the system to greater scrutiny and independence, particularly locally. The Government have resisted almost every move to increase both democracy and accountability in the national health service. In Committee, they knocked back amendment after amendment on those issues whenever they arose. They will no doubt do the same with this amendment—I expect little better of them.
The Government have no belief in democracy in the national health service. We have realised that time and time again as they have made their reforms. No doubt the "Old Pals Act" will prevail this evening.
§ Mr. Malone
I am delighted, as always, to oblige the hon. Member for Doncaster, North (Mr. Hughes) by not rising to any of the invitations that he gives to accept any of the amendments that are tabled. Can I say, Madam Deputy Speaker—
§ Mr. Malone
Mr. Deputy Speaker. My goodness, one has to be rapid in perception in the House, with the changes that take place.
Mr. Deputy Speaker, I hope that it will not be regarded as a serious discourtesy, but I wish to refer to the hon. Member for Cardiff, West (Mr. Morgan), who is not in the Chamber. I must say, in accordance with several admonitions from the Chair this afternoon, that I have not given the hon. Gentleman notice that I intended to refer to him, because I wish to make a fairly friendly comment.
When I slipped out earlier, as my hon. Friend the Parliamentary Under-Secretary of State for Wales, the hon. Member for Clwyd, North-West (Mr. Richards), was responsible for an amendment, I did not expect that, when the hon. Member for Cardiff, West had finished, I would return to the Chamber to discover that all the clocks had stopped—but, having listened to him in Committee, I was not entirely surprised.
242 I have listened to the debate on amendment No. 4, and several questions occur to me. First, where will that paragon of independence be found? If we took the amendment literally, it is hard to imagine who would be left to take up that important appointment. I assumed that the Opposition tabled the amendment with serious intent, and I considered whether we could accept it. I was tempted by what the hon. Member for Doncaster, North said, and I might well have been tempted to accept the amendment on behalf of the Government, had there not been several problems.
The amendment appeared to rule out anyone employed by the national health service as an independent contractor; so 830,000-odd souls in the country are ruled out by the amendment to start with. The amendment ruled out anyone with any type of contract with the NHS—whatever that means. Perhaps patients have contracts with the NHS—that is 78 per cent. of the public who visit their general practitioner. The amendment appeared to rule out any public sector employee or public office-holder and anyone who was a member of a political party—and presumably is a member of a political party—or identified with a cause. That no doubt also rules out many voluntary organisations.
Amendment No. 4 is the amendment from the planet Mars, because only someone from the planet Mars would qualify to serve as the independent assessor if that amendment were to be passed. On that substantive and important reservation, I suggest that the House should reject the amendment in any event.
My right hon. Friend the Secretary of State published new guidelines for the appointment of chairmen and non-executive directors of NHS authorities and trusts on 14 February 1995. The guidelines, which draw together examples of current best practice and appointment procedures, demonstrate the Government's commitment to a fair and open appointments system based on merit, not patronage. The implementation of those guidelines from 1 April 1996 throughout England will ensure that the NHS continues to benefit from the services of non-executives of the highest calibre.
It is an insult to all those who serve the national health service in a non-executive capacity that the Labour party continues to attack them in a way that is reprehensible and entirely without substance.
The new guidelines make it absolutely clear that all new candidates for non-executive appointments will be sifted by a panel of at least three people. Perhaps that meets the independence criterion in the Opposition amendment.
Surely the people best placed to judge whether a candidate is suited to the demands of service as a non-executive director are people already working in that sector. I object to the suggestion in the amendment that people who are meant to be independent should be cut off from the service. I should have thought that the solution to ensuring that proper appointments are made is that people who know the way in which the service works, who can bring some of their knowledge to bear, are far better suited to select people who will serve the health service as chairmen and non-executive directors. That is why the guidelines say that people chosen to serve on the sifting panels should be local health authority or trust chairmen or non-executives.
We recognise the need to avoid possible accusations of bias in the appointments system. We have said in the guidelines that members of the sifting panel must not be drawn from the same NHS health authority or trust board, 243 and that the panel may include an independent member. We have suggested, for example, that it might be a member of a local community health council—which no doubt would be welcomed by the Labour party—a local justice of the peace, or someone who is involved in the community. We recognise the value of the view of someone who is detached from the NHS, but who cannot be permanently detached from the NHS as the Labour party suggests in its amendment. The new guidelines establish the flexibility to meet local demands without compromising standards in the appointment process.
On this issue, the Government are adamant that the best people, chosen from the widest cross-section of the population, are serving our national health service. I know that Opposition Members like to mock them, but that does no service to those who have given voluntarily to a substantial and a good cause. I think it is disgraceful that Opposition Members continue to do that.
The amendment constitutes an absurd suggestion to introduce an independence that would detach people from the health service rather than bind them to it. The new guidelines will draw people from an even wider pool of candidates by advertisement, thereby encapsulating what is already well-established best practice. I suggest that the House reject the amendment.
§ Amendment negatived.
§ Order for Third Reading read.9.36 pm
§ The Secretary of State for Health (Mrs. Virginia Bottomley)
I beg to move, That the Bill be now read the Third time.
This has been an extremely important debate, and I valued being present for Report as I was not able to serve on the Committee. It takes forward two of the Government's most important objectives for the national health service and it devolves many important responsibilities closer to patients, while ensuring that all parts of the national health service work to common standards upholding its ethos and its values.
The Bill abolishes the regional health authorities and will create a new and more effective local health authority with responsibilities across the broad sweep of health and health care. It will also make a major contribution towards our goal of a primary care-led NHS. The merger of DHAs and family health services authorities is welcomed throughout the House, and I am sure that it will lead to much greater clarity for all of our constituents—the users of the health service.
The new authorities will be in a stronger position to take an all-round view of local health needs; they will be able to secure a sensitive balance between prevention and treatment and between primary, community and hospital-based care.
§ Mr. Heppell
The Secretary of State has talked about the consensus in the House concerning the amalgamation of the FHSAs and the DHAs. We want to see those two authorities merged into one; however, we want it to be done in an efficient and effective way.
This is my only opportunity to ask the Secretary of State how she intends to respond to my hon. Friend the Member for Sherwood (Mr. Tipping), who wrote to her on 31 October to ask about the appointment of a new chief executive of the Health Commission. The former 244 chief executive of the FHSA, Mr. Tony Ruffell, was away on gardening leave. The Secretary of State replied then that he was being made redundant and that the matter was being sorted out. Apparently it was not sorted out, and my hon. Friend then asked the Prime Minister on 2 February—
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. That really is not a Third Reading point. I call the Secretary of State.
§ Mrs. Bottomley
As you have said, Mr. Deputy Speaker, it is not a Third Reading point. That matter is still being investigated and I think that the individuals concerned are entitled to receive replies before I deal in the House with the issue of people's occupations.
I am very pleased that, in Committee, a number of clarifications and improvements were made to the Bill. We have been able to clarify the question of junior hospital doctors, and focus on the importance of education and training and the role of postgraduate deans. Of particular importance is the amendment that the House accepted today which requires new health authorities to secure professional advice from across the whole range of disciplines.
It is that integration of professional advice, rather than the rigid traditional structures, that will be much more effective. That process will include nurses, doctors and other health professionals, and it will give statutory backing to the commitment that I made on Second Reading that professional advice should become professional involvement.
I draw the House's attention to a recent survey carried out among local directors of public health, reported in The Guardian last week. There was much debate in Committee about the role of directors of public health.
The report showed that most of those involved see the NHS health reforms that have taken place over the past five years as having produced clear benefits in terms of improved public health. It revealed that 90 per cent. said that, since the reforms, the needs of the population were either being better met or at least that there had been no change; 91 per cent. saw benefits or at least no change from the purchaser provider system; 85 per cent. said that waiting times for in-patient treatment had improved; 65 per cent. said that hospital surroundings were better; 75 per cent. of local directors of public health thought that fundholding had improved the effectiveness of public health service or at least had led to no change. I hope that all those who feel strongly about the role of the directors of public health will at least take note of their opinions.
I remind the House that, only five years ago, we were debating the Third Reading of the National Health Service and Community Care Act 1990. Then, the Parliamentary Secretary spelled out the key issues as the need to provide better patient care, the need to continue with a NHS funded by the taxpayer, largely free at the point of delivery, the achievement of better value for money, the achievement of better choice for patients and the delegation of authority to NHS staff closer to patients. All those objectives are being achieved, and the improvements in patient care and a more flexible responsive service are at the heart of all our changes.
The Bill marks the end of a period of change and reorganisation to free the NHS better to carry out its vital task for the people of Britain. The role of GPs is vital. 245 They, with other members of the primary health care team, have a pivotal role in shaping the provision of services. Advances in practice should not be held back simply because they are not available everywhere at the same time.
Our policy is to level up, not down. I point out to the House—it is a very important point—that under our legislation, for the first time ever, the district director of public health will become a statutory post.
The real point about the directors is that we are devolving important responsibilities to local level, where they properly belong. Regional directors of public health will have a new and important role within the regional offices.
Apart from the clarification of the important nature of the Bill, we have learnt something else about the attitude of the Opposition. They continue to attack managers, but support bureaucracy. In Committee, they sought to amend the Bill to introduce strategic health planning authorities—a bureaucratic nightmare, a waste of money and proof of a Labour party still wedded to centralism not dynamism; to indecision not innovation and to pen pushers not patients.
In contrast, our Bill will save £150 million every year for better patient care. The Labour party's advocacy of regional bureaucracy finds few supporters elsewhere and its enthusiasm for putting councillors in charge of the NHS finds even fewer friends. The BMA has rejected local authority control, and the RCN does not want councillors in charge. Nye Bevan did not want it, and the NHS does not want it. Anyone who has worked under the tyranny of Labour-controlled local authorities knows only too well that our constituents do not wish the health service to be run in same way as Labour-controlled local authorities.
The Bill will create accountable health authorities with a job to do and the means to do it. It will reinforce our policy of allocating money to populations and not to institutions. Accountability will be strengthened through the public having access to a single body.
The new authorities will involve the public in decisions about priorities. They must take on more responsibility for explaining the key issues that the health service faces. My hon. Friends were right to focus on the quality, calibre and merit of those involved as non-executives and executives on health authorities as well as trusts.
The Bill is a sensible, timely and effective measure. It will build on the achievement of the new NHS and it will make it an even better place to respond to the changing needs of the patients. It is part of the Government's enduring, unshakeable commitment to the national health service and I commend it to the House.
§ Mrs. Beckett
I was a little surprised to discover that the Secretary of State intended to speak on Third Reading. As I recall, it is not customary for a Minister who has not bothered to serve on a Standing Committee to take the prime slot in the winding-up speeches. I am no longer surprised, however: it is clear that the right hon. Lady wanted to bore us with yet more of her irrelevant ranting.
246 It was right, however, for the Secretary of State to refer to an aspect of the Bill to which I too wish to begin by referring. Although explored in Committee, that aspect has not been discussed much on the Floor of the House. I refer to the merger of district health authorities and family health services authorities to create the new health authorities which alone will replace the existing regional authorities.
My party does not oppose the principle of such a merger; in fact, we have advocated it for some time, although we have never suggested that the merged authorities should replace the existing regions. Despite our support for the principle, however, the way in which the issue has been handled casts an interesting light on the Government's attitudes.
First, the Secretary of State indicated in her statement announcing the legislation in October 1993 that mergers between authorities would be permitted by the legislation; in fact, they are to be compulsory. Secondly, to further the programme of mergers, the Secretary of State has taken sweeping powers in the Bill—more sweeping, I understand, than those allowed by any precedent. She has done so despite the doubt that experience of the Child Support Agency must confer on precedents of this kind, and on the idea of taking all the powers in legislation and leaving all the detail to regulations.
The third revealing aspect even of this agreed element of the Bill is the way in which elements of the proposals that might arouse discussion or dissent have been withheld. I refer particularly to proposals relating to the shape and geographical spread of the new authorities. Ministers are well aware that the proposals arc likely to prove controversial: in fact, they were warned about that on Second Reading by a Conservative Member, the hon. Member for Hereford (Mr. Shepherd). I have given notice to the hon. Gentleman of my intention to quote what he said.
The hon. Gentleman expressed his strong preference, and that of his constituents, for the present structure, whereby a more local health authority—a district health authority—relates to the Department of Health via a regional authority, rather than being structured like the previous, broader health authorities that drew in other elements across the area involved.
We all know that the chances are that boundaries have been drawn up for the new authorities. Many administrators probably know what they are, but Parliament and the people will not be told until it is too late for the House to reject the Bill. The information that we lack about the new merged authorities, however, pales into insignificance in comparison with the information that we lack about the main provision of the Bill, which deals with the abolition of regional health authorities.
The Secretary of State said a moment ago that it was only five years since the last major reorganisation Bill was discussed in the House. That is true—and it was as a consequence of those changes that greater powers were given to the regional health authorities whose abolition the Secretary of State now proposes. It is perhaps in that respect particularly that the Bill reaffirms the Secretary of State's reputation as the Madame Mao of the national health service, proceeding with her continuous revolution. Every element of the Bill takes us further towards the cultural revolution of privatisation that she espouses, 247 concentrating power as it does with individual health businesses that have been set up to be ripe for privatisation.
The Bill will eliminate any pockets of resistance on the 14 regional authorities by abolishing them—although any lingering doubts about the need for their existence in their present form must surely be reinforced by the fact that so many of their functions are to be retained at regional level and, in the case of mental health tribunals, not just at the level of regional offices but at the level and in the structure of the existing 14 regions.
The Bill will introduce positive vetting of a small group of regional representatives, all of whom are to be hand-picked by the Secretary of State. It will extend the practice of gagging independent medical experts such as the directors of public health. Although the Secretary of State spoke warmly of their role, she knows very well that the regional directors strongly resent the loss of their independence. The Bill will also reduce the rights of medical, nursing and other groups to the degree of representation that they have enjoyed in the past.
The Secretary of State congratulated herself on giving way to our representations and on reinstating some statutory right to consultation in the Bill. Nevertheless, the Bill takes away the role that those representatives have enjoyed in similar authorities in the past. The Bill will end the collection and publication of regional statistics, other than those approved by the Secretary of State. It will concentrate power, presently dispersed through a tier of authorities, in the hands of the Secretary of State.
Just over a year ago, the British Medical Association expressed surprise and concern at the proposals, saying:this has not been a consultation exercise in the proper sense of the word".It said that people hadbeen presented with a fait accompli.It questioned the rationale of the exercise of abolishing regions,particularly since the increased size of the new regions will inevitably create communication difficulties which can only serve to undermine efficiency.It is no clearer now than it was on Second Reading before Christmas why the Government have really brought forward a Bill that has such substantial and damaging effects on the structures and staff of our health service, and that creates so little benefit. It is undoubtedly true that the Bill creates the opportunity for the Secretary of State to implement one recommendation of the Maples report: to create a closed world of health care in which staff, from regional directors of public health to nurses and others working on our hospital wards, can more effectively be silenced and gagged about what is happening in the health service.
Earlier today, the Minister was sniffy about his claim that the Bill would make no real difference to the information available, but I should like to give the House examples, first, of the Department's way with statistics, and, secondly, of its way with other information. Those examples cast doubt on the Minister's assurances.
In a press release published on 13 February, the Minister publicised information about the role of junior doctors. He referred to a questionnaire that was sent to them in July last year. It asked how the new roles were affecting their work. The press release says that 17 per cent. of junior doctors felt that their hours of work had 248 reduced. Clearly, it did not seem pertinent to the Minister to say that that presumably meant that 83 per cent. did not feel that their hours had been reduced.
The press release draws attention to the fact 40 per cent. of junior doctors were experiencing more satisfaction in their work, which presumably means that 60 per cent. were not experiencing more satisfaction in their work. That is an interesting example of how the gloss on a piece of information can somehow subtly change its meaning.
Apart from the issue of the statistics that the Department publishes, and how they are described, there is the issue of the new open government code proposed for the national health service. A report in December drew attention to the views of the Campaign for Freedom of Information on that matter. The campaign pointed out that, if that code of practice went ahead, information that would have to be disclosed today by the Department of Health could in future be withheld by health authorities and national health service trusts.
It says that the new coderepeats the failings of the central 'open government' code, but omits its positive elements"—if such there be. It draws attention to the fact that the code allowsall information on commercial or contractual activities to be withheld—not merely information which could prejudice such activities, as in the central government code.Every piece of information that can be described or classified as relating to commercial or contractual activities may be withheld. In this new health service for which the Secretary of State takes such credit, just about everything comes under commercial and contractual activity.
It is almost certainly the case that the major reason for the Bill is the control of information, but is it the only reason? We can dispose of the Government's excuses without too much difficulty. They claim that the Bill has been introduced because of their pressing desire to reduce bureaucracy and to create savings.
On Friday, I received a parliamentary answer from the Department. It shows not only that the number of general and senior managers employed has soared far beyond what could be explained by the reclassifying of people as managers, but that the salary bill for such posts has gone from £156 million before the health changes to £600 million last year. Most of that burgeoning growth in numbers and costs has taken place not at regional health authority level—the Minister of State admitted today that the number of staff employed at regional level has fallen—but because of the division of trusts into individual businesses.
There is yet another reason why there is no need for us to take the Government's claims seriously. They are hellbent on introducing locally determined pay. They have been pressing the pay review body for years to accept that that is Government policy and it must be the framework within which their own recommendations are made. Introducing local pay will mean hiring a fresh army of negotiators and administrators for every single trust. The BMA estimates that introducing it for doctors alone would cost £40 million at least, which would wipe out every penny of the savings that the Government claim have inspired the Bill. So they cannot be in it for the money.
There are other potential reasons apart from secrecy. There were 14 regional health authorities with a minimum of about 140 board members. The clear pattern of the 249 Government's appointments is that those selected must be hand-picked Government loyalists. Perhaps there are not 140 people left in Britain who still loyally believe in the Secretary of State's health service changes.
That view is strengthened by the fact that the 14 RHA are being replaced by eight regional offices in which the voice of the people is heard through eight individuals appointed by the Secretary of State. Rumour has it that those eight will soon be six. Perhaps even they are showing dangerously independent tendencies. I wonder whether finding even six reliable followers will soon be too much for Madam Mao. How long will it be before we have a gang of four?
The other possible reason for the abolition of regional health authorities lies in the reaction of the Secretary of State's shock troops in the trusts. In the document "Managing the NHS", published by the Office of Health Economics, William Laing says:Accountability of Trusts to central government has also been exercised through RHAs. Controversy arose because many NHS Trust chairs claimed that RHAs were attempting to exercise excessive and inappropriate control over Trust's operational activities.Perhaps they still believe in the national health service.
Mr. Laing goes on:The issue of who should monitor Trusts has now been resolved by the government's decision to abolish regional health authorities.Dr. Jeremy Lee Potter—[Interruption.] Yes, the former Conservative voter, as he has said himself—recently said:at the root of the NHS changes lies political dogma.What really matters is where that dogma-driven change will lead. The Minister of State accused me today of claiming that the health service is being fragmented and that it is being centralised. He is correct: I did make both those claims, and both are justified. A total of 500 individual health businesses delivering health care is fragmentation by anyone's standards.
It is the framework to which those businesses relate that is the real giveaway. That framework now consists simply of area health authorities which cannot possibly come together to present an alternative strategic view as the regional health authorities used to do. Within that framework, the individual trust will concern itself solely with its own business and the individual health authority will concern itself solely with its own area. Apart from that, we shall be left with a structure about which the BMA says that, instead of a "management tier … independent of" the Executive at national level, there will be an "increase in centralised control".
In the document "Managing the New NHS" the new arrangements are described as a "single corporate structure". That structure will be without a countervailing voice, without any pretence of any democratic input, and every appointment within it will be made by and at the hands of the Secretary of State.
The Secretary of State, like the Government and like the Bill, becomes more discredited daily. We shall vote to reject the Bill tonight, and if and when the British people 250 are next given the opportunity, if they vote to preserve and enhance their health service, they will vote to reject this Government.
§ Mr. Malone
On behalf of my right hon. Friend, Madam Mao, may I present compliments to Polly Pot on the other side of the House, and make this simple point?
The Labour party has opposed a Bill that will reduce bureaucracy, and create savings that can be spent on patients. That shows precisely where the Labour party stands on the issue. It always has, and always will. The Labour party is always for the vested interests of the producer, not the consumer—the patient, whom the Bill is designed to serve. I hope that the House gives it a Third Reading tonight.
§ Question put, That the Bill be now read the Third time:—
§ The House divided: Ayes 285, Noes 243.253
|Division No. 81]||[10.00 pm|
|Ainsworth, Peter (East Surrey)||Clarke, Rt Hon Kenneth (Ru'clif)|
|Aitken, Rt Hon Jonathan||Clifton-Brown, Geoffrey|
|Alexander, Richard||Colvin, Michael|
|Alison, Rt Hon Michael (Selby)||Congdon, David|
|Allason, Rupert (Torbay)||Conway, Derek|
|Amess, David||Coombs, Anthony (Wyre For'st)|
|Arbuthnot, James||Coombs, Simon (Swindon)|
|Arnold, Jacques (Gravesham)||Cope, Rt Hon Sir John|
|Arnold, Sir Thomas (Hazel Grv)||Couchman, James|
|Ashby, David||Cran, James|
|Atkins, Robert||Currie, Mrs Edwina (S D'by'ire)|
|Atkinson, David (Bour'mouth E)||Curry, David (Skipton & Ripon)|
|Atkinson, Peter (Hexham)||Davies, Quentin (Stamford)|
|Baker, Rt Hon Kenneth (Mole V)||Day, Stephen|
|Baker, Nicholas (North Dorset)||Deva, Nirj Joseph|
|Baldry, Tony||Devlin, Tim|
|Banks, Matthew (Southport)||Dicks, Terry|
|Batiste, Spencer||Douglas-Hamilton, Lord James|
|Bellingham, Henry||Dover, Den|
|Bendall, Vivian||Duncan, Alan|
|Beresford, Sir Paul||Duncan Smith, Iain|
|Biffen, Rt Hon John||Dunn, Bob|
|Bonsor, Sir Nicholas||Durant, Sir Anthony|
|Booth, Hartley||Dykes, Hugh|
|Boswell, Tim||Eggar, Rt Hon Tim|
|Bottomley, Peter (Eltham)||Elletson, Harold|
|Bottomley, Rt Hon Virginia||Evans, David (Welwyn Hatfield)|
|Bowden, Sir Andrew||Evans, Jonathan (Brecon)|
|Bowis, John||Evans, Nigel (Ribble Valley)|
|Boyson, Rt Hon Sir Rhodes||Evans, Roger (Monmouth)|
|Brandreth, Gyles||Evennett, David|
|Brazier, Julian||Faber, David|
|Bright, Sir Graham||Fabricant, Michael|
|Brooke, Rt Hon Peter||Field, Barry (Isle of Wight)|
|Brown, M (Brigg & Cl'thorpes)||Fishburn, Dudley|
|Browning, Mrs Angela||Forman, Nigel|
|Bruce, Ian (Dorset)||Forsyth, Rt Hon Michael (Stirling)|
|Burns, Simon||Forth, Eric|
|Burt, Alistair||Fox, Dr Liam (Woodspring)|
|Butcher, John||Fox, Sir Marcus (Shipley)|
|Butler, Peter||Freeman, Rt Hon Roger|
|Butterfill, John||French, Douglas|
|Carlisle, John (Luton North)||Fry, Sir Peter|
|Carlisle, Sir Kenneth (Lincoln)||Gale, Roger|
|Carrington, Matthew||Gallie, Phil|
|Carttiss, Michael||Gardiner, Sir George|
|Cash, William||Garnier, Edward|
|Channon, Rt Hon Paul||Gill, Christopher|
|Chapman, Sydney||Gillan, Cheryl|
|Clappison, James||Goodlad, Rt Hon Alastair|
|Clark, Dr Michael (Rochford)||Goodson-Wickes, Dr Charles|
|Gorman, Mrs Teresa||Marshall, Sir Michael (Arundel)|
|Gorst, Sir John||Martin, David (Portsmouth S)|
|Grant, Sir A (SW Cambs)||Mates, Michael|
|Greenway, Harry (Ealing N)||Mawhinney, Rt Hon Dr Brian|
|Greenway, John (Ryedale)||Merchant, Piers|
|Griffiths, Peter (Portsmouth, N)||Mills, Iain|
|Grylls, Sir Michael||Mitchell, Andrew (Gedling)|
|Gummer, Rt Hon John Selwyn||Mitchell, Sir David (NW Hants)|
|Hague, William||Moate, Sir Roger|
|Hamilton, Neil (Tatton)||Monro, Sir Hector|
|Hampson, Dr Keith||Montgomery, Sir Fergus|
|Hanley, Rt Hon Jeremy||Nelson, Anthony|
|Hannam, Sir John||Neubert, Sir Michael|
|Harris, David||Newton, Rt Hon Tony|
|Haselhurst, Alan||Nicholls, Patrick|
|Hawkins, Nick||Nicholson, David (Taunton)|
|Hawksley, Warren||Nicholson, Emma (Devon West)|
|Hayes, Jerry||Norris, Steve|
|Heald, Oliver||Onslow, Rt Hon Sir Cranley|
|Heath, Rt Hon Sir Edward||Oppenheim, Phillip|
|Heathcoat-Amory, David||Ottaway, Richard|
|Hendry, Charles||Page, Richard|
|Hicks, Robert||Paice, James|
|Higgins, Rt Hon Sir Terence||Patnick, Sir Irvine|
|Hill, James (Southampton Test)||Patten, Rt Hon John|
|Hogg, Rt Hon Douglas (G'tham)||Pawsey, James|
|Horam, John||Peacock, Mrs Elizabeth|
|Hordern, Rt Hon Sir Peter||Pickles, Eric|
|Howard, Rt Hon Michael||Porter, Barry (Wirral S)|
|Howarth, Alan (Strat'rd-on-A)||Porter, David (Waveney)|
|Howell, Rt Hon David (G'dford)||Portillo, Rt Hon Michael|
|Howell, Sir Ralph (N Norfolk)||Powell, William (Corby)|
|Hughes, Robert G (Harrow W)||Redwood, Rt Hon John|
|Hunt, Sir John (Ravensbourne)||Renton, Rt Hon Tim|
|Hurd, Rt Hon Douglas||Richards, Rod|
|Jack, Michael||Riddick, Graham|
|Jackson, Robert (Wantage)||Rifkind, Rt Hon Malcolm|
|Jenkin, Bernard||Robathan, Andrew|
|Jessel, Toby||Robertson, Raymond (Ab'dn S)|
|Jones, Gwilym (Cardiff N)||Robinson, Mark (Somerton)|
|Jones, Robert B (W Hertfdshr)||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|
|Knapman, Roger||Sainsbury, Rt Hon Sir Timothy|
|Knight, Mrs Angela (Erewash)||Scott, Rt Hon Sir Nicholas|
|Knight, Greg (Derby N)||Shaw, David (Dover)|
|Knight, Dame Jill (Bir'm E'st'n)||Shaw, Sir Giles (Pudsey)|
|Knox, Sir David||Shephard, Rt Hon Gillian|
|Kynoch, George (Kincardine)||Shepherd, Colin (Hereford)|
|Lait, Mrs Jacqui||Shepherd, Richard (Aldridge)|
|Lang, Rt Hon Ian||Shersby, Michael|
|Lawrence, Sir Ivan||Skeet, Sir Trevor|
|Legg, Barry||Smith, Tim (Beaconsfield)|
|Leigh, Edward||Soames, Nicholas|
|Lennox-Boyd, Sir Mark||Speed, Sir Keith|
|Lester, Jim (Broxtowe)||Spicer, Sir James (W Dorset)|
|Lidington, David||Spicer, Michael (S Worcs)|
|Lightbown, David||Spink, Dr Robert|
|Lilley, Rt Hon Peter||Spring, Richard|
|Lloyd, Rt Hon Sir Peter (Fareham)||Sproat, Iain|
|Lord, Michael||Squire, Robin (Hornchurch)|
|Luff, Peter||Stanley, Rt Hon Sir John|
|Lyell, Rt Hon Sir Nicholas||Steen, Anthony|
|MacGregor, Rt Hon John||Stern, Michael|
|MacKay, Andrew||Stewart, Allan|
|McLoughlin, Patrick||Streeter, Gary|
|McNair-Wilson, Sir Patrick||Sumberg, David|
|Madel, Sir David||Sweeney, Walter|
|Maitland, Lady Olga||Sykes, John|
|Malone, Gerald||Tapsell, Sir Peter|
|Mans, Keith||Taylor, Ian (Esher)|
|Marland, Paul||Taylor, John M (Solihull)|
|Marlow, Tony||Temple-Morris, Peter|
|Marshall, John (Hendon S)||Thomason, Roy|
|Thompson, Sir Donald (C'er V)||Watts, John|
|Thompson, Patrick (Norwich N)||Wells, Bowen|
|Thornton, Sir Malcolm||Whitney, Ray|
|Thurnham, Peter||Whittingdale, John|
|Townend, John (Bridlington)||Widdecombe, Ann|
|Townsend, Cyril D (Bexl'yh'th)||Wiggin, Sir Jerry|
|Tracey, Richard||Willetts, David|
|Tredinnick, David||Wilshire, David|
|Trend Michael||Winterton, Mrs Arm (Congleton)|
|Winterton, Nicholas (Macc'fld)|
|Trotter, Neville||Wolfson, Mark|
|Twinn, Dr Ian||Wood, Timothy|
|Vaughan, Sir Gerard||Yeo, Tim|
|Walden, George||Young, Rt Hon Sir George|
|Walker, Bill (N Tayside)|
|Waller, Gary||Tellers for the Ayes:|
|Wardle, Charles (Bexhill)||Mr. Timothy Kirkhope and Mr. Michael Bates.|
|Abbott, Ms Diane||Davies, Bryan (Oldham C'tral)|
|Adams, Mrs Irene||Davies, Rt Hon Denzil (Llanelli)|
|Ainger, Nick||Davies, Ron (Caerphilly)|
|Allen, Graham||Davis, Terry (B'ham, H'dge H'l)|
|Alton, David||Denham, John|
|Armstrong, Hilary||Dewar, Donald|
|Ashton, Joe||Dixon, Don|
|Austin-Walker, John||Dobson, Frank|
|Banks, Tony (Newham NW)||Donohoe, Brian H|
|Barnes, Harry||Dowd, Jim|
|Barron, Kevin||Dunnachie, Jimmy|
|Battle, John||Eagle, Ms Angela|
|Bayley, Hugh||Eastham, Ken|
|Beckett, Rt Hon Margaret||Enright, Derek|
|Bell, Stuart||Etherington, Bill|
|Benn, Rt Hon Tony||Evans, John (St Helens N)|
|Bennett, Andrew F||Fatchett, Derek|
|Benton, Joe||Field, Frank (Birkenhead)|
|Bermingham, Gerald||Fisher, Mark|
|Berry, Roger||Flynn, Paul|
|Betts, Clive||Foster, Rt Hon Derek|
|Blunkett, David||Foulkes, George|
|Boateng, Paul||Fraser, John|
|Boyes, Roland||Fyfe, Maria|
|Bradley, Keith||Galbraith, Sam|
|Bray, Dr Jeremy||Galloway, George|
|Brown, N (N'c'tle upon Tyne E)||Gapes, Mike|
|Bruce, Malcolm (Gordon)||Gerrard, Neil|
|Burden, Richard||Gilbert, Rt Hon Dr John|
|Byers, Stephen||Godman, Dr Norman A|
|Caborn, Richard||Golding, Mrs Llin|
|Callaghan, Jim||Graham, Thomas|
|Campbell, Mrs Anne (C'bridge)||Grant, Bernie (Tottenham)|
|Campbell, Ronnie (Blyth V)||Griffiths, Nigel (Edinburgh S)|
|Campbell-Savours, D N||Griffiths, Win (Bridgend)|
|Caravan, Dennis||Grocott, Bruce|
|Cann, Jamie||Gunnell, John|
|Chidgey, David||Hain, Peter|
|Chisholm, Malcolm||Hall, Mike|
|Church, Judith||Hanson, David|
|Clapham, Michael||Harvey, Nick|
|Clarke, Tom (Monklands W)||Henderson, Doug|
|Clelland, David||Heppell, John|
|Clwyd, Mrs Ann||Hill, Keith (Streatham)|
|Coffey, Ann||Hinchliffe, David|
|Connarty, Michael||Hodge, Margaret|
|Corbett, Robin||Hoey, Kate|
|Cousins, Jim||Hogg, Norman (Cumbernauld)|
|Cox, Tom||Home Robertson, John|
|Cummings, John||Hood, Jimmy|
|Cunliffe, Lawrence||Hoon, Geoffrey|
|Cunningham, Jim (Covy SE)||Howarth, George (Knowsley North)|
|Cunningham, Rt Hon Dr John||Hoyle, Doug|
|Dalyell, Tam||Hughes, Kevin (Doncaster N)|
|Darling, Alistair||Hughes, Robert (Aberdeen N)|
|Davidson, Ian||Hughes, Roy (Newport E)|
|Hughes, Simon (Southwark)||Parry, Robert|
|Hutton, John||Patchett, Terry|
|Illsley, Eric||Pearson, Ian|
|Ingram, Adam||Pendry, Tom|
|Jackson, Glenda (H'stead)||Pickthall, Colin|
|Jackson, Helen (Shefld, H)||Pike, Peter L|
|Jamieson, David||Pope, Greg|
|Jones, leuan Wyn (Ynys Mon)||Powell, Ray (Ogmore)|
|Jones, Jon Owen (Cardiff C)||Prentice, Bridget (LeW'm E)|
|Jones, Lynne (B'ham S O)||Prentice, Gordon (Pendle)|
|Jones, Martyn (Clwyd, SW)||Prescott Rt Hon John|
|Jones, Nigel (Cheltenham)||Primarolo, Dawn|
|Jowell, Tessa||Purchase, Ken|
|Keen, Alan||Randal, Stuart|
|Kennedy, Jane (Lpool Brdgn)||Raynsford, Nick|
|Kilfoyle, Peter||Redmond, Martin|
|Lewis, Terry||Reid, Dr John|
|Liddell, Mrs Helen||Rendel, David|
|Litherland, Robert||Robertson, George (Hamilton)|
|Livingstone, Ken||Roche, Mrs Barbara|
|Lloyd, Tony (Stratford)||Rogers, Allan|
|Llwyd, Elfyn||Rooker, Jeff|
|Loyden, Eddie||Rooney, Terry|
|Lynne, Ms Liz||Ross, Ernie (Dundee W)|
|McAllion, John||Rowlands, Ted|
|McAvoy, Thomas||Ruddock, Joan|
|McCartney, Ian||Salmond, Alex|
|Macdonald, Calum||Sedgemore, Brian|
|McFall, John||Sheerman, Barry|
|McKelvey, William||Shore, Rt Hon Peter|
|Mackinlay, Andrew||Short, Clare|
|McMaster, Gordon||Skinner, Dennis|
|McNamara, Kevin||Smith, Andrew (Oxford E)|
|MacShane, Denis||Smith, Chris (Isfton S & F'sbury)|
|McWilliam, John||Smith, Llew (Blaenau Gwent)|
|Madden, Max||Soley, Clive|
|Maddock, Diana||Spearing, Nigel|
|Mahon, Alice||Spellar, John|
|Mandelson, Peter||Steinberg, Gerry|
|Marek, Dr John||Stevenson, George|
|Marshall, David (Shettleston)||Stott, Roger|
|Marshall, Jim (Leicester, S)||Strang, Dr. Gavin|
|Martin, Michael J (Springburn)||Straw, Jack|
|Maxton, John||Sutcliffe, Gerry|
|Meacher, Michael||Taylor, Mrs Ann (Dewsbury)|
|Meale, Alan||Timms, Stephen|
|Michie, Bill (Sheffield Heeley)||Tipping, Paddy|
|Michie, Mrs Ray (Argyll & Bute)||Touhig, Don|
|Milburn, Alan||Turner, Dennis|
|Miller, Andrew||Walker, Rt Hon Sir Harold|
|Mitchell, Austin (Gt Grimsby)||Walley, Joan|
|Moonie, Dr Lewis||Wardell, Gareth (Gower)|
|Morgan, Rhodri||Wareing, Robert N|
|Morley, Elliot||Watson, Mike|
|Morris, Rt Hon Alfred (Wy'nshawe)||Wicks, Malcolm|
|Morris, Estelle (B'ham Yardley)||Wigley, Dafydd|
|Morris, Rt Hon John (Aberavon)||Williams, Rt Hon Alan (Sw'n W)|
|Mowlam, Marjorie||Williams, Alan W (Carmarthen)|
|Mullin, Chris||Wilson, Brian|
|Murphy, Paul||Wise, Audrey|
|Oakes, Rt Hon Gordon||Worthington, Tony|
|O'Brien, Mike (N W'kshire)||Wray, Jimmy|
|O'Brien, William (Normanton)||Wright, Dr Tony|
|Olner, Bill||Tellers for the Noes:|
|ONeil, Martin||Mr. George Mudie and Mr. Eric Clarke.|
|Orme, Rt Hon Stanley|
§ Question accordingly agreed to.
§ Bill read the Third time, and passed.