National Health Service

HC Deb 09 December 1997 vol 302 cc796-810 3.33 pm

The Secretary of State for Health (Mr. Frank Dobson)

In good times and in bad, I have always been proud to be a member of the Labour party and I have never been as proud as I am today, as a Labour Secretary of State for Health to announce the publication of our proposals to renew and modernise the national health service, which our party founded. These are set out in our White Paper "The New NHS".

This White Paper is a turning point for the health service, the 1 million staff who work in it and all of us who use it. This Government were elected to save the heath service. We were also elected to change it for the better. We want to give it a new lease of life. Today we outline a 10-year programme of modernisation which guarantees that the NHS will get better each year—delivering quicker, higher-quality services for patients. The pace of change will be measured, but each year will bring new and visible improvements. Our plan is to give our country a modern and dependable health service that is once again the envy of the world.

We will make a start straight away. The White Paper abolishes the wasteful and bureaucratic competitive internal market introduced by the Tories. It sets out how services will respond more readily to patient needs, and describes new targets against which performance will be judged. Doctors and nurses will be in the driving seat. It spells out a whole new approach that we have called integrated care. It will break down the Berlin wall between health and social care, so that patients get swift access to care and treatment rather than being passed from pillar to post.

The changes we are outlining today will put quality, fairness and efficiency at the heart of the national health service. Quality will give patients a guarantee of excellence wherever they live. Standards will be raised right across the country. Fairness will give patients an NHS that is there for them when they need it, where they need it, regardless of their ability to pay—a one-nation NHS. Efficiency will deliver more money for patient care. There will be a relentless drive to cut out waste and unnecessary bureaucracy.

We will abolish the internal market, because it has failed. It has failed to deliver quality of care, fairness for patients or efficient services. It has set doctor against doctor, and hospital against hospital. Its business culture has been at odds with the ethos of the NHS and those who work within it. Patients want an NHS where staff can work together to provide better services, rather than having to compete against each other.

When I became Secretary of State, I promised that we would listen to the people on the front line—the nurses and doctors, midwives and other professionals and staff in the NHS. We have kept that promise. We have listened. That is why our proposals go with the grain. We are building on what has worked; we are discarding what has failed. For us what counts is what works. There will be no return to the command and control structures of the 1970s. Nor will there be a continuation of the divisive fragmentation of the 1990s. Instead there will be a third way—a new model for a new century.

We will keep the separation between planning and providing services, but we will end competition and replace it with a new statutory duty of partnership so that local health services pull together rather than pull apart. We will end fundholding and replace it with primary care groups in each area, putting doctors and nurses in charge of shaping services for all patients. We will end the culture of secrecy and commercialisation, and replace it with a new duty of openness that will share best practice for the benefit of all patients. We will end short-term contacts, cost per case contracts and extra contractual referrals, and replace them with long-term agreements that offer stability and focus on quality.

Our detailed proposals for doing all that are set out in the 81 pages of the White Paper. The proposals will cut the number of commissioning bodies from around 4,000 to about 500.

We will set up primary care groups involving family doctors and community nurses in every area. They will be responsible for commissioning services for their local communities, and will account to health authorities for their activities.

General practitioners and community nurses will have a choice about the form their primary care group takes. For example, they will have the power to become free-standing primary care trusts, able to run community health services, including community hospitals. They will have a single unified budget, no part of which will be capped; so money will always be there to guarantee that patients get the medicine they need, when they need it.

The new unified budget will give GPs maximum choice in how patients' needs are met. All primary care groups will work closely with social services to provide properly integrated care.

For the first time, NHS trusts will have a statutory duty to co-operate with other parts of the NHS and to meet quality standards. They will remain responsible for treatment and care, and hospital doctors and nurses will have a greater say in shaping local services for patients.

Over time, health authorities will relinquish most of their commissioning responsibilities. They will be leaner organisations with stronger powers. They will draw up long-term programmes for improving the health of their area—in consultation with local NHS trusts and primary care groups, but also with local authorities, voluntary bodies and education and research institutions. The health improvement programmes will provide the broad framework for local action to improve general health and health services.

All of us who use the NHS deserve a guarantee of excellence. There will be new national action to extend quality and efficiency into every part of the NHS, backed by a new performance framework that will measure what counts for patients.

There will be a new National Institute for Clinical Excellence to give a strong lead on clinical and cost effectiveness, drawing up new guidelines from the latest scientific evidence.

There will be new national service frameworks—on the lines of the Calman-Hine frameworks, which have worked so well in cancer treatment—that will guarantee consistent access to services and quality of care for all patients. The frameworks will draw on the best evidence available to establish the best ways of providing particular services.

To underpin the drive for quality, there will be a new commission for health improvement, to spread best practice and tackle shortcomings.

Patients will also have a guarantee that public money is being used to best effect. NHS trusts will no longer be competing, but they will be comparing: comparison, not competition, will drive efficiency. A national schedule of comparative costs of treating different conditions will be drawn up, and each NHS trust will be judged against it.

Management costs will be capped. There will be clear incentives and sanctions to drive performance improvements at every level. Trust performance will be benchmarked for both quality and efficiency, and the results will be made available to the public.

Over the lifetime of this Parliament, we estimate that the changes will shift an extra £1 billion from bureaucracy into front-line patient services. That will be on top of the extra £1.5 billion that the Chancellor has made available this year and next year for the NHS. We will continue to raise spending in real terms every year on the health service.

The changes will give patients a modern and dependable health service that makes best use of developments in modern medicine and information technology, to offer readily available high-quality services.

We have already promised to cut waiting lists. We will have done so by the end of this Parliament. I announce today three new milestones by which people will be able to chart our progress towards the new NHS.

First—at home—everyone will be able to contact NHS Direct, which is a new 24-hour telephone advice line staffed by nurses. Three pilot care and advice helplines will begin in March 1998. By 2000, it will cover the entire country.

Secondly—at a community level—patients will benefit from quicker test results, up-to-date specialist advice in their own doctor's surgery and on-line booking of out-patient appointments by connecting every family doctor to NHSnet, which is the NHS's own information super-highway. Demonstration sites will be in operation in 1998, and the services will be available to general practitioners across the country by 2002.

Thirdly—in hospitals—everyone with suspected cancer will be guaranteed a specialist appointment within two weeks of their GP deciding that they need to be seen. That will start in 1999 for every woman with suspected breast cancer, and be extended to all other cases of suspected cancer by 2000.

We have great ambitions for the national health service. We will take on those who say that the NHS has had its day, and all we can do is preside over its decline. We will work with the 1 million people who make the NHS so special, even now, to turn it into a modern and dependable service for the coming century.

We know that doctors and nurses and all the staff of the national health service wish to rid themselves of the unfairness and inefficiency of the current system. That is our ambition, too. It is what they want, and it is what the people of this country want.

Next year, the national health service celebrates its 50th birthday. The Labour party that founded the national health service is now setting about modernising it to prepare it for the challenges of the next 50 years: a new national health service, drawing on new technology, new drugs, new quality standards and new ways of working; a new national health service, based on its timeless principle that the best health services should be available to all—the best for all, quality and equality for the new century.

Mr. John Maples (Stratford-on-Avon)

The dilemma facing the Secretary of State in formulating policy is the same one that faced us. His policy objective is one that we share—to improve the quantity and quality of patient care—but that is difficult to achieve in the context of an aging population, medical advances, rising expectations and limited money.

What all that calls for is maximum financial efficiency and maximum clinical effectiveness, and the structure of the national health service needs mechanisms to drive that. We did that when we were in office. We introduced general management and we introduced the purchaser-provider split to separate commissioning from delivery of service, which allowed trusts to get on with providing services.

We gave contestability of contracts to provide some choice between providers. We instituted fundholding, which put money and decisions as near to patients as possible. I remind the House that, although the Labour Government are adopting many of those principles today, they opposed them all when they were suggested.

Those mechanisms drove change. When the Secretary of State and I talk to trusts—although I doubt the Secretary of State asks this question, because he will not want to hear the answer—they say that most of the change achieved in the past five years has been driven by GP fundholders, not by health authorities. In a recent survey, 85 per cent. of the trusts surveyed said exactly that, and 70 per cent. of those said that the changes that had been driven had benefited all patients, not just those of GP fundholders.

Of this country's GPs, 58 per cent. have chosen to become fundholders, and more than 60 per cent. of this country's patients are patients of fundholders—they, too, believe that the change has been effective, and 93 per cent. of them wish to retain their practice-based budget. Almost all academics and health economists agree with that, and their criticism of us is not that we instituted an internal market, but that we never really let it work.

What is crucial is who holds the budget. Fundholders were happy to take that on, balancing their clinical freedom with financial responsibility. If the Secretary of State's commissioning groups do not have that same power, they will not achieve the same results or, indeed, the better results to which he aspires.

I welcome the Government's acceptance of many of the principles of the internal market. I welcome the retention of the purchaser-provider split, with the choices that that allows. I welcome the retention of the principle of a primary-care-led NHS. I welcome GPs remaining in the driving seat in developing primary care and commissioning secondary care. All that builds on principles that were established by our reforms. I congratulate the Secretary of State on accepting and building on those reforms, as his colleagues will find he has done when they take the time to read the White Paper.

However, I am concerned that the new group commissioning model is being imposed on all GPs, and that it may prove too prescriptive. There has been enormous value in the variety of commissioning models that have developed in the past five years, including fundholding and multifunds on one side, and commissioning groups of non-fundholders on the other. We cannot support the total abolition of fundholding, and we shall work over the coming weeks to persuade him that, within his group commissioning model, practice-level budgets should continue for those GPs who want them.

There is a danger that the loss of independence of fundholders will lead to a loss of the initiatives that they have developed for their patients—for example, more patient services available within practices, not in hospitals—and of improvements in hospital services that have been driven by fundholders.

We shall press the right hon. Gentleman to allow maximum flexibility in his new commissioning group structure, and let GPs choose control over practice-based budgets where that is what they want. I am not sure how groups of 50 to 60 GPs will manage to agree anything. If they cannot agree and if they cannot devolve budgets, there is a danger that they will become mini-health authorities.

Flowing through the White Paper—notwithstanding what I have welcomed about it—there is a touching old Labour faith in co-operation and good will; but these new commissioning groups will succeed only if they have the power to make real choices. If the new commissioning groups are not flexible and cannot make real choices to influence providers, they will not achieve the objectives that the Secretary of State has set for them.

The White Paper is unclear on a couple of points. The right hon. Gentleman will appreciate that I have not had a chance to study it in detail, but I should be grateful for some clarification. Will the commissioning groups be able to make choices among secondary care providers? Will they be able to devolve part of their budgets internally within the groups? Will the Secretary of State try to ensure a full day's debate on the White Paper in the new year, once we have all had a chance to study it?

Is the Secretary of State's model for GP commissioning open to further suggestions? Will it give GPs the flexibility to develop commissioning in ways that they may choose—perhaps different ways in different places? Will GPs be compelled to use a particular hospital, or will they be able to choose which hospital to send patients to?

What does the right hon. Gentleman have to say to the 58 per cent. of GPs who have chosen fundholding, or to the 93 per cent. of this group who say that they want to keep practice-based budgeting? After all, they number more than half the country's GPs. Why should they be prevented from improving patient care as they wish?

Will the Secretary of State in due course—perhaps not today—detail how the £1 billion that he says will be saved from reduced red tape will be achieved? Can he promise us today that, under Labour, the number of qualified nurses will increase by at least 3,000 a year on average, as it did under the former Government? Can he promise to beat our record of increasing the number of in-patient and day cases treated by an average of more than 4 per cent. a year? Above all, can he promise to beat the previous Government's record of increasing national health service funding by more than 3 per cent. a year in real terms?

We and the British people will judge the right hon. Gentleman's stewardship of the Department, and these reforms, by those exacting standards.

Mr. Dobson

The response of the hon. Member for Stratford-on-Avon (Mr. Maples) suggests that the country believed that we had a sort of NHS nirvana until the end of April 1997. Most people do not like what has happened to the health service; most people working in it do not like it, either. They find it wasteful and unfair to patients. They do not like the fact that those working in the NHS have been forced to participate in activities that they find unfair and unpleasant.

It was not I who described the effects of the internal market on doctors as repugnant: it was Sandy Macara, the chairman of the British Medical Association, who said that the present system is repugnant to doctors. What is more, he did not try to single out doctors in the way the previous Government tried to.

My hon. Friend the Member for Rugby and Kenilworth (Mr. King) spoke earlier of a problem that had arisen in Rugby because of the internal market: nothing was done, nothing could be done. GPs, whether fundholders or non-fundholders, could not bring about any improvements in the hospital in question. As a result, the people of Rugby have been punished, in effect, by having their hospital taken away from them. Our proposals to establish quality standards and ensure that they are met, and to give more power to GPs and community nurses, will prevent just that sort of episode.

The hon. Gentleman asked me whether GPs will be allowed to send patients to the hospital of their choice. He actually used more obscure language, but I think that that is what he meant. Before the previous Government's changes, a GP could send patients to any hospital in the land. It was that Government who introduced restrictions; we, of course, will allow GPs to do so again. But we must not put GPs in the position of not wanting to send people living in Rugby to Rugby hospital because it is not good enough. They should not be forced to send people to Coventry for a decent level of care. We need to ensure decent care in every hospital in the country. The Tory system has failed to deliver that.

The hon. Gentleman spoke mockingly of a touching old Labour faith in co-operation and good will I plead guilty to that any day; most doctors and nurses would plead guilty to it as well. They were horrified that their management sometimes told them that they were not allowed to co-operate with the hospital down the road because it might undermine their commercial position.

I have talked to nurses and to cardiac surgeons who tell me that, for commercial reasons, their management prevented them from disclosing to others and publishing scientific papers about improvements in treatment because that local management thought that it would undermine the competitive position of the hospital for which they were working. We will be getting rid of all those absurdities.

The hon. Member for Stratford-on-Avon talked as if everything had worked well. We have to get down to the solid examples of what was going on. Under the present arrangements, we have, in theory, national standards for cervical cancer and breast cancer screening. There is no statutory obligation on the trusts carrying out the screening to meet any of the quality levels that have been established. Virtually their only obligation is to break even, and, under the previous Government, an increasing number could not even do that.

We are putting in place a system that will set standards and place obligations on those who are responsible for meeting those standards. They will be obliged to meet them, and we will put in place quality assurance arrangements which will ensure that they do meet them. Doctors, nurses, midwives, other professionals, non-professionals and managers in the health service have told me that they want the sort of things that we are proposing. If the hon. Gentleman thinks that what we are proposing today will be unpopular with the professions concerned, he should wait for a day or two and see what their response is.

Mr. David Hinchliffe (Wakefield)

I offer a warm welcome to my right hon. Friend's statement, which will be widely welcomed throughout the country. One of the consequences of the previous Government's record on the NHS is that I regularly find myself writing five, six, seven or more separate letters about one constituent's problems because of all the various agencies which were brought about through the previous Government's fragmentation of the NHS. That occurs particularly where we have an overlap between health and social care.

Can my right hon. Friend say a little more about his proposals to break down what he rightly describes as the Berlin wall between health and social care? If my right hon. Friend goes back to 1974, he will see that, historically, one of the most damaging decisions for health care in this country was that of Sir Keith Joseph, when he removed from local authorities the public health function and started to create the confusion that has reigned ever since on the issue of social care and health care.

Mr. Dobson

I thank my honourable and good Friend for his welcome for what we have announced today. We are trying to address exactly the point he made about patients and the people representing them being badgered and passed from pillar to post because of the need to approach half a dozen agencies within the national health service and the local authority in order to get proper care for somebody.

It is difficult enough for a Member of Parliament, and it must be almost impossible for some poor old lady who probably cannot see very well or has other problems. My hon. Friend obviously shares my view that the touching faith in co-operation and good will might apply there as well as in the arrangements we are making. We will be producing a further White Paper on social care at the beginning of the new year.

On public health, the chief medical officer, Sir Kenneth Calman, is presently looking at how best to deliver the public health function at national and local level. I have not yet seen his report, but I would expect that he might see a greater role for local authorities, which used to play a bigger part than they do now.

Mr. Simon Hughes (Southwark, North and Bermondsey)

A serious White Paper on the future of the NHS is very welcome. As today's successor to the party which was the other parent of the NHS, we will always be constructive in battling for the best publicly funded national health service. We will support the right hon. Gentleman and his colleagues in everything they do to achieve that.

Where we differ, it will not be personal antagonism; it will be because we have a different view of how to get there. That will always be the basis of our criticism. Like other hon. Members, I hope that we have an opportunity for a full debate early in the new year when we have all had the chance to consider the White Paper—as we will carefully—and give a response in due course.

The big questions for the Secretary of State are those asked outside this House: what will the health service do, and will there be the resources to pay for it? However welcome a National Institute for Clinical Excellence may be, there will still be two sorts of rationing for health service patients. First, for this Parliament at least, some 1 million people at a time are likely to be rationed by waiting lists. Secondly, there will still be rationing by post code—or will it be the case that, no matter where people live, they will always have access to exactly the same services as everybody else? That is a main cause of complaint now.

Is there really proof that the proposed system for commissioning will be much more cost-efficient than the present one? There is some evidence to the contrary. Where is the evidence that it will be more accountable? Many of us believe that representatives of the public, democratically elected—not professionals—should choose the priorities in health and social care. The White Paper appears to place more power in the hands of professionals.

Of course we welcome saving money from thousands of unnecessary contracts, if that is the case. However, will the right hon. Gentleman assure me that claims that, for example, £1 billion will be saved in bureaucracy—that is the figure in the White Paper—will be independently verified, as opposed to just being the subject of Government pronouncement and spin doctor repetition? It is a high figure: 10 per cent. of the management costs of the health service. I want the right hon. Gentleman to confirm that he really does believe that 10 per cent. of management costs can be saved during this Parliament.

I have two final points. First, will the right hon. Gentleman confirm that the internal market is not being abolished? The Tory internal market is being abolished, and we welcome that, but, if there are purchasers and providers, and if there are contracts—even if they are called service agreements—the reality is that there is a market. Or is the right hon. Gentleman saying, as he did in the Rugby example, that there will be no opportunity for a purchasing doctor to choose to go outside his area if he so wished? [Interruption.] If there is to be choice, there is a market, and if there is a market, it is continuing—

Madam Speaker

Order. The hon. Gentleman made the point that we will debate these matters in full in a few months' time. I appreciate that he is the Liberal Democrat spokesman, but even so he is taking an inordinate length of time. There must be 50 or 60 Members trying to catch my eye, and there is no way in which even half of them can be called if this continues. I want just one question from each Member called, and then I shall wind up questions on the statement.

Mr. Hughes

Will the Secretary of State say whether, as well as his good aspirations, the Government intend to increase, in real terms, the amount of public wealth spent on national health? We get it on the cheap. Will there be not just the plans, but the resources that the NHS needs?

Mr. Dobson

I do not know whether I dare welcome the hon. Gentleman's welcome for the White Paper. It is a serious and solid document, and I pay tribute to my hon. Friend the Member for Darlington (Mr. Milburn) for the enormous amount of hard work that he put into its preparation.

The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) raised a huge number of topics. I shall try to reduce that to a few points. First, there will be massive reductions in the number of transactions within the NHS and the number of people carrying out those transactions. The commissioning will come down from between around 4,000 bodies of one sort or another to about 500. That will have parallel beneficial effects on those dealing with them.

There is no internal market. There cannot be a market unless there is competition, and there is not going to be competition. Generally speaking, most GPs in York, for example, where I came from originally, want to be able to send their patients to York district general hospital, because it is the local hospital and because it is convenient for patients and their relatives.

GPs want the hospital to be absolutely top-notch, but, unlike under the present system, they will be able to send their patients to Leeds, Sheffield or wherever for specialist treatment if they so choose. We cannot have the situation that arose in Rugby, when nothing happened, the hospital went down the drain, and the population of the area were punished for the failures of management within the NHS. That is what we are going to avoid. There will be massive reductions in costs.

Yes, we want to apply national standards. Our arrangements are intended to tackle and eliminate the gross variations in treatment and quality, but I come back to one point: despite everything that has happened, for most people in most parts of the country and for most of the time, the NHS does a damned good job, and they are grateful.

Mr. Tam Dalyell (Linlithgow)

What is to be the form and function of the proposed National Institute for Clinical Excellence?

Madam Speaker

Well done.

Mr. Dobson

It is intended to bring together the various professionals to consider the latest evidence on new technology and new drugs, to assess their value and decide which ones are worth pushing, and in effect brand some things as good for the NHS. It will then be up to the rest of the machinery to get on with it, but the process will be led by the professionals. The standards applied will have to be acceptable to the professions. I hope that the institute will be successful.

Mrs. Virginia Bottomley (South-West Surrey)

The proposals represent more evolution and modification than some of the destructive and extremely negative comments that the Labour party made in opposition, but what specific targets is the Secretary of State planning to set?

As my hon. Friend the Member for Stratford-on-Avon (Mr. Maples) said, over the past 18 years, the average increase in spending has run at 3 per cent. in real terms, whereas the right hon. Gentleman is looking at 1.7 per cent. in real terms. He has to do more with less. The only specific target announced so far was to take 100,000 people off the waiting lists, but that was followed by the biggest increase in the number of people on waiting lists that the NHS has ever known. What are the targets, and what redress will there be if the Secretary of State fails to meet them?

Mr. Dobson

I should have thought that the right hon. Lady knew from her experience as Secretary of State that, when anyone starts reciting figures about the money that has been spent on the health service, the public switch off. They switch off if I do it, and they certainly used to switch off when she did it. After all, she was found in several opinion polls to be the least sincere politician in Britain, and God knows there is a lot of competition.

People will see change and improvement in the national health service year in, year out, because we will bring together the people working in the service—doctors, nurses and others—rather than have them working against one another. They will be improving standards, we will be putting in place the appropriate machinery, and we will be increasing the money available to the NHS in real terms year on year.

The right hon. Lady was a member of the Government who set the last budget. This year and next year, we are finding £1.5 billion on top of what her Government intended to find, so a period of quiet from her might not be a bad idea.

Ann Keen (Brentford and Isleworth)

On behalf of community nurses and other health professionals, I congratulate my right hon. Friend the Secretary of State. He is proud, we are proud, and I know that Aneurin Bevan would be particularly proud. I welcome the shared role of community nurses and general practitioners. Will my right hon. Friend enlarge on how he envisages the development of the role of community nurses?

Mr. Dobson

There will be a greater role for all nurses who want to increase their contribution, and who have the necessary and skills and training. Community nurses will play an important and influential role, along with general practitioners, in the commissioning process.

Commissioning is not the only issue. One of the problems of the previous system was that the organisation of general practitioners centred on purchasing hospital care. More joint effort and thought should be put into improving primary and community services.

Mr. Nicholas Winterton (Macclesfield)

As an honorary vice-president of the Royal College of Midwives, I congratulate the Secretary of State on reversing the fragmentation that was occurring in the national health service, and ensuring that it is an integrated, seamless service. Does he accept that there is some concern about the abolition of fundholding, because fundholding practices provide the widest range of medical services at a doctor's surgery or medical centre rather than a hospital, saving the health service money? Will he give an assurance that his reforms will not bring that to an end?

Mr. Dobson

I thank the hon. Gentleman for his welcome. I have said this before and I shall say it again: he has made a singular contribution—an honest, decent contribution—to health debates. He has always stuck to his guns, and I respect him for that.

We are trying to ensure that the best manifestations of fundholding, together with the big improvements that non-fundholders have made in recent years, remain and strengthen the system. We want to eliminate the disadvantages. We may even manage to convince a substantial number of fundholders. Indeed, I think that we may have convinced them already.

Ms Jean Corston (Bristol, East)

Does my right hon. Friend accept that the White Paper will be warmly welcomed by those doctors and health care workers who have pioneered locality commissioning schemes, such as that in south-east London, on the basis of co-operation and good will in the face of Tory market dogma? The range of services they provide is the envy of many fundholders. Will he confirm that, at long last, doctors and nurses will be put in the driving seat for decisions about the treatment that patients should get?

Mr. Dobson

I can certainly confirm that we intend that doctors, nurses and other health care professionals should be in the driving seat. As for fundholders, as those hon. Members who were at Health questions know, we have established 42 pilot commissioning schemes, most of which involve fundholders from those areas who volunteered to take part.

Multifunds and similar ideas are steps away from the individualistic aspects of fundholding—a recognition that, when all the doctors, community nurses and other primary care professionals in one area get together, they can be more influential and have more scope and choice than when they act as individuals. I know that that may sound a trifle socialistic; but it is true.

Mr. John Wilkinson (Ruislip-Northwood)

Will the right hon. Gentleman assure me that the reforms to the functions of health authorities will ensure the future of joint hospitals trusts, such as the Mount Vernon and Watford Hospitals NHS trust in my constituency? There must co-operation between the commissioning health authorities in a locality rather than competition. The York model, together with the limitless funds supposedly available for general practitioners in the future, should ensure that they will be able to commission services in the local hospital, which my constituents and those in Watford greatly appreciate.

Mr. Dobson

I do not like making promises that I cannot guarantee to deliver, and I certainly cannot guarantee the future of any particular hospital when it is raised in the Chamber as it has just been. I would expect GPs in the hon. Gentleman's constituency to try to make sure that the best secondary hospital services were available to their patients as near to their patients' homes as is sensibly convenient, and reasonably cost-effective. I hope that everyone involved in the health service in the area will co-operate to that end. I welcome the hon. Gentleman as an obvious co-operator among the wild competitors opposite.

Jane Griffiths (Reading, East)

Does my right hon. Friend agree that the abolition of the Tory internal market will result in the abolition of the senseless competition between NHS organisations such as hospital trusts? Instead of sharing expertise and information and co-operating with each other, they have been tempted to compete against one another, to the detriment of us all.

Mr. Dobson

I can certainly confirm that, in future, trusts will have a statutory obligation to deliver services to the quality standards that have been laid down. They will also be under a statutory obligation to co-operate with other parts of the national health service. It is a pretty extraordinary thought that, until we change the law, my hon. Friend's local hospital is under no obligation to co-operate with the hospital in Slough, which is not far down the road. It seems crazy, but that is the system we have inherited.

Mr. David Curry (Skipton and Ripon)

If the Government intend to have no more than about 500 commissioning units, that implies that each will cover a very large area—particularly in rural areas—including some minuscule practices serving no more than 2,000 patients? If a rural area has a natural coherence and identity, will the Secretary of State ensure that there is sufficient flexibility to recognise that and that no artificial limit will be placed on the number of people that can constitute one of the commissioning groups?

Mr. Dobson

As the right hon. Gentleman may recollect from when he was an Environment Minister, I am a great believer in horses for courses. We do not seek to enforce one model in every city, suburb and rural area. We want a system that meets the needs of the patients. We are determined to provide a national health service that is moulded to the needs of the patient, rather than the patient having to be moulded to the institutions.

Mr. Harry Cohen (Leyton and Wanstead)

I warmly welcome the White Paper. Will my right hon. Friend explain its impact on maternity services? In the next 12 months, 750,000 women will give birth, and virtually all of them will be attended by midwives. Will he give an assurance that the budget for maternity services will not rest solely with GPs, but that other professionals such as midwives will have a say?

Mr. Dobson

That is certainly the case. There will be an increased role for everyone involved in primary care, including midwives, who also have a significant role in hospitals. That may be one sector where massive savings can be achieved—in any particular town or city, it is possible to predict how many women will become pregnant in any given year.

However, in many areas, contracts are issued case by case, and the paperwork costs a fortune. Longer-term contracts that are not issued case by case, would produce savings, particularly in maternity services, as it is possible to predict how many people need treatment and run a financial system that suits those circumstances, instead of the ridiculous system now in place.

Mr. Tony Baldry (Banbury)

From reading the White Paper, it would appear that the Secretary of State is not proposing any substantial reduction in the number of NHS trusts, but rather that trusts co-operate in primary care plans and various other things through health authorities. Will he give thought to ensuring that proposals to reorganise NHS trusts are put on hold while implications are considered?

One of the difficulties with the example of the Rugby NHS trust, which the right hon. Gentleman cited, is that it is a small NHS general hospital trust. There must be provision in NHS services for small hospitals, such as the Rugbys of this world or Horton general hospital in Banbury. If he is not proposing substantially to reduce the number of NHS trusts, will he consider putting such proposals on hold until we have all had a chance to consider the implications of today's White Paper, especially for smaller hospitals?

Mr. Dobson

That would not be a sensible way of approaching matters. The point that I made at Question Time was that we want to encourage mergers between trust and trust and health authority and health authority which appear to make sense to people in the locality. We do not want to lay down the law; we want to encourage them.

More than 50-odd trusts are involved in merger talks about which the public know. I do not think that any virtue would be served in going back on our recent decision to agree to the merger in Derby, or holding back our examination of the proposal which I understand will be coming from Leeds to merge the two acute trusts there.

I do not accept the hon. Gentleman's point. In certain particular circumstances, it might be wise to hold off certain mergers, but that should, generally speaking, be a matter for those in the locality concerned.

Mr. Ivan Lewis (Bury, South)

Will my right hon. Friend confirm that the only basis for the competition in the health service under the previous Government was that they were preparing it for privatisation? Does he acknowledge that people will welcome the White Paper because it proves that, without privatising the NHS or encouraging competition, it can be modernised by encouraging collaboration and all the values which were the basis of the health service when it was created?

Mr. Dobson

I entirely agree with my hon. Friend.

Mr. Roger Gale (North Thanet)

The right hon. Gentleman has stressed the need for the health service to reflect patients' needs. That is a view which I share entirely. What safeguards does he intend to build into his system to ensure that medical freemasonry and cosy relationships between some GPs and some consultants do not militate against patients' interests and choice?

Mr. Michael Fabricant (Lichfield)

That is a googly.

Mr. Dobson

No, it is not a googly. We have to work on the assumption that the bulk of the medical profession does a good job, wants to do a good job, does not want a cushy number and wants to look after patients—although there will be a limited number of people who will not fall into those categories. We need in place a system that ensures that they do their job properly to the professional standards that their professional colleagues have laid down. That will certainly come about as a result of the National Institute of Clinical Excellence.

I very much welcome the fairly recent decision of the General Medical Council to address the question of doctor performance and people who are not living up to professional standards of patient treatment. Although self-regulation is not right in other areas, I strongly believe that it is appropriate for the medical and nursing professions. However, it is up to them to demonstrate to their colleagues and the public that self-regulation works. We want to encourage them to do so.

Mr. Dennis Skinner (Bolsover)

Is my right hon. Friend aware that the reason why he is able to make today's statement is that the British people woke up in time? They realised earlier this year—and perhaps a bit before—that the national health service was on its way to the hands of insurance companies and other speculators, which would probably create a service costing twice as much and similar to that in America?

Blessed with this good fortune, I hope that my right hon. Friend will realise that he will have to fight for every penny with the Chancellor of the Exchequer—£10 billion extra already collected in taxes—due to the advance of medical science. He will always have to remember this: the NHS is not just a service; it is a cause worth fighting for.

Mr. Dobson

I certainly agree with the last point that my hon. Friend makes. The national health service is popular with people in this country, partly because it provides them with such a good service when they and their families are in need, and partly because of the principles on which it is based. When I am doing okay, I pay in to look after people who are in trouble: in turn, if I fall ill or have an accident, other people pay in to look after me.

People believe, because of that principle, that the national health service does not just bind the nation's wounds: it helps to bind the nation together. That is why the people treasure it.

Mr. Eric Forth (Bromley and Chislehurst)

The Secretary of State referred to quality standards and targets. Is there any contradiction between those and the reference he also made to long-term agreements? If too many institutions are committed to long-term agreements and fail to meet the quality standards or targets, insufficient flexibility may exist to enable the institutions to improve to meet the targets.

Mr. Dobson

We live in a world of dilemmas, and the right hon. Gentleman's point contains some truth. Therefore, we will have to try to ensure that the problem does not arise.

It is not a question of the local primary care group making an agreement with its local hospital on how many services will be provided and to what standard and price they will be delivered. I expect that arrangements will be made so that, if standards are not met, either improvements can be enforced or the institutions can break out of the contract.

We do not want the ultimate weapon to be used, but it may need to be available in the negotiations to give weight to the demands of the primary care group. Primary care groups and their patients do not wish to be forced to transfer their trade to another hospital 20 miles away. That is why, in parallel with the pressures that the primary care group will be able to apply locally, we will introduce national measures to drive up standards and to ensure that they are maintained.

Madam Speaker

Thank you, Mr. Dobson. Go and rest your voice.