§ Ms Harriet Harman (Peckham)
I beg to move,That this House notes with concern the growing demoralisation of those who work in the National Health Service; recognises that those who work in the NHS are dismayed that they cannot provide the quality of care that they and their patients want and that they feel that, without consultation, changes in the NHS detrimental to patient care are forced upon them; notes that NHS staff are concerned that they are spending more time on paperwork and less time with patients; notes that the number of managers is growing while the number of beds and nurses is cut; deplores the unfairness that saw the pay of chief executives rise by more than twice that of nurses; notes that there are now staff shortages both in hospitals and in the community and there is an increasing reliance on unpaid overtime, locums and agency staff; and calls on the Government to recognise demoralisation in the NHS, affirm that the NHS staff are its most precious resource, affirm that there should be fair pay and proper attention to staff security, end the growing use of short-term contracts, ensure that all NHS staff should be able to speak out about their professional concerns, and that at all levels of the NHS the views of staff should be heard and acted upon.I make the usual declaration: all declarable interests appear in the Register of Members' Interests, as required.
Today's debate is about one of the most important problems facing the national health service today. It is about the demoralisation of doctors, nurses and the rest of the health-care team, the large number of vacancies caused by NHS staff voting with their feet and leaving the service and the damage to patient care. It provides a chance for the Secretary of State to admit that there is a crisis in NHS morale, and to set out the action that he plans to take to tackle it.
The NHS team—from porters to professors of medicine, from catering assistants to consultant cardiologists—are the most important resource of the NHS, our most precious public service. Yet this Tory Government have systematically trampled on them, and on the service in which they serve. Doctors and nurses see their work as a vocation, not just a job.
When NHS staff look at the Secretary of State, they do not see a man who recognises or reflects their concerns. He is going in the opposite direction from NHS staff. They want beds to stay open; the Secretary of State closes them. They want more nurses at the patient's bedside; the Secretary of State wants more managers. They want to spend more time caring for patients; the Secretary of State makes them spend more time on paperwork. They want a public sector NHS; the Secretary of State wants commercialisation and privatisation. Doctors and nurses work longer and longer hours to cover vacant posts, as advertisements for staff remain unanswered month after month.
§ Mr. Jacques Arnold (Gravesham)
I am fascinated. The hon. Lady is telling us, with great authority, what various people in the national health service think. Only a short while ago, she was busy telling us that doctors did 812 not want fundholding practices to be introduced. Can she explain why more than half the GPs in the country are now fundholders, and making a success of it?
§ Ms Harman
I think that the hon. Gentleman is in the wrong debate. I explained at great length why GPs joining fundholding represented not a vote of confidence in fundholding but an attempt to get the best for their patients in an unfair system. He should listen.
The last straw for NHS staff is the Secretary of State's refusal to recognise the damage that he is doing, as he is in this debate. "Crisis? What crisis?", he says. "Morale? It is fine," he tells us. "Recruitment? No problem." The debate will illustrate two different approaches to NHS staff. On one hand, we see staff as the most vital asset of the NHS and a resource on which to draw. On the other hand, the Government see NHS staff as a nuisance and a cost to be reduced as far as possible.
Demoralisation affects doctors and nurses throughout the NHS. In hospital and in the community, the evidence is overwhelming. The shortage of doctors in accident and emergency departments has worsened the casualty crisis. I spoke to an A and E consultant in the south-east. Unfortunately, he asked not to be named. Increasingly, that is a problem among NHS staff, who are concerned but not able even to speak out.
The consultant works in a busy casualty department that treats 60,000 patients a year—from a toddler with a squashed finger to an old lady who has had a heart attack. There are supposed to be two A and E consultants in that hospital; there is only one. The other post has been vacant for 12 months; they have found it impossible to recruit. As a result, the consultant has to work longer and longer hours. He says that he is spread too thinly to be supervising and training junior doctors and that he spends less and less time caring for patients. He works at least 60 hours every week and is able to spend only nine hours seeing patients. Yet caring for patients took him into the NHS.
I asked the consultant what would happen if he left his post. There was a long pause before he said that there would be a major crisis, the department would probably no longer be recognised for training purposes, they would lose their junior doctors, it would probably be run on locums for a bit and then it would shut. That is what people on the front line feel. It is the same story around the country.
§ The Secretary of State for Health (Mr. Stephen Dorrell)
The hon. Lady has cited the experience of a particular health service doctor who does not wish to be named. He has no reason to fear being named.
§ Mr. Dorrell
Consultant. If on the basis of total confidentiality the hon. Lady wants to send me details of the experience and the hospital to which she has referred, I will have the case examined and reply to her in detail about the background. I will protect the confidentiality of the doctor. The doctor need have no concern. Instead of shadows and innuendo and erecting a theory to which it is impossible to respond, the hon. Lady should allow us to examine the specifics of the case and respond to them.
§ Ms Harman
I shall discuss with the doctor to whom I spoke—I have a verbatim account of a discussion that 813 I had with him at the end of last week—how his confidentiality can be protected. The Secretary of State says that the doctor has nothing to fear, but people do have something to fear and they are afraid to speak up.
§ Ms Harman
It is no good saying, "Rubbish"; it is a fact that people are afraid. I will make sure that the Secretary of State is satisfied that I am citing a real circumstance. We will get back to the doctor and sort the situation out. They may say, "Rubbish," but staff tell the same story around the country.
§ Mrs. Alice Mahon (Halifax)
The case that my hon. Friend mentions is not unique. We have all heard of similar experiences. I sent details of the case of one woman, whose doctor told her to write to me, to the Secretary of State for Health. She was trundled across the M62 from an intensive care bed where she had been told that she had only a 50:50 chance of survival, brought back a few days later and dared not speak out. I received the most unsatisfactory answer from the Secretary of State. He thought that that was good practice.
§ Ms Harman
My hon. Friend raises a very important case. It is a tragedy when those caring for patients are unable to speak out about what they face because they fear not support, sympathy and action from the Government, but retribution and gagging.
The morale of NHS staff has never been lower. Those who can leave do so. It has become ever more difficult to recruit staff to vacancies; posts are covered by locums and unpaid overtime. Staff are under stress, and their morale falls further—it is a vicious circle. It is becoming increasingly difficult to recruit GPs. According to Dr. Ian Banks of the BMA:The problem of GP recruitment has now reached crisis proportions and is bound to affect the quality of care to patients.Nearly one quarter of newly qualified young doctors are considering not entering the profession for which they have trained. Those who have become GPs want to quit. Almost half of Britain's GPs are leaving general practice, and those who stay in general practice want to quit early. Six out of 10 GPs plan to take early retirement because, for them, there is more time spent on paperwork and less time spent with patients. They are unable to keep up with medical developments, and they are angry at the damage to patient care that has been caused by the Tory NHS reforms.
§ Mr. Michael Fabricant (Mid-Staffordshire)
Is the hon. Lady aware that, by April, every GP in Lichfield will be a fundholder? Is she aware that several GPs have told me that, were a Labour Government elected who would abolish GP fundholding, they would wish to quit the NHS?
§ Ms Harman
The hon. Gentleman fails to address the issue. There is a serious problem of recruiting GPs, and not enough GPs are going into training to enter general practice. Is the hon. Gentleman trying to tell the House that there is not a problem? The situation is not acceptable.
814 The same story applies to nurses. Nurses' morale is at an all-time low. More than one in three nurses have said that they would leave nursing if they could, and one in five say that they will leave nursing in the next two years. They are overworked, but they feel insecure. It is hardly surprising that 78 per cent. of the nurses who were surveyed by Unison felt that morale in their wards had worsened during the past year. It is tragic that 46 per cent. of nurses no longer enjoy going to work, and that 28 per cent. of them regret their decision to go into nursing.
Those nurses dread the occasion when the next person leaves—the next vacancy that cannot be filled except by unpaid overtime by those who remain. I shall give the Secretary of State an example of somebody who, fortunately, is prepared to be named. A district nurse in south London, Jane Tierney, told me about working in her community last weekend. On Friday, with the increasing pace of discharge from hospital, a patient had been discharged with a feeding tube inserted. They had been in such a hurry to discharge the patient that they had not performed the normal test feed.
When the patient arrived home, Jane was there to nurse him. She discovered that she could not feed him because a bit of the feeding apparatus was missing. She spent her whole weekend ringing round and trying to get the piece of equipment that was unsatisfactory, because of the patient's early discharge. The patient was desperate: he could not be fed.
Jane Tierney joined the NHS to care for her patients, not to spend all weekend telephoning the hospital. She even telephoned the manufacturer. She said that she is spending increasingly more time battling with hospitals about discharge—they, too, are under pressure—and battling with social services about who will do what. Social services are under pressure; hospitals are under pressure; and the nurses get squeezed in the middle.
There is a vacancy on Jane's team which has been empty for 18 months, which is not surprising. She is therefore working increasing amounts of unpaid overtime. Her team is dreading the time when the next person leaves and there is yet another vacancy.
It is clear to everyone that the Tories value managers more than front-line staff. Last year, chief executives' pay increased at twice the rate of nurses' pay increases. Chief executives' pay rose by 7.6 per cent., while nurses' pay rose by 3.2 per cent. Since 1989, there have been 20,000 more managers recruited, while the number of nurses has been cut by 50,000.
§ Mr. Michael Brown (Brigg and Cleethorpes)
Is the hon. Lady including in her attack on NHS managers those who used to be called ward sisters? Technically, they are probably managers according to her description, yet they are on the front line of health and patient care. The hon. Lady should be careful when using such statistics, because the regrading of staff means that ward sisters may be included as managers although they are in the front line of patient care.
§ Ms Harman
The new managers have been recruited to run the internal market. I am not talking about those who manage NHS staff and who have always been there. The Secretary of State says that he will cut bureaucracy, but it is ironic that he is cutting not the sales or finance 815 directors—even more of them are being appointed—but the very nurse managers to whom the hon. Member for Brigg and Cleethorpes (Mr. Brown) referred.
Since 1989, 20,000 more managers have been recruited whereas the number of nurses has fallen by 50,000. That is the Government's record. When the Government can afford to spend an extra £1.5 billion on bureaucracy to run the internal market every year, it is hard to understand why nurses should have to accept a below inflation 2 per cent. pay increase without having lower morale and without more of them voting with their feet and leaving the NHS. It will only make matters worse if the pay award has to be funded by further bed cuts.
It is not that the Secretary of State has not been told about staff shortages; it is simply that he has refused to listen and is still refusing to do so. The Medical Workforce Standing Advisory Committee reported last year that 25 per cent.—one quarter—of consultant posts were unfilled and that 12 per cent. of advertised consultant posts received no applications at all.
Most trusts are struggling to appoint doctors. According to a survey by the National Association of Health Authorities and Trusts, the worst problems are in psychiatry and anaesthetics. A third of trusts are now offering recruitment incentives. Hartlepool hospital was so desperate to get an anaesthetist that it paid for his jeep and Rottweiler to be flown over from the United States.
As doctors leave the NHS through early retirement, the shortages get worse. Consultants and specialists are being driven out of the NHS by the intolerable pressure put on them by the Tory market in health.
§ Mr. Denis MacShane (Rotherham)
Is my hon. Friend aware that the district general hospital in Rotherham has had to spend £250,000 to recruit accident and emergency doctors from South Africa where they are desperately needed? Half their salaries go to a private agency—such is the poor morale and unwillingness among our junior doctors to work in A and E departments.
§ Ms Harman
As my hon. Friend says, the staff shortage is leading the NHS to spend huge sums of money. When people leave, their replacements have to be advertised for and then trained. Expensive locums and agency staff have to be used, so the failure to retain staff in the NHS is paid for not only in terms of patient care but in terms of hard-pressed NHS cash.
Let me cite the example of a consultant who was prepared to allow me to use his name in the debate. I am grateful to him. Dr. Peter Fisher is a consultant at Banbury who has been in the NHS for more than 30 years. He says that he is the only person he knows of his age who is not seeking early retirement. He says that the bed cuts have 816 profoundly affected the quality of care that doctors are now able to provide. All over the hospital, patients are shunted around—
§ Mr. Dunn
I did not call the hon. Lady a chicken; perhaps she should have her ears syringed. Does she remember the debate on health during the week in which she was having a little local difficulty with her party? A member of her staff contacted Dartford and Gravesham health authority to ask how many beds it had cut in the previous six to 12 months. Will she please tell the House the answer that she was given, because it might reveal that the facts that she is using today are highly selective?
§ Ms Harman
I have quoted from surveys by nationally accredited organisations, including the Royal College of Nursing, the National Association of Health Authorities and Trusts and the British Medical Association. I have quoted from every national, independent source possible, so I do not think that the hon. Member's intervention is to the point.
I was in the middle of talking about Dr. Peter Fisher—
§ Mr. Arnold
On a point of order, Madam Speaker. The hon. Lady referred to my district and I would like to give her the answer.
§ Madam Speaker
During the course of speeches, hon. Members refer to many districts. The hon. Lady has said that she will not give way at this stage.
§ Madam Speaker
I think that the hon. Gentleman may have misunderstood. If I understood correctly, the hon. Lady referred to the hon. Member for Gravesham (Mr 817 Arnold), who tried to intervene. Is that right? [Interruption.] The hon. Lady referred to the hon. Gentleman who was trying to intervene. Is that correct?
§ Mr. Arnold
On a point of order, Madam Speaker. The hon. Lady referred to me when she said that the point was a point of debate two weeks ago. However, the point I wished to make was precisely the point made by my hon. Friend the Member for Dartford (Mr. Dunn).
§ Madam Speaker
That is not a point of order. It is a point of debate and, if the hon. Lady allows the hon. Gentleman to intervene, he can make the point.
§ Dr. Peter Fisher says that morale is at rock bottom. I shall explain the situation, because the Secretary of State does not talk to doctors who are working in the NHS so he does not know the circumstances. When beds are closed and more and more patients come in, surgical patients are put in medical wards and medical patients are put in surgical wards. The surgical team of nurses, who are experts at dealing with surgical patients, end up missing problems with medical patients, and vice versa. The nurses hate that situation and the doctors hate it. It breaks up the team and it undermines the quality of patient care. Danger signs are not noticed, and the patients suffer.
§ Doctors and nurses also hate the misrepresentation that is constantly perpetrated by the Secretary of State. He has done it again. The Minister of State tried to challenge the Sheffield memorandum in questions today. I remind the House that the Sheffield memorandum shows that there is a two-tier waiting list for out-patient prospective waiting times in the Royal Hallamshire hospital, the Nether Edge hospital and the Jessop hospital for women.
§ Mr. Dorrell
That is an important point. The hon. Lady said that my hon. Friend the Minister of State misled the House. My hon. Friend drew the attention of the House and of the hon. Lady to a letter written by Mr. Kevan Taylor, the head of contracting for Sheffield health authority. He is a person who presumably knows what is going on in Sheffield, and he says:There are no marked differences in access times for fundholder and non-fundholder patients.Those are not the words of my hon. Friend or the words of anyone divorced from the situation. They are the words of the person who is responsible for the quality of care 818 delivered to the patients whom the hon. Lady has mentioned. The letter says "no marked differences". That is not what the hon. Lady told the House last week.
§ Ms Harman
I told the House last week—I stand by what I said and repeat it to the House today—that the average out-patient prospective waiting times show a two-tier list. The Secretary of State has quoted from a letter in The Independent that is not from the hospitals that are making the appointments and carrying out the operations, but from the purchasing organisation. If he looks at the letter from Kevan Taylor, he will see that it does not contradict the Sheffield bulletin.
§ Mr. Dorrell
The service being delivered today to patients does not reflect the difference that the hon. Lady talks about. I shall quote from another passage in the letter, which states:The facts about the current situation are shown in the fully validated waiting time data for December 1995that was five weeks ago, which is fairly recent by most statistical standards. The letter continues:This data shows that at the end of December 85 per cent. of fundholder patients and 83 per cent. of non-fundholder patients had been waiting less than 13 weeks.Those are the facts as reported by the people on the ground. They are wildly at variance with what the hon. Lady said to the House of Commons last week.
§ Ms Harman
The Secretary of State has once again made the position worse. Only this afternoon, my assistant spoke to the deputy chief executive of the hospitals running the waiting lists. He confirmed that the differentials between the waiting lists that we quoted are absolutely right. It does the Secretary of State no credit when he seeks to conceal the situation instead of finding out about it and sorting it out.
§ Mr. MacShane
As Member of Parliament for a constituency in the catchment area, I can assure the Secretary of State that that list is in every doctor's surgery and in most hospital doctors' hands, and is causing outrage and scandal. The Secretary of State would not dare to come to Rotherham or South Yorkshire with the mendacious nonsense that there is not a two-tier waiting list system for fundholding and non-fundholding GPs.
§ Ms Harman
Last week, the Secretary of State acknowledged that there was a two-tier waiting list in Sheffield, and tried to defend it. This week, he has changed his position and is trying to deny it. There are two-tier waiting lists—he is not quoting the facts. We are right on this point and he is wrong. He does himself no credit by continuing to deny that.
§ Mr. Dorrell
When the hon. Lady can produce an example of one patient from a fundholding practice and another patient from a non-fundholding practice whose waiting times show the differential to which the hon. Lady referred, I shall withdraw my remarks in the House. Until the hon. Lady can produce a specific case where that difference has been established, I shall rest on the 819 evidence from the statutory health authority, whose job it is to deliver good-quality care to patients of the Sheffield area.
§ Mr. Campbell-Savours
Will my hon. Friend call on the Chairman of the Select Committee, who last week said that, as Chairman of that Committee, she was prepared to look at the list? Will my hon. Friend call on her to have a Select Committee inquiry so that we can establish the facts?
§ Mr. Ronnie Campbell (Blyth Valley)
As a member of the Parliamentary Commissioner for Administration Select Committee, I asked a few weeks ago whether the ombudsman would be prepared to look at complaints that non-fundholder patients are being put behind fundholder patients on waiting lists. Does my hon. Friend agree that her evidence and that of other hon. Members should be put before the ombudsman so that he can investigate it?
§ Mrs. Roe
I prefer not to be constantly interrupted by the hon. Gentleman, who never allows anyone to say anything.
The Committee has considered the purchasing element of the purchaser-provider split and has already produced a report on that. One of my colleagues who serves on the Select Committee is already sitting in the Chamber and will no doubt contribute to the debate later, and we have heard the arguments of the hon. Member for Halifax (Mrs. Mahon). I am sure that members of the Select Committee will take heed of what the hon. Lady says as well as the hon. Gentleman, and in due course they may well wish to take those opinions into account and conduct
820 an inquiry, but it is for them to decide. In my Committee, we act democratically and the whole Committee decides, not only the Chairman.
§ Mrs. Mahon
I thank my hon. Friend for once again giving way, and for her patience.
I would welcome an inquiry into the two-tier system that is developing, but when I sent the Secretary of State a letter, of which my hon. Friend has a copy, showing clearly that one cannot have access to clinical psychology services in Calderdale unless one is on the list of a GP fundholder, I received an unsatisfactory answer from the Secretary of State. He has a copy of that letter.
§ Ms Harman
I believe that that letter was submitted in the previous debate and, once again, the Secretary of State refuses to acknowledge it. He also refuses to acknowledge the shortage of nurses.
Two thirds of hospital trusts find it difficult to recruit nurses. Leighton hospital in Crewe has 76 unfilled vacancies. Glasgow Royal infirmary delayed opening its winter medical ward by two months because of a problem in recruiting nurses. One thousand Australian nurses are being recruited by the British Nursing Association. "Golden hellos" of £2,000 each are being offered as incentives for nurse recruitment. King's College hospital in my constituency in south London has sent managers to Ireland, Australia, Finland, Canada and Hong Kong.
§ Ms Harman
It is not only that hospitals cannot fill the vacancies; they cannot even bring agency staff to the patient's bedside, and staff shortages are affecting patient care. The Queen Elizabeth hospital in Birmingham had four intensive care unit beds, two of which stood empty for six months because it was impossible to obtain specialist intensive care nurses. With the two intensive care unit beds always occupied by emergencies, patients waiting for heart surgery had to have their operations cancelled repeatedly.
§ Ms Harman
In parts of London, one in 10 hospital doctors is not part of the team but only temporary. Consultants work 30 per cent. more hours than contracted by the NHS. More than half of all nurses work unpaid overtime to keep the service going.
821 What is the Government's response? Where is their action to lift staff morale and to retain staff?
§ Ms Harman
Opposition Members recognise the low morale in the NHS and regard it as being of the utmost seriousness. We propose today five steps that the Government might take to start to rebuild the confidence of NHS staff.
First, the Government should give health professionals a say in planning the NHS.
§ Mr. Porter
On a point of order, Mr. Deputy Speaker. It would be extremely helpful if the hon. Member for Peckham (Ms Harman) would confirm whether she intends to give way to any hon. Member at any stage. If riot, I shall not continue to waste my time here.
§ Mr. Deputy Speaker (Sir Geoffrey Lofthouse)
That is not a point of order for the Chair. The hon. Member for Wirral, South (Mr. Porter) knows full well that right hon. and hon. Members must decide whether they wish to give way.
§ Ms Harman
I am putting before the House five proposals that I believe would lift the morale of national health service staff and help to stem the tide of staff leaving the NHS which is threatening patient care. I shall not give way to any more Conservative Members today.
Trust must be rebuilt, because no one trusts a word that the Government say about the NHS. Trust is built on dialogue and dialogue starts with listening. Labour listens to nurses and doctors, but the only doctor that the Secretary of State listens to is a Dr. Mawhinney.
Secondly, the Secretary of State should act to end the gag on NHS staff. Health professionals should be able to talk about their work in the way that they used to. Doctors, nurses and health professionals are now afraid to speak out and express their views. Labour believes that all health service staff should speak freely about their professional concerns—that is in the public interest. We endorse consultants' freedom to speak out and we wish to see that right respected and extended to all health professionals in the NHS.
Thirdly, safety at work for NHS employees is becoming a major issue. The Secretary of State should address NHS employees' growing concern about their personal safety at work. It is a problem for GPs, for staff working in the community, those working on their own and going into people's homes, community psychiatric nurses, staff working in accident and emergency departments, and particularly for women staff. The NHS should ensure their safety at work and it should always prosecute assailants when they are identified.
822 Any staff member who is injured at work should receive the support of the NHS, but, in reality, staff believe that that support is not there. A London GP, Dr. Anthony Inwald, went to the defence of a colleague who was being threatened by a patient wielding a kitchen knife, and he was stabbed by the patient and seriously wounded. The incident caught the attention of the nation, but it did not attract the attention of the Secretary of State: he was not interested.
Fourthly, there should be fair pay and conditions in the NHS. Will the Secretary of State agree to ending the short-term contracts that are now spreading throughout the national health service? In some trusts, almost a third of nursing staff are on fixed-term contracts, and one in six nurses are on a bank or an agency contract. That is no way to create a sound basis of teamwork in patient care. Many trusts are going even further, proposing contracts which allow the hospitals to alter work locations, working hours and working patterns. Zero-hours contracts are beginning to appear in the NHS. That must stop.
On top of that, the Government are diverting scarce NHS resources away from front-line staff who are caring for patients to managers who are running the internal market. We believe that there must be fair pay and conditions. A national service needs national pay—local pay bargaining, as it currently stands, is divisive and wasteful. It leads to hundreds of different pay negotiations across the country and it takes nurses away from the wards. This morning I met a nurse who said, "I joined the NHS to nurse, but I am spending all my time negotiating".
Fifthly, there should be a moratorium on the bed closures that are causing the casualty crisis and an end to two-tier waiting lists, which are damaging morale in the NHS.
The test today for the Secretary of State is whether he is prepared to acknowledge that NHS staff morale is at an all-time low. The eyes of 1 million NHS employees are upon him. Will he rise to the challenge and pledge action to tackle the NHS staffing crisis? We have proposed measures to start rebuilding staff morale; we have offered the solutions. Does he have the courage to take that action?
§ The Secretary of State for Health (Mr. Stephen Dorrell)
I beg to move, to leave out from "House" to the end of the Question and to add instead thereof:`pays tribute to the dedication and commitment of the NHS's staff; welcomes the investment in professional development for all NHS staff made by the Government since 1979, in particular the investment in high quality nurse training represented by Project 2000, the development of new nursing specialties, for example, in general practice and paediatric intensive care nursing, the increase in the number of doctors, nurses, midwives and consultants, the reduction in on-call hours for junior hospital doctors, the establishment of an independent Pay Review Body for nurses, the increase of nearly 70 per cent. in nurses' earnings, the establishment of the principle of local pay for nurses which has delivered fair and flexible settlements and the development of high quality NHS general management: commends the recent announcement by the Secretary of State for Health of an 8 per cent. real terms cut in administration budgets for health authorities and trusts next year, together with an efficiency scrutiny which will identify and eradicate unnecessary paperwork; and looks forward to the further development of the National Health Service.'The title of the debate is: "Morale of National Health Service Staff', and I shall have quite a lot to say about that. However, it was clear from the speech by the 823 hon. Member for Peckham (Ms Harman) that the substance of the debate is morale in the Labour party. The Opposition are really concerned to give their troops something that they can talk about. They have had some difficulty with that this year, and they have been casting around for an issue that they can approach.
The Leader of the Opposition went to Singapore to talk about stakeholding, but that did not work. Then he started talking about the tartan tax and the Scottish Parliament, but that did not work either. Now he puts the hon. Lady in to talk about morale in the NHS. On the basis of her speech this afternoon, that does not seem likely to work any better than it did last week, when she tried to secure the support of her right hon. and hon. Friends in rejecting the words of her predecessor as Opposition health spokesman, the right hon. Member for Derby, South (Mrs. Beckett), in a Labour amendment.
§ Mr. Dorrell
Mr. Enoch Powell once said that a quotation is, by definition, out of context. I challenge the hon. Gentleman to find a quotation that is in context.
§ Mr. Dunn
Will my right hon. Friend cast his mind back to the question raised by the hon. Member for Peckham? During a recent debate, a member of her staff, presumably paid for by Unison, rang the Dartford and Gravesham health authority to ask how many beds had been cut in the past six to 12 months. [Interruption.] I wish that the hon. Lady would listen for a moment. This is a debate. The answer that was given to a Mr. Ross, who works for the hon. Lady, was that no beds had been closed in the past six or 12 months, and that 22 extra beds had been provided to take account of the winter influx of patients. The hon. Lady did not use that statistic—why not?
§ Mr. Dorrell
My hon. Friend asks what I think is a rhetorical question, and the answer is that it did not suit the hon. Lady's argument. When I used that as an example of the national health service responding to the increase in the emergency work load by providing extra medical bed space to allow extra medical admissions during the peak of winter demand, the hon. Lady said that I was misleading the House. She is quite wrong about that. It beggars belief that anyone could seriously believe, as the hon. Lady apparently does, that, if a hospital has a short-term peak of emergency work load, it should respond by building a brand new ward block.
§ Mr. Dorrell
The hon. Gentleman is quite right to say that is silly. Perhaps he should persuade the hon. Lady of that, as she attempted to use that argument.
The hon. Lady is in some difficulty. She is trying to rebuild morale in her own party. I am setting out to destroy that morale, and there is not much of it left. When 824 she tried to advance her arguments a week ago, 32 of her hon. Friends chose not to support her in the Division Lobbies, including the deputy leader of the Labour party.
§ Mr. Dorrell
The hon. Gentleman says that he was paired, but the Government majority at the end of the debate rather gives the lie to that proposition.
§ Sir Peter Hordern (Horsham)
Did my right hon. Friend hear the hon. Lady saying that there should be no short-term appointment of nurses, but that there should be large-scale, permanent recruitment to cover every possible event and shortage in the event of a sudden disease? Surely that would require the most enormous increase in expenditure. I thought that the Labour party was being very careful not to make any public expenditure commitments. Surely the hon. Lady has blown the gaff in that direction as well.
§ Mr. Dorrell
The hon. Lady blows the gaff in that direction most times when she is on her feet. My hon. Friend was absolutely right to say that the good management of a NHS hospital, now as in the past, must ensure not only good employer provision for the majority of the long-term work force in that hospital, but the capacity to respond in a short-term way to short-term needs. If the hon. Lady does not understand that, she has not reached first base on how to deliver good value out of the resources available to the NHS.
I will deal now with the substance of the arguments that the hon. Member for Peckham put before the House. I begin by reflecting that, given the pressures to which the health service has been subject over the past couple of months with the increase in its emergency work load—there is no argument about that—I might have hoped for an acknowledgement from the lips of the hon. Member for Peckham this afternoon of the debt that every NHS patient owes to health service staff—doctors, nurses, midwives and administrators.
They have delivered through the winter emergency care at the time that it was needed, in the overwhelming majority of cases, to an extremely high clinical standard. They have done so while at the same time maintaining progress on the elective surgical work load, maintaining the development of primary care and maintaining the development of mental health services.
This winter, the NHS has been working under strain, and I had hoped that the hon. Member for Peckham might have seen fit to recognise the skill, dedication and commitment of NHS staff in a debate of this nature. However, the hon. Lady did not. I simply observe that she did not, and I am sure that my right hon. and hon. Friends—and, I suspect, most Opposition Members—join me in reflecting that debt in the House this afternoon.
§ Mrs. Mahon
Is the Secretary of State aware that, at Halifax general hospital, men were put on the 825 gynaecological ward because of the shortage of beds? How does the right hon. Gentleman imagine that things will carry on after Northowram hospital is closed and another 300 beds are lost in the next couple of years?
§ Mr. Dorrell
I have already acknowledged that the health service has been working under unprecedented pressure this winter, in responding to the emergency work load.
§ Mr. Dorrell
The hon. Gentleman asks about bed cuts, but the hon. Member for Halifax (Mrs. Mahon) asked whether it was ideal for a man to be treated on an obstetrics and gynaecology ward. The answer is no, that is not ideal—but if I were a man in need of emergency medical care, I would prefer to be in one of those beds than in no bed at all. That response is one that the health service has always provided—[Interruption.]
§ Mr. Deputy Speaker
Order. It is no use asking the Secretary of State questions if he is not allowed to answer. I am having great difficulty hearing the right hon. Gentleman, so I am sure that the rest of the House is having the same difficulty.
§ Mr. Dorrell
I hoped also that the hon. Member for Peckham might have recognised some of the progress that we have made over the past few years with a number of key issues that must be addressed if the NHS is to be a good employer.
§ Mr. Dorrell
I should like first to make some progress.
The hon. Member for Peckham talked a lot about nurses. One key improvement over the past few years has been the dramatic rise in the quality and record of training NHS nurses.
§ Mr. Dorrell
I want to make more progress; then I will give way.
I remind the House of the starting point on nurse training. The Judge report in 1985 recorded the position that prevailed then in NHS nurse training, and which had prevailed for some time. In 1983–84, 25,000 students of nursing were admitted to training. The report commented:The best available evidence suggests that 15–20% will not even complete the course, and of those that survive some 30% may fail the qualifying examination at their first attempt. Of those who do eventually qualify, many are disillusioned with the preparation they have received, enjoy only a minimal engagement in clinical practice, change jobs with disconcerting regularity, find themselves caught in a machine".That was the assessment of the position prior to the Government's introduction of Project 2000 in 1990, which led to an improvement in nurse training. In those days, 30 to 35 per cent. of those who commenced nursing training did not continue in nursing practice. Today, the fall-out rate is 20 per cent. Since 1990, the Government 826 have cut the fall-out rate by almost half as a result of the improved training and employment terms available to nurses. In a debate such as this, the hon. Lady might have mentioned this fact. The national health service is investing in its most precious asset: the professional staff who deliver the health care for which the Government are responsible.
§ Mr. Gunnell
Does the Secretary of State agree that the number of people who undertake nursing training has decreased dramatically? For example, between 1992 and 1995, it decreased from 21,000 to 13,000.
§ Mr. Dorrell
The figure for next year's commissions is 17,000. The Government have improved nurse training, resulting in a decrease in the fall-out rate of 35 per cent. to 20 per cent. We may therefore need to take in fewer nurses at the beginning of the training. That was the purpose of the improvement, as recommended in the Judge report. The Government accepted that recommendation in the context of Project 2000, to ensure that the professional staff of the NHS receive the high-quality training needed if we are to deliver high-quality health care.
§ Mr. Fabricant
Is my right hon. Friend aware that a hostile reporter from a local newspaper contacted senior nurses at the Victoria hospital in Lichfield? A senior nurse said that, because of the health care reforms, for the first time she is able fully to use the valuable training that she has received. She said that this is because money is following the patient, because of general practitioner fundholding and because of greater integration between GPs and the hospital. She is now able to be a real nurse, whereas she said that, in the 1970s, all she could do was think where to send the next day's sheets to be laundered.
§ Mr. Dorrell
My hon. Friend has put his finger precisely on the point: nurses receive a better quality of training as a result of the changes that the Government have introduced in the health service. The Government have invested an extra £60 million to improve the quality of nurse training. Professional development for nurses allows a more rewarding practice and a better use of those higher-quality skills that we pay to provide through the training programme. The national health service is investing in the training of its nurses.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I do not question the improvements in the training and qualifications of nurses. However, there are still severe shortages of staff, and senior nurses report that they regularly cannot recruit or retain staff. Recently, a senior nurse at Guy's told me that Guy's and St. Thomas's NHS trust is down by 40 intensive care nurses. What do the Government propose to meet the severe current shortfall in qualified nurses, which is not being met from agency and overseas sources?
§ Mr. Dorrell
The hon. Gentleman makes a number of points. What has happened with respect to intensive care nurses employed in the national health service during the last five years? In 1989, there were 32,500 intensive care nurses, whereas this year there are 40,500—an increase of 24 per cent. The Government will continue to ensure that we have a nursing work force that is able to meet the intensive care needs of the health service.
827 The hon. Gentleman also referred to the shortage of nurses in the health service. In the past week, independent advice has been published on this issue. The review body examined precisely the point that the hon. Gentleman raised. Its report stated:We have carefully weighed all the evidence presented to us and we are not persuaded that there is a general nationwide shortage of nursing staff at the moment.There are clearly local difficulties and problems with particular specialties, and we believe that local pay may be part of the solution to these problems.So the review body examined the hon. Gentleman's point and recognised, as the Government have by accepting the report, that there are some local shortages. Furthermore, the review body recommended a way of dealing with them which the Government have accepted. I hope that that satisfies the hon. Gentleman.
§ Mr. Simon Hughes
I know what the review body recommended, but the Secretary of State must accept the consequences. If the Government have stipulated that there should be a 2 per cent. national increase, and that additional increases should be funded by local hospital trusts, depending on the circumstances, how can the right hon. Gentleman assure us that there is enough money in the kitty for the trust to be able to pay for the increases that it will need to adopt in order to recruit all the nurses it needs?
§ Mr. Dorrell
The hon. Gentleman has asked another question that the review body has already examined: whether there are enough resources to provide for a decent deal for nurses. Once again, I quote the review body's report:The allocation of resources to the NHS for 1996–97 means that most providers should be able to reward staff for improvements in efficiency and effectiveness while delivering increased volume and quality of care to patients. This `win-win' outcome can, however, be achieved only if purchasers and providers work constructively together.I agree. I want local staff groups and local managers to address the issues of each health provider locally—precisely to meet the concerns that the hon. Member for Southwark and Bermondsey has expressed.
Pay is clearly at the heart of much of the issue that the hon. Member for Peckham raised this afternoon. The key thing about pay—nurses understand it, but the hon. Lady did not refer to it at all—is the fact that average earnings of nurses have increased by £125 a week in today's values compared with the figures that we inherited in 1979.
Nurses should look at what the Government have done for them over the past 16 years, and in the shorter period since 1990—since when they have enjoyed a 10 per cent. real-terms increase. As for the future, nurses must also bear in mind the improved living standards with which the Government have provided them; and they should recognise that no nurse in the NHS has yet received a pay offer for next year. The Government have accepted the recommendation of the review body. Furthermore, the Government are working within the terms of the agreement that we signed with the nursing unions four months ago. Both arrangements provide for local pay in a national context.
828 This is not, contrary to what is sometimes suggested, a low-pay agenda. The proposition that local pay equals low pay was examined by the review body and explicitly rejected:The experience of other industries, and our reading of the limited evidence so far available about Trust contracts, suggest that local terms and conditions as a whole are unlikely to be less favourable than those embodied in national agreements, and may in some respects be more favourable. Local pay can be expected to lead to new pay structures and working arrangements but we do not see it as a low pay' agenda".That is also the position of the Government.
The hon. Member for Peckham said that she was hostile to local pay and local flexibility. She is going to have real difficulty squaring that with the first proposition in her five-point plan for the Government—the idea that we should listen to health professionals and allow them a say. It defeats me how we can allow them a say at local level and insist at the same time on national structures—contrary to our agreements with the nursing unions and with the review body. I will happily give way to the hon. Lady if she can enlighten me.
§ Mr. Dorrell
I gave way to the hon. Lady to allow her to reconcile the two propositions—that we should listen to local staff groups, and that we should have national pay determination. How can she reconcile that with her five-point plan—or with the words of the leader of her party? Speaking about the British political system only last week, the right hon. Member for Sedgefield (Mr. Blair) said:In part … the disaffection is because people feel no ownership, no stake"—; that wonderful word—in much of the political process. The citizen feels remote from power, because he or she is remote from power. Britain is THE most centralised government of any large state in the western world.This afternoon, the hon. Member for Peckham has come here to argue for further centralisation: a national formula for dealing with nurses' pay that would prevent health service employers from listening to local staff groups and bring more power to the centre. In short, this would prevent local solutions being found for local problems. It is impossible for the hon. Lady to reconcile her support for centralising national bargaining with her speech today or with the words of her leader in his much-trumpeted constitutional lecture of last week.
As for managers' pay, the answer is straightforward. As the hon. Lady well knows, I have imposed an 8 per cent. real-terms cut on the budget out of which chief executives' and administrators' pay in the health service comes. I have provided growth money, on the other hand, for the payment of doctors and nurses. As the review body found, that will provide for a proper balance of growing demand and growing service provision, as well as fair terms for nurses and all other clinical staff in the health service.
§ Mr. Dorrell
First, they did not; secondly, I have clearly set out the arrangements under which the budgets 829 for these different parts of the health service will work in the next 12 months. The budget out of which administrators are paid is being cut, the budget from which nurses and doctors are paid is growing.
Nurses are not the only people to benefit from this dramatic improvement in the investment in human resources available to the health service. Exactly the same is true of the doctors. It will be within the memory of everyone in this House that, until a very short time ago, the NHS used to rely on absurdly long hours being worked by junior medical staff. That is why the Government, at the beginning of the decade, introduced a new deal for junior doctors. It is worth reminding the House of the progress that we have made in improving the terms of junior doctors in the NHS.
There used to be 13,000 posts in the NHS in which doctors were on call for an average of more than 83 hours a week. Now there are no such posts. There used to be 14,000 hard-pressed posts in which doctors were on call for more than 72 hours a week. Now there are virtually none—295, to be precise. By the end of this year, we are on course to have eliminated every junior doctor post with an on-call requirement of more than an average 72 hours a week. [Interruption.]
Opposition Members may find this funny, but no junior doctor does. Neither does any junior doctor find it remotely funny to have had £65 million in extra resources provided to ensure that the work load placed on junior doctors in training is kept within reasonable bounds. Nor do they think that it is funny that we have created an extra 2,500 medical posts—consultants and juniors—to ensure that the workload is more fairly spread around the medical work force of the health service. Nor do they think that it is funny that the number of consultants has grown over the past five years—
§ Mr. Dorrell
Not at the moment, because the hon. Member for Peckham seems to think that it is funny that we have cut the excessive workload of junior doctors throughout the health service. The hon. Lady says that we have not. She will not find many doctors who do not agree with the proposition that we have cut the unreasonable, excessive workload for junior doctors, and, furthermore, that we have increased the consultant work force in the NHS by 14 per cent. over the past five years.
The Government are committed not just to good training for nurses, which I have described, but to high-quality training for doctors, to a reasonable workload for doctors and to investment in the continuing education to ensure that doctors, nurses—all the professional staff of the health service—keep their skills up to date to ensure that medical and other professional practice continues to develop within the NHS. That is the most important single investment that the NHS can make.
More important than all the buildings and expensive kit, we must ensure that the health service has the best quality human skills that we can muster to deliver health care to our patients. The professional staff of the health 830 service will have noted that Opposition Front-Benchers, who bring the subject of NHS morale to the House, find it a subject for private entertainment.
§ Mr. Campbell
What would the Secretary of State say to a gynaecologist who wrote to me in these terms:Having observed the midwives on the ward on several occasions, I am struck by the fact on many occasions they are tired, exhausted, confused, scurrying around trying to maintain basic standards."?
§ Mr. Dorrell
The hon. Gentleman quotes from a letter that I have not seen. I have made it absolutely clear that I regard the training of doctors, nurses and all the professional staff in the health service a high priority. That is why I provided extra money in last year's pay settlement to ensure that the health service invests in its people, and then, having trained them, that it is a good employer and gives them fair terms.
§ Dame Jill Knight (Birmingham, Edgbaston)
Has my right hon. Friend been able to find out from Opposition Members, who consider that things are so bad—indeed, the hon. Member for Blyth Valley (Mr. Campbell) obviously feels that if more money were spent, all of the tiredness would go—how much more money per annum the Labour party would put in to avoid these situations?
§ Mr. Dorrell
My hon. Friend raises an extremely important point. As she knows, it is a rhetorical question. The answer is no. They have made no commitment. They have not even matched the commitment that the Government give: that year by year there will be real-terms growth in the extra resources for the health service. Opposition Members are remaining very mum now. They have not been to the hon. Member for Dunfermline, East (Mr. Brown) to get that cleared, have they?
I shall give way to the hon. Member for Peckham if she will tell the health service how much extra money a Labour Government would promise.
§ Mr. Dorrell
With all respect to the hon. Gentleman, I doubt whether he is in a position to speak with authority on this subject.
I shall happily give way to the hon. Lady if she is prepared to tell the House and the nation how much extra money a Labour Government would promise.
Her silence speaks volumes. She is not even prepared—
§ Mr. Dorrell
The hon. Member for Workington may have ambitions, but I am afraid that I have to remove the delusion.
§ Mr. Dorrell
I have talked about training and investment in the human skills of the health service. We 831 have done something else for the professionals who work in the health service: we have given every professional working in the health service the opportunity and the support that is necessary to deliver an improving quality of care.
Last week, we debated fundholding. That has given GPs throughout the country the opportunity to improve the care that is available to their patients. It has strengthened the voice of primary health care in the health service and has provided a broader range of provision to patients in the surgeries.
§ Mr. Dorrell
No, we spent a long time on fundholding last week.
We announced yesterday the best results seen on waiting times in the health service within living memory. We announced that just under 21,000 patients had been on a waiting list for more than a year. Throughout the 1980s—this is not a political point, as the figure was inherited from the 1970s as well—the number of people who were on a waiting list for more than a year was plus or minus 200,000 for more than a decade. That figure is now down to 21,000. That figure was referred to as sleight of hand. It is no such thing. We have cut the waiting time for patients on in-patient waiting lists, so that nobody waits for more than 18 months. A few years ago, 80,000 people had been waiting for more than two years. Now, nobody waits for more than 18 months. The number of patients waiting for more than 12 months is down to 21,000. The average waiting time on an NHS waiting list has been cut from nine months to four months. That is real progress, and patients who are on waiting lists, or feel that they may be on one for elective surgery in the health service, understand that very well. It represents a dramatic improvement in the quality of the elective surgery service that is provided by the NHS.
§ Mr. Kevin Hughes (Doncaster, North)
I am grateful to the Secretary of State for giving way on waiting lists, because I hope that he will tell us which one he is referring to. Is it the waiting list to get on the waiting list, or is it the proper waiting list? As far as patients are concerned, when they have been to see their GP, they are on a waiting list, but the Government, through their people in the health authorities, have created two waiting lists: first, they put the patient on a waiting list for an appointment to see a consultant—a list that they could be on for 12 months before they are even seen—and secondly, when they get to him, they are put on a waiting list for 18 months. That makes two and a half years, not 18 months.
§ Mr. Dorrell
The hon. Gentleman is simply wrong. Opposition Members claim to be supporters of the NHS, but when there is a clear improvement in the quality of service available to NHS patients, one might have hoped that Opposition Members would welcome it. It is simply untrue to say that patients on waiting lists do not wait a shorter time than a few years ago. In-patients are waiting a shorter time for admission, and [Interruption.]
§ Mr. Dorrell
If the hon. Member for Doncaster, North will contain himself in silence for a moment, I shall tell him 832 the answer. He referred to outpatient waiting times for patients who are waiting, after referral by their GP, to be seen by a consultant in an outpatient appointment. The health service has never monitored that before. [HON. MEMBERS: "That is not true." I was a Health Minister between 1990–92. I regularly asked: how long do people wait between referral and their first outpatient appointment? I was told, "We do not know, because the information is not collected." It was the Conservative Government who recognised that that needed to be controlled and limited. It was the Conservative Government who introduced the patients charter standard that said that 90 per cent. of patients should be seen at their first outpatient appointment after referral within 13 weeks, and all of them within 26 weeks. The Government are delivering the progress that the hon. Gentleman asks for and does not recognise when he sees it.
§ Mr. Nigel Evans (Ribble Valley)
Does my right hon. Friend agree that it is not just the success in waiting lists about which we should be proud but the fact that since 1991 more than 1 million people have been treated in the NHS—that is an extra 3,500 a day—and that it is not just the money that is invested in bricks and mortar that is important but the money that is invested in patient care? It is the patients whom we want to see served.
§ Mr. Dorrell
My hon. Friend is right. Waiting times are an important measure, but there are many others. My hon. Friend quoted one. Let me quote some others. We delivered the first breast screening programme in the European Union for the health service. I thought that the Opposition would have celebrated that. In Harefield hospital, just outside London, we have the world's largest centre for heart and lung transplants. Such transplants were unheard of 30 years ago. The world's first heart transplant took place in 1969. We all know that it is now routine business in hospitals throughout the health service. More transplants take place at Harefield hospital than at any other hospital on earth.
§ Mr. Dorrell
The hon. Gentleman is excited. I have been arguing throughout that it is the professional staff of the health service who deliver health care. Like the hon. Gentleman, I count myself a supporter of the NHS. Unlike the hon. Gentleman, however, I celebrate its successes.
Surely the NHS is something of which every citizen should be proud. Similarly, we should be proud that Harefield hospital is a great success story within the NHS. We should be proud also that the NHS is delivering improved patient care for people with strokes, asthma and diabetes, for example. Surely we should be proud that the NHS is improving the care that is available for cancer patients. We should take pride in the fact that it is now a routine operation in the health service to have joint replacement, to have keyhole surgery or to have modern lithotripsy.
The hon. Member for Rother Valley (Mr. Barron) is right when he asserts that it is not politicians or managers who deliver these services. The answer lies in the development of modern medicine. The hon. Gentleman 833 might serve his cause rather better, however, if he recognised that, throughout the health service, we are seeing the developments to which I have referred.
Patients are being given care that was undreamed of 20 years ago. Health care is improving. That is why the answer to the first oral question this afternoon was to the effect that the people of the United Kingdom are living longer. That is because we have the best NHS we have ever had. Of course it is not perfect. An organisation that employs 1 million people will, of course, occasionally make a mistake. The central fact, however, is that NHS patients living in this country receive care that is better than it has ever been, and it is improving year by year.
The attempts by the Opposition to paint the NHS as a system—[Interruption.] The British people believe me. It seems that it is only some Opposition Members who do not. When NHS patients are questioned, 90 per cent. of them recognise that we are delivering through the NHS a good health service. Hon. Members—[Horn. MEMBERS: "They don't believe you."] Opposition Members are precisely wrong when they say that. National health service patients know very well that service is improving year by year. They do not believe the Opposition's claims that, if they were in government, they would somehow do better. They are right not to believe those claims. They know that they should not believe them.
§ Mr. Dorrell
The NHS is a service with ambitions. The staff want to see it develop. They want to see the Government continue to support it. It is clear—
§ Mr. Deputy Speaker
Order. The Secretary of State has made it clear that he is not giving way. The hon. Member should remain in his place.
§ Mr. Dorrell
The people who work in the health service have learnt that the Labour party shows only a dilettanti interest in the NHS. They have seen through the hon. Member for Peckham. That is why the debate will 834 fail in its central purpose, which is to motivate Labour Back-Bench Members. The hon. Lady has failed to do that. The only result of the debate is to lay bare once again—I welcome the chance to do it on a weekly basis, and we shall be doing it week after week, because we are looking forward to each debate—before the House and the country the emptiness or the vacuum that is at the heart of the modern Labour party.
§ Mrs. Mahon
On a point of order, Mr. Deputy Speaker. The Secretary of State has promised us a debate every week on the national health service. Should the right hon. Gentleman declare an interest? I understand that he does not use the NHS, and has private medical insurance.
§ 5.4 pm
§ Mr. Bruce Grocott (The Wrekin)
The Secretary of State talked about there being a debate on the health service week after week. This is the third occasion in the past couple of weeks when the gist of the debate has been that Opposition Members say that the public are not happy with the way in which the Government are managing the health service, but the Secretary of State, at some length, and supported by his right hon. and hon. Friends, says that the public are happy with the Government's management.
The Secretary of State is in the fortunate position of being able to resolve the problem, so that we do not have to continue to debate the subject week after week. He can suggest to the Prime Minister that, as soon as possible, we should have a general election so that the public can decide whether they are confident about the Government's running of the NHS.
I suspect that one of the many reasons why the Government would like a debate on the NHS week after week is that, as long as such debates take place, we do not have to throw the matter open for the public to decide. The Government know what the public will decide on what for the Government will be the grim day when they face the electorate. They know that many of the Conservative Members who have spoken this afternoon and in previous debates on the NHS will not be with us much longer.
§ Mr. Edward O'Hara (Knowsley, South)
Did my hon. Friend note the small print that appeared last week in The Daily Telegraph opinion poll, which revealed that the Tories appear to have come within 30 percentage points of the Labour party? On reading the small print, it was apparent that as many as three out of four people were terrified of another Tory Government because of what another Tory Administration might do to the national health service.
§ Mr. Grocott
I do not normally turn to The Daily Telegraph for evidence to produce in arguments, but I am sure that my hon. Friend and I are in complete agreement.
The Government have an ideal opportunity to test public opinion—they can quickly move the writ for a by-election in the constituency of South-East Staffordshire. Perhaps the Secretary of State could persuade the Prime Minister to do that.
835 I shall be brief and refer only to a specific constituency issue that involves morale in the national health service. I am to meet the Secretary of State's ministerial colleague, the Under-Secretary of State for Health, Baroness Cumberlege, with the members of a delegation from my constituency and the surrounding area. I am grateful for the opportunity.
We are to meet the Minister tomorrow afternoon, following a vote of no confidence—49 general practitioners and 26 consultants in and around my constituency were involved—in the management of the health service by the Shropshire health authority. I think that Ministers will acknowledge that that is a serious matter. I shall spend three or four minutes explaining how the situation arose and a couple of minutes suggesting how the issue might be resolved.
The background to the vote of no confidence was the way in which the health authority has been making decisions. That decision-making process was highlighted during the consultative period last year when the health authority published a document entitled "Shaping Shropshire's Health". The background is straightforward: the growth of Telford new town, which I have the honour to represent. It can be acknowledged that the appearance of a new town will produce changes in an area's population structure.
The population of my constituency is growing rapidly. A hospital was built to serve the new town. Unfortunately, the balance of hospital services between the county town of Shrewsbury and the new town of Telford is out of kilter, given the way in which the population has changed. It is the resolution of that problem that goes to the heart of the vote of no confidence.
The focus of the debate is on a consultant maternity service. We in the Wrekin and surrounding areas believe strongly—this view is not confined to my constituency—that the case for our having our own consultant maternity unit is overwhelming. Last year, the health authority partly recognised that fact by publishing the "Maternity Care in Shropshire" document, which suggested three possible solutions. One was to retain the consultant maternity unit in Shrewsbury. The second was to close the Shrewsbury unit and open one at the Princess Royal hospital in Telford in my constituency.
The third, which I strongly favour, was to recognise the changing population balance and to split the consultant maternity unit between the two hospitals, both of which cover populations large enough to justify a unit of their own. Overwhelming arguments exist for doing that and they involve medical issues, which is one of the reasons why general practitioners and consultants signed the motion.
In brief, those arguments are that women in the east of the county, including my constituency, are more likely to be admitted for consultant hospital care than are women in the west. The east has a younger population, which means, obviously, that more babies will be born there—all the population trends show that. More than twice as many babies of low birth weight are born to Wrekin mothers as to mothers in any other part of the country. Strong medical support exists, therefore, for a two-unit consultancy service.
There is overwhelming public opinion in favour of two units. Last year, there were petitions signed by 27,000 people who wanted the health authority to provide them with a consultant maternity unit. Significantly, we were 836 supported by the community health council which, as all hon. Members know, has responsibility for considering health service provision across the region.
The community health council's comments about the need for our own consultant unit included this evidence:Women booked to deliver at the Consultant unit"—in Shrewsbury—have graphically described the problems they experience travelling there in labour, particularly if they have to rely on others for transport. They have referred to the physical discomfort, the stress and fear of being out of contact with a hospital and the acceleration or cessation of labour en route.The council added:There was a strong desire for continuity of care and carer during pregnancy and childbirth and it was felt this was only likely to be achieved if Telford had its own unit.The population argument is easy to describe, and it is compelling. I should be grateful if the Minister, in his winding-up speech, would refer to it. It has been said repeatedly that 2,500 births a year are more than enough to justify a consultant maternity unit. It is projected that, in the county of Shropshire, by 2011, there will be more than 5,000 births. In fact, the projected figure is 5,358—heaven knows how anyone can be as precise as that. The number is, however, more than enough to justify two consultant units.
On grounds of clinical matters, public opinion and population, there is an overwhelming case for our own consultant maternity unit, but—this is where the immediate problem arose—in its meeting on 16 November, the health authority basically said no to all those representations. Over the years, I have been involved in numerous campaigns. I have never known a campaign with as much public support as this one. I have been involved in many campaigns where people are opposed to something. We all know that is easier to mount a campaign in opposition to something than in support of something, but the campaign to have our own consultant maternity unit has had a level of public support like nothing I have seen.
When the health authority said no, and that there should be no change and no recognition of the changing population in the county, it was little surprise to me that doctors decided to publish, in the Shropshire Star on 2 January, the following resolution, again with all-party support—it was signed by leaders of the Labour, Conservative and Liberal Democratic parties and by 49 GPs and 26 consultants.We the undersigned are seriously concerned by recent decisions regarding the strategy for hospital services in Shropshire and no longer have confidence in the ability of the Shropshire Health Authority to plan future health care for the people of East Shropshire.I am sure that the Secretary of State will recognise that that is a serious state of affairs. When we meet the Under-Secretary of State tomorrow, I hope that she will respond to our modest request that, following the clinical evidence and public opinion in the region, she will ask the health authority to reconsider.
When the hospital was built in Telford, again as a result of all-party support and a campaign over many years, to meet the growing needs of a new town, it was never planned to be a static hospital. It is on a good site and there is room for expansion. It was always assumed that, as the population grew, services would grow to meet population need.
837 The consultant maternity unit issue has focused public opinion in a way that hardly any other service could have done. I simply appeal to the Secretary of State to recognise that, in Shropshire, there is a morale problem, which is clearly spelt out in the resolution, and to take seriously the overwhelming representations that have been made to him.
§ Mr. Peter Luff (Worcester)
It will not have escaped hon. Members' attention that the hon. Member for Peckham (Ms Harman) could not put any figure on the amount of money that a future Labour Government might spend on the health service. I had had hopes that the hon. Member for The Wrekin (Mr. Grocott) who, I believe, is parliamentary private secretary to the Leader of the Opposition, might have been able to shed a bit more light on that subject, but those hopes were quickly dashed.
Perhaps I should not be too harsh on the Labour party. It makes a pleasant change for an Opposition-initiated debate about health matters not to be dominated by talk about money, as the health service is about much more than just that. It is indeed about a high level of morale. Before the hon. Member for Peckham leaves, I thank her for what she has done to boost morale among Conservative Members recently. The right decision that she took for her son was not the right decision for morale on the Labour Benches.
Most of the motion that we are being invited to endorse is simply fatuous nonsense, but we can agree on one thing: the high importance that we all attach to nursing staff in the national health service. We all agree that it is important that the House should affirm that
the NHS staff are its most precious resource".That unites all hon. Members.
We also agree—if I understood my right hon. Friend the Secretary of State for Health correctly, he agrees, too—that the views of staff in the NHS should be heard clearly. As a constituency Member of Parliament, I sometimes find that a tricky exercise. Different branches of NHS staff do not always agree about the priorities for health delivery locally. Hospitals, doctors, general practitioners, nurses and ancillary workers often disagree about the priorities that should be attached to various issues in the local health service. They all make an invaluable contribution, but that does not necessarily mean that they should be expected to speak with one voice. Naturally, they have their own priorities.
The question that the motion begs is what makes for high morale in the NHS. Obviously pay is a factor—it would be wrong to deny that—but a host of other intangible and tangible issues affect morale. They include job satisfaction, good working conditions—by which I mean a hospital's physical environment—a sense of direction and purpose in the health service as a whole and in the trust for which staff work, and patients' manifest gratitude to staff for their help in making them fit and well again and able to go about their daily lives.
If there is one thing that destroys morale in the health service, it is the Labour party's constant denigration of what is being achieved. If there is one thing that I find especially shabby about the way in which the Opposition 838 behave on this issue, it is their malicious attempt to weaken morale in the health service for narrow party advantage.
It is important to state clearly that the health service's achievements in recent years under this Government have been built firmly on extra money and on ensuring that that money is spent well. It must be repeated time and again that spending on the NHS in England is up sharply: by 70 per cent. in real terms since 1979. Moreover, health service spending represents a larger share of national income. When we took office in 1979, the Labour party was spending just 4.7 per cent. of gross domestic product on health; now, we are spending some 6 per cent. That is a sharply increased share of an increased national income.
It is obviously important to discuss pay, as it has a significant impact on morale. No active constituency Member of Parliament could fail to be aware of the public concern about nurses' pay; probably no group in society is more admired than nurses, and rightly so. That is precisely why their pay has risen by so much—by some 70 per cent. over and above inflation under the present Government. I am told that an experienced ward sister now earns about £22,000 per year.
I do not take kindly to lectures from the Labour party about nurses' pay. It was Labour that cut their pay, in real terms, when it last had any responsibility for health. It was the Conservatives' respect for nurses that led us to establish the Nurses and Midwives Pay Review Body in, I believe, 1983. It is essential for that body's findings always to be respected. Sometimes they will please the nurses and alarm the Treasury; on other occasions, they may please the Treasury and upset the nurses. That is the nature of independent bodies.
I issue not a warning but a judgment when I say that I do not think that nurses can seriously expect to retain an independent body to review their pay if they are prepared to accept the outcome only when it suits them. I hope that the Government will continue to accept the pay review body's recommendations in full, as they have in the past. We should also remember that—as my right hon. Friend the Secretary of State pointed out—no nurse has yet received a pay award. Personally, I hope that the awards will be well above the 2 per cent. minimum established by the pay review body: I want nurses' pay to continue to grow in real terms. We should also remember that many individual nurses will in any event receive considerably more than 2 per cent., plus the locally agreed settlement, because many receive annual salary increments.
I should say, in fairness—I try to be a fair man—that there are signs of a few recruitment difficulties in certain specialties in my constituency, but I suspect that pay is not the root cause. I suspect that the problems are also caused by something of which my right hon. Friend has considerable personal experience—continuing concern about delay in the building of our new district general hospital.
The independence of the pay review body shines through every page of its report. It is important for people outside to understand that: the Government have accepted independent advice. The report states:Pay increases for nursing staff in 1995–96 have compared favourably with awards in the public sector and been broadly in line with those in the private sector, despite problems associated with the introduction of a measure of local pay determination … We further recommend that individual Trusts should engage in 839 negotiation with their staff representatives for local pay increases in 1996–97. We note that the Government is providing 3.9 per cent. additional resources to the HCHS"—the hospital and community health services—in England in 1996–97. We have no reason to think that Scotland and Wales will be worse off. We believe that these resources should enable all Trusts to offer reasonable local pay increases to their staff, in addition to our recommended increase in national salary scales.The body is at pains to point out some of the problems as well:The Review Body is not a negotiating partner and we have not sought to determine conditions of employment. However we would be remiss if we did not point out that in our view local pay arrangements can only contribute to increasing efficiency and job satisfaction if all aspects of work organisation are considered.I hope that trusts will consider that recommendation carefully.
The review body says a great deal about its own independence. It says, for example:The Review Body has in our view always to work within the broad framework for the NHS established by Government policies: this would apply to any Government and any policy framework. This does not affect the Review Body's independence, which means that we come to our own judgement on the issues we are required to consider. We accepted in our last report that local pay determination was an inherent part of the Government's NHS reforms. In particular we felt that Trusts and staff representatives should be able to use local pay bargaining to achieve greater flexibility and efficiency in delivering health services, for example, by responding to the local labour market, or by improving the quality and quantity of patient care.That is what drives the review body, and I think that it is absolutely right. What the body says gives the lie to the line peddled by the hon. Member for Peckham, that a national health service is all about national pay scales. It manifestly is not: a national health service is not a national employment service. Addressing local issues means achieving equality of care. That is the real need of the health service. The pay review body's report makes it clear that achieving that equality can be assisted by an element of local pay bargaining. For me, that is what a national health service is all about.
I said that morale in the health service was not just a question of pay. Working in a successful organisation matters to everyone, whatever field they are in. It is certainly true that the NHS has been a spectacular success: the Labour party tries to conceal that, but, I hope, consistently fails to do so.
§ Mr. Luff
No, I do not think I will. I observed the way in which the hon. Gentleman treated my right hon. Friend the Secretary of State, and I have no particular desire to give him any currency.
This year, hospitals will carry out 3 million more treatments than in 1979 and 1 million more than in 1991, when reforms were introduced. That is reflected in shorter waiting times. Over the past five years—my right hon. Friend made this point, but it bears repetition—the number of patients waiting for more than a year has fallen from more than 200,000 to about 31,600, the lowest figure since 1948. Over the past six years, the average wait for treatment has halved.
In Worcester, the success has been particularly spectacular, as my right hon. Friend saw for himself on Christmas eve when we toured Worcester Royal infirmary 840 together. I hope that he agrees that what we saw suggested that nurse-patient relations at the infirmary were of the highest order, as they have always been. I also hope that he agrees that, during our walk around the wards, there was an atmosphere of professional dedication and high-quality patient care. That suggests to me that morale in my hospital trust is reasonably high. Perhaps in areas that we did not see it is not quite so high, but certainly it is generally good, as it has every reason to be.
Worcester Royal infirmary treated 2,851 more patients in 1994–95, and is on course to treat a surprisingly precise 3,444 in the current financial year. That represents increases in activity of 7.9 per cent. and 7 per cent. in two successive years. Further increases are planned for the coming year. Maximum waiting times have fallen sharply in my constituency. In 1993–94, the trust reduced them from two years to one; in 1994–95, they were reduced from 12 months to nine; this year, the trust is on target for a reduction from nine months to six. That is a phenomenal achievement by any standards, but it does not stop there. Worcester Royal infirmary is one of the 12 significantly improved hospitals in the national league tables. It was awarded a charter mark for its out-patient work, and it was the first hospital in England to win World Health Organisation status as a health-promoting hospital.
I know from what I see in my surgery, read in my post bag and hear from friends who have received treatment at the hospital, how grateful patients are for the quality of care that they are given there. I know that almost every patient receives an extremely favourable impression. There is a "but", however. My right hon. Friend probably knows what is coming.
Morale is also about good facilities. I am glad to say that facilities have been provided at a spectacular rate throughout the country: I believe that there has been a multi-million-pound project every week throughout the lifetime of the present Government. That is a real shot in the arm for the morale of those working with the new facilities. The massive increase in funds that the Government have made available to the NHS has made that possible.
Worcester's new hospital, however, is overdue. I am delighted to be able to tell my right hon. Friend that approval for the outline business case has now been won from the region, and the trust's ambition is to get contracts signed this year. Three private finance initiative syndicates have already pre-qualified, and the invitation to tender will go out early in the spring, with bids due in the summer. I look to my right hon. Friend to ensure that no obstacles or elephant traps are placed in the way of the new hospital by, for example, his friends in the Treasury.
I know what keeping to the predicted schedules for building that new hospital will do for the morale of the Worcester Royal infirmary trust staff. The new hospital, which will have a fine range of core services, will be one of which to be proud. I know that other hospitals in the region are facing severe difficulties because plans for them are inappropriate, but I am confident that the trust, the health authority, the region and the Department will not make those mistakes again.
I am delighted that the hospital is likely to be built using money from the private finance initiative. I am sure that that will produce some innovative solutions to the health needs of Worcester. Freeing up the supply of 841 capital should enable more such hospitals to be built in other parts of the country sooner than might otherwise have been possible.
Morale also relates to working in a well-managed organisation. Working in a badly managed organisation is incredibly poor for morale. Although I hope that nothing that the hon. Member for Peckham said suggested that management is intrinsically bad, that was the impression that I formed from her remarks. It is generally accepted that the NHS has been appallingly under-managed. Bureaucracy must be resisted and I welcome the 8 per cent. real-terms cut in administration costs across the health service that my right hon. Friend the Secretary of State repeatedly reminds us has been made this year.
I welcome the reduction in the number of executive directors in my trust. My right hon. Friend the Secretary of State's plans to fight bureaucracy are impressive. The abolition of a whole tier of the health service, opposed by the Labour party, is welcome. The merging of three health authorities into one in my county is also welcome. What does that do for bureaucracy? It does a great deal; it helpfully releases resources for patient care.
Reducing bureaucracy locally is not always as uncontroversial as it might appear. The merger of two community health trusts in my county has been opposed—sadly—by one vote on my local community health council. Interestingly, the debate and the voting was swung by the intervention of my former Labour opponent at the last election. He persuaded the community health council to oppose a further reduction in local health service bureaucracy—so much for Labour's opposition to bureaucracy at a local level. Give Labour a chance and it supports unnecessary management costs and less money for patient care. It is yet another case of do as we say, not as we do.
I think that I am right in saying that the right hon. Member for Derby, South (Mrs. Beckett) said a year ago:I do not think it's really in question any more that the NHS has been under-managed in the past.Perhaps the hon. Member for Peckham, who now speaks on such matters from the Opposition Front Bench, needs to be reminded of that. The £34 billion or so that we spend each year on the health service must be properly managed—the House has a right to expect my right hon. Friend the Secretary of State to ensure accountability and effectiveness in delivering a high level of patient care.
I do not think that many hon. Members know that I worked in the NHS for a few months in 1973, as a hospital porter. The huge scope to manage resources more effectively rapidly became clear to me. The Socialist Health Association gave some very wise advice to the Labour party last January, when it was quoted in The Guardian as saying:the NHS was traditionally under-managed and the Partythe Labour party—should avoid 'bureaucrat-bashing' … It is clear that in an organisation such as the NHS, good management is a prerequisite for good patient care".I had hoped to hear something in this debate about the Labour party's plans for the health service. As far as I could tell, my right hon. Friend the Secretary of State agreed with much of Labour's five-point plan and is already putting it in place himself.
842 The Labour party needs to bear in mind three things. First, it is still not promising any new money, yet constantly suggests that we are not spending enough. The silence when my right hon. Friend confronted the hon. Member for Peckham with that point spoke volumes. In fact, I noticed that she even avoided catching his eye while he put the point to her because she was so embarrassed by it.
Secondly, Labour's plans for the NHS, if it were ever to form a Government, involve substantial extra costs with no increased patient care. A national minimum wage would directly and indirectly increase costs through reclaimed differentials, and its plans to end competitive tendering would build costs back into the system and reduce funds for patient care.
Thirdly, even though the Labour party cannot quite work out what it does not like about our health service reforms, it plans more upheaval—even of reforms that are working well and that the medical profession has said it likes, such as GP fundholding. Those are three direct routes to lower morale. The system has experienced major change and the Labour party seems to want to impose more on it. That change is delivering the goods and should be allowed to settle down.
The fundamental test of the health service, which those who work in it should apply, is not the number of beds, the waiting list, or the management levels, but the results that it is delivering in improved health care. I have cited some of those results, as did my right hon. Friend the Secretary of State.
Two facts that really matter about the health service that should encourage the highest possible morale among all those who work in it are: a child born today has a two-year longer life expectancy than he or she would have had in 1979—that is a result of the Government's policies—and, since 1979, the proportion of babies dying in the first year of their life has halved. Such results give the lie to the Labour party's arguments.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I welcome the debate, although, like last week's, it has not added greatly so far to the sum of human knowledge. Although the hon. Member for Peckham (Ms Harman) was right to identify the lack of morale, I join others who have identified her huge flaw in not mentioning what the Labour party would do about the biggest issue connected with morale: pay. [Interruption.] The hon. Member for Fife, Central (Mr. McLeish) says that he will answer that in his winding-up speech, so I shall look—
§ Mr. Hughes
He said that from a sedentary position a few moments ago. He will either deal with the issue and we will have an answer, or he will not do so and we will go without an answer. I was not expecting an answer—I do not think that the Labour party has one. I hope that all those who are interested will read the account of the debate and realise that, although it is very easy to say what is wrong with the health service, it is much more difficult to come up with the recipe to put it right.
The hon. Member for Peckham described five points. First, she said that health professionals should be given a say, with which the Minister and every hon. Member 843 agrees. Secondly, she said that there should be an end to employees being gagged. I did not hear the Secretary of State agree with that, but my hon. Friends and I certainly do. Thirdly, she said that there should be improved safety at work, which is a general proposition that others and I would support. Fourthly, she said that there should be fair pay, which is easy to enunciate without any elaboration. The fifth point got lost in the general exchange on what fair pay might be. We clearly have to wait for another day to find out what the Labour party will do in practical terms about the pay of NHS staff.
I expressly join the Secretary of State in congratulating and thanking the people who work for the health service—the largest employer in the country—for all they do and for their dedication. That is where we ought to start. I am all too willing to support many phrases in the Government amendment. There has been considerable improvement in many parts of the health service, such as nurse training, and many of the developments have produced better qualified people.
There is, however, some difficulty. I confirm that there is low morale in many parts of the health service, which the Secretary of State has not yet addressed. I hope that the Minister will address it. It is no secret to aficionados of health service debates that across the country Liberal Democrats are surveying morale, among many other issues. [Interruption.] I shall add factual evidence that confirms that morale is low. [Interruption.] Since hon. Members are always rightly sceptical of the veracity of such evidence, I shall even cite the number of forms sent out and the number of responses returned.
The leader of the Liberal Democrat party in the west midlands, John Hemming, and the deputy leader, Paul Keech, who are respectively our prospective candidates in Birmingham and in Hereford, carried out a survey among the majority of practices—that is a real test—in Birmingham and Hereford, in which 354 forms were returned. In answer to the question, "Are you seriously considering leaving medicine by early retirement?",41 per cent. of GPs said that they were.
That survey was conducted at the end of last year. When Chris Fox, a colleague who is our prospective candidate in Windsor—the seat of the deputy chairman of the Conservative party—asked GPs in that constituency the same question, more than 50 per cent. said that they were considering early retirement. To ensure that the statistics are on the record, I should like to point out that 30 per cent. of GPs in that constituency replied, representing 70 per cent. of the practices. I shall give the House two further statistics, only to demonstrate that my proposition has many resources to back it up.
Steve Jarvis, our prospective parliamentary candidate for Hertfordshire, North-East, had a reply rate of 42 per cent. to his survey, and more than half the GPs in that constituency are seriously considering giving up medicine. The results of those surveys will be compiled in future—so that people do not have to wait for their exciting conclusion.
My colleague, Mark Oaten, who is our prospective candidate in Winchester—
§ Mr. Simon Hughes
It is not outrageous at all; it is fact. 844 Mark Oaten received replies from more than 80 per cent. of the practices in that constituency, and 47 per cent. of the GPs there were seriously considering leaving the profession by taking early retirement.
§ Mr. Hughes
Of course I shall give way to the hon. Gentleman, with whom I discover I share one thing in common—I, too, was once a hospital porter.
§ Mr. Hughes
If the hon. Gentleman and his colleagues want to join my colleagues in conducting the surveys, I should be entirely happy for that to happen and would equally attribute the results to them.
§ The Minister for Health (Mr. Gerald Malone)
I should like to clarify a point, because the hon. Gentleman has mentioned my constituency. Is this the same survey that came from the Liberal Democrats' style book of campaigning tactics, which asked, in a general sense, what Nora Batty's view was of the local health service? I must know what we are talking about. That survey predicated its approach with the view that, of course, a vast majority of people would be demoralised. If it is the same one, I should certainly like to know.
§ Mr. Hughes
I do not know whether Nora Batty features in it. However, as it is the Minister's constituency, I shall happily send him a copy of the surveys. We could then debate the health service in Winchester, as my colleague in Winchester would be happy to do.
It seems me that there is abundant evidence for my proposition. The surveys were obviously a partisan collection, but they had responses from independent professionals. The surveys are borne out by all the other evidence. It ill behoves the Secretary of State—I hope that the Minister will not make the same mistake—to fail to acknowledge that there is a common dissatisfaction among professionals. One has only to ask the representative professional bodies to confirm that; whether one asks the BMA or the Royal College of Nursing, the evidence is the same. All the briefings that Members of Parliament receive from those bodies confirm those facts.
I shall not cite the evidence which we received in anticipation of today's debate, although I shall cite two other recent pieces of evidence. The first is a report, from last June, of the Department of Health's medical work force standing advisory committee. It contained clear evidence that there is a shortage of doctors in the hospital sector, as set out on page 18, and in general practice. A significant number of posts remained unfilled and without applicants. In response to the pay review body's recommendations and the Government's response to them, Michael Lowe, the BMA deputy secretary, said in a letter:The underlying failure of the Review Body to acknowledge an act upon the excessive and unsustainable workload facing doctors is further exacerbated by the Government's gratuitous insult of phasing the award.845 That is the most telling point; doctors have complained that the award, once recommended, will be phased in.
Nurses are entirely unhappy. The general secretary of the Royal College of Nursing has said on the radio and, during the weekend, in the newspapers that nurses find a fundamental award of 2 per cent., with a prospective local top-up, entirely unsatisfactory, and that they will campaign for a 6 per cent. basic award everywhere. Of course pay is not the only influence on morale. Other things impinge on morale, such as stress and work load; the number of people working in the ward, practice or hospital; how staff are treated by management; and how often they must go for locums or to an agency. Our job is to seek to alleviate those factors; that is our collective responsibility.
I should say one other thing to elaborate the point that I made in my intervention on the Secretary of State's speech. There are acute crises in various parts of the health service. The Secretary of State was right in saying that the review body did not say that the crises were occurring everywhere. However, that does not mean that the crises are not acute where they exist. One directorate at my local hospital, in the Guy's and St. Thomas's NHS trust, lost 13 staff nurses between November last year and January this year. That loss of people from one department cannot be sustained without a huge impact.
Whenever I have gone around to my local hospital, I have been able to testify to the truth of most patients' view—to which the hon. Member for Worcester (Mr. Luff) alluded—that the staff there do an excellent job. However, the patients often also recognise how much stress and overwork the staff experience, and how that makes it difficult for staff to do the job that they would like to do.
I should like to give a few propositions on how we might proceed. My right hon. and hon. Friends and I stated our position on pay in an amendment on the Order Paper, which was in contradistinction to the Labour party's position. We believe that there should be a pay review. We ask the Government to re-think the pay increase that has been awarded to nurses and for the national pay increase to keep pace, at least, with inflation. It is extremely unfair that nurses—uniquely, out of all the people to have had a pay increase recommended—have had recommended a below-inflation pay increase. Of course I appreciate that the increase may be topped up by local awards, but the fundamental 2 per cent. award is clearly below inflation.
What shall we do? It is right to say that the elimination of short-term contracts would help considerably, because they undermine morale. One of the problems of the NHS structure, in which trusts themselves have short-term contracts, is that trusts employ people only on short-term contracts. That is a fundamental flaw in the system. There must also be increased flexibility in the types of contract that are offered. I am not saying that they should not be long-term, but people need to have sabbaticals, to share jobs and to have part-time contracts, particularly to encourage returners—the people who have left a profession, especially nursing, and want to return to it.
There must be—sadly, we heard not a word about it from the Secretary of State—effective forward planning. One of the dangers of a divided NHS, as it is under 846 the current structure, is that there is no clear planning to meet the staff demand. When professional colleagues who advised our party in 1992 examined what would be the likely result of current policy, it was found that there would be a shortage of nurses, doctors, consultants and senior registrars in many places. Indeed, we are short of those people. We are not adequately planning ahead. We cannot leave such matters to the market. We have a national health service, and it must have people to meet patients' demands. I am grateful that the Minister agrees with that, and I hope that he will tell us how the Government propose to deal with that problem, so that we can plan for adequate staff and prevent shortages.
A small point—it does not apply everywhere in the country—is that there should be adequate staff accommodation, which is a factor in recruiting younger new staff in particular. There is now less staff accommodation, and trusts should sometimes subsidise it to enable staff to work in hospitals.
We believe that there should be one NHS pay review body, to deal with the disparity between management and other pay grades. The pay of everyone, from chief executives to cleaners, would be reviewed by the same body. That would prevent the situation in which the pay levels of some grades and professions are decided without taking into account the pay levels of others. The current position absolutely gets the goat of people who work in the mainstream of the health service.
I shall take the example of my local health service. If a nurse there is on £10,000, £15,000 or £20,000 and the chief executive is on £115,000 or thereabouts, nothing will persuade that nurse that the pay levels are equitable, however big a responsibility the chief executive has.
We believe that the pay review body's recommendations should be altered or varied only with the assent of the House of Commons. If the Government decide not to follow the recommendations, as they have done this year by delaying implementation, that should require parliamentary approval. That would give parliamentary protection against the actions of any Government who wanted to change what the independent body recommended.
We believe that there should be national criteria for local flexibility. There is a need for local flexibility, but there should be national criteria to govern how that is applied. For example, there should be flexibility to reorganise the staff structure in a trust, to deal with a local recruitment problem or to reward exemplary performances. However, local flexibility should be used within a pattern established for the country as a whole.
I shall mention two more issues. First, compulsory competitive tendering should be optional, and not compulsory. Secondly, the medical hierarchy should be reformed. I could elaborate on that, but I will not. However, the present structure is not compatible in many ways with the best use of resources. If we took less time to train our specialists, if we had specialists accredited earlier by the professional colleges and if we increased the number of consultant posts by bringing people into consultant grades earlier, we would start to fill the gaps in the system.
There are ways of dealing with morale in the health service. We have a duty to health service employees and, more important, to the patients to improve morale. The implication of today's debate is that all three parties,
847 and especially the Labour party, need to come clean with the employees in the health service on what they would do in practical terms to improve morale. Words on the Order Paper are not enough.
§ Mr. Deputy Speaker
Order. There are 39 minutes available before the winding-up speeches. Four hon. Members hope to catch my eye and, with co-operation, they should all be successful.
§ Mr. Michael Fabricant (Mid-Staffordshire)
I had hoped to follow the hon. Member for The Wrekin (Mr. Grocott). I have nothing against the hon. Member for Southwark and Bermondsey (Mr. Hughes), but I sat on a Select Committee with the hon. Member for The Wrekin and he raised several important and interesting points about his constituency today. I felt that he did credit to the House by raising non-party political points, especially as he is the parliamentary private secretary to the Leader of the Opposition.
I also give considerable credit to the hon. Member for Southwark and Bermondsey. At least his party has the courage and honesty to table an amendment that gives its view about the nurses' pay review body. The hon. Gentleman did not say how he intended to fund any recommendations, if his party were ever in office, perhaps because he believes that his party will never be in office.
§ Mr. Simon Hughes
We have agreed to fund the commitment made in the amendment. I have cleared it with my Treasury colleagues and I can speak to and underwrite that commitment.
§ Mr. Fabricant
The hon. Gentleman's party is clearly prepared to put its cheque book where its mouth is. That is more than can be said for the Labour party.
I listened very carefully to the speech by the hon. Member for Peckham (Ms Harman)—I notice that she is not gracing us with her presence—and she did not say whether she supported the independent pay review body. Although she made several comments about the funding of nurses' pay, she made no commitment whatever—even when challenged by the Secretary of State—on how the funding might be achieved. It will be noted that she was not prepared to make any spending commitment on behalf of her party.
In the constant whinge from the hon. Member for Peckham, she came up with no new ideas for patient care. The Labour party appears to be bereft of new ideas, and all it wants to do is to destroy the one policy that has increased morale in the medical profession—the formation of GP fundholders.
I made the point, in an intervention in the speech by my right hon. Friend the Secretary of State for Health, that it is not by chance that every GP in Lichfield will be a fundholder by April. I have spoken to many of them—for example, Barry Jones of the Minster practice. Unlike the hon. Member for Peckham, I am not frightened to mention the names of general practitioners who speak to me. Barry Jones has told me that he has become a fundholder because it helps him to be a better doctor and to give better care
That is what the national health service is all about. We 848 have heard nothing from the Labour party except that it would destroy the system. We have not heard what new systems it might create.
We should never forget—I do not believe the point has been mentioned in the debate so far—that the national health service is the biggest employer by far in the United Kingdom. It is bigger than the armed forces. Surely the Labour party does not want to go back to the system that existed in 1948. That was a huge and unworkable bureaucracy. The hon. Member for Fife, Central (Mr. McLeish) shakes his head, but the Labour party has spent most of its time today criticising bureaucracy. Whether one runs the national health service or a large corporation, one has to decentralise control and that is exactly what we are doing.
Different criteria affect morale, as my hon. Friend the Member for Worcester (Mr. Luff) mentioned. One of those criteria is the facilities that are available. In Lichfield, we are blessed with modern facilities. The facilities in the constituencies of Mid-Staffordshire and of South-East Staffordshire mean that patients can be treated in modern hospitals. Stafford hospital was built no more than five years ago. The hospital in Cannock—I am surprised that the hon. Member for Cannock and Burntwood (Dr. Wright) is not present, perhaps because he would be the first person to recognise the truth of my point—is brand new. Massive improvements are being made at the Victoria hospital in my patch of Lichfield, where I live.
Recent improvements at the Victoria hospital in Lichfield include a recent increase in out-patient capital spending by £200,000, and an increase in spending on day surgery by £400,000. The number of staff serving out-patients has increased and there has been a huge increase in activity. The number of out-patients has increased from around 11,000 in 1994 to 15,000 in 1995 and the number of day surgery cases from 231 to 670 over the same period. Those are examples of the changes that took place in the national health service partly under the leadership of my right hon. Friend the Secretary of State, who used to be a Minister of State in the Department of Health.
There has been a fundamental change and money now follows the patients, not the other way around. That is not just a slogan. Lichfield patients who previously had to go to Sutton Coldfield, Stafford or Burton are now treated in modern facilities in Lichfield. Consultants from Wolverhampton, Sutton Coldfield and Burton now send patients to Lichfield to be treated.
I smile wryly when I hear that morale in the British Medical Association is low. I suspect that it was no lower in 1948 when the Labour Government brought in the national health service. I hesitate to say it, but the BMA is rarely enthusiastic about any form of change. The consultants were not at all enthusiastic about moving from Wolverhampton and treating patients in Lichfield. They would, of course, much rather have patients shipped over to Wolverhampton, as that is convenient for them.
I had a sneaking sense of agreement with the hon. Member for Southwark and Bermondsey when he said that we should reconsider the tiers and structures that exist in the national health service, particularly the way in which people become junior doctors, housemen and junior and senior consultants. It almost reminds me of the way that one became a pilot in British Airways in the old days: it was not due to ability, but was a matter of moving into dead mens' 849 shoes. We certainly do not want that system in today's health service, and the practice is changing because of the current reforms.
It is important to say that there are now new services at the Victoria hospital in Lichfield due not only to the national changes that have taken place because of Department of Health initiatives but to the Premier Health national health service trust. I pay tribute to Margaret Whalley, the chairman of Premier Health, and Mike Marchment, who lives in Lichfield and who is the chief executive of Premier Health. It is thanks to them and to the facilities that have been made available by the Government that new services have been installed at the Victoria hospital over the past 18 months.
Those services include rehabilitation medicine, direct access surgery, an evening radiology service, an evening physiotherapy service and additional orthopaedic, dermatology and gynaecology out-patient services. Day case income is currently £50,000 above target. There has been a massive rebuild of in-patient facilities.
Given the huge number of advertisements that we heard from the hon. Member for Southwark and Bermondsey, perhaps I might be allowed to say that I was recently invited to open a new wing at the Victoria hospital for out-patient care and minor surgery. There is an additional 20-place day unit, and the rehabilitation facilities have been extended. There are also more day surgery facilities.
In an intervention, I mentioned the statement made by a ward sister at the Victoria hospital in Lichfield when she was asked about changes that continue to take place in the Lichfield area. When she was asked whether she was demoralised, she said that she was not because she could now use her training for the first time, whereas previously she had been more concerned with the narrow area of nursing care, which had meant that she was unable to provide the service that she wanted to give to her patients.
The liaison that now exists between general practitioners—all of whom will be fundholders come this April—and the local hospital is almost returning to the sort of Tannochbrae system that used to exist before the formation of the NHS. There is a true community spirit and good patient care in Lichfield without the invidious systems that existed in the days of Tannochbrae, when people had to pay for patient care. That should never be forgotten.
One constantly hears from the Labour party about two-tier systems that cannot be substantiated. There is no two-tier system—there certainly could not be in Lichfield, as all the GPs are fundholders. Patient care in Lichfield is free at the point of service. For the first time, some consultants are having to get off their bottoms and come to Lichfield to treat patients, rather than the poor patients having to visit the consultants. That is one of the most important aspects of the changes that have taken place. We have heard absolutely nothing from the Labour party, merely criticisms and talk about dismantling the GP fundholding service. We have heard no answer to the question, how would the Labour party pay for some of the changes about which it talks?
There will never be enough money paid to nurses, but let us not forget that it was this Government who introduced an independent pay review body. This Government are keeping to their commitment of paying what the independent pay review body recommends. We should notforget that the average earnings of a nurse in 1979 were £67.80. We should not 850 forget—perhaps you, Mr. Deputy Speaker, were in the House at the time—that before 1979, under a Labour Government, nurses suffered a pay cut. It was not merely a cut in real terms, but an actual pay cut. Such a cut was unheard of.
The ward sister in Lichfield told me that not only did she suffer a pay cut when she was a nurse, but she had to worry about where she would get the sheets laundered. She said that the health service was in such a dreadful state under the so-called Labour Government that not even the most basic things could be organised. The Labour Government always claimed that they cared—perhaps they cared, but they could not deliver.
In 1979, the average earnings of a nurse were £67.80; they are now £310.90. If a nurse's average earnings had kept pace with the retail prices index—with inflation—since we inherited the 1979 wage level, nurses would now be earning only £186. A nurse now earns £310—£125 more than inflation, while the Labour party dares to teach us about how we should steward the health service.
It ill behoves the Labour party to preach lessons to us. The hon. Member for Peckham sits on the Opposition Front Bench saying nothing and avoiding the eye of the Secretary of State for Health when he asks her how she would pay for Labour's policies and what sort of funding commitment she is prepared to make on behalf of her party. Anything that now follows can only be empty rhetoric.
§ 6.7 pm
§ Mr. Kevin Hughes (Doncaster, North)
After the rant from the Secretary of State, it is obvious that the Government did not want today's debate on health. We all know that there is no good time for the Government to have a health debate, but after a week when they announced a mere 2 per cent. increase for nurses and when the Prime Minister stood at the Dispatch Box and refused to condemn the massive golden handshake given to Cedric Brown of British Gas, we can certainly see why the Government do not want health issues on the agenda.
The hon. Member for Mid-Staffordshire (Mr. Fabricant), in his closing remarks, mentioned an average nurse receiving £310 per week. I suspect that, at his advice surgery this weekend, there will be a queue of average nurses wanting to know where their share is. I do not believe that an average nurse receives £310. The hon. Gentleman may be able to ratchet the figure up by lumping together the money of consultants and chief executives, but he will not be able to arrive at that figure on the basis of the figures for nursing staff.
§ Mr. Fabricant
The figures come from the earnings-related database and the standard payroll system. The information applies to nurses—it does not include any other bodies.
§ Mr. Hughes
I certainly cannot accept that the average nurse receives £310 per week, and I do not think that the average nurse would agree with the hon. Gentleman.
The Royal College of Nursing described the nurses' pay award asderisory and out of touch",and it will not tackle the increasingly evident shortages and low morale in the service.
851 I pay tribute to the work of national health service staff in Doncaster and throughout the country who, despite the Government's policies, manage to provide an excellent service and much comfort and advice to patients. I am sure that, in initiating the debate, my Front-Bench colleagues wanted to recognise that service and to take the Government to task for what they have done to the morale of those dedicated staff over the years.
The Government surely cannot fail to perceive that morale in the NHS is low and falling, that increased work loads are causing stress and that low pay awards and the strain of increased bureaucracy are producing outrage. The Government must realise that doctors are leaving the NHS due to poor working conditions and that, worryingly, nursing shortages are increasing.
That is happening against the background of encroaching privatisation of the national health service. Beds are being shut and we hear daily honor stories of patients being shunted around the country in search of a bed. The latest, published in today's Standard, is entitled:Meningitis scare boy faced 100-mile trip for hospital bed".His parents took him to the Frimley Park hospital in Camberley, but were told to take him to Poole in Dorset. That is what the national health service has been reduced to under the present Government. Patients are being shunted from hospital to hospital and from county to county.
Artificial waiting lists are being created. Accident and emergency admissions have increased by 16 per cent. in the past five years. Do the Government not realise that doctors and nurses feel let down by a Government whose policies have made them unable to get on with the work to which NHS staff are dedicated—that of caring for patients?
There is much anecdotal evidence about staff morale in the NHS. People are very anxious about the lack of resources and about short-term thinking. There are reports from the RCN that, in my constituency, the Doncaster Royal infirmary has a shortage of theatre nurses and there are not enough specialist nurses to cover the operating theatre; yet 32 senior nursing posts have been threatened in the Trent region alone as part of the Government's proposals for management cuts. Those are nursing cuts, not management cuts.
§ Mr. O'Hara
My hon. Friend will not be surprised to hear about the position in a hospital in my area.
Faced with the task of making a 5 per cent. cut in a £4 million management budget—£200,000—the management found that they had to invest an extra £200,000 to finance the internal market. They had to meet the costs of corresponding with general practitioners in connection with meeting contractual standards and enhancing their record keeping to meet the continued data requirements of the regional office. They had to spend £70,000 on correspondence, £80,000 on medical reports and £50,000 to meet the data requirements of regional office.
Does it therefore surprise my hon. Friend to know that, when it came to the crunch, most of the cuts were in nursing staff and pharmaceutical staff and not in management?
§ Mr. Hughes
My hon. Friend is right to draw attention to that position. No, I am not surprised. His words reinforce my arguments.
852 Today, we hear of six nursing sisters working in accident and emergency at Leicester Royal infirmary facing redundancy while at the same hospital parts of the accident and emergency department have recently had to be closed on occasions due to staff shortages. There are worrying reports that the use of bank and agency staff is increasing, which obviously denies patients all-important continuity of care.
Nurse managers complain that non-clinical duties take up too much time and that they are not on the wards as much as they would like. They are consumed by paperwork. Those issues, in my constituency and others, reflect the position locally and nationally, which gives cause for concern.
Unison officials in the Trent area have reported that nursing shortages are becoming worse and that increasing numbers of staff do double shifts to keep the service running. Between 1989 and 1994, the number of nurses in the Trent region was cut by 9 per cent. while the number of managers escalated by 470 per cent. A survey undertaken by the Institute for Employment Studies for the Royal College of Nursing shows that nearly 40 per cent. of nurses in the Trent region said that they would leave nursing if they could.
The national statistics speak for themselves: 90 per cent. of nurses felt thatlocal pay will result in unfair dealsfor some nurses, and 87 per cent. felt that local pay would increase uncertainty about future pay. Moreover, an increasing proportion of nurses regarded nursing as an insecure job. As nurses leave the profession, student places have nevertheless decreased dramatically—by two thirds since 1983.
More and more hard evidence is emerging of increasing stress and low morale among doctors. As recently as yesterday, we heard of a survey carried out by Middlesex university among London GPs. It was a small survey, but the results were revealing: 98 per cent. of the doctors questioned complained that their paperwork had increased, and nine out of 10 said that they did not have enough time to keep up with medical developments. Two thirds of the GPs said that they had less time to spend with each patient since the NHS changes.
The British Medical Association recognises that many doctors are leaving the medical profession. The reasons that it cites for that haemorrhage of staff are increasing work load, inflexible training, the internal market and the long hours worked by junior doctors. In a study of 229 doctors, it was found that half had thought of leaving the profession. A recruitment survey by the National Association of Health Authorities and Trusts noted a significant fall in the number of trainee doctors wanting to become GPs. It attributes that fall to the low morale and increased work loads in general practice.
We may also consider more specific cases. Christopher Adams resigned as head consultant in February 1995 from the department of neurosurgery at Radcliffe infirmary, Oxford, after being asked to create waiting lists artificially. In an article in the British Medical Journal, Mr. Adams said that his department, which has the lowest average cost per case in England, at one point becameunsafe … hyperefficient …. with exhausted and demoralised staff"—his words, not mine.
853 The Government must answer some serious questions, not only for Opposition Members, but for nurses, doctors and patients. The Secretary of State must admit that NHS staff morale is at an all-time low, and he must admit the reasons for that and tell us what action he plans to take. Will the Secretary of State tackle the NHS staffing crisis and ensure that there are not shortages of senior nurses, especially in operating theatres and accident and emergency departments? Shortages of nurses and lack of planning for nursing needs are placing patient care at risk and contribute to low morale among nurses in the NHS. Exhausted and demoralised staff are putting patient care at risk. Medical experts express those anxieties. The Government must listen to the opinions of those professionals—the doctors and nurses who are struggling to keep the national health service running as well as it does.
The Government do not seem to realise what they are doing. They cannot continue with low pay awards for nurses and longer working hours in the name of efficiency. They cannot continually cut nursing student places in the light of increasing shortages and they cannot continue to run down the morale of NHS staff still further. The Government tell us that the NHS is safe in their hands, but the doctors and nurses do not believe it; Opposition Members certainly do not believe it—and we know that the public do not believe it either.
§ Mrs. Margaret Ewing (Moray)
I shall be brief, as the hon. Member for South Suffolk (Mr. Yeo) also wishes to speak in the 10 minutes before the Front-Bench winding up speeches begin. I could employ the old Scottish trick of speaking extremely quickly and putting all of my comments on the record. However, I shall try to condense my points, which I want to make quite forcefully.
The debate is about the morale of national health service staff. No hon. Member from any political party can be unaware of the fact that the morale of NHS staff at all levels has been severely affected over a considerable period—not just by one change, but by a series of changes which have created uncertainty. The British Medical Association produced documentation in November 1995 which pointed to a decline in morale among general practitioners, a steady decrease in the number of doctors entering training for general practice and so on.
The Royal College of Nursing has produced its own statistics. It referred me, as a member of the parliamentary panel, to an independent survey on the recruiting, retraining and rewarding of nurses undertaken by the Institute for Employment Studies in 1995. It drew attention to the fact that 60 per cent. of nurses said that they could earn more for less effort if they left the profession and almost 40 per cent. of nurses said that they would leave nursing if they could. Those findings are indicative of the many references that have been provided to those hon. Members who are interested in the subject.
I shall give the House just one example. A consultant in Glasgow picked up a copy of the British Medical Journal and found his post advertised in that publication. He had not been consulted and he did not know of any plan to replace him: he simply saw his job advertised in the British Medical Journal. Incidents of that kind do a great deal to undermine morale in the NHS.
854 All hon. Members are aware of the individual and joint views of those who work in our health service locally, including those of the Royal College of Nursing, Unison and the various local representatives of the General Medical Council. I am proud of the national health service developments that have taken place in Moray—I refer particularly to developments at Dr. Gray's hospital. However, we are far from complacent about the delivery of services as some areas continue to cause concern, and with the best will in the world, many of the issues that we have to address in Moray are related to funding.
The argument about local versus national pay bargaining can be viewed in that context. Last year the Government cunningly—if I may put it like that—announced that nurses would receive a 3 per cent. pay increase. However, the Government said that they would fund only 1 per cent. and that the other 2 per cent. must be found at trust level. It was the first time that such an arrangement had been attempted. The Government argued that the trusts would be able to find the money and that there would be no differentials in pay, irrespective of where in the United Kingdom a nurse worked. Many trusts were expected to bring forward efficiency savings to fund the 2 per cent. pay increase.
I was lucky, as my trust area managed to provide a staff pay increase of 3 per cent. across the board with no strings attached. However, that trust can make no further efficiency savings that will not impact directly on patient care. It is important to argue consistently against the idea that there should be competitiveness of that sort within the health service, but that is what is occurring with local pay bargaining.
In the present round of pay bargaining, there appears to be a deliberate attitude of divide and rule within the medical profession. The philosophy of the NHS is to ensure that there is a direct relationship between the patient and whoever delivers the service—be it consultants, GPs, nurses or ancillary workers who often play a fundamental role in patient care. In the current pay round, we are witnessing the fracturing of that relationship—which is critical to the well-being of the national health service--and a rupturing of the partnership concept.
I shall now address those problems, as I believe that every politician has a responsibility to offer constructive suggestions. We must look at the system and define what is good and what is bad; we must determine what can be retained and what must be changed. For example, do we need to spend so much money on media training for health boards? Must six people be involved in making referrals—rather than one, as was previously the case—as a result of the workings of the internal market? Should £30 million of taxpayers' money be squandered on Health Care International in Clydebank? HCI had the temerity to advertise in last Saturday's edition of The Scotsman and last Sunday's edition of the Scotland on Sunday inviting women to attend the medical centre for breast cancer screening. That undermines the idea of a national breast screening campaign, and I pay tribute to the hon. Member, for Edinburgh, Leith (Mr. Chisholm) who has been at the forefront of the campaign in Scotland.
Most importantly, all political parties have a responsibility to put their money where their mouth is. This morning, I met representatives of the British Medical Association and I put before them the Scottish National party's budget proposals, which are open to public 855 scrutiny. We have said where we would spend money in the national health service. I believe that all political parties have the same responsibility, and I hope that they will follow our lead.
§ Mr. Tim Yeo (South Suffolk)
I am grateful for the opportunity to contribute briefly to the debate and I thank the hon. Member for Moray (Mrs. Ewing) for abbreviating her remarks to accommodate me. I was attending a Committee of the House from a quarter to four until I entered the Chamber, which is why I was unable to hear the earlier speeches in the debate.
I wish to participate in the debate because of my long-standing interest in health issues, which is due to many factors—not least the fact that my family and I have had no private medical insurance since the time that I entered this place, and I therefore rely to a considerable extent on the national health service.
I obviously cannot comment on the earlier speeches in the debate, although I noted that the hon. Member for Southwark and Bermondsey (Mr. Hughes) referred to the absence of beef in Labour contributions. He questioned what the Labour party would do to improve the alleged low morale among staff in the national health service. The question of NHS staff morale is a very important one, but I do not recognise the motion's claim about growing demoralisation. No one would pretend that every detail of the NHS is perfect, but many staff are proud to work in the service: they are optimistic about its future and they relish the opportunities that the changes of the past few years offer.
I shall make two points in the short time available. The first is a historic one. I recall the state of morale in the national health service in early 1979. In January of that year, my father was in hospital and nearing the end of his life. As he was nearly 90, that was no great surprise and not particularly tragic, as it was the end of a happy and successful life—much of it spent working in the national health service. When it was clear that the NHS hospital where he was being treated could do no more for him, my mother and I decided that he should be moved to a nursing home closer to her house to spend the last three or four days of his life.
However, my father's last illness coincided with a period of industrial disruption in the national health service. I do not think that a strike is evidence of very high morale among NHS staff, but that is what occurred in the last few months of the last Labour Government. That strike may have had the consent—possibly even the active encouragement—of the trade unions which later merged to form Unison, whose support Labour Members are happy to accept.
As a consequence of that industrial action, I had to smuggle my father out of the hospital just three days before his death and transport him in a privately hired ambulance across a picket line in the middle of the night. Many of the excellent staff who had treated him were embarrassed, distressed and ashamed at what was happening. Labour party policy on the national health service had reduced their morale to a level as low as could possibly be imagined. That was the state of play in 1979.
My second point relates to this year's pay deal for NHS staff—particularly nurses. I shall not retread the ground that has been well covered by my hon. Friends, who dealt 856 with how badly nurses' pay suffered under Labour. I do not know how much nurses will get this year, although it is clear that they have every reason to be optimistic and confident about the outcome. As my right hon. Friend the Secretary of State pointed out at Question Time this afternoon, nurses have done extraordinarily well and much better under the Conservative Government.
The system of local pay and negotiation is a key advantage. Anyone who has been involved in the management of any organisation, particularly one that operates at a large number of different locations, will know that staff are happiest and their morale is highest when decisions are taken at the lowest possible level and the decision making process is devolved as far down the line as possible. Nothing is worse for staff morale than the sense that their interests are being neglected at the sharp end, that they have no input in the decision making process and that key policies are being set centrally.
The most important and influential policy decisions that affect morale inevitably concern pay, so local pay negotiations can make a huge contribution to achieving and maintaining high morale in the national health service. Those who oppose or criticise the system of local pay negotiation are actively undermining the morale of NHS staff. I particularly regret the fact that some people, both within and outside the House, have tried to distort the position by claiming that nurses have received a 2 per cent. pay offer. That is not the case. I am sure that, when my hon. Friend the Minister of State replies to the debate, he will confirm that last year's local pay decisions did more than protect nurses' interests—they produced a satisfactory outcome. This year, many local employers will add significantly to the 2 per cent. national pay increase.
As local pay negotiations become the norm over the next few years, nurses will identify even more with the national health service in their communities and employers will recognise local conditions. As someone who is extremely concerned about the morale of national health service staff, I strongly commend the system of local pay and commend the Government amendment to the Opposition motion.
§ Mr. Henry McLeish (Fife, Central)
I am pleased to reply to the debate. Let me begin with a point on which the whole House will unite. National health service staff do an excellent job year in, year out and over Christmas—a particularly difficult time—they did more than their pay levels would suggest. That reinforces the concern that has been expressed about the recent pay review, particularly by nurses. We should also praise the work of the London hospitals on Friday evening after the terrible outrage in the east end. Members will agree that the staff represent one of the most precious assets of the NHS.
As usual, we have had an interesting debate. According to Conservative Members, there are no problems. They seem to say, "Read my lips: there are no problems with the national health service."
§ Mr. McLeish
The Minister says, "No." He will have a chance to tell us about those problems when he replies to the debate. The Government intend to make no concessions to patients, the public or the Opposition.
§ Mr. Malone
As far as I can recollect, the hon. Gentleman was listening to the speech by my right 857 hon. Friend the Secretary of State, who specifically acknowledged that there were problems in the NHS and spelled them out in detail. It is quite wrong of the hon. Gentleman to suggest that he did not, and I am sure that he would like to put that right.
§ Mr. McLeish
I listened to Secretary of State, and I did not hear him enumerate the problems, but I await with interest the Minister's reply to the debate.
The Secretary of State was highly selective about pay review quotes. The essence of the debate is morale and motivation in the national health service, hut the Secretary of State forgot to mention that, tucked away in the review body report published last week, was the following paragraph:As we commented last year, changes in the wider business and labour market environment have affected the morale of employees in a number of sectors. However, the pace of change in the NHS: heavy workloads; significant and sustained pressure on resources; fears about job security; and, we suspect, the course of this year's pay dispute, will all have exacerbated staff anxieties.The Secretary of State joins us at a time when the pay review body has conceded that there are major problems of morale and motivation. Not only did he refuse to acknowledge them, but, by logical definition, he will do nothing about them.
It is important that we put firmly on record what has happened to our national health service. It is indisputable that there are major problems that are recognised by all parties, but not by the Government. Why have we lost 60,000 beds and 50,000 nurses in five years? Ministers may quibble, but those are the Government's own figures.
Ministers should not attack their own Department of Health and their own civil servants. We have 19,000 fewer nurses in training. The Government like to talk about customers, and there are now 20,000 more managers in the national health service. It is ridiculous for the Secretary of State to champion the nurses against the bureaucrats. In the past five years, we have seen front-line care disappear, and a management explosion in the national health service.
This morning, my hon. Friend the Member for Darlington (Mr. Milburn) produced an excellent report highlighting the fact that an additional £1.1 billion has been spent on bureaucracy in the past five years. That represents £6 for every second in the past five years. It is hard to find the right word to describe that, but "scandal" is the first word that comes to my lips. All those factors make it easy to deduce why morale and motivation are major problems in the national health service.
We no longer talk about bed availability; we shall soon be tabling questions about trolley availability. We shall talk not about ward closures, but about corridor closures, and, as I have said, Ministers no longer talk about patients; on a number of occasions, they have described them as "customers". Does that not underline what we have been saying over the past few years—that the Government see the national health service as a business and an internal market, but at the end of the day they do not wish to talk about the patients?
§ Mr. Ian McCartney (Makerfield)
An example of that occurred in my constituency recently, when a gentlemen 858 who had undergone an operation woke up in an ambulance, having been driven more than 30 miles to another hospital because his bed had been reallocated while he was in the operating theatre. Neither he nor his family had been informed before the operation.
§ Mr. McLeish
My hon. Friend strengthens our attack on the Government. We are living in the real world, and the NHS is populated by real patients, with real anxieties and concerns. Why do they never seem to interface with Ministers or Conservative Back Benchers, although they recount their recent visits to hospitals? They do not want to acknowledge that, despite relentlessly pursuing five years of internal reforms, they simply have not got it right. Now, they are squandering the most precious resource of the NHS—the staff, their commitment and their skills.
The debate is about morale, so we have to ask why it is at such a low ebb. The Government believe that everything in the garden is rosy, so why should we have a debate on morale in the national health service?
§ Mr. McLeish
The Minister says from a sedentary position that it is habit-forming. We would love to have a debate on the health service every week in Government time. [Interruption.] I hope that the Minister passes that note to the Leader of the House and to the Conservative Chief Whip.
Finally, I shall spell out our case against the Government. The first point that affects morale is that the Secretary of State is keen to tell interviewers that he believes that he should have private health care as a safety net. What does that do for the morale of doctors and nurses? It is not good enough. In recent interviews, he said, "We should try to make it as good as possible, but I still have private health care insurance." His predecessor, now the Secretary of State for National Heritage, may not have many qualities, but she does not have private health care. [HON. MEMBERS: "That is cheap."] It may be cheap, but it is accurate.
In the Observer on 11 February, an advertisement for Norwich Union Health Care Ltd. took advantage of the hypocrisy of the Secretary of State and others, using a quote from the Minister of State and two quotes from the British Medical Journal, all about delays. But of course, the advertisement states:The hospital says you can have a bed straight away.It adds:When it comes to healthcare, we talk sense.One disgraceful aspect of Government policy is that it is driving people into the private sector.
§ Mr. McLeish
I have little enough time left, and I have given way before to the Minister.
The Secretary of State's lead on the private health care issue is only adding to the problem.
As to the pay award, press comments read: "Anger over 2 per cent.", "Outrage at mean awards", "Nurses accuse Tories of contempt for the NHS", "Nurses to fight for rise of 5.6 per cent.", "Fury over NHS pay insult". One would have thought that the Government, faced with a battery 859 of problems, would have shown some contrition—just a bit of humility and recognition that nurses do a good job and should be rewarded. Not a bit of it. The award and the Government's response was not only insulting but provocative. Perhaps the Government want to provoke, rather than to ease the burden.
The third issue on which our case is based is the health service's future direction. The Government will try to convince everyone that their agenda is not one of privatisation or commercialisation. No one believes them. There are in place the building blocks of further fragmentation, commercialisation and contractualisation over the next year. Ultimately, through the private finance initiative, market testing and other methods, there will be privatisation. That is the challenge for the Government. That is why the public do not believe that the health service is safe in Conservative hands.
§ Mr. McLeish
The Secretary of State continues to interrupt, and I am happy that he should—but he must answer a question that he ignored earlier. What is the reason for the money-go-round of the internal market, with its bureaucrats in place? The Government lecture us on waste and fiscal prudence. It is time that official organisations within the House started to examine what the internal market is doing and its consequences.
My hon. Friend the Member for Peckham (Ms Harman) rightly highlighted the problem of recruiting nurses and doctors. The Government simply walk away. For them, the problem does not exist. If a Government are to take the NHS seriously, recruitment is the only strategy to deploy when faced with the criticisms that we are making.
Health service morale is being destroyed by the daily diet of regional and national newspaper reports of tragic incidents of hospitals posting "Full up" signs and patients having to travel across the Pennines. That issue should unite the House, as it threatens to undermine the fabric of a one-nation health service. The Government know the problems, but do not wish to do anything about them.
The Government's first line of defence is, "It has nothing to do with us. We do not collect the information. That information is not centrally held." Only after a recent parliamentary question by one of my hon. Friends are we building up the picture in respect of paediatric intensive care beds. The Government did not have relevant information. The Secretary of State said, "That is nothing to do with me. We only pass the budgets. It is over to the NHS." Thankfully but belatedly, the Government now accept that they have a role to play. The Government's defence is, "Don't ask us"—a hear no evil, see no evil, speak no evil, attitude.
The Government's second line of defence is, "Blame it on the trusts. Blame it on the managers." God forbid, there are a lot of managers around. Can the Government really pass the buck? They cannot. They set the policy. They have relentlessly pursued internal reforms for five years. The trusts are only implementing Government policy, so it seems astonishing that the Government are still blaming trusts. Their answer to every issue raised in the House and elsewhere is, "It must be due to inefficient management." Sixty thousand beds have been lost, but, according to the Government, that is still a management problem.
The Government's third defence is, "We spend more on the NHS year on year." If we accept that claim at face value and put aside inflation, technology and increasing 860 costs, are we to believe that more money is being spent? If it is, the logical question is, "Where is it being spent?" There has been extra spending on bureaucracy of £1.1 billion over the past five years, and £500 million is being spent on non-NHS provision. Under the PFI, deals are done secretly. What is the risk? What is the return? How much of the taxpayers' money is feather-bedding deals? The Government will not publish details, so Ministers should not argue and laugh.
I want to clear up any confusion that lurks in the mind of the Secretary of State on these occasions. I think that something lurks there. The Government are wedded to three words—private finance initiative. As with many other issues, the Government see no alternative way forward other than their setpieces, and no reason for dialogue.
§ Mr. Dorrell
The hon. Gentleman ought to be better informed about what his hon. Friends are up to, because, according to The Times today, the shadow Treasury Minister, the hon. Member for Edinburgh, Central (Mr. Darling)is currently meeting City lawyers and seems to be whispering reassuring wordsabout the private finance initiative. The conclusion drawn by the people in receipt of those whispers is:There may be a certain amount of rebadging, but the essentials would remain the same.
§ Mr. McLeish
The Secretary of State raises an important issue, and must deal with it. He ought to deal with the Stonehaven issue. The right hon. Gentleman goes about England saying, "No clinical services: read my lips." In Scotland, the Secretary of State has sold off virtually everything in that state hospital to the private sector. Will policy in England be contrary to that in Scotland, or is Scotland being tested in respect of the NHS as it was with the poll tax?
The Government do not like our attack on waste. There are also £100 million of GP fundholder surpluses lying unused. A recent article in the Observer suggested that NHS suppliers may be taking £400 million from the health service. It is vital that the Public Accounts Committee takes on board the workings of the internal market in the NHS. There is no accountability or no cost-benefit analysis by the Department of Health. The cost to the taxpayer and benefits to patients must be high up on such an appraisal.
I urge the Minister for Health, when he winds up, to embrace and endorse that idea, to get to the bottom of whether the internal market is working, and—more importantly—in whose interest it is working. We need to know what is happening and where the money is going. It is a Government issue of massive waste in the NHS. The Government lecture us about where cash will be found for this or that. If one considers the £1.1 billion spent on bureaucracy, one sees that there is a significant difference between ourselves and Government Members. We believe in front-line care and in doctors and nurses. We do not believe in adding further to bureaucracy.
When the Minister winds up, I would like him to answer this simple question: are the Government happy for £1.1 billion cash to be used merely to police the internal market?
§ Mr. McLeish
The Secretary of State says that, but the fact remains that we provided time for the hon. Member for South Suffolk (Mr. Yeo), who had not been in the Chamber for most of the debate, but who informed the Chair of his wish to speak.
The Government do not like to be confronted with the waste argument. The Government's case is flimsy. Their arguments, "It is nothing to do with us" or "Blame it on the trusts", will not stand up. They are spending more and more money, but creating more and more waste.
The Government pretend that bed closures are all about care in the community and continuing care. The Government simply cannot match bed closures with what is happening in care in the community. That defence will not wash with the public.
The Labour party would like the Secretary of State to face the real issues. Today, he said nothing about the crisis affecting morale in the national health service. There is a crisis at the heart of the Government's policies, which reveals the unacceptable face of their policies for the NHS. We would like to see a reprioritisation of what is happening, and a refocusing on the important issues. The public, patients, taxpayers, doctors, all the staff of the national health service and the Opposition parties cannot be wrong. The Government must listen, because if they do not, we will.
§ The Minister for Health (Mr. Gerald Malone)
I will not exactly follow the stream of consciousness of the hon. Member for Fife, Central (Mr. McLeish) with respect to the health service, but I will deal with a number of the foundation stones with which the Opposition thought they would underpin their argument today—and there were precious few of those.
I do not know why the Opposition called this debate. If it was to underpin morale on their Back Benches, they clearly have not succeeded, because no one bothered to turn up to listen.
We have heard another debate predicated on a false assertion supported by an exaggeration that the health service is in a state of collapse. The Government admit that the health service is under tension, that it is delivering more health care than ever before, that its staff are working extremely hard, and that problems must be addressed. My right hon. Friend the Secretary of State quite clearly said in his speech that the problems need to be addressed. However, we do not accept the grotesque image of the national health service, of those who work in it and of the way they feel about it that has been painted by Labour Members.
Labour Members relied on a number of arguments, which I shall deal with individually. They referred to recruitment. They said that the NHS was now denuded of front-line staff, and that there simply are not enough people to provide a service. I shall cite some figures for the hon. Member for Peckham (Ms Harman) that might change her mind, although she is not interested in evidence; she prefers assertion. I shall refer to some medical manpower numbers.
Between 1984 and 1994, the number of general medical practitioners increased from 23,640 to 26,567—a 12.38 per cent. increase. The hon. Lady would no doubt 862 argue, on the basis of assertion, that they have a far harder task. Those figures are accompanied by a decrease in the average list size from 2,089 to 1,900.
When the Opposition refer to nursing figures, they always ignore—this is perhaps one of the most unforgivable ways in which they try to bend the figures—all the changes and transfers between nursing staff, the context in which they used to work and how they work now. One reason why fewer nurses work in hospitals is that 60 per cent. of the activity is to be found in day case surgery, where fewer of them are needed. There has been a great transfer across the service and the way in which nurses work. I refer to the number of GP practice staff.
§ Mr. Malone
The hon. Lady says, "From the private sector." I do not want to talk about the private sector; I want to talk about the NHS.
In 1984, there were 25,994 GP practice staff, and now there are 51,833—an increase of 99.4 per cent. The number of nurses included in GP practice staff has increased from 1,924 to 9,099—an increase of 372.92 per cent.
These staff increases have occurred in a service that the Labour party says is being denuded of people at the front line. Where is there more of a front line than in primary care? Whose policies have ensured that these talents are now being devoted to primary care, which was not the case in the past? Since 1979, the number of nurses has increased by some 55,000. Labour Members choose to ignore—
§ Mr. Malone
I may give way to the hon. Gentleman in a moment, but I do not have much time in which to speak, because he squeezed me out. I shall anticipate what the hon. Gentleman was going to say.
Usually, Labour Members selectively quote figures and ignore what has happened in agency nursing and bank contracts. I was delighted that today, for the first time, they acknowledged the existence of such agency and bank nurses. Their failure to take those figures into account has resulted in the lower figures to which they have referred.
The Labour party has also said that there are not enough nurses in training. This year, there are 14,920 in training, and next year there will be 17,080—they are all decided by training commissions across the country—an increase of 14.4 per cent.
§ Mr. McLeish
In 1989, there were 62,100 training nurses in the health service, and in 1994, including the learners and Project 2000, there were 32,000—a decrease of 19,000. Will the Minister accept those figures as correct?
§ Mr. Malone
My right hon. Friend explained why that was so: the wastage rate has decreased by 50 per cent. Of course there will be fewer people in training if more are staying in the service. I should have thought that the hon. Gentleman would welcome the fact that retention rates were up, and that more people were finishing their training and working in the NHS rather than leaving it.
863 The other point of strength that Labour Members always think they have is what is happening to senior house officers, and we heard that argument again in the debate today. I advise hon. Members that SHO strength is extremely good. My right hon. Friend and I were both concerned about what happened in accident and emergency departments on 1 February last year, and we undertook to monitor the situation.
I am pleased to tell the House—although the Labour party will not welcome it—that SHO strength in the regions monitored to date now totals 945, and there are now 59 vacancies—only 6.3 per cent. Most trusts, when consulted, find that because of an agreement the Government have reached with the profession they are able to fill those posts with staff grade doctors. That has destroyed yet another myth that the Labour party has peddled.
Labour Members claimed that there is low morale in the NHS. I am astonished that they ignored—in fact, they considered it a matter of ridicule—what we have done about junior doctors' hours. I remember when that was the test of whether the Government would be successful in raising the morale of those who work in the hospital sector. The targets that the Government have reached are remarkable, as is acknowledged by junior doctors.
There is 99 per cent. compliance with the target to eliminate hard-pressed, on-call posts contracted for more than 72 hours a week. I inform hon. Members that 93 per cent. of the 27,994 junior doctors complied with the end of 1996 targets. That is a tremendous achievement, for which we have fought hard and in which we have invested a tremendous amount of money. It goes hand in hand with the creation of the specialist registrar grade which came into effect on 1 January, enabling junior doctors, when they get to the more senior posts, to spend more time in training than in providing service commitment.
Labour Members' solution was a five-point plan. Conservative Members agreed with four of the points—they were all apple pie and motherhood. [Interruption.] We agree with the concept of fair pay. We established the independent review body that delivers fair pay on an annual basis, unlike the Labour party, which chose to cut it. Unfortunately, the fifth point appears to have been lost—doubtless we will learn about that in due course.
The hon. Member for Peckham would not be drawn on the most important question. If she were serious about introducing a policy to improve the NHS if she were ever in government, she would say how much money would be provided. I ask her that question again—perhaps, during the debate, she has been able to have a word with the Member for Dunfermline, East (Mr. Brown) to find out the position of the Labour party in this regard.
Will she now give the House a commitment that she would at least imitate what this Government has done since 1979 with respect to increasing expenditure on the health service? Well, as the whole House can see, the hon. Lady sits firmly in her place—unable, as the health spokesman of her party, to give such a commitment. And this is a debate in which she has claimed that morale in the health service is at an all-time low.
The Opposition have been found out; the arguments they have put to the House this afternoon about the health service have amounted to no more than the usual innuendo and denigration of a service that provides 864 excellent care for the whole population. The hon. Lady's argument has been demolished. The country will recognise that, and the House will recognise it, too.
§ Question put, That the original words stand part of the Question:—
§ The House divided: Ayes 272, Noes 302.868
|Division No. 52]||[18.59 pm|
|Abbott, Ms Diane||Dalyell, Tam|
|Anger, Nick||Darling, Alistair|
|Ainsworth, Robert (Cov'try NE)||Davidson, Ian|
|Allen, Graham||Davies, Bryan (Oldham C'tral)|
|Alton, David||Davies, Chris (L'Boro & S'worlh)|
|Anderson, Donald (Swansea E)||Davies, Rt Hon Denzil (Llanelli)|
|Anderson, Ms Janet (Ros'dale)||Davies, Ron (Caerphilly)|
|Armstrong, Hilary||Davis, Terry (B'ham, H'dge H'l)|
|Ashdown, Rt Hon Paddy||Denham, John|
|Ashton, Joe||Dewar, Donald|
|Austin-Walker, John||Dixon, Don|
|Banks, Tony (Newham NW)||Dowd, Jim|
|Barnes, Harry||Eagle, Ms Angela|
|Barron, Kevin||Eastham, Ken|
|Battle, John||Etherington, Bill|
|Bayley, Hugh||Evans, John (St Helens N)|
|Beckett, Rt Hon Margaret||Ewing, Mrs Margaret|
|Beith, Rt Hon A J||Fatchett, Derek|
|Bell, Stuart||Faulds, Andrew|
|Benn, Rt Hon Tony||Field, Frank (Birkenhead)|
|Bennett, Andrew F||Fisher, Mark|
|Benton, Joe||Foster, Rt Hon Derek|
|Bermingham, Gerald||Foster, Don (Bath)|
|Berry, Roger||Fyfe, Maria|
|Betts, Clive||Galloway, George|
|Blunkett, David||Gapes, Mike|
|Boateng, Paul||Garrett, John|
|Bradley, Keith||George, Bruce|
|Bray, Dr Jeremy||Gerrard, Neil|
|Brown, Gordon (Dunfermline E)||Gilbert, Rt Hon Dr John|
|Brown, N (N'ette upon Tyne E)||Godman, Dr Norman A|
|Bruce, Malcolm (Gordon)||Godsiff, Roger|
|Burden, Richard||Golding, Mrs Llin|
|Byers, Stephen||Gordon, Mildred|
|Caborn, Richard||Grant, Bernie (Tottenham)|
|Callaghan, Jim||Griffiths, Nigel (Edinburgh S)|
|Campbell, Mrs Anne (C'bridge)||Griffiths, Win (Bridgend)|
|Campbell, Menzies (Fife NE)||Grocott, Bruce|
|Campbell, Ronnie (Blyth V)||Gunnell, John|
|Campbell-Savours, D N||Hain, Peter|
|Canavan, Dennis||Hall, Mike|
|Carlile, Alexander (Montgomery)||Hanson, David|
|Chidgey, David||Hardy, Peter|
|Church, Judith||Harman, Ms Harriet|
|Clapham, Michael||Harvey, Nick|
|Clark, Dr David (South Shields)||Hattersley, Rt Hon Roy|
|Clarke, Eric (Midlothian)||Henderson, Doug|
|Clarke, Tom (Monldands W)||Heppell, John|
|Clelland, David||Hinchliffe, David|
|Clwyd, Mrs Ann||Hodge, Margaret|
|Coffey, Ann||Hoey, Kate|
|Cohen, Harry||Hogg, Norman (Cumbernauld)|
|Connarty, Michael||Home Robertson, John|
|Cook, Frank (Stockton N)||Hood, Jimmy|
|Corbett, Robin||Hoon, Geoffrey|
|Corbyn, Jeremy||Howarth, Alan (Strat'rd-on-A)|
|Corston, Jean||Howarth, George (Knowsley North)|
|Cousins, Jim||Howells, Dr Kim (Pontypridd)|
|Cox, Tom||Hoyle, Doug|
|Cummings, John||Hughes, Kevin (Doncaster N)|
|Cunliffe, Lawrence||Hughes, Roy (Newport E)|
|Cunningham, Jim (Covy SE)||Hughes, Simon (Southwark)|
|Cunningham, Roseanna||Hutton, John|
|Dafis, Cynog||Illsley, Eric|
|Ingram, Adam||Pike, Peter L|
|Jackson, Glenda (H'stead)||Pope, Greg|
|Jackson, Helen (Shefld, H)||Prentice, Bridget (Lew'm E)|
|Jamieson, David||Prentice, Gordon (Pendle)|
|Janner, Greville||Primarolo, Dawn|
|Jones, Barry (Alyn and D'side)||Purchase, Ken|
|Jones, Ieuan Wyn (Ynys MÔn)||Quin, Ms Joyce|
|Jones, Jon Owen (Cardiff C)||Radice, Giles|
|Jones, Lynne (B'ham S O)||Randall, Stuart|
|Jones, Martyn (Clwyd, SW)||Raynsford, Nick|
|Jones, Nigel (Cheltenham)||Reid, Dr John|
|Jowell, Tessa||Rendel, David|
|Kaufman, Rt Hon Gerald||Robertson, George (Hamilton)|
|Keen, Alan||Robinson, Geoffrey (Co'try NW)|
|Kennedy, Charles (Ross,C&S)||Roche, Mrs Barbara|
|Kennedy, Jane (L'pool Br'dg'n)||Rogers, Allan|
|Khabra, Piara S||Rooker, Jeff|
|Kilfoyle, Peter||Rooney, Terry|
|Kirkwood, Archy||Ross, Ernie (Dundee W)|
|Liddell, Mrs Helen||Rowlands, Ted|
|Litherland, Robert||Ruddock, Joan|
|Livingstone, Ken||Salmond, Alex|
|Lloyd, Tony (Stretford)||Sedgemore, Brian|
|Loyden, Eddie||Sheerman, Barry|
|Lynne, Ms Liz||Sheldon, Rt Hon Robert|
|McAllion, John||Shore, Rt Hon Peter|
|McAvoy, Thomas||Short, Clare|
|McCartney, Ian||Simpson, Alan|
|McCartney, Robert||Skinner, Dennis|
|McFall, John||Smith, Andrew (Oxford E)|
|McLeish, Henry||Smith, Chris (Isl'ton S & F'sbury)|
|Maclennan, Robert||Smith, Llew (Blaenau Gwent)|
|McMaster, Gordon||Snape, Peter|
|McNamara, Kevin||Soley, Clive|
|MacShane, Denis||Spearing, Nigel|
|McWilliam, John||Spellar, John|
|Madden, Max||Squire, Rachel (Dunfermline W)|
|Maddock, Diana||Steel, Rt Hon Sir David|
|Mahon, Alice||Steinberg, Gerry|
|Mandelson, Peter||Stevenson, George|
|Marek, Dr John||Stott, Roger|
|Marshall, David (Shettleston)||Strang, Dr. Gavin|
|Marshall, Jim (Leicester, S)||Straw, Jack|
|Martin, Michael J (Springburn)||Sutcliffe, Gerry|
|Martlew, Eric||Taylor, Mrs Ann (Dewsbury)|
|Maxton, John||Taylor, Matthew (Truro)|
|Meacher, Michael||Thompson, Jack (Wansbeck)|
|Meale, Alan||Timms, Stephen|
|Michael, Alun||Tipping, Paddy|
|Michie, Bill (Sheffield Heeley)||Touhig, Don|
|Michie, Mrs Ray (Argyll & Bute)||Trickett, Jon|
|Milburn, Alan||Tyler, Paul|
|Miller, Andrew||Vaz, Keith|
|Mitchell, Austin (Gt Grimsby)||Walker, Rt Hon Sir Harold|
|Moonie, Dr Lewis||Wallace, James|
|Morgan, Rhodri||Walley, Joan|
|Morley, Elliot||Wardeil, Gareth (Gower)|
|Morris, Rt Hon Alfred (Wy'nshawe)||Wareing, Robert N|
|Morris, Estelle (B'ham Yardley)||Watson, Mike|
|Morris, Rt Hon John (Aberavon)||Wicks, Malcolm|
|Mudie, George||Wigley, Dafydd|
|Mullin, Chris||Williams, Rt Hon Alan (Sw'n W)|
|Murphy, Paul||Wlliams, Alan W. (Carmarthen)|
|Oakes, Rt Hon Gordon||Wilson, Brian|
|O'Brien, Mike (N W'kshire)||Winnick, David|
|O'Brien, William (Normanton)||Wise, Audrey|
|O'Hara, Edward||Worthington, Tony|
|Olner, Bill||Wray, Jimmy|
|O'Neill, Martin||Wright, Dr Tony|
|Orme, Rt Hon Stanley||Young, David (Bolton SE)|
|Pearson, Ian||Tellers for the Ayes:|
|Pendry, Tom||Mr. Dennis Turner and|
|Pickthall, Colin||Mr. Malcolm Chisholm.|
|Ainsworth, Peter (East Surrey)||Dover, Den|
|Aitken, Rt Hon Jonathan||Duncan, Alan|
|Alexander, Richard||Duncan-Smith, Iain|
|Alison, Rt Hon Michael (Selby)||Dunn, Bob|
|Allason, Rupert (Torbay)||Durant, Sir Anthony|
|Amess, David||Dykes, Hugh|
|Ancram, Rt Hon Michael||Eggar, Rt Hon Tim|
|Arbuthnot, James||Elletson, Harold|
|Arnold, Jacques (Gravesham)||Emery, Rt Hon Sir Peter|
|Arnold, Sir Thomas (Hazel Grv)||Evans, David (Welwyn Hatfield)|
|Ashby, David||Evans, Jonathan (Brecon)|
|Aspinwall, Jack||Evans, Nigel (Ribble Valley)|
|Atkins, Rt Hon Robert||Evans, Roger (Monmouth)|
|Atkinson, David (Bour'mouth E)||Evennett, David|
|Baker, Rt Hon Kenneth (Mole V)||Faber, David|
|Baker, Nicholas (North Dorset)||Fabricant, Michael|
|Baldly, Tony||Fenner, Dame Peggy|
|Banks, Matthew (Southport)||Field, Barry (Isle of Wight)|
|Banks, Robert (Harrogate)||Fishburn, Dudley|
|Bates, Michael||Forman, Nigel|
|Beggs, Roy||Forsyth, Rt Hon Michael (Stirling)|
|Bellingham, Henry||Forsythe, Clifford (S Antrim)|
|Bendall, Vivian||Forth, Eric|
|Beresford, Sir Paul||Fowler, Rt Hon Sir Norman|
|Biffen, Rt Hon John||Fox, Dr Liam (Woodspring)|
|Body, Sir Richard||Fox, Rt Hon Sir Marcus (Shipley)|
|Bonsor, Sir Nicholas||Freeman, Rt Hon Roger|
|Booth, Hartley||French, Douglas|
|Boswell, Tim||Fry, Sir Peter|
|Bottomley, Peter (Eltham)||Gale, Roger|
|Bottomley, Rt Hon Virginia||Gardiner, Sir George|
|Bowden, Sir Andrew||Garel-Jones, Rt Hon Tristan|
|Bowis, John||Garnier, Edward|
|Boyson, Rt Hon Sir Rhodes||Gill, Christopher|
|Brandreth, Gyles||Gillan, Cheryl|
|Brazier, Julian||Goodlad, Rt Hon Alastair|
|Bright, Sir Graham||Goodson-Wickes, Dr Charles|
|Brooke, Rt Hon Peter||Gorman, Mrs Teresa|
|Brown, M (Brigg & Cl'thorpes)||Gorst, Sir John|
|Browning, Mrs Angela||Grant, Sir A (SW Cambs)|
|Bruce, Ian (Dorset)||Greenway, Harry (Ealing N)|
|Budgen, Nicholas||Greenway, John (Ryedale)|
|Burns, Simon||Griffiths, Peter (Portsmouth, N)|
|Burt, Alistair||Grylls, Sir Michael|
|Butcher, John||Gummer, Rt Hon John Selwyn|
|Butler, Peter||Hague, Rt Hon William|
|Butterfill, John||Hamilton, Neil (Tatton)|
|Carlisle, John (Luton North)||Hampson, Dr Keith|
|Carlisle, Sir Kenneth (Lincoln)||Hanley, Rt Hon Jeremy|
|Carrington, Matthew||Hannam, Sir John|
|Carttiss, Michael||Hargreaves, Andrew|
|Cash, William||Harris, David|
|Chapman, Sir Sydney||Hawkins, Nick|
|Churchill, Mr||Hawksley, Warren|
|Clappison, James||Hayes, Jerry|
|Clark, Dr Michael (Rochford)||Heald, Oliver|
|Clarke, Rt Hon Kenneth (Ru'clif)||Heathcoat-Amory, David|
|Clifton-Brown, Geoffrey||Hendry, Charles|
|Coe, Sebastian||Heseltine, Rt Hon Michael|
|Colvin, Michael||Hicks, Robert|
|Congdon, David||Higgins, Rt Hon Sir Terence|
|Coombs, Anthony (Wyre For'st)||Hill, James (Southampton Test)|
|Coombs, Simon (Swindon)||Hogg, Rt Hon Douglas (G'tham)|
|Cope, Rt Hon Sir John||Horam, John|
|Cormack, Sir Patrick||Hordem, Rt Hon Sir Peter|
|Couchman, James||Howard, Rt Hon Michael|
|Cran, James||Howell, Rt Hon David (G'dford)|
|Currie, Mrs Edwina (S D'bylre)||Howell, Sir Ralph (N Norfolk)|
|Curry, David (Skipton & Ripon)||Hughes, Robert G (Harrow W)|
|Davies, Quentin (Stamford)||Hunt, Rt Hon David (Wirral W)|
|Deva, Nirj Joseph||Hunt, Sir John (Ravensboume)|
|Devlin, Tim||Hunter, Andrew|
|Dicks, Terry||Hurd, Rt Hon Douglas|
|Dorrell, Rt Hon Stephen||Jack, Michael|
|Douglas-Hamilton, Lord James||Jackson, Robert (Wantage)|
|Jenkin, Bernard||Nicholls, Patrick|
|Johnson Smith, Sir Geoffrey||Nicholson, David (Taunton)|
|Jones, Gwilym (Cardiff N)||Norris, Steve|
|Jones, Robert B (W Hertfdshr)||Onslow, Rt Hon Sir Cranley|
|Jopling, Rt Hon Michael||Oppenheim, Phillip|
|Kellett-Bowman, Dame Elaine||Ottaway, Richard|
|Key, Robert||Page, Richard|
|King, Rt Hon Tom||Paice, James|
|Kirkhope, Timothy||Patnick, Sir Irvine|
|Knapman, Roger||Patten, Rt Hon John|
|Knight, Mrs Angela (Erewash)||Pattie, Rt Hon Sir Geoffrey|
|Knight, Rt Hon Greg (Derby N)||Pawsey, James|
|Knight, Dame Jill (Bir'm E'st'n)||Peacock, Mrs Elizabeth|
|Knox, Sir David||Porter, Barry (Wirral S)|
|Kynoch, George (Kincardine)||Porter, David (Waveney)|
|Lait, Mrs Jacqui||Portillo, Rt Hon Michael|
|Lang, Rt Hon Ian||Powell, William (Corby)|
|Lawrence, Sir Ivan||Rathbone, Tim|
|Legg, Barry||Redwood, Rt Hon John|
|Leigh, Edward||Richards, Rod|
|Lennox-Boyd, Sir Mark||Riddick, Graham|
|Lester, Sir James (Broxtowe)||Rifkind, Rt Hon Malcolm|
|Lidington, David||Robathan, Andrew|
|Lloyd, Rt Hon Sir Peter (Fareham)||Roberts, Rt Hon Sir Wyn|
|Lord, Michael||Robertson, Raymond (Ab'd'n S)|
|Luff, Peter||Robinson, Mark (Somerton)|
|Lyell, Rt Hon Sir Nicholas||Roe, Mrs Marion (Broxbourne)|
|MacGregor, Rt Hon John||Ross, William (E Londonderry)|
|MacKay, Andrew||Rowe, Andrew (Mid Kent)|
|Maclean, Rt Hon David||Rumbold, Rt Hon Dame Angela|
|McLoughlin, Patrick||Sackville, Tom|
|McNair-Wilson, Sir Patrick||Scott, Rt Hon Sir Nicholas|
|Maitland, Lady Olga||Shaw, David (Dover)|
|Malone, Gerald||Shaw, Sir Giles (Pudsey)|
|Mans, Keith||Shepherd, Sir Colin (Hereford)|
|Marland, Paul||Shepherd, Richard (Aldridge)|
|Marlow, Tony||Shersby, Sir Michael|
|Marshall, John (Hendon S)||Sims, Roger|
|Marshall, Sir Michael (Arundel)||Skeet, Sir Trevor|
|Martin, David (Portsmouth S)||Smith, Sir Dudley (Warwick)|
|Mawhinney, Rt Hon Dr Brian||Smith, Tim (Beaconsfield)|
|Mellor, Rt Hon David||Smyth, The Reverend Martin|
|Merchant, Piers||Soames, Nicholas|
|Mills, Iain||Speed, Sir Keith|
|Mitchell, Andrew (Gedling)||Spencer, Sir Derek|
|Mitchell, Sir David (NW Hants)||Spicer, Sir James (W Dorset)|
|Moate, Sir Roger||Spicer, Sir Michael (S Worcs)|
|Molyneaux, Rt Hon Sir James||Spink, Dr Robert|
|Monro, Rt Hon Sir Hector||Spring, Richard|
|Montgomery, Sir Fergus||Sproat, Iain|
|Needham, Rt Hon Richard||Squire, Robin (Hornchurch)|
|Nelson, Anthony||Stanley, Rt Hon Sir John|
|Neubert, Sir Michael||Steen, Anthony|
|Newton, Rt Hon Tony||Stern, Michael|
|Streeter, Gary||Walker, Bill (N Tayside)|
|Sumberg, David||Waller, Gary|
|Sweeney, Walter||Ward, John|
|Sykes, John||Wardle, Charles (Bexhill)|
|Tapsell, Sir Peter||Waterson, Nigel|
|Taylor, Ian (Esher)||Watts, John|
|Taylor, John M (Solihull)||Wells, Bowen|
|Taylor, Sir Teddy (Southend, E)||Wheeler, Rt Hon Sir John|
|Temple-Morris, Peter||Whitney, Ray|
|Thomason, Roy||Whittingdale, John|
|Thompson, Sir Donald (C'er V)||Widdecombe, Ann|
|Thompson, Patrick (Norwich N)||Wiggin, Sir Jerry|
|Thornton, Sir Malcolm||Wilkinson, John|
|Townend, John (Bridlington)||Willetts, David|
|Townsend, Cyril D (Bexl'yh'th)||Wilshire, David|
|Tracey, Richard||Winterton, Mrs Ann (Congleton)|
|Tredinnick, David||Winterton, Nicholas (Macc'f'ld)|
|Trend, Michael||Wolfson, Mark|
|Trotter, Neville||Yeo, Tim|
|Twinn, Dr Ian||Young, Rt Hon Sir George|
|Vaughan, Sir Gerard|
|Viggers, Peter||Tellers for the Noes:|
|Waldegrave, Rt Hon William||Mr. Timothy Wood and|
|Walden, George||Mr. Derek Conway.|
§ Question accordingly negatived.
§ Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments) and agreed to.
§ MADAM DEPUTY SPEAKER forthwith declared the main Question, as amended, to be agreed to.
§ That this House pays tribute to the dedication and commitment of the NHS's staff; welcomes the investment in professional development for all NHS staff made by the Government since 1979, in particular the investment in high quality nurse training represented by Project 2000, the development of new nursing specialities, for example, in general practice and paediatric intensive care nursing, the increase in the number of doctors, nurses, midwives and consultants, the reduction in on-call hours for junior hospital doctors, the establishment of an independent Pay Review Body for nurses, the increase of nearly 70 per cent. in nurses' earnings, the establishment of the principle of local pay for nurses which has delivered fair and flexible settlements and the development of high quality NHS general management; commends the recent announcement by the Secretary of State for Health of an 8 per cent. real terms cut in administration budgets for health authorities and trusts next year, together with an efficiency scrutiny which will identify and eradicate unnecessary paperwork; and looks forward to the further development of the National Health Service.