§ Madam Deputy Speaker (Dame Janet Fookes)
Madam Speaker has selected the amendment in the name of the Prime Minister.
§ Ms Harriet Harman (Peckham)
I beg to move,That this House notes that patients are suffering as NHS services are overstretched, that there is a shortage of intensive care beds, that waiting lists are long and set to rise, that patients have to spend hours on trolleys in Accident and Emergency Departments because of the cuts in hospital beds and that community and mental health services are struggling to meet growing need; believes that the Government aims to reduce the NHS to a safety net service, that people should not be forced to pay to go private to get excellent and prompt care and that the NHS must meet patients' needs and expectations; regards it as a scandal that extra resources put into the NHS have been squandered by the Government on extra bureaucracy for the internal market; and calls on the Government to cut the red tape and put the money into patient care, scrap the internal market, replace GP fundholding with GP commissioning, and thereby renew the NHS as a one nation health service which is fairer and more efficient.For millions of people throughout Britain, the NHS means security and peace of mind. At a time of growing insecurity—insecurity at work and fear of crime—and uncertainty, the NHS means knowing that there is at least one area of our lives where we can be sure that we will get what we need when we need it, no ifs, no buts. That was the founding principle of the NHS that Labour created, and that remains its central principle today, or at least it should be.
But the NHS is under threat. People are having to pay for more and more aspects of their health care. If the Conservatives were to be re-elected at the next election, they would strip the NHS down to all but the basic emergency services. We know that from what the Conservatives are doing and saying.
Services are being pushed out of the NHS. Take dentistry. First, the Tories put up charges so high that the dentist's bill makes one think that one has gone private. Then it becomes harder and harder to find an NHS dentist, so people do end up paying to go private. NHS dental lists now have 2 million fewer people than two years ago.
Take long-term care. The Tories promised care from the cradle to the grave. Then they closed the nursing beds in the NHS and people now have to pay to go private or go through a means test.
More and more people are having to pay for their operations. The number of people covered by private medical insurance has more than doubled. Under the Tories it has risen by 124 per cent.
As NHS hospital beds close, private hospital beds open. During the past 15 years, the number of private hospital beds has increased by 66 per cent., while the number of NHS hospital beds has been cut by 28 per cent.
The Tories are beginning openly to admit that what they really want is for the NHS to be cut down to core services, as they describe them, so that it becomes a safety net service. The Secretary of State, in his recent statement to the House on long-term care for the elderly, said: 360The Government believe that the principal responsibility for making that provision must rest with the individual citizen … We shall continue to provide a safety net."—[Official Report, 7 May 1996; Vol. 277, c. 29–31.]On BBC's "Question Time" last month, the Chief Secretary to the Treasury said:The real question is, 'What are the key core things we should be doing and what are the things that are further down the list of priorities that are less important for health services to be doing at the public expense?'
§ The Secretary of State for Health (Mr. Stephen Dorrell)
The hon. Lady accurately quoted from a statement that I made on the subject of the social care of the elderly. As she knows, ever since 1948, social care has been a means-tested service within the welfare state. Is she committing the Labour party to making it a universal tax-funded service?
§ Ms Harman
I am saying—[Interruption.]Might I be allowed to answer?
I am saying that the Government are pushing services that used to be free under the NHS out of the NHS. People used to get long-term nursing care in the NHS. Then it was an NHS service and it was free. Now it has been pushed out of the NHS, redescribed as a social care service and is subject to a means test. It is no good the Secretary of State trying to fiddle around with definitions. A whole generation of elderly people in Britain know that the Government's promises have been broken.
§ Mr. Dorrell
I am grateful to the hon. Lady for giving way again. She knows that we have closed 20,000 geriatric beds in the NHS over 17 years and we have seen a growth in the private sector of nursing and residential care of bed space of 250,000, 80 per cent. of which are supported from public funds. Is she committing the Labour party to providing that service on the taxpayer? The elderly people of this country are entitled to know the answer to that question. Is she committing Labour to paying out of tax revenues, or is she committing Labour to continuing the present policy?
§ Ms Harman
I am saying that a whole load of services that used to be provided free in the NHS have now been pushed out of it, so that people have to pay for them or they have to be means-tested. The figures that the Secretary of State has just given the House have assisted my case.
As the Tories cut services, patients suffer. In December last year, 10-year-old Nicholas Geldard collapsed at home, seriously ill. No intensive care bed could be found for him in the Greater Manchester area, so he had to travel 69 miles across the Pennines to Leeds, where he arrived 12 hours later, but he was dead on arrival. There are many other similar tragic cases. The survey that we carried out earlier this year of paediatric intensive care units showed that during the first four months of this year no fewer than 330 critically ill children were turned away from intensive care beds—in every region of the country.
What was the Secretary of State's response to this tragic situation? He said, certainly, that there should be more intensive care beds, but he said nothing about where the extra money would come from—
§ Ms Harman
Yes, but not how they were to be funded. Up and down the country doctors are warning that patient 361 care is being put at risk and that the quality of care that they want to give their patients is suffering because the Government want hospitals to treat more and more patients, but without enough money. I should like to quote some of the doctors who have spoken up on the issue. Dr. Christopher Adams, consultant neurosurgeon at the John Radcliffe infirmary in Oxford, resigned his post, saying:It got to a stage where we were churning out patients so fast it became dangerous.As hospital beds are cut—the Tories have cut one in five NHS hospital beds—patients are forced to wait for treatment on trolleys in casualty departments. In January this year, the British Medical Association warned of a severe and prolonged crisis in the acute sector. In the Good Hope hospital, people were having to wait for long periods on trolleys in accident and emergency. Ambulances brought in more patients, but they could not be taken out of the ambulances to the A and E department because the department was already full of patients lying on trolleys, unable to be admitted to the wards because the wards were full—because bed numbers had been cut. So the patients waited in the ambulances. Then, when the ambulances were called out again, they could not do their emergency runs because patients were still waiting inside them.
In the Royal Hallamshire hospital in Sheffield, patients waited up to 19 hours on trolleys, and a consultant physician warned:For God's sake, do not get ill … To be taken as an ill patient into an acute casualty or admissions ward is now a major danger in life.Patients are waiting too long on waiting lists for treatment. That means misery for them. Having to wait a long time for treatment is the criticism that patients most frequently make of the NHS. One million people are waiting for operations; 250,000 of them have been waiting for more than six months. Long waits matter a great deal to patients and to those working in the NHS, yet only last week the Secretary of State for Health gave hospitals the go-ahead to increase the times that they make patients wait before treatment. Patients are often in pain or discomfort, and waiting puts additional stress on them and on their families and jobs.
No wonder so many people feel driven to pay to go private for the health care that they need. It is not just hospitals; community and mental health services are also struggling. But even after people have had to wait a long time for treatment, when they telephone the hospital on the day of an operation, they are often told that it has been cancelled. Last year 55,000 patients were told that at the very last minute. That number is increasing. It is unacceptable that patients have to wait months for treatment, only to have their operations cancelled on the day that they are due to go into hospital. Patients are being pushed into the private sector—pushed into paying— because of the fear and uncertainty of waiting and of operations being cancelled.
§ Dr. Charles Goodson-Wickes (Wimbledon)
I take it from the hon. Lady's speech that she endorses the fact that 362 trade union members take advantage of the independent sector—the Manor House hospital, the Benenden hospital, et cetera—and jump the queue?
§ Ms Harman
The hospital that the hon. Gentleman mentioned is a long-standing charity; it is not at all the same issue that we are dealing with today—we are dealing with the failure of the national health service to meet people's needs under the Conservative Government. People are having to pay, to go private, to get the treatment that they need.
§ Ms Harman
No, I shall not give way again.
I refer to 64-year-old David Miller, from Surrey, who had his operation cancelled no fewer than 10 times at the Hammersmith hospital. In May this year, he decided to go private, only to be told that his liver cancer had spread too far and that it was too late for surgery.
The Government tell people, "Your child needs an intensive care bed, but they are all full—sorry." People are being taken into accident and emergency departments and told, "You will be admitted, but you will have to wait hours on a trolley because all the beds in the hospital are full—sorry." People who are told that they need a hip replacement want to have it done right away, but they are told, "You will have to wait months—sorry."
While the Government are telling patients that they cannot get the care that they need, and while one in three health authorities is rationing, they are pouring money into the NHS bureaucracy. That is a scandal. The Government are saying, "We are putting more money into the NHS"—it is in their amendment, and no doubt the Secretary of State will talk about it. It is not how much money they are putting in; it is what they are spending it on. The doctors are right: the NHS needs more money for patient care, but every year the Government are siphoning off precious NHS resources. Hundreds of millions of pounds that should be going to patient care services are being put into the growing bureaucracy to run the internal market.
§ Mr. Rod Richards (Clwyd, North-West)
Is the hon. Lady aware that if we were to guarantee accident and emergency admissions in every single hospital in the country, we would have to keep approximately 20 per cent. of our hospital beds vacant and that the resources to service the beds would have to be made available? Is she in favour of that?
§ Ms Harman
The hon. Member has referred to occupation levels. It is true that because so many patients are being crowded into so few beds, hospitals do not have the capacity to deal with sudden or temporary increases in emergency admissions. That is what happened this year— there was a temporary increase in emergency admissions. There were no safety margins—one in five hospital beds had been cut—and people had to wait for hours on trolleys.
It now costs an extra £1.5 billion every year in administration just to run the Government's NHS internal market. Of course it is important to have good management of patient care services, but that is not the sort of management that we have seen growing under the Tories. The Tories have not appointed managers who are dedicated to running clinical services; they have appointed thousands 363 of extra accountants and bureaucrats to run the internal market. There are managers to draw up annual contracts, managers to consider and approve extra-contractual referrals, managers to negotiate with general practitioner fundholder practice managers, managers to send out invoices, managers to query invoices and managers to deal with the managers who are querying the invoices.
Apparently, the NHS now needs no fewer than 70 different types of managers—not managers to run the patient services, not managers to get the best out of the people and the money in a large organisation, but managers to manage the market. There are sales managers, contract managers, business managers, marketing managers—the managers who manage the market have no connection with patient care, except that they are taking money away from patient care.
The NHS is tied up with red tape and it is bogged down in paperwork. For example, last year, my local hospitals—Guy's and St. Thomas's—had to process and send out 57,000 invoices to health authorities and GP fundholders. My local health authority, Lambeth, Southwark and Lewisham, is one of the health authorities to which the hospitals send their invoices. The madness of the Tory internal market means not only that Guy's and St. Thomas's have to appoint the managers to draw up and process 57,000 invoices and send them out to GPs and health authorities, but the health authority has to appoint managers to approve and process 26,000 invoices to buy health care for its local population from local hospitals. That is madness.
Extra-contractual referrals are just one of the costly, bureaucratic examples of the Tory market madness in the NHS. Patients can now be referred to hospitals only if the GP—if the GP is a fundholder—or the health authority, if the GP is a non-fundholder, has a contract. Otherwise patients have to get approval for an extra-contractual referral.
I shall give the House details of the recent case of a woman with back pain who was being treated by her GP. She had been to the local hospital, but it could not sort her out, so she went back to her GP, who decided to send her to the Royal National Orthopaedic hospital because the problem was serious and had been troubling her for some time. The GP had to apply to the health authority for approval for an extra-contractual referral and it took five months for that to be approved.
Five people were tied up in the red tape of processing the case, let us remember, of a woman being sent to a specialist by her GP because the local hospital could not help. The GP had to fill in forms and make telephone calls. The director of public health at the health authority had to fill in forms and make telephone calls. The administrators at the health authority and the administrators and the consultant at the Royal National Orthopaedic hospital had to waste their time and money, too.
The result was that the woman was given approval to go to the Royal National Orthopaedic hospital for £120-worth of consultation. That was the value placed on her treatment, but we calculate that the bureaucratic cost of seeking the approval, after all the procedures that had to be followed, was no less than £360. The treatment was worth only £120, yet the bureaucracy spent £360 to authorise it. If the Government cut the red tape and put 364 the money into patient care, three patients could have been treated at the Royal National Orthopaedic hospital instead of lingering on waiting lists.
§ Ms Harman
If the Secretary of State wishes to intervene, will he confirm that he will abolish the extra-contractual referral system, which we warned all along was wrong? Will he abolish it and put the £22 million that it costs every year into patient care? Will he admit that we were right and that the system was market madness?
§ Mr. Dorrell
The hon. Lady has accurately described the process of the extra-contractual referral system as it now is, but she has omitted to mention that I announced a month ago that it will be simplified.
§ Ms Harman
I know well the announcement that the Secretary of State made a month ago. I read the document, which has the catchy title "Seeing the wood, sparing the trees"—it emanates not from the Ministry of Agriculture, Fisheries and Food, but from the national health service executive. I have examined carefully what the Secretary of State plans to do with extra-contractual referrals. He seeks not extra-contractual referrals, but compliance with a protocol: it is the same market madness. Until the Secretary of State recognises that he cannot run the service through the market, he will continue to pour hundreds of millions of pounds into bureaucracy that should go into patient services.
The Government are seeking protocol compliance instead of extra-contractual referral approvals. But it will make no difference: it will still tie up GPs, hospital consultants and those in the health authority. However, instead of ECRs, it will be protocol compliance. That is nonsense.
§ Mr. Dorrell
The hon. Lady responded to my challenge when I said that she did not understand it. She cannot understand it if she claims that the health authority will still be involved in the approval of ECRs. That is what we are abolishing.
§ Ms Harman
Health authorities will be involved in drawing up the protocol and establishing compliance with it. They are specifically included in the protocol requirements with which GPs must conform. It is not me, but the Secretary of State, who does not understand how the system will work.
It cannot be right that, while more managers are being appointed to run the internal market, the number of nurses on the wards is being cut. There are now 20,000 more managers in the NHS than there were five years ago. At the same time, there are 50,000 fewer nurses on the wards. That means that there are more people to count the cost of care and fewer people to provide it. The expenditure 365 of public money must command public support. The public do not want to see money drained from their front-line services into bureaucracy.
There is no point in the Secretary of State saying that he will reduce the number of managers and that he is "bureau-sceptic". His Government created the internal market and that system demands bureaucracy. Until he scraps the market, the demands for red tape will grow and grow. The administrative costs of the NHS have soared from £2 billion to £4 billion in the past 10 years. But that is only the beginning, because the market is still in its infancy. Only half of GPs are fundholders. If the Government were to take forward their plans and all GPs were to become fundholders, administration costs would double.
A hospital that is quoted in the Secretary of State's report complains that it must have 900 separate annual contracts with 900 different fundholders. If the Tories got into office again, that hospital would have 2,000 fundholders and 2,000 separate annual contracts. It would have to send out hundreds of thousands of invoices every year.
As I predicted, the Secretary of State has said that his recent efficiency scrutiny report will reduce bureaucracy in the NHS. However, the savings that he purports to announce do not exist—they are wishful thinking. It is an inescapable fact that his system—the internal market—drains £1.5 billion a year from patient care into bureaucracy. The Government cannot scrap the bureaucracy because they will not scrap the internal market. They will not do what the people want: cut the red tape and put the money into patient care.
The provision of public services must command public support. Public services must provide what people want and people's expectations will change over time. Labour will renew the NHS. We will strip out the market, strip away the bureaucracy and put the money into patient care. We will also recognise changes in people's lives and in their aspirations. People want services that fit in with their lives—they do not want to reorganise their lives around service provision. People do not want to have to wait and then receive an appointment card through the post—which probably arrives while they are on holiday—telling them when it is convenient for the NHS to treat them.
Last year 5 million patients did not turn up for out-patient appointments—the technical term is "Do Not Attends". Those 5 million people received appointments without being asked whether they could make them and they were unable to cancel them. People receive appointment cards through the post—at last notifying them of the date of their appointment—but if they try to contact the service provider they may get an answerphone or they may be referred to someone else. Therefore, they are unable to cancel their appointments.
People want to book a time for treatment that fits in with what is going on in their lives. It should not be a matter of waiting until a person is told when his or her hernia operation will be done. People should be able to choose the time so that an operation interferes with their work or family arrangements as little as possible. People want a say in where, when and how they are treated. They do not want to wait. The private sector knows that, which is why the newspapers and our letter boxes are full of invitations to go private.
366 The advertisements say, "The NHS makes you wait. You don't want to wait and you don't have to wait—go private". The system then becomes more unfair and more expensive. Those who can afford it, go private—many of them reluctantly. Those who cannot afford it are left using a service that inexorably becomes a poor service for the poor. Any service that is used exclusively by those who have no other choice is doomed to decline. A public service cannot thrive on a captive audience. While more and more people become refugees out of the NHS, those who cannot afford to pay to go private are left behind. They are not grateful, but resentful because they cannot get the care that they need promptly. People should not have to pay to go private: they should get what they need on the NHS. The Government should cut the waste and cut the waiting. They will not, but Labour will.
The choice before the country is clear: a struggling NHS that is being stripped back to a safety net under the Tories or a one-nation NHS that is renewed as a public service under Labour. The British people want Labour's future for the NHS. That is one of the many reasons why Labour must become the Government after the next election.
§ Madam Deputy Speaker
For the convenience of the House, I inform hon. Members that Madam Speaker has decided that there shall be a 10-minute limit on speeches between the hours of 7 pm and 9 pm.
§ 5.7 pm
§ 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:'congratulates the staff of the National Health Service for providing high quality care to a record number of patients, and notes that their achievements have been underpinned by the Government's unique commitment to increasing National Health Service funding, which has meant an extra £9.5 billion since 1992, and is dismayed that the Opposition proposals put ideology before patients, in particular by removing the option of fundholding from the 50 per cent. of general practitioners who have decided that this system offers the best prospect for their patients.'.This afternoon, the House has witnessed yet again a spectacle with which we have become depressingly familiar during health debates. The hon. Member for Peckham (Ms Harman) had time to set out clear answers to the questions that many people within and outside the national health service are asking about the Labour party's future policies for the NHS.
What are the hon. Lady's answers to the questions about the future of primary care? What are her answers to the questions about the future of mental health care and cancer care? How would she organise training and research within the national health service? How would she address the questions of clinical effectiveness that are at the core of modern health care delivery?
The most important question from the British Medical Association this week is how much money Labour would put into the national health service. Will Labour give a commitment to deliver more than an average of 3 per cent. growth in real terms over 17 years? That is what we have done since 1979. Will Labour commit itself to matching our funding record for the national health service?
§ Ms Harman
When the Secretary of State mentions the increase in resources that he has taken from the public 367 purse and put into the NHS, will he say how much of that figure he has siphoned away into bureaucracy? Will he confirm that, in one year, 50 per cent. of the extra resources in the NHS were siphoned off and never went anywhere near patient care?
§ Mr. Dorrell
The hon. Lady had better contain her patience, as I have quite a lot to say about the internal market and administrative costs. I shall come to that in the fullness of time.
When I gave way to the hon. Lady, she dodged the question about how much money Labour in government would provide the NHS. The House and the country will understand that, in one speech, the hon. Lady cannot cover all those questions, but it is depressing that she did not touch on a single one of them. That is something that neither I nor the country will understand. No wonder the Leader of the Opposition is already returning to the charge of postponing the shadow Cabinet elections. We see in today's edition of The Daily Telegraph that the Labour Whips have told the Leader of the Opposition that the party's health spokesman faces a humiliating defeat and that she could receive as few as 40 votes. We know that the right hon. Gentleman is loyal to the hon. Lady. Nobody could accuse him of being anything other than very loyal—indeed, almost touchingly and sentimentally loyal—to the hon. Lady. He talks a lot about middle-class insecurity. He seems to see the hon. Lady as an important element in meeting the concerns about middle-class insecurity.
My sympathies are with Opposition Back Benchers, because from their cradles they have been brought up to believe that the NHS is home ground for Labour. They are used to losing arguments on defence. Indeed, they do not remember winning an argument on defence. They are used to losing arguments on the economy. They are not very interested in wealth creation. They are used to losing arguments on law and order, because they know that they voted against all the effective measures. What they cannot forgive the hon. Lady is that they are now losing arguments on health within the NHS and the country as well.
To my hon. Friends I say spare a thought for Labour Back Benchers in their predicament. Here we are in a pre-election year, and the Labour leader, last week, went to a major health service conference to deliver a much trumpeted speech, which was said to set out Labour's agenda for the future of the NHS. How was that speech received the following day? The Independent devoted its whole editorial to an assessment of the Labour leader's speech.
§ Mr. Dorrell
It did not mention me that day because I had not yet spoken.
Under the heading "Labour on health: an acute case of evasion", the editorial said:not a great deal was to be expected of Tony Blair's keynote speech on health yesterday. In the event, even less was offered.
§ Mr. Dorrell
It was received as a failure by The Independent. Let me quote further. [Interruption.] 368 The doctors were not there in huge numbers, either. It was primarily a conference of health authorities and trust managers. [Interruption.]
§ Madam Deputy Speaker
Order. There are too many sedentary interventions, particularly from hon. Members on the Front Benches. I expect Front Benchers in particular to set a good example.
§ Mr. Dorrell
The editorial continued:professionally, organisationally and morally the health service is in remarkably fine fettle. To suggest otherwise, as Labour may well do, is to play into the hands of those merchants of social policy apocalypse who are willing us into a crisis that does not and need not exist".I do not agree with everything that The Independent writes, but I agree whole-heartedly with that.
§ Mr. Robert Ainsworth (Coventry, North-East)
If the Secretary of State wants to know what is depressingly familiar, and if he is genuinely concerned about Opposition Back Benchers, he will be aware that our speeches will be limited to 10 minutes. He has spoken for seven minutes and has not said a word about the NHS or about his Government's record over the past 17 years. Will he please get on to the subject at some point?
§ Mr. Dorrell
I can well understand the hon. Gentleman's sensitivity when his leader's speech on Labour's home subject is received as badly as that by The Independent.
The person responsible for that policy failure is the hon. Member for Peckham. I shall go through some of the themes that she developed in her speech—they are familiar Harman themes—and analyse precisely what they mean. Let us begin with the slogan "Labour would abolish the internal market". I want to be clear about what the phrase "the internal market" means. We have a system under the reformed health service where we do not fund hospitals and health providers directly. We fund them through purchasers. We fund those purchasers in turn on the basis of need through a weighted capitation formula.
§ Mr. Dorrell
I remind the hon. Gentleman that his party is committed to maintaining precisely that structure.
Health authorities are in turn free to commission care from individual trusts and other providers of health care in a way that reflects local need and the views of general practitioners, both fundholding and non-fundholding, including commissioning. The market, in so far as an internal market exists in the NHS—it is a phrase of which the hon. Lady is fond—exists because the purchasers control the money into the system and are free to decide which providers in the health service meet the needs that they identify.
§ Mr. Dorrell
No. This is an important point. I want to develop it; then I shall give way.
369 That is the sense in which there is a market. Funded purchasers are free to decide where they commission care. The health service wants to know which elements of that system the Labour party would change if it were given the opportunity. The policy document that it issued last summer was absolutely clear on this matter: it would not change the separation between purchase and provision. It said clearly:We want health authorities to commission care, but we do not want them to run hospitals on a day-to-day basis.So the Labour party maintains the distinction between purchaser and provider. Furthermore, the policy document was also clear that purchasers would be free to choose where they placed their commissioning arrangements.
§ Mr. Dorrell
I said that I shall give way in a moment. I want to develop this argument.
Again I quoteHealth authorities will have agreements with different local health services and will have choice as to where to place them to suit patient needs.Last summer, Labour was committed to maintaining both key elements of what the hon. Lady describes as the internal market.
Not more than a fortnight ago, the hon. Lady went to the Institute of Health Services Management to deliver a speech. A passage of her speech was headed "Abolishing the Market", so I was interested to read it to understand precisely which of the two building blocks of the market she would strike away. Would it be the separation of purchase and provision, or would it be the freedom of purchasers to choose where they commissioned care? Her speech was clear in answer to the first question. She—no more than her predecessor—is not in favour of abolishing the distinction between purchase and provision. She said:The planning of health services and the delivery of health care are distinct responsibilities. They will be kept separate.That could not be clearer. But what is very much less clear to me, and I suggest it should be to the hon. Member for Islwyn (Mr. Touhig) if he reads the six-paragraph section on abolishing the market, is how maintaining the purchase and provision system that we have established— [Interruption.] I am quite prepared to amend the terms to planning and commissioning, as the distinction between them is not very different. In what sense does that deliver abolition of the market?
The question that the hon. Lady did not answer in her speech to the IHSM was whether she maintains the second commitment made by her predecessor, in regard to the planning of health authority functions. Would health authorities be free to choose, in the interests of local people, where they commissioned their health care? If the answer is yes, there would be no change in the present internal structure of the health service; if the answer is no, there is a fundamental change. In that event, the hon. Lady would indeed be abolishing the internal market. We are entitled to know whether that is the policy that Labour would pursue.
The question to the hon. Lady is extremely simple: would Labour abolish health authorities' right to choose the commissioner that satisfied the needs that they have 370 identified, or not? I am happy to give way to the hon. Lady, so that she can clarify whether Labour would abolish that freedom to choose.
§ Ms Harman
The Secretary of State has involved himself in an administrative confusion. In my speech, I gave the example of a woman with back pain. She had used the service of her local hospital, to which she would have been referred by her GP. If she cannot be dealt with in that hospital, her GP will refer her to the Royal National Orthopaedic hospital. She will either use her local services—if she and her GP decide that they should start her care—or be referred to a specialist hospital. The patient and her GP, not some bureaucracy, will decide.
Yes, there are distinct and separate functions. That seemed to confuse the Secretary of State. He says that on the one hand there is responsibility for the day-to-day running of services in the hospital, and on the other hand there is responsibility for assessing the health needs of the local population and planning and shaping services to deliver longer-term improvements. Those are simple functions, but it might help the right hon. Gentleman to concentrate on our view—with which we have been consistent throughout—that the decision on where a patient should go is not a commissioning decision, but a decision to be made by the patient and his or her GP.
§ Mr. Dorrell
That argument has two fundamental flaws. First, many aspects of health care are not the subject of GP referral. The hon. Lady has not told us who decides where provision is commissioned when there is no GP referral. Secondly, she has said that the health authority is responsible for planning the pattern of health care provision, but if the GP has absolute freedom of referral without any reference to the health authority's planning, there is no connection between the planning and the referral.
The hon. Lady has not made clear the means by which health authorities discharge their obligation to ensure that health provision in a particular district meets the need that they have identified. That is the question that she must answer. Are health authorities free to choose the hospitals from which they commission, or not? The hon. Lady has avoided that question again.
§ Mr. Touhig
I am very interested in what the Secretary of State has been saying about commissioning and the market. Would he care to comment on Gwent health commission's decision to market-test the care of the terminally ill? The main provider of that care is a local charity which spent £10,000 on its tender bid, only for the commission to abandon the whole procedure halfway through. Is that a sensible use of resources and planning?
§ Mr. Dorrell
Any health commission that is deciding which services best meet the needs of its patients should be free to look at alternative providers, whether, in the case of terminal care, the provider is a charity-funded hospice or part of the NHS. The principle that a health authority should be free to choose where to commission care is a fundamental part of good management, and I do not resile from it.
§ Mr. Burden
The Secretary of State said earlier that health purchasers should be free to purchase care for their local populations with resources given to them on the 371 basis of need. Last year, the right hon. Gentleman promised health authorities a 1.1 per cent. increase. Birmingham was given an increase of 0.5 per cent.; rather surprisingly, Huntingdon was given a 1.7 per cent. increase, despite being shown to have one of the highest levels of bureaucracy in the country. Is the right hon. Gentleman saying that Huntingdon's health care needs are greater than those of Birmingham?
§ Mr. Dorrell
As the hon. Gentleman knows, I am simply saying that there is a formula determining the distribution of resources—a need-based formula, devised for us in the university of York. The hon. Member for York (Mr. Bayley) knows very well how that formula evolved. If the hon. Member for Birmingham, Northfield (Mr. Burden) knows of a better way of channelling resources to different health authorities, reflecting both population and need, we shall be happy to hear from him. As the House knows, we allow the system to evolve every year.
§ Mr. Bayley
The Secretary of State did not acknowledge that the Government refused to implement the independently determined formula. Instead, they amended it in order to shift resources from the north to the south, and from inner cities to shire counties.
As the right hon. Gentleman is having difficulty in understanding the difference between Labour and Conservative policy on the NHS internal market, may I give him a practical example? My constituency contains an extremely large fundholding practice with 20,000 patients. That practice decided to shift its contract for community health services from one trust to another, believing that that would improve services for its patients. Its action greatly weakened the services of the trust that it had formerly used, and the level of community health service support for all the other GPs in York declined as a result.
The difference between Labour and Conservative policy is that the Conservative party's free market approach allows such dog-eat-dog developments, while the Labour approach of commissioning would make one general practice deal with another and reach agreement on the best pattern of local services.
§ Mr. Dorrell
Not for the first time, the hon. Gentleman had better clear his line with his hon. Friend the Member for Peckham. Only a few minutes ago, the hon. Lady was saying that, under her system, GPs would have absolute freedom to decide where patients were referred. It is essential to focusing on the delivery of high-quality care for those responsible for fashioning the pattern of provision to do so in the way that is dictated by the interests of the patients for whom they are responsible. That is the merit of the fundholding system.
Let me give the last word on the merits, or otherwise, of the system that we have introduced, which grants health authorities greater freedom to decide where to commission care. That last word should, perhaps, go to Lord Winston, a Labour spokesman in another place. According to him, 372The internal market has resulted in many hospitals improving outpatient facilities, improving comfort for patients, improving waiting times in clinics and in some cases improving waiting lists."—[Official Report, House of Lords, 26 February 1996; Vol. 569, c. 1460.]There is no doubt that that has happened. That is the case for the internal market, which the hon. Lady is committed to abolishing—or so she says; she cannot substantiate the commitment.
Another issue which the hon. Lady is fond of discussing is that of administrative costs. We have heard more from her on that subject today. Both she and the Leader of the Opposition are fond of referring to what The Independent, in that same editorial, described as a "golden stream" of resources available from administrative savings.
The hon. Lady's problem is the same as that of the Leader of the Opposition: no one believes them, for very good reasons. It is the original political mirage. The hon. Lady says that we do not need to provide extra resources; we can secure all the resources through administrative savings.
§ Mr. Dorrell
We have not. We have delivered growing resources to the NHS and a more efficiently managed health service for more than 17 years, because benefits to patients are our driving consideration.
The right hon. Member for Derby, South (Mrs. Beckett), who was the predecessor of the hon. Member for Peckham as Labour's health spokesperson, was clear about NHS management. On 19 February 1995, she said on "The World This Weekend":I don't think it's really in question any more that the NHS has been undermanaged in the past.What would Labour do about ensuring that the NHS of the future is efficiently managed? The hon. Member for Peckham is fond of talking in general terms of saving £1.5 billion in administrative costs, and she did so again today, but that proposition is absurd.
§ Mr. Dorrell
The hon. Lady denies saying that. I will quote her verbatim from an interview which she gave on 20 June, not long ago:As we have said, we think the overall figure is somewhere between £1.4 billion and £1.7 billion.The hon. Lady says that is the extent of the resources that will be available to expand provision. How would Labour deliver remotely that sum of money?
§ Ms Harman
We have said, and we stick by this claim—the Government's figures and independent estimates support this—that it costs an extra £1.5 billion every year in administrative costs to run the market. If one abolishes the annual contracting round, all the people needed to negotiate contracts will no longer be required. If fundholding is replaced with GP commissioning, hundreds of thousands of invoices will not have to be processed by managers. When there is freedom of referral and patient choice instead of the bureaucracy of extra-contractual referral, there will be no need for all that paperwork. Chris Ham said on the "Today" programme: 373They can release hundreds of millions of pounds from the internal market and put it into patient care.
§ Mr. Dorrell
The hon. Lady has been more precise than Chris Ham. She claimed that she will release £1.5 billion. The House must assess the plausibility of that claim, remembering that total NHS expenditure on general and senior managers, and on administrative and clerical staff in 1994–95, was £2.4 billion.
§ Mr. Dorrell
No, that figure is a lot more than M2. It relates to all administrative and clerical salaries in the NHS. The hon. Lady claims that she can save almost exactly 60 per cent. of total spend. I invite the House to test that claim against basic plausibility. Does anyone believe that the hon. Lady, by taking over my job, can release 60 per cent. of the health service's administrative costs? In the interview that I quoted earlier, Nick Ross asked the hon. Member for Peckham to demonstrate how she would set about releasing 60 per cent. of NHS administrative costs. She started with an example involving £20 million. She may have identified one saving of £20 million, and I assume that was not the smallest that the hon. Lady could think of—it was probably one of the largest. The hon. Lady must find another 74 examples to get near her target of savings of £1.5 billion.
§ Mr. Eric Martlew (Carlisle)
In 1977, Cumbria had one health authority and the only salary paid was £2,000, to the chairman of that quango. Today, Cumbria has two health authorities and seven trusts at a cost of £332,000. Is that money not spent on bureaucracy?
§ Mr. Dorrell
The hon. Gentleman is wrong in several respects. In 1977, every part of the country was covered by a general practitioner committee, health authority, area health authority and regional health authority. [HON. MEMBERS: "NO."] Labour Members may deny that that happened, but in 1977, every part of the country was within a health region, area and district—and was also covered by a family practitioner committee. Another problem for the hon. Member for Fife, Central (Mr. McLeish) is that Labour is committed to maintaining the distinction between health authorities and health providers.
Two other factors make the Opposition's claim of £1.5 billion savings wholly absurd. One of the big administrative savings which we made in recent years was from the abolition of regional health authorities—which Labour voted against. Removing that unnecessary tier produced savings of £100 million. The £2.4 billion spent on administration accounts for 7.5 per cent. of the NHS total spend. How much does the hon. Lady intend to save from that sum? I have already committed the Government to a programme of administrative savings to reduce administrative costs by £300 million, which is 1 per cent. of the total. If the hon. Lady thinks that she can go beyond that, she owes it to the House and to the country to explain how.
§ Mr. Simon Hughes (Southwark and Bermondsey)
NHS consultants, the Royal College of Nursing, the British Medical Association and family doctors, apart from asserting that the money spent on administration is 374 a misuse of resources, complain about the impact of the paperwork and bureaucracy brought about by the 1990 Act. Does the Secretary of State say that they are wrong? Does he accept those complaints, and will he do something to meet those serious concerns—which are driving many people out of the profession?
§ Mr. Dorrell
I have implemented the recommendations of two efficiency scrutinies which were designed to reduce unnecessary administrative processes. When the Leader of the Opposition addressed the National Association of Health Authorities and Trusts last week, he acknowledged that nowhere in the health service was there an appetite for further fundamental administrative reform, which is why I am confident that Labour would not deliver the pledge that it is fond of making, to abolish the internal market. I am confident, because when Labour Members are asked to demonstrate how they would do that, they never can.
Another question for which we await an answer from Labour Front Benchers relates to fundholding, which has troubled them ever since fundholding was established. The policy background is clear. More than one half of GPs have opted into fundholding because they believe that it delivers the best prospect of care for their patients. [HON. MEMBERS: "NO."] Labour Members must ask GPs what other purpose they had. If GPs do not believe that fundholding offers the best prospects of improving patient care, one must inquire why they made that choice.
§ Mr. Dorrell
The Audit Commission recently examined fundholding, and its director was asked about its report. He said on radio:Most fundholders have…produced some benefits for patients and 10 per cent. of fundholders have done very well indeed.Given that 10 per cent. of fundholders have done well and all fundholders have produced some benefits, what is the proper response? We are clear that the right way forward is to level up. Where 10 per cent. of fundholders have led, we should encourage and ensure that others follow, to deliver the same benefits to their patients. Fundholding and the system that lies behind it are a ratchet to improve standards and efficiency. Labour takes a different approach. I want a precise answer to this question.
Does the hon. Member for Fife, Central speak directly and with authority for Labour on the subject of fundholding? On 6 March, he went to Guildford—to the South Thames Fundholders Association—and, to that assembly, committed a Labour Government to abolish fundholding. His words were:Fundholding will end on 31 March 1998",the year after an election, assuming that it would take place next spring. He went on to say:The Audit Commission has shown that fundholding managers have not achieved anything worth saving. They will go.Is that true? The hon. Gentleman said that fundholding managers will go?
§ Mr. Dorrell
So it is not the Labour party's policy to abolish fundholding? We cannot run fundholding without 375 fundholding managers. Will they go or will they not? They are real people with real jobs. They are entitled to know whether the Labour party will sustain them in jobs. Will they go or will they not go? What is the answer to that question? We are entitled to know. I give way to the hon. Member for Peckham or to the hon. Member for Fife, Central.
§ Ms Harman
I have said that we will replace GP fundholding with GP commissioning. We will do that not only because GP fundholding is unfair, part of a two-tier system, and because it makes it impossible to plan improvements across a locality, but because it costs hundreds of millions of pounds in bureaucracy and provides no extra benefit for patients.
If there is a simple choice between employment of more practice managers or administrators to support practice managers and more health visitors or midwives—that is, in fact, the choice—we will choose to put cash into front-line patient services. We will not, as the Secretary of State is doing, champion mountain upon mountainous layer of extra bureaucracy. How on earth can he justify that?
§ Mr. Dorrell
No one can say that I have not given the hon. Lady an opportunity to clarify the policy. The hon. Member for Fife, Central was clear: he said that fundholding would end. The hon. Lady has refused to endorse that policy. If the hon. Gentleman wishes to remove any doubt, I shall give way.
§ Mr. McLeish
I am very happy to put the record straight. With his experience, the Secretary of State should be a bit wiser in the material that he uses. The simple fact is that, after addressing a group of south Thames fundholders at their invitation, three of the fundholders—whom I regard as enthusiastic fundholders—provided copy to the periodical to which he referred.
All the comments which were made were complete and utter lies. I cannot say anything more to put the record straight. They were made deliberately to achieve that in which the Secretary of State is indulging. I regret that, but I hope that I have put him straight on the record. I tell him sincerely that those comments and ideas attributed to me were not simply wrong; they were untruths.
§ Mr. Dorrell
I accept that the hon. Gentleman was not accurately reported in that meeting, which, in itself, is not the most important issue in the world. What is important is for those who work in the fundholding system to know whether Labour would end fundholding. We still do not have an answer.
§ Mr. Dorrell
In that case, why is the hon. Member for Fife, Central at such pains to deny that he defended Labour policy to the south Thames fundholders? It is true or is it not true?
§ Mr. McLeish
I expect a great deal more from a struggling Secretary of State. We are replacing fundholding. Read my lips: we are replacing fundholding. I said that the comments to which he referred were simply 376 untruths passed on from a meeting. That is the important distinction which he must draw. I hope that the Secretary of State will control his worst excesses and apply himself to the facts. We will replace fundholding.
§ Mr. Dorrell
I understand what happened at the Thames meeting. I am simply picking up on the question of the word "end". I asked whether the Labour party would end fundholding.
§ Mr. Dorrell
Again the hon. Member for Peckham says, "Yes." Why is it that the hon. Member for Fife, Central leaps to his feet to deny that he used the word "end" when he went to the south Thames meeting on 6 March? The truth is that Labour Front Benchers have not agreed among themselves—still less have they agreed with anyone else in their party—what their policy is, and that is true not only on the fundholding issue.
The same problem exists on the private finance initiative, which is an absolutely key issue for the NHS. The PFI offers the health service the prospect of escape from a system of capital planning of which it has been a prisoner since the day it was established. The PFI offers escape from short-termism. The Leader of the Opposition understands that. He said:The PFI is right in principle.That may be the only matter on which he agrees with the right hon. Member for Kingston upon Hull, East (Mr. Prescott), who claims paternity of the PFI.
So the senior people in the Labour party are quite clear where they stand on the PFI—they are in favour of it. The hon. Member for Rother Valley (Mr. Barron) is also in favour of it; he is another member of this "team". He said:We do not disagree with the PFI. How could we?…It was Labour who first thought of partnerships between the public and private sector.I am not sure that the idea of partnerships between the public and private sector did not antedate the foundation of the Labour party, if truth be told.
The hon. Member for Rother Valley is keen to be on the record as supporting the PFI. He is a shrewd fellow and clearly thinks that it is more important to his career to be close to the Leader of the Opposition than to be close to his boss on the Front-Bench team—because the hon. Member for Peckham does not support the PFI. His boss on the Front-Bench team takes a distinctively different view of it. She said that the PFI wasa new trick to privatise the Health Service.She also said:I don't call it the Private Finance Initiative, I call it a privatisation initiative.We are entitled to know which of these various stars among Labour Front Benchers speak for the Labour party on health. They speak with different voices on different days to different audiences.
§ Mr. Dorrell
I will tell the hon. Gentleman exactly what I think about the PFI. I think that it is the best opportunity that the health service has to ensure that it 377 escapes from capital short-term planning and delivers the modern equipment and buildings that we need to ensure that the NHS meets the challenges of the next century.
The hon. Member for Peckham has an opportunity to tell us her position. We do not ask her to take the opportunity today, but we ask her to take it tomorrow. I understand that she will go to talk to Unison tomorrow on the PFI. Unison's position on the PFI seems pretty clear from this advertisement, which states:PFI: the biggest threat to your health since 1947.It has even designed a logo to encapsulate the message, which states:Unison says no to private finance.The hon. Lady has to decide before the meeting—at 12.30 pm tomorrow, at the Cumberland hotel—whether she is on the Unison side of that argument or on the side of the Leader of the Opposition and the hon. Member for Rother Valley. The health service needs to know the answer to that.
I conclude with a little advice to the hon. Member for Peckham. She would do well to back the Leader of the Opposition. In my humble opinion, the right hon. Member for Sedgefield (Mr. Blair) remains her best and only hope, because the fact is that Labour's health policy is a shambles. Labour Members have a slogan on the internal market, but they have absolutely no substance to back it up. They have no idea what they would do about fundholding. They have no idea what they will do about the PFI. Their policy on resources on health relies on a non-existent El Dorado.
The hon. Member for Peckham survives by the indulgence of the right hon. Member for Sedgefield, who demeans himself and his party by his unwillingness to face even one of the real issues facing the NHS. Where there should be substance, there is a vacuum. His speech to NAHAT last week was as trivial as it was content-free. Even the high spots last week were not so much soundbites as soundnibbles.
The right hon. Member for Sedgefield has done the hon. Member for Peckham a favour by organising this debate on the night of the biggest football match of the year so far, so that she can conduct it in decent obscurity. But he cannot protect her for very much longer. Sooner or later her failure will be exposed, as the voters realise that it is the Tories who deliver on the national health service.
§ Mrs. Audrey Wise (Preston)
I want to raise two major points in the time available to me. One relates to fragmentation and the lack of co-ordination and the other to the bureaucratic nonsense of so many of the so-called activity and efficiency measures introduced by the Government.
I shall start with the latter, but before doing so I want to comment on the remark made by the hon. Member for Clwyd, North-West (Mr. Richards) about emergency admissions. He seemed surprised to find that we expect beds to be available for emergency admissions. I expect beds to be available and vacant, as needed, for emergency admissions, and I expect fire engines and ambulances to be standing waiting just in case I have a heart attack or 378 there is a fire at my home. I am obviously grossly extravagant in my expectations, but I can tell the hon. Gentleman that those expectations are shared by the overwhelming majority of the population.
The problems with bureaucracy go back a long time. One of its major manifestations is compulsory competitive tendering. CCT does not necessarily lead to the best value being obtained, but rather to trouble and expense being incurred in obtaining normal services.
Although I am on good terms with my local district general hospital and although I believe that those managing it are doing their level best in difficult circumstances, I want to give a small critical example of the sort of problem that arises. Cleaning is obviously basic in a hospital. A constituent drew my attention to a lack of cleanliness at the Royal Preston hospital at the turn of the year. I was very concerned about that. I had been a patient in the hospital, but before CCT was introduced. I can tell the Secretary of State that the hospital was sparkling then.
I investigated the problem and it was confirmed that there were difficulties. The chief executive said:The problem relating to the cleanliness of the wards relates to difficulties encountered by the contractors in maintaining sufficient staff on the wards.I wrote asking whether the contractors did not pay adequate wages. I was told that they paid the same wages as were usual and that any recruitment difficulties experienced from time to time were more to do with the local labour market.
I know that many, many people in Preston are desperate for work. I do not believe that good employers cannot obtain staff for a job that is not unpopular. As cleaning jobs go, cleaning a hospital is regarded as very useful work that carries with it some sort of standing in the community. It is not a rubbish job—or it should not be. It is an essential job.
I was told by the chief executive:A meeting is to be held shortly with the director of the company with an expectation that the problems will be overcome.The problem with that is that the meeting was scheduled to take place three months after the identification of the problem of lack of cleanliness. Three months is a long time to have cleaning problems in a hospital. That sort of problem arises not because of any inefficiency by the chief executive, but because he no longer runs the show. Other people employ those who are performing that essential service in the hospital. That does not lead to good management.
I can tell the Secretary of State that I know of cases—not in the Royal Preston, but elsewhere—of apparent savings in supplies contracting. The only problem has been that the search for and the delay while waiting to identify those minuscule savings have more than swallowed up several years' cumulative savings. Again, that is not such a good idea.
Finished consultant episodes are now a measure of activity or efficiency in the NHS. I do not believe that they measure either of those—they certainly do not measure efficiency. Indeed, I have recently learnt that they do not even measure activity. Gimmicks or ruses are employed so that a hospital can show a massive increase in its activity through finished consultant episodes. It is very easy—the hospital simply discharges patients to whom previously it would have said, "Come back next 379 month." It now says, "Go to your general practitioner." The GP then refers the patient back to the hospital, but it counts as a new consultant episode. The hospital can then say that far more people are being treated. Finished consultant episodes do not equate to people being treated. That should be lesson No. 1 for any Secretary of State who wants to get real efficiency in the NHS. Some of the effort put into accountants chasing pieces of paper should be put into finding sensible measures of outcome in the NHS and treatment for patients.
I want to refer to the lack of co-ordination, especially in relation to child health. A report was published 20 years ago, having been commissioned by the then Government. It was one of the rare excursions by the powers that be into children's health—a subject that has been grossly neglected by the House and by successive Governments. However, 20 years ago the then Labour Government published the Court report, the essential plank of which was that there needed to be more co-ordination in the provision of a children's health service. We still do not have a children's health service. In fact, if any hon. Member cares to consult any voluntary organisation, I can promise that the story that that hon. Member will be told will be one of fragmentation, competition, lack of communication and general chaos, which in my opinion is not too strong a word to use.
It is deplorable that there should be quarrels between health services, social services and education services about who pays for what, while the children go without. A sensible Government would give more than a steer on who pays for speech therapy, for instance, instead of allowing it to be shunted between local education authorities and health authorities, while the children go without. I would not mind if the argument were being conducted on the side, at the same time as provision was being made, although I would still think that they should not put too much time and effort into the arguments. However, the children go without while the squabbles continue.
I am sure that, in general, voluntary organisations would echo an organisation called Aid for Children with Tracheostomies. It complains bitterly about difficulties in obtaining essential equipment, disposable supplies and respite care. All those are needed for children who are being nursed in the community, which is a growing trend. Along with that growing trend should go a growing provision of essential equipment, disposable supplies and respite care; otherwise, the children are being short-changed. Indeed, I do believe that children and their parents are being short-changed.
Respite care at home is a very good idea. Unfortunately, it is difficult to organise. It is hard to understand that because keeping a child in hospital for one night costs about £150, apart from any treatment costs. I am reliably informed that full respite nursing care for the equivalent period would cost £80—a saving of £70. One would think that all authorities would be queuing up to provide respite care at home, but no money for such care appears to have been built into the community nursing service budget. Therefore, a liaison nurse—assuming that there is one, which is quite a big assumption in some places—has to approach a GP and request that the GP puts in a bid for health authority funding.
My hon. Friend the Member for Peckham (Ms Harman) cited examples of bids being made for extra-contractual referrals. I am not too happy about the fact that a 380 community nursing service may think that respite care is needed for a child at home, but can arrange it only through a GP, who must bid—which presumably means that it may or may not be granted—for something that is not only better but cheaper. Despite that, the Government tell us that they know how to run the national health service.
There is a lack not only of respite care at home but of a community children's nursing service. Not only are children in hospital still as likely to be nursed in adult wards as they are in children's wards, but when they are discharged for continuing care at home, there is a 50:50 chance of there being no community children's nursing service in their area. That means that their care is not supervised by qualified children's nurses.
For the benefit of Ministers' education—if they will spare time from their conversation and listen—I should point out that it is a prime tenet of children's medicine that children are not simply small adults. They require very specialist care, yet in 50 per cent. of the country there is no community children's nursing service and only 10 per cent. of the country has a 24-hour children's community nursing service.
Children are increasingly being discharged to their homes when they still need quite elaborate care, which is undertaken by parents. Parents are entitled to proper back-up, supervision and, indeed, nursing services, but they are being exploited; gross advantage is being taken of their keenness to have their children at home. It is no part of a parent's duty to undertake, for example, procedures such as passing nasogastric tubes, yet in our constituencies a person may be expected to do that as the price for having their child at home instead of in hospital, which is entirely wrong.
I am astonished at the complacency to which we have been treated by the Secretary of State, who thinks that the Conservatives deliver health care and protect the national health service. If he were a sick child or a parent of a sick child, he would be a good deal less complacent.
§ Mr. Michael Fabricant (Mid-Staffordshire)
Does the hon. Lady recall that, when the Labour party was in power in 1977, it cut nurses' pay? Does she recall that in 1978 and 1979, sheets in hospitals—yes, including in children's hospitals—were not being cleaned because of the winter of discontent? Is that the legacy of which she is so proud?
§ Mrs. Wise
If the hon. Gentleman chatted with any nurse in his area, he would find that a different comparison would be drawn. Nurses may not be going on strike collectively, but they are doing so individually by leaving the service. Has the hon. Gentleman ever chatted to a nurse and had that nurse tell him about the times when she has gone home and cried because of the inadequacy of the service that she was trying to provide? If he has not had that experience, he has not talked to many nurses.
I congratulate my hon. Friends on the motion. I am quite sure that when we condemn the Government for their handling of the NHS, the bureaucracy, the lack of efficiency, the preference for competition over planning, the lack of any strategic thought and especially the lack of so many basic services, the people of this country are on our side of the argument and regard the Secretary of State's statements as simply incredible.
§ 6.4 pm
§ Mrs. Marion Roe (Broxbourne)
I listened very carefully to the points made by the hon. Member for Peckham (Ms Harman), who, unfortunately, is just leaving the Chamber, but I totally disagree with her. Patient care in the national health service is most certainly not dominated by bureaucracy. To maintain that argument does a great disservice not only to the very good managers of the national health service but to the improvements in patient care that have been made since the advent of the national health service reforms.
The taxpayer surely has every right to expect that public money is spent wisely and that it is committed to achieve the ends that Parliament considers most vital. It is simply common sense that, in an organisation the size of the NHS, that requires strong leadership and robust financial control. That is the role of NHS managers. I believe, along with many others, that the many recent achievements of the NHS would not have been possible without them. The achievements to which I refer have not in any sense been attained in an ivory tower; they are solid, demonstrable improvements in patient services. I shall give a few examples of such achievements by citing what has occurred in the two hospitals that serve my constituents.
Over the past five years at the East Hertfordshire NHS trust, which operates at the Queen Elizabeth II hospital in Welwyn Garden City, there has been a 30 per cent. increase in the number of day cases and in-patients treated, including a 14 per cent. increase in emergency admissions. Over the same period, more than 33 per cent. more out-patients have been treated. Accident and emergency attendances have increased by more than 5 per cent. a year since 1991, but with the recent introduction of assessment units for children and GP-referred patients the trust has managed to control the number of unnecessary and, of course, costly emergency admissions.
For patients awaiting routine surgery, there has been a huge reduction in overall waiting time. On 31 March 1993, almost 600 people had waited longer than 12 months for their operation, but on 31 March 1996 only one person had waited longer than 12 months. That patient was admitted in early April. The appointment of many new consultants enables the trust to provide a very wide range of services locally so that patients do not have to make the tiring and often stressful journey into London.
Since 1991, a range of new units and services has been planned, built and put into service. They include a new day surgery unit that performs operations for more than 7,000 patients a year, the joint development of a magnetic resonance unit providing a state-of-the-art diagnostic imaging service, a new residential and respite care unit for younger physically disabled people, a pre-discharge unit for elderly patients awaiting assessment for longer-term care, a stroke rehabilitation unit, a complete new hospital ward for gynaecology patients and a high-dependency unit for coronary care and other serious medical conditions.
That is typical of what has been achieved in east Hertfordshire since the introduction of the NHS reforms. Those who are familiar with the funding of health services in the shires will be well aware that it was certainly not the result of over-generous funding. While all those developments were taking place, the revenue funding available to east Hertfordshire rose by only 3 per cent. It is 382 a superb record of efficient management and it equates to an efficiency gain of 22 per cent. in total or 4 per cent. on average each year, which well exceeds the national target of 3 per cent.
I am aware that those major advances in patient services are reflected throughout the country. They have been achieved not through bureaucracy but through skilled and effective management. Therefore, it must be clear that prudent investment in good managers pays dividends.
Those achievements have been attained against a background of low management costs. In 1996, East Hertfordshire NHS trust recorded management and administration costs of 5.7 per cent. of its overall expenditure. That low total would be the envy of many organisations with far simpler remits. However, we must not forget that many doctors, nurses and technical and professional staff are involved in the management of the NHS, and that is exactly as the taxpayer would wish. Of the 5.7 per cent. that I have just quoted, 1.7 per cent. relates to staff with a clinical or technical function.
Similar successes have also been achieved in the Chase Farm Hospitals NHS trust, which operates from Chase Farm hospital. Management of the trust is based around 12 practice management groups—the local version of clinical directorates, which were introduced in 1991—based on the major specialties. Each is headed by a PMG chairman who is a senior consultant in that specialty. PMGs are responsible for the quality of services, financial management, staff management and development and planning service developments through the annual business planning process. PMGs make budget and day-to-day decisions about services, so many important decisions are made at the chalk face rather than in the boardroom. About 50 per cent. of the full-time consultants are directly involved in management and there are excellent working relationships among medical, nursing, management and other professional staff.
The past three years at Chase Farm have seen the development of new, innovative services and the appointment of 14 new consultants, with additional consultant posts in general surgery, oral and maxillofacial surgery, obstetrics and gynaecology, anaesthetics, paediatrics and accident and new consultant appointments in orthopaedics, ear nose and throat and medicine.
The Chase Farm trust also places the highest priority on developing relationships and communications with GPs and various important initiatives have been developed. There is a GP forum, which is an open meeting for GPs that is held every Sunday morning. Farmfacts is a newsletter specifically for GPs and practice staff. Regular contact has been established with individual practices and doctors and managers visit GPs in their surgeries to focus on specific issues. There is a medical director helpline, which provides a regular time when the trust's medical director is available for GP queries, and there is also a GP adviser to the trust who attends all the board meetings.
Through its relationships with GPs the trust has developed services much closer to patients' homes. For example, there is a consultant-led clinic in my constituency at the Cheshunt community hospital as well as numerous GP surgeries. Those initiatives are the result of discussions between consultants and GPs about the services that they require for their patients.
383 Another recent innovation is allowing a consortium of Cheshunt GPs to use the community hospital as a base for their out-of-hours service.
Clearly, it is important to take account of every member of staff in the hospital who is involved in its management, but many managers retain significant clinical responsibilities. They include the chief pharmacist, the chief physiotherapist and other senior professional and technical staff. The medical director is a busy surgeon who fulfils his management role in four weekly sessions.
It is an inescapable fact, however, that the NHS internal market, which has been in operation since 1991, has incurred some elements of bureaucracy that could be dispensed with by carefully targeted action. For example, we need to examine whether staff time should be taken up with issuing invoices and checking queries. There may be scope for simplifying the system—a task that my right hon. Friend the Secretary of State has well in hand through the major efficiency scrutiny that he has launched in the NHS.
It would be particularly welcome for the recommendations of the scrutiny team to concentrate on those areas where staff have to check and confirm the details of patient care that have been provided in good faith by hospitals and community services. More straightforward administration of extra-contractual and tertiary referrals could be achieved at no cost to the effectiveness or control of patient care.
Finally, after five years of enormously effective operation, we must acknowledge that some elements of the NHS reforms may require adjustment. As I have already said, that is now in hand. However, we must keep clearly in mind what the NHS reforms were meant to achieve. The purpose of the reforms, in addition to a much increased involvement of doctors in key decisions, was to ensure that taxpayers' money was spent on patient care and that that could be demonstrated clearly through a system of accountability between purchasers and providers. That those objectives have been achieved cannot be questioned.
§ Mr. Bayley
I have listened with interest to the hon. Lady. She mentioned a considerable list of service improvements at the Queen Elizabeth II hospital over a five-year period and said that during that time the hospital's income had increased by only 3 per cent. in real terms. Earlier this afternoon, the Secretary of State said that the NHS had received a real terms increase of 3 per cent. in each of those years. Which figure is right? Is it 3 per cent. per year or 3 per cent. over five years?
§ Mrs. Roe
I was absolutely clear, but I shall repeat what I said so that the hon. Gentleman does not misunderstand me. He will find that I said that while various developments were taking place, the revenue funding available to East Hertfordshire NHS trust rose by only 3 per cent. Those in Hertfordshire complained because they did not believe that they were being generously over-funded, and colleagues from Hertfordshire have brought that to the attention of the House on numerous occasions.
The objectives of the reforms have been achieved—that cannot be questioned. The Government's emphasis on improving patient care guaranteed that the objectives would be achieved, and with their worthwhile and timely 384 efficiency scrutiny they have seized the opportunity to take stock of the system that they put in place and to support the vast improvements in patient care that have taken place. I hope that the scrutiny's detailed recommendations will enable us to put an end to the claims that are made—so often on an uniformed basis—of an over-bureaucratic structure in the NHS. I am glad to confirm that, from my constituents' point of view, the focus of the NHS remains clearly on the patients, whose care must always come first.
§ Mr. Simon Hughes (Southwark and Bermondsey)
This debate is rather like pass the parcel, with everyone hoping to get in before the match starts later on. For the information of the House, it is still nil-nil between France and the Czechs in the second half of extra time.
The debate was started by a set of assertions in the Labour motion that I hope the Government—although they would generally be unhappy about agreeing to them—will accept. These include the statements that NHS services are overstretched, however many resources are put in; that there is a shortage of intensive care beds, certainly where they are needed; that waiting lists are over-long and people cannot get the service at the place or time they want; that there are still people waiting on trolleys in accident and emergency departments; and that there is great pressure on community health services. There can be no honest dispute about those matters.
Whether or not it is the Government's policy, it is a fact—as the hon. Member for Peckham (Ms Harman) rightly said—that many people are driven to private health care, even though they would not choose to do so, simply because they cannot be treated in time. Although there will always be rationing in the health service, and the debate is not about "whether" but "how", the test of whether we have a national health service is whether it has the capacity to meet the clinical needs of people throughout the UK.
The key debate tonight is about whether we are spending money on unnecessary bureaucracy at the expense of and to the detriment of patient care. All the evidence and submissions that I have seen for this and other debates make it clear that we are. Bureaucracy has been growing and, in the words of my party's amendment—which was not selected—excessive, expensive and often unnecessarybureaucracy has resulted from the 1990 reforms.
I accept that the Government have always made additional capital investment in the NHS, and that there has been real terms growth throughout their period of office, but it is getting a bit thin. It is now down to an increase of 0.1 per cent. this year over the last, but the Government are just about making their manifesto commitment. The test that matters to people outside is whether that growth results in money being diverted to the patient.
There are issues that the Government have not yet accepted and addressed. For example, many people have experience of a two-tier health service. It does make a difference whether one is the patient of a fundholder or not, and one often does get seen more quickly as a patient of a fundholder. The reason for that is that the trust will take the fundholding patient because it wants to keep the 385 fundholder's contract rather than that of the commission or local health authority, because the trust can be more secure about the future of the commission's contract.
There is a real debate about making sure that money is properly spent and not wasted. The Government accept privately—although they may not do so publicly—that an unnecessary amount has been spent on bureaucracy as a result of the changes. We must all have constituency experiences—I certainly have—of local GPs and people working at, for example, Guy's hospital in my constituency who have given examples of bureaucracy gone mad in terms of the way in which people move from the moment their need is expressed to treatment. No one can be satisfied with that in the health service.
I shall refer to, rather than elaborate on, the professions I cited in an earlier intervention on the Secretary of State, who say that the system is far too bureaucratic and add that they are suffering under it. They are suffering not just because it is costing money, but because it is diverting resources and time, and demotivating them from the service that they want to provide.
First—the hon. Member for Peckham referred to this event also—a news conference was organised by the British Medical Association on 16 May, the report of which stated:Flagship hospital trusts are reportedly seeing their once-efficient departments slowly destroyed by government requirements for trusts to make year-on-year efficiency savings of 3 per cent. But they are not allowed to use any surpluses to increase capital resources, such as beds, in the following financial year. Instead they have to use them to cut prices.The Royal College of Nursing has signalled certain specific concerns, and has made the point that it is a bad economy to cut out senior nursing posts—one of the consequences of the Government's reductions in certain budgets at a time of nursing shortages. If there are nursing shortages and less experienced groups of nurses, we need the senior nurses in post to be able to make sure that they manage less experienced staff and plug the gaps better.
According to the RCN, the number of nurses fell by 2 per cent. in 1992–93 and by 1.27 per cent. in 1993–94. More worryingly—I hope that this concern is shared across the House, and I know that the Select Committee has declared its concern—the number of pre-registration students has gone down considerably, from 37,000 qualifying in 1983 to 14,000 in 1995. There is real concern about the future of people coming into the health service to train as GPs or nurses.
The RCN suggested two matters of particular concern. First, the introduction of local pay bargaining is extremely time-wasting and debilitating. There are now 488 sets of local pay negotiations—what a waste of time and effort. There should be a minimum guaranteed pay scale for nurses across the NHS. If one wants to top up that scale as a result of extra bonuses for work done—rather than negotiated pay—then that can be done.
It is noticeable that, as of a couple of weeks ago, out of the 488 employers in the NHS, only 111 had concluded negotiations four months after the pay review report. That is the first thing we could do to save an enormous amount of time and effort, and to stop distracting people.
Secondly, every year now, the commissioner, which is the local health authority, and the trust, as the supplier, must negotiate the contract. Contract negotiations year in, 386 year out, are the most time-consuming and frustrating exercises. Nobody in the public service wants a one-year contract, and we should get away from the idea that that is the way to run the NHS. That is what takes all the time, and that is where all these extra people are employed.
That is also what produces all the paperwork referred to by the hon. Member for Peckham. We must move very quickly, and I hope that the Government will introduce regulations so that we have much less frequent contract renegotiations.
The BMA has made some additional points. It says that there has been a huge duplication of administrative effort and a large diversion of resources into administration. GPs around the country—the Minister will have heard this from GPs in Winchester—tell us that the thing that bugs them the most is the paperwork. The Minister knows that that is the case whether it is our survey or his, private or public.
§ Mr. Hughes
They are not bogus, but they are consistent in saying that what bugs GPs most is paperwork. GPs went into general practice to be doctors, not administrators. The most recent survey of GPs' work load, which was conducted by the British Medical Association, showed that the average weekly time spent on practice administration had risen 85 per cent. since 1985–86. Claim forms, recording data, commissioning, fundholding and the patients charter were regarded as bugbears.
I accept that the Government have addressed some of those concerns, and that the NHS executive report "Patients not Paper" made 65 recommendations, which are being implemented. I hope that we go on down that road, because we have to reduce the administrative burden on our doctors.
I hope that the Minister will reply to the representation of the National Health Service Consultants Association. Its executive committee met the Secretary of State in March. It was asked what it would recommend, given that the Secretary of State would not concede that the 1990 reforms should be torn up. It wrote to him in May, but had had no reply to its propositions by 20 June. It is clear about the problem. I shall quote its view, because it is up to date and on the ball.
The association states:the great weight of evidence presented to us indicates that features of the Act and what has developed from it are the prime causes of the current low morale in all branches of the medical profession and indeed throughout the NHS.The association is frustrated because the service is fragmented. Loyalty to the concept of the NHS is being replaced by corporate loyalty to the local individual unit, which encourages destructive rivalries and antagonisms, lack of openness and interference with rational strategic planning. A major source of dissatisfaction is that the pricing system is patently arbitrary, is at the mercy of creative accounting, and produces clinical absurdities that bring the system into disrepute.
The association says that there is no justification for the explosion in the use of external management consultants to report on every problem that occurs. The investment in newsletters and public relations departments to present 387 policies in the most favourable light is a bad use of money. The Minister has received 12 recommendations from the association to reduce bureaucracy and divert resources. I ask that the Government reply as soon as possible and accept, as far as possible, its proposals, which are based on experience and put reasonably, and which include many good ideas.
A constituent of mine, in discussing the local council and its services, told me in a letter last week that he was busy fighting cancer and did not have time to fight bureaucrats. That is what people in the health service want to do. I shall put the central allegation to the Government and then make suggestions for progress. I shall do so quickly, for the twin purposes of letting other hon. Members speak and releasing myself.
I hope that the Government accept that it is unarguable that administration costs have risen from 6 to 11 per cent. of spending since the 1990 reforms were introduced. We have gone from 500 general managers—I know that there has been some redefinition—to some 20,000. Redundancy payments have risen from £12 million to £114 million a year. That shows the extent of managerial upheaval.
My first proposal for change is that the contract period be extended from one to three years. That is no good unless the people involved know how much money is coming down the tracks. It is no good if the budget is given, whether in west Hertfordshire or elsewhere, on a year-by-year basis. The same complaint applies to local government.
A clear idea is needed of the money that will be available over the next few years. Of course circumstances change and there has to be flexibility, but it would be possible to have a financial framework within which one could know the parameters of the money that was to be given. Within that, there could be adjustments, but it would allow people to plan. Will the Government consider extending the one-year contract period to three years?
Can we avoid having to price everything? It is quite possible to give a round figure price for the day cost of conventional care in a hospital. We should not have to cost separately the bedpan, the sheets, use of the fan and breakfast. There must be a day rate, as with paying hospital beds or private hotels. It is nonsense to go down to such particulars. We could avoid much costing by having a more generalised process.
There must be a return to a sense of the public service ethos. One problem is that many managers have not come up from the national health service. Many people in the health service feel that managers do not understand what they have to manage. Let us train people from inside the health service—people who know about managing the service. When we need efficiency cuts, let us not imagine that cutting senior managers is necessarily the best way to achieve cuts.
Thirdly, can we have longer staff contracts? Short-term staff contracts are demoralising and demotivating. It is not good employment practice, but it is more bureaucratic. It means that many agency staff are employed. It is possible to move efficiently and quickly to longer-term contracts that give everyone a sense of security and the institution a sense of coherence.
Fourthly, staff planning needs must be better met. That used to be the responsibility of regional health authorities, but they have gone. We have regional health chairmen 388 with nothing to chair; that is nonsense. Local trusts or health authorities cannot plan staff levels because they are too small. They are having to form consortia. We need to return to regional planning of health service staff needs.
Fifthly, can we end the nonsense of local pay negotiations? Sixthly, can we end the system that requires the health service negotiating process to be rather like the United Nations Security Council? When health authorities, trusts and other players must all agree something, it takes only one agency to say no to veto the whole thing. Perhaps a regional tier or national inspectorate could cut through that. Whichever is needed, we must avoid having to get everyone to sign up to everything before anything can go ahead.
Penultimately, it is not right to attack management. I agree with the hon. Member for Broxbourne (Mrs. Roe), who chairs the Select Committee, that many managers do a good job. I was in Harrogate hospital at a conference recently. They are doing an excellent job in managing that trust. It is not the managers who are the problem, but the systems that we have imposed. I agree with her and the hon. Member for Peckham that it is the bureaucracy that we have introduced that is debilitating all the players.
Lastly, the NHS performance indicators will be published next week. There will no doubt be great trumpeting from the Government that they all show that the NHS is performing better. However, the indicators are all related to time; none is related to the quality of care.
The test of the NHS is not how many people are put through a certain number of beds in a certain number of days: it is the quality of care people have, whether they are in-patients or out-patients. All the statistics in the world showing that we are treating more people more quickly are of no use to anyone if the care is not of an ever higher quality. I hope that the Government understand that it is not the politicians who have the biggest cause to complain about the bureaucracy, but the patients and the people working for the NHS, and they do so because they want the money to go on patient care.
§ Dr. Charles Goodson-Wickes (Wimbledon)
As the general election approaches, debates on health care become ever more bemusing and intriguing. Opposition Members' speeches today have demonstrated all too well the increasing contradictions and anomalies in the Opposition's policies, which have been so well exploited by my right hon. Friend the Secretary of State. I have no doubt that my hon. Friend the Minister for Health will probe further when he replies.
I begin by deploring the fact that, at this time of year, the chairman of council of the British Medical Association seeks to provide emotive headlines at the BMA's annual conference. I had better declare an interest straight away, as the BMA is my trade union. The sort of language he has used, which is translated into the headlines we read, is reminiscent of the worst days of the old TUC conferences: "Health service heading for disaster"; "NHS sinking like the Titanic". Such headlines are not only singularly unhelpful—indeed, untrue—but totally out of keeping with the medical profession and all it stands for.
The ethos of the medical profession is surely to reassure and to act in the best interests of patients. It must adapt to changing times, but in that adaptation and change, must assist, with the prime object always in view—the welfare of the patients it is looking after.
389 When on earth were there not politicians bemoaning chaos and crisis in the NHS, combined with limited resources? "Underfunding" is an emotive left-wing word which has got into the Opposition's vocabulary as a cover-all description which completely fudges everything that we are in politics for—to make decisions about priorities, within limited resources. It is nonsense to talk about underfunding.
Our job here, on whichever side of the House we sit, is to decide where best we can use the taxpayers' money. It is a fundamental naivety for the Opposition always to go on about underfunding, when we should be talking about efficiency and patient care.
§ Dr. Goodson-Wickes
I certainly do not. The hon. Gentleman has not been following my train of thought. In an ideal world, every Secretary of State would have an unlimited budget, and the world would be a lot better for that. But that is not the sort of Utopia in which we live. I am sure that the hon. Gentleman recognises that. I welcome the fact that his right hon. Friends on the Opposition Front Bench increasingly recognise that, and are beginning to see the realities of life. I look forward to the hon. Gentleman joining that club in due course.
After all, Nye Bevan himself wholly failed, in all his admirable work in setting up the NHS, with all-party backing—the Conservative and Liberal parties, Beveridge, all worked together in the all-party tradition to set up the NHS—[Interruption.] If anyone disagrees, they have only to read the history books. I will send them the bumf whenever they like.
But in setting up the NHS, Nye Bevan himself wholly failed to recognise the infinite demand which would result thereafter. He thought that ill health would, to coin a phrase, at a stroke be eradicable, that everyone would be cured instantly, and that people thereafter would not become ill. I forgive him for that. He could not possibly have foretold the developments in medical technology and so on, which have now opened unforeseen areas of expertise for the benefit of patients and populations.
§ Mr. Simon Hughes
Without getting into a debate about Nye Bevan, I have one factual point to make. I hope that the hon. Gentleman will not deny that, in the 1945–50 Parliament, the Labour and Liberal parties voted for the NHS legislation, and the Tory party voted against it.
§ Dr. Goodson-Wickes
I said that I was perfectly prepared to send hon. Members the exact basis on which the Conservative party did that. But the hon. Gentleman, being a fair-minded man, will acknowledge that the Conservative party had a considerable input in the setting up of the NHS. We go back to 1911 and Lloyd George. I hope that the hon. Gentleman will be happier now that I have mentioned Lloyd George.
The hon. Gentleman knows perfectly well that the workings of this place are such that, for bizarre reasons, particular parties go into particular Lobbies, and then the reasons are dissected. We all know the truth. I am sure that the hon. Gentleman and Opposition Members will 390 acknowledge the Conservative party's input. However, I give Nye Bevan the credit for getting the NHS legislation on to the statute book.
The perfect must never be the enemy of the good. One of the uncomfortable messages we must all address on a non-party political basis is well set out in a leading article in this week's British Medical Journal. I was critical about that publication earlier this week, so I had better be polite about it today. The article, headed "Rationing health care: moving the debate forward", says:In Britain neither the Government nor the main opposition party will openly acknowledge the inevitability of rationing health care.That is at the nub of every debate that we have about health care. Commentators believe that the Government should lead a debate on how best to ration health care. We are talking not about whether one should or should not ration health care, but about how best to do it. Anyone who says otherwise is living in the Utopian world to which I referred earlier in reply to the hon. Member for Carlisle (Mr. Martlew).
The article continues:Many people in the health service think that more funds should be available for health care, and many members of the public support such a proposal. But these are separate debates. More effectiveness and more money will not"—I repeat, not—remove the need to deny effective treatments.In other words, to go back to the hon. Gentleman's intervention, however much money one has, the resources will never be available to give effective treatment to all patients regardless of need. That is an entirely non-political argument.
Five years on from the NHS reforms, it is an appropriate time to take stock. Having spent most of my career in the NHS, I have had ample opportunity to see bureaucray at first hand, and bureacracy is the subject of the motion today. I have seen the appallingly long waiting lists for admission, the inadequate administration of case notes, the lack of a proper appointment system in out-patient departments with either no appointment system at all or multiple bookings, and the lack of liaison with investigation results coming back after patients have been seen.
On top of all that—I say this with humility about my profession—all too often in the past, superimposed upon all those inadequacies has been an air of condescension and old-fashioned paternalism which suits this day and age particularly badly. Any reform which helps to remedy some of those problems, and which the Government have been so conspicuously successful in achieving, is warmly to be welcomed—I imagine, on both sides of the House.
Where do we go from here? I believe that the Government's record stands up to the closest scrutiny. I welcome the shift from secondary care to primary care, with all that that involves for GPs and their close involvement with patients. I want to quote a letter sent to all Members of this House from the BMA, dated 2 November of last year:The Government's reforms offer improved services to patients, both in quality and range".Of course, resources must mirror these changes-although they are not infinite. I certainly hope that GPs' careers will be further enhanced; likewise their job and clinical satisfaction.
391 There is no district general hospital in my constituency, but the borough of Merton's is arguably the best served population in the country, in that it contains three superb district general hospitals which serve my constituency: St. George's Hospital NHS trust, Kingston Hospital NHS trust and St. Helier Hospital NHS trust. I keep in close touch with all of them to find out how they are dealing with the Government's reforms, particularly in respect of bureaucracy.
The St. George's Hospital trust warmly welcomes the efficiency scrutiny exercise now under way, and believes that it will offer scope to allow the hospital to reduce administrative effort—for instance, in invoicing each month, as mentioned by the Chairman of the Select Committee. The hospital will also be able to simplify contract payments with purchasers and to reduce the need for pre-authorisation from purchasers. That will lead to reduced bureaucracy in the internal market.
My hon. Friend the Member for Broxbourne (Mrs. Roe) and I would do anything to reduce the bureaucracy that inevitably arises during any administrative change. The fact that St. George's is reacting so positively to the initiative is a good omen for the future.
The hospital has already speeded up communications within the trust by using e-mail technology. It has developed an integrated information support scheme that speeds up patient results to doctors, reduces the time spent chasing medical records and generally reduces bureaucracy and paper chasing, thereby allowing more time for hands-on patient care. It is important to eliminate the sort of problems which I said at the beginning I had seen at first hand.
Information links to GP practices have been greatly enhanced, allowing laboratory and radiology results to be passed on quickly and permitting GPs' letters and discharge statements to be electronically mailed. This, too, will alleviate the old problem of time spent chasing paper. I believe that all hon. Members would endorse such an objective.
I tried earlier to intervene on the hon. Member for Peckham (Ms Harman) while she was waxing lyrical about the bureaucracy surrounding fundholding practices. The House will have noted that she declined to give way, despite my trying to intervene several times. I have specific examples that rebut what she alleged is happening to increasing numbers of GP fundholders.
The Kingston Hospital trust document explains exactly what I mean. It has set up a so-called GP multi-fund, which, although it consists of about 40 practices, enables the hospital to deal with a single management group. I do not know whether that pattern is followed around the country; if not, it should be, because it is eminently sensible. I hope that the hon. Member for Peckham will visit Kingston hospital and find out at first hand how well the system is working—instead of waffling on about thousands of GP fundholding practices and the bumf that she says they generate. It simply does not work like that.
Kingston is also talking to the district health authority and to the multi-fund group about providing electronic data transfer between GPs and the hospital, thereby reducing administrative costs. The hospital's management structure is flat, with authority and responsibility delegated close to the point of patient contact.
392 Kingston Hospital trust is set to achieve the target of management cost savings of 5 per cent., a reduction of more than £150,000. It is all very well to swap insults across the Floor of the House, but it is more sensible to look at the figures and see what is actually happening.
The same good developments are to be found at St. Helier NHS trust and at Queen Mary's NHS trust in Roehampton, which also serves a few people from my constituency. Furthermore, I have good news about the Nelson hospital—one of the old cottage-type hospitals which had been virtually condemned to closure. Thanks to efforts at local and national level, it will now have a future, providing the Labour-controlled council is co-operative, offering enhanced day care facilities, physiotherapy, occupational therapy and radiology—all in the heart of my constituency: a most welcome development.
I pay tribute to the community health council in my constituency. My first contact with such councils was in Islington, where I was the prospective parliamentary candidate in 1979. I do not know whether things have changed in Islington, in line with the change of attitude represented by the Leader of the Opposition, but at the time its CHC was a politically motivated left-wing pressure group. Nevertheless I pay tribute to the community health council in my area, which could not be less politically motivated. I have not the slightest idea of the politics of those who serve on it, whom I meet regularly and who offer a uniformly constructive and helpful analysis of what is going on. I congratulate them on that.
The Secretary of State extolled the virtues of removing unnecessary tiers of administration throughout the NHS. I vividly remember the time I sat in the office of the chief executive of the South-West Thames regional health authority, in Paddington. On the wall was an idiotic map, showing his area of responsibility, stretching from Wandsworth to the south coast of Sussex. At the time, my elder son was a patient in an NHS Chichester hospital. I could discern nothing—apart from excellent medical care—linking Paddington, Wandsworth and the southern reaches of Sussex, however. It was ludicrous, and it just showed what a good idea it was to abolish the regional health authorities and put in hand the subsequent reorganisation.
Not only has Merton and Sutton health authority merged with the local family planning committee; we have gone further and merged the Merton, Sutton and Wandsworth health authority with the family planning committee. That will lead to financial savings, and give my constituents a much better service.
I do not want my speech to be a litany of good news and congratulations for the Government. There have been problems in my constituency—in fact, I am surprised that Labour Members have not intervened in this regard. For example, there has been national publicity about accident and emergency facilities at St. Helier hospital, which serves my constituents who live in the southern part of the borough. I have had regular meetings with the management of St. Helier hospital, and I have every confidence that it will tackle what is an uncomfortable situation—patients have been left, inappropriately, in corridors. That is unacceptable.
The management at St. Helier hospital has told me that the main problem is the phenomenon known as bed blocking—I suppose that we will get used to the term. 393 Apparently, "bed blocking" means that patients who are perfectly fit to be discharged from hospital do not have the facilities to be so discharged and thus take up beds that could be used for emergency admissions. This is unacceptable.
I offer my hon. Friend the Minister a radical solution to the problem—I do not know how receptive he is to radical solutions. If he is in a tier-abolishing and streamlining mood, he might examine the merits of looking at the roles of the community NHS trusts in relation to local authority social service departments to see whether the liaison between the two is good enough. If it is not, would he consider talking to his colleague in the Department of Social Security? There could be scope for further amalgamations and abolitions of tiers.
The Labour party is coy about its plans for the future. I do not wish to jeopardise the hon. Member for Peckham's chances of re-election to the Labour shadow Cabinet—if such an election takes place—but some of the semantics we heard from her today were quite extraordinary. She was asked whether fundholding will be abolished, or whether it will re-emerge as general practitioner commissioning.
If the Labour party believes in choice and diversity, will it say whether new Labour believes in a mixed economy in health care? The hon. Member for Stockport (Ms Coffey) is shaking her head—but I do not know whether it is in response to my argument. I hope that the hon. Member for Fife, Central (Mr. Mc Leish) will clarify the situation in winding up.
The former research director of the Fabian Society, Stephen Pollard, stated:For Labour to put forward a credible social and economic policy—with specific costings for healthcare—it should examine the approach adopted by its Socialist colleagues abroad and embrace the benefits that can be derived from an enhanced British independent healthcare sector.What is the Labour party's official view in that regard? Geoff Mulgan, the director of Demos, stated:Mutual help can fill the gaps in provision of everything from money, to food shops and housing.Does the Labour party endorse a trend towards the great mutuals of the past and of the present, such as the John Lewis Partnership, the Co-op and BUPA? The Labour party should let the House and the country know its views in this regard.
I was once a consultant to BUPA. When Frank Chapple was the general secretary of the Electrical, Electronic, Telecommunication and Plumbing Union, the union joined BUPA. He wanted to ensure that his members had the best possible health care available. I am not carping from a purist point of view, because, as a Conservative, I believe that everyone has the right to the best possible treatment available. If the general secretary of the EETPU chose to sign up all his members for private health care, well and good. I congratulate him, and I hope that they all benefited from it.
As I said in an intervention, there has been a long tradition of the trade union movement looking after its members with private health care outside the national health service—I refer to the Manor House hospital and to the Benenden hospital, one of the largest independent hospitals in the country.
394 The Labour party's argument is riddled with hypocrisy, and it is about time it came clean and told us what it stands for and what its plans are for the future. Does it believe in a mixed economy in health care?
In years to come, the most important thing will be getting value for money. The right hon. Member for Sedgefield (Mr. Blair) made a speech in this regard earlier in the week. The Times refers to his speech, and states:If Labour won the general election there would be no unnecessary reorganisation in the NHS. He said also that he had no intention of pumping in more money until it had been established whether the present budget was being well spent.Hear, hear, to that. I wonder whether he has told the hon. Member for Peckham. Why should we look in a crystal ball when we can read the book? I have read the book according to the Leader of the Opposition.
§ Dr. Goodson-Wickes
I shall conclude my speech—if hon. Members do not wish to intervene.
I refer to a saying of Sir Richard Doll, which I used to have framed in my consulting room—I used to get my patients to read it. He is well known by hon. Members as one of the supreme epidemiologists—and he was suitably honoured in a recent honours list. He first came to prominence when he demonstrated the causal link between smoking and carcinoma bronchus. He said:It is not for doctors to advise people to live their lives as invalids in order to die healthy.I suggest that the essence of Labour policy is to spread alarm among patients, when all the trends—while far from perfect—are for the better and in the interests of patients. I have the greatest confidence in the reforms proposed by the Government. They have been tackled in a practical and robust way. I suggest that the Labour party offers only uncertainty—and uncertainty is one of the worst things in this life. A patient, by definition, feels unwell, uneasy and uncertain. The last thing a patient wants is uncertainty about what the Labour party is going to do to the national health service, which we all value.
§ 7.9 pm
§ Mr. Don Touhig (Islwyn)
The hon. Member for Wimbledon (Dr. Goodson-Wickes) spoke for about 27 minutes—but I do not know whether hon. Members are any wiser. We know that history is not his strong point because he spoke about the Tories supporting the foundation of the national health service. I wonder what Aneurin Bevan, the architect of the national health service, would say if he knew that this week the British Medical Association has said that the health service is being cut to the bone. No one should pretend that today's national health service is the one that Nye Bevan and the Labour party created. The task of providing health care is as great a challenge now as it has ever been. Health care systems across Europe face conflicting demands, from the political pressure to provide every citizen with better access to care to the need to keep costs at a level that the nation and its taxpayers are prepared to pay and can 395 afford. Added to that political juggling are the pressures of modern health care—the mounting costs of care, a general aging of the population, changing disease patterns, increased expectations and advances in medical science and technology.
Health care in Europe has developed from the two basic models of a system of mandatory insurance supplemented by public funds and a universal system of state-funded health care. Rising public expectations set against the difficulties of financing health care inevitably lead us to examine how we fund health care, but that is a subject for another debate. Today, we are addressing the issue of bureaucracy in the health service.
The task of providing an adequate health service for the next millennium is not an easy one. We need to consider carefully how we will rise to the challenge. The Government's response has been to increase bureaucracy and to pour resources into an ever-growing army of administrators, rather than into primary health care. That is not the way to meet the challenge. Bureaucracy has risen to ridiculous levels in the health service. In 1993–94, the Government put an extra £1.4 billion into the NHS and every penny went on bureaucracy, not on patient care. As my hon. Friend the Member for Peckham (Ms Harman) said earlier—she is not in her place at the moment—the health service now has 50,000 fewer nurses compared with 1989, but it has 20,000 extra managers. The cost of administering the NHS has increased from 9.2 per cent. of the total expenditure on the NHS to 15.6 per cent.
While all that is happening, hospitals are refusing people who need treatment because of problems with funding. That is a scandal that cannot be tolerated in a civilised society on the eve of the new millennium, but it is being repeated across the country. I was in Hamburg recently and I learned about some initiatives that the German health service has taken to overcome the problems of meeting public aspirations for health care at the same time as controlling costs. The cost of some 25 per cent. of hospital procedures has been agreed between the Government, the medical profession and others by identifying diagnostic related groups. Those patient management categories have been negotiated between the hospital association and the insurance funds in all state hospitals to ensure quality and good care. It is intended that that practice will apply to 80 per cent. of hospital procedures.
Meanwhile, the Government continue with their obsession to develop the market in the NHS, instead of balancing costs against expectations. That obsession means that young diabetics, in my county of Gwent, have to pay for special insulin syringes because the local hospital cannot afford the £4,000 yearly cost of the service. In my constituency, a group of local women provide a cancer advice surgery. Last year, the bulk of its funding came from the mayor's charity appeal and it operates from a portakabin in a car park behind the high street. The group is sustained by volunteers and they are doing the work that should be done by the NHS. Such gaps are all too common.
Another reason why today's national health service is not the one that Bevan created is the element of commercialisation that has been allowed to sweep in like the incoming tide. While it might be appropriate to market-test for some services in a hospital—portering, catering and cleaning—it is not acceptable or effective to 396 privatise clinical services that directly affect patient care. Already sterile supplies, dental care, ophthalmology, pathology and pharmacy services have been handed to the private sector. Abortion services, psychology, speech therapy, physiotherapy and occupational therapy services have been market-tested as the inevitable consequence of an NHS that operates with a blind faith in market forces. No balance has been sought or achieved.
The markets may do many things well, but left to themselves the markets will not educate our children, they will not provide the infrastructure that the country needs and they will not provide an acceptable level of health care for our people. Health care is not a product that can be packaged, marketed and sold by formula, at least not in a civilised society which, while valuing the individual, cares for the whole community. Health care is not simply an economic question of supply and demand: it has a human element that makes it unique. Health care is about curing the sick, relieving pain and caring for the young, old and infirm. For most of us, the possession of all the wealth in the world would be no substitute for good health. We must bear that unique element of health care in mind when we consider the subject of effective management.
We need effective management in the NHS. We already have some good and effective managers in the NHS—some of the managers working in my area do a splendid job—but we do not need managers who are fixated on market testing and contracting out. The NHS needs skilled managers who can develop strategies and schemes, balance budgets and control costs properly, but who also appreciate that they run a unique service of health care. Those who are active and working in health care need to have a say in the management of the health service.
I recommend to the House the United Kingdom nursing leadership programme, which is sponsored by Johnson and Johnson and the King's Fund. The programme seeks to tap into the unrealised potential of nurses to produce leaders who can make vital contributions to the development of health care. It operates over two years and nurses have a non-nurse, board-level mentor and undertake relevant secondments to improve their knowledge and skills. That break with the traditional career paths for nurses is to be applauded because it is one way in which experienced health care staff can move to board level, thus aiding their personal development and, most importantly, providing a much needed health care perspective at board level. We should welcome that major new learning opportunity.
Nurse leaders will need to be strategists, environmentalists, slick political operators and confident leaders and they will need to show a sense of purpose. The programme will help them develop those skills. There is a needfor nurses to work with the whole systemso that they too arestake-holders",and can contribute fully to the development of new approaches to health care.
§ Mr. Touhig
The word "stake-holders" was a quotation from the programme set out by the King's Fund.
397 The rub is that the participants have to contribute £1,000 towards the cost of the programme. The Government are prepared to put £1.4 billion a year into the bureaucracy of health service, but they have not invested in that programme. They are concerned about bureaucracy and administration, but they are not concerned about the nurses—those at what my father would call "the coal face".
The Secretary of State for Health, who is not in his place, said in February that the policy on the nurses' pay award was not for a 2 per cent. rise, but for locally negotiated pay. Why is it that, four months later, 75 per cent. of health trusts have failed to make deals with nurses on local pay? That is a disgrace.
Hospitals are not oil companies, supermarkets or engineering firms and it is wrong to think that we can take managers from such backgrounds and expect them to provide effective health care. Obsessive political dogma mixed with blind faith in the markets is a potent medicine that produces privatisation—a prescription that will kill the national health service.
§ Mr. Michael Fabricant (Mid-Staffordshire)
The debate so far has revealed confusion and empty platitudes from the hon. Member for Peckham (Ms Harman) on the Labour Front Bench. I shall identify three areas in which Government policy has been shown to work by setting a safety net below which nobody can fall. That is Conservative party policy and what we would want from the NHS.
The first issue is the private finance initiative. There is a clear chasm between Labour Front Benchers, because the Leader of the Opposition supports the PFI but the hon. Member for Peckham has said again today that she thinks that the PFI is a recipe for the privatisation of the NHS. I shall refer also to trusts and, if I have time, to GP fundholding. I commend to the hon. Member for Peckham and to all Opposition Front-Bench Members the excellent book published by the Treasury entitled "Private Opportunity, Public Benefit", which explains the private finance initiative. It shows how the PFI acts to support the national health service—which is why the Leader of the Opposition has a different view from the shadow health spokesperson.
According to page 9, more than 50 small schemes—that is, schemes under £10 million—are under development or are already in operation. They include waste incineration schemes for south Kent hospitals, a magnetic resonance imaging scanner for the Mid-Sussex NHS trust, a combined heat and power scheme for St. James's University Hospital NHS trust, dialysis services for South Tees Acute Hospitals NHS trust, the completion of negotiations for a concourse development for the Queen's medical centre in Nottingham, and a number of other projects that are under way in Scotland. They are examples of the PFI working for, and not against, the NHS. The PFI is providing additional resources for the NHS. I cannot understand why the hon. Lady disagrees with her leader and insists that the PFI be opposed.
As to trusts, I find it incredible that Opposition Members continue to use what I call Mandelson alliterations. The latest one is "market madness". Far from 398 creating the market to which the hon. Lady referred, I believe that the trusts have created efficiency. That efficiency has not saved money for the Treasury, but provided better services for patients. That is good news. As my hon. Friend the Member for Wimbledon (Dr. Goodson-Wickes) said earlier, every Government Department has limited resources and we must determine how best to use those resources.
It is interesting to note that the Government have increased spending on the national health service by four times since 1979 and by £9.5 billion in the past few years. It is fascinating that the Labour party is not prepared to make a commitment this evening to similar increases in expenditure. We have heard only empty rhetoric from Labour Members.
I recently visited the Staffordshire ambulance trust, which the National Audit Office has identified as having the best response rates of any ambulance trust in England and Wales. I congratulate the service—particularly the chief executive, Roger Thayne—on that achievement. The Staffordshire ambulance trust has introduced an interesting new concept that it developed partly from a computer package from San Diego. It is the first ambulance trust to apply the concept. Every nine seconds, the trust has updates on where its ambulances are located in Staffordshire. Instead of being in depots as in other ambulance trusts, Staffordshire ambulances are placed strategically around the county and thus are able to respond quickly to calls.
That is the sort of innovative idea that can be introduced under local management. However, the Labour party derides local management. If Labour were to come to power, it would abolish local management, even though that provides the innovation which leads to better health care provision in Staffordshire.
§ Mr. Fabricant
No, I shall not give way, as I may speak for only 10 minutes.
I pay tribute also to the Premier Health trust in Staffordshire—which is ably chaired by Mrs. Margaret Whalley—and to the chief executive, Dr. Diana Rawle, who recently replaced Mike Marchment. The trust is responsible for the Victoria hospital in Lichfield, which has expanded its facilities. At one time, it was thought that a major district general hospital should be built some distance away from Lichfield to serve the people of Lichfield. However, the Premier Health trust—under local management and working hand in glove with local doctors and nurses—has ensured that the Victoria hospital provides the services in Lichfield for the people of Lichfield.
The hospital has a larger minor injuries unit, a new antenatal and maternity ward—which I opened recently—and increased facilities in the renal ward. There has been a rebuild of the in-patient facility, the rehabilitation department has been expanded and there are increased day surgery and out-patient services. Those facilities are available through the Premier Health trust, which owes its existence to so-called "market madness".
As to GP fundholding, it was incredible to watch the hon. Member for Peckham wriggle on the end of her hook. She said that she would not abolish GP fundholding, but then she said that she would abolish it 399 and introduce in its place "contracting"—or some other Mandelson expression. At the end of the day, we need the managers, the market and, most importantly, the resources. [Interruption.] However, I am sure that the hon. Member for Carlisle (Mr. Martlew)—who tries to intervene from a sedentary position—will not make any financial commitments.
Today I received a fax from Dr. Simon Elsdon, who is based in Staffordshire. I spoke with him last night and he said that he is not obsessed with dogma regarding who owns hospitals or who employs doctors and consultants, so long as good, efficient health care is free at the point of delivery. That is what GP fundholding is all about.
Labour Members are fond of using soundbites, but they have demonstrated today that they lack the ability to manage the economy or the health service. As with its education policy, Labour seeks not to push up health standards but to aggregate at the mediocre. Labour, through the abolition of the critical purchaser-provider divide, would destroy the expansion of hospitals such as the Victoria in Lichfield, or the expansion of the efficient Staffordshire ambulance service. Labour, through its abolition of fundholding, would emasculate general practitioners and thus weaken service provision to patients. Labour, through its opposition to the private finance initiative, would halt hospital building in its tracks.
Labour, by not committing itself to extra funding in the NHS, is limited to empty rhetoric and alliterative Mandelson soundbites. Labour, through its adherence to dogma, is determined to set in concrete an outmoded and ill-planned structure that was designed before 1948. While the Government can take pride in the fact that we have quadrupled NHS resources and empowered doctors for the benefit and well-being of their patients, Labour merely offers surgery by soundbite.
§ Ms Rachel Squire (Dunfermline, West)
We have just heard 10 minutes of empty rhetoric and classic soundbites from the hon. Member for Mid-Staffordshire (Mr. Fabricant). I hope that he will listen while I tell him a little about life in the real world for those who depend on the national health service.
I begin by paying tribute to the vast majority of NHS staff for their dedication, commitment and expertise. That is what has kept the national health service going, as it struggled against the impact of 17 years of Conservative Government policy. As a reward, the staff have been paid peanuts for providing vital health care. They have seen the privatisation of health care and they have watched while millions of pounds of public money was spent lining the pockets of the Tories' friends and creating more and more tiers of management.
I wish to use the brief time available to me tonight to highlight what is occurring in the real world. I shall focus particularly on what is happening at my local district general hospital, the Queen Margaret Hospital NHS trust in west Fife. For months, patients, their relatives and the staff have told me how the trust's bureaucracy and its managerial approach have led to the early discharge of patients—particularly the frail elderly—a lack of information and to ever-longer waiting lists.
I have raised my concerns with the chief executive and the health board. I have spent months listening to them saying, first, that I have not heard the full story; secondly, 400 that prompt action has been taken; and, thirdly, that the complaint that has been raised with me is not a common one. I have been willing to accept that, as a Member of Parliament, I tend to hear rather more complaints than praise, but I have reached the conclusion that I have used the procedures for too long, and it is time for me to make public my concerns about what NHS bureaucracy and the Government's policies, encouraged and promoted by Fife health board and the Queen Margaret Hospital NHS trust, have meant to my constituents.
Let me outline a few of the examples that I had hoped to quote in more detail tonight. Until recently, the Queen Margaret hospital had four consultant radiologists, covering the whole of Fife. Even that is not enough to deal with the demand and provide a fully comprehensive service. But from August there will be only one full-time consultant radiologist, because the other three resigned in disgust at the managerial approach to radiology services, which they believe has resulted in a reduction in quality patient care. When I met the chief executive at the beginning of this month, he put the resignations down largely to personality conflicts. Yet, surprise, surprise, the consultants who are leaving have been snapped up by nearby hospitals.
I quote what one of the consultants said in his letter of resignation:When I first came to the Queen Margaret Hospital three years ago, like the rest of the staff at the hospital, I was excited by the new challenges, new equipment and the future potential of developing appropriate and top quality services to Fife patients. However, in the last three years I have seen this deteriorate to a point I find professionally and personally unworkable due to a style of management that has no concept of prevalent future roles in modern Radiology which puts balance sheets and outward appearance before patient care and staff requirements for working conditions.The problems in providing a radiology service became apparent to me during the past two years in complaints from constituents. I have raised the matter on more than one occasion with the hospital trust management, but as a direct result of its behaviour, the Government's policies and the behaviour of Fife health board, which is supposed to ensure that such services are provided, the people of Dunfermline and Fife as a whole will be without an essential quality service that affects many areas of diagnosis and treatment, including surgery. There is a national shortage of consultant radiologists, so what hope is there that patient services will be provided or restored?
The second example of NHS bureaucracy and the Government's policies concerns a consultant ophthalmologist. As I said earlier, I have detected growing concerns for a considerable time, but it was difficult to get substantial evidence because patients and relatives were afraid to go public with their complaints in case they came back on them, and staff were afraid that if they spoke out they would be dismissed. A consultant ophthalmologist did speak out and he was dismissed, even though the vice-chairman of the trust said:I should stress that Dr. Hunter's clinical competence has not at any time been at issue.Dr. Hunter was sacked because he dared to complain about the senior trust management. Is it any wonder that the people of west Fife have no faith in the hospital trust management?
As well as the treatment of consultants, that approach has affected the whole staffing of the hospital. The House will not be surprised to learn that the ancillary staff, 401 who do such essential work, as my hon. Friend the Member for Preston (Mrs. Wise) said earlier in an excellent point, have not only been subject to private contractors, who offer lower pay and worse conditions, but they were recently told that when their contracts come up for renewal in the autumn, the trust will not even bother to make an in-house bid. Yet this is the trust that spent time drawing up a reward package for itself and the people who supported it.
Let me make it clear that the people of west Fife, indeed, Fife as a whole, never wanted trusts. They felt that the time and money involved could be better spent on providing patient care, but they have been landed with three of them. When they complain to me, they make it quite clear that they are not complaining about the vast majority of staff at the hospital. They blame the senior management and the Government for what is happening to patient care.
I was going to quote a number of complaints, but I have time to quote from only one—a letter that I received from a lady last month. I shall quote extracts from it, as it is about the real world of NHS bureaucracy and the Government's policies. She said:Dear Ms Squire,I am returning to work after three months' leave following major surgery … I was in Ward 19 … and was astonished to find on my arrival that I was sharing a room with two geriatrics and two patients awaiting eye surgery. I was told that Ward 10—the original Gynae ward—had been closed last year to make way for another Day Hospital ward. In the course of that week … as the continual battle for beds went on … lack of funds meant that the ward lacked a permanent charge nurse … On my sixth day, my consultant informed me that I would probably be allowed home three days later but that unfortunately I would have to be moved to another ward otherwise he would be unable to perform the next day's operations … On my return from the bathroom about 9.30 am, my bed had been stripped … and so I sat in a chair until I was finally moved downstairs to a short stay ward at 1.30 pm"—four hours later.One of the other ladies moved was 78 years old and had been moved five times in a week! … In my opinion, there are too many 'people in suits' with no medical knowledge who put money before patients' welfare.My conclusion is that the Conservative Government is guilty of serious underfunding in health and, if it was not for the unstinting dedication of all professional and ancillary staff, the National Health Service would be moving ever more quickly into line with the substandard healthcare".Those words speak more powerfully than mine. I challenge the Government to conduct a full investigation—
§ Mr. David Porter (Waveney)
On one level, we should feel some sympathy for the Labour party, caught as it is on health policies with two faces, one of which is its more public soundbite, alarmist, shroud-waving face, which slams the Government at every opportunity; the other, its more private, supposedly honest, wishful-thinking-that-it-will-soon-be-in-power face, which has to recognise the fact that many Conservative reforms work, 402 are popular with many health care professionals and are more effectively spending more public money to deliver an ever-improving public service.
What the Labour party is trying to do with its contortions of producing a credible alternative policy is to criticise the Conservatives and at the same time devise similar policies with other names. It cannot have it both ways. Even double-jointed contortionists cannot do that. We know that any health care policy must take account of the primary aim of the NHS: the appropriate and effective care of the people. It must then take account of the simultaneous relentless rise in public demand and expectation. Just witness hip replacements and cataract removals, which were unheard of just a few years ago but are now taken for granted as of right. It also must allow for developments in technology and changes in medical science and practice, including working practices. Then there is the ever-present reality of a finite resource, however much the economy grows. All that adds up to a complicated equation, and I think that it is a tribute to all professionals in the NHS and Conservative policies that we have such a success story with health in Great Britain.
One of many benefits of the reforms has been a move towards more localised responses to local needs. Where there are high incidences of asthma or a more elderly population than average, for instance, we can deliver a more local health service—an LHS within the NHS. That brings me to some specific comments about my own area. I am entirely in favour of doing away with needless bureaucracy, but, to me, that also means not letting the NHS bureaucracy lay down a model for local delivery that fits the bureaucratic mind but is not in the best interests of local people. For that reason, my hon. Friend the Member for Great Yarmouth (Mr. Carttiss) and I fought hard to oppose the break-up of the former Great Yarmouth and Waveney health authority, with the two halves going to Suffolk and east Norfolk. We lost that battle to the bureaucrats who advised the then Secretary of State.
We fought the fight, both locally and in the House, because the district general hospital, the local community hospitals and the health authority were seen to be very much part of the community. Since then, we have moved into a new era—and there is the possibility of moving even further, cutting bureaucracy and putting more money into patient care.
I have asked the authority to examine the set-up of the two health trusts that provide most health care in north Suffolk and east Norfolk. I am definitely not talking about a merger or takeover by the James Paget NHS trust, but a new trust—possibly called the Great Yarmouth and Waveney NHS trust—could be formed, and management costs of £1.5 million could be saved. I have asked for the money to be ring-fenced for the patients of Waveney and Great Yarmouth, rather than being reclaimed centrally. That has the potential for a creative and cost-beneficial reform of bureaucracy, although I recognise that some staff will not look kindly on further administrative changes.
In general, over the years, my area has seen agreement across the parties and consensus about people's health needs, regardless of how we represent them at different levels. However, as the next election has been getting closer, there has been a good deal of scaremongering from my opponents. One piece of panic-raising has concerned care of the elderly—hospital beds for them, and the viability of the community hospitals at Lowestoft, 403 Beccles, Southwold and Halesworth. The introduction of eligibility criteria has given rise to fears among elderly people that continuing care will not be available when they need it. That fear has been fed by local Labour activists who, apparently, can measure a service only by bed numbers—even empty beds—and seem incapable of looking at the totality of the service.
It is clear that the NHS has important responsibilities for arranging and funding care of people who require in-patient care under specialised clinical supervision in a hospital or nursing home in the voluntary or independent sector, but it must be funded by the NHS. Suffolk Health is closely monitoring the new eligibility criteria with a group of GPs, NHS providers, community health councils, carers and users. That is the local NHS at its best.
Labour is right to draw attention to occasions when the service falls short of expected standards, but it has neither told us what it would do if given a chance nor cited any of the thousands of daily success stories involving people living longer, more fulfilled lives thanks to our NHS, with waiting lists declining in Suffolk as elsewhere, more positive patient outcomes and the achievement of patients charter standards. I congratulate Suffolk health authority, and its chairman Joanna Spicer in particular. I also congratulate James Paget hospital and the Anglian Harbours trust on all that they have achieved, and express my confidence in what they will achieve in the future.
I do not expect members of the Opposition Front-Bench team to be interested in putting their views into perspective by reference to Suffolk, but I did expect their national account to reflect a more accurate picture, to support the health service and to tell us more of their own plans so that the public could consider them. All that we heard was, "Labour will renew the NHS." The Labour party should wake up to the fact that the NHS has been renewed during the past 15 years.
Health care in north Suffolk and east Norfolk has been transformed during the lifetime of the present Government. I know, because I use the service a good deal: I do not speak only as a politician. I use it perhaps more than the average amount, given that I have four children and a condition in my feet that is health care intensive. The service that I use is good and deserves to be commended, even as we seek to improve it further.
§ Mr. McLeish
On a point of order, Mr. Deputy Speaker. May I brighten up the proceedings—I hope that Conservative Members will agree about that—by informing the House that England is winning one-nil as a result of a goal by Shearer? As a Scot, I am quite glad to raise that in the House.
§ Mr. Eric Martlew (Carlisle)
I do not know whether you have heard the rugby results, Mr. Deputy Speaker. England is playing Wales tonight.
I am pleased to have been called, even on a day on which we should all be watching television, if not actually at Wembley. The debate is important. The motion concerns the way in which the Government have run down the NHS, and the way in which bureaucracy is choking the service. The position in my constituency is 404 no different from that anywhere else. We now have 429 trusts, all with chief executives and board members, and all producing minutes stamped "Private and Confidential". In some hospitals, people have as much chance of meeting an auditor or accountant as of meeting a consultant—and the consultant is likely to be from Coopers and Lybrand, and nothing to do with medicine.
Reference has been made to the private finance initiative. So far, in my constituency, the PFI has produced a good deal of paper and a good deal of money for consultants and solicitors, but no new building. The same is true throughout the country. There are no big schemes, and in Carlisle the PFI has delayed a scheme by three years. That means that we are unlikely to get 474 beds for a new hospital—a figure decided not just by medical consultants in the hospital but by the previous chief executive of the Carlisle Hospitals NHS trust, Mr. Clive Moth. I think it only right to say something about Mr. Moth's unexpected departure from the trust. On 3 May this year, the trust suddenly issued a short press release saying that he was taking early retirement. When pressed on whether he would serve his full notice, the trust told us that he had already cleared his desk and left.
Mr. Moth was a crucial figure in the PFI scheme. He was negotiating with the Treasury, with AMEC, the only company involved in the bid—there was no competition—and with the Department of Health. No one in my constituency believes that he took voluntary early retirement: that is a fairy tale put about by the trust, which does no credit to the trust or its chairman. The truth is slowly starting to come out, however. It appears that Mr. Moth was not anxious to reduce the number of beds in the new development, or to reach a deal for the trust that would mean that it would not be able to afford to pay the rental in the future. He was not prepared to accept that the rent would be paid while patients would have to be: turned away, so he had to go. We do not know whether he was forced out by AMEC or the Government; it could have been a combination of the two.
Miraculously, the Government just happened to have a spare civil servant to take Mr. Moth's place—a Mr. Peter Johnson. Mr. Johnson, a former Whitehall civil servant, had been sent north to arrange for hospitals to become trusts, and had done a good deal of work on the PFI in recent years. However, he had no experience of running hospitals in the recent past, if at all. I understand that he will do this last task for the NHS before retiring.
The football situation seems to be getting worse. I understand that the score is now one-one.
Mr. Johnson was given the task of putting the PFI through at all costs. Perhaps the Minister will be able to tell me whether the acting chief executive is on performance-related pay, and, if he is, what the target is. Is it to get the deal signed and the PFI hospital built? No other hospitals are currently being built. Can the Minister confirm that the Carlisle Hospitals NHS trust has a deficit of between £500,000 and £1 million? If so, will that mean redundancies?
The PFI scheme was originally part new build and part refurbishment. I understand there has been a departure from that specification and that the contractor, AMEC, is suggesting that it should build additional accommodation and take the central tower block, which was going to be refurbished. It is 30 years old but still in reasonably good condition. There are fears in my constituency that AMEC 405 will use the tower block for a hospital—it was designed for that purpose. We could end up with a private hospital right in the middle of the infirmary, which is not wanted by my constituents.
On 3 June, the hospital's medical staff committee unanimously passed a resolution that it would not accept fewer than 474 beds and that, if the trust accepted the contractor's proposal, the staff would not work with the trust. If PFI provides 474 beds and the trust can afford the project, it should go ahead—we have been waiting more than 20 years. If that is not the case, I am assured that in the past the Government have provided public money if a PFI scheme has not come off.
When I intervened on the Secretary of State, I said that things have changed since 1977, when Cumbria had one area health authority. The Secretary of State was wrong to say that there were district health authorities, but there were family practitioner committees. Cumbria's health authority had one paid member—and I declare an interest, because that person was me. I received £2,000 a year, which is equivalent to £6,600 today. I thought that I was most fortunate and it was a great privilege to chair that authority. Today, Cumbria has two health authorities and seven trusts. Each chair receives £17,000 a year and each non-executive member receives £5,000 a year. The total cost exceeds £330,000, which could be spent on patient care. The Government say that the number of regional health authorities has fallen, but if one adds them to the number of trusts, they total 529 quangos. Their chairmen each receives an average of £17,000 a year and the 2,645 non-executive directors each receives £5,000. Therefore, it costs £22 million to service the quangos with the Government's place persons. Cumbria does not need all those trusts. The ambulance trust is nonsense, and Carlisle has a community trust and a hospital trust when only one is needed.
I suggest to Labour Front Benchers that if those organisations are to be retained, their chairs should be paid a small salary—£6,600, equivalent to that paid in 1977—and the board members should receive compensation for loss of earnings and expenses. Those boards have brought no benefits to the NHS and the quality of the people who serve on them is no better than when I served on a health authority in the 1970s and 1980s. The big difference is that some people who served on boards in those days were known because they had been before the electorate and had won elections, so they were locally accountable.
§ Dame Jill Knight (Birmingham, Edgbaston)
When I know that the House is to debate the health service, I always read what the British Medical Association has to say before I prepare my speech. One can always rely on the BMA to spread alarm and despondency. Sometimes, I think that BMA should stand for Boundless Misery Alliance. The BMA has attacked every Government reform ferociously and has portrayed every advance as a retreat. As generic prescribing, fundholding and trusts have been introduced over the years, the BMA has fought 406 them tooth and claw. As time passes, the association realises how good are those reforms and its objections gradually peter out. Then the BMA says, "If there is the catastrophe of a Labour Government, we hope to heaven that they will not alter Conservative reforms."
The BMA only grudgingly acknowledges the ever-increasing amount of money allocated to the NHS and the extraordinary advances in expert treatments. Of course those advances are due to the cleverness of medical practitioners, but they also mean that the NHS has to find a great deal more money to fund them. The leader in this week's British Medical Journal calls for a debate on rationing health care. It states thatgovernments should come clean with the public and lead a debate on how best to ration health careand that neither the Government nor the Opposition face the facts. The leader continues:Most commentators accept that rationing is inevitable, but the debate keeps returning to this point because the politicians refuse to acknowledge it.The word "rationing" is totally inappropriate in this context because it conjures up visions of hard-faced bureaucrats producing ration books, tearing out coupons every time someone visits a doctor, dentist, chemist or optometrist and saying, "You can't have an appendectomy, a hip replacement or a baby because you have used all your tickets."
I checked three different dictionaries for definitions of rationing in the Library. One was afixed daily allowance of food served out for man or animal".That has nothing to do with health care. Chambers dictionary defines rationing as afixed allowance or portion, especially of food".The Oxford dictionary defines rationing as afixed allowance or individual share of provisions … daily allowance of food allotted to each officer or man.It even mentions a ration of one pound of bread and three quarters of a pound of meat, and refers to an officially limited allowance for civilians in time of war. That has nothing to do with the problems facing health care.
Opposition Members should understand that the BMA is blaming them as much as us. The association says that neither party has the guts to debate the most important matter in health care today—rationing.
The British Medical Journal acknowledges that doctors have always judged whether a particular patient should receive certain treatment. There is nothing new about that. Suddenly, it has to be called rationing and there is a big public debate. The leader blows the gaff later. It states:We use rationing as a summary term to describe the process of choosing between beneficial services. We have adopted this term because it provokes the greatest public controversy.In other words, it is all about frightening the horses. I wonder whether the BMA wants Government decrees on which patients should receive expensive drugs, whether smokers should receive cancer treatment, whether drinkers should be given liver transplants and whether there should be an age cut-off for any treatment. Surely those must be medical decisions. The BMA is totally on the wrong track. How can such decisions ever be taken by Government, or even by public agreement? The Government cannot decide whether or to what extent a patient might benefit from a particular treatment.
407 There might be a case for decreeing that fertility treatment for women over 55, for example, should not be allowed. Others might say that it is madness to spend millions of pounds on aborting babies, then spend further millions of pounds on enabling women who cannot have babies to have them. I can imagine the howls of rage from the BMA and from the medical profession if the House tried to lay down rules on those matters.
The BMJ article does not finish there. It goes on to state:The British Government likes to suggest that the drive for effectiveness will obviate the need for rationing.I have never heard one Minister say any such thing in any speech, and I have never seen such a statement in writing.
Let us be clear about what the BMA is asking. I understand the BMA's position if it is suggesting that GPs should not be called out on trivial matters or that ambulances should not be called out—as many are—on very trivial matters when people could manage perfectly well to take themselves to hospital. However, this week's call from the BMA to demand that we have a great national debate on rationing is wrong.
It is right that we ask the public to regard the health service with some sensitivity, to recognise that we should not call out a doctor if one is not needed and that we should not call an ambulance if it is possible to get to hospital without one. That is not what the BMA is saying, and we should be absolutely clear about that.
Moreover, to help us in our deliberations, the BMA produced a paper for this very debate today. It is a parliamentary brief on bureaucracy and patient care. In that paper, the BMA states that there isa huge duplication of administrative effort",but it does not describe that duplication. Of much more relevance, the paper states that a scrutiny team's report on administrative overweighting, produced in July, was welcomed by the Government, and its recommendations will be implemented by December this year. Simpler claim forms will be in place by next Monday. The BMA is therefore saying in this briefing paper that the issues that the BMA has raised with the Government on bureaucracy and overmanning have been well addressed.
The paper speaks of the turmoil in public district health departments because of the Government's initiative to reduce management costs. I point out to Labour Members that they cannot accuse us of doing nothing when the BMA has itself made it clear that we are doing something.
I realise that all hon. Members have an extremely short time to speak in this debate, and that others have still to speak, but any hon. Member who thinks that any Government of any colour will be able immediately to address every medical need as it arises—such as a preferred doctor or hospital—is living in cloud cuckoo land. Our record on health care is very good, and I support it all the way.
§ 8.3 pm
§ Mr. Richard Burden (Birmingham, Northfield)
I do not know how to follow that speech, Mr. Deputy Speaker. However, I shall take you back almost a year—to 3 July 1995—when there was a debate in the House on the national health service. I made a speech in that debate, in which I told the House about a primary health care centre 408 in my constituency. Actually it was not "in" my constituency—but it was scheduled to be built in my constituency.
I told the House about how that project—which had been promised several years previously and talked about for many years before that—had not yet been started. The first reason was that—as a result of the market mechanism imposed by the Government on the NHS—none of the trusts could decide which of them had the responsibility to build that primary health care centre.
We had also been told by the then regional health authority—the West Midlands regional health authority, which was particularly popular with the Government—that the capital had been made available. However, last year, I was told that there would be a further delay in building the primary health care centre because—although the capital had been earmarked some years before, and the problem of who had the responsibility to co-ordinate its building had been overcome—the project had to be financed through the PFI. I was assured that matters would still be all right. I was assured that all the tenders would be in by last October, a business case would approved, and that matters would be well in train by this year. That is the problem.
The first stone has not been laid in the primary health care centre. As late as last January, I was still being told by the health trust and by managers that the project was on track. However, a couple of weeks ago, it transpired that the health care centre will be delayed yet again. Why is that? It has been discovered that the PFI—which is much vaunted by the Government—cannot produce the goods for it. Two years after the capital was allocated, the project was delayed because of market operation. It was then put through this ridiculous mechanism, the PFI, which did not work in the first place.
I shall quote from a letter that I received from the developers of that site—called Rubery Hollymoor—who put in a bid and have now found that their bid is unacceptable. They said:You will be aware that the assessment criteria for PFI schemes are constantly changing and without a clear direction many consortia involved in healthcare projects are becoming increasingly frustrated. Our consortium alone have expended approximately £100,000 in abortive costs on this relatively small scheme.The sad fact is that unless public sector funding can be secured for this project in the very near future, the local community will not have the benefit of the planned facility for several years.They enclosed a copy of their most recent letter to the trust.
The fact is that something that was promised some years ago has still not been built, and it is now in question. I ask the Minister whether he will now guarantee that the finance and capital that was promised all those years ago will be made available. He may say that he cannot answer that question without some notice, but last week in Health questions I asked this Minister—the Under-Secretary of State for Health, the hon. Member for Orpington (Mr. Horam)—that very question. I asked him whether it is fair that local people should be denied facilities that they have been promised because of a scheme that they did not invent or ask for, but which the Government have imposed on them.
I am glad that the Minister is in the Chamber today. In reply to my question last week, he told me:I do not know the particular scheme to which the hon. Gentleman refers, but I shall look into it. None the less, the PFI is accelerating the process. We are breaking out of the traditional system whereby 409 everybody has to wait for the Treasury—waiting for Godot, one might say. If the scheme is good, provides value for money, and the risk is properly apportioned, it can obtain private sector finance. We are talking about a new era for hospital building in Britain, yet we still do not know what the Opposition think about it."—[Official Report, 18 June 1996; Vol. 279, c. 678.]I will tell the Minister what I think about it. I am all in favour of trying to attract private finance when it speeds matters up, when it helps and when it is additional. I am not in favour—I do not know anyone who is, apart from Conservative Members—of schemes that delay the process, cost the private sector thousands of pounds and destroy their confidence, or that end up requiring public funds but with question marks over a capital budget that was supposedly already there.
In his reply, will the Minister for Health tell the House what that scheme and other PFI schemes have cost the NHS in bureaucratic costs, paperwork and preparation? What have they cost the private sector? Will he give a guarantee—no ifs, no buts and no plans—that that primary health care centre, which has been demanded by the people of Longbridge and promised to them, will be built next year? If he cannot give that guarantee, the private finance initiative, in the way that it is operated by the Government, will be shown up for the sham that it really is.
I want to touch on one other area that also concerns primary care—community services. For too long, that has been the Cinderella service of the NHS. Time and again, Ministers tell us that waiting times are coming down. I acknowledge that, in parts of the acute sector, waiting times have come down, but why do Ministers never give all the figures for all the services provided by the NHS? Why are they rather vague when they talk about community services?
In my constituency, a little five-year-old boy called Matthew Kelsall has been on the waiting list in Birmingham for occupational therapy since May 1995. His mother was told that he would probably be seen in July this year. She has now been told—after pressure from me—that an action plan is being drawn up to improve services and to tackle the waiting list. The result of that action plan is that Matthew is not likely to be seen until December. I may not be very good at sums, but I think that that is a rather longer wait than was originally promised.
That is the operation of the market. It is the way that the health service is being treated by the Government. Community services—the services that are less visible and so do not catch the headlines—suffer time and again. When will the Government come clean and admit that they have not properly funded the waiting list initiative? When will they come clean and admit that they have funded it by borrowing against the future and borrowing from general practitioner underspends? There is no continuing commitment to fund the waiting list initiative.
At the end of the waiting list initiative, when waiting lists are, perhaps, down a little more, how will the Government maintain that improvement? Will they put in the necessary money? Is so, where will it come from? Or will they allow waiting lists to rise again? If they do put the money in, will it be taken from other parts of the NHS? Will it once again be dragged away from community services, family health care services and so on? The public have a right to know.
The Government have trumpeted their so-called waiting list initiative, but the public should know the full truth about what will happen to it. They have a right to the 410 community services that they require. Earlier, the Secretary of State said that the NHS is now led by primary health care. Despite the best efforts of the staff who work in primary health services and in community services—the front-line staff and the managers—the circumstances under which they operate, the market mechanism and the way that resources are being diverted away from primary health services give the lie to the Minister's claim. They and the House have a right to expect straight answers from the Government.
§ Mr. Piers Merchant (Beckenham)
I welcome the opportunity that the Opposition have provided today for a debate on health. There needs to be a serious debate on the dilemma, which all future Governments will increasingly face, of an almost limitless demand for new health provision, following more and more innovations, and the limited resources available. Unfortunately, the Opposition have ducked that debate. Instead, they have reduced the level of discussion to party political point scoring. That is a great pity, because that debate should take place.
The Opposition want to talk about all the things that they can find wrong with the national health service as well as a great many things that they cannot find wrong, but which they invent. The most obvious recent ploy has been to talk about bureaucracy because they think that will go down well with the public. The reality is that if they stripped out dozens of administrators, either it would be impossible to obtain an efficient use of resources or the clinicians would end up doing administrative tasks when they should be looking after patients.
The Government have been tackling the whole issue of bureaucracy, to try to keep it to a minimum. They have introduced a whole series of initiatives over the past few years: the abolition of the 12 regional health authorities—a whole tier of administration taken away, but a move that the Opposition opposed—the joining together of district health authorities and family health services authorities; the reduction in the number of health authorities in Wales; the requirement for a 5 per cent. reduction in administrative costs across the board; as well as the efficiency scrutiny teams that have quite literally cut out millions of forms. In my area, the Bromley Hospitals trust has saved £350,000 by streamlining its management operations through natural wastage, without affecting either clinical standards or staffing. It has done away with two director level posts to gain the greatest efficiency from the minimum number of administrators. That is the reality on bureaucracy.
I want to deal with a few of the issues that are of concern to real people. First, there is the issue of waiting lists. There have been waiting lists ever since the NHS started, but, quite naturally, patients want them to be kept to the minimum. That is precisely what the Government have achieved. Waiting lists have been reduced to their lowest-ever level. In fact, the last figures that I saw showed that the number of patients waiting more than a year for an operation had fallen to only 4,000—the lowest level since 1948. They also showed that 50 per cent. of all patients are treated immediately, a further 50 per cent. of the remainder are treated within five weeks and 75 per cent. of the remainder within three months. In my area, Bromley Hospitals trust has reduced to zero the number of patients who wait for more than one year and its overall waiting list has come down by 25 per cent.
411 Secondly, all areas have benefited from new facilities during the past few years, not least the area that I represent. However, we are badly in need of a new acute hospital, as my hon. Friend the Minister knows only too well. The advance plan for a new acute hospital has reached the PFI stage and three tenders are expected by the end of July, with a firm business plan by October and a financial agreement by the end of the year. I hope soon to see the plan set in bricks and mortar.
That is being provided on top of the significant investment that has already been made—for example, a new day treatment unit that has resulted in a 25 per cent. increase in day cases. I visited the unit after it opened in March. It is an excellent unit that has been warmly welcomed by both clinicians and patients. At the local community hospital in Orpington, my hon. Friend the Minister's constituency, there has been a £2.4 million investment to upgrade its services. Last year in Beckenham, my constituency, £1 million was spent on new facilities for local people—a minor treatment unit, new diagnostics, a paediatric clinic, community health facilities, education and so on. All those have brought great benefit to local people. In May, there was a 16 per cent. increase over last year in patients being treated.
Thirdly, there were problems with accident and emergency facilities earlier this year, especially in January when there was an unprecedented level of demand. Like other health authorities, Bromley has taken firm action to deal with the problem. Between last September and March, waiting time in Bromley hospitals has been reduced by a third. In Bromley hospital itself, where the A and E unit is located, there have been a number of major innovations—a new consultant; minor treatment facilities that screen out people who do not need major A and E attention, which makes the system more efficient; two new wards; some specialised beds to look after people with the most serious illnesses and injuries; and a new observation ward. So major work has been done that matches investment into the three next nearest accident and emergency hospitals, all of which have benefited in the past year by investments of £1 million or more.
At Bromley hospital, £1.26 million will be spent on new investment this year and about £900,000 in the following year—all to improve the accident and emergency facilities. I am very happy that that problem, which should not have occurred but did, has been swiftly dealt with, the necessary money has been provided and the necessary investment has been carried out. I am sure that that is already delivering great benefits.
Developing and widening primary care is of the essence. I am delighted with the Government's approach to that—part of which, of course, is the extremely beneficial GP fundholding scheme. The widening of the scope of GPs' provision will not only satisfy patients, who would prefer services to be available from the GP whom they know, trust and can get on with easily and to whom access is easy, but take pressure off hospitals. It will take pressure off A and E departments because minor injuries can be handled by the GP, off consultancy services because they can sometimes be provided at the GP's clinic, and off diagnostics because, although much of it has traditionally taken place in hospitals, it can now be carried out by GPs.
It is time that the great advances that have been made in the NHS and the great benefits of the Government's reforms were properly recognised. It is time that the 412 Opposition paid proper tribute to the teamwork between clinicians and administrators who, by working together, are essential to the many excellent facilities and success stories in the NHS—they exist, whatever the hon. Member for Peckham (Ms Harman) may think. Most important, it is time that the Opposition stopped the point scoring, the double think and the double talk, and recognised the reality of the excellent NHS and the extent to which it has improved as a result of the Government's reforms.
§ Mr. Robert Ainsworth (Coventry, North-East)
I want to use this debate to raise two local issues that are causing great concern in the Coventry area. They are, first, the impact of the Government's policy, including the private finance initiative, on the hospital services in the city, and secondly, if I get time, health inequalities.
The Secretary of State said that the PFI had freed the national health service from short-term capital restrictions. Actually, what has been achieved is nothing other than delay. In 1987, Walsgrave hospital, the biggest hospital in the Coventry area, was identified as in urgent need of capital repairs. It is a 1960s building that looks fine from the outside, but, as hon. Members know, buildings built in that period cause some grave concerns. The hospital was in the queue for £20 million, but reorganisation by the Government, who insisted that there was far too much inefficiency in the NHS and intended to sort it out, put that capital allocation on hold, and the much needed work was not done.
We in the area were then told that, if the hospital applied for trust status, we would get the required capital. Walsgrave hospital did exactly that, and became a trust in the second wave. We cleared all the hurdles right up to political clearance at ministerial level for a £30 million capital allocation that was needed by the hospital. Then the Government changed the rules again and said that all capital must be referred to the PFI. Again, the capital allocation was cancelled.
Many good news stories have been generated during the process. We heard, "Good news—Walsgrave is in for a £30 million bid." Halfway through the PFI process, we heard, "Good news—Walsgrave is in for a £50 million bid." Now that we are down to one preferred operator, we hear, "Good news—Walsgrave is in for a £100 million bid." The proposed deal is basically for large land disposal, extensive development and 25-year control of clinical and non-clinical services. There is much to be commended, but some great concerns have been thrown up by a dilemma.
The second hospital in the city, Coventry and Warwickshire hospital, is on a central site. As part of the proposals—although those who are putting the good news spin on the story are trying to keep the two separate—the Coventry and Warwickshire hospital will all but close. My fear is that we will get the very worst of all worlds.
Birmingham central hospital was replaced by a minor injuries unit in order to offset public concern at the loss of facilities. It closed within a year. There is massive concern in Coventry that it will get exactly the same treatment. There is great public pressure to keep facilities in the city centre. It is a good location that is accessible to the entire city. I fear that we will get a minor injuries unit that will dissipate public concern and get rid of the 413 pressure. In order to push the main proposals through, we will wind up with an unviable facility that will close within a relatively short period at cost to the public purse.
The other concern among people is affordability. As I said, we are down to a single bidder in the PFI process, but there is a huge gap of millions of pounds—I cannot get the information to pin the figure down—between what is in the district health authority's budgets that would fund the PFI proposal and what the private sector is saying that it wants in order to make the scheme work. The public money is simply not there, unless the Minister is prepared to give assurances that there is an alternative public route to the necessary works at Walsgrave.
Alternatives are not available, so what on earth is going to happen to health service budgets in order to lever in the PFI proposal? What will be scrapped? What will be chucked aside? What savings will be made? What will it mean for the terms and conditions of people who work there? What will it mean for the actual service by the time the private sector has knocked it into shape to get the profit that it needs to fund the 25-year, £100 million proposal?
Another concern I have over the way in which the Government are operating the PFI, which all hon. Members are entitled to have, is about the process, and the lack of accountability. The proposed scheme in Coventry has come out at twice the original cost at the end of a nine-month process, during which, as a Member of Parliament, I have been offered access to the detail only on the basis that it is private and confidential, and that I share it with absolutely no one.
The chief executive of the community health council has been told by the chief executive of the Walsgrave Hospitals trust that the PFI is nothing to do with the CHC; it has no remit whatever to consider the PFI, despite the fact that the proposal will effectively set the scene for health service delivery in the entire city for many years to come. That is quite disgraceful. There are grave concerns about the loss of city centre provision and the affordability of the scheme. The last thing we want is a hospital that no one can afford to run or use, as I understand already exists in Solihull.
Will alternative funding be available? I want the Minister to say what control he is prepared to give up in return for the risk transfer. Even if we can shoehorn the proposal into the existing budgets, the private sector will not be prepared to accept the risks involved in running clinical and non-clinical services for a 25-year period without having total control.
Another issue, which I shall have to raise briefly because of the 10-minutes rule, relates to health inequalities. Much work has been carried out in Coventry to identify the scale of the problem there.
Earlier this evening, we discussed funding inequalities. Hon. Members know jolly well that proposals were made to ensure equality of funding across the nation, but they were rejected or amended by the Government in the most deplorable way. Although Coventry suffers as a result of funding inequalities, I shall concentrate on health inequalities.
Research conducted in Coventry some time ago, which has not been challenged, proves that, on average, men living in the more affluent parts of the city such as the 414 Bablake ward live nine years longer than men living in the Henley ward. Women in the Earlsdon ward live 10 years longer than women in the Henley ward.
Research on child health issues demonstrates further inequalities. The results of a study conducted in Coventry show that, if national statistics were applied to Coventry, 20 out of 47 stillbirths or first-week deaths of infants would have been avoided. It shows that 13 out of 31 neonatal deaths would have been avoided, and that 200 out of 383 infants born under 2,500 g would have avoided that difficulty.
The broad thrust of those findings is that the problem in Coventry is worse than the national average by more than a third. That must apply to other cities, as our problems are no worse than theirs. It is an absolute disgrace that those problems should occur in a so-called developed western country. One would expect them to be limited to third-world countries as we approach the end of the century. Nothing is being done to address those issues.
§ Mr. Peter Luff (Worcester)
Having listened to the speeches of the hon. Members for Carlisle (Mr. Martlew), for Birmingham, Northfield (Mr. Burden) and for Coventry, North-East (Mr. Ainsworth), I have started to feel sorry for the Opposition. I realised that they have to believe—or try to believe—the worst of absolutely everything, when the reality—if only they would look at it objectively—is so very different. I now know where Eeyore's sad and gloomy place is—on the Opposition Benches.
If time had permitted, I had hoped to share with the House an article written by Roy Porter, a medical historian at the Wellcome Institute for the History of Medicine, that states that the problem goes back some 200 years to the 18th century. It is not so much new Labour as very old Labour indeed.
How refreshing it was to hear the speeches of Conservative Members, particularly the speech of my hon. Friend the Member for Beckenham (Mr. Merchant). My experience reflects his. New facilities have been provided in partnership with the private sector at Evesham community hospital and the Spring Gardens health centre in Worcester. The Worcester royal infirmary has a new accident and emergency service and improved rheumatology services, and we are to have a new hospital at last, having been in the queue for 30 years.
Opposition Members wring their hands in despair at delays of a year here and there. I do not want delays in the building of hospitals, but we have been waiting 30 years for a new hospital under the old Treasury capital funding system, and the PFI gives us the hope of getting one at long last.
The short title of the debate is "Bureaucracy and Patient Care in the NHS". We are all enemies of bureaucracy and in favour of patient care. Bureaucracy is a word that was coined in the 19th century. John Stuart Mill wrote in the "Westminster Review" ofthat vast net-work of administrative tyranny … that system of bureaucracy, which leaves no free agent in all France, except the man at Paris who pulls the wires.A bureaucrat is defined in the Oxford English Dictionary as 415An official who endeavours to concentrate administrative power in his bureau.We are all against bureaucracy, but I hope that we are in favour of management. There are four pages in the Oxford English Dictionary defining management, and almost all are complimentary. I thought that it was common ground across the House.
My right hon. Friend the Secretary of State reminded us that, when the right hon. Member for Derby, South (Mrs. Beckett) was the Opposition spokesman on health, she said on television:I don't think it's really in question any more that the traditional NHS was under-managed".One would not think that from the speech of the hon. Member for Peckham (Ms Harman) this afternoon.
I am dispirited by the dishonesty of Labour's attack. A year or two ago, the Opposition targeted company cars, some of which are used by district nurses and health visitors. They totally ignored the reclassification of many nursing grades as managers in their artificially inflated figures for so-called bureaucracy, and, as Conservative Members have repeated time and again, they have resisted every serious attempt by the Government to reduce bureaucracy. They have opposed it nationally and locally.
Labour voted against the abolition of regional health authorities. That saved hundreds of jobs in my region, and released thousands of pounds for better patient care. Locally, the former Labour leader of Worcester city council recently urged his Labour colleagues on the community health council to vote against the merger of two community health trusts. That would have reduced bureaucracy and released funds for patient care. Labour says one thing and does another.
When will Labour come clean on where it stands on my right hon. Friend the Secretary of State's attempt to reduce administrative costs by 5 per cent. in cash terms or 8 per cent. in real terms? It is extraordinary that we have heard nothing about that.
Of course I understand that the change that the Government have brought to the health service threatens established relationships. It makes consultants feel uncomfortable and imposes extra burdens on GPs, but huge benefits flow from that change. GPs are responding magnificently in seeking to reduce bureaucracy. The "GP links" initiative has reduced the number of forms that GPs need to fill in for the health authority. Many practices have direct computer links to the health authority, vastly reducing the administrative burden.
The "patients, not paper" initiative has responded to exactly the same concern. Extensive consultations with GPs and practice managers have achieved dramatic results. Forms have been simplified and eliminated, in a way that would gladden the heart of my right hon. Friend the Deputy Prime Minister.
Form GMS1 for patient registration replaces eight old forms. The new maternity form GMS2 replaces three old forms. Form GMS3—the multi-purpose claim form for non-registered practices—replaces eight old forms. Form GMS4 is a new payment booklet that replaces nine old forms. Those four new forms replace 28 old forms. What an achievement that is, and what a dramatic increase in bureaucracy. For the benefit of Hansard, that was said with irony.
GP fundholders have cut red tape. They are providing in-house services leading to better patient care and less bureaucracy. They provide physiotherapy services, 416 out-patient clinics and surgical procedures. Some GP practices even offer vasectomies. There are electronic links with hospitals making direct bookings for day case surgery offering patients the choice when they want to be treated. They are improving communications with consultants and reducing unnecessary follow-up out-patient attendance by seeing their patients in their surgeries. They are providing better patient care and less bureaucracy time and again.
Where does Labour stand? What is Labour's policy? I think that we heard it from the Front Bench, although I was unclear earlier. It is to strengthen the power of bureaucrats in the national health service by abolishing GP fundholding and returning responsibility for purchasing to the health authority bureaucrats—managers, as I prefer to call them. They are the very managers who now recognise with stark clarity that GPs are in the best position to manage patient care.
The role of NHS managers in a primary care-led NHS should be to facilitate greater purchasing by GPs. They should manage the performance of GPs and hold them to account, but they should not buy services for patients they do not know and will never meet. The success of GP fundholding in my area is a great tribute to the system, and all the scare stories have been proved false. No practice has overspent in the year that has just ended, and the resources have been used by GPs significantly to improve services. They have done so, for example, by increasing the number of social workers in practices.
The trouble that the Labour party has in this debate is the thought that dares not speak its name and which lurks behind all its rhetoric. The shadow Chancellor will not let Labour Members speak that thought, which is, "Is there: more money or not?" That is the question they cannot and will not answer. It is true that the UK spends less on health than most other OECD countries, but that is not: because the Government have not provided the expenditure. Other countries are spending more because there is increased spending by free citizens on private health care. Perhaps that is a policy that Labour might like to consider—giving people choice, something that the Conservatives favour.
The BMA says that an extra £6 billion is needed—a figure plucked from the air. It reminds me of what J. Paul Getty said in response to the question, "How much money does it take to be happy?" He replied, "Just a little more." That seems to be the policy of the BMA. In fact, the Government have given a lot more, but there has been little gratitude from the BMA. I must be careful what I say here, but I work in the Lord Chancellor's Department as a PPS, and I am used to professional groups wanting "a little more" and dressing it up as professional concern.
Labour's misrepresentation constantly shocks and amazes me. It chooses the few figures that suit it, and ignores all the others. There are great Labour press releases about the reduction in bed numbers. However, I judge the success of the NHS not by how many beds it has, but by how healthy the country is and by how many patients it treats. The NHS is not an hotel—it is meant to make people better.
Labour ignores the increase in resources and the increase in the hospital building programme—something it cut the last time it had control. It ignores the real terms increase in staff pay—something, again, that Labour cut when it last had control. It ignores the reduction in waiting 417 times, although a disparaging reference was made to it earlier. Labour ignores the fact that there are 55,000 more nurses and midwives and 22,500 more doctors and dentists. That is 85 nurses and 35 doctors for every constituency in the land.
I am not saying that there is no more that we could do, as there is always more to do. For example, we could help pharmacists, nurses and therapists to play a wider role in the NHS, and give more of them the ability to prescribe. A practical suggestion is that we could review the NHS superannuation regulations to enable practice nurses to work together effectively. The real test of the health service is what it is doing. The Government have increased life expectancy in this country by some two to three years, and that is the real test of what our health service is doing today.
§ Mr. Jacques Arnold (Gravesham)
This debate is about bureaucracy and patient care in the NHS, and I would like to concentrate on patient care.
The Government have carried out massive reforms of the NHS, and the British people should judge patient care within the NHS by the results. In the past year alone, the NHS has carried out 8.6 million consultant episodes in our hospitals.
It is worth reflecting that in the four years since the reforms the number of such episodes has risen by no less than 25 per cent.—a massive increase in health care. I well remember that when I first entered the House the talk in the NHS was very much about waiting lists. It is worth noting that, following the reforms, no more people are waiting more than 18 months for an operation, and the 12-month waiting list has fallen throughout the country to just over 4,000 people.
That is no surprise, as the Conservative Government have spent an immense amount on the NHS compared to the previous Labour Government. There are now 55,000 extra qualified nurses and midwives and 22,500 extra doctors and dentists, so we should take no lessons from Labour about our record of improving health services and about the treatment given to our constituents.
The motion refers to bureaucracy in the NHS. There has been an increase in the number of administrators in the NHS, but let us be clear about what has been going on. We always used to take pride—and perhaps some amusement—from the fact that the NHS was the largest employer in the world after the Indian railway and the Red Army. The massive bureaucracy that we inherited from Labour has been transformed into a new structure that provides better health care for our people.
In making this massive transition, the scope for cock-ups and disasters has been immense. Therefore, I do not begrudge the Government and the NHS taking the sensible decision to manage the transition as they have done. We must not put at risk the lives of patients. There are massive transitions in industry, but we are not talking in this case about tins of beans that can be left out in the rain as a result of a change in management practices—we are talking about the lives of our constituents. The Government have had to think carefully about the administration of the transition. It is worth bearing it in mind that, in this year alone, the Government have set a 418 target—now that the reforms are bedded down—of an 8 per cent. reduction in the administrative costs of the NHS. Unsurprisingly, Labour made no mention of that policy decision in the motion.
Where are the bureaucrats and administrators? They are up front and at the sharp end, ensuring that we get value for money from our NHS. For instance, there are now more secretaries, bursars and administrators in fundholding practices to ensure that, under the direct control and instruction of GPs, efficiency is achieved. More than half my constituents now receive excellent services from general practitioners who have chosen to become fundholders. Why have they done so? They have done so because they care about the health of their patients and they want to be able to get things done. That is precisely what they are doing by investing the funds available to the NHS much more sensitively. Considerable as those funds are, we want value for money.
Fundholding practices are now contracting consultants to their surgeries. One of the fundholding practices in my constituency now has a physician consultant once a week, a surgical consultant every fortnight and a urological consultant every month. The practice is bringing more and more expert health care closer to the patient. But that needs to be managed and administered so that the practice gets the maximum value from those consultants by carefully timetabling and co-ordinating what needs to be done.
Proper administration is a good thing, but that is not mentioned in the motion. During the transition, we said goodbye to the massive bureaucracy so beloved of the Labour party. In my area, the regional health authority, which has a vast building at Bexhill-on-Sea, is a thing of the past. It has packed its tent, and gone off to goodness knows where. But we no longer have that massive bureaucracy trying to direct health care in my area from all the way up the Sussex coast.
Likewise, the district health authority's vast bureaucracy at Darenth Park is no more, and I am delighted to see that even the buildings have been bulldozed. As I told the House this morning, the whole area has been cleared for our brand new £100 million district general hospital. That is being built not thanks to the old-fashioned capital provision arrangements to which the Labour party is harking back but because of the PFI. Hospital work is well advanced for that site.
The purpose of administrators is to help to reduce waiting lists. When I became a Member of Parliament, one of the first problems that I encountered at my surgery was constituents complaining about the handling of their bookings for consultations at hospital. They were called 20 or 50 at a time, like so many potatoes in a row and stuffed in a waiting room. Consultants suited themselves about how many patients they would see and in what order. Under the old Labour system, consultants were responsible to the region for contracts, so the local hospital service had no control over them. When consultants had completed the time that they had deigned to make available, patients were sent packing to book another time. Under proper administration, with the efficiency required by the Conservative Government, patients are seen on time.
The hon. Member for Peckham (Ms Harman) spoke with ghoulish glee about patients whom she claimed had to lie on trolleys in corridors. She does not realise that in 419 any big business such as the health service decisions must be made. To be certain that beds will be available for a peak demand from accident and emergency departments, 20 per cent. of bed space must be left unutilised to ensure that there is enough room for emergency admissions at all times. A choice has to be made. Should bed use be kept down to 80 per cent.? If so, higher waiting lists will result, as they did in the past. The number of operations achieved by the NHS has gone up and up while waiting lists have gone down and down because of the maximum use. The price that we pay is that at times of unexpected peaks, which, thank goodness, are comparatively rare, patients may have to wait on trolleys.
We must understand that trolleys are not like the things Mrs. Mopp wheels the tea through offices on; they are like mobile hospital beds. Their mattresses are thinner than those of hospital beds for obvious clinical reasons. The pejorative use of the word "trolley" is a misnomer. If beds are run at high usage, cancellations of constituents' operations will occasionally result.
§ Mr. Kevin Hughes (Doncaster, North)
Once again, we are debating health issues at an embarrassing time for the Government. Then again, every time that we debate them it is embarrassing for the Government. We can tell that from the tirade of personal attacks that have been launched on my hon. Friend the Member for Peckham (Ms Harman), not least by the Secretary of State. He and other Conservative Members have launched such attacks, rather than political ones, because they are bankrupt of policies. Never mind what the Secretary of State said; I have every confidence that my hon. Friend will be the Secretary of State for Health after the next general election.
The British Medical Association is holding its annual conference, at which it has warned that disaster threatens our national health service because of the exodus of general practitioners. The issues that we are debating show why doctors and nurses suffer from low morale and are leaving the medical profession and why most people do not trust the Tories with our national health service.
It is obvious that bureaucracy in the national health service has risen sharply since the reforms of 1991. Even the Government admit that. However, they have failed to clarify to the public how huge the rise is and how detrimental the misallocation of resources is to patient care. They keep saying that the NHS is funded sufficiently. Yet at a time of limited resources, they have introduced reforms that have sent the bill for NHS bureaucracy rocketing sky high. At the same time, patient care is suffering because of a lack of funding.
More than one in six NHS acute beds have been cut since 1990–7,664 beds were cut in England last year alone. Patient services are being cut. Paediatric intensive care has faced a crisis. Accident and emergency provision faces financial catastrophe. Only this week, the chairman of the BMA commented that dangerous cuts in funding were sinking the NHS, yet the Government do not respond to the crisis. They do not listen to the medical profession. The cost of bureaucracy in the NHS continues to soar.
420 Today, Labour released figures on administrative spending by health authorities that highlight the huge rise in bureaucracy. In the Trent region alone, the cost of bureaucracy rose by £32 million to more than £90 million—a rise of nearly 55 per cent. in only four years. That is the highest rise of any region. During the same period that administrative costs have soared, patient care has suffered because of the lack of financial resources: 2,986 beds have been cut in Trent region since 1990–91. That is a shocking 13 per cent. of its total beds. In the past year, the number of cancelled operations in the region has risen by 36.5 per cent. and the number of nurses has been cut by 9 per cent. in only five years. However, in the same period, the number of managers in the region has increased by a staggering 470 per cent.
In Doncaster, the purchasing administration budget has risen by £641,000 in only three years—an increase of more than 25 per cent.—yet patient services have had to be cut at local hospitals for financial reasons. It is absurd. Money is being thrown into paperwork, management and massive bureaucracy in negotiating contracts while patient services are being drastically and wrongly cut because of a lack of resources.
Primary care is also suffering from increased bureaucracy. GPs feel that additional bureaucracy is putting them under pressure and that patient care is therefore suffering. Many responses to our recent consultation of GPs concerned bureaucracy. There was frequent mention of the massive increase in the paperwork involved daily in general practice. Comments that I received from GPs in my constituency highlighted concern about mushrooming bureaucracy and the increase in the management tier, which needs to be kept in proportion to the number of people being managed.
The BMA also condemns the increase in bureaucracy, citing it as a reason forGP morale being at its lowest ebb for many years",and warns that that isstifling innovation and the further development of patient services in many practices.A 1992–93 survey of GPs' work load showed that the reported average weekly time spent on practice administration associated with the provision of general medical services had increased by 85 per cent. since 1985–86.
In a survey carried out by Middlesex university earlier this year, 98 per cent. of GPs questioned complained that their paperwork had increased by nearly 90 per cent.
It is clear that the changes in the NHS brought about by the Government are swamping GPs with paperwork and damaging patient care. Britain has an excellent record on primary care. We cannot let the Government go on pushing it past its limits.
The GP fundholding scheme has increased spending on managers. Management costs within health authorities and extra contracting and transaction costs for trusts are not met by efficiency savings. Those are the findings of the Audit Commission; they are not mine. GP fundholding carries a huge burden of increased bureaucracy. Management costs are as high as £80,000 per practice. A recent NHS executive report comments that GP fundholding carries a significant administration tail, which, in a number of places, is excessive.
In addition, hospital trusts are being financially hammered by the costs of administrating fundholding contracts. The NHS executive report states: 421Income from fundholding for most Trusts is between 5 and 10 per cent. of the total revenue … yet most employ at least twice as many people to support fundholder contracts … as they employ to support the Health Authority contracts.The amount of paperwork generated by many individual contracts is astronomical.
Another problem concerns GP fundholder underspending. Underspending by GP fundholders in the Doncaster area has resulted in £900,000 not being spent on hospital services. That has resulted in two hospital wards in Doncaster being closed. GP fundholders' underspending is being blamed for those hospital ward closures. It is not just me who is saying that, but people at the Doncaster royal infirmary as well.
§ Mr. Hughes
No, I will not give way because my colleagues are waiting to speak.
The sad fact about the Government and their changes is that market forces do not work in health care. The reality is that market forces driven by the Government are wrecking our health services. The truth is that our health service is not safe in the Government's hands and everybody except Conservative Back Benchers knows that.
§ 9.1 pm
§ Mr. Hugh Bayley (York)
I shall speak briefly about paediatric intensive care in Yorkshire because current provision is wholly inadequate. It is inadequate to the point that it is putting the lives of children at risk.
In the whole of Yorkshire we have just seven general paediatric intensive care beds to serve a population of more than 1 million children. It is one of the worst population-bed ratios in the country. Five of those paediatric intensive care beds are at Leeds general infirmary and last year it had to turn away 75 desperately ill children during the year, 61 of them during the winter months, because all the beds were full and none could be made available.
On 6 March the Secretary of State made a statement to the House about improvements that he intended to make to intensive care services. He promised that those extra beds would be in by the coming winter. The Yorkshire regional health authority carried out a study of the needs in our region and determined that three extra paediatric intensive care beds and six extra high-dependency beds were required.
The local purchasing authorities have agreed to fund just one of the nine additional beds which the regional health authority decided were required. That shows the consequences of the Government's NHS internal market working at its worst. Year after year of efficiency savings have forced hospitals to cut beds; but the pressure to cut beds is greatest on intensive care beds because they are the most expensive. That leads to the perverse result that the beds of which there is the severest shortage are the very ones needed for the most severely ill patients.
Earlier, my hon. Friend the Member for Peckham (Ms Harman) referred to the case of Nicholas Geldard. Let me remind the House briefly of what happened to 422 him. He was a 10-year-old boy who was taken ill. His parents called an ambulance and he was taken to Stockport general infirmary. The casualty department decided that he needed a scan but did not have a scanner, so an ambulance was called to transfer the child to Stepping Hill hospital. It took an hour to arrive; by the time the boy got to Stepping Hill hospital the scanner had closed for the day. It operates only from nine to five. So it was decided to leave the scan to the following day. When the child became more ill in the night he was transferred to Hope hospital.
At the Hope hospital a brain haemorrhage was diagnosed and doctors said that the boy needed an immediate operation—but they had no paediatric intensive care bed. So they telephoned around the region, and then further afield, and eventually found a bed at Leeds general infirmary. So nine or 10 hours later the child was taken by ambulance over the Pennines through a snowstorm. When he got to the hospital and doctors examined him the child was found to be dead: he had arrived too late.
I have here a letter from Dr. Mark Darowski, the director of the paediatric intensive care unit at the LGI. He says:I was the clinician who had to declare him dead and to deal with the understandable anger and devastation of his family … I would therefore like to bring to your attention the impending crisis which will occur in Yorkshire despite the assertions of the Minister. Without adequate provision it is only a matter of time before other families suffer in the way that Nicholas Geldard's has.I have written to the Secretary of State about the points raised with me by the LGI unit, asking two questions. I asked whether the right hon. Gentleman was satisfied that the one additional paediatric intensive care bed that our region is to get will be adequate to meet the need. Secondly, if he does not believe it adequate—he cannot believe that, given what he said to the House on 6 March—I asked him what action he and the NHS executive will take to override the internal market decision to supply only one additional bed, so as to ensure that the nine that are needed are provided.
Because I have given notice in writing of my questions to the Secretary of State well in advance of this debate, may I have an answer tonight from the Minister of State? Is one extra bed enough for the needs of desperately ill children in Yorkshire? If not, what will the Minister and the Department do to increase provision so that, contrary to the warning issued by the director of the LGI paediatric intensive care unit, there are no more desperate cases like that of Nicholas Geldard?
§ 9.8 pm
§ Mr. Ken Purchase (Wolverhampton, North-East)
I am grateful to hon. Members for allowing me a few moments in which to bring to the attention of the House a serious matter in my constituency. First it is necessary to provide a little background. But even before that I want to contradict one or two of the assertions made this evening by Conservative Members.
First, disregarding the changes in the administration of the health services that the Government have made, it must be remembered that the thousands of people who worked as administrators in our health services throughout the 1960s, 1970s and 1980s did an absolutely splendid professional job and deserve recognition for it. More of that in a moment.
423 I abhor the suggestion that only general practitioners who have gone for contract holding are giving a good service to our patients. General practitioners, and those working with them in the health services, give their best— their work is of a tremendously high standard—whether they are on payment by results, whether they are fundholders or whether they are working under the old-fashioned rules of public service in the interests of patients. The balance should be redressed because some people pretend that there have been improvements in the health service only since these reforms. That is nonsense.
I shall refer to the way in which we have reached this point of additional bureaucracy in the health service. I— along with many other people—served in the health service on district committees and on area committees, and for no pay. We were proud to do so. In those days, we did not need the kind of reward that we see today— it is multiplied again and again on trusts and on other organisations that have been put together by the Government as part of the quangocracy. It is an absolute disgrace—there is no need for it whatsoever and it has not led to a qualitative improvement in any of the administrative services within the health framework.
I refer to competitive tendering. I wonder whether it will ever be possible for us to get a figure on the amount of money that has been spent on financial consultants. They allegedly helped the in-house teams put their tenders together and conducted the training that was necessary for them to promote their services. There was a business plan, and cash flow problems resulted therein. There was a change in the working hours and the practices that had to be undertaken. Thousands of pounds—if not millions of pounds—were spent on consultants who were offering so-called management advice.
The upshot of all this is that up and down the country the in-house teams are still doing the same work—and probably for less money in terms of the hourly rates and the salaries that they receive. In many instances, we have lost workers off the wards, particularly those who were cleaners in the hotel services. They have suffered tremendously as a result of that part of the Government's so-called reforms.
I refer to contracting out, particularly in the west midlands. Millions of pounds were lost in computer scams—contracting out failed miserably. It ultimately resulted in the ignominious resignation of the then chairman of the region, Sir James Ackers. He literally had to be forced through the door—there was a public outcry—because of the way in which he administered the Government's reforms in the health service in the west midlands. However, worse was to follow in the litany of waste that the Conservative Government thrust on the national health service. The Government had the temerity to pay this man to leave the health service—he was paid thousands of pounds in compensation. What an absolute disgrace.
§ Mr. Purchase
Yes, it is endemic. The Government filled the quangocracy with their friends, many of whom had no experience in the health service or in the ethos that underpins it. There has been one scam after another in Wales, in Scotland, in the south-east of England and in the west midlands.
424 I draw the attention of hon. Members to the serious problem that we have in Wolverhampton in relation to the hospital services. This year, for the fifth year in a row, they have to find £2.4 million is worth of savings— equivalent to 3 per cent. The Government seem to think that efficiency savings can continue ad infinitum, but the savings have to be taken from a smaller total resource and many departments are already stressed because they have to provide an increasing level of service. They have been asked to treat the same number of patients for 3 per cent. less or to increase the amount of work they do, but this year, in Wolverhampton, the hospitals are being asked to find £2.4 million in cash by the NHS executive. That will be difficult, if not impossible.
I shall tell the House what will happen in Wolverhampton to meet that programme of cuts in services. Two intensive care beds out of a total of seven will close. That is not many to start with, but we will lose two. A day surgery unit will close for two weeks during August and two weeks at Christmas to try to recoup some expenditure. The main operating theatres will close for two weeks in August and at Christmas. Seven orthopaedic beds, six surgical beds, 10 gynaecology beds and nine neurology beds will be lost. The list goes on. Those closures will be made to meet the programme of cuts demanded by the Government and administered through the NHS executive.
The closure of an acute medical ward that specialises in the care of the elderly has been proposed and that will mean a reduction of 33 per cent. in the service. The freezing of posts is an old chestnut, but so many posts have been frozen for so many years that few or no posts are left that are not urgently needed. The quality of patient care is bound to diminish as a result. A further 11 posts in the operating theatres will not be filled.
That is the programme that faces my authority in Wolverhampton. The question is not whether the trusts are efficient or effective, because the health service has been run effectively and efficiently for as long as people can remember. I accuse the Government of misunderstanding the nature of what they call market-driven efficiency. We have seen year-on-year improvements in technology, management techniques and operating practices. Those improvements would have happened anyway.
§ Mr. Purchase
Yes, they would. The Minister should ask the people who have worked in the service for years, probably before he started work. They have given the community their best, but he might not understand that. The way in which the Government have acted in the public services has demoralised the staff and demolished the spirit of the people who have provided those services since 1945 and the great reforms of the then Labour Government.
We have heard many individual examples of suffering and difficulties created by the so-called market reforms. They are not reforms: they are a diminution of the service and that is shown every day. The dreadful cuts that I have mentioned, which will befall the people of Wolverhampton, exemplify that point. Earlier, the hon. Member for Birmingham, Edgbaston (Dame J. Knight) suggested that Labour Members told scare stories to frighten the horses. Our stories do not frighten the horses, but they scare the patients to death.
§ Mr. Henry McLeish (Fife, Central)
Unfortunately, I have not been given the up-to-date result, but I imagine that it is full time and if the score has stayed the same it will be one-all. Extra time will be played and, as the nation will be on a knife-edge, we can get on with the health debate. I am sure that if more information comes into the Chamber, we can pass it on to those assembled.
It is interesting to hear the different approaches of hon. Members on both sides of the House. Most of my hon. Friends have made sensible, constructive and incisive points about health problems in their areas.
§ Mr. McLeish
The difference between the Opposition and the Government is that we deal with reality and we do not seek to hide within a self-constructed fantasy.
We have had excellent contributions from my hon. Friends, who have tried to bring the real concerns of the people whom they represent to the Chamber.
In sharp contrast, and despite the efforts of the Secretary of State, three Conservative contributions highlighted the differences in the approaches of the Government and the Opposition. The hon. Member for Mid-Staffordshire (Mr. Fabricant) let the cat out of the bag when he said that the Government are providing a safety net. We argue that the Tories are making that claim throughout the country. The second extraordinary contribution came from the hon. Member for Wimbledon (Dr. Goodson-Wickes), who said that there were sound reasons why the Tories voted against the NHS legislation in 1946. The Conservatives have clearly continued to accept only grudgingly the unique and best public service in this country.
The hon. Member for Gravesham (Mr. Arnold) crystallised the Government's approach to health when he said that trolleys should become an accepted part of NHS culture and language.
§ Mr. Arnold
On a point of order, Mr. Deputy Speaker. Is it in order to misquote an hon. Member and then not allow him to correct that misquote?
§ Mr. Deputy Speaker
The hon. Member for Fife, Central (Mr. McLeish) is responsible for his own speech.
§ Mr. McLeish
In a grown-up political environment, if one makes a comment, one lives with the consequences. The hon. Gentleman suggested that trolleys were more comfortable than people think. Labour Members believe that patients should have beds and not trolleys. We believe that patients should be in wards and not in corridors and that patients should be seen by doctors and not left waiting for hours in accident and emergency wards. The hon. Gentleman may not like it, but that is what he said. It is important that the nation understands what is happening.
§ Mr. Arnold
I said in my contribution that a choice must be made. In order to make certain that beds are 426 available, one must operate beds at 20 per cent. below capacity. The decision to operate them at a higher capacity is one of the reasons why waiting lists have been reduced. One must make a choice and strike a balance. If the hon. Gentleman wishes to say categorically that a Labour Government would operate at only 80 per cent. of capacity, he should do so. He must make a choice.
§ Mr. McLeish
The hon. Gentleman did not deny my comments—that is the important point. He can exaggerate and set up smokescreens but, at the end of the day, the Conservative party has advocated trolleys as an acceptable part of NHS language and culture.
It was interesting to note also the characteristic contribution by the Secretary of State. It was uninspiring, but that is nothing new. It is important to note that, while he decided to go on the attack—with their record, that is the only thing that the Government can do—he failed to tell the House about his contribution at the conference of the National Association of Health Authorities and Trusts. The Times of Saturday 22 June summed it up by saying:Dorrell gives the go-ahead for longer hospital waiting lists".If that is not a white-flag surrender job, I do not know what is. The Government have lambasted every political party about their views on the NHS. They claim that they are cutting bureaucracy and that they will invest more in patient care. That is not happening in the real world of the national health service.
The Secretary of State said that, as a consequence of the crisis in the national health service, the Government's great initiative to reduce waiting lists has been abandoned. The Government's market-driven NHS simply cannot cope with the burgeoning bureaucracy and the fact that there is not enough investment in patient care. Bureaucratic costs in the national health service are spiralling out of control.
It is hypocritical of Ministers to come to the Dispatch Box and wax lyrical about their actions now that the horse has bolted. The stable door cannot be closed: health costs are spiralling out of control and Ministers do not have a clue what to do about it. Even more worrying is the fact that they simply do not care. Ministers are sitting at the centre of the market-led NHS, unconcerned about the crises throughout the health service. They know about them, but they are unwilling to address them. Today the Secretary of State confirmed our belief that, in his opportunism, he is more concerned about the future of the Conservative party after its defeat at the next election than about real patients in the national health service.
More important, the debate has been about defining points in the NHS for the debate that will take place between now and the general election. Let us be clear what those points are. First, the Government want a residual NHS. They do not want to see a one-nation health service.
§ Mr. McLeish
The hon. Gentleman may shout "Rubbish!", but if the Government want to ignore the reality of public opinion, public perception and professional concern between now and the general election, that is fine by me, because, in government, we shall start to address some of the issues that they are ignoring. Secondly, Conservatives regard the health service as a business—a view that is not shared by the Labour party or the country. The health service is a public service with a 427 very distinct ethos. That is what makes it work. That is why we have commitment from nurses, doctors and ancillary services throughout the length and breadth of the land. The Conservatives are in danger of squandering that most precious of resources, and that is a defining issue.
The main issue, which is what the debate is about, is the Conservatives' obsession with bureaucracy and the market. The Secretary of State and the Minister can shed crocodile tears about what they are doing, but it simply will not wash. The Conservative party has constructed a market that is destroying the heart of the NHS, but it cannot do anything about it because, despite the disappearance of the previous Prime Minister, it is still gripped with ideology when a bit more pragmatism would do well in the NHS.
In contrast to the Conservatives' market obsession, the Labour party wants to see a collaborative model. We want to see a national health service that co-operates. Look at the shambles of British Rail. We want to avoid that prospect for the NHS. We want to put the NHS back together again. That makes sense for everyone who works in it, and it makes sense for patients.
One defining point that the Conservatives simply cannot run away from is their ability to squander vast sums of taxpayers' money, not in the interest of patients or professionals but in the interest of ideology. There is something fundamentally immoral about other people's moneys being used for a political and ideological adventure. But they are guilty of that, and whatever they say about it, that is a key issue.
The most important defining issue between Labour and the Conservatives is the fact that we believe in the NHS.
§ Mr. McLeish
In 50 years, the NHS has provided an excellent quality of life for people in this country. We believe in a world-class service for the next 50 years, not the residual service that the Government are working towards.
We have talked about defining points, and that is crucial, because the next election will be fought not on the evasion that we see from Conservative Members but on the reality that faces patients and professionals in every part of England, Scotland, Wales and Northern Ireland. The Conservatives can run, but at the time of reckoning they simply will not be able to hide. Let me give a warning to the Government. They may think that the five years of reforms have changed the face of the NHS. They have not. The great work that has been done by the NHS in the past 50 years has not been undone by five years of reforms, but if we have another five years of these crazy reforms, the next 50 years of the NHS will be completely and utterly destroyed. We simply will not stand for that. The Minister and the Secretary of State should be warned that they will face a vigorous campaign about the choice that we will offer at the next election.
§ Mr. Mackinlay
The only point on which I take issue with my hon. Friend is the fact that he referred to only five years of Government-imposed reforms. Their reforms are like the painting of the Forth bridge—they start on one end and they never finish. They keep reforming their reforms. I remember that it was "Sir Sheath Durex"—[Laughter.]— or whatever his name was—Sir Keith Joseph—who reformed the NHS. He created the area health authorities and the regional health authorities and set up the 428 bureaucracy which then had to be abolished, and the Conservatives have continued with reforms since they came back into office.
§ Mr. McLeish
No doubt it would be unparliamentary for me to repeat part of what my hon. Friend said, but he chose an excellent analogy in the Forth bridge. Never mind the painting; the bridge has been sold. It is an interesting analogy, given what may happen to the national health service.
The Government are out of touch with national sentiment, and out of step with public concerns. Let me repeat the obvious: the sooner they are out of office, the better it will be for the future of the NHS. My central charge is this. The artificial market is being propped up by the spending of more and more money on this market madness, and a paperchase is being substituted for the delivery of patient care. We believe in a patient-centred NHS—in patient choice and patient care. We have heard speeches defending managers, bureaucrats and almost everyone, but I did not hear much mention of patients. Perhaps that is another defining issue that the Government have forgotten to challenge.
It is important to remind the Government of the catalogue of chaos that currently constitutes parts of the NHS. We have heard about intensive care tonight: we have heard about paediatrics, and accident and emergency departments. We are seeing the development of two-tierism throughout the country. The Government defend that. They enjoy the fact that some patients have more rights of referral than others. It is a disgrace, but they are happy to trumpet it as a success.
The Government also defend the private finance initiative. We have posed an interesting question to the Secretary of State, which he ducks on every occasion. Where are the contracts? How many are there, and how many openings will my hon. Friend the Member for Peckham (Ms Harman) be attending as Secretary of State; for Health when we take over in a few months' time? I fear that it will not be as many as she would like. [Interruption.] Ministers are now discussing the future of the PFI. The fact is that it is going nowhere, because it is expensive. [Interruption.] Perhaps I should sit down, and allow the: debate on the Government Front Bench to become public.
Ministers have mentioned the sum of £500 million, but that figure could be £500 billion. Unless it is translated into positive action—bricks and mortar—patients will not be helped.
Let me raise a more serious point. There is a crisis in relation to health inequalities, which the Government simply will not address. In 1994, there were 11.4 infant deaths per 1,000 live births, but in Kingston and Richmond the figure was 3.1. It is a factor of four. Why is that? Poverty and affluence are clearly involved, but another key issue is lack of access to health care throughout the country. The Government talk of bureaucracy, but I submit that saving people from early death should always be a priority in any health service.
§ Mr. McLeish
That is fine, but I want to know what the Secretary of State intends to do. Let me give him another statistic for good measure. In 1994 there were 126 deaths from breast cancer per 100,000 of the population, but in 429 Chichester there were only 51. On the vital issues of coronary heart disease, breast cancer, infant mortality and long-term illnesses, there are unacceptable differences throughout a so-called one-nation health service. I think that we know the reason for that: the Government have simply run out of energy, enthusiasm and commitment to health equality.
Here is a statistic that the Government do not like. Over the past five years the number of nurses has fallen by 50,000, and there are 19,000 fewer in training—but, of course, there are 20,000 extra managers. Does that not constitute a comment on the current state of the NHS? [HON. MEMBERS: "Not true."] Conservative Members chorus "Not true," but they are the Government's figures—sourced by the Library from Government computers.
Two other issues dominate the health scene. One is the crisis in cancer care.
§ Mr. McLeish
I can tell the Whip that if the health service is fragmented, contractorised and competitive, there can be no rational or regional planning. Thousands of cancer patients have been badly served by the Government's crazy market set-up. Perhaps the Whip will reflect on his reaction and support my remarks.
The health aspects of food are also in a shambles, as we have seen with the beef and powdered baby milk crises. When the Government do not trust the people, they end up in a mess. Of concern to all is that we have doctor against doctor, hospital against hospital, GP against GP and district health authority against district health authority. One cannot deny the realities of the market. The present competitive system is costing the taxpayer an absolute fortune and all that the Government can say is that we are denying reality. It is clear from the practical problems experienced by our constituents that that is so.
I have spoken about the manifestations of the crisis in the health service, so now I will highlight the core issues. It is impossible to imagine that the Government will continue to squander money on bureaucracy when investment in patient care is required. Hon. Members spoke earlier about the wonderful asset of NHS staff and the key players, but their morale is at rock bottom, with 900,000 people looking for leadership. They need not look to the Government Benches because in a privatised set-up, staff are regarded only as hired hands. We regard those staff as a vital asset. They must be given leadership and allowed to participate.
The privatisation of the railways has provided a classic example of a Government whose ideology blinkers them from reality. [Interruption.] Conservative Members may tut, but the British Rail network has been split into 100 parts, and that is called efficiency. The same is happening with the health service. There are free-standing GPs, free-standing trusts and a PFI that seeks to embrace services rather than bricks and mortar. All the building blocks are there and the market will ultimately destroy much of the legacy that it will inherit over the next decade.
Nor is there any momentum in the NHS; instead there is a yearning for a change of Government. The Minister will know from visiting GPs that they are sick and tired of a Government who preach the principle of listening but never 430 listen. A few years ago, the Government created the monster of the market, which is eating up cash and cannot be controlled. My hon. Friend the Member for Peckham said that when there is a Labour Government, we will control the market. We will ensure that hard-earned taxpayers' money is transferred to patient care, which is the big issue for the next century—not patient charters or crocodile tears over not being able to save on bureaucracy.
After 50 years of the NHS, why should the public have to wait and worry? The country should have a Government who address all the issues in the interests of patients. That ultimately means cutting bureaucracy and giving a new boost to the NHS culture that the patient is the most important consideration. If that is done, all the talk about positive outcomes will be proved right, because we will stop people dying unnecessarily. We will overcome health variations, which are impossible to support in a modern society. We will also give leadership to the 900,000 NHS staff—who are yearning for change, which only Labour can provide.
§ The Minister for Health (Mr. Gerald Malone)
In his closing remarks, the hon. Member for Fife, Central (Mr. McLeish) said that this debate had had several defining points, and he is the Labour Front Bencher who decided to say that one of those defining points was finance. I must tell him and the hon. Member for Peckham (Ms Harman)—who dodged the issue when opening the debate—that I shall spend some time in my speech pressing Opposition Members to state precisely how they would fund the NHS. That is the core of the issue.
On a year-on-year basis, in real terms this Government have spent more than any other Government have ever spent, and we have issued a commitment to continue doing so. We heard nothing from any Opposition Member about how they would deal with that core point.
The hon. Members for Fife, Central and for Peckham have approached this debate principally on the hypothesis that they will be able to fund the necessary increase in NHS spending by cutting bureaucracy. They have supported that statement with figures that are dodgy, to say the least. I shall set out the true position and describe what the Government have done to bear down vigorously on management costs in the NHS.
Last October, my right hon. Friend the Secretary of State for Health announced a 5 per cent. cash reduction—8 per cent. in real terms—in the costs of running health authorities and in trust management costs in 1996–97, the merger of district health authorities and family health services authorities and the abolition of regional health authorities. In a debate that is based on the abolition of bureaucracy, the House will be interested to note that the Labour party opposed the measure to abolish regional health authorities.
Those measures will release about £300 million for patient care by 1996–97. That is composed of £54 million from cuts in health authority costs, £95 million from cuts in trust management costs, £101 million from abolition of regional health authorities and £55 million from streamlining the Department of Health—which has been done with great vigour.
When it comes to bearing down on bureaucracy in the NHS and ensuring that we get the best value for taxpayers' money, the Government have a first-class record. In a 431 moment, I shall deal with some of the points made by Opposition Members about bureaucracy in some detail and show how their argument is flawed, but first I shall deal with the speeches made by hon. Members on both sides of the House.
My hon. Friend the Member for Broxbourne (Mrs. Roe) made a robust defence of management. As Chairman of the Select Committee on Health, she was able to do so from a position that provides her—and other Committee members—with a great insight into the importance of proper management. I find it somewhat paradoxical that Opposition Members are constantly saying that we have too much management and bureaucracy in the NHS, yet, when they sit on the Select Committee and when they table parliamentary questions, they are the ones who demand NHS facts, figures and proper accountability—which requires that a proper management structure is in place.
My hon. Friend the Member for Broxbourne quite rightly made the point that if our national health service, which is responsible for £40 billion of taxpayers' money per annum, is to be accountable, it must be properly managed: first, to be accountable and, secondly, to be effective.
The hon. Member for Southwark and Bermondsey (Mr. Hughes)—who has not returned to the Chamber—came out, as he always does, with many interesting figures, none of which I recognise. He made one point about the National Health Service Consultants Association. I can tell him that a reply to the letter that he mentioned will be on its way to that association soon.
The hon. Member for Preston (Mrs. Wise) expressed some concerns about community health care for children. I am sure that she will be pleased to know that, after full consultations in which more than 250 responses were received, a guide on community child health services is with the printers and will be issued soon. I hope that she will welcome that.
§ Mr. Malone
I apologise for not giving way to the hon. Lady, but my time is limited, and I want to deal with all the speeches by hon. Members on both sides of the House.
My hon. Friend the Member for Wimbledon (Dr. Goodson-Wickes), who said that he might not be able to be in his place for the winding-up speeches, made a historical speech. He reminded us of pointless past bureaucracy in the health service. He was right to make that point vigorously. The Government are focusing the management function on providing effective increases in patient care and on ensuring that inefficiency is driven out of the service. My hon. Friend specifically said that he hoped that liaison between community health trusts and social services committees could be encouraged. I heartily endorse that view. Indeed, we encourage that practice wherever possible.
The hon. Member for Islwyn (Mr. Touhig) derided the voluntary sector. I was amazed. Unfortunately, it is something that he and his friends do too often. He complained that some services for patients—in particular a voluntary, I presume counselling, service for cancer patients—are delivered by voluntary 432 organisations. As I go around the country, I frequently hear that argument, usually levelled at leagues of friends who in fact do tremendous work for the public sector and underpin the connection between the health service and the community.
When Labour Members deride those organisations and say, as the hon. Gentleman did, that those services should be delivered from public funds—[Interruption.] That is exactly what the hon. Gentleman said. Labour Members do no service to the thousands of people who add to the services provided by the NHS.
§ Mr. Malone
No, I will not give way.
The hon. Member for Islwyn went on to make some useful points about nurse leadership and development, which I heartily endorse.
§ Mr. Touhig
It is, Mr. Deputy Speaker. I am entitled to ensure that my remarks in this Chamber are not misrepresented. I made no such statement and I seek the support of the Chair in this matter.
§ Mr. Deputy Speaker
Order. The hon. Gentleman has been in the House for sufficient time to know that there are opportunities available to him to deal with that—for example, the Order Paper, and so on—and that he should not attempt to bring the Chair into any interpretation of any hon. Member's speech.
§ Mr. Malone
My hon. Friend the Member for Mid-Staffordshire (Mr. Fabricant) rightly praised trusts for being efficient. He mentioned one in particular in his constituency, which I visited some time ago, where I saw precisely what NHS reforms have been able to bring to trusts. It is not just that they are more efficient and can deliver better health care; it is that as in Newham, where I was this week, and in Andover, where I was yesterday, trust hospitals, with their new freedoms, are now able to provide more efficient, but better, health care to patients in their community by entering into partnerships with other trusts and developing those in a way that the Opposition entirely ignore.
The hon. Member for Dunfermline, West (Ms Squire) made points relating to her constituency, which I shall draw to the attention of my right hon. Friend the Secretary of State for Scotland.
My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) made an important point about the British Medical Association acknowledging that the Government have addressed the problems of bureaucracy. The BMA has welcomed that. In the light of this conference season, praise from the BMA is, perhaps, not usual, but it is clearly something that the Government welcome when it comes. The BMA made an important point.
433 My hon. Friend the Member for Beckenham (Mr. Merchant) rightly referred to bureaucracy being streamlined and waiting lists going down in his constituency. He also pointed out that, as a result of NHS reforms and changes that the Government have brought to bear, there is new hospital building in his constituency. I welcome that, too.
The hon. Member for Coventry, North-East (Mr. Ainsworth) referred to private finance solutions for Walsgrave and Bromsgrove. He said that he was afraid that they would not be affordable. I have to disappoint him—Walsgrave Hospitals NHS trust will be announcing its plans and its preferred private sector partnership at the end of this week.
As business cases are approved and the PFI is going out on a planned process towards completion, Opposition Members crow, but they crow too early, for the PFI will be a fundamental way to provide new funds for the NHS and capital development. Before, people had to wait for an inordinate amount of time. The hon. Member for Peckham will know full well about the cases when they are finally announced in a formal way, and I promise her that she will then be smiling—perhaps—slightly on the other side of her face.
My hon. Friend the Member for Worcester (Mr. Luff) made a powerful speech in which he set out the proper role of management and talked about the course of change to reduce bureaucracy that had constantly been opposed by the Labour party. He was quite right to do that. On one hand, the Labour party decides to feature bureaucracy as the basis of this debate, and on the other it entirely ignores and stands in the way at local level of the effort to get bureaucracy out of the health service and improve efficiency.
The hon. Member for York (Mr. Bayley) made a specific point to which he asked me to respond. I have asked officials about the prior notice that he gave, but I am sorry to tell him that there is no trace of it. There is an outstanding letter to my right hon. Friend the Secretary of State to which the hon. Gentleman will receive a reply in due course.
During the opening speeches, a degree of sensitivity was displayed by the hon. Member for Fife, Central. It was because the issue strikes at the heart of Labour's problem. Labour Members talk in soundbites about health, but propose nothing. When they propose something and they are found out for proposing it, their first reaction is to deny it, as the hon. Gentleman did. Let us pin the Labour party down about fundholding, which now services 52 per cent. of England's population. The hon. Gentleman is quoted as saying that once in powerwe will remove the internal market and the principle of a single practice holding a budget will not be there.
§ Mr. Malone
Replace or abolish? I am not quite sure which. In the eyes of any fundholder, "replacing" is a euphemism for "abolishing". I understand that those who attended the conference at which the hon. Gentleman spoke were not convinced by the euphemism and entirely understood the purpose of the hon. Gentleman and his party: it was to do away with all the excellent work that 434 fundholders have built up over seven waves of fundholding. I shall give way to the hon. Gentleman if he will deny that.
§ Mr. McLeish
I would have thought that the intervention in relation to the Secretary of State's comments would iron out that particular point, but it would appear that, to gain some cheap political points, the Minister will not acknowledge the sincerity and honesty with which I said that the comments reported by the Secretary of State were simply untrue. Does the Minister accept the sincerity of the point that I am making or is he going to ignore it and make political points anyway? [Interruption.]
§ Mr. Malone
We want to know what the Labour party and the hon. Gentleman mean—so do fundholders, and so do the 150 of them who were at the meeting. They will no doubt have their views on what the hon. Gentleman has said, which, of course, I accept in the spirit of a debate across the Dispatch Box.
I said that I would look with some care at what the Labour party was saying about bureaucracy and figures. I accuse it of playing fast and loose with figures all the time and of ensuring that a false picture of the health service is represented. I shall refer to one instance of that.
I nodded in the direction of the hon. Member for Darlington (Mr. Milburn). I am perfectly happy to answer his parliamentary questions. He issued a press release today on a subject at the core of this debate—health authority administrative spending, which, according to his press release, rose by more than £315 million to £1.1 billion between 1991 and 1994–95.
I remember answering the hon. Gentleman's parliamentary question and I also remember writing to him because I thought that the figures should not be misunderstood and should be properly explained. My letter said:The figures have not been adjusted to constant prices. Changes over the years and the roles and responsibilities of health authorities and the transfer of functions to NHS Trusts … also mean that the figures are not strictly comparable.Health authorities now fulfil a substantial number of functions that they did not have in the past—involving public health and programmes for the relief of AIDS. An analysis of the figures on the proper terms—which I set out in my letter to the hon. Gentleman—shows that the truth is rather different. To fund those increased and changed activities, there has been an increase in expenditure from 1991–92 to 1994–95 of 0.1 per cent. per annum in real terms. That puts matters in a different context. What is more, those figures do not take into account the abolition of regional health authorities, saving some £101 million. Although the hon. Gentleman says that he wants to decrease bureaucracy, the Labour party opposed that £101 million.
If we want to look at the defining moments to which the hon. Member for Fife, Central referred, there is one source to which we can turn with confidence—the recent speech by the Leader of the Opposition at the NAHAT conference. It was a speech full of contradictions. He heard the message loud and clear when he said:You do not want more major upheaval".435 However, in the next breath, he promised the health service that he would replace the internal market, causing the upheaval that he claimed it did not want. In the following breath, he said:Planning and delivery of health care will remain distinct functions".That undertaking from the right hon. Gentleman totally undermines the case of the hon. Member for Peckham, as it defends the mechanisms of purchasing and delivery and promises that they will remain firmly in place. It is absolutely typical of the Opposition to make an assertion and slide away from it.
It is important to note that that speech supported a deceitful party policy. At its centre is Labour's big lie. Labour refuses to say how much it will spend on health. Where is Labour's commitment to build on the success of the health service that Opposition Members have persistently mentioned tonight? Everyone involved in the health service understands that the engine of growth in our NHS is, and always has been, proper funding. Of course, efficiency gains improve patient care, as does cutting bureaucracy—which Labour opposed in the House. However, if one asks anyone who works in the NHS what is the litmus test of the Government's commitment, the answer will be a commitment to fund on a continuing basis. My right hon. Friend the Prime Minister has set out that commitment to increase funding in real terms in the next Parliament, as the Government have done consistently since we came to power.
What does the Leader of the Opposition have to say about that? It should have been up front on page 1 of his speech. I read page 1 of his speech and it was not there. Nor was it on pages 2, 3, 4, 5, 6, 7 and 8. On page 9, in the dying moments of the speech, the right hon. Gentleman steels himself. The audience sits on the edge of its seat and hears that a Labour Government would look at whether there was a funding gap that needed to be bridged. That is highly courageous, but utterly meaningless. The Opposition constantly complain that we do not spend enough as a percentage of GDP on health. I invite the right hon. Gentleman to let us know what Labour would do. We have increased spending as a proportion of GDP by more than 1 per cent.
The NHS has been well defended and well supported by the Government. It now delivers more health care than ever before, and has more doctors and nurses delivering health care to patients. Yet again, that figure has been entirely distorted by Labour. Since 1984, the number of qualified nurses in the NHS providing care for patients has increased by 22,950.
This has been a debate in which the Opposition have failed the test of supporting the NHS. They run for cover as soon as any suggestion is made of a true commitment.
§ Question, That the Question be now put, put and agreed to.
§ Question put accordingly, That the original words stand part of the Question:—
§ The House divided: Ayes 217, Noes 260.439
|Division No. 158]||[9.59 pm|
|Abbott, Ms Diane||Garrett, John|
|Adams, Mrs Irene||George, Bruce|
|Ainger, Nick||Gerrard, Neil|
|Ainsworth, Robert (Cov'try NE)||Godman, Dr Norman A|
|Allen, Graham||Godsiff, Roger|
|Anderson, Donald (Swansea E)||Golding, Mrs Llin|
|Austin-Walker, John||Griffiths, Win (Bridgend)|
|Barnes, Harry||Grocott, Bruce|
|Barron, Kevin||Gunnell, John|
|Battle, John||Harman, Ms Harriet|
|Bayley, Hugh||Hattersley, Rt Hon Roy|
|Beckett, Rt Hon Margaret||Henderson, Doug|
|Bell, Stuart||Heppell, John|
|Benn, Rt Hon Tony||Hill, Keith (Streatham)|
|Benton, Joe||Hinchliffe, David|
|Bermingham, Gerald||Hodge, Margaret|
|Berry, Roger||Home Robertson, John|
|Betts, Clive||Hood, Jimmy|
|Blunkett, David||Howarth, George (Knowsley North)|
|Bradley, Keith||Howells, Dr Kim (Pontypridd)|
|Brown, N (N'c'tle upon Tyne E)||Hoyle, Doug|
|Burden, Richard||Hughes, Kevin (Doncaster N)|
|Byers, Stephen||Hutton, John|
|Caborn, Richard||Ingram, Adam|
|Callaghan, Jim||Jackson, Glenda (H'stead)|
|Campbell, Mrs Anne (C'bridge)||Jackson, Helen (Shef'ld, H)|
|Campbell, Menzies (Fife NE)||Jamieson, David|
|Campbell-Savours, D N||Janner, Greville|
|Canavan, Dennis||Jenkins, Brian (SE Staff)|
|Cann, Jamie||Jones, Barry (Alyn and D'side)|
|Carlile, Alexander (Montgomery)||Jones, Lynne (B'ham S O)|
|Chidgey, David||Jones, Martyn (Clwyd, SW)|
|Chisholm, Malcolm||Jones, Nigel (Cheltenham)|
|Clapham, Michael||Jowell, Tessa|
|Clark, Dr David (South Shields)||Kaufman, Rt Hon Gerald|
|Clarke, Eric (Midlothian)||Keen, Alan|
|Clarke, Tom (Monklands W)||Kennedy, Charles (Ross, C&S)|
|Clwyd, Mrs Ann||Khabra, Piara S|
|Coffey, Ann||Kilfoyle, Peter|
|Cohen, Harry||Lestor, Joan (Eccles)|
|Corbett, Robin||Liddell, Mrs Helen|
|Corbyn, Jeremy||Livingstone, Ken|
|Corston, Jean||Lloyd, Tony (Stretford)|
|Cousins, Jim||Loyden, Eddie|
|Cunningham, Jim (Covy SE)||Lynne, Ms Liz|
|Dafis, Cynog||McAllion, John|
|Darling, Alistair||McAvoy, Thomas|
|Davidson, Ian||McCartney, Ian|
|Davies, Bryan (Oldham C'tral)||Macdonald, Calum|
|Davies, Chris (L'Boro & S'worth)||McFall, John|
|Davies, Rt Hon Denzil (Llanelli)||McKelvey, William|
|Davies, Ron (Caerphilly)||Mackinlay, Andrew|
|Dewar, Donald||McLeish, Henry|
|Dixon, Don||McNamara, Kevin|
|Dobson, Frank||McWilliam, John|
|Donohoe, Brian H||Madden, Max|
|Dowd, Jim||Maddock, Diana|
|Dunwoody, Mrs Gwyneth||Mahon, Alice|
|Eagle, Ms Angela||Mandelson, Peter|
|Eastham, Ken||Marshall, David (Shettleston)|
|Ewing, Mrs Margaret||Marshall, Jim (Leicester, S)|
|Fatchett, Derek||Martin, Michael J (Springburn)|
|Faulds, Andrew||Martlew, Eric|
|Field, Frank (Birkenhead)||Maxton, John|
|Fisher, Mark||Meacher, Michael|
|Flynn, Paul||Meale, Alan|
|Foster, Rt Hon Derek||Michael, Alun|
|Foster, Don (Bath)||Michie, Bill (Sheffield Heeley)|
|Foulkes, George||Michie, Mrs Ray (Argyll & Bute)|
|Fraser, John||Milburn, Alan|
|Fyfe, Maria||Mitchell, Austin (Gt Grimsby)|
|Gapes, Mike||Moonie, Dr Lewis|
|Morgan, Rhodri||Short, Clare|
|Morley, Elliot||Simpson, Alan|
|Morris, Rt Hon Alfred (Wy'nshawe,||Skinner, Dennis|
|Morris, Estelle (B'ham Yardley)||Smith, Andrew (Oxford E)|
|Morris, Rt Hon John (Aberavon)||Smith, Chris (Isl'ton S & F'sbury)|
|Mowlam, Marjorie||Smith, Llew (Blaenau Gwent)|
|Mudie, George||Soley, Clive|
|Mullin, Chris||Spearing, Nigel|
|Murphy, Paul||Spellar, John|
|Oakes, Rt Hon Gordon||Squire, Rachel (Dunfermline W)|
|O'Brien, Mike (N W'kshire)||Stevenson, George|
|O'Brien, William (Normanton)||Stott, Roger|
|O'Hara, Edward||Strang, Dr. Gavin|
|Olner, Bill||Straw, Jack|
|O'Neill, Martin||Sutcliffe, Gerry|
|Parry, Robert||Taylor, Mrs Ann (Dewsbury)|
|Pearson, Ian||Timms, Stephen|
|Pike, Peter L||Touhig, Don|
|Powell, Sir Ray (Ogmore)||Trickett, Jon|
|Prentice, Gordon (Pendle)||Tyler, Paul|
|Purchase, Ken||Walker, Rt Hon Sir Harold|
|Quin, Ms Joyce||Wallace, James|
|Radice, Giles||Wardell, Gareth (Gower)|
|Randall, Stuart||Wareing, Robert N|
|Raynsford, Nick||Welsh, Andrew|
|Reid, Dr John||Wicks, Malcolm|
|Rendel, David||Wigley, Dafydd|
|Robertson, George (Hamilton)||Williams, Rt Hon Alan (Sw'n W)|
|Robinson, Geoffrey (Co'try NW)||Williams, Alan W (Carmarthen)|
|Roche, Mrs Barbara||Winnick, David|
|Rooker, Jeff||Wise, Audrey|
|Rooney, Terry||Worthington, Tony|
|Ross, Ernie (Dundee W)||Wright, Dr Tony|
|Rowlands, Ted||Young, David (Bolton SE)|
|Sheerman, Barry||Tellers for the Ayes:|
|Sheldon, Rt Hon Robert||Mr. Peter Hain and|
|Shore, Rt Hon Peter||Mrs. Jane Kennedy|
|Ainsworth, Peter (East Surrey)||Butterfill, John|
|Aitken, Rt Hon Jonathan||Carlisle, John (Luton North)|
|Alison, Rt Hon Michael (Selby)||Carlisle, Sir Kenneth (Lincoln)|
|Allason, Rupert (Torbay)||Carrington, Matthew|
|Amess, David||Carttiss, Michael|
|Arbuthnot, James||Cash, William|
|Arnold, Jacques (Gravesham)||Channon, Rt Hon Paul|
|Ashby, David||Chapman, Sir Sydney|
|Atkins, Rt Hon Robert||Churchill, Mr|
|Atkinson, Peter (Hexham)||Clappison, James|
|Baker, Rt Hon Kenneth (Mole V)||Clark, Dr Michael (Rochford)|
|Baker, Nicholas (North Dorset)||Clarke, Rt Hon Kenneth (Ru'clif)|
|Baldry, Tony||Clifton-Brown, Geoffrey|
|Banks, Matthew (Southport)||Coe, Sebastian|
|Banks, Robert (Harrogate)||Colvin, Michael|
|Batiste, Spencer||Congdon, David|
|Bellingham, Henry||Coombs, Anthony (Wyre For'st)|
|Bendall, Vivian||Cormack, Sir Patrick|
|Beresford, Sir Paul||Couchman, James|
|Biffen, Rt Hon John||Cran, James|
|Body, Sir Richard||Currie, Mrs Edwina (S D'by'ire)|
|Bonsor, Sir Nicholas||Curry, David (Skipton & Ripon)|
|Booth, Hartley||Davies, Quentin (Stamford)|
|Boswell, Tim||Day, Stephen|
|Bottomley, Peter (Eltham)||Deva, Nirj Joseph|
|Bowis, John||Devlin, Tim|
|Boyson, Rt Hon Sir Rhodes||Dorrell, Rt Hon Stephen|
|Brandreth, Gyles||Douglas-Hamilton, Lord James|
|Brazier, Julian||Dover, Den|
|Bright, Sir Graham||Duncan, Alan|
|Brooke, Rt Hon Peter||Duncan Smith, lain|
|Brown, M (Brigg & Cl'thorpes)||Dunn, Bob|
|Browning, Mrs Angela||Dykes, Hugh|
|Budgen, Nicholas||Eggar, Rt Hon Tim|
|Burns, Simon||Elletson, Harold|
|Emery, Rt Hon Sir Peter||Lilley, Rt Hon Peter|
|Evans, David (Welwyn Hatfield)||Lloyd, Rt Hon Sir Peter (Fareham)|
|Evans, Jonathan (Brecon)||Lord, Michael|
|Evans, Roger (Monmouth)||Luff, Peter|
|Evennett, David||Lyell, Rt Hon Sir Nicholas|
|Faber, David||MacGregor, Rt Hon John|
|Fabricant, Michael||MacKay, Andrew|
|Field, Barry (Isle of Wight)||Maclean, Rt Hon David|
|Fishburn, Dudley||McNair-Wilson, Sir Patrick|
|Forman, Nigel||Madel, Sir David|
|Forsyth, Rt Hon Michael (Stirling)||Maitland, Lady Olga|
|Forth, Eric||Malone, Gerald|
|Fox, Rt Hon Sir Marcus (Shipley)||Mans, Keith|
|Freeman, Rt Hon Roger||Marland, Paul|
|French, Douglas||Marlow, Tony|
|Fry, Sir Peter||Marshall, John (Hendon S)|
|Gale, Roger||Marshall, Sir Michael (Arundel)|
|Gallie, Phil||Martin, David (Portsmouth S)|
|Gardiner, Sir George||Merchant, Piers|
|Gamier, Edward||Mills, Iain|
|Gill, Christopher||Mitchell, Andrew (Gedling)|
|Gillan, Cheryl||Mitchell, Sir David (NW Hants)|
|Goodlad, Rt Hon Alastair||Moate, Sir Roger|
|Goodson-Wickes, Dr Charles||Molyneaux, Rt Hon Sir James|
|Gorst, Sir John||Monro, Rt Hon Sir Hector|
|Grant Sir A (SW Cambs)||Montgomery, Sir Fergus|
|Greenway, Harry (Ealing N)||Moss, Malcolm|
|Greenway, John (Ryedale)||Nelson, Anthony|
|Griffiths, Peter (Portsmouth, N)||Neubert, Sir Michael|
|Grylls, Sir Michael||Newton, Rt Hon Tony|
|Hague, Rt Hon William||Nicholls, Patrick|
|Hamilton, Neil (Tatton)||Norris, Steve|
|Hampson, Dr Keith||Ottaway, Richard|
|Hanley, Rt Hon Jeremy||Page, Richard|
|Hannam, Sir John||Paice, James|
|Hargreaves, Andrew||Patten, Rt Hon John|
|Haselhurst, Sir Alan||Pickles, Eric|
|Hawkins, Nick||Porter, Barry (Wirral S)|
|Hawksley, Warren||Porter, David (Waveney)|
|Heald, Oliver||Portillo, Rt Hon Michael|
|Hendry, Charles||Powell, William (Corby)|
|Heseltine, Rt Hon Michael||Redwood, Rt Hon John|
|Hicks, Sir Robert||Renton, Rt Hon Tim|
|Higgins, Rt Hon Sir Terence||Richards, Rod|
|Hill, Sir James (Southampton Test)||Riddick, Graham|
|Horam, John||Rifkind, Rt Hon Malcolm|
|Hordem, Rt Hon Sir Peter||Robathan, Andrew|
|Howell, Rt Hon David (G'dford)||Roberts, Rt Hon Sir Wyn|
|Howell, Sir Ralph (N Norfolk)||Robinson, Mark (Somerton)|
|Hughes, Robert G (Harrow W)||Roe, Mrs Marion (Broxbourne)|
|Hunt, Rt Hon David (Wirral W)||Rowe, Andrew (Mid Kent)|
|Hunter, Andrew||Rurnbold, Rt Hon Dame Angela|
|Hurd, Rt Hon Douglas||Sackville, Tom|
|Jack, Michael||Sainsbury, Rt Hon Sir Timothy|
|Jenkin, Bernard||Scott, Rt Hon Sir Nicholas|
|Jessel, Toby||Shaw, David (Dover)|
|Johnson Smith, Sir Geoffrey||Shaw, Sir Giles (Pudsey)|
|Jones, Gwilym (Cardiff N)||Shephard, Rt Hon Gillian|
|Jones, Robert B (W Hertfdshr)||Shepherd, Sir Colin (Hereford)|
|Jones, Nigel (Cheltenham)||Shepherd, Richard (Aldridge)|
|Kellett-Bowman, Dame Elaine||Shersby, Sir Michael|
|Key, Robert||Sims, Sir Roger|
|Knapman, Roger||Skeet, Sir Trevor|
|Knight, Mrs Angela (Erewash)||Smith, Tim (Beaconsfield)|
|Knight, Rt Hon Greg (Demy N)||Smyth, The Reverend Martin|
|Knight, Dame Jill (Bir'm E'st'n)||Spencer, Sir Derek|
|Knox, Sir David||Spicer, Sir James (W Dorset)|
|Kynoch, George (Kincardine)||Spink, Dr Robert|
|Lait, Mrs Jacqui||Spring, Richard|
|Lang, Rt Hon Ian||Sproat, Iain|
|Lawrence, Sir Ivan||Stanley, Rt Hon Sir John|
|Legg, Barry||Steen, Anthony|
|Leigh, Edward||Stephen, Michael|
|Lennox-Boyd, Sir Mark||Stem, Michael|
|Lester, Sir James (Broxtowe)||Stewart, Allan|
|Lidington, David||Streeter, Gary|
|Sumberg, David||Walker, Bill (N Tayside)|
|Sweeney, Walter||Ward, John|
|Sykes, John||Wardle, Charles (Bexhill)|
|Tapsell, Sir Peter||Waterson, Nigel|
|Taylor, John M (Solihull)||Watts, John|
|Taylor, Sir Teddy (Southend, E)||Wells, Bowen|
|Temple-Morris, Peter||Whitney, Ray|
|Thomason, Roy||Whittingdale, John|
|Thompson, Sir Donald (C'er V)||Widdecombe, Ann|
|Thompson, Patrick (Norwich N)||Wiggin, Sir Jerry|
|Thornton, Sir Malcolm||Wilkinson, John|
|Thurnham, Peter||Wilshire, David|
|Townsend, Cyril D (Bexl'yh'th)||Winterton, Nicholas (Macc'fld)|
|Tredinnick, David||Wood, Timothy|
|Trend, Michael||Yeo, Tim|
|Trotter, Neville||Young, Rt Hon Sir George|
|Twinn, Dr Ian|
|Viggers, Peter||Tellers for the Noes:|
|Waldegrave, Rt Hon William||Mr. Derek Conway and|
|Walden, George||Mr. Patrick McLoughlin|
§ 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.
§ MR. DEPUTY SPEAKER forthwith declared the main Question, as amended, to be agreed to.
§ That this House congratulates the staff of the National Health Service for providing high quality care to a record number of patients, and notes that their achievements have been underpinned by the Government's unique commitment to increasing National Health Service funding, which has meant an extra £9.5 billion since 1992, and is dismayed that the Opposition proposals put ideology before patients, in particular by removing the option of fundholding from the 50 per cent. of general practitioners who have decided that this system offers the best prospect for their patients.