Health

HC Deb 17 November 1995 vol 267 cc240-309 9.34 am

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

Some parts of the parliamentary year and the parliamentary ritual are completely predictable. That is particularly true of the events surrounding the State Opening of Parliament. We have become familiar down the centuries with the arrival in the Chamber of Black Rod, the procession of Members of the House of Commons to the House of Lords and hearing the Queen's Speech. Another predictable ritual is that the Leader of the Opposition returns to the House the afternoon after hearing the Queen's Speech and declares it to be a mouse.

The Leader of the Opposition is a deeply conservative person. He has performed his role with his usual aplomb and spoken the lines allotted to him. Like him, I attended a public school and I know the atmosphere in which we were both educated. The public schools of the 1960s rather frowned upon individuality and did not encourage originality. Fettes certainly left its mark on the speech of the Leader of the Opposition this week.

The speech of the Leader of the Opposition was deeply disappointing and unoriginal. The right hon. Gentleman clearly failed to rise to the challenge facing him as Leader of the Opposition at that moment: to set out to the House and the country what Labour considers to be the priorities facing the nation and, more importantly, how it would address them. The right hon. Gentleman's speech contained no suggestions, no policies and no proposals. I shall be listening with interest to the speech of the hon. Member for Peckham (Ms Harman), assuming that she catches your eye, Madam Speaker, to hear what she argues should be done in the national health service. I look forward to hearing her proposals and specific suggestions.

Ms Harriet Harman (Peckham)

Getting the Tories out of Government.

Mr. Dorrell

The British people will not regard that as a remotely satisfactory answer to the challenge that faces the Opposition, that is, to tell them how, if they were elected to office, they would address the problems affecting the national health service or any other aspects of Government.

By contrast, the Government have set out consistently—it was reaffirmed in the Queen's Speech earlier this week—a coherent strategy for dealing with the issues facing the Government and the people of Britain. My right hon. Friend the Prime Minister made it clear in his speech that the Government attach prime importance to three clear priorities that face the country.

First, and overwhelmingly most importantly, we must ensure that the United Kingdom is internationally competitive and able to earn its living in the world. Unless we have an answer to the problem as to how we earn our living in the next 10 years, our debate on the national health service today is mere hot air. What pays for the national health service is the competitiveness of the British economy.

The Opposition are full of soundbites but they have no proposals at all which rise to the challenge of showing how Britain will earn its living in the world over the next 10 or 15 years. That is the first leg that the Prime Minister made clear underlies the Government's strategy, which is set out in the Queen's Speech and which reaffirms the strategy that we have been developing for a considerable time.

Secondly, the Government have shown themselves determined to address the problems of individual rights, stability and the maintenance of law and order in Britain to ensure that the people of Britain can be confident that the Government will carry out their most basic responsibility, which is to provide an atmosphere of stability that respects the rights and obligations of individual citizens. That, again, is something in which the Opposition are utterly uninterested. Over the past 16 years, the Government have consistently introduced proposals to deal with the problem of rising crime and to reassert individual rights and responsibilities. The Opposition have fought those proposals.

The third leg of the Government's strategy, to which my right hon. Friend the Prime Minister and the Government attach great importance, is the improvement of public services. That is what we are debating today. It is an area where the Opposition face a specific and focused challenge. Instead of soundbites and press releases bemoaning this or that failure in a public service, how would they improve the management of public services, if they were ever to find themselves in Government? How would they increase the resources of public services? How would they change the culture of public services—in particular the national health service so that it can deliver better quality health care to the people of this country?

Mr. Nigel Spearing (Newham, South)

A fundamental is implicit in the right hon. Gentleman's remarks about public service, and in the health service that fundamental is care. Does the right hon. Gentleman really believe that care is a marketable commodity?

Mr. Dorrell

What I believe in passionately, and it is a shared commitment across the parties, is the principle that health care should be available to those who need it without being asked whether they can afford to pay for it. That is the simple idea on which the health service is founded. Our health service has been more successful in delivering that principle, under Governments of both political complexions, than have equivalent health care systems in other countries. That much is agreed between the parties.

What is not agreed is whether, as we face the day-to-day implementation and delivery of that shared commitment, the Opposition are man and woman enough to face the hard issues that must be faced if they are to turn high-flown rhetoric into hard reality.

Mr. John Austin-Walker (Woolwich)

Does the right hon. Gentleman accept that, under his community care proposals, many elderly people are now being means tested and are paying for services that previously they would have received free under the NHS?

Mr. Dorrell

There are now about a quarter of a million more beds for elderly people—ensuring the provision of care at public expense—than was the case in 1979. That has been part of the growing improvement in community care over the past 16 years. Indeed, it has been one of the fastest growing aspects of public service.

Mr. Tom Clarke (Monklands, West)

Only because there are more elderly people.

Mr. Dorrell

That is certainly one factor, but it is true to say that the public service now much better meets that demand than it did in 1979. I recall that when I was first elected to this place, one of the tasks that used to face hon. Members week by week was finding places in part III accommodation for elderly people clearly incapable of looking after, and providing for, themselves at home. The only option available to them was to go on a waiting list for part III accommodation. This Government have abolished that waiting list. I do not think that any hon. Member has had to engage in that activity for several years, yet it used to employ a substantial part of our time.

I want to deal with the specific proposals for which I am departmentally responsible and which were included in the Gracious Speech. I believe that both are welcomed by all parties. The first is the Bill relating to the health service commissioner, which will implement a key proposal of the Wilson committee, which examined the reform of the handling of complaints within the NHS. Both sides of the House agree that the committee produced proposals that will substantially improve the handling of complaints. It suggested a three-tier approach. The first is to encourage complainants and the local health care deliverer to resolve their difficulties informally. If that fails, the second is the establishment of a three-person lay panel at local level, with the majority of its members being independent of the trust or health care provider, to consider the complaint. If both those fail, the third tier is for the complaint to be examined by the health service commissioner.

If we are to deliver that system, which the Government accept and endorse, we need to extend the commissioner's powers to allow him to examine both the activities of the family health services and the clinical questions and complaints put to him. The Bill will provide for that. It is an important step forward in ensuring that the health service respects its obligation to listen to its patients and to their complaints and to learn from them. It will ensure that the health service treats its patients as human beings as well as as patients.

The other Bill for which I am directly responsible is the Community Care (Direct Payments) Bill, which was introduced in the other place yesterday. It will give local authorities the power to pay cash to certain people entitled to community care services—that is, cash in lieu of services—so that individual recipients will be able to take the cash and buy their community care in the way that they choose, rather than having to accept the direct provision from a local authority. The disabled groups have pressed for that change for a long time. It is ironic that one of the most ardent supporters of the proposal has been the hon. Member for Stratford-on-Avon (Mr. Howarth). I look forward to his endorsement of at least that aspect of the Gracious Speech.

Mr. Tom Clarke

Will the right hon. Gentleman confirm or deny the policy of his predecessor, the right hon. Member for South-West Surrey (Mrs. Bottomley), that direct payments should apply only to people under the age of 65 and should be very limited? What do regulations 3, 4 and 5 actually mean? How widespread is the Government's approach?

Mr. Dorrell

The Government's approach has avowedly been to welcome the principle, but not to introduce it for all beneficiaries of community care at the first stage. Instead, we want to focus on specific groups so that we can test the system and ensure that it is well proven before it is implemented generally. [Interruption.] The hon. Member for Monklands, West (Mr. Clarke) seems perturbed by that. The Opposition regularly tell us that new ideas should be tested so that we can find out whether they work before they are made available to everybody. We are taking the Opposition's advice in this case. We accept the direct payment principle and we will introduce it incrementally, starting with defined groups, so that we can determine whether it works.

Both the Bills are modest, but they are important developments in, and underline the Government's commitment to, public services, and in particular the NHS. It is a matter of public record that, since 1979, the Government have put huge additional resources into the NHS. There has also been a huge increase in the number of patients that it treats. Perhaps most important of all, certainly in patients' perception of the NHS, is the dramatic broadening of the range of treatments available. I take no political credit for that. It is the result of medical science developing. Medicine can now treat a broader range of conditions more successfully than it could in 1979. Medical developments have been made available to NHS patients successfully over the past 16 years; a broader range of treatment is available. Furthermore, there are higher-class buildings and facilities in which treatments are made available. We have seen a dramatic development of the NHS over the past 16 years.

Sir Sydney Chapman (Chipping Barnet)

Is my right hon. Friend aware that the outturn expenditure on the NHS this year shows that we are now spending £30,000 million a year more on the service than was spent upon it when the Government came to power 16 years ago? Is that fact not a matter for commendation rather than condemnation?

Mr. Dorrell

I could not agree more with my hon. Friend. The huge increase in resources that has been devoted to the NHS is widely welcomed by many people, not all of whom are the Government's political sympathisers. The real-terms growth of the money available to the NHS this year compared with 1979 is about 70 per cent. It has grown by nearly three quarters in real terms since the Government came to power. That reflects a commitment to growth in terms of the number of patients treated and in the range of treatments available as well as to improvement in the quality of the conditions in which treatments are made available. That is a matter of public record.

As I was saying earlier in answer to the hon. Member for Newham, South (Mr. Spearing), there is no distinction between the Front Benches about the vital importance to the people of ensuring that we maintain a system of health care that allows the benefits of medical science to be made available to the patients of the health service on the basis of their clinical needs, not of their ability to pay. Unfortunately, Opposition Members are making repeated attempts—the hon. Member for Peckham is involved, as was her predecessor—to create distinctions where there is none. There are plenty of other distinctions but on the principle or commitment, to which I have referred, there is no distinction.

Mr. Stephen Timms (Newham, North-East)

I am pleased that the Secretary of State is talking about resources within the health service. I want to ask him about the allocation of resources within the service. He will know that his predecessor introduced a new capitation formula for distributing resources between district health authorities. It was based on research undertaken by York university, which carried the recommendation that resources should be focused on the most disadvantaged areas. Is the right hon. Gentleman aware of the effect of that formula on the East London and the City health authority, which has by far the greatest concentration of deprivation in the United Kingdom? In fact, it loses £23 million under the new formula whereas other much less disadvantaged areas gain under it. Will he review the outcome? Perhaps he will comment upon it this morning.

Mr. Dorrell

The formula was reviewed on the Government's authority using the independent advice of York university. To pick up the hon. Gentleman's phrase, it was not York university that recommended that we should target resources on areas where needs are greatest. That was the design criterion. That was the question that we put to York university. We said, "We want to target health resources at the areas where need is greatest. You tell us how to construct a formula that measures health need in such a way as to allow us to deliver our policy objective"—that is the Government's policy objective, not that of York university—"to ensure that health resources are targeted at need."

That is the central purpose of the health service. It has to apply that policy at every level, starting from the top, in allocating resources through the weighted capitation formula. The hon. Gentleman is picking up, as it were, the formula produced by York university and saying that he disagrees with the professors at York in their answer to the question that we asked of them.

Mr. Spearing

The result, not the answer.

Mr. Dorrell

Well, the result or the answer. I accept the hon. Gentleman's amendment. The hon. Member for Newham, North-East (Mr. Timms) disagrees with the result rather than the answer that York university offered. The hon. Member for Newham, South accepts that we asked the right question but he does not like York's answer. Perhaps that is something that he had better take up with the university.

Mr. Timms

I am not disagreeing with the York university outcome. Instead, I am disagreeing with the way in which the Government have interpreted and modified the results of the university's research to produce figures that are diametrically opposed to what York university recommended. It is the way in which the Government have implemented the research that has been at fault.

Mr. Dorrell

With great respect, that is not true. The weighted capitation formula that has been introduced by the Government is based squarely on the advice of York university. We asked the university a specific question and it gave us a specific answer. That is the answer that we have implemented.

Mr. Simon Hughes (Southwark and Bermondsey)

There is no doubt that the health service has received substantially more resources since 1979. Will the Secretary of State put on record how much he believes the health service has received in additional resources bearing in mind the amount that is needed to keep pace with inflation in the health service, given the greater number of elderly people who are using the service and the greater cost of the high technology that the service uses? What is the real-terms comparative cost compared with NHS inflation over the period since 1979?

Mr. Dorrell

I have never understood that argument. Inflation is not specific to any individual part of the economy. Inflation means a rise in the general level of prices. We cannot have a general level of prices in different parts of the economy. The argument that there is a specific cost increase in different parts of the economy that is faster than the increase in other parts would be more persuasive if I could find any part of the economy where it was said that costs had been increasing more slowly than in the economy in general.

The reality is that we do not collect NHS pounds, education pounds or defence pounds in taxation. The reality is that we collect pounds. The extra resources that have been devoted to the health service have been paid for through taxation. The increased moneys made available to the health service reflect more than 1 per cent. of the gross national income increase available to the health service since 1979. The argument is not advanced by trying to invent a specific NHS currency. The currency in which people pay taxes is pounds sterling. We have provided much more of that resource to the health service over the past 16 years.

Sir Sydney Chapman

Perhaps the hon. Member for Southwark and Bermondsey (Mr. Hughes) will be reassured when I say that, since 1979, the amount of money that we have spent on the health service, as measured by a percentage of gross domestic product, has increased from 4.7 to 6 per cent. That is a considerable and significant increase.

Mr. Dorrell

My hon. Friend is absolutely right. That is the 1 per cent. plus to which I was referring.

The hon. Member for Peckham has been trying to open up a distinction between the Conservative and Labour parties over the past few days, and most recently during a couple of interviews that we both gave to BBC radio this morning. She is working herself up into a substantial lather over an argument that she might care to reflect upon before she takes it too much further. The guts of her argument amount to this: 40 health authorities use NHS resources in a way that reflects their local health priorities. That is the charge that she is levelling. She is saying that we are using resources in a way that reflects priorities. If that is the charge, I ask that the other 60 authorities— there are 100 health authorities in the NHS—be taken into account as well.

It would be a scandal if the health service used resources in a way that did not reflect health priorities. If we responded to the hon. Lady's argument and spent money independently of health priorities, my permanent secretary would properly be before the Public Accounts Committee for abuse and waste of public funds. Of course it is true that those 40 health authorities, and the other 60 as well, use public money in a way that reflects their priorities. That is a charge to which we plead guilty.

Ms Harman

The charge that we are making today and will continue to make is that the NHS is now rationing. If someone needs those treatments but in their area it has been rationed out, that means that he cannot get it on the NHS. He have to go private. Rationing is sweeping through the NHS today, and the Minister is responsible for that.

Mr. Dorrell

The problem with that argument is a minor matter of fact. If one goes and talks to the private operators who offer elective surgery services in competition with the health services, what they actually tell us is not that more and more people are leaving to go private, as the hon. Lady says, but that the service that is available from the NHS on elective surgery has improved so much since the introduction of the patients charter, and the reduction of waiting times, that fewer of them are going into private care, not more. The hon. Lady is simply tripped up by the facts that she uses in support of her argument. She is simply plain wrong.

We come back to the argument whether we should use resources in the health service in a way that reflects priorities. That is not, I should have thought, a revolutionary concept, but let me quote to the hon. Lady a sentence that she might find of interest: There is always likely to be a gap between the services which are provided and the demands made upon them. Difficult choices have to be made to decide how far particular demands should be met. Those are not my words. They are not the words of somebody who has been engaged in some lurch to the right—I imagine that the hon. Member for Peckham would probably not accept that description of herself. They are the words of Mrs. Barbara Castle, as she then was, as Labour Health Secretary in 1976. In that year, she published a document headed "Priorities for Health and Personal Social Services in England". It was an explicit document, which set out to target—

Mr. Tom Clarke

Is that the best that the hon. Gentleman can do—20 years ago?

Mr. Dorrell

Indeed. I have to go back quite a long way to find any quote from any Labour spokesman in office, I am pleased to say. It seems to me to be relevant that Lady Castle—who is not normally regarded as a signed-up supporter of my right hon. Friend the Member for Wokingham (Mr. Redwood) in every argument that he pursues—as Health Secretary published a document explicitly intended to focus the minds of health service managers on the need to assess their priorities and target their resources on the delivery of those priorities. The attempt of the hon. Member for Peckham to stir up this argument as some new scandal is one of the silliest arguments that I have heard in a long time. As an editorial in The Guardian made clear on this subject a fortnight ago, it is an approach to the management of the health service, which has been there not merely as a matter of fact but as the duty of health service managers since 4 July 1948. The moment one spends taxpayers' money, one has an obligation to target it on resources. So to seek to open up that argument, frankly, is silly.

Much more serious is the question to the hon. Lady over the extent to which she shares the developing consensus on what should happen in the national health service, because one of the most interesting documents recently about the health service was published by the hon. Lady's predecessor, in June this year, entitled "Renewing the NHS: Labour's Agenda for a Healthier Britain". It was the considered and much fought-over text published by the right hon. Member—

Ms Harman

It was not fought over.

Mr. Dorrell

The hon. Lady says that it was not fought over, but there are some passages in it in which one can almost feel the presence of the right hon. Member for Sedgefield (Mr. Blair), the Leader of the Opposition, leaning over the shoulder of the right hon. Member for Derby, South (Mrs. Beckett), dictating specific text. Nobody will persuade me that it was all the script of one hand. One can see the joins.

Let us go on to look at precisely what is said about the fierce arguments that the right hon. Lady and I used to have when we both previously held the health portfolio. In the run-up to the previous election, the Government introduced a series of reforms. The key reform in that process was the separation of purchasing from provision and the giving to purchasers of health care a choice as to which health provider should meet specific needs for their local population. That reform meant three things: first, calling NHS hospitals to account, establishing an independent accountability mechanism; secondly, giving purchasers a choice about where the health need of a particular area was to be met; and thirdly, because the purchasers had a choice, it meant a degree of rivalry, of friendly competition between the providers of health care. That was the fundamental change that we introduced in 1991.

At that time, the hon. Lady's boss, the present shadow Foreign Secretary, described that reform as "a monumental irrelevance".

Ms Harman

Hear, hear.

Mr. Dorrell

The hon. Lady has to be careful. She needs to read a more up-to-date version of the Labour party text, because this document, which is more up to date than the "monumental irrelevance" text, says—

Mr. Tom Clarke

This is supposed to be a debate on the Queen's Speech.

Mr. Dorrell

This is the Queen's Speech.

The question that the Labour party must face is how it would change the policies that we are pursuing.

The text on separation of purchasing and provision is now this: We believe there should be a separation in the planning and delivery of health care. We want health authorities to commission care, but we do not want them to run hospitals on a day to day basis. Is that now the policy of the Opposition, or is it not? The hon. Lady appeared to reject it.

Ms Harman

It was then.

Mr. Dorrell

It certainly was not.

Ms Harman

It certainly was.

Mr. Dorrell

The introduction of a split between purchase and provision was the reform over which the hon. Lady fought most vigorously because she said, quite rightly, that that was what created the internal market.

Ms Harman

The right hon. Gentleman is completely misquoting what we said. What we are objecting to is the internal market, with its transaction costs and unfairness. It was always the case before the internal market was introduced that there was freedom of referral and of choice. The internal market restricted that. Before the Government's NHS reforms were brought into place, my hon. Friend the Member for Livingston (Mr. Cook) put forward the proposal that we should have a separate planning function and local devolved management, but what we never agreed with then, what we warned against then and profoundly disagree with now is the unfairness and cost of the internal market.

Mr. Dorrell

Excellent. The hon. Lady is at least on to the key point. Of course it is true that if one separates purchase from provision and gives purchasers a choice— [Interruption.] Did the hon. Lady say that there should be no choice?

Ms Harman

What I said is that GPs always had a choice. The internal market prevents the choice that was always available for GPs to refer their patients where they thought that they could best be treated. They always had that choice. Indeed, the resources followed the patient. The introduction of the internal market means that the patient has to go where the contracts are placed, and choice is restricted. It was because we are in favour of choice and clinical freedom of referral that we so objected then to the internal market and so object to it now.

Mr. Dorrell

The hon. Lady is completely missing the point, or is eliding two issues. She talks about choice in the referral by GPs. What she does not talk about is the choice of the health authorities as the separate planners, commissioners, purchasers—whichever word one wants to use—of health care. The key question is whether the health authorities have a choice. In terms of creating accountability within the health service, the question is whether health authorities have a choice as to which hospital or provider meets the needs of a particular population. The key change is to introduce a choice for the health authorities between different providers in order that they can compare the service between different providers and create the incentive for the providers to improve their care.

Mr. Spearing

rose—

Mr. Dorrell

No, I am going to finish this point.

That was the key reform in 1991 which the Labour party opposed. It now says that it accepts—indeed, endorses—the separation of purchase and provision. It says something else as well. This is even more important, because it is the fundamental discipline that underlies what the hon. Lady and many others call the internal market.

The same Labour party document goes on to say: Health authorities will have agreements with different local health services, and will have choice as to where to place them to suit patient needs. If health authorities are to be given choices in regard to where they place what they call health-care agreements and we call contracts—I accept the amendment—it is clear that Labour has accepted the fundamental change, which was introduced in 1991, and which the present shadow Foreign Secretary described then as a monumental irrelevance.

Mr. Spearing

We are coming to the nub of an important issue. Of course there is a choice, but surely it is a choice not just of provider but of price. The Secretary of State is requiring contractors to compete in terms of price, but I defy anyone to claim the ability to estimate the cost of the commodity involved. It is not like the production of a specific service or mechanical function. Surely the contractors will reduce the price as far as they can to secure the contract—which means that the service to the patient and the way in which it is delivered will suffer desperately. Choice involves price and competition; that is why we object to it.

Mr. Dorrell

The idea that a purchaser or planner who can choose where he places a contract or agreement to meet a local health need should be debarred from considering price or value for money is an extraordinary proposition. Most people would find it difficult to accept the implication of the hon. Gentleman's remarks.

The fact is that the Labour party now accepts the key reform that was introduced in 1991. We then encounter a problem. The Labour party also accepts an important principle to which the Government are deeply committed, and which is essential if we are to improve the quality of health care: the strengthening of the primary health care system.

Again, there is no difficulty in regard to objectives. We all agree that we deliver a better-quality, better-value service to patients if a broader range of services is available through the primary health care system, and if the GP plays an active role in the commissioning of secondary care for his patients and the opportunity to act as advocate for them. The disagreement is over how such a service can be delivered. The Government introduced the fundholding scheme as a means of achieving that shared objective—but how would Labour react to a scheme that was accurately focused on the delivery of objectives on which we all agree: the enhancement of primary care, and the empowerment of the GP as commissioner and advocate on behalf of his or her patients?

The first line of defence came from the hon. Member for Peckham, in her previous incarnation. On 15 March 1990, she said: There is no support … for the concept of fund-holding".— [Official Report, 15 March 1990; Vol.169, c.687.] So far, just over 50 per cent. of GPs support fundholding. The hon. Lady was clearly wrong about that, and has been proved wrong. The point was put to her with some force in a recent television interview by Andrew Rawnsley, who said: The problem is that a lot of GPs rather like fundholding. They think they are better placed to make these decisions than you sitting up in Whitehall. The hon. Lady responded: Well, let's be quite clear about this, Andrew. GP fundholding was not an idea of doctors; it was imposed on doctors. That was said not in 1990, but within the last few weeks.

Andrew Rawnsley—not me—said: Well, the majority have now applied for it. It seems to be appealing to them. I think that, in that exchange, Mr. Rawnsley won. [Interruption.] I shall go on, although I do not think that the House will want to hear the whole interview. Let me just finish my sentence", said the hon. Lady. They've warmed to it", said Mr. Rawnsley, quite rightly. The hon. Lady then said: Let me finish. They have not warmed to it; they were wholly opposed to it. Perhaps the hon. Lady would like to explain why, if they were wholly opposed to it—[Interruption.] How much more does the hon. Lady want me to read out? I assure her that I shall return to that interview: there is plenty more in it.

The hon. Lady argued that GP fundholders do not like fundholding. In fact, 50 per cent. of GPs have voluntarily applied to become fundholders. The hon. Lady has some difficulty—[Interruption.] No doubt she will be able to return to that interview later.

Labour then decided that, as it clearly could not win the argument by pointing to GPs' own actions, it had better do a bit of research. The problem is that every time we do some research Labour does not like the answers, and calls for more and more research. Let me cite a few bits of research on GP fundholding that should at least allow the hon. Lady to accept that GPs are not biased against the idea.

Julian Legrand, founder of the Socialist Health Society, says: Perhaps the biggest success story of the reforms, fundholding is now widely thought to be at the cutting edge of the reforms. There is one biased researcher who has formed an opinion that the Labour party does not like.

Then there is Professor Abel Smith, former adviser to Mrs. Barbara Castle. Mrs. Castle keeps recurring. Hers was a rather more robust and direct approach—a willingness to think through the issues—than that of today's Labour party. Her former researcher states: There is no overwhelming evidence that fundholders are able to get a better deal for their patients from hospitals. Fundholding represents a major transfer of power from specialists to GPs. Then there is the predecessor of the hon. Member for Peckham—who, presumably, cannot be dismissed as being biased in favour of the Government. When the right hon. Member for Derby, South went to the fundholders' conference recently—no doubt adopting her most appealing tones—she said: We want genuinely to pay tribute to the role that you as fundholders have played in kick-starting and developing innovative practice in both primary care and the acute sector. Whether we examine the views of independent researchers or those of a former Opposition spokesman, the evidence repeatedly demonstrates that fundholders are in a uniquely powerful position to improve the quality of care. The hon. Lady asked, "What about the patients of doctors who are not fundholders?" GP commissioners— who are regularly cited as an alternative by the Labour party—acknowledge that they are exercising freedoms and exploiting ideas that the fundholders were the first to develop.

Mr. Deputy Speaker (Mr. Michael Morris)

Order. I apologise for interrupting the Secretary of State, but it is not appropriate for messages to be passed between the Chamber and any member of the public.

Mr. Dorrell

There are two cases for fundholding. First, it empowers GPs to improve the care available to their patients; secondly, once they have established an improvement that benefits their patients, other NHS GPs quite properly then look to their arrangements to ensure that the same service is available to their patients.

That leaves Labour with a problem. Labour Members say that they are committed to improving the quality of primary care, but they do not like the most powerful means that we have devised to deliver precisely that objective. At least the right hon. Member for Derby, South was clear: she said that she would abolish fundholding. She was sometimes a bit vague about exactly when she would abolish it, but it was clear that that was the commitment for as long as she remained the Opposition spokesman.

Let us return to the interview with Mr. Rawnsley. The hon. Member for Peckham has produced a different approach: Labour is no longer committed to abolishing fundholding. Mr. Andrew Rawnsley said: You are clearly against it so you will scrap GP funds. The hon. Lady replied: No. What we are saying is we will replace it. Therefore, there has been a change of policy. Labour will not abandon or abolish it, it will replace it. That is an interesting policy development and I look forward to hearing it explored by the hon. Lady in her policy speeches. That brings me to another point.

Mr. Timms

I should like to ask the Minister about fundholding. Will he join me in commending the efforts of those doctors who have come together to form multi-funds, quite explicitly to avoid the most damaging effects on their patients of individual practice fundholding?

Mr. Dorrell

I have made it clear that Government policy has never been that every GP in the health service should become a fundholder. When one speaks to GPs who use other forms of commissioning, it is clear that the great majority of them recognise that they get a hearing from health authorities and are able to engage more directly than ever before in the health service in calling secondary care to account because fundholding has changed the terms of trade and the nature of the relationship between primary and secondary care. All GPs benefit from that. To abandon fundholding would be to take the relationship back to what it used to be when it was dominated by the acute sector and primary care benefited from a great deal of rhetoric but was never given the power to deliver the commitments that were given by politicians.

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

Does the Minister accept that he has created a two-tier system in which one group of doctors is able to bargain on the basis of having a great deal of cash and the other group, if it is lucky, might be able to say that its patients are getting a different level of care. The Minister may think that that is a brilliant service but I think that it is abominable.

Mr. Dorrell

The hon. Lady should listen to some of the people who are not fundholders. They argue that they do not wish to become fundholders but recognise that they are able to do what they do because of fundholding. How will the hon. Lady explain to those doctors that relationships in the health service will go back to what they were before fundholding when there was a great deal of good will and many speeches about the importance of primary care but nothing happened because the system was dominated by the acute sector?

The hon. Member for Peckham used to enjoy hinting, when she was formerly a health spokesman, that Labour would spend more on health. Since that time, she has been shadow Chief Secretary and it was one of my more enjoyable experiences during my time in the Treasury to listen to the hon. Lady arguing a very un-Chief Secretary-like case. She must have been the only holder of that portfolio ever to argue for more and more spending. The normal and conventional duty of a Chief Secretary is to impose some kind of restraint on extra spending commitments.

Ms Harman

That is fantasy.

Mr. Dorrell

It is not fantasy. The hon. Lady should look at the speech. In it she made a number of specific commitments to extra spending: it was an extremely expensive speech. The reality is that matters have become somewhat tighter since she left that post. They are probably not tight enough, but certainly tighter, and particularly in the health service. The Leader of the Opposition not only dictated the key sentences in the document from which I have quoted but made some statements on television which the hon. Lady would find quite uncomfortable. In "The Money Programme" on 24 September the right hon. Gentleman was specifically asked about extra spending on the health service. Peter Jay asked: It is your strategy, I think, that people are interested in. You will yourself have to increase taxes, will you not, in order to finance the increased spending programmes which Labour is talking about? The Leader of the Opposition replied: Well, you don't need necessarily to increase spending at all. He did not speak about taxes, and he went on: In many of the areas we are talking about, for example, in the health service, there is money being wasted. In response to a question about extra spending, the right hon. Gentleman was specifically making it clear that he regards extra money for the health service as an extremely low priority and was not prepared even to commit himself to any increased spending. That is a less generous commitment to the health service than that of the Government, because we are committed to a year-by-year increase in the real resources that are made available to the national health service. That increase has averaged 3 per cent. per annum in real terms since 1979.

I acknowledge that there is no difference between the parties on the commitment to the delivery of a high-quality, universal health care system. The real division is between Conservatives, who are prepared to take the necessary steps to deliver it, and Labour, which is prepared simply to wish for it without facing any of the real decisions. The question that the House and the country must face if we want to deliver a high-quality health service is how to sustain and deliver it, given the background of rising expectations, the advances of modern medicine and all the other pressures.

If the hon. Lady is to be taken seriously in her new portfolio, she will have to address some key issues. She has to recognise, as her predecessor ultimately and rather begrudgingly did, that the traditional health service was undermanaged and that investment in managing the service was needed. Secondly, we have to ensure that managers in the health service are allowed to improve its efficiency. Labour's commitment to abandon market testing must be ditched. That commitment would cost Labour £130 million and it would deliver exactly the same patient services but more expensively.

The hon. Lady will have to consider her predecessor's affection for regional health authorities. It is extraordinary that, although the hon. Lady likes to make speeches about there being too many administrators, Labour opposed the abolition of regional health authorities. That means that Labour opposed a saving of £60 million during the passage of that legislation in the previous Session. The Opposition will have to look again at how they develop their policy on partnerships with the private sector. They will have to allow institutions to change because if the health service is to deliver an efficient, high-quality health care system next year or five or 10 years hence, Labour will have to face some hard decisions.

Labour must recognise the need to invest in research and development, and that is the easy bit—extra money to understand what is effective. When that knowledge has been developed, it has to be used to ensure that clinical practice changes and that clinically less effective treatments are not preferred. The hon. Lady will have to learn about those pressures and disciplines if she is to be taken seriously as a party spokesman who is interested in and committed to the future of the NHS.

The Government have led the way at every stage in the process of health politics. I do not challenge Labour's general, genial good will towards the NHS. The Opposition certainly offer ineffectual support and make speeches about what a wonderful institution it is, but when the chips are down, they offer no real commitment to the NHS because commitment does not mean soundbites: it means thinking through the issues, understanding them and producing solutions. It means fighting against the vested interests that often oppose solutions and taking difficult decisions.

Ms Harman

Who are they?

Mr. Dorrell

One of them consists of the people who opposed market testing. Nurses are a great vested interest. I look forward to seeing the hon. Lady taking to the barricades and fighting the vested interests of nurses—if that is what she thinks they are. She will have to learn to resist the soundbite and prefer substance if she wants to be taken seriously as someone who is committed to the future of the NHS. Labour offers only a feeble echo of what the Government have decided to do. It is a late echo, a late endorsement of what has been shown to work. That is the true divide between the parties. Labour Members are not participants in the argument, but dilettante bystanders until the solutions have been shown to work. Until we hear something of substance from the Labour party about how the health service can face the next decade's challenges, it will be viewed by all true friends of the national health service with contempt.

10.29 am

Ms Harriet Harman (Peckham)

The Secretary of State for Health is clearly practising for Opposition. He sounded not like the Secretary of State, but the shadow Secretary of State. In his wholly defensive speech, which lasted for nearly 55 minutes, he spent most of his time attacking Labour's plans for the national health service and hardly any time defending his Government's NHS record, let alone putting forward how they will solve the problems that they have created in the NHS. All he can do, like the other Secretaries of State, is attack Labour instead of getting on with the business of good government. That is exactly what we have seen this morning.

The Secretary of State for Social Security (Mr. Peter Lilley)

The hon. Lady is reading from a prepared speech.

Ms Harman

I wrote those words on hearing the speech of the Secretary of State for Health. I could not possibly have anticipated how defensive he would be.

Labour has made health the subject of this debate on the Gracious Speech because it has a duty to expose the Conservatives' hidden agenda. The two-tier health service is with us today and the privatised NHS will be with us tomorrow: that is the sole aim of Tory health policy. The British people are proud of the NHS. They believe in a health service that is free at the point of need. With good reason, they do not trust the Tories to sustain and support that health service.

I shall set out what lies behind the Tories's health policy, how, under a Tory party that has lurched to the right, we are clearly on the road to a privatised NHS and what we will do to stop that process.

Of course I would not have expected the Secretary of State to deal with the Tory health agenda today because it is a hidden agenda. The Tories do not want this debate now or in future. The former Tory party deputy chairman, John Maples, spelt it out clearly and gave the game away. In his notorious Maples memorandum, he said that, for the Tories the best coverage for the next 12 months would be zero media coverage on the national health service. He clearly recognised that any news on the NHS was bad news for the Tories.

Mr. Donald Anderson (Swansea, East)

Far from zero publicity on the health service, is it not a fact that people up and down the country are recognising the real crisis in the health service? I look forward to handing to my hon. Friend an unprecedented edition of the local newspaper in south-west Wales, the Evening Post, entitled: "Your Health Service In Crisis: Sick and Tired", in which even that independent newspaper felt impelled to show to its already knowledgeable population what is happening locally and throughout the country.

Ms Harman

I shall carefully consider the information that I hope my hon. Friend will give me. Of course he is right. The British people will not allow the truth about the national health service to be swept under the carpet by this Government and nor will we.

Labour created the NHS and it is our duty to ensure that Tory Ministers do not succeed in destroying it.

Mr. Hartley Booth (Finchley)

The hon. Lady refers to truth. As she is in favour of truth and open government, will she say what Labour Front-Bench Members receive from Unison?

Ms Harman

I am not dealing with that point in this speech. All the Registers of Members' Interests are properly complied with and, if the hon. Gentleman wants, he can look the information up in the Library.

Labour created the NHS and we will not allow distractions from the Tory Back Benches or hidden agendas from the Tory Front Benches to distract from that. The Tories' single-minded agenda, relentless but never admitted, is to push as many services out into the private sector and, at the same time, make the NHS work like the private sector. All that is done in the face of opposition from people who use the NHS and work in it, whose morale is at an all-time low.

Take the case of long-term nursing care. Close the long-stay wards and people must go into the private sector. They used to receive treatment free and now they have to pay. Take the case of dentistry. First, charges were pushed up so high that people could hardly tell the difference between NHS and private dentistry; then fewer and fewer dentists did NHS work, so more and more people ended up going private.

Mr. Lilley

The hon. Lady just told the House that information about the amount of money that Front-Bench Members receive from Unison was in the Register of Members' Interests. I have it before me and that information is not there. Perhaps she would inform the House just how much they do receive.

Ms Harman

The House voted for a change in the procedure for declaration of interests. We propelled that change, which the Tories tried to prevent. It is now through and the information will all be placed in the Register of Members' Interests.

Mr. Dorrell

rose—

Ms Harman

No, I will not give way on that point. I have made it clear. The Secretary of State for Health did not want to discuss what is going on in the national health service. All he wants to do is smear Labour and attack what we are trying to do. He has failed to deal with the real question of what is going on in the NHS, so I and my colleagues will do that in this debate and ignore Tory Members' disruptions.

Mr. Dorrell

Will the hon. Lady give way?

Ms Harman

No. I have made it clear. The Government are not prepared to talk about what is going on in the national health service and are resorting to tactics of distracting and cutting across in this debate. Their agenda is clear and I will not give way on that basis. I shall continue my speech because I am talking about what the British people are concerned about, which is the destruction of the NHS by this Conservative Government.

Mr. Piers Merchant (Beckenham)

On a point of order, Mr. Deputy Speaker. Will you clarify a point? I was under the impression that hon. Members should declare an interest if they are to make a speech on a subject. As an interest is clearly involved here and no declaration has been made, will you guide us as to whether that is correct?

Mr. Deputy Speaker

It is entirely up to each hon. Member to decide whether they have an interest to declare: it is not for the occupant of the Chair to rule on that. Before we go any further down this route, I say to hon. Members that, in the Table Office, there is a published document, which I have before me, which outlines the new rules specifically.

Ms Harman

It is absolutely clear that the Conservatives' interest is in covering up their destruction of the national health service and the effect that it is having on patients. I have mentioned dentistry. Charges were pushed up so high that people could hardly tell whether they were receiving NHS or private dentistry. Then fewer and fewer dentists did NHS work so more and more patients went private. There are 2.3 million fewer people on NHS dentist lists than there were 18 months ago: 2.3 million more people have to pay because they cannot receive NHS treatment. The Tories can deny that it is privatisation—indeed, they do—but the British people know that it is. They used to receive their dental treatment on the NHS; then they had to go private.

Mr. Dorrell

The numbers are the same.

Ms Harman

The Secretary of State has not read the answers to the parliamentary questions that I asked him. There are 2.3 million fewer people on NHS dentist lists than there were 18 months ago and, month by month, family health services authorities register an increase in people who apply to them for help in finding an NHS dentist.

The British people know that this is privatisation. They used to expect that, if they needed long-term nursing care, it would be provided on the NHS. Now it must be provided privately. A new engine of privatisation is being driven into the heart of the national health service: rationing. An increasing number of health authorities are chopping, bit by bit, the services available on the national health service. The Government pretend that it is not happening, but the evidence is absolutely clear.

It is clear from local health purchasing plans that treatment on the NHS is becoming a lottery: what one can get depends on where one lives. District by district, lists are emerging of what one cannot get on the national health service.

Mr. Dorrell

Will the hon. Lady give way on that point?

Ms Harman

I shall not give way to the Secretary of State. He failed to set out what the Government seek to do and simply attacked the Labour party. I shall not allow him to use my speech as a further opportunity to attack our plans. I am discussing what is actually going on in the national health service—

Mr. Dorrell

You are lying.

Mr. Deputy Speaker

Order. I heard the word "lying". That is not an acceptable word.

Mr. Dorrell

I apologise for the use of that word, Mr. Deputy Speaker, which I withdraw. But it makes me angry to hear people clearly misrepresenting what is going on in the health service. When patients go to the health service for treatment, the doctor's opinion determines what treatment they get.

Mr. Thomas McAvoy (Glasgow, Rutherglen)

On a point of order, Mr. Deputy Speaker. The Secretary of State has apologised for saying, "You are lying". Is he then entitled to go on and make the false accusation that he made in the first place?

Mr. Deputy Speaker

Order. I must be the judge of that.

Ms Harman

It is no misrepresentation to say that what people can get depends on where they live. District by district, lists are emerging of what people cannot get on the national health service. Two years ago, only four local health authorities were rationing—excluding treatment from the NHS. Now, using the Blackwell Masters database, we have shown that 40 health authorities—a third of all authorities in the country—are rationing. It is no good the Conservatives objecting to the word "rationing", because that is what health authorities themselves call it.

One must be careful where one falls ill as this rationing sweeps through the national health service. Do not get the menopause in west Kent as no specialist menopause services will be provided there. Do not get brittle bones in Dorset as no more screening for osteoporosis will be provided there. Do not get infected wisdom teeth in Hertfordshire or Kingston and Richmond. Do not get a glue ear in the Isle of Wight or the other authorities that have declared themselves to be grommet-free zones. Do not have a stroke in Buckingham as savings in stroke management are being sought in that area. Do not have difficulty having a baby in the former Health Secretary's constituency of South-West Surrey, as no NHS fertility treatment will be provided there. However, west Kent seems to be pursuing a policy to increase the birth rate: no block contracts for male or female sterilisation; and no contracts for abortion.

Those excluded treatments are the thin end of the wedge. Yesterday it was grommets and fertility treatment; today it is varicose veins and osteoporosis screening; tomorrow, it will be hernias and hip replacements. Concern about rationing is mounting in the medical profession. Dr. Sandy Macara, chairman of the BMA, said in a speech this week: I deeply regret the passive endorsement of the perceived inevitability of rationing. It is tantamount to telling our paymasters that we do not require more adequate resources, that we will get together to agree which of our patients' needs will not be met, that we will, in Shakespeare's words, 'bend with the remover to remove'. The Secretary of State must come clean. He has just had an opportunity to do so but he failed to take it. The Government pretend that they know nothing about this. I asked the Secretary of State to place copies of all the health authorities' and commissions' purchasing plans in the Library and the Minister answered that copies of the plans were not available centrally. I asked the Secretary of State to specify where some treatments were not available on the NHS and his Minister replied that the information was not available. He did not say that it was not happening or admit that it was happening, but simply said that the Government did not know. Well, the Labour party does know, and we are telling the country today that rationing is sweeping through the national health service.

I asked the Secretary of State for Health what plans he had to establish a national database that lists by health authority which treatments are available on the NHS and which are excluded and available only privately. The answer from his Minister was no, they had no such plans. That is not knowing on purpose—a feigned, calculating ignorance—so that the Secretary of State can pretend that the effect at local level of the decisions that he has taken nationally will be blamed on local health authorities but not on him. He must admit what is going on and, unless he is prepared to condemn the wholesale removal by managers' edict of treatments from the NHS, it will be clear that he secretly endorses it.

For all his denials in those parliamentary answers, we know that the Secretary of State is up to his neck in it. Of course he knows what is going on. How could I possibly believe the answers to those parliamentary questions saying that the Government do not collect the information centrally? They must collect it, for they drive it. They are driving rationing because it leads to privatisation. If people cannot get what they need on the NHS, they must either go without treatment or go private. Private health care is booming, contrary to what the Secretary of State said, and rationing is set to give it another boost.

The private sector is encroaching on the NHS. The Secretary of State says that the NHS needs fewer hospital beds. He derides our complaint about hospital beds, saying that NHS hospital beds are an old-fashioned issue for discussion. Let us look at what is happening. There are 28 per cent. fewer NHS acute hospital beds than there were 15 years ago, but there are 68 per cent. more private beds than there were 15 years ago. The Secretary of State said that fewer beds are a sign of improvement in the NHS. Can it be that more beds are a sign of improvement in the private sector?

It is the same story with hospitals. There are 28 per cent. fewer NHS hospitals but 47 per cent. more private hospitals than there were 15 years ago. That shows the relentless advance of privatisation. People fear and dread the privatisation of health care because they know what it means: unfairness and a massive increase in costs. People fear and dread the commercialisation of the NHS because they know what it means: fewer nurses and more managers.

The Tory alibi for slicing acute services out of the NHS is that we cannot afford it. They say that the demand for health care is infinite, there is a bottomless pit and we simply cannot do it. They grossly overstate the growth in demand for health care in order to use it cynically as an excuse to promote the argument that more and more services must go into the private sector. With an ageing population and new techniques there is obviously an increasing demand, but demand for health care is not infinite. It is more expensive as well as more unfair to push that demand out of the NHS and into the private sector. The evidence from around the world is overwhelming: private health care is more costly and more unfair.

Competition in health care does not reduce costs, it increases them. In the United States, where all health care is privately delivered and there is a well-developed private health care market, total expenditure on health is equivalent to nearly 16 per cent. of gross domestic product. In this country, with the NHS, total spending on health is under 7 per cent. of GDP.

No doubt, the Government will label our complaints about rationing as scaremongering. [HON. MEMBERS: "Yes."] Conservative Members say yes. They accused us of scaremongering when we warned that the consequences of an internal market would be huge increases in the cost of administration, but we were right. Every year, an extra £1.5 billion is spent on administration, on managers and accountants.

There has been some discussion about extra resources, but look where they are going. In 1986, there were 500 general and senior managers in the NHS. In 1993, there were 20,000—an increase of nearly 4,000 per cent. Over the same period, the number of nurses and midwives in the NHS dropped by 9 per cent. We want more resources in patient care and fewer resources for managers and accountants.

The result of the Government's actions is that there are more people to count the cost of treatment, and fewer people to provide the treatment. They have put cost before care and profit before patients.

The Secretary of State has recently said that he is a "bureau-sceptic". He is criticising the administration that he has created. If I was a health service manager, I would think it was pretty cheap for the Government to create so much bureaucracy and then attack it. But that is their style. The Secretary of State now says that he is a "bureau-septic" and he attacks all the managers. That is a surprise to those of us who remember what he said at the time of the NHS reforms, when he was a junior Health Minister. I know what he said then because I read the debates last night. He was what I can only describe as a "bureau-fanatic". In a debate in March 1991, he extolled the virtues of more and more management in the NHS. "Health care management" he enthused is good quality health care for the patient —it is hard to see how that is the case— and good value for money for the taxpayer. That is what the investment in management is designed to achieve". The Government went on to invest £1.5 billion extra. Does the Secretary of State think that that £1.5 billion extra provides good-quality health care for patients? Does he think that £1.5 billion extra spent every year on accountants and managers is good value for money for taxpayers? The patients do not. They would rather it was spent on the people providing the care.

The Secretary of State dealt with primary care services. We warned that giving control over their own funds to some GPs, but not to others, as my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) mentioned, would mean that purchasing power, and not clinical need, dictated priorities for treatment. That was our accusation, and that is what is happening. The Government accused us then of scaremongering, but we were right.

In the Minister for Health's constituency, the Winchester and Eastleigh Health Care NHS trust and the North and Mid-Hampshire health commission announced that, because the commission had no further cash, the trust was not going to take any non-urgent cases from non-fundholding GPs until the end of the financial year in March 1996. Fundholding GPs on the local purchasing group, non-fundholding GPs, the trust and the commission are trying to club together to buy the hip replacement operations for the patients of non-fundholders who would lose out. They are trying at local level to make an unfair system fair. They are trying to make sense out of a senseless system. There is a two-tier waiting list, as we warned that there would be. Patients of fundholding GPs wait for no more than 10 months for hip replacements. Patients of other GPs wait for anything up to 18 months. Admission to hospital is based on purchasing power, not on clinical need.

We also warned that to close hospitals in London without improving primary and community care services would cause a crisis. We were accused of scaremongering, but we were right. Patients at King's College hospital spend up to 18 hours on trolleys in the accident and emergency department.

Let me tell the House what happened to my constituent, Mrs. Foster, who was rushed to the A and E department at King's at 8.40 pm on 3 October with a suspected heart attack. She was seen quickly by a doctor and put on a trolley in A and E. She waited for 19 hours on that trolley in a room with 10 other people on trolleys, including stab victims, one of whom died while she was waiting. Mrs. Foster asked for a bed pan, and she was given one—an hour later. She asked for a pillow and was given one—four hours later. She was finally moved to a bed in a ward at 3.40 on the following afternoon.

Let me make it absolutely clear that Mr. and Mrs. Foster have no complaints about the excellent staff, but they are unhappy to see a situation in which bed shortages mean that the staff cannot provide the services that they want to provide, and which patients need.

We warned that hospitals would compete instead of co-operating and that planning would give way to market forces. The Secretary of State mentioned that this morning, when he spoke about rivalry and friendly competition. Let me tell him how the internal market is working in practice.

The Government accused the Opposition of scaremongering when we said that hospitals would stop co-operating and would fight against each other. The House should note the example of Sue Snowdon, a consultant kidney specialist at Dulwich hospital. She has been told to take three months leave from her job rather than work her notice before she moves to her new job at St. George's hospital. Dulwich hospital is paying her to work in her garden, but not on its wards, because it fears that if she continued to treat her patients at Dulwich they would follow her to St. George's, and Dulwich would lose money.

We warned that the Government were privatising the NHS bit by bit, and we were right. We warned that they are making the NHS more like the private sector, and that is what they are doing. The market-testing of clinical services, which is now sweeping through the NHS, is taking that strategy forward.

The British people want two things from their health care services—excellent care and fairness. One cannot achieve fairness in a privatised, commercialised system. It is particularly important that the NHS gives equal access to everyone because of the health inequalities that mar our country, which the Secretary of State did not even mention. How long one lives and how good one's health remains is determined by one's income and social status—whether one is rich or poor. "The Health of the Nation" and numerous other reports have charted the gross social and economic inequalities of divided Britain, which lead to health inequalities.

It is vital that the Department of Health should take the lead in ensuring that other Departments and local government work together to end the inequalities that lead to the gap in people's relative health. It is also vital that the NHS is able to provide that equal access to health care; otherwise we will have an unequal NHS, and that will worsen rather than redress health inequality.

The Gracious Speech contains two specific health measures. We welcome the Bill to strengthen complaints procedures and look forward to studying its detail. I know that my hon. Friend the Member for Monklands, West (Mr. Clarke) would like to mention the important issue of direct payments for people with disabilities, should he manage to catch your eye, Mr. Deputy Speaker.

We also welcome the measure to empower the users of services, but we seek an assurance that that legislation will not contain any perverse incentive to compel users to buy purely from the private sector. We want the Bill to provide a genuine extension of choice, but for that to happen there must be a level playing field between public and private provision; otherwise choice will be extinguished as the public sector is simply driven out of the market.

We want genuine choice for users of community care, but we also want to ensure that those who receive such care are afforded proper protection against low-quality and substandard services. Now is the time for the Government to act on Labour's call for a proper system of regulation and inspection of the whole range of community care services, public and private, residential and domiciliary. Perhaps the proposed Bill will give them the opportunity to do so.

The Tories never had any mandate from the British people for their health reforms. Remember all their consultations on opting out hospitals? Those were a complete sham. The reforms have never won the support of the British people, and the NHS must be freed from crude Tory free-market dogma. Labour will take it forward to meet the new and great challenges of the next century.

We shall attack and redress health inequalities and improve primary care services, providing fair treatment for every patient and a say for every doctor in the services available to his or her patients. We shall develop services based on research and evaluation, and provide a fair framework of services and support for the growing number of elderly and disabled people. We shall restore the morale of those who work in the NHS by ensuring that they have a bigger say in how it is run. That is what the Gracious Speech and the Secretary of State's speech should have said, but they did not.

Comprehensive health care agreements will replace costly and bureaucratic annual contracts between hospitals and health authorities. Paperwork will be cut and the money put into the front line. The NHS is the most tangible evidence there is that we can achieve more together than we can achieve alone, privately trying to bribe our way through the system. We shall fight to defend the national health service from Tory attack, until we get into government and ensure its renewal.

11.1 am

Sir Rhodes Boyson (Brent, North)

I welcome the opportunity to speak on the Gracious Speech, and I shall raise several topics, beginning with my concern about health and then moving on to education and other subjects.

The Queen's Speech has obviously already cheered up the economy. Yesterday we learnt that the annual rate of inflation had fallen by 0.7 per cent. to 3.2 per cent, and in October the budget surplus was £1.3 billion. The good news in the Queen's Speech is already showing in our economy.

I welcome the Secretary of State to his new post, and assure him that whatever differences I have or will have with him, I respect him considerably as a person of integrity and of foresight. Two factors affecting health concern me and many other London Members. First, the number of beds in London has been cut more than the number in the rest of the country, and the figures seem to bear that out. That is a general concern.

Secondly, I know that the situation at Edgware hospital concerns several of my hon. Friends, as well as myself. I refused to vote for the Government after the debate on the health service in London because I was worried, and still am, about Edgware hospital. The Secretary of State willingly met me, and other hon. Members, soon after his appointment, and we put our views to him. I expected then, and I still expect, something to be done about Edgware hospital.

I was thus rather surprised to read an article in the Hendon Times a couple of weeks ago—an article that reveals the value of local newspapers. According to the Hendon Times, in a short debate in another place Baroness Cumberlege said that He— the Secretary of State— does not intend to revisit the decisions taken by previous Secretaries of State". She also said that the Government had gone to great lengths to explain the compelling benefits for patients from the planned changes". I was concerned about that, because I did not know that the debate had taken place—I probably should have read the House of Lords Hansard. If the Secretary of State does not intend to revisit the decisions taken by previous Secretaries of State, that is his privilege, but I shall most certainly revisit them, and so will the people in my area. Those decisions have not gone away, and cannot be dismissed in that way.

People may have gone to great lengths to explain the compelling benefits for patients from the planned changes", but my people still do not believe them. They still believe that the Secretary of State is wrong, and that the decision on Edgware hospital—the single decision that concerns me most—was wrong too.

I shall not speak at length on the subject, because I want to speak about other subjects on which I can support the Government, but I must put on record the fact that I am still concerned about Edgware hospital, especially the cutting of the casualty department.

Other hon. Members will have their own views on the subject, but in my constituency the main difficulty is getting from one place to another. It can take 50 minutes to travel the step from the Edgware hospital to Northwick Park hospital on a Saturday afternoon, and a casualty could be dead before he got there. I do not know where the traffic surveillance is done, but that is one of the most difficult areas in London in which to move about.

I leave the matter there for now, although I trust that the Secretary of State understands that I am not leaving it on one side, because my people are so concerned about it. Obviously one does not expect everything to be granted, but one expects to be listened to in the House, and the people who live on the Edgware side of my constituency expect some concession.

As a London Member of Parliament I am concerned about several issues in London. I am a Lancastrian, but I have now lived half my life in London, and although my accent has not changed, my views on certain aspects of London have changed since I came down here. I saw London as a boy, and my father always referred to anybody south of Manchester as a "city slicker". I have noticed that most "city slickers" are as varied and as honourable as people in Blackpool. I cannot say more than that, because I cannot give a greater compliment. If I wake up in the next world and a green tram passes, I shall know that I am in heaven. If it does not, that will not be heaven. The Blackpool trams will be up there with the tower.

Several things concerning London worry me. I voted for the abolition of the Greater London council. [HON. MEMBERS: "Oh."] At that time I was right, but we now have probably the only capital in the world without an elected body to speak for it. [Interruption.] Some of my hon. Friends may disagree with what I say, and that is their right, but the difficulty is: how are we to speak for London these days? There is no London body, although various bodies have tried to take on the role.

I am worried about the traffic in London, and I was concerned that there was no reference to crossrail in the Gracious Speech. My people want crossrail, and so does the rest of the city. Over the next 10 years we need not only crossrail but two new tube lines in London, if the city is to remain, as I wish it to, one of the six great capitals of the world. I regret the fact that there was no mention of crossrail.

I have heard rumours that the Treasury does not favour crossrail, but I hope that I am wrong. Indeed, I may be wrong in all that I say on these subjects. I hope that the rumour that I have heard is not true. There will be great disappointment among business men, in the City and among the population of London if we do not continue with crossrail.

Another matter that worries me is the future of the painted hall at Greenwich. We were sea people: in my childhood I read mainly books about the sea and I joined the navy as a boy seaman at the beginning of my naval career. Our history on the sea is finer than that of any other country, and that record will continue. People who forget have no future. We must never forget that we were and still are a sea people. We have a great river running through London; it is one of the finest in the world.

I am therefore worried about what is happening at Greenwich. We have a marvellous maritime museum there, which is one of the best in the world. Everyone should visit the exhibitions held there, as I do from time to time. I hope that something can be done to preserve the painted hall and the rest of the buildings so that the public can view them.

I know that Greenwich university has taken an interest in the site, and I am concerned about the status of the profession of which I was a member before I entered the House: teaching. There is a crisis of confidence in teaching in this country; it does not involve simply money, but status. The site at Greenwich could be used as a staff college for headmasters. They could learn about the country's history if they had not been properly taught at school and the college could become a great institution to raise the status of the teaching profession. There is much talk at present about the maritime museum and Greenwich university. The painted hall would provide the ideal place for a staff college, where senior heads could meet other people within the profession and further their teaching techniques.

There are some educational issues on which I agree with the Government—I am sure that my hon. Friends will be delighted to hear that. I agree with them on grant-maintained schools and the assisted places scheme. Although the subject was not mentioned specifically in the Queen's Speech, the Prime Minister has mentioned the prospect of doubling the number of students on assisted places schemes and an increase in the number of grant-maintained schools, which have been highly successful.

All but one of the secondary schools in my constituency are grant maintained. I took no part in their decision to become grant maintained, but left the matter entirely to the parents of the pupils. They made the decision, sometimes against the wishes of trade unions. The parents were balloted and, as a result, the schools became grant maintained. All the schools have improved—I visited one, Preston Manor, on Tuesday. Grant-maintained schools have proved to be an excellent innovation in this country.

When I was a headmaster I said that I was responsible to the parents, not to the governing body. I also said that if in any year when I was head of the school, fewer people wanted to attend it than there were vacancies, I would resign. The pupils and parents know whether the school is working properly or not. It is far better for the parent body to be in charge of the school than the local education authority, which is basically concerned about numbers.

Grant-maintained schools have been highly successful. I very much regret that the Labour party's policy is not to keep them, but to take away their freedoms. If, as the Labour party has suggested, foundation schools are introduced and we see the return of local authority representatives, we shall have taken a step back. There is no doubt that parents in my constituency will not vote to end the system of grant-maintained schools. I do not think that the Labour party realises the difficulties that it will encounter over such votes. Almost 100 per cent. of the secondary schools in my area are grant maintained—about 12 primary schools in Brent are grant maintained. I cannot always say that Brent leads the world, but perhaps it does in this case.

Mr. John Marshall (Hendon, South)

Brent is not doing too badly now.

Sir Rhodes Boyson

I must not be diverted from my speech by my hon. Friend.

The Labour party is making a bad mistake by pretending that it will continue with grant-maintained schools while pursuing a policy of wiping out their independence. I pay tribute to Sir Robert Balchin, the chairman of the Grant-Maintained Schools Foundation.

The Prime Minister mentioned doubling the number of assisted places. The scheme has been very successful. I steered it through the House and used to argue with one Opposition Member about its introduction. Some 30,000 children now have places on that scheme. Those children come from some of the most deprived homes in the country and attend some of the finest schools. If that is not reverse discrimination—which I believe the Labour party once believed in—I do not know what is. It is a good scheme that takes children from poor homes and places them in some of the best schools in the country. There are five applications for every one of the 30,000 places on the assisted places scheme.

It is interesting that three out of five Labour voters in a MORI poll held last year wanted the assisted places scheme to continue. I am not here to help the Labour party win the next general election. If it continues with its current policies, it will be damaged. I do not want it to win the next election, but I do not want to see it damaged. The next general election will be fought on such issues. As three out of five Labour voters want the assisted places scheme to continue, unless Labour wants to lose the general election it would be remiss to continue with its present policies. Perhaps it wants to lose the general election because it has become so used to being in opposition that it wants to remain there. There are certain advantages in doing so: it can grumble about everything without taking responsibility for anything.

The sort of people who take advantage of the scheme are bus drivers, nurses, clergymen, postal workers and divorced mothers. They send their children to some of the best schools in the country, and their ability to do so is not based on income. The average income of the families of children on the assisted places scheme is only £10,975–60 per cent. of them earn less than £10,000. The scheme does not give money to the rich, but takes people from the bottom of society's economic pile and gives them the best opportunities.

Mr. Marshall

Will my right hon. Friend confirm the statement made in the letters column of today's The Times that almost all the schoolchildren who participate in the assisted places scheme go on to win places at university?

Sir Rhodes Boyson

I am very grateful to my hon. Friend for that intervention. I believe that the figure is 90 per cent., which may be higher than the number of students from Eton who go on to university. If the Labour party wipes out the assisted places scheme, many people will register their disapproval at the ballot box. I shall certainly give them the opportunity to do so by making sure that Labour's policy is public knowledge.

I had thought that the Labour party was becoming more realistic in its views—after all, Labour Members are quite pleasant people. However, this week I read a statement by the Labour education spokesman proposing to phase out A-levels. We can have three-year degree courses in this country only if we also have A-levels. We have the shortest degree courses in the world because the second year in the sixth form is equivalent to the first year at university. If A-levels are wiped out, we will have to spend more money providing four and five-year degree courses. A-levels are the gold standard of British education and I was amazed to read the Labour spokesman's statement. I hope that it will be denied during the debate today and that Labour Members will admit that they made a mistake by failing to read the small print or something like that.

We need a vocational certificate in Britain that is equivalent in status to academic A-levels. That is what our European friends have—I am a Eurosceptic, but I must be friendly to Europe in this debate on the Queen's Speech. Like Europe, we must have a certificate on the technological side that is equivalent to the academic side.

At the beginning of my speech I said that the economy is improving—and we have seen signs of that in the past two days. I think that the Government could show their faith in the future by using any available money to increase Christmas bonuses for pensioners. Today's pensioners suffered the unemployment of the 1930s—it was particularly bad in the north country where I come from—and they suffered through the war. I was a social security Minister and every year we talked about doing something for pensioners. If there is any money available in the Budget arising from reductions in taxation and so on, the Government could improve pensioners' Christmases by increasing the bonus to £50—or £100 if the economy continues to boom.

I am convinced that the Conservative party's education policies are the best in the country. Occasionally my views differ from those of my Government on minor matters, but that does not lessen my overall support for the Government and the welcome that I give to the Queen's Speech.

11.23 am

Mrs. Gwyneth Dunwoody (Crewe and Nantwich)

I hope that the right hon. Member for Brent, North (Sir Rhodes Boyson) will forgive me if I do not follow him in all the twists and turns of his carefully structured speech. The House of Commons is advantaged by the fact that he is a Member—not least because he is not teaching in the state system.

Sir Rhodes Boyson

I spent the whole of my life teaching in the state system and I was educated in the state system. I want to see the state system flourish rather than being ruined by the Labour party.

Mrs. Dunwoody

That is exactly my point.

Mr. John Marshall

Will the hon. Lady give way?

Mrs. Dunwoody

No. The hon. Gentleman has just entered the Chamber and he must take his own chances.

This morning the Secretary of State talked at considerable length about the great advantages of a public school education. I am afraid that I did not enjoy those advantages and my constituents must listen to the product of the state school system speaking in what I regard as fairly clear and understandable English. I do not regard my state school education as a disadvantage.

I would have appreciated an equal amount of plain speaking from the Secretary of State this morning. He took a long time to say very little about the future of the national health service. For many people, the reality is not what we heard from the Secretary of State this morning: the reality is that the health service is run by increasingly overworked staff who have very low morale. They are very worried about their inability to provide the level of care that they were trained to administer and many doctors and nurses do not see a clear pattern of development in their professions in the future.

When discussing what is occurring in the NHS, we should recognise that some of the best ideas are subverted not because there is anything wrong with the core decision to change the way in which health service provision works, but because the resources and the staff are not available to deliver the necessary level of care.

I shall spend a few minutes discussing the provision of care in the community in my constituency. Cheshire has not done well in the spending assessments and there are very real differences between Cheshire and comparable counties. That has meant that those who provide care services face a continuing battle to balance the amount of money with demand for services.

That is the depressing aspect of the debate. My constituents know what is happening in health care provision; they see it every day. They see the pressures on hospitals and the fact that fundholding general practitioners have access to large amounts of money— which they occasionally do not spend correctly—while other GPs have to argue and fight in order to secure the same level of attention for their patients. That is not providing an improved health system: that is a simple two-tier system.

The Secretary of State knows the right words to use, but he cannot disguise the real situation. The Government are very good at using weasel words to disguise the real state of health care in this country. I will give way to the Secretary of State if he believes that he has not had enough time to debate the subject this morning.

Mr. Dorrell

The hon. Lady says that she listens to her constituents, who know in detail what is occurring in the health service in Cheshire. Unless her constituency is wildly out of line with what is happening in the rest of the country, the hon. Lady may like to comment on the fact that, when polls are taken asking people what they think about the service that they receive from the NHS, nine out of 10 say that it is either good or very good.

Mrs. Dunwoody

If the Secretary of State relies heavily on opinion polls, he will know how popular the Government are and how the average person is not persuaded about the correctness of their health policies. The people are firmly convinced that the Government have got it wrong, and I agree with them.

The local health authority produced a very glossy document entitled "Continuing Health Care for people with longer-term illness or disability in Cheshire". Using the same terminology as the Government, it states: Where a patient has been assessed as outlined above as needing care in a nursing home or residential care home … they have the right, under the directions of choice … to choose, within the policies of the county council and within the limits of cost and assessed needs, which home they wish to move to. Where, however"— there is a nice little sentence tucked on the end— a place in the particular home chosen by the patient is not currently available and is unlikely to be available within three weeks … that person should be discharged to another home until a place becomes available. That is the real choice. Owing to the enormous pressure on funds, Cheshire will constantly have to address a gap between what it is expected to provide and what it can provide. If there is any pressure within the NHS people will be told, "We are terribly sorry, but although you might have liked to have gone to a particular place, you will be discharged when it suits us." The Cheshire Disabilities Federation has been discussing the problems with the social services department. Its representatives are so worried that they have asked to come and see the Minister.

The Cheshire Disabilities Federation was told that a number of changes were being considered to deal with the overspend. They included a reduced assessment in response times. That is simple. It means blocking more NHS beds. A reduced work force was also proposed. That means letting people go and not replacing them. Cheshire social services also proposed slower responses to hospital discharge requests, the development of more restrictive eligibility criteria, the closure of some local authority residential provision for older people and some day care provision and to combine the rest of the changes across client groups.

Those proposals sound fairly straightforward, but they hide the fact that in future fewer elderly people will be able to get day care assessment, fewer elderly people will be able to leave the NHS at the speed they require or obtain the level of care at the place that they wish, and fewer staff will be provided where they are most desperately needed. I do not regard that as a suitable way of planning health care in my county or an adequate response to the needs of an elderly population.

In my constituency, because of the high incidence of industrial diseases, many people require a higher level of care than those with larger incomes and a different level of life enhancement, but there is now greater pressure on the services that they desperately need. There is probably a higher proportion of people suffering from industrial deafness, there are certainly more people suffering from asbestosis and there are people desperately needing care because they are alone, such as single mothers on desperately low incomes trying to cope in difficult circumstances. The effect of that is apparent throughout the population.

I had hoped that the Secretary of State would come here this morning, not to deliver an hour's party polemic, but to make a serious attempt to identify the difficulties in the health service and the problems that the Government have created with fragmentation and to attempt to find a way of putting it back together.

No one need doubt that the excrescences of management are so great that they are not only costing clinical care a great deal of money, but they are becoming painfully obvious. My national health service trust pays some employees £80,000 a year—and they are not chief executives. It is not an improvement in management; it is that there are more managers.

Nor has there been better planning in my local national health trust. Some time ago, a decision was made to go off into the private sector and build an incinerator to dispose of clinical waste. A great deal of effort and money was put into planning that pseudo-commercial development. We were told that the incinerator would be enormously effective and would attract industry. People would be happy to use the facilities and all the extra money would be poured into the NHS to provide better clinical care. That plan then disappeared off the face of God's earth because there have been changes in the circumstances which apparently were not allowed for in the original market testing that we had been hearing about at great length. Suddenly the whole plan was dropped with no discussion about what it cost the NHS or people in the area, or what the decision meant in terms of patient care.

I have seen the deterioration of care within the NHS in my lifetime and in my constituency. I have watched staff being told to reapply for their own jobs, argue for their particular little corners and deal with circumstances that mean that people have been forced seriously to consider private provision. I have watched the Government encourage private health care, not only in terms of financial and fiscal benefits but in every other way. It is a deliberate plan to run down the health service in a deleterious and dangerous way.

This morning I seriously thought that the Secretary of State would try to identify the real problems so that we could attempt to build a general consensus and begin planning for a better future. Instead, we had a supercilious and shallow assessment of the political difficulties which frankly do not do the present Government any credit.

I can only say to my constituents that those of us who care about the future of the NHS will make them only one pledge: that an incoming Labour Government at least will be aware of the real problems and seek to address them as urgently as possible.

11.36 am

Sir Sydney Chapman (Chipping Barnet)

As the House will know, this is my re-entry attempt as I am speaking in a debate on the Floor of the House for the first time in nearly seven years. The reason is that until last July, I had the privilege of being in the Government Whips Office. One condition of belonging to that most prestigious club, of which right hon. Friend the Secretary of State for Health has had some experience, is that one is supposed to take a vow of silence. It was not a complete vow of silence, because I should say, with all due immodesty, that we made some of the most popular speeches in the House, not only because they were the shortest, but because we asked the person in the Chair to adjourn the House.

I have to say, and I hope I am not breaking the Official Secrets Act in so doing, that I could best describe more than six and a half years in the Whips Office by saying that as time passed I increasingly realised the truth of the ancient Chinese curse, "May you live in interesting times". However, just as every Member agrees on one thing—that it is an honour and privilege to have the opportunity to serve our constituents in this august Chamber—I would like to put on record my appreciation to my right hon. Friend the Prime Minister for the privilege that I felt in serving in his Administration and that of his predecessor. To adapt a well-worn adage, they also serve who only stand and Whip.

I should also add that, as some of my hon. Friends will know, for the past three and a quarter years I had the additional privilege of being Vice-Chamberlain of Her Majesty's Household. That required three specific and extra duties: to carry messages to and from the House and to write to Her Majesty every day that the House was sitting to let her know what was going on. As those letters will not be made public for 30 years, I assure the House that I always wrote with impeccable political impartiality. Thirdly, on three occasions I had the duty to be the hostage at state openings of Parliament and I could not return here until the safe return of Her Majesty to Buckingham palace. The problem was when she safely returned I wanted to stay there rather than come back here.

I am grateful to have the opportunity to follow the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) as I was born in a different part of the county that she represents. I am also pleased to follow also my right hon. Friend the Member for Brent, North (Sir R. Boyson), for whom I have such a tremendous regard that I have just signed his nomination papers for re-election to our 1922 Committee.

It is worth remembering that when we are talking about the national health service, we are talking about people. The difficulty that politicians face is that in addressing the problems and achievements of the NHS, we inevitably have to deal with statistics. Some will come tumbling from my lips. The Government's greatest achievement in the NHS over the past 16 years is to have committed— thanks to the taxpayer—an additional £30,000 million a year to the service. As my right hon. Friend the Secretary of State said, that represents an increase in real terms, after allowing for inflation, of 70 per cent.

I am trying to deal with the real issues in the NHS. The hon. Member for Crewe and Nantwich, for whom I have a great deal of respect, was rather unfair in her comments on my right hon. Friend's speech. Of course there are problems, the main one being the escalating demand for NHS services. That is due to two factors—first, because of the introduction of so many new and very expensive operations, treatments and drugs, and, secondly, because as the years go by demographic changes in our society result in more elderly people as a percentage of our total population. Not long ago, my right hon. Friend the Secretary of State for Social Security said that 42 per cent. of his budget is spent on the elderly in our society, who represent about 16 per cent. of the total population. A staggering statistic to bear in mind is that as those demographic changes continue, in 35 years' time there will be 50 per cent. more elderly people and a correspondingly shrinking work force.

The very exciting, almost mind-boggling, advances that there have been and will continue to be in medical know-how and technology have had a profound effect on the way that we deliver health care services to the nation. There is a good example of that in Barnet and I want to pick up one or two of the relevant points mentioned in the eloquent speech by my right hon. Friend the Member for Brent, North.

For more than 60 years we have been fighting for a new general hospital in Barnet. I shall be even-handed in political partisanship and admit that successive Governments have thwarted that wish. In 1970, Barnet received approval to demolish old huts—separate corrugated iron sheds, which are presently wards and where operations have been carried out—and to build a new ward block. That was frustrated by a Labour Government. I can be even more politically even-handed by saying that the then Minister responsible for health was a Dr. David Owen, who I understand has moved to new political pastures and, for all I know, may be moving even further. He wrote to Barnet community health council in 1975: We are all aware of the pressing need for better hospital facilities in the Barnet area. It is the economic situation we face which prevents us remedying Barnet's particular difficulties. I shall continue to be even-handed and say that a new Barnet general hospital was put back on the agenda four or five years later. By that time there had been a change of Government. At the beginning of 1980 the health authority put forward proposals to build a surgical block, but a year later that scheme fell victim to the need to rein in public spending. We must treat with caution some of the Opposition's admonitions when they talk about the need for more funding for the NHS.

The good news is that the first phase of the redevelopment of Barnet is going ahead and is due for completion in 1997. That phase centres around a new and enlarged accident and emergency department with a new maternity unit. In recent years my constituents facing a happy event have had to go to Edgware to have their babies. Soon, those who want to do so can have them in Barnet.

The problem in Barnet cannot be put simply, but it must be put medically and fairly. Because the A and E departments were on two separate sites, sufficient cover could not be given to both. There is a popular misconception among all our constituents that an A and E department in a hospital can cater for any accident or emergency. That is not the case and never has been. There is strong evidence, at least in my part of the world, that where A and E facilities have been split over two sites lives have been lost.

I want to quote one or two statistics—not those produced by politicians, but given to us by the experts. A Royal College of Surgeons' report contains the shocking statistic that one in four deaths in A and E departments is avoidable. A British Orthopaedic Association report states that one in five people is inadequately treated after major surgery and one in eight left with a severe avoidable disability. I find those statistics shocking.

Even closer to home, a study undertaken by a Dr. Richard Warren shows that in the old north-west Thames region—it is now amalgamated into a new north Thames region—there were 86 avoidable deaths a year in A and E departments. It seems to me that if we are at all interested in what must be the highest priority of any health service—to save lives—changes must be made to reduce the number of deaths and casualties. That can be achieved by having a new and enlarged A and E department on one site. We should not forsake the other site completely, but use it for other NHS functions, including a minor accident treatment centre.

I have at least partial good news for my right hon. Friend the Member for Brent, North, for my hon. Friends the Members for Hendon, South (Mr. Marshall) and for Finchley (Mr. Booth), who I am delighted to see here today, and for my hon. Friend the Member for Hendon, North (Sir J. Gorst), who is unavoidably absent. The new minor accident treatment centre, which we have been promised before the A and E department at Edgware merges with Barnet, is due to open next week. We can take comfort from that.

Mr. Booth

Will my hon. Friend allow the comment to be made that the casualty unit in Edgware will cope with the problem raised by my right hon. Friend the Member for Brent, North (Sir R. Boyson)? Is he aware that there is a fear in the Edgware area that people may die before they reach a casualty unit in that there will be, as part of the casualty unit in Edgware, a place where crisis cases will be stabilised, as they are in the community hospital in Finchley, before they are moved on, in time, to the major trauma centre, which will be either Northwick Park hospital or Barnet general?

Sir Sydney Chapman

As my hon. Friend will understand, I cannot be expected to answer his question definitively.

It is important to understand that the majority of cases now being dealt with at Edgware will continue to be dealt with there. Of about 40,000 cases a year that are dealt with at the accident and emergency department at Edgware, only 1 or 2 per cent. could be described as life threatening. Even if one of my constituents collapsed and suffered a serious injury almost in the next road to Barnet general hospital, he or she would not necessarily be taken to that hospital. According to the seriousness and the nature of the injury, it may be that the person could best be dealt with at another hospital. I am sorry to be so morbid, but a person collapsing just outside Edgware hospital may not, even now, be taken to it. He or she may be taken to Northwick Park, the Royal Free or Barnet general.

It is important that we get these issues over to the public honestly and intelligibly. My hon. Friend the Member for Finchley will know that nowadays about 55 per cent. of surgery cases are day care. That has been a tremendous development in the NHS.

I am extremely grateful to have been called to make a contribution to this important debate. I shall conclude by iterating my central point: the delivery of our health care service must change according, and as necessary, to the massive changes and advances that are taking place in medical technology. With much political opprobrium, the Government have been responding responsibly and responsively. The way that they are managing our health service through the various agencies is the most realistic, relevant and responsive in meeting the needs of our constituents. I give them a simple and direct message: keep at it. Whatever the opprobrium the Government now face, tomorrow the people will realise that they took the right decisions in the long term for the benefit of our constituents and for that of the NHS.

11.52 am

Mr. Simon Hughes (Southwark and Bermondsey)

I welcome the hon. Member for Chipping Barnet (Sir S. Chapman) back to full voice after his relative purdah while doing the job that he enjoyed most—writing a daily letter to the Queen. Perhaps he might recommend to Her Majesty that in future some form of direct mail would be a more time-efficient method of sending and receiving messages, thus releasing his successors from letter writing and enabling them to have time to do other things. There could even be a direct television feed from the Chamber. That would allow Her Majesty to have a more rounded view of things.

I am happy, of course, to take up the hon. Gentleman's remarks. He is a distinguished London Member. I did not know until today that he, like me, had the honour of being born in Cheshire and is, therefore, a supporter of that fair county, like the hon. Member for Crewe and Nantwich (Mrs. Dunwoody).

I have only recently been given the job of looking after health and welfare policy for my party. I succeed my hon. and learned Friend the Member for Montgomery (Mr. Carlile). It might be thought that there is all the difference in the world between the health needs of the people of Machynlleth and those of the people of the Old Kent road, and so there is in one sense, but the national health service was designed by Beveridge and introduced and implemented by the Attlee Labour Government to be a service that afforded equal access for all. It was intended to be a national health service covering the four countries of the United Kingdom.

The test of how well we are doing is not how easily we can find fault in the policies, embryonic or completed, of other political parties, although that is a proper test of their seriousness, but how well we are providing the health care that the nation needs from the resources that the nation can afford to spend on them.

I come to my new job with the recent experience of the battle over the future of Guy's hospital, which is in my constituency. It was a paradox that my first speech on health was at the final meeting of the medical and dental committee of Guy's hospital before its demise and merger with a new medical and dental committee of Guy's and St Thomas's. I shall not talk about Guy's today because it has been discussed many times previously and I have no doubt that it will be discussed again.

I merely say that the debate about the future of one of Britain's most eminent hospitals taught me that there is an important agenda that we must all consider. It covers matters that affect the hon. Member for Chipping Barnet and other Members. How do we ensure that the health service does not spend unnecessarily large sums on management when it should be spending those moneys on front-line care? How do we ensure that the decisions that are taken in the health service are made as democratically as possible and not behind closed doors in secret, as so often happens nowadays? How do we ensure that we do not, in the interests of political dogma of the day or of the political agenda of an Administration, destroy excellence that cannot be replaced? How do we ensure that we build up the morale of all those in the health service so that we have adequate recruits and do not find ourselves short, in time, of A and E consultants, nurses or any other specialists in the service? Lastly, how do we ensure that the health service has the confidence of the public?

Whatever the Secretary of State may say and believe, a huge proportion of the British people is greatly worried and sceptical about how safe the health service is in the Government's hands. I shall give an example. Recently, the Association of London Authorities commissioned a large opinion poll to ascertain the issues of greatest concern to Londoners. It is significant that health came top of the list. That is no accident.

Before this debate I spoke to the person in my office who has looked after health matters with me over the past five years. I asked her to reflect on the five years and to tell me what issues kept on arising in correspondence or during telephone conversations. One such issue was the morale of those who work in the service. Another was how people felt about getting into the service when they needed to use it. How long do they have to wait? How long do they have to wait for treatment after an initial appointment? Why cannot people get a bed in many parts of the country? They are bussed around and sometimes, in tragic cases, they are flown around the country only to die as a consequence. How is it that when someone is lucky enough to get a bed he or she finds that a person of the opposite sex is in the next bed, often in extremely embarassing circumstances? That happens in our modern health service in 1995. How is it that hospital patients are so often let down badly by the treatment that they receive? Some patients are left on their own because there are not the staff to attend to them. Sometimes there is severe neglect.

There are serious concerns about the future of NHS dentistry, which were alluded to by the hon. Member for Peckham (Ms Harman). There is great and genuine concern about the amount of money being spent on management, advertising and public relations, for example. The inevitable consequence of the way in which we now organise the health service, with so many different sub-agencies all having to deal with each other, is that one builds up huge amounts of management, passing letters to each other, making contracts, negotiating. It is not the incorporated service that it was. That has to be dealt with, because a huge amount of resources are wasted in that direction.

Why do we still have such inequality between those who buy into the service? Fundholding has produced an inequality of access for the person who is meant, on my behalf as a lay person, to have access: my local GP. Why have we ended up in 1995 with a two-tier policy for access to health and not the originally intended common policy available to all? Those issues are constantly raised by our constituents and fellow citizens. In some ways, it is not different in the Machynlleths and the Marylebones. There are differences. Primary care is often much worse in the inner cities than the rural areas. There is an issue about prescribing GPs in rural areas that does not exist in the inner city.

On some items, there is often a common concern throughout the country. One such common concern is the insidious spread of the private sector through the health service, which may lead to bits of it being sold off. The reality is that the proposal for Guy's hospital—if one can get hold of the plans, which is difficult—is that part of it will go for private use. That is accepted as being part of the agenda, but it has never been voted for by the country. The people have never said that is how they want their health service to proceed. Yes, one has to buy in private services, but it is intended to be a public service run in an accountable way by and for the public.

I can be brief on the Queen's Speech because the Queen's Speech was brief on the subject of health. There were two proposals for two modest measures. As the Secretary of State indicated, they are both structural as opposed to budgetary or resource-filled. One proposes better access to a better procedure for complaints to the ombudsman; the other proposes to give people with certain forms of disability the right to buy their own care. I welcome both. They will be good measures. We shall try to make them as good as we can when the House considers them. The Government will have our support.

I notice that the second was specifically said not to bring any more resources with it. That does not surprise me, because, of course, there was nothing about more resources for the health service. I know that it was not the Budget speech—that is yet to come—but I imagine that we shall not see any significant additional resources anyway, even when the second half of the Government's programme is unveiled, which is what they are going to spend, for which we shall have to wait another 10 days.

Mr. Spearing

I had not intended to intervene, but I read in the Queen's Speech that there will be legislation to enable particular groups of people who want to purchase their own community care. Surely the hon. Gentleman is assuming that it would be of equivalent value to the totality of community care and that there could perhaps be private organisations, such as Southwark health care plc or Newham community privatised health services, which creates the very sort of market in health care, for which the boroughs are responsible, that has ruined the health service itself?

Mr. Hughes

I rarely dissent from the views of the hon. Gentleman, apart from on Europe, where he is a Euro-sceptic and I am a Euro-fanatic, but on this issue he may be reading too much into the proposal. My understanding is that the proposal is wanted and that it gives the local authority power to enable people to buy their own care rather than have it bought for them. That does not presume that it comes from any place different from where the local authority might purchase it. I believe that to be the case.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis)

rose—

Mr. Hughes

I shall let the Minister confirm that.

Mr. Bowis

I am happy to intervene to say that the hon. Member for Southwark and Bermondsey (Mr. Hughes) is totally correct and the hon. Member for Newham, South (Mr. Spearing) is totally wrong. The measure will, following the proper and due assessment of somebody's care needs, enable that person, if he or she so chooses, to have the equivalent money. Therefore, there is no financial implication to find and purchase the care to suit the individual's needs. It is more flexible. It is what disabled people want. I am grateful for the hon. Gentleman's welcome for it.

Mr. Tom Clarke

rose—

Mr. Hughes

The hon. Gentleman who speaks on these matters for the Labour party wants to intervene. I hope that I am getting time out for this. I give way one more time.

Mr. Clarke

I am grateful to the hon. Gentleman, but although he is a usually generous person, on this occasion he should be really careful. My hon. Friend the Member for Newham, South (Mr. Spearing) is much nearer the point. If the hon. Gentleman reads the small print of the Bill that was published in another place yesterday, he will see that my hon. Friend is right on the ball.

Mr. Hughes

I have seen the Bill, including the small print. I did not mean to indicate to the hon. Member for Monklands, West that I, like he, will not give the Bill particular care and scrutiny when it is before us to ensure that it delivers what it was intended to deliver and responds to the requests that were properly made by disabled people and others for a more flexible system. We shall come back to that. The Bill will probably be before us fairly soon—perhaps in the new year—given its start in another place yesterday.

I think that we all know that behind the debate about structure is the debate about the Budget, and that is the key issue. That is why I asked the Secretary of State about real-value increases in funds. Yes, we have increased considerably, as the hon. Member for Chipping Barnet said when he intervened, the proportion of our GDP that we spend on health, but we are still significantly below the average of our neighbours and comparable countries, both in Europe and the European Union, and across the Atlantic, too. In countries such as the United States, the balance between public and private contribution is different. We all know that.

The test of the health service and how well it does is the user—the public—rather than those who work in it, important though they are. It is important that, as we plan the future of the health service, we use the test: are the public getting the health service that they want? So that there cannot be any misunderstanding, I shall briefly set out my party's priorities for the health service. If anybody is interested, they can buy the booklet, which was the policy passed at our conference. It is called "Building on the Best of the NHS". We had a full and frank debate this year, including one controversial item, to which I shall return in a second.

First, we have to put the money where most people will benefit most easily to the maximum benefit. That is why we argue that it is good to hypothecate some of the revenue collected—I dissent from the Secretary of State on this point—and put it specifically into health uses. We would put an extra 5p on tobacco duty, which we would use to make eye tests and dental checks free again and to freeze prescription charges. We think that that is a good idea. We think that the public would benefit considerably from it and that it is the right way to proceed. A further 1p on tobacco duty would allow some extra money to go into community care. The beneficial consequence of those proposals is that by reducing smoking we considerably reduce the bill to the health service, because smoking costs the health service a considerable amount—an estimated £600 million a year.

The next area that needs reform is the undemocratic mess of the structure of the health service. The Nolan committee made it clear that there needs to be much better scrutiny of those who are appointed. Many of us would say that we need to reduce the number of people who are appointed and have considerably more people elected. The Secretary of State personally appoints more than 5,000 people to NHS jobs. The reality, therefore, is that decisions are taken by nominees of the Secretary of State, not by representatives of the local community, and thus not in a way that is accountable in any real sense of the word. I agree with the Secretary of State that there will be difficult decisions about priorities, but they are currently taken by placemen and placewomen, often by their medical advisers and not by community representatives, who are the best people to make those judgments, just as in Parliament we have to make priority decisions for the nation as a whole. We must have more consultation about the setting of priorities. We must have far greater accountability for appointments to trusts, the constitution of NHS trusts, health authorities and community health councils.

As local government becomes more accountable and is reformed, health commissioning should be passed to local authorities. There is debate about that in the profession, but our party has supported the concept. The link between social services and health is becoming ever closer; logically, they should be united in the context of commissioning at local level.

We must also consider the long term. I have always believed that, despite all the efforts of bodies such as the Health Education Authority, the country still spends too much time, effort and money in concentrating on building the best health-care system rather than ensuring that we have the best health. We need social policies that reduce inequality and improve health.

We must not continue to allow the rich to get richer and the poor to get poorer; we must not continue—in 1995—to condemn large numbers of people to living in overcrowded, unsatisfactory accommodation. We must not continue to allow so many people to be out of work, and thus unable to earn a decent income enabling them to be warm and well looked after. We must not allow education to be so poor that people cannot take the decisions that are best for their health. Nowadays the pollution of the environment—particularly in urban areas, and particularly as a result of vehicle emissions—induces, directly or indirectly, additional disease. We must concentrate on the health promotion agenda if we are to secure the health in the nation that will allow us to meet the bills that the NHS will always demand.

The public are as committed to the NHS as they have ever been, but they are aware that we still spend less than they would wish. They are aware that many needs are still unmet in health and community care. As all the surveys show, they would prefer additional investment in those services to a cheap, short-term cut of a penny or two in income tax. We need directly beneficial investment in the health service. For instance, the public would welcome a reinstatement of free eye checks.

We must reclaim the NHS from the bureaucrats, administrators and appointees, and give it back to real people. We must also keep an eye on the long-term bills: by investing in a healthier nation, we shall both reduce our bills and manage our resources better.

I shall be sad if debates such as this become party-political banter rather than an attempt—with as much agreement as possible—to obtain the securest possible public health service, free at the point of delivery, for all in the next century and beyond.

12.12 pm

Mr. Hartley Booth (Finchley)

It is a pleasure to follow the hon. Member for Southwark and Bermondsey (Mr. Hughes), with whom I have been debating for 20 years or more. The hon. Gentleman is still wrong in various respects: for instance, his suggestion that it is possible to finance all sorts of wonderful improvements in the NHS by increasing the tax on tobacco by 5p is simply wrong. The hon. Gentleman knows what happens in the European free market about which he is so enthusiastic; he knows that we would lose rather than gain by hiking up tobacco prices in the way that he suggests. People would buy tobacco in other countries such as France.

I pay tribute to my hon. Friend the Member for Chipping Barnet (Sir S. Chapman). He served his term on the Front Bench for nearly seven years, and has now broken his Trappist vow. We are glad to reclaim what we lost during those years: my hon. Friend need no longer be taciturn.

The Queen's speech requires us to look beyond the proposals that it contains. It should focus our minds on the very purpose of government. I have always believed that Government's aim should be to transcend the immediate—to view long-term objectives, to rise above self-interest and to bring prosperity of body, mind and spirit to all our people. According to the hon. Member for Peckham (Ms Harman), the Queen's Speech merely laid out the road to a privatised health service. There is, to say the least, a vast chasm between what I would define as the Government's aims and the hon. Lady's limited perception of those aims.

Testing the wider perception of Labour's view of our aims does not produce much more illumination. The right hon. Member for Sedgefield (Mr. Blair) said that our proposals in the Queen's speech were a rag-bag and right-wing; he described them as "a mouse". That was how he described excellent proposals that will improve education, tackle organised crime and improve our housing stock, as well as dealing with problems in transport and broadcasting and the complaints of NHS patients. Those proposals do not constitute a mouse; they certainly do not constitute a rag-bag. And the stuff about right-wing is all talk.

As for the experiences of the chairman of the Conservative party this week, he was not an example of the ship of state that leaks from the top. He did not leak; he referred to the Gracious Speech in advance, quite properly. He simply said that the proposals in it would be good, and that they had a second purpose in flushing out Labour. Why not? That is absolutely right. In painting him as a villain, Labour Members lower themselves to the level of the paint-hurlers of the street. That is just another example of Labour's claim that the best form of defence is attack.

What proposals did Mr. Blair seriously advance?

Mr. Deputy Speaker

Order. The hon. Gentleman should refer to the right hon. Member for Sedgefield.

Mr. Booth

What did the right hon. Member for Sedgefield say? What were his proposals? He certainly had a wonderful proposal for central heating: lots and lots of hot air. He who talks of mice and trivia demonstrated his concern. In his speech, he said, "Let us consider Nolan." He was obviously concerned about the pay of Members of Parliament. He also said: "Let us consider utilities' bosses." He was clearly concerned about the politics of envy. And he said, "Let us consider Iraq." All those points were sideshows; the right hon. Gentleman disregarded the important aspects. Except by way of a passing reference, the right hon. Gentleman did not consider the earnings of Britain as a whole. To him it was more important to speak about the pay of hon. Members. He did not consider the successes of the utilities and privatisation. His theme was the envy of a few, but he should have said that privatisation has transformed Britain. Before it happened we pumped £50 million a week into the nationalised industries, but now we receive £50 million a week from them in taxation.

In considering our export achievements the Leader of the Opposition referred only to Iraq, and that is disgraceful. The right hon. Gentleman purports to be the leader of the Government in waiting, but, as my right hon. Friend the Prime Minister said, he is not fit to govern.

There has been no reference in the debate to our excellent proposals for legislation on a chemical weapons convention and a comprehensive test ban treaty. The Gracious Speech refers to drug misuse. I am sure that the whole House would wish to express sympathy to the parents of Leah Betts, who died yesterday. If the death of that girl is a warning to the hundreds of thousands of young people who may be offered drugs at parties and if they refuse them because they remember her tragic demise, she will not have died in vain.

The Government propose to increase free trade. Labour is clearly keen on Europe but it should be warned that as well as the endemic socialism in Europe and our criticism of Europe's courts, there is also endemic protectionism.

Mr. Spearing

There is no endemic socialism there.

Mr. Booth

I note the hon. Gentleman's intervention. He is well versed in European matters, but Europe's endemic protectionism is a threat to us as a world trading nation, and we must understand that. We must argue against protectionism even when it is propounded by the famous Mr. Goldsmith.

Thank goodness that we intend to combat fraud in the European Union and ensure that flexible labour markets are restrained and social costs lowered. We shall hear more about that and Labour will ignore the issue at its peril. The people are beginning to understand it and they will not allow Labour to push its line.

The Gracious Speech mentions support for the middle east peace process. Earlier this week there were tributes in the House to Premier Rabin. We wish Mr. Peres well in his burden of carrying forward the peace process.

Once again the Gracious Speech refers to the importance of Northern Ireland. Over many years we at least have accepted that Northern Ireland is worthy of being at the top of the agenda.

Before I deal with health I should like to deal with the reference in the Gracious Speech to the economy. People are always better off under Labour, but they are the people in France, Germany and Japan—our competitor countries. They do rather better and Britain does much worse.

Why do we hope to reduce taxation? The Gracious Speech mentions the improved performance of the economy and we are open about our desire to improve it further by reducing taxation. Labour would have it that we want to reduce taxation to bribe people to vote Conservative, but nothing could be further from the truth and nothing could portray Labour more accurately in its true colours as a party of envy and not of economic understanding. The real reason for wishing to lower personal taxation is that every time that it has been done the country has benefited and the Treasury has received more money.

The Institute of Fiscal Studies confirms that as we lowered personal taxation in the 1980s receipts went up. More people from all over the world stayed in Britain, contributed to our economy and paid more to the Treasury. As we reduced corporation tax we became a magnet for investment. Therefore, reducing corporation tax was a valuable stimulus to the economy. Labour says that reducing taxation is bribery but it is not: it is a vital ingredient of our vibrant economy. Sadly, we need to reiterate that all too often as the jibe is thrown at us by the Opposition.

The Government propose to improve and expand nursery education, but this is my opportunity on behalf of my constituents to sound a note of caution to the Government. I hope that it will be recorded, although I am sure that Ministers always listen to Back Benchers. I see that a note is being taken, as it always is, by our listening Ministers. We need improvements in nursery education, but they must be flexible. They must recognise that in different boroughs and different localities there are different needs. Barnet and Finchley already have excellent nursery services. Some £2,600 per head for three and four-year-olds is shelled out for that. The Government propose £1,100 for four-year-olds and that represents a reduction of £2,600 for three-year-olds and a pro rata reduction for four-year-olds. I hope that we in Barnet will be allowed to keep our present system which is much better than what is proposed for other areas that have no provision at all. It will be an improvement for them but it would certainly not be an improvement for us. We hope, therefore, to have the opportunity to continue what we have in that region.

We must recognise that asylum is not a race issue, but a world issue of great importance which I hope hon. Members will treat with the seriousness that it deserves. Around the world, 200 million to 300 million people are potential economic migrants. In Africa, Asia and southern America, there are huge migratory trends. I hope that the balance between accurately defining what is and what is not an economic migrant and the need to allow people who want and deserve asylum from terror into our country is accurately described and dealt with in our legislation. I look forward to that.

The homeless issue is a cri de coeur for myself. For some years, I have been battling to get through a Conservative proposal, although it has had some support from other quarters, to ensure that homeless people's needs are recognised. There are seven empty houses for every homeless person and 825,000 void properties, of which about 110,000 are in the public sector. The fact is now recognised by the Department of the Environment. I want a bigger recognition of that scandal. I want the Government to stand up and recognise that we have that huge resource of empty property, which could be used for homeless people. As a nation, we have no excuse for having empty properties when we have homeless people. The two must be married up. It will also have benign Treasury implications, so there is no reason on earth why Ministers cannot welcome that proposal with both arms. I hope that, at a conference in February next year, they will announce some proposals to welcome it.

As I opened my mouth this morning to brush my teeth, I found that there was a second reason for opening it. I had my radio on and I heard the hon. Member for Peckham (Ms Harman) say that the Government were encouraging administration and bureaucracy and spending a fortune on it in the NHS. Nothing could astonish me more. That was a statement from a spokeswoman for the Labour party, which seriously suggests that competitive tendering is nonsense and is to be kept out of the system, yet we know that, whenever competitive tendering is permitted in local authorities or the NHS, on average, there is a 7 per cent. saving.

The hon. Lady said that the Government, who introduced competitive tendering and want it in the NHS and elsewhere, want bureaucracy and not savings. Was it because she is so close to certain trade unions? When I asked this morning about her support from Unison, she was reticent. I hope that she will find time to place in the Library of the House of Commons information about how much Labour Front-Bench Members receive from Unison. Many hon. Members and others would like to know so that we may achieve a balance in these issues.

The Government's NHS proposals must be set in context. They may be small in themselves, but they are part of a series of reforms that have taken the NHS further forward than at any time since the 1940s, when it was introduced by the Labour Government. As my hon. Friend the Member for Chipping Barnet (Sir S. Chapman) said in an eminent intervention, there has been a huge rise in funding—it has increased by 70 per cent.—and we have taken courageous decisions of choice and priorities throughout our period with the NHS.

A Front-Bench Labour Member referred to a limited period when apparently the number of nurses fell, but, from 1983 to 1993, there were 18,000 extra nurses and 8,000 extra doctors and dentists. Throughout the service, we have ensured not only that we were increasing staff, but that their terms and conditions of service improved. We have allowed more time off for nurses as well because we have recognised that they are in a stressful position.

Mr. Spearing

The hon. Gentleman extolled competitive tendering. Earlier, I got the Secretary of State for Health to agree that choice meant price and that price in competitive tendering could sometimes mean constraints on the operation of or indeed the end of the firm, or a reduction in the terms and conditions of employment, including those for nurses. Does the hon. Gentleman agree therefore that competitive tendering, where hospitals can press terms and conditions on their employees or go out business, is not appropriate to the health service?

Mr. Booth

Not at all. I do not fully understand the hon. Gentleman's point, because what he said broadened the issue considerably. When competitive tendering in the NHS is properly administered, the rules of labour law are applied properly so that no one is exploited. We have laws to ensure that people do not work too long. If a private operator is brought in, the rules for its employees are often much more stringent than those for the old public sector employers who, because of Crown immunity, were often exempt from the full rigours of employment law.

Mr. Austin-Walker

Does the hon. Gentleman acknowledge that, in Hillingdon, Pall Mall care services have taken over under a private contract and have reduced workers' pay below the level at which they qualify for family credit?

Mr. Booth

It is essential that contracts of service are drafted so that such problems—I accept that it is a problem—do not arise. The drafting of contracts is important and future contracts must learn from past mistakes. Another safety valve is that, if a contractor does not provide what is required in the contract, it can be ripped up and started again.

Mr. Austin-Walker

I hope that the Minister will clarify the position when he replies. I understand that it is not permissible to place in the terms and conditions of a contract conditions relating to pay.

Mr. Booth

That would be a breach of British law. People in the private sector cannot be exempt from the application of rules that the House has passed for their benefit. If examples of that exist, the hon. Gentleman will no doubt bring them to the Minister's attention and he will deal with the matter.

Opposition Front-Bench Members have raised the issue of fundholders time and again. The hon. Member for Crewe and Nantwich (Mrs. Dunwoody) said with great scorn that there were two levels of care. We can have two provisions, both of which are good and can be right. The fact that there is a choice does not mean that one is wrong. That can be demonstrated by the fact that 50 per cent. of doctors have decided to become fundholders while 50 per cent. have not. It cannot be argued that those who have chosen not to become fundholders have hit the rule book, because they can now join others and become fundholders.

When I visited a GP fundholder in my constituency I saw the amazing extra provision that he and his partner were making available to his patients, all because he had been given personal responsibility for his budget. He had a physiotherapist on site, saving time, money and inconvenience, and he had made various other medical services available for his patients. That would all be denied if we went down the Labour party route. GP fundholders and NHS trusts have brought decisions closer to patients. When one needs a GP, an appointment now takes only two days whereas it used to take weeks.

I am told I have to rush so I will move on quickly. There are proposals to change the jurisdiction of the ombudsman, which have been sought for 20 years. During 1994 and 1995, there were more than 250 cases in which clinical complaints about the NHS were rejected by the ombudsman, Mr. William Reid. The ombudsman has been wanting change for over 20 years. But will the Labour party praise that change? I do not hear any praise coming from Labour Front Benchers. Perhaps we will hear some at the end of the debate. At least the spokesman for the Liberal Democrats supported the change.

The Labour party has not praised the fact that the proposal will widen the jurisdiction of the ombudsman to GPs, dentists, pharmacists and opticians. The Labour party does not praise the fact that we have provided greater choice in the provision of community care. I am pleased that the Liberal Democrats are supporting that.

There are two points that I would like the Minister, in his closing remarks, to address. The NHS still needs, despite its great achievements, to improve in various areas, including health prevention and administration. I have mentioned the issue of autism in the House before. There are thousands of forgotten and unknown children in this country with autism. Children with autism are on a continuum and it is difficult to define. The complaint was not even known about 20 or 30 years ago, and nor was the related ailment, Aspberger's syndrome. I would like the Minister to recognise the importance of new moves, not least the national autistic resource centre that was launched this week. It is important to help the many children with autism and the many parents who suffer because of their child's problem with autism.

The second issue is the problem of residential care and the NHS. I have been campaigning all year for elderly people who have problems with residential care. Although the Labour party, during the 1940s, proposed to means-test the income and capital resources of the elderly, it is only now that means-testing has become an acute problem. I would like the Minister to tell us that the Government will be more generous to elderly folk in residential care who are in huge difficulties at the moment.

The greatest test of NHS success is the longevity of our people. During the past 15 years, life expectancy has risen from 69 to 74 for men and from 74 to 79 for women. Life expectancy has improved largely because of the success of the NHS. I do not believe that we should end the debate without acknowledging and thanking the NHS for its role in producing that great success.

12.43 pm

Mr. John Austin-Walker (Woolwich)

Before I commence, I should say that I am a member, and have been for 23 years, of the Manufacturing, Science and Finance Union, which includes in its membership doctors, health visitors, community and school nurses, and a wide range of professional, technical and ancillary staff in the NHS.

In view of the current guidelines, I thought that I should make that statement early. The Table Office could not provide guidance on whether I needed to declare an interest in the debate, but I notified the people there because, with my right hon. Friend the Member for Chesterfield (Mr. Benn), I had tabled an amendment to the Address. I should add that MSF makes a contribution of £600 per annum to my constituency party. In the interests of open government, the House is entitled to know that.

Mr. Lilley

The hon. Gentleman has done the right thing; will he condemn his Front-Bench spokesmen for refusing to do as he has done, and tell the House how much they are paid in sponsorship by Unison?

Mr. Austin-Walker

I made my statement at the beginning so that we would not be diverted by irrelevancies during this important debate. I consulted the Table Office and read the guidelines, but they are not precise or clear. My understanding was that it was up to me to decide whether I regarded myself as having an interest, and I believed that I should err on the side of caution and make the declaration. I am sure that my Front-Bench colleagues will make their own judgment, study the guidelines and act in accordance with the principles of disclosure.

Mr. John Marshall

rose —

Mr. Austin-Walker

I am not prepared to give way to the hon. Member for Hendon, South, who came into the Chamber at 11 o'clock and has been in and out like a fiddler's elbow ever since.

The Queen's Speech was an obvious disappointment for anyone interested in health, which, as the hon. Member for Southwark and Bermondsey (Mr. Hughes) said, and as the recent survey by the all-party Association of London Government showed, is the main worry among Londoners. Londoners face particular problems of underfunding, but their concerns are shared throughout the country.

Poverty and poor social and environmental factors are key determinants of ill health, and the Queen's Speech gives little suggestion that the Government have any plans to deal with the increasing inequalities in society.

On Wednesday my hon. Friend the Member for Sheffield, Attercliffe (Mr. Betts) mentioned the King's Fund report, which shows that, for the first time in 50 years, death rates among the poorest people are rising. The report confirmed that social divisions have accelerated at a rate not matched for such a sustained period in any other rich industrialised society. While the incomes of the poorest 10 per cent. have fallen by 17 per cent. in real terms, the incomes of the richest 10 per cent. have risen by 62 per cent.

What my hon. Friend the Member for Attercliffe said about Sheffield applies also to my area, which is served by the Bexley and Greenwich area health authority, and to other parts of London. Indeed, a recent report revealed that all the inner London boroughs are included in the list of the 20 most deprived local authorities in the country.

My hon. Friend the Member for Newham, North-East (Mr. Timms) spoke earlier about the distortion in the way in which health resources are distributed, and there is nothing in the Queen's Speech to suggest that that will be redressed. Taking evidence from directors of public health before the recess, the Health Select Committee heard that current calculations tend to take resources away from deprived areas in favour of more affluent areas.

For example, in my region of South Thames money is taken away from areas such as Camberwell, Woolwich and Lambeth and given to areas such as Worthing and Eastbourne. In my hon. Friend's region money is taken away from the deprived parts of east London and given to the leafier parts of Essex. As the director of public health for Croydon said in the British Medical Journal last June, to distribute resources according to age without distinguishing between poor elderly and rich elderly, is to discriminate against the group which has the greatest need of all. That point was also eloquently made by my hon. Friend the Member for Crewe and Nantwich (Mrs. Dunwoody) in connection with Cheshire.

Nationally, that arrangement transfers resources from the north of England to the coastal areas of the south. As my hon. Friend the Member for Halifax (Mrs. Mahon) has said, there has been a shift of resources, including money, from poorer to richer areas, and that fulfils the Government's political objectives.

In London, after the Tomlinson report, it became the perceived wisdom that London received a larger share of the NHS cake than it deserved. It was argued that London contained 15 per cent. of the population and received 20 per cent. of resources. Analysis of the allocations for the current year for hospital and community health services— the HCHS allocation—shows that the capital's share has dipped below 15 per cent. Professor Jarman has shown that, when adjusted for factors such as market forces and London weighting, the allocation to district health authorities in London was more than 5 per cent. lower than the national average resources per capita.

In March last year at the Select Committee on Health the hon. Member for Croydon, North-East (Mr. Congdon) asked the then Secretary of State what proportion of resources should be allocated to London bearing in mind higher costs and deprivation factors. The right hon. Lady replied: my view is that we should seek to close the gap … I accept that there continue to be reasons why London has special needs. We accept that on health and we accept that on personal social services. The right hon. Lady who said that was hell-bent on closing hospitals throughout the capital—Bart's, Edgware, Greenwich district hospital and Guy's.

In their lurch to the right, the Government seem to be paying heed to the clarion calls of the right hon. Member for Wokingham (Mr. Redwood). I wish that the present Secretary of State would take heed of the contribution of the right hon. Member for Wokingham to the debate on Wednesday, when he said: there must be enough different types of hospital from which people can choose. That means bringing an end to many closure programmes."—[Official Report, 14 November 1995; Vol. 267, c. 44.] London's share of NHS resources has dipped below 15 per cent. The previous Secretary of State said that she accepted that there was a need to close the gap and that London has special needs, in the spheres of both health and social services. But under the standard spending assessment distribution mechanism, London received 21.8 per cent. of the total personal social services for this year. If national health service resources were to be distributed on a similar basis to the SSAs, London would have received £5 billion compared to less than £3.5 billion. London would, should and could have had an extra £1.5 billion this year. Perhaps then the right hon. Member for Brent, North (Sir R. Boyson) would have seen Edgware hospital saved.

The Queen's Speech also held little comfort for elderly people. The former Chancellor, Lord Howe, took great credit for breaking the link between pensions and average earnings so that the average pensioner income has fallen since the Tories came to power from one third of average male earnings to only one fifth—pensioners are now £20 a week worse off. Once again this winter we can expect beds in hospitals up and down the country to be blocked by elderly people who are too poor to heat their homes and who suffer from hypothermia. Some will recover and be discharged, but thousands will die and thousands more will not recover sufficiently to be discharged and will require long-term care. That is Tory Britain as we approach the new millennium.

I refer briefly to community care, particularly the long-term care of elderly people. In the 1980s, owing to social security changes, there was an explosion in often unnecessary institutionalisation of elderly people in the mushrooming private nursing homes, with a consequent dramatic increase in the DSS bill. That was followed by the 1990 national health service and community care reforms, which centred on closing NHS geriatric beds and placing responsibility on cash-limited social services departments which, unlike the NHS, rely on means-tested charges—a point made by the hon. Member for Finchley (Mr. Booth). That could be seen as a scheme to raid the elderly's private savings.

More recently, restrictions on council spending and the requirement to spend a substantial proportion of community care money in the so-called independent sector has resulted in the continuing privatisation of community care. In both those processes, the provision of domiciliary care and support has taken second place to residential care. The move from NHS provision to community care has led to a great disparity in treatment and services, with some elderly people being charged for services while others are not. They are often charged not on the basis of need or their ability to pay, but on the basis of the type of building or the area in which they live. The move has also led to arguments about what constitutes nursing care, which is supposed to be provided free at the point of need.

I accept that nursing care can be broken down into a series of tasks or various components, some of which require the skill of a qualified nurse and some of which do not. However, it cannot be right to use that as a mechanism whereby elderly people are charged for some elements of their care and not for others. Nor can it be used as an excuse to make cuts in some areas through spurious grading exercises.

I shall give one example of differing treatment. An elderly person in an NHS hospital who uses incontinence pads or who makes use of the incontinence laundry service is not charged. However, once that person is in the community—whether at home or resident in a local authority or private nursing home—that person may be charged depending upon the area in which he or she lives. We must ask another question in this case: where is the continence nurse?

I am sure that if nurses were intimately involved in purchasing and commissioning decisions, prevention and health promotion would shoot up the priority list. I believe that nurses can play a very real role in locality commissioning. I am sorry that that prospect is not mentioned in the Queen's Speech—we will have to wait until the next Queen's Speech under a future Labour Government.

Means testing and reliance on private insurance schemes or requiring pensioners to sell their homes does not provide a cheaper service. Such schemes may require a lower tax input, but they do not provide a cheaper scheme. What is not covered collectively by the taxpayer becomes a charge on the individual or an insurance bill.

We must also consider the gender issue if the Government are contemplating going down the private insurance road. The majority of those who need care now, and who are likely to need long-term care in the future, are women. Hopefully, we shall see continuing improvements in the area of equal opportunity, but today—and for the foreseeable future—women are more likely to need long-term care and are more likely to have career breaks and not enjoy continuity of employment.

Women in my constituency tend not to have careers: those who are in paid employment have jobs. Apart from breaks in employment, women tend to be in lower-paid work, which is often part-time, and they may not receive holiday pay—that is certainly the case if they work in the contracted-out services of the NHS. They are less likely to be in an occupational pension scheme and less able to contribute to a private insurance scheme. Therefore, they are much more likely to have to depend upon state-funded provision. Furthermore, any scheme that is funded through private insurance will prove more expensive in terms of administration, bureaucracy and assessment.

I now turn to an issue that is not included in the Queen's Speech. There is nothing in the speech to suggest that the Government intend to deviate in any way from their doctrinaire policies. The private finance initiative currently threatens the hospital service in Woolwich. The Brook hospital is to close next week and that may be followed next year by the closure of Greenwich district hospital. We now find that the hospital that the NHS was to inherit from the Ministry of Defence—the former Queen Elizabeth military hospital, which is now the Queen Elizabeth hospital, Woolwich—could be handed over, lock, stock and barrel, to the private sector.

The hospital needs to be refurbished and expanded. The Government could have provided the necessary money, but instead the development is subject to the private finance initiative. Why is that so? It is because the Government say that they must transfer the risk. What risk is that? If there is a risk—or if that is what the Government are telling the private sector—-the private sector will clearly want an additional payment as a reward for taking that risk.

Last week the railway rolling stock was sold for about half its value—some of it to a Japanese bank—so that we can rent it back again. Do we honestly believe that Japanese banks are interested in providing an efficient, effective and reasonable transport system for the British people, any more than they are interested in providing a decent health care service?

In addition, as a result of the PFI there have been considerable delays in health service building. Can the Minister tell us what delays have occurred as a result of the PFI? What guarantees can he give that the Queen Elizabeth hospital will be ready in time for my constituents in Woolwich, Plumstead, Abbey Wood and Thamesmead and the neighbouring areas of Erith, Belvedere, Northumberland Heath, Greenwich, Eltham, Welling and Bexleyheath?

The entire private finance initiative is a financial con trick. It is not cheaper at the end of the day and it is not only left-wing politicians who say so. Peter Puplett, the former group economist at Tarmac, wrote in The Daily Telegraph: The initiative will cost taxpayers much more in the long term than the traditional system of paying for public investment, either out of current tax revenues or from borrowing. The Economist commented that it will give the Government an opportunity for creative accounting designed to disguise their spending commitments. I would like to refer briefly to mental health care in London. I am only too aware of the inappropriateness of hospital care for many patients who should be cared for and treated in the community. On the other hand, I am also painfully aware of those people who urgently need hospital provision—often short-term in a crisis—when no bed is available. Bed occupancy figures in my area show occupancy levels in excess of 120 per cent. It can take a consultant psychiatrist 36 hours to find an emergency bed. I represent a constituency in south-east London where patients sometimes have to be placed as far away as Woking or Oxford, some in expensive private hospitals at NHS expense.

Coupled with the inadequate provision of emergency beds is the appallingly low level of community support services. Patients are placed on a supervision register on discharge because it is feared that without support they could be a danger to themselves and others. Yet in the North Thames region, fewer than one in 10 of those discharged in the first quarter of this year have been seen even once a month by community psychiatric staff. There is a wide chasm between the rhetoric of community care and the grim reality. There can be no case for closure of psychiatric beds until effective community care provision is in place.

I referred earlier to the private finance initiative. I referred to the need for openness in government and for disclosure. I belong to a union that represents people who work in the national health service. Those people have a vested interest in the national health service, not only as it is their employer, but because they use it.

Who will benefit from the private finance initiative? Already construction companies such as McAlpine and Tarmac are forming consortia with private health care companies. It should not go unnoticed that McAlpine and Tarmac between them contributed £1 million to Conservative party funds. That is the sleaze, that is the corruption and that is the distortion and we ought to bring it to an end.

1.3 pm

Mr. John Marshall (Hendon, South)

I listened with some interest to the speech of the hon. Member for Woolwich (Mr. Austin-Walker). I congratulate him on declaring an interest at the beginning of his speech. When he signed an amendment to the Gracious Speech about trade union rights, he did not, as a sponsored trade union Member, think it right to declare that interest.

Mr. Austin-Walker

I said at the outset that I had consulted the Table Office and registered that interest. It will appear when the motion is printed next and before the vote takes place. I made that abundantly clear at the start of the debate.

Mr. Marshall

I am glad that the hon. Gentleman has now explained himself. When I raised the matter on a point of order yesterday afternoon, none of the sponsored trade union Members who signed an amendment dealing with trade union rights had declared that interest. We smoked out two yesterday afternoon, we have now smoked out a third and there are some more to be smoked out.

I was surprised by the hon. Gentleman's attitude towards the PFI. He asked who would benefit from it. As a London Member, I can tell him that hundreds of thousands of our fellow citizens in the capital will benefit because the largest project under the PFI is the provision of new trains for the Northern line. As he should know, by the middle of next year there will be a significant number of new trains, provided under the PFI, taking Londoners to work on the Northern line. As a London Member, he should welcome that rather than criticise the PFI.

Mr. Spearing

Japanese owned.

Mr. Marshall

The owner is not Japanese—it is GEC, a good British company that provides hundreds of thousands of jobs, is a major British exporter, and is headed by Lord Prior.

The PFI succeeded in increasing the level of investment in London Underground, with the result that the Northern line will undergo a £1 billion modernisation project. Surely Labour Members should welcome that, not criticise it.

The debate shows that the Opposition do not understand what the PFI is about. It is not about Japanese companies running the NHS; it is about companies providing the property in which the NHS can provide care for patients. One does not need to be the property owner in order to run the hospital. Some of the greatest retailing companies do not own the shops from which they trade. Labour Members should come with me to Brent Cross in my constituency, where companies such as Marks and Spencer and Boots provide an excellent service from shops that they do not own, but rent. So will it be with the PFI. Someone will own the hospital and the local authority will use it to continue to provide a first-rate service.

Mr. Spearing

Surely under a national health service the people own the hospitals.

Mr. Marshall

It is a question not of who owns the hospital, but of who provides the service, whether it is a good service and whether it is free at the point of consumption. When a patient goes into the operating theatre, the last question he wants to ask the surgeon or anaesthetist is, "Who owns the theatre?" He wants the best possible treatment, as speedily as possible, with excellent after care.

The success of the Government's health policies is shown in a document from Healthcare Financial Management Associates which was reported in today's press. It shows that between 1988–89 and 1992–93 there was an increase of 500,000–8.6 per cent.—in the number of patients treated. The interesting point is that that increase occurred at a time when the number of NHS beds had been reduced by 18.4 per cent. The statistics confirm that the number of people being treated can be increased despite a decrease in the number of beds. Indeed, the figures relate only to the period 1992–93. Since then, the Government's NHS reforms have further increased the number of patients being treated.

I listened with amazement to the hon. Member for Crewe and Nantwich (Mrs. Dunwoody), who spoke about a deterioration in health care. In fact, the statistics for the number of patients being treated, the length of time people wait for treatment and the nature of treatments under the NHS all show that the health service that she described is not one that the vast majority of patients would recognise. They have experienced the new treatments, the reduction in waiting times and the increase in the number of people being treated.

When I did a survey of my constituents, I included two questions. The first was, "Have you recently been treated by the NHS?" Everyone who responded yes to the first question was asked to move on to the second question, which was whether the treatment was good or very good or whether he had any other comment to make. Everyone who commented on the treatment received under the NHS said that it was excellent. Everyone was thoroughly satisfied with the service. It ill behoves Members to spend their time denigrating the quality of treatment given by dedicated NHS staff. The service is first rate, and the vast majority of those who go into hospital would confirm that.

I am amazed by the Labour party's attitude to general practitioner fundholding. Labour Members talk about a two-tier service and fail to recognise that fundholders are giving their patients a better service than they received four or five years ago. I would expect most Members to say, "I welcome this improvement for my constituents." That is not the Labour party's approach. Instead, Labour Members complain that their constituents are getting a better service through fundholders than before. That sums up the Labour party when it comes to the health service.

What has the Labour party to offer the health service? First, it would burden the health service with additional costs. It would introduce a national minimum wage. It is still at an unspecified level, but it would no doubt mean that the NHS would have to pay more in wages than at present. Given the Labour party's attitude to charges, there is no doubt that it would deprive the NHS of some revenue in future. Labour's future for the NHS is higher costs and less revenue through charges. We are told by the shadow Treasury team that there is no commitment to spend extra money. There is nothing in Labour's prescription for the NHS that will do anything to shorten waiting lists, to increase the availability of hospital beds or to provide an improved service for patients. It presents a dishonest prospectus when it criticises the Government. Labour does not have a penny more to spend, but at the same time it has additional costs to impose. It will, as I have said, deprive the NHS of revenue.

I congratulate my right hon. and hon. Friends on the consequences of the reforms that have led to an improvement in the quality of service within the NHS. There are, however, one or two issues that I wish briefly to raise.

My right hon. and hon. Friends will, I am sure, have read early-day motion 3, which has 238 signatures. Some years ago, the Government decided, rightly in my view, that they should give help to haemophiliacs infected with HIV. I believe that it is equally right to give assistance to those who have been infected with hepatitis C. Some 600 or 700 of those people will develop sclerosis of the liver. When they do, they know that they have limited life expectancy. I ask the Government to reconsider the problem. If they were to limit assistance to those individuals who developed sclerosis of the liver, they would have to compensate about 600 or 700. They would do that over a number of years. The cost to the Exchequer would probably be about £40 million, no more. The compensation would not be very expensive and morally it would be right.

I welcome the determination of my right hon. Friend the Secretary of State to listen to public opinion before determining what he will do about future hospital closure programmes. Sometimes we have gone for the technically very advanced when many local communities would have much preferred their local hospital to remain. I support many of the points made by my right hon. Friend the Member for Brent, North (Sir R. Boyson).

My hon. Friend the Member for Finchley (Mr. Booth) talked about preserved rights for the small group of relatively elderly people who were in homes before community care came into effect. Currently, we have seen threats to some of them: they would get assistance only if they were moved from one home to another. It seems quite wrong to threaten to move a lady or gentleman of 75, 80, 85 or 90 to another home before giving assistance under the community care policies. Those elderly people have all helped themselves until their funds ran out. I do not think that the Government should look at that problem in quite the way in which they have.

I am pleased to see that my right hon. Friend the Secretary of State for Social Security will be winding up the debate, because there are two issues about which I feel strongly in respect of the social security budget. The first is the level of housing benefit, which is a rapidly rising cost that distorts the housing market, forces up rents in the private sector and acts as a severe disincentive to those who receive it ever to get off benefit. The second problem is the size of the bill for single-parent families. It is currently just under £10 billion. Our noble Friend Lord Lawson once talked about the need for fiscal neutrality. I believe that there should be neutrality between families and one-parent families, but our benefit and tax systems do not do that at the moment, and there is a perverse incentive for single-parenthood rather than for married couples. I hope that my right hon. Friend may in a few days' time be able to give us some knowledge about some of the single-parent benefits. There is a strong case for saying that in the future single parents should be deprived of some of those benefits. There is an equally strong case for freezing them for existing recipients.

Strong social security and health measures depend on a strong economy. We must emphasise the way in which the Government have managed to transform whole rafts of British industry, as my hon. Friend the Member for Finchley said, by privatising sectors of the economy, which has led to vast increases in productivity, huge increases in investment and a much better quality of service for the customer. Industries such as BT, British Airways or British Steel have all been transformed since they came into the private sector and are no longer the subject of state subsidies and state intervention. Some of us can remember the quality of service that we had from BT in the early 1980s. In those days, most payphones— two thirds—did not work. Today, there are many more payphones and they actually work. Today, the cost of telephone calls is dramatically lower than it was at the beginning of the 1980s. Industry has become much more profitable and contributes much more to the Exchequer. By improving the basic infrastructure of industry, telecommunications, steel and so on, we have helped to encourage other companies to come into this country.

I am glad that the Gracious Speech gives encouragement to grant-maintained schools, because the first such school in London was Hendon school, in my constituency. The second was Queen Elizabeth's boys school in the constituency of my right hon. Friend the Member for South Norfolk (Mr. MacGregor). I remember taking him to Hendon school. After he had gone around it, he met some of the teachers. One of them came up to him and said, "Mr. MacGregor, I am a member of the Labour party." One wondered what would happen next. He then said, "But the best thing that happened to this school was that it became grant-maintained." When Hendon school was under local authority control, it was severely under-subscribed. Today, it is heavily oversubscribed. I am glad that it has become one of the first language academies in the country.

I shall refer briefly to the proposed asylum Bill. This country has had a very long history of providing a haven for victims of persecution, be they the Huguenot refugees or those who came to this country in the late 1930s under the "kinder" transport scheme from Germany and elsewhere. Many of my constituents came to Britain in 1938 and 1939 as refugees from Nazi persecution. Obviously, they are entirely sympathetic to genuine refugees; but, as all of us know from our constituency cases, the current arrangements are being abused.

I shall always remember a telephone call that I received on a Saturday in February this year. My children told me, "Father, it is Downing street on the line." They thought that something was going to happen. In fact, Downing street was on the line asking whether I would take a telephone call from a firm of solicitors. The firm of solicitors told me that a certain individual, who had been an illegal immigrant for some years, was due to be deported at 10 o'clock the following morning—but, I was told, a telephone call from me would save him.

When I made my telephone call, it did not have the effect that the solicitors had expected. The next morning I telephoned Heathrow again, and was told, "You may be interested to learn that he was due to fly out at 10 o'clock this morning, and that at 9.5 am—after a conversation with his solicitor—he applied for asylum." The clock started to tick all over again: that meant that that person would have a significantly longer period in the United Kingdom.

We must all have felt ashamed recently when it was divulged that some Algerians who had applied for political asylum were using the hospitality of the British people and the Department of Social Security, in the form of income support and housing benefit, to plan bombing raids in Paris. Hon. Members may have read in one of the leaders in last week's Mail on Sunday that that hateful organisation HUT, which seeks to foment hatred and racism on our university campuses, is another asylum seeker and is receiving income support and housing benefit from the British taxpayer. Only today, the press reports that President Mubarak of Egypt is complaining to the British Government that we are supporting opponents of his regime who are seeking asylum in this country and misusing our hospitality.

This is not a question of racism. Our immigration controls are being circumvented by individuals who come here as economic migrants. They frequently do not apply for asylum when they arrive. They may apply a month or two after their arrival; or—as in the examples that I have given—they may not apply until they are found out and told to go home.

It is, perhaps, significant that 95 per cent. of appeals launched by those who are refused asylum are turned down. My right hon. Friend the Secretary of State for Social Security is surely right to say that it is no longer proper for applicants to continue to receive income support and housing benefit while their appeals are being considered. Let us suppose that, by some mischance, my hon. Friend the Member for Chipping Barnet (Sir S. Chapman) applied for income support, and was turned down. While the appeal was being heard, he could not receive income support. Why do we put asylum seekers on a higher level than everyone else?

I believe that the Government's proposals are fair and right, and that they will be accepted by 99 per cent.—if not 99.9 per cent.—of people in this country.

1.23 pm

Mr. Nigel Spearing (Newham, South)

In the closing part of his speech, the hon. Member for Hendon, South (Mr. Marshall) mentioned circumstances that may or may not be widespread. I, too, have occasionally encountered such cases. In some instances, asylum has not been granted, and people have returned to a certain country that I will not name. The Foreign Office can give me no guarantee that they have not subsequently been killed.

I agree with the hon. Gentleman that this is an important matter. It is so important that I hope that he will join me and his hon. Friend the Member for South Staffordshire (Sir P. Cormack) in the atmosphere that was introduced by the Prime Minister in an intervention on my right hon. Friend the Member for Sedgefield (Mr. Blair) on Wednesday that this matter should go to a Special Standing Committee or through a special Committee procedure. Without that, this important matter cannot be dealt with in the way that it should.

The hon. Member for Hendon, South spoke about a person going to hospital and not caring less who owned it when he was placed on the operating table. Of course that would be true at the time, but even the constituents of Hendon, South would not be too content if, for example, Barnet hospital, which we have heard about in the debate, or Edgware hospital, if it is saved, were paying rent for a building or land to some private company that had to make a profit. I think that we can leave the matter there.

I had an exchange with the hon. Member for Southwark and Bermondsey (Mr. Hughes) about the increased involvement of the private sector in health care. The hon. Gentleman and I spoke about the Gracious Speech and the proposed legislation. The hon. Gentleman was a bit trusting because he and the Minister, who I am glad to see in his place, said that I was wrong. I hope that in replying for the Opposition, my hon. Friend the Member for Monklands, West (Mr. Clarke) will mention that some sections in the legislation make it quite clear that the Government have in mind that "particular groups of people" may be paid by a local authority to purchase health care in the community. If that is done, the grant can be lower because another part of the document states that account may be taken of financial circumstances.

If the person concerned has the means to supplement the amount, perhaps to a higher sum to be paid to a private provider, there will be every inducement for him to do that. There might be an inducement for some of his relatives or friends to help with that supplement, especially if the service is more immediate than that which could be provided by the local authority, whose expenditure is capped. There is every reason to suppose that there will be an inducement not only for the payment to be made by the local authority following local demand, but also for an increase in private providers, and that means an increase in private contractors in the health service providing that community care. Perhaps the Minister or the Secretary of State for Social Services, who has just entered the Chamber and is in consultation with his hon. Friend, will deny that possibility. I shall win either way because if the hon. Member for Southwark and Bermondsey and the Minister are right I shall be pleased. However, if I am right some people will get a nasty surprise.

I now turn to the wider issue of health service funding and how it is organised. I mentioned the basic principles in an intervention on the Secretary of State and later in an intervention on the hon. Member for Finchley (Mr. Booth). Appropriately enough, I made those interventions when we were debating contracts and competitive tendering. Quite clearly there is a problem about the amount to be spent on the NHS but we understand that, as a proportion of GNP, the figure is about half that of the United States of America. As the Secretary of State said in opening the debate, we spend the money very efficiently. So what is the problem? The problem of course is priorities. In The Guardian today, under the headline "Rationing in Third of NHS", an article makes accusations about what is coming up. The Secretary of State for Social Security may say that it is newspaper tittle-tattle, but he owes the House and public an explanation or a refutation, if he can make one, of that article. He will of course have been shown it by his officials and he may take the opportunity of refuting it, if he can.

Baroness Thatcher, the former right hon. Member for Finchley, in her famous White Paper, "Working for Patients", specifically introduced an element of commercial competition in the health service. At the time, I was most disturbed. I said that we were introducing care as a commodity. That is why I asked the Secretary of State for Health whether he believed that care was a negotiable and commercial commodity. If everyone, including the media, reads the record or if they were listening or watching, they will find that he did not answer the question. Once one introduces that element, one is in dire trouble.

At the time—I make no apologies for it—I issued a public challenge to any London Conservative Member to debate with me whether such a matter was against Christian principle. I was not saying that it was against Christian faith: that is another matter. Many people agree with Christian principles, even if they do not agree with Christian faith and they have every right to do so. The point is, however, how can one estimate the amount of care that a person will need? One cannot do it like an enterprising firm in my constituency called Clutch King. It has all the clutches of every motor car and it will give a person a contract. One can estimate that, but when an elderly person goes into hospital, perhaps for a relatively simple operation, how much extra care can one estimate? One cannot do so. We therefore have that provider-purchaser relationship.

To keep in business, to prevent itself from becoming bankrupt and to prevent imposing changes in employment conditions on its staff, who are full of good will—I disregard the argument about whether it would be legal to change those conditions, although I understand that, under subcontracting, it will be—a hospital will be at financial risk. Is it Guy's hospital that has gone bankrupt?

What sort of a health service is it if health service workers know that their enterprise—at ward level, in the dispensary or in relation to a specialist service—is likely to be wiped out because of such competition? We suspect that that has happened in respect of the blood transfusion service. The Brentwood service, which serves hospitals in north-east London and Essex, will be wiped out. Did that happen for any reason other than the introduction of those inappropriate principles in the health service? That has not yet been sufficiently understood in the country or in the Government.

A third of the beds in the East London and City health authority are to be dispersed, abandoned and reduced— 24 of them in a proposed transfer from St. Andrew's hospital in Bow to extensions at Newham General hospital. How can that be given the bed shortages that my hon. Friend the Member for Peckham (Ms Harman) mentioned? We know that the problem applies across London. How can that be? It seems mad. In addition, notifiable diseases and people's ages and demands are going up.

I know that all sorts of technique exists. We are told that technique projections speed treatment up, that people are going in and out of hospital quicker because of, for example, key-hole surgery, which is right, but let us always keep a surplus of beds and ensure that they are not required. That would be the right way to proceed, but commercial forces come into play and force the closure of beds.

The borough of Newham, which is the size of Derby, Nottingham or Leicester, has no secure accommodation. It is difficult to get people to certify when things go wrong. The pressures on people in east London are tremendous, so people go berserk and all sorts of things happen. My hon. Friend the Member for Woolwich (Mr. Austin-Walker) mentioned people who are a danger to others and themselves. A terrible murder was committed in Stratford.

I gave notice to the Secretary of State for Health, who is no longer here, that I would mention the law relating to the release from psychiatric hospitals of people who had been transferred from prison. My researches show that the law is defective in that matter. People leave psychiatric hospital when they have served their sentence and I can find no proper procedure whereby a definitive decision is taken about signing them out. I hope that the Minister can point to the relevant chapter and verse in the law, because I cannot find it. I cannot accept the findings of the Woodley panel in relation to that double murder, when one of my constituents murdered another because a person who should not have been in the community had been discharged.

St. Bartholomew's hospital, which is one of the greatest hospitals in the world, has been dispersed. How does that conserve our Christian tradition of a medical service, particularly as it serves people in a large built-up area? What will happen to a taxi driver who lives in Newham if he has a heart attack in that area in the future? Those pursuing that policy must answer that question.

I shall close my speech by injecting into the debate on the Queen's Speech a theme that has not been developed in the House before, but which no Conservative Member could refute. The national health service is a prime public service. Public service in this country and this House has been one of the great themes of this century. Indeed, it is one of the great things about Britain and our community. In the past 10 years, however, a difference of opinion has emerged on the Government Benches. Some, such as the former Member for Wolverhampton, South-West, Mr. Enoch Powell, or the hon. Member for Ludlow (Mr. Gill), believe that public service is important on a narrow range of matters, while the one-nation Tories believe that it is important on a wide range of matters. But others do not believe in a public service at all. They get around that by saying that it is an intrusion by the state. They beat it back at every point and inject private enterprise and capital as far as they can. They have done it with gas and water, are doing it with the railway and are now trying to do it with the health service to an even greater extent.

The hon. Member for Hendon, South says that it does not matter who owns the hospitals as long as the service is all right. That is one example where privatisation has gone too far. It is undermining the traditional British concept of public service, which the Government, not only in this Queen's Speech but in Queen's Speeches over the past five or 10 years, have undermined. The public now sense that. I hope that, in this debate, I have shown how that has worked insidiously. It may be a clue to the basic differences that now exist on both sides of the House and the reason why the Government should go as soon as possible.

1.39 pm

Mr. Michael Stephen (Shoreham)

Anyone reading the newspapers these days, or listening to Labour or Liberal spokesmen, would think that the Conservative party has destroyed the national health service. The reality is the exact opposite. The national health service has been one of the greatest successes of this Conservative Government and its predecessors over the past 16 years.

Today, we treat more patients than ever before, to a higher standard than ever before, and waiting times are now lower than ever before. If we compare that record with the position 16 years ago, what did we see then? Nurses' pay was allowed, by the Labour Government, to fall below the rate of inflation. The hospital building programme was abandoned. Cancer patients were unable to enter hospitals because of picket lines by trade unionists outside. So well did the Labour Government look after pensioners that they could not even find the money to pay their Christmas bonus for two years running.

The number of beds is often used by those who do not really understand the health service as an index of success or failure. Paradoxically, the better the health service gets, the fewer the beds we need, for a variety of reasons, and I shall mention one or two. The pharmaceutical companies round the world have developed wonderful new drugs, and that means that conditions that would, in the past, have led to hospital in-patient treatment no longer require any hospital treatment at all. Technical developments have meant that surgeons are able to deal with people as day cases when, in the old days, they would have been admitted for a week or more to hospital. The introduction of GP fundholding has meant that more surgical and medical procedures are carried out in GPs' surgeries close to where patients live, so that they do not have to go into hospital.

The Opposition suggest that there should be empty beds, just in case. Of course, any sensible hospital manager would try to plan so that he has enough beds for normal demand, but there will always be peak demand. If there are enough empty beds to meet peak demand that occurs once in a blue moon, the money tied up keeping those beds empty is wasted, and could otherwise be spent on patient care. That is a matter of judgment for hospital administrators and it is more an art than a science.

Hospital administrators are much derided by the Opposition. I happen to think that the administration of a multi-million pound service should be done by administrators. In the old days, administration was done by doctors and nurses, some of whom were good at administration and some of whom were not. What the Government have done is to decide that administrators should be employed to administer.

In the old days, some extraordinary things happened because of lack of good administration. A friend of mine, who is a surgeon, told me that he operated for only a small proportion of the time that he could, because the administration did not put the people on the operating table. Again, a constituent came to my surgery to say that his mother had died in hospital two years before, yet incontinence pads were still arriving. The family had told the hospital that the old lady was dead, but that made no difference. The family were using the incontinence pads for loft insulation. That was the kind of waste that happened when hospitals were not properly administered.

The number of administrators, about which the Labour party talks so often, is frankly irrelevant. What matters is the number of patients that we are treating; the standards to which we are treating them; and the time that they have to wait. It does not matter how many administrators there are—the bottom line is patient care.

I do not have the honour to represent a London constituency, but I am aware of the standards of excellence that exist in some London hospitals. I am sure that my right hon. Friend the Secretary of State for Health is determined to see that those centres of excellence are not broken up. The people concerned may move to different buildings—that does not matter all that much. What matters is that the medical teams and centres of excellence remain able to do their jobs.

I am glad that resources have been shifted out of the capital down to my county of West Sussex. We have been receiving many millions of pounds in extra funding for the past three years, and we shall soon be up to the capitation target that we should have reached a long time ago.

I congratulate the Secretary of State and his predecessor on the £41 million that has been made available for building an almost completely new hospital in Worthing to serve my constituents. I also congratulate the West Sussex district health authority and the FHSA for the tremendous work that has been done for my constituents over the past year. They have brought down waiting times dramatically and improved the quality of care enormously.

Every constituent to whom I have talked, who has had experience of the NHS, has nothing but praise for the service. The only people who criticise it are people who read the misleading articles in the newspapers and listen to Liberal and Labour Members.

Hurstwood Park in Sussex is a centre of excellence in neurology. Experts say that it is no longer suitable for that highly technical branch of medicine, and perhaps some changes will be necessary. However, I hope that my right hon. Friend will bear in mind the wish of all the people of West Sussex that there should remain easily accessible to us not only neurology services but neurosurgery too.

We must always ensure that anyone who wishes to have an NHS dentist can have one. I am a little concerned about the activities of some of the private health insurance people, who are telling dentists that if they persuade their patients to take out private policies the dentists will get more money. I ask my right hon. Friend to keep an eye on the activities of such companies, and to ensure that if no NHS dentist is available in a locality, the FHSA employs one so that all our constituents can get NHS dental treatment.

As for mental illness, of course there should be places to accommodate all those persons who are so mentally ill that they could be a danger to their fellow citizens. I know that the Government take that responsibility seriously. However, one of the problems is that we cannot lock somebody up unless a psychiatrist will certify that that is necessary for the protection of that person or the public. All too often problems arise because psychiatrists are not willing so to certify.

GP fundholders have made a tremendous difference to the delivery of NHS care to our constituents, because they have turned the health service into a primary care led system—a system led by those who are closest to the patients, have the most direct contact with them and understand their needs and requirements best.

The flexibility accorded to GP fundholders also means that they have been able to provide services such as physiotherapy and chiropody for patients in their surgeries, rather than patients having to wait and go to a hospital.

I have the honour to represent a constituency containing many people over retirement age. It is absolutely essential that, whatever a person's age, free NHS care both in hospital and through the GP should be available. I know that the Government are committed to providing those services.

However, although the needs of some people who are very old but who do not need in-patient treatment in hospital could be met by residential care outside hospital, many cannot afford to pay for such care. It is important that the Government do everything that they can to give the best possible help so that people can provide throughout their lives for meeting the costs of residential care in their old age.

It is not, and never should be, necessary for someone to sell the family home to pay for his residential care if his spouse still needs to live in it. If a house is sold voluntarily it should never be, and is not, necessary for the remaining spouse to find himself or herself with nowhere to live. Only the surplus after the remaining spouse has been properly accommodated should be used to pay for the care of the person who has had to go into residential care.

I have been in the House for three and a half years and I have listened to Labour and Liberal Democrat Members in debates on a wide range of subjects. I have been disappointed with what I have heard. I thought there might be some truth in the suggestion that Labour had changed, but that is not so. I believe that the leader of the Labour party might have changed—or wishes the public to think that he has changed—but I have no doubt that most of his right hon. and hon. Friends, on whose votes he will rely if ever he is to form and sustain a Government, do not agree with him. They are honest men and women; they are socialists through and through, and believe the Labour party to be a socialist party. They want nothing of the quasi-Conservative policies that the leader of the Labour party is peddling in order to get elected at the next general election.

I listened to the speech of the Leader of the Opposition on Wednesday. During the half hour or so that he spoke I waited to hear a single constructive proposal as to how he and a future Labour Government, were we ever unfortunate enough to have one, would deal with the problems that the Labour party is so ready to identify and of which we are all, in any event, aware. But I listened in vain. Apart from a few vague phrases which were so general as to be meaningless, his speech contained no constructive proposals.

The British people cannot have confidence that the Labour party has any idea of how to deal with the problems of tomorrow any more than it knew how to deal with the problems of more than 16 years ago which resulted in the terrible mess that the country was in when we took office in 1979. I hope that when the British people come to make their decision, they will realise the true character of the Labour party, will not support the Labour party and will give the Conservative Government another opportunity to build on the tremendous success that they have achieved over the past 16 years.

1.51 pm

Mr. Tom Clarke (Monklands, West)

This has been an interesting debate; it would have been all the more interesting and informative if right hon. and hon. Members had adhered to our informal agreement. We might then have heard from my hon. Friend the Member for Glasgow, Rutherglen (Mr. McAvoy), who is now unlikely to catch your eye, Madam Deputy Speaker.

In a speech that lasted for one minute less than one hour, the Secretary of State for Health did not seem to give us a statement on the health service, his responsibilities and the Queen's Speech, but a screen test for a future role as Leader of the Opposition. I am sorry to have to say this to him, but I have some experience of the film industry and I do not think that he did very well. But he need not worry too much about that as I do not think that he has much competition.

The Secretary of State spoke about my right hon. Friend the Leader of the Opposition producing a mouse of a speech, which was particularly odd when considered in the light of the central issue of direct payments, which is, I understand, the flagship of the Government's care in the community policy. What we heard from the Secretary of State was a mere squeak—it was quite inadequate.

Care in the community is an extremely important issue. If we wish to separate rhetoric from reality we need look no further than the speeches of my hon. Friends the Members for Crewe and Nantwich (Mrs. Dunwoody), for Woolwich (Mr. Austin-Walker) and for Newham, South (Mr. Spearing). We heard nothing from the Government to confirm the crisis that exists in care in the community; Conservative Members sit back almost as though pretending that the crisis does not exist. It is not as though the Government were not warned: they were warned years ago by the National Audit Office. That warning led to the Griffiths report and, ultimately, to the National Health Service and Community Care Act 1990. Sir Roy Griffiths said then, and his view is just as applicable now, that given the chaos in community care, the one alternative not open to a responsive Government was to do nothing, which seems to be precisely what the Government have done.

The Secretary of State for Social Security need not listen to me. I occasionally see him and his right hon. and hon. Friends in sociable settings when we meet distinguished organisations and voluntary bodies. Those people know what is going on in the field and I refer the Secretary of State to some of their views about community care.

Scope recently produced a document entitled "Disabled in Britain: Counting on Community Care", in which it discussed the idea of charging for services. It said that local authorities have always been able to charge for domiciliary services but that, until recently, few did so. However, under community care, central Government allocates money to local authorities on the assumption that 9 per cent. of the revenue for the services will be raised through charges to service users. If the shortfall is not met through charges, the guidance advises local authorities to forgo that service provision. According to Scope, consequently many social services departments have either been forced to start charging for services they previously provided free or have increased existing charges.

A survey tells us that 17 per cent. of disabled respondents say that they have had to refuse a service because they could not afford to pay for it and that 18 per cent. have had to start paying for a service that they had previously received free of charge. If that is not lurching to the right, I do not know what is.

We can also refer to the views of distinguished bodies such as the Royal College of Psychiatrists. Its report revealed that, since the introduction of care in the community, there have been 34 killings by seriously mentally ill patients in contact with psychiatric services. The Zito trust—which was founded in the name of Jonathan Zito, the musician who was murdered on the London Underground—puts the figure at one killing a month. In other words, a murder is likely to be committed every month by a known patient who has been referred to doctors previously on the grounds of mental illness. We are invited to ignore that reality of community care in Britain.

Mr. Stephen

Will the hon. Gentleman give way?

Mr. Clarke

Yes, but the hon. Gentleman should bear in mind the fact that his speech cut into the Minister's time and he is about to do that again.

Mr. Lilley

That is my problem, not the hon. Gentleman's.

Mr. Stephen

How many of the patients to which the hon. Gentleman has referred were certified by psychiatrists as needing to be locked up for the protection of the public?

Mr. Clarke

I would be delighted to debate the matter if time allowed. I look forward to such a debate. As the Minister observed that the time considerations are his problem and not mine, he should not be too surprised if he finds that he can speak for only a few minutes.

The severely mentally ill are far more likely to do harm to themselves than to others. If that fact is not crucial to community care, what is? The National Schizophrenia Fellowship published a report last month highlighting the number of suicides among people suffering from schizophrenia. The report suggested that one in 10 schizophrenics commits suicide, and it admits that its methodology has probably underestimated the figure. There are about 250,000 schizophrenics in the United Kingdom.

They are not the views of a Labour party that is behaving irresponsibly—although we take them on board—they are the views of responsible organisations and responsible people. Bharat Mehta, the chief executive of the NSF, said: Independent studies show that suicide rates are highest in the first month after discharge from hospital. Currently, people are being discharged too soon before adequate preparations for living in the community can be made". In its 1992 paper "Health of the Nation", the Department of Health said that the Government had set a target of a 33 per cent. reduction in the suicide rate among people with severe mental illness. Two years later, in its follow-up paper entitled "Fit for the Future", the Department of Health admitted that it had been unable to report any findings because no definition of "severe mental illness" had been agreed.

There has also been an increase in violence, particularly towards social workers and GPs. Sadly, a doctor was murdered this year in Airdrie, the town next to my constituency. They are not isolated incidents. The Government do not seem to realise what is happening. They publish polished documents and spend money on advertising which is a world apart from the reality that I am now seeking to address. What is their view on the fact that 85 per cent. of people with learning difficulties live in the community and are provided with very little care?

On disability, a few weeks ago we debated a quarter of a century of the important Act that my right hon. Friend the Member for Manchester, Wythenshawe (Mr. Morris)—the Chronically Sick and Disabled Persons Act 1970—took through the House. That Act and the Disabled Persons (Services, Consultation and Representation) Act 1986 that I piloted through the House are not fully implemented. May I say to the hon. Member for Shoreham (Mr. Stephen) that if the section of the 1986 Act had been fully implemented and assessments made before people left psychiatric hospitals, the problem that he identified would not have occurred.

Mr. Lilley

What does the hon. Gentleman propose should be done to tackle the problem of violence that he identifies and I believe greatly exaggerates? As, on Second Reading, the Labour party opposed the measures that we introduced to provide supervised treatment of patients in the community, what does he now propose in addition to them?

Mr. Clarke

I am not surprised that the Secretary of State completely distorted what I said. He did not appear to realise that I was quoting the views of professional bodies, organisations and individuals working in community care. I did not submit those views, although I now endorse them. It would be an insensitive Secretary of State who rejected those views with such speed.

The right hon. Gentleman asked what we proposed to do. We shall not have to wait very long to be in government, but I shall tell him what he ought to do as we are debating his Government's Queen's Speech. He should tell us when the so-called Disability Discrimination Act 1995 will be implemented. He should tell us when the Government will implement the two earlier Acts to which I referred. Particularly in view of the problem of carers, which does not influence the Secretary of State one iota, he should tell us something about yesterday's excellent publication—he might challenge it until I tell him that the Department of Health made a considerable contribution to its production and I congratulate Mr. Roger Tyrell on that—"Stronger Links", which dealt with the need for caring for children who are disabled. I challenge the Secretary of State to tell us what he proposes to do about that document as the facts are known to his Department.

What about problems of children with disability? The health service management unit report published in March stated that up to 40,000 young carers in the United Kingdom are aged between 11 and 18. More than half of them live with a lone parent and almost half that number have mental problems. The Secretary of State should address those issues if he proposes to deal with the problem at all.

If the Government's care in the community policy is as successful as we are told, before we finish debating the Queen's Speech next week can the Secretary of State or the Home Secretary explain why there is still an enormous problem of mentally ill patients in prison? Last year we were told that the figure was 19.2 per cent. The Minister has not updated the figures today. I challenge him to do so and to produce the report that Professor John Gunn has already delivered to his Department which shows that one third of remand prisoners have a medically diagnosed mental disorder. I challenge him too to tell me whether in his speech or any other speech to the Conservative party conference, when Ministers crowed about law and order, they explained the real problems in Britain's prisons and the additional problems being created by their policy of care in the community.

Mr. John Marshall

rose—

Mr. Clarke

I am not giving way because I want to be fair to the Secretary of State and give him time to respond to the debate.

I challenge the Government to do what the Opposition will do when we are in Government, which is to produce a plain person's guide to the various Acts relevant to disability and care in the community. That should not be too difficult; after all, shortly after the Secretary of State left his previous post at the Treasury last year, and after the disgraceful scenes in this House when the disability Bills were being debated, the Government found £1 million for their propaganda to persuade people that they were sympathetic to disability and care in the community issues. Of that £1 million, only a miserable £2,000 was spent on making their propaganda available to people with hearing impairments or unable to read, for whatever reason.

The money is there and I again challenge the Government to produce a plain person's guide. If they did it as well as the document dealing with young carers was done, it would be a welcome but considerable departure from the Department's approach to these important matters.

I also invite the Secretary of State to spend a little more time going around the country talking to organisations of and for disabled people and of and for carers. Above all, he should talk to those individuals and families for whom the Government's care in the community policy has been a disastrous failure. Within those groups he should talk to the young disabled people who leave school at 19. It is a traumatic time for them, their parents and their communities. Sadly, there is no Government strategy to deal with all those serious problems.

If there was a strategy for joint planning, such as that included in my 1986 Act, the people of England, Scotland and Wales would be far better served. The health authorities would be working with social services and social work departments and with patients and their advocates. Once again, people leaving hospitals on the basis of assessments would know that their future was secure and that they would not be sleeping on the streets.

The Minister dealing with disability matters a few months ago is now the Secretary of State for Wales. When I went to Wales I was appalled to be told that best practice is being discontinued to the point where one group of people with learning difficulties were told that they would be placed in homes in the community, but were then profoundly disappointed when they were simply put on a bus and sent elsewhere.

I want to conclude with the important issue of direct payments. We welcome the principle, but it must not go the way of community care. For the Government to raise the expectations of disabled people and then to disappoint them by failing to deliver was bad enough the first time— to do so again would be inexcusable. If, as the chairman of the Conservative party has said, it is necessary to separate rhetoric from reality, that could not be more true than for this issue.

So far, the Government have said little about what the words in the Bill actually mean. It was published only at 7 o'clock this morning, when my hon. Friend the Member for Peckham (Ms Harman) was already in the BBC studios. There are a number of areas of specific concern on which the Government have not yet told us their thinking.

First, the then Secretary of State for Health said last year that direct payments would be limited to those able and willing to manage their care. What does that mean? Why is that not made clear in the Bill? The Government have become fond of putting as little as possible in a Bill, keeping back most of the important details and producing them from behind closed doors as regulations. Is the Bill another example of that? It is not a trivial matter. If the Government intend to make a distinction between those disabled people who are willing and able to manage their care and those who are not, we need to know how that distinction is to be drawn. I hope that we are not about to consider a measure that will introduce a new form of discrimination between one group of disabled people and another. It would seem that provision will be made for disabled people only if they can show a lesser degree of disability.

I have in mind the large group of people with learning disabilities. Those who attended the Mencap conference at Blackpool last week would as well. In drafting the Bill and defining who will be eligible to receive direct payments, let us have an assurance from the Government that the concept of able and willing will not be so defined as to exclude all those with learning disabilities. If Ministers intend to draft regulations in a way that discriminates against those people, let me remind them that many of the beneficiaries of independent living funds that are made available from central Government resources are people with learning disabilities.

Secondly, what of access to direct payments for frail elderly people? There is concern among those consulted by Ministers that it is intended to make direct payments available only to those aged under 65. In February, a Law Commission report on mental incapacity strongly recommended that there should be a presumption against lack of capacity. In other words, it recommended that people should be presumed capable unless shown otherwise on the available evidence. That approach should apply across the board. If direct payments are to liberate those with disabilities, there should be no blanket presumption of incapacity discrimination based on type of disability or on age. It should be open to all those people who believe that they are able or willing to manage their own care to seek direct payments to allow them to do so. There should be no presumption against them in advance of their applications being made.

Thirdly, let us consider the discretionary nature of what is being proposed. I hope that Ministers will reflect on the anomaly that will arise if direct payments are available to a disabled person in one area but not in another. We need to know that direct payments will be provided fairly and with adequate support. It is equally important that disabled people are not denied the right to choose not to receive direct payments and instead to continue to use services provided by local authorities if they wish to do so. Direct payments must not be allowed to justify the withdrawal of services now provided for disabled people. Many disabled people would be appalled if it transpired that all the fine words about choice and control were only rhetoric to disguise the usual Tory agenda of privatisation, cuts and closures.

Disabled people have heard fine words from the Government before. They have no more reason than anyone else to trust the Tories. We have heard much this week about smoking out the Opposition. A Government intent on waging trench warfare instead of governing are not a pretty sight, as we have seen today. It is not surprising that their promises of good intentions are not trusted. We intend to smoke out the Government. We know better than to judge the Government on what they promise on direct payments, as on other commitments. We shall judge them on what they deliver, and the people of Britain will have the final say.

2.14 pm

The Secretary of State for Social Security (Mr. Peter Lilley)

The debate was opened with a powerful speech by my right hon. Friend the Secretary of State for Health, who effectively demolished the Opposition spokesman and made a well-reasoned case for what the Government are doing and intend to go on doing for the rest of this Parliament and into the next.

We heard interesting contributions from a number of my hon. Friends and from a number of Opposition Members. My right hon. Friend the Member for Brent, North (Sir R. Boyson) made a number of interesting and important points, not least about the value of assisted places, which, he said, involve taking pupils from poor homes to send them to the best schools, as a result of which 90 per cent. go on to university. That, believe it or not, is opposed by the Opposition.

Unfortunately, I missed my hon. Friend the Member for Chipping Barnet (Sir S. Chapman) making his return visit after his period in captivity, which usually takes place at this time of the year. We are delighted to have his contributions.

My hon. Friend the Member for Finchley (Mr. Booth) asked me to pay particular attention to the importance of autism and the treatment of it. I entirely endorse what he had to say. He will be glad to know that there are now double the number of speech and language therapists working than there were 10 years ago. The amount spent on the problem has trebled since 1979.

My hon. Friend the Member for Hendon, South (Mr. Marshall) endorsed the reforms that we are making in housing benefit. He was right to emphasise the impact that the present system has on driving up rents, and the importance of making the changes that we are making.

My hon. Friend the Member for Shoreham (Mr. Stephen) pointed out the nonsense and absurdity of the Opposition's policy in suggesting that one can manage a health service without any management.

I enjoyed, as always, the contribution from the hon. Member for Newham, South (Mr. Spearing), for whom I have a high regard—indeed, I share his principles—but I believe that his approach and that of my Government can equally be reconciled with the Christian principles that he mentioned. The test is: which does better in providing good care and service for the patient? We believe that the evidence is overwhelming that our reforms achieve better results than they would were we to stick with an unreformed national health service that is run in the interests of the unions, which seemed to be what he wished.

Mr. Spearing

I am grateful for the Secretary of State's remarks—we could continue this exchange elsewhere— but does he seriously think that health service personnel run the health service for themselves?

Mr. Lilley

We are determined that it should be run for the patients. If I misinterpreted the implications of his remarks as involving a greater role, obviously I withdraw the point that I made.

The best speech from the Opposition, including those from hon. Members on the Opposition Front Bench, was made by the hon. Member for Woolwich (Mr. Austin-Walker). Although I do not agree with him, what he said was thoughtful, reasoned and contained facts that ornament the Opposition's speeches. He also did the honourable thing and obeyed the new rules; he declared his interest and told us how much he receives. I do not need to know that, because I know that all Members of the House are honourable, but if we have new rules, they should be adhered to.

The hon. Gentleman's remarks were in marked contrast to those of his hon. Friend the Member for Peckham (Ms Harman) on the Opposition Front Bench, who has kindly returned, having not listened to the debate in which she made an opening speech. She gave one of her better speeches—judging purely by her previous speeches— although she was unable to reconstruct the edifice that my right hon. Friend had systematically demolished. She put the traditional Labour view, which, of course, coincides with the traditional trade union view, but she was marred by her refusal to abide by the new Nolan code rules that were agreed by the House. Those rules are explicit. Anyone taking part in a debate must declare any interest. It is no longer good enough just to have it in the Register of Members' Interests. Worse still, she refused, even when challenged, to say how much Unison pays to sponsor Labour's Front-Bench health team. I will give way to her now if she cares to make good that defect and obeys the rules of the House. The Opposition turned what should have been an issue designed to improve the standing of the House into a partisan attack on the Conservative party. Now that the rules are in place, they refuse to adhere to them. That is monstrous. Has the hon. Lady the endorsement of her party's leader? No Conservative Member would have the endorsement of the leader of our party if he or she did not adhere to the new rules.

Mr. Tom Clarke

I do not understand why the Secretary of State is agonising so much. Given the clear decision made by the House last week, we shall of course consult the Commissioner for Parliamentary Standards; we shall apply the guidelines, take advice and implement the Commissioner's recommendations fully and openly. Will the Secretary of State do the same—and will he tell us who is contributing to the Conservative party, including those with an interest in today's debate?

Mr. Lilley

Of course I shall do the same. I have no interest to declare, and I shall not try to hide under the temporary opt-out that the Labour party has given itself.

This is the first opportunity that I have had to speak opposite the hon. Member for Monklands, West (Mr. Clarke), and I am delighted to do so. I know that he has a long-standing and distinguished interest in disability issues. He is strongly opposed to discrimination against disabled people—

Mr. John Marshall

My right hon. Friend says that the hon. Member for Monklands, West (Mr. Clarke) is strongly opposed to discrimination. Has he not heard of Monklands?

Mr. Tom Clarke

On a point of order, Madam Deputy Speaker. An inquiry is being held in Monklands at this moment, and the Secretary of State for Scotland appointed the reporter. It is outrageous that an hon. Member should intervene at this point, and I ask for your protection on behalf of the decent citizens of Monklands.

Madam Deputy Speaker (Dame Janet Fookes)

I am not sure that the hon. Gentleman needs my protection.

Mr. Tom Clarke

The point is, Madam Deputy Speaker, that the hon. Member for Hendon, South (Mr. Marshall), not for the first time—along with other Conservative Members—has criticised people in Monklands who have not the right of reply. That is disgraceful, and the hon. Gentleman ought to withdraw what he said.

Madam Deputy Speaker

Order. I think that the point has been made. We must now return to the subject of the debate.

Mr. Lilley

I never left it, Madam Deputy Speaker.

I am glad that the hon. Member for Monklands, West is criticising his hon. Friend the Member for Livingston (Mr. Cook), who makes outrageous accusations relating to Conservative Members in connection with issues involved in the Scott inquiry, although that inquiry is under way. Does the hon. Gentleman believe that the rules applying to the inquiry in Monklands should also apply to the Scott inquiry?

Madam Deputy Speaker

Order. I have given a warning about returning to the subject of the debate; it applies equally to both sides of the House.

Mr. Lilley

I return to the subject of discrimination, of which the hon. Member for Monklands, West is a connoisseur.

Mr. Tom Clarke

You would know.

Mr. Lilley

I return to the subject of disability, in which regard I pay tribute to the hon. Gentleman's interests.

The fact is that the Government have enormously enhanced provision for the disabled. In one respect, disabled people were not properly catered for by the Beveridge arrangements that were introduced at the end of the war. We now spend five times as much as the last Labour Government did; we help six times as many disabled people with the cost of care, and we help eight times as many people with their mobility needs. With the independent living fund, we help severely disabled people to live at home. We have also delivered the Disability Discrimination Act. Whatever objections Opposition Members may have to the Act, they must recognise that it constitutes the biggest legislative advance for disabled people since the war.

We are now adding to that with new legislation that will allow some disabled people more choice and control over their lives—the Community Care (Direct Payments) Bill. The Bill has been widely welcomed among the lobbies representing disabled people, but it has been comprehensively attacked by Opposition Members today. Although the hon. Member for Monklands, West told us that he supported the principle, he seemed rather worried about whether the legislation would undermine the provision of services by local authorities. What it will do is give greater choice and opportunity to disabled people where local authorities use the powers that we give them. Of course we shall make sure that in defining those who are able and willing we genuinely meet the real meaning of those words and do not use them artificially to restrict those who should not be restricted.

It was suggested that anomalies may arise as a result of giving local authorities discretion. Of course it is inevitable that when discretion is allowed arrangements will not be the same throughout the country, but we are in the business of increasing local government discretion while Labour now seems to be opposed to it.

Fundamental to our debates and especially to my concerns as Secretary of State for Social Security is the battle against unemployment and the Government's strategy to continue to reduce it. That is central to our approach. We should all be able to agree on three matters. First, we should agree that unemployment, especially among the young, is a scourge that we should do all in our power to reduce. Secondly, we all want to see more people in work and fewer out of work whatever their age. Thirdly, we should all welcome the latest figures which show, using the common International Labour Organisation definition of unemployment, that in Britain a higher proportion of people are in work than in any comparable country in the European Community.

In Britain the number of those in work is substantially above the average. In the average EU country only 60 per cent. of people have jobs but 68 per cent. of people of working age in this country have jobs. For the first time, the number of people out of work in Britain is lower than in any major country in western Europe, including Germany. Our policies are working in tackling the greatest scourge facing modern industrial countries. We should be proud of that and ensure that the success is reinforced.

The contrast with other countries is even greater in the battle against unemployment among the young. It is far too high everywhere. In the United Kingdom more than 13 per cent. of our young people are without jobs but in France the figure is 27 per cent. and in Spain it is 41 per cent. I mention those two countries because they are the only two with a statutory minimum wage, and they apply the full provisions of the social chapter. I have a question for Opposition Front-Bench spokesmen. If the cause of higher unemployment in France and Spain is not the national minimum wage or the social chapter provisions, what is it?

Ms Harman

One of the big burdens on business and an enormous tax on jobs that will inhibit job growth is if more and more people have to take out private health insurance and expect their employers to pay. In America people cannot rely on public health care and have to have private health insurance. That is the biggest burden on employers there and it is the same in all other countries that do not have a national health service. Employers have to pay the social costs for their employees. The Secretary of State invited me to intervene and I have enlightened him.

Mr. Lilley

I asked the hon. Lady to say whether she has an answer to the simple question: why do the Opposition think that these measures would reduce unemployment in this country when they have increased it in the only countries where they have been applied? What other explanation do the Opposition have for that high unemployment? The hon. Lady has none.

Early this week in a speech to the CBI the Leader of the Opposition tried to set business men's minds at rest about the social chapter. He said that it was not a matter of concern for business men and he continued: The social chapter is not detailed legislation. It is a set of principles. Each piece of legislation will be judged on its merits. (I have no intention whatever of agreeing to anything and everything that emerges from the European Union). That is simply false. The social chapter of the Maastricht treaty is not just a list of principles: it is a transfer of the power to make decisions from this country to the European Community institutions. It means that, once we have transferred such power, decisions made by a sufficient majority of Ministers voting in Brussels would become the law of the land, even if the right hon. Member for Sedgefield (Mr. Blair), the whole Government and every hon. Member voted against them. That is a fact. It cannot be denied. It was tacitly admitted by the hon. Member for Glasgow, Garscadden (Mr. Dewar) in debate with me on the "Today" programme. We demand that the Leader of the Opposition comes back to the House, sets the record straight and ceases to try and mislead this country's business men, who, reading the article by Stanley Kalms in The Times, are not misled by what the right hon. Gentleman has said.

Today, in addition we should be discussing welfare state reform because that is one of the key issues—

It being half-past Two o'clock, the debate stood adjourned.

Debate to be resumed on Monday 20 November.