§ The Secretary of State for Health (Mr. Frank Dobson)
At the general election, the people knew that the national health service was in a bad way. They could see what a mess the NHS was in after 18 years under the Tories and they feared for its future. In response to their concerns, we promised to save the NHS, to guarantee its future, to stick to the principles on which it was founded and to renew and modernise it so that people in every part of the country get top-quality treatment. We are keeping those promises and the measures announced in the Queen's Speech will mark another big step forward.
All that we want to do will take time. We cannot put right in 18 short months all the damage that the Tories did over 18 long years, but we can make a good start and we have. We have got under way the biggest hospital building programme in the history of the NHS. New hospitals started under this Government are already being built on sites at Dartford and Gravesham, Norfolk and Norwich, Royal Berkshire and Battle in Reading, Carlisle, Calderdale, north Durham, south Manchester, High Wycombe, Amersham, Greenwich, central Sheffield and Rochdale. The building programme does not end there. Our £2.4 billion programme is planned to deliver a further 20 new hospitals from the new Royal London in Whitechapel to the Royal hospital in Gloucester, and in places as far apart as Newcastle, Hereford and Hull.
The renewal programme does not end there. Far too many patients and staff have for far too long been expected to put up with run-down, shabby premises and unreliable equipment. We must change all that and we are changing it. More money is being invested in renovation and modernising older buildings and in replacing run-down plant and equipment. Next year, one quarter of existing accident and emergency departments will be modernised to provide faster, better services for patients and, equally important, a safer working environment for staff.
Since we got in, we have increased spending on the NHS by £2 billion more than the previous Government had budgeted to spend. As we announced in the summer, after conducting our comprehensive spending review we will be investing an extra £21 billion in the NHS over the next three years, an average annual increase of 4.7 per cent.—described by the NHS Confederation as "beyond our wildest dreams". It was certainly beyond the wildest dreams of the Tory and Liberal parties. They and various newspapers announced in advance of the comprehensive spending review that any increase less than 3 per cent. a year would not be enough. Compared with what they called for, we are investing half as much again—£21 billion to strengthen and modernise the NHS to make it fit for the new century, the new millennium.
§ Miss Ann Widdecombe (Maidstone and The Weald)
Does not the right hon. Gentleman misrepresent the position of both the Liberals, for whom I do not particularly want to speak, and ourselves? Did we not say anything less than 3.1 per cent. over the lifetime of the Parliament? Over the lifetime of the Parliament the Government are spending not 4.7 per cent., but 3.6 per cent.
§ Mr. Dobson
The right hon. Lady is wrong. Representatives of the Tory party said that they expected 324 us in future years to match what they had been spending on the NHS. We are matching it virtually this year, although this budget was set not by this Government, but is a hangover from the previous Government. Next year, the year after that and the year after that the increase will average 4.7 per cent., which is far in excess of anything that the Tories called for. The right hon. Lady should sit still and accept that we are doing more than they asked us to do. In those circumstances Opposition Members should sit tight and say, "Thank you".
§ Mr. Simon Burns (West Chelmsford)
What thanks should my constituents give the right hon. Gentleman concerning hospital waiting lists? Some have been waiting for 12 months or more for treatment. According to the Department's own figures, on 31 March 1997, 104 people were waiting for hospital treatment and as of 30 September—18 months after the Labour Government came to power—1,155 people were waiting for hospital treatment. What thanks should those people give the right hon. Gentleman?
§ Mr. Dobson
From bitter experience of these debates, I take the hon. Gentleman's figures with a pinch of salt. [Interruption.] I did not say that they are wrong, but that I take them with a pinch of salt. I will check afterwards because, strangely, I do not have every figure to hand. What I do know is that since April, hospital waiting lists in the country as a whole have come down by the best part of 100,000, just as we said that they would when we found the extra £500 million to bring them down—£500 million that Tory Front-Bench spokesmen said that we should not have found. It is no good them prating about the length of waiting lists and then objecting to us finding the money to bring them down.
§ Mr. Dobson
Looking further to the future, we have committed this Government, and, therefore, future Governments, to increasing the number of medical student places from 5,000 to 6,000 to avoid shortages of doctors in six, seven, eight or more years. That is because this Government take their long-term responsibilities seriously. When it takes such a long time to train doctors and nurses, short-term measures simply will not do. That is why we are increasing the number of training places for both doctors and nurses.
Over the past few years, the system of nurse education and training has developed in a way that has deterred the recruitment of young people who did not relish an academic course, and some new nurses are not as well equipped with the necessary practical skills as they and the health service would like when they start work. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting is already looking into this, and we intend to work with the professions to modernise nurse education and training to deal with these and associated problems while retaining the better aspects of the current system.
We have already started to encourage care assistants and others to train to be nurses by providing the necessary courses and by letting them keep their existing salaries while they are carrying out their training. That is one way 325 of getting into nursing people who, under the present system, have felt excluded. We think that that is right and proper. I hope that everyone in the House agrees with what we are doing because we need the right staff with the right skills.
§ Mr. Simon Hughes (Southwark, North and Bermondsey)
Will the right hon. Gentleman give way?
§ Mr. Dobson
Go on then.
§ Mr. Hughes
No one could disagree with the intentions behind the Government's staffing policy, but when does the Secretary of State expect the shortages of places for about 1,000 midwives, 1,000 doctors and 10,000 nurses to be made up?
§ Mr. Dobson
It certainly will not be tomorrow. The problem has not arisen over the past 18 months, but has been building up over a long period. In some places there are sufficient nurses, midwives or doctors while in others there are shortages. It is almost impossible to predict at the Dispatch Box with worthwhile precision when that is likely to be put right, except in particular areas. That is what we are going to address.
§ Dr. Evan Harris (Oxford, West and Abingdon)
Will the right hon. Gentleman give way? It is to help him out.
§ Mr. Dobson
I do not think that I am so desperate that I need to be helped out by a Liberal, but I will risk it.
§ Dr. Harris
I am grateful to the right hon. Gentleman for not trusting his better judgment. The recommendation was for an urgent increase of 1,000 medical school places. The Government's pledge is to do it over seven years. If that is how long it takes to implement the Campbell committee report, it will be time for another crisis. The matter is urgent. Does he share the British Medical Association's regret that the timetable is not quicker?
§ Mr. Dobson
We are on schedule with the earlier recommendations and intend to be on schedule or better with the new recommendations, which we have accepted. Strangely, the Campbell committee did not, like a Liberal, think that we could suddenly create 1,000 extra medical student places with a flick. That shows that Sir Colin Campbell and his colleagues live in the real world, unlike the Liberals.
We have to look after the staff we have better than we are currently doing. We are already taking action to protect them from the assaults and abuse to which they have been subjected. We are getting help and advice from the Suzy Lamplugh Trust, which has great expertise, about hospital layouts and methods of working. With the help of my right hon. Friends the Lord Chancellor and the Home Secretary, we are ensuring that the louts who assault nurses, doctors and ambulance staff are caught and punished. When discussing the problem with members of the professions, they tell me that when they raised it with my Tory predecessors, the answer they got was, "These sorts of assault and abuse reflect the society we live in now." Well, it is not going to be that sort of society in future.
326 Hospitals have been told to introduce family-friendly employment policies, to improve occupational health and to deal with the racism and discrimination that still shame some parts of our national health service. We all know that pay is a crucial factor. We have made a start by introducing extra pay and status for nurses and midwives at the top of their grades, so that to continue nursing will be worth their while, instead of their being forced to further their career by going into management.
We want all health service staff to be properly and fairly rewarded, but, as my right hon. Friend the Prime Minister told the Royal College of Nursing, we know that pay has to be affordable and support our modernisation agenda. With the agreement of those concerned, we have made clearer the terms of reference of the review bodies. We know how unwelcome the staging of pay awards has been; the challenge that faces the review bodies is to produce recommendations that are fair to staff and affordable for the NHS, so that staging can be avoided.
When we entered office, waiting lists were the longest in history and rising fast. We promised to bring them down, but, as I have told the House before, when I looked at the prospects for last winter, I had to make a difficult decision. I decided that the most urgent need was to avoid a winter crisis, so I asked the national health service to concentrate on winter pressures, which it did. I also said that if that meant that waiting lists continued to rise, I would take the responsibility. They did rise and I did take the responsibility. We are not like the Tories: we do not blame health service staff when things go wrong, only to claim the credit when they go right.
Since the end of April, waiting lists have started to fall. We found an extra £500 million to help to bring them down and the NHS staff are doing a brilliant job with the money. Waiting lists fell by 3,000 in May; by 21,000 in June; by 20,000 in July; by 20,000 in August; by 29,000 in September; and they are still falling fast. Since that has started to happen, the Tories and the Liberals, led by the right hon. Member for Maidstone and The Weald (Miss Widdecombe), have claimed to have discovered examples of fiddled figures and of people who have had to wait more than 18 months for treatment. Every single one of their claims has been proved untrue. They make their allegations, but do not check the facts; in so doing, they smear the hard-working staff who they say are fiddling the figures.
§ Miss Widdecombe
The right hon. Gentleman says that every one of our allegations has been proved untrue. Would he tell me what is untrue about the case of Mr. Wiles, who waited 32 months?
§ Mr. Dobson
If the right hon. Lady will give me the details, I shall look into that case. There are 44 million people in England, but the right hon. Lady picks just one of them and says, "Here's a name—has this man had his operation delayed?" All I can say is that every case I have seen on paper has proved to be untrue.
§ Mr. Dobson
No, I will not.
The Leader of the Opposition has picked up that bad habit from the right hon. Member for Maidstone and The Weald. It must be admitted that the right 327 hon. Gentleman's speech on Tuesday was a fun-packed affair, but it was also a fact-free zone. He peddled one of the right hon. Lady's good old stories about Bradford. She knows that what she says about Bradford is not true, so either she warned her right hon. Friend not to use that story and he did not heed the warning, or she dropped him in it. Maybe she has gone off him. The right hon. Gentleman should watch out: look at what the right hon. Lady did to her former boss at the Home Office.
§ Miss Widdecombe
As the right hon. Gentleman loves all things on paper, he will presumably have taken the trouble to read the internal memorandum circulated at Bradford hospitals NHS trust by Bradford—not by us. That internal memorandum has been supplied to him. Is he saying that it is a pack of lies?
§ Mr. Dobson
That memorandum is wrong in one particular respect. It says that new guidelines have been issued, but that is not the case. Bradford is following the national health service executive's data manual, which was published in January 1997. In case the right hon. Lady is suffering from a premature attack of Alzheimer's, I remind her that the Tory Government were in power in January 1997. Bradford is following the procedures that they laid down. I might add—for what it is worth—that not a single person has been removed from the list, even as a result of implementing the Tories' guidelines.
§ Miss Widdecombe
§ Mr. Dobson
I will give way to my hon. Friend from Bradford, who may know a little about the situation.
§ Mr. Rooney
I thank the Secretary of State for giving way. The chief executive of Bradford hospitals NHS trust has written to me regarding the remarks of the right hon. Member for Richmond, Yorks (Mr. Hague). He writes:I thought you would appreciate a brief note from me to explain that he has fundamentally misunderstood the internal memorandum… No patients were removed from the waiting list as a result of this memorandum. All categories of patients previously included in statutory waiting list returns continue to be included".
§ Mr. Dobson
And answer came there none.
To ensure that waiting lists continue to fall, I have announced an extra £320 million from our NHS modernisation fund to continue next year our relentless war on waiting. I hope that my hon. Friend the Member for Bradford, North (Mr. Rooney) will continue his relentless war in search of the truth. Not only waiting lists, but waiting times will come down.
We also inherited from the Tories huge cuts in the number of hospital beds. For years, the accepted wisdom was that reducing the number of beds in the health service did not affect patient care. That notion always struck me as being slightly contrary to common sense. It is certainly a fact that, in order to cope with winter pressures last year and perform the extra waiting list operations this year, hospitals have used scores of extra wards and hundreds of extra beds.
328 Of course, beds are not the be-all and end-all in the health service, but we will not keep waiting lists and waiting times down unless we have the right number and type of beds in the right place. Under the Tories, every hospital was encouraged to do its own thing. As a result, there was no sensible planning and co-ordination. That is why I have established an inquiry to discover how many beds we really need, what sort of beds they should be and how to make the best use of every single one of them. We have also started to put right many of the other problems facing patients and the NHS.
Take cancer, for example. When we came to power, breast and cervical cancer screening systems in some parts of the country were a scandal. It is no wonder: under the previous Government's internal market, nobody had the power to check screening standards. We have changed all that—it is one reason why we are scrapping the Tories' internal market. We are setting new performance standards and we will ensure that they are met. The national health service executive regions have been given that job. Tory shadow Ministers call it centralisation, but I call it common sense. There must be no more scandals like Devon and Exeter, and Kent and Canterbury, which occurred because there was no one to check that standards were being met.
We have put extra money into breast cancer treatment. By next April, every woman who is referred urgently to a breast cancer specialist should be seen within two weeks. We are putting extra money into treating bowel cancer. On top of that, we plan a multi-million pound lottery-funded boost to the fight against cancer. That will mean new scanners, new breast screening equipment and new linear accelerators to provide better and quicker diagnosis and treatment. It will mean extra help for hospices. We will make the NHS the best cancer service in the whole wide world.
We have started to harness the power of information technology to meet patients' needs. We are committed to investing £1 billion on new systems so that when patients visit the doctor or district nurse or go into hospital at any time of the day or night, their accurate records will be available at the touch of a button. Test results can therefore be dispatched instantly and doctors will be able to discuss patients' scans or X-rays with a specialist looking at a screen hundreds or even thousands of miles away.
We have also launched pilot schemes for booked admissions so that people can arrange over the phone to go into hospital at a time that suits them. If their GP says that they need an out-patient visit, the receptionist at the surgery will be able to make the booking. If, when they go to out-patients, they are told that they need to come into hospital for in-patient treatment, they will be able to book their admission there and then.
§ Mr. Graham Brady (Altrincham and Sale, West)
Will the Secretary of State give way?
§ Mr. Dobson
No, I will not.
We have made a start on all those proposals and many more and, above all, after long and careful consultation with doctors, nurses, midwives, professions allied to 329 medicine and NHS managers, we have made a start on getting rid of the Tories' divisive internal market, which was unfair and inefficient.
§ Mr. Dobson
That system set doctor against doctor and hospital against hospital, and slowed down the spread of new and better treatment and ways of working. It was wasting a fortune on paperwork. I shall give a simple example. When we got into power, the eighth wave of GP fundholding was about to go ahead, and the Tories had put £20 million into the NHS budget just to pay for the paperwork that was involved. We stopped that measure and put half the money saved into breast cancer treatment, where most people would think that it was better spent.
In place of the divisive system that we inherited, and following detailed consultations with representatives of all the professions involved and negotiations with the British Medical Association, representing the doctors, we are going ahead with the establishment of primary care groups. Their boards will consist of GPs, nurses, representatives of social services and lay members. In each primary care group, doctors can choose, if they wish, to elect a majority of the members of the board and take the chair.
With the co-operation of the professions, 481 primary care groups have been established in shadow form and will come into operation next April as sub-committees of their health authority. As we promised, we are putting doctors and nurses in the driving seat. They will be responsible not only for commissioning services from hospitals, but for deciding local priorities and raising standards of care.
The development of primary care groups and the ending of GP fundholding commands the support of the medical profession. In June, the local medical committees conference of the BMA came out in favour of the proposals by an overwhelming majority. The Royal College of Nursing, the Royal College of Midwives and other bodies representing professional staff also support what we propose.
Of course, some doctors are nervous about our proposals. After all the ridiculous reorganisation of the Tory years, who could blame anyone in the NHS for having doubts about any further changes? Doctors have a lot at stake: their patients' well-being, their careers, their premises and their livelihoods and those of their families. That is why we have been careful to involve them at every stage in formulating our policies. That is how this Government work. It is no good the Tories and Liberal Democrats trying to make trouble.
On Tuesday, the Leader of the Opposition said, in his blithely fact-free way, that our proposals would take power away from GPs. That is a funny way to describe an arrangement whereby GPs elect those who will represent them on the board that covers their local area and whereby they can have a built-in majority on the board. That is good enough for the BMA, but apparently it is not good enough for the Tory leader. I have to admit that he is consistent because his attitude to the House of Lords suggests that he would not recognise a built-in majority if one bit him.
330 The changes will lead to a massive reduction in bureaucracy. At present, the transactions between trusts and GPs involve nearly 4,000 separate purchasers. Our proposals reduce the number of organisations commissioning services to 481. They will also mean a move from contracts covering a year or less to service agreements covering several years. We are on target to reduce the cost of NHS paperwork by £1 billion over this Parliament—£1 billion less on paperwork, £1 billion more for patients.
We are determined to raise standards throughout the NHS to those of the best. In this, again, we have the support of the professionals. I am fortunate to be the Secretary of State for Health now as there has never been a time when the doctors, nurses and midwives were so committed to raising standards, spreading good practice and dealing promptly and effectively with the small minority of practitioners who let down their patients and their profession. Up to now, the NHS as an organisation has made no contribution to raising professional standards. We propose to augment what the professions have been trying to do. That is why our proposals command their support.
Patients want to be assured that their local hospital is up to scratch.
§ Mr. Dobson
No, I will not give way at the moment.
To do that we need clearer national standards, applicable throughout the NHS. We need national standards because patients are not willing to put up with variable quality and second best. That is why we are setting up what we call NICE—the National Institute for Clinical Excellence. It will draw up authoritative guidelines on a wide range of treatments and conditions, and so help to ensure that patients everywhere get faster access to treatments that work well.
The National Institute for Clinical Excellence will be professional-led. I have appointed as chairman designate Professor Michael Rawlins from Newcastle university, the Royal Victoria infirmary and the Freeman hospital, Newcastle. I promised the medical profession that we would appoint someone who commanded its support and respect. As I made the announcement at a meeting chaired by the chairman of the BMA who said that I had done exactly what I had promised, I am confident that Professor Rawlins is the man for the job.
We are also going to launch a rolling programme of national service frameworks, which will set out "service blueprints" for major conditions. To be fair, the previous Government established one national service framework for cancer, and it is developing well. We have established one covering children's intensive care, and we are now working on heart disease and mental health. For the first time ever, the NHS will have clear standards in each area, spanning primary, secondary and tertiary care.
Of course, it is no good having standards if they are not implemented and monitored. Above all, this needs action locally, within primary care groups and local hospitals. That is why our national health service Bill will place a legal duty of quality and "clinical governance" on every NHS organisation. In future, all hospital doctors will have to take part in national external audit, and we shall work with the professions to modernise the system of 331 self-regulation so that it is able to command the confidence of the public. It has to become more effective, more open and more accountable. It cannot operate in isolation, but must form part of an integrated approach to raising standards.
All this will be backed up by a new commission for health improvement. Patients themselves will be represented on the commission, and its findings will be published. It will be responsible for checking on the standards of every trust, and it will have statutory powers to investigate concerns about clinical quality and to report on the clinical governance of trusts. In extreme cases, it will be able to recommend to the Secretary of State that new teams of experienced doctors, nurses and managers are sent in promptly to take over the running of any service that is failing.
I must make it clear that none of this is designed just as a clampdown on poor performance after the event; it is designed to ensure high standards in the first place, and to nip problems in the bud before they ever do patients harm. At its bluntest, what patients want is a system that prevents future tragedies like that at Bristol before they happen, not one that just apportions blame and punishment afterwards. That is what the NHS Bill is designed to do; that is why it commands the support of the profession; and that is what we are determined to achieve.
§ Mr. Brady
I am grateful to the Secretary of State for giving way eventually. It was apparent to all in the House why he was so evasive at the point at which I first sought to intervene. Will he take this opportunity to make it clear that, when patients are pre-booked for operations or in-patient treatment, of which he has made so much, they come off waiting lists—sometimes several weeks before an operation?
§ Mr. Dobson
As the pre-booking system that I have just been describing has not yet begun, it is a little difficult for the hon. Gentleman to say that such things are happening already. The system is entirely new; people on the list are clearly waiting for treatment. Let me make it clear—
§ Mr. Dobson
The definition that we inherited from the previous Government is that people who are waiting for treatment go on waiting lists if they are fit and immediately available for surgery, even if they have a booked appointment. I see no reason to change that. The hon. Gentleman should not peddle another misleading approach. You can see how evasive I am, Madam Speaker.
The NHS Bill will cover a wide variety of measures to improve the quality of treatment and care in every part of the country, and will change the law to improve co-operation between the health service and local social services. All that will be spelt out in due course.
We propose two legislative changes to protect the taxpayer and the health service's funds. The pharmaceutical price regulatory scheme is being renegotiated. To date, the scheme has been voluntary, and I hope and expect that we shall be able to reach another 332 voluntary agreement with representatives of drug companies which meets their legitimate objectives as well as those of the NHS. We have, however, decided to seek reserve powers to ensure that all companies subsequently comply with the agreement. That should have no significant impact on the vast majority which always have complied and are complying at present. It is directed at a small minority of maverick companies. We estimate that their failure to comply has cost the NHS £28 million this year. That cannot be allowed to continue; it must be stopped.
As announced by the Chancellor of the Exchequer, as long ago as his first Budget last year, we will amend the Road Traffic Act 1988, passed by the previous Government, to make it easier for hospitals to collect from insurance companies the money that they have been entitled in law to collect since the 1930s. The present arrangements simply do not work and, as a result, the NHS is losing a huge amount of revenue. We do not know how much; estimates vary from £30 million a year to more than £500 million a year. Whatever the figure, the extra funds for the NHS will be very useful.
§ Mr. Dobson
The right hon. Lady should let me finish. There are two charges under the present law: an emergency treatment fee of £21.30, which is supposed to be collected at the hospital directly from any motorist who has been involved in an accident. That raises very little, asking for it causes great offence and it is not what NHS accident and emergency staff are there for. The Tories promised to abolish it, and broke their promise. We will abolish it.
The other charge is levied on insurance companies when a motor accident victim makes a successful claim for compensation. At present, it covers the cost of out-patient treatment up to £295, and the cost of in-patient treatment up to £2,949. That money should have been collected in the past; it was not, but it will be from now on, and I am glad that we are doing it. Apparently, the right hon. Member for Maidstone and The Weald does not want me to give way any more.
Under the Tories, the health gap between the well-off and the badly off widened. It was a shameful consequence of 18 years of Tory rule. The Government are determined to narrow that health gap. In July 1997, shortly after taking office, I invited the former chief medical officer, Sir Donald Acheson, to conduct an inquiry into health inequalities in Britain. I did so because I was determined to make an early start on our mission to reduce health inequalities the top priority in our overall programme to improve the nation's health. Today, I welcome his report. It is a further stage in our unprecedented programme to tackle inequalities in health.
No previous Government have ever set themselves such ambitious targets, but we are confident that we can succeed, because the whole Government are taking action. Led by the Prime Minister, all members of the Cabinet are working together to tackle the problems that make people ill.
Poverty is a principal source of ill health. Poor people are ill more often, and die sooner. Our tax and benefit changes, the working families tax credit and the minimum 333 wage mean that work will pay a guaranteed minimum of £190 a week for a family. That will guarantee a minimum income of at least £5.50 an hour for a lone parent in work with one child, and £6.37 an hour for an adult with two children.
A poor start in life is bad for health. Our £540 million sure start programme, under the supervision of my right hon. Friend the Minister for Public Health, will give young children and their parents the child care and support that they need, so that every child in our country is given the best possible start in life.
A decent education sets people up for better health in later life. Earlier this month, as part of our work to drive up standards in schools, we announced an extra £250 million aimed at children who are disaffected with their schools and with society in general. That should help them.
Being old and cold in winter because of a lack of money to buy warm clothes and good food, and being afraid to turn the fire on, is bad for health. Our £2.5 billion boost to pensions will ensure that the poorest pensioners are the biggest winners, with a guaranteed minimum weekly income of £75 for single pensioners. That will drive up health standards, as will our plans for annual winter fuel payments, the £150 million investment in home energy efficiency, the availability this winter, for the first time, of flu jabs for all those over 75, and the scrapping of the Tory charges for eye tests for pensioners.
Low wages can only reasonably be described as a health hazard. We are improving health by introducing a national minimum wage, putting money into the pockets and handbags of the worst off who are in work. Bad housing makes people ill, so we are investing £4 billion in the building of new and better homes for people who have nowhere decent to live. That will improve their health. Being out of work makes people ill; our new deal, financed from the windfall levy and opposed by both Opposition parties, has helped more than 400,000 extra people into jobs.
By April next year, 13 million people will be helped in 26 health action zones designed specifically to tackle health inequalities in areas including inner cities, coalfield communities, struggling rural areas and places where wealth and poverty live cheek by jowl.
§ Mr. David Rendel (Newbury)
Much of what the Secretary of State has announced may be welcomed on both sides, but does he agree that cuts in incapacity benefit and widows' pensions will not improve health?
§ Mr. Dobson
The hon. Gentleman should wait to find out what the proposals actually are before commenting on them. No doubt he will say that there ought to be increases, and that they will all be financed by the penny on income tax that the Liberal Democrats have been promising everyone.
We are investing £800 million in the new deal for communities to help the most deprived parts of the country. A reshaped single regeneration budget of £2.3 billion over the next three years will be targeted on the most deprived authorities to a greater extent than it was under the last Government. The integrated transport White Paper will help to ensure that public transport is a powerful weapon to alleviate poverty, improve access to jobs, and strengthen families and communities. The social 334 exclusion unit will continue to co-ordinate a national drive to support people who have been cut off from the mainstream of society, which also damages health.
We are already doing most of what is called for in the Acheson report. We are tackling health inequalities with action throughout Government, and there is an important—although not exclusive—role for the Department of Health. Modernising the health service and ensuring fair access in every part of the country to services is a vital component of that effort.
Health action zones are already starting to identify and tackle health inequalities in the most deprived areas. There will be a network of healthy living centres throughout the country which will be working to improve the health of the worst-off. We shall soon be publishing our White Paper against smoking, with action focused on the socially disadvantaged who are most likely to smoke and therefore most likely to suffer the evil consequences.
Our Green Paper, "Our Healthier Nation", made clear our commitment to tackling health inequalities. The Acheson report will be used to ensure that the White Paper on public health, due next year, will be based on the best available evidence.
I am grateful to Sir Donald Acheson and to the many knowledgeable people who assisted him in producing his report. Inequalities that have persisted throughout the century and often worsened in the past two decades will not be swept away overnight. Their work will be a key influence on our long-term strategy to narrow the health gap.
All the measures that the Government are taking show that we are not only working to renew and rebuild the health service. We are also tackling the things that make people ill in the first place. It will be a long job and there will be problems along the way. However, we are keeping our promises. We are changing priorities, changing the law and finding the money. No doubt the Tories will now demonstrate that they oppose the whole lot.
§ Miss Ann Widdecombe (Maidstone and The Weald)
The Secretary of State commented that the Opposition should sometimes say thank you. The right hon. Gentleman has demonstrated clearly that sometimes the Government should say sorry. That is what he should have started by saying.
The proposals on health in the Queen's Speech show finally and beyond all doubt that the Government are much more interested in political control than in patient care. They further reflect a great wasted opportunity, in that the Secretary of State has not addressed the central problem in the health service, which will trouble any Government, no matter what their political complexion: the huge disparity between expectation and demand and the capacity of resources and manpower to keep up with that expectation and demand.
The fact remains that even if the Secretary of State were spending all that he is claiming to be spending, it would still not be possible to close that gap. The absence—in this addressing of the health service, which in reality addresses nothing at all—of any serious plan for coping with the single greatest problem of the health service cries out as an indictment against the Government's approach.
There is something else for which the Secretary of State should apologise, although it is a matter for him: in the course of an exchange with me, he made a frivolous 335 comment about Alzheimer's disease. I must tell the right hon. Gentleman that Alzheimer's is not a joke. Many people will be grossly offended by what he has said, including people who are caring for the sufferers of Alzheimer's—and I dare say that there are people in the House who fall into that category.
Political control lies at the heart of the Government's agenda. It is an agenda to control everything from the fiddles in the waiting list statistics to the medicines that a family doctor is allowed to prescribe to patients. That is what the measures in the Queen's Speech will permit the Government to do. There will be top-to-bottom turbulence in our health service that will disrupt and disturb the work of doctors and nurses, and create uncertainty and upheaval for patients for years to come. That is exactly the reverse of what the Prime Minister promised. In June 1996, the right hon. Gentleman pledged to health service managers that there would be no great upheavals. That is another Labour pledge broken.
The control culture that is being imposed on our health service is set to cause great harm to patients and to the morale of our doctors and nurses. Already our hospitals are buckling under the strain of trying to meet the Government's bogus pledge on waiting lists. We know that operations are being cancelled, that hospitals are facing terrible staff shortages, we know that doctors and nurses are working horrendous hours to force through quick procedures, and the trolley problem is growing. Do we remember the trolley problem? That was what Labour promised to abolish the moment it came to power—[Interruption.]—the patients lying in corridors waiting to be seen, which is now, apparently, a subject of great hilarity on the Government Benches.
The right hon. Member for Camberwell and Peckham (Ms Harman) had the trolley problem in mind when she opined:If I am Secretary of State for Health I will lie awake at night worrying until we get this sorted out.I do not want to disturb the peaceful nights that the right hon. Lady is doubtless now enjoying, but Labour's obsession with its fiddled waiting list pledge is resulting in an army of trolleys descending on the health service.
The situation seems to be particularly serious at the Royal Liverpool hospital. The Liverpool Echo tells of patients waiting for hours on trolleys in hospital corridors, apparently terrified by out-of-control youths. An elderly patient's daughter wrote to me, telling of her mother's seven-hour wait in pain on an uncomfortable and unsuitable light trolley in appallingly hot conditions, just to be seen by the doctors. It is horrifying to hear of a 95-year-old man examined in public on a trolley in the waiting room of the accident and emergency department, to be told that his leg was to be amputated. That happened just one week after the first anniversary of the new Labour Government. The man died one week later.
Just two years ago, as Leader of the Opposition, the present Prime Minister said:I do not see why people should be kept waiting on trolleys for hours in a modern NHS.He promised a task force specifically to look into the problem of patients waiting on trolleys. The right hon. Member for Camberwell and Peckham promised weekly performance checks on the number of patients waiting 336 on trolleys. What happened? Where is the task force? Where are the performance checks? More broken promises, and more early pledges cancelled.
Another example is the Minister of State's comment on accident victims. He said:The increased charges are a tax on accident victimsand described the provision in the Road Traffic Act 1988 as "a sick law". Is it still a sick law, now that he is responsible for widening its scope? If not, how does his proposal differ from the present system, and will the extended charge be compulsory?
§ The Minister of State, Department of Health (Mr. Alan Milburn)
In the interests of accuracy and the pursuit of truth again—and to set the record straight for the right hon. Lady, as I would not want her to be wrong again—what I have campaigned against both in opposition and in government is the emergency treatment fee. It is insensitive to patients and embarrassing for staff. The right hon. Lady's Government promised to abolish it, but they failed to deliver that promise. This Government are abolishing it, and I am proud that we are.
§ Miss Widdecombe
The Minister of State referred to a tax on accidents. If, as a result of the Government's proposals, it is true that insurance premiums will go up—I shall not make a value judgment on whether that should happen or not—is that a tax on accidents? Is that the first new charge that the Labour party is to introduce on free NHS treatment? I shall willingly give way to the Minister of State, who made the comments, but I see that the Secretary of State wants to respond.
§ Mr. Dobson
My right hon. Friend the Minister of State was correcting the right hon. Lady's assertions about him.
We are not introducing anything new. Since 1930 or 1933, depending on one's interpretation, anyone who has been the victim of a road accident and has made a successful claim against an insurance company should have been charged—or his insurance company should have been charged—for the treatment. However, that has not been done. We intend to make the system work as Parliament intended when it re-affirmed that by passing the Road Traffic Act 1988 without any votes against. That is not a tax on accidents, but an emergency charge on anyone who needed treatment was a tax.
§ Mr. John Bercow (Buckingham)
On a point of order, Madam Speaker. I seek your guidance. Is it not out of order for an hon. Member to be reading a newspaper in the Chamber, which, it seems clear, the hon. Member for Rugby and Kenilworth (Mr. King) was doing until a few moments ago?
§ Madam Speaker
If a newspaper article relates to the debate, or if information is being obtained from it, it is in order to read it, whether in Committee or in the Chamber.
§ Mr. Andy King (Rugby and Kenilworth)
Thank you, Madam Speaker.
§ Miss Widdecombe
I return to the matter in hand, which is the subject of the debate between the Secretary of State and myself.
337 I quite understand what the right hon. Gentleman has said, which is that he is seeking to change the system by which money is collected. But he also said that that was to collect it more efficiently and to get the money in. If that is true, I think that he will accept that the additional sum, which has not hitherto been collected as efficiently as it should have been, will have to be covered.
The question is simply this. If, in the process of covering that—I make no value judgment on whether this should be so; I am simply asking—drivers have to pay more, is that not a charge? The Secretary of State does not want to answer.
All these problems and bungles are happening at a time when the health service is supposed to be awash with new funding. The Secretary of State never tires of bragging about all the money that he claims to be spending, so how can anyone now believe—
§ Mr. Dobson
Is the right hon. Lady's definition of a bungle 18 years of not getting in money to which the NHS was entitled, or a Government who, after 18 months, are going to get that money in?
§ Miss Widdecombe
My definition of a bungle is when a Secretary of State does not know what is a charge and what is not. That is a bungle. He is afraid of the word "charge", but when the matter is discussed in the House, the exact extent of the way in which the Government are wriggling out of calling this a charge will become extremely clear.
How can anyone now believe the Government's warm words about modernisation? The truth is that too much of the money that the hon. Gentleman claims he is spending will go on a new bureaucracy—the bureaucracy that will not be cut in the upheaval that the Prime Minister assured us he was not about to impose on our health service.
Primary care groups will cost £150 million to set up. Is that a bureaucratic expense or not? Dragooning family doctors into general practitioner collectives—
§ The Minister for Public Health (Ms Tessa Jowell)
§ Miss Widdecombe
The hon. Lady obviously takes exception to the word "dragooning", so let us examine it.
When the Conservative Government set up fundholding, it was voluntary. Primary care groups are not voluntary. When we set up fundholding, doctors could choose whether to become fundholders. They have no choice about joining primary care groups.
§ Ms Julia Drown (South Swindon)
Does the right hon. Lady accept that, in making the system that she mentions voluntary, her Government necessarily set one doctor against another and one patient against another, whereas primary care groups will ensure that patients are treated like with like, and that clinical priority becomes the priority?
§ Miss Widdecombe
No, because what the hon. Lady proposes is a levelling down, not a levelling up. By the time that we left office, between 50 and 60 per cent. of general practitioners were either fundholders or had applied to become fundholders because they saw the system working. We introduced the system gradually and 338 volunteers entered the first phases, and thereafter it was still voluntary. More and more doctors were joining the system and, had it continued, every doctor would have been either a fundholder or a member of a multifund. That would have given flexibility to each and every doctor to exercise in the interests of each and every patient. Every patient in the NHS with a fundholding doctor had exactly the same rights as any patient going to a private doctor to consult that doctor about where and to whom to be referred. That was what we did with fundholding, and that is what is being abolished. Patients' rights are being abolished, and doctors' rights to their clinical judgments are being abolished.
There is no choice. They are being dragooned. They are not even being dragooned gradually—it is all happening in one big bang, so that if anything is going to go wrong, it will go wrong universally on the first day. That is the policy of the Government.
§ Miss Widdecombe
The hon. Member for South Swindon (Ms Drown) must control her jack-in-the-box tendency. I will not give way at the moment. I have already explained it to her—she wants to level down; the Secretary of State wants to level down; and the Minister of State is wholly committed to levelling down. The Conservative party wants to level up.
§ Mr. Simon Hughes
I take it from that that the right hon. Lady is opposed to the Government's proposals. Will she elaborate on one linked point? Does she also hold to the view, expressed at her party conference, that the NHS will work properly only if fewer people use it by going private?
§ Miss Widdecombe
What I expressed at the party conference was that it was total spending that counted. If one simply looked at public spending, and ignored completely the contribution that people made in their own right, one was necessarily limiting the degree to which we could increase total spending. If the Secretary of State would like to look at the spending patterns of our major European partners, he will find that, whereas public spending differs by a few points of 1 per cent., private spending differs by multiples. Those countries do not have many of the problems that we have because they have learnt that it is total spending that counts.
Actually, I should not be addressing the Secretary of State—I really ought to be addressing the hon. Member for Southwark, North and Bermondsey (Mr. Hughes). However, it is easy to confuse the Labour party and the Liberal Democrats today, and we are never quite sure when the Liberal Democrats are in opposition and when they are part of the Government.
§ Mr. Hughes
Will the right hon. Lady give way?
§ Miss Widdecombe
For the Opposition or the Government?
§ Mr. Hughes
§ Miss Widdecombe
I shall give way.
§ Mr. Hughes
I wish to press the right hon. Lady a little further. That was a long answer about health funding 339 comparisons. Is the short answer to my question that she believes that the health service will only function better if fewer people use it because they go private?
§ Miss Widdecombe
I believe that the health service can treat more people and can give a comprehensive range of treatments if some of the burden of expenditure is shared. At the moment—as the hon. Member for Southwark, North and Bermondsey knows, because he has said so in this House—a number of people have no treatment at all and cannot exercise any alternative.
I have letters from elderly people, telling me that they can no longer receive clinical treatment for varicose veins on the NHS. Several have cashed in their life savings to go private. I make this deduction. Some people cash in their life savings and go private, however difficult that may be. Therefore, there must be people who cannot get the operations that are no longer available and cannot exercise a private alternative. At conference, I said that we would help to get a greater range of treatment available to NHS patients if there were more sharing between the private and the public sectors.
Perhaps I can return to the Queen's Speech, which we are supposed to be addressing. I am sorry that I was led into a discussion of my party conference. I am flattered that the hon. Member for Southwark, North and Bermondsey took such a close interest in it and I would be delighted to give him a verbatim copy if he wants to study it.
§ Miss Widdecombe
I will give way again later, but I want to make some progress now.
Let us consider the national institute for the control of expenditure—sorry, I mean the national institute for clinical excellence—which will be the Government's rationing mechanism. As the Government claim that there is no rationing, where is the final directive that the Secretary of State promised on Viagra? I am extremely grateful to Viagra. It solved a very big problem: getting the Government to admit the truth—that the NHS has always rationed, is rationing and is likely to ration increasingly as it is unable to satisfy every last demand for every new treatment.
That is the truth that I stated at our party conference and that the hon. Member for Southwark, North and Bermondsey has also stated, but from which Labour Members consistently hide. The NHS cannot meet every last expectation. Undeniably, the national institute for clinical excellence will lay down what it calls priorities and what the man in the street would call rationing, forcing it on PCGs and removing once again the clinical discretion of individual doctors.
Can the Minister of State confirm his threat to change the Medical Act 1983 by ministerial edict rather than by secondary legislation if he wants to dismantle the 150-year-old tradition of clinical self-regulation, as exemplified by the General Medical Council? He sits tight.
The Government told us that NICE and CHIMP—the commission for health improvement—would not require any extra funding, but the British Medical Association and 340 the Royal College of Physicians disagree, telling us that without 10 per cent. more consultants, effective pilot schemes and proper evaluation the proposals will be catastrophic. Can the Secretary of State produce 10 per cent. more consultants? Will there be effective pilot schemes? Will he evaluate the proposals before rushing into them? I suspect that the answers will be no, no and no.
NICE and CHIMP will not be the end of the exciting career opportunities that the Government are creating for Tony's clinical cronies. We are also to have an advisory committee on resource allocation, a capital prioritisation advisory group and local education consortiums. It is unclear how health and local authorities are to be duty bound to administer joint investment plans without new co-ordinating bureaucracy.
Can this really be what the Government meant when they said that they would divert money from health service managers into front-line patient care? Even without this massive increase in pen pushing, the huge upheaval in the health service under Labour's new structures of political control will devastate patient care.
The Government are not abolishing the internal market, as they claim. If the Secretary of State needs a definition, the internal market is the purchaser-provider split, and the Government are keeping that, by their own admission. The administrative shock of imposing massive new bureaucracies nationwide, combined with huge regulatory control on family doctors, will be immense, with consequent disturbance to patients.
The centrepiece of the agenda is the imposition of primary care groups. If they are so popular, one wonders why the Secretary of State does not propose to ballot the medical profession. Why was he not prepared to do that if he was so sure that a majority would be in his favour?
§ Mr. Dobson
Some people at the BMA urged the GPs' representatives to hold a ballot and they decided—I assume that they are in contact with the members they represent—that that was not necessary, because the bulk of GPs agreed with what we were doing, following all the consultations we had had with them and the excellent, if tough, negotiations that they had had with my right hon. Friend the Minister of State. It is no good the right hon. Lady screeching away about how terrible our proposal is and what harm it will do to general practice, when the general practitioners accept it.
§ Miss Widdecombe
But they do not accept it. Since then, the BMA have produced several opinion polls. It was not a comprehensive ballot, but one poll showed that 55 per cent. of doctors wanted nothing to do with the running of primary care groups.
Will the Secretary of State confirm that, if his Bill is not in place by 1 April—and that is a tight and ambitious timetable—his entire upheaval of family doctor services will be in ruins, because he will not have the power to coerce the many unwilling GPs into collectives? Does he have a contingency plan to avert the chaos that that would bring to our health service or is he hoping against hope that fundholding family doctors will come quietly and surrender their autonomy to his regime of political control?
According to a poll in BMA News on 4 February 1998—if the Secretary of State wants the reference, although he has had time enough to catch up with the 341 findings—55 per cent. of doctors actively want no part in the running of the collective. Can we blame them? Primary care groups are set to make medical eunuchs out of our family doctors by giving them responsibility but taking away power.
Doctors will have responsibility for rationing, through the guidance of NICE and Prodigy, and prescription budgets will be capped for the first time in the history of our health service. I shall repeat that, in case the Secretary of State missed it: prescription budgets will be capped for the first time in the history of our health service. Doctors will bear the responsibility for the Government's failure to meet their fiddled waiting lists, because doctors will have to reduce their referral rates to hospitals.
§ Mr. Tony McNulty (Harrow, East)
This is no good.
§ Miss Widdecombe
No, indeed, the proposals are no good. They are rotten and the hon. Gentleman is right.
§ Mr. Dobson
Will the right hon. Lady give way?
§ Miss Widdecombe
I shall give way in a minute. Individual family doctors will have no power to manage their budgets. They will have no power to innovate or to maintain the specialised services that they have developed for patients through fundholding. Doctors will have no power to drive improvements to local hospital services. The Secretary of State is keeping all the power, but he is making others responsible for his policies.
§ Mr. Vernon Coaker (Gedling)
The right hon. Lady has gone to great lengths to defend doctors and their professional status. Will she acknowledge that one of the advantages of primary care groups is that they value not only doctors, but nurses, health visitors and all the other people who contribute to the community's health? She is undermining their role in the primary care groups.
§ Miss Widdecombe
The hon. Gentleman should ask the nurses, because they complain bitterly that they have been squeezed out. The nurses say that the Secretary of State and the Minister of State gave way to the doctors. The nurses claim that the situation is exactly the opposite to the one that the hon. Gentleman suggests.
§ Mr. Coaker
Will the right hon. Lady give way?
§ Miss Widdecombe
No. His first intervention was not worth having and the second one almost certainly will not be.
§ Mr. Dobson
§ Miss Widdecombe
Sit down! I beg your pardon, Madam Speaker. I was not calling on you to sit down. Would the Secretary of State please sit down and wait until I give way to him, which I have said I shall do. I am a lady who keeps her word and I shall give way to him when I come to a natural pause. When I give way I hope that the Secretary of State will answer the following question. Will he admit that his proposals will impose a four-tier service for patients, with the quality of care determined by postcode? Those patients who were previously served in an area with many fundholding 342 family doctors will be lucky, because they are likely to be served by a primary care group that is not simply a focus group for the local health authority.
The right hon. Gentleman should take note of the BMA's GP committee chairman, who has stated that collectives will mean thatpeople in different parts of the country will receive different levels of service… we will see increasing variations in how the NHS is developing… this cannot be good for patient care.The most insidious thing of all about that is that the patient will have no choice.
§ Mr. Dobson
For once, the right hon. Lady gave us the origin of one of her facts, saying that a poll had shown that doctors were against our proposals, but she admitted that that poll was published in February. I have to tell her that this summer, the British Medical Association, representing doctors, agreed to accept what we are proposing. It is reasonable to assume that those who had been fundholders might have been the most opposed to what we are doing, but today, Clive Park, general manager of the National Association of Primary Care—to which the National Association of Fund Holding Practices has changed its name—has said that it wants to make sure that PCGs work and work well, and that it will support the Government.
§ Miss Widdecombe
§ Mr. Michael Fabricant (Lichfield)
Will my right hon. Friend give way?
§ Miss Widdecombe
I think that I must first answer the Secretary of State's point. Of course doctors, being responsible, will try to make work any legislation that is foisted upon them. They are not irresponsible people, and they will not sit in the streets, refusing to make it work. They will do their best. The point is that the Government are making that extremely hard for them.
§ Mr. Fabricant
My right hon. Friend is absolutely right. My office spoke yesterday to a fundholders' association, and its president said that there was no point in opposing a Government who have such a large majority that they will twist the doctors' arms. That shows how committed that association is.
§ Miss Widdecombe
It does not sound like a terribly enthusiastic endorsement of the Government's proposals.
Hitherto, patients have been able to choose a fundholding family doctor if they thought that it would benefit their care. Under the GP collectives system, they will be assigned to a PCG simply on the basis of where they live. We will end up with a four-tier service distributed according to postcode.
§ Helen Jones (Warrington, North)
I have listened carefully to what the right hon. Lady has said about patients having the choice of a fundholding practice. That clearly is not true in my constituency where the most deprived areas have few fundholding practices. The people who live there do not have that choice. Under the system introduced by the previous Government, those people had lower levels of primary health care, higher rates of limiting long-term illness and a much worse 343 service than that in the more affluent areas in the south of Warrington. Does the right hon. Lady want all that to persist?
§ Miss Widdecombe
The hon. Lady listened to me so carefully that she has made my point for me. That is exactly what I was saying. We wanted to level services up. We wanted patients who did not have fundholding GPs to be able to go to fundholding GPs. We wanted every GP to be a fundholder or a member of a multi-fundholding practice. I have the interests of the hon. Lady's constituents at heart. She would level them all down.
Quality of patient care will depend on the rung of the primary care group on which the patient's own collective stands. If the collectives are on the first rung, they will be totally toothless, and all that they will be able to do is to advise their health authorities. If they are on the fourth rung, they may have a little freedom, subject to the controls of NICE and CHIMP, to provide something other than a basic service. Labour's collectives will not have any control over their own budgets, or the ability to try to re-develop some of the innovations lost with fundholding until they have been able to wrench free of the grip of the health authorities, and that may take years.
Let us turn to the Secretary of State's favourite boast—waiting lists. It is well known by now that his official statistics do not begin to reflect the full nature of the problem that he has created. He knows better than anyone that the figures are being fiddled and the patients are being diddled.
§ Mr. McNulty
Does the script say, "Pause here for laughter?"
§ Miss Widdecombe
I shall go on saying that, because it is true. Labour Members may moan and groan, but they will do more moaning and groaning when their constituents realise exactly what the patient care reforms will mean to them. When they realise that they can no longer discuss with their doctor where and to whom they should be referred, there will be moaning and groaning and the Government will be called to account. I would not be at all surprised if it was the Government's stewardship of the NHS that was the most potent factor in bringing them down at the next general election.
It is not merely a question of the massive distortions in clinical priorities that have been caused by treating quick, simple cases at the expense of more complex, and often more serious, ones. We need look no further than the Secretary of State's own figures, which show that the number of people waiting more than 12 months has doubled since he came to power. How he can smile about it, I do not know. The British Medical Association has told him time and again that, unfortunately, giving priority for political reasons to patients whose need is lessis happening because the Government have put themselves and therefore all of us on a most unfortunate hook.Those are the words of the previous chairman, Dr. Sandy Macara. When he referred to "all of us", I think that he meant patients and not merely practitioners.
The Secretary of State has himself admitted, albeit reluctantly and after a lot of probing and questioning, that there is "some build up" in the waiting list to go on the 344 waiting list. In other words, he has shifted the bulge from one list to another. So, when will he publish the combined figure with all his waiting lists added together, as he promised? He has the information already. What is he afraid of? Is he afraid that that will prove that the real waiting lists are still rising as a direct result of his bungling?
Let me help him, since he has the figures but does not appear to be able to add them up. Doing so would show that for the last month for which figures were available the real waiting lists were up 243,600 since the election—almost five times higher than the figure that the Government now claim.
The right hon. Gentleman may not be aware of the waiting list for the excision of skin cancers, which, according to a local doctor, currently extends to about four months—four months for a cancer waiting list, that Essex Rivers health care trust refuses even to acknowledge or to put into its submissions to central returns on waiting lists. He likes paper and I can give him the documentary evidence.
§ Mr. Dobson
Will the right hon. Lady please give me the documentary evidence and I will deal with it.
§ Miss Widdecombe
The right hon. Gentleman is good at this. "Give me the documentary evidence," he says, "and I will deal with it." Unfortunately, he does not. Instead, he puts a good spin on what has been going on. He does not deal with the problem. For example, when we raised the problem of a child who had certainly waited in excess of the longest limits that the right hon. Gentleman claims, giving the name and all the details of the trust concerned, we were told from the Dispatch Box by the Minister of State—it is in Hansard—that the operation would take place on such and such a date as the trust had always planned. That was a good piece of spin, which was heavily undermined by the fact that a motorcycle courier was dispatched that very evening with the date of the operation.
§ Dr. Harris
The right hon. Lady is making an important point about the distortion of clinical priorities produced by the political need to bring down waiting lists rather than waiting times, and the underfunding of operations on an average cost basis. I join her in condemning that practice, but she must be careful not to fall into a similar trap with regard to basal cell carcinomas of the skin, for which a waiting time of four months might be appropriate to enable more urgent operations to be carried out. It is wrong to politicise any individual condition, particularly for people who may be waiting for treatment for such a cancer, which does not need urgent excision.
§ Miss Widdecombe
Then the Government should not make rash promises about a maximum waiting time of a fortnight. If that case is to be made, the hon. Gentleman should make it to the Government and convince them. Then we would not have such rash promises.
The Government have made a pledge, which they are distorting clinical priorities to deliver and they have made another pledge that they are coming nowhere near meeting. If the Government said, with humility, that that is because the problems of the NHS are not susceptible 345 merely to political solutions but are deep because demand and supply are so badly out of kilter, we might then have a rational and grown-up debate on the NHS instead of always having to deal with the Government's political priorities.
The right hon. Gentleman has challenged me to let him know of any fiddles that are going on so that he can sort them out. He has just said so. There is one, so I shall ask him to do something about it right away. It beggars belief that the Government try to claim credit for spurious waiting list falls and refuse to acknowledge the slightest shred of responsibility for the most blatant fiddles, even when those fiddles are the direct result of the climate of fear that the right hon. Gentleman has created in his panic to meet his so-called early pledge. We have found two further fiddles.
The Withington hospital in Manchester has a two-year waiting list for appointments with an orthopaedic consultant. I cannot believe that the right hon. Gentleman knew nothing of this, because he has been inaccurately boasting that he had eliminated two-year waiting lists. To get round this inconvenient fact, some patients have been palmed off on to physiotherapy practitioners, thus eliminating them altogether from the waiting list statistics. Again, we have documentary evidence.
Will the right hon. Gentleman assure the House that no patients are being kept off waiting lists by hospitals refusing for months to give a firm date for an operation, and then placed on the official statistics at the last moment by offering the patient a date and carrying out the operation super quickly? I should be surprised if he can give that assurance, because, apparently, that is happening in Macclesfield and in Altrincham. Again, I have some documentary evidence. It is not good enough for the Secretary of State to come to the House and, whenever we rumble one of his little fiddles, to say that he will make sure that it does not happen again. [Interruption.]
§ Miss Widdecombe
The right hon. Gentleman has just said honestly that he cannot claim to make sure that that does not happen again. We note that.
§ Mr. Andy King
The right hon. Lady is a control freak.
§ Miss Widdecombe
Not a control freak. Oh dear, oh dear. If the hon. Gentleman asks the BMA, the nurses, those who will be rationed by NICE and those who may no longer exercise clinical judgment, the words "control freak" would be the first that they would apply to the Government.
For some time we and the BMA have been calling for a new system of waiting times for particular disease groups, instead of the crude, politicised system of waiting lists. I agree that it is not politically appealing, but it is at least practical and it is the system that measures what matters most to patients—whether they have been waiting for more than the appropriate time. If the right hon. Gentleman decides to go for that system, I will not tease him about how he has abandoned his pledge or his central political boast. I will welcome what he has done and support it. The Opposition will say, "Well done", but I do not somehow think that we will be able to do that.
May we at least have an assurance that the right hon. Gentleman will investigate ways of moving towards that common-sense approach and away from the discredited, 346 crude and fiddled waiting lists that are now posing some danger to patient care? I do not think that he will give that assurance, because his priority is not patient care but political control. It is evident in their scandal of broken pledges and patients on trolleys; in their hidden rationing agenda of NICE and CHIMP; in their refusal to take responsibility, despite taking unprecedented control over clinical judgment and health service planning; in clinical priorities that are being distorted by their waiting list obsession; and in taking choice away from patients and family doctors. As services suffer, patients suffer, waiting lists are fiddled and GPs are dragooned into collectives, this Queen's Speech sets out a blueprint for a centralised, bureaucratic health service set to undergo an unprecedented, deeply unwanted upheaval, where Ministers have all the power and none of the responsibility and where it is all about political control, not patient care.
Will the Government finally admit that they have failed abysmally on the NHS? Will they admit that the reason for that failure is that for two decades the Labour party deceived the British electorate into imagining that there was some magic wand to wave and that it would be a Labour Government who would wave it? Tell that to the patients who have been waiting for more than 12 months, to those who have found waiting times increased under this Government and to the doctors who are about to lose the power to exercise their judgment on behalf of their patients. Tell that to all those who will find yet another huge bureaucratic upheaval in the NHS. Tell it to the patients lying on trolleys and to all the people who write to me saying that the Government have broken pledge after pledge. [Interruption.] They laugh. The Government find patients on trolleys funny. The man who cracked a cruel joke about Alzheimer's thinks that patients lying on trolleys are funny. Let the nation see them laugh. They will not be laughing when they are called to account for what they have done.
§ Mr. Terry Rooney (Bradford, North)
I am inclined to say, "Now for something completely different." I rise principally to speak on social security but I must say a few words about health, especially after that performance.
Having never had to suffer a night in hospital, and having been a rare visitor to my general practitioner, my knowledge of the health service is limited to the experiences of my family and constituents. My constituents are delighted with the changes that they have seen in the past 18 months. Doctors in the Bradford health authority area willingly and rapidly agreed four primary care groups. The only time that there was a point at issue was when some were asked to cross the boundary into Leeds and there was danger of a revolution, as I am sure my right hon. Friend the Secretary of State understands.
Since the general election, Bradford health authority has received an additional £43 million, of which £34 million is over and above what was in the plans of the previous Administration. I pay tribute to the Minister of State, my right hon. Friend the Member for Darlington (Mr. Milburn), for his wisdom in selecting Bradford as one of the first health action zones. He knows that much of the bid was based on collaboration between the health authority and the social services department, which is about the best in the country. That is undoubtedly the way 347 forward and it is bringing new thinking into the provision of not only health care but health prevention, which must be the focus for the future.
I must toss in a cautionary note. Under Bradford health authority, there are still two hospital trusts and two community health trusts, with four chief executives, four boards, four finance directors, four personnel directors and all the rest. The sooner they come together, the better.
Finally on health, my right hon. Friend the Secretary of State knows about the advice, which I regard as nonsense, of the Medical Defence Union to its members never to say sorry. It is time that that advice was challenged for the rubbish that it is. Far too many cases finish in litigation because someone early on, when something has gone wrong—as things always will—refuses to say sorry because their insurance company has told them not to do so. I have had three cases that finished up in unnecessary litigation. Money disappears out of the health service as a result.
I am pleased by the commitment to the continuation of welfare reform announced in the Queen's Speech. The reform is based on clearly defined and public principles: that all those who can work, should; that there is security for those who cannot; that the state has a responsibility to help people into work, which we are doing through the new deal, education and the national child care strategy; and that work should pay. The minimum wage and the working families tax credit are helping those on the lowest incomes.
Under this Government, reform is based on those principles, which are maintained throughout, and not on requests from the Treasury. The previous Government doubled the social security budget but poverty increased dramatically. When they left office, 2.3 million children were in families dependent on income support for their sole income, and 1 million pensioners were entitled to income support but did not claim it. Take-up rates where nowhere near what they should have been. For income support, the take-up rate was only 79 per cent. and for family credit only 70 per cent. I am pleased that the Government have started pilot schemes to ensure that those 1 million pensioners claim the benefit to which they are entitled, and to discover the reasons why they have not done so and deal with them. Pensioners are a group who, perhaps more than any other, deserve an adequate income.
The working families tax credit is welcome because, unlike family credit, take-up will be automatic. The recent announcement by my right hon. Friend the Secretary of State for Social Security about the single gateway represents a magnificent and massive step forward, for two reasons: first, only those who are entitled to benefits will get them; and secondly, those who are entitled will get what they are entitled to get. Sadly, all too often that is not the case at present.
The Government are already putting their reforms into practice. Pensioners are being given £2.5 billion through the minimum pension guarantee and winter fuel payments. There has been a record increase in child benefit; the disability income guarantee has come on stream; and mobility payments for three and four-year-olds have been introduced for the first time—what a tragedy that it took 20 years to do that.
348 Reform of the ridiculous and discredited all-work test has been proposed. What a testament to the previous Government that is: one is either fit for work, in which case one is kicked down to the job centre to sign on and start looking for a job, or one is unfit for work; there is nothing in between. That is nonsense. On that basis, no one should ever claim incapacity benefit, because there is always one day in the week when one feels able to do something. A system that judges people to be either fit or unfit for work, with nothing in between, is a joke.
I welcome the extension to one year of the period in which people who are in receipt of incapacity benefit can try work and see whether they are fit for it, without fear of losing their entitlement. The most recent statement on widows and widowers is welcome, because for the first time all people—male and female—in that sad position will be treated in the same way. In addition, we shall be supporting people, especially those with children, in their time of need.
Two areas of welfare epitomise the difference between the Labour Government and the previous Administration—disability living allowance and the Child Support Agency. We had the nonsense of 40 per cent. of all lifetime awards of the care allowance element of DLA being on the lowest rate. If one is in such a condition that one needs an award for life, it is nonsensical to be given only the minimum rate. Logically, a lifetime award should be at the higher rate. In addition, far too many DLA claims—about 50 per cent. of the total—were awarded without any medical evidence being produced to support them.
We need to ensure that those who are entitled to DLA receive it, but, because of the lax manner in which the system was set up and the lack of training given to staff, far too many awards are incorrect. However, the benefit integrity project has been a disaster and I am delighted that my right hon. Friend the Secretary of State is to abolish it and introduce a reasonable, fair and sensible means of assessment. We need to move forward.
The Child Support Agency has been heavily criticised and much debated in the House. Seven years after its inception, and despite three major pieces of legislation, only one in eight parents with care get the full maintenance to which they are entitled. What a testament to the previous Government. The principal problem with the CSA is that, right from the start, it was not child focused. It was not about the family, it was about the need of the Treasury. That was the driving force from day one, which is why it has become such a mess.
The proposals in the Green Paper published earlier this year have been the subject of wide consultation and I believe that the principles have been widely accepted. The consultation was genuine and many of the comments received have been taken on board. When the legislation is published, we shall see the benefits of that consultation and of the Government having taken advice from a wide range of sources, instead of presuming that they know best. The system we propose will give genuine support to families and it will be fair, transparent and simple. People will understand, accept and respect the new child support system. We are developing an active modern service for claimants to replace the dead hand of bureaucracy. The linkage with the Employment Service in assistance schemes to get people into work is of real benefit.
349 Tremendous economic benefits are associated with being in work. The roots of prosperity will always be through work and never through the benefits system. However, it is important that proper conditions of work are maintained. I welcome particularly the Government's fairness at work proposals that we expect to see translated into legislation—especially those such as parental leave, which will affect families. The Government's extension of the maternity leave qualification, which has changed from two years to one year, will affect some 1.5 million women. The change in statutory maternity leave from 14 to 18 weeks will benefit 2.3 million women.
Those in work will have a better standard of living in the future through the introduction of the minimum wage. The working time directive—which has been much derided by the Opposition—will benefit families. It is a fact that, in the 1990s, it is still acceptable for people to work 60, 70 and 80 hours a week. How is that consistent with a family friendly employment policy? It is not.
The welfare reform programme, although good in itself, cannot be viewed in isolation. It must be linked to other social programmes if it is to bring combined benefits. We must address poverty and injustice and make work pay. We must remove barriers to work and ensure decent terms and conditions at work. We need a modern, active social security system that provides help to those in need when they need it and dispenses with the bureaucracy of the past. We must recognise that people can better themselves through work and provide employment opportunities to those who need them.
We have addressed the poverty of income, but we must address also the poverty of expectation. I am sure that all hon. Members will identify with the situation in my constituency where there are boys and girls of six, seven or eight whose older brothers and sisters, mothers and fathers, grandparents and aunts and uncles are out of work. Those children go on to become truants and disruptive pupils because they see no point in education when they will not be able to get a job when they leave school. We must eliminate the poverty of expectation and give that generation the hope and the opportunities that, sadly, too many of their parents and grandparents were denied. They were abandoned by the previous Government. The knock-on effects in terms of health and education are enormous and there are great bounties to be reaped.
My right hon. Friend spoke eloquently about the effect of poverty on health, and a similar argument applies to education. We must take a wide-ranging look at those issues. I look forward to the forthcoming pensions Green Paper. Nobody wants to see the present situation repeated in the future. Too many people are approaching old age with insufficient incomes. We need a permanent, and I believe compulsory, second-tier pension system. We have had compulsory second-tier pensions in the form of the state earnings-related pension scheme since 1975, and we must translate that into stakeholder pensions so that future generations do not suffer income poverty.
In conclusion, I congratulate my right hon. Friend on his work so far. I look forward to the publication of the legislation mentioned in the Queen's Speech and hope that further measures will be taken. More power to his elbow.
§ Mr. Michael Heseltine (Henley)
When reading through the Gracious Speech and the speeches of the Prime Minister and the Leader of the Opposition, the single overwhelming conclusion one draws is the stark contrast between the reality of the Government's actions and the rhetoric in which they clothe those actions. The Gracious Speech contains much high-flown talk about enhanced competitiveness and an effective economy, but it also contains many measures to move the economy in precisely the opposite direction.
A naivety seems to flow from the Prime Minister's rather breathless approach. He thinks that, if he says something, it will happen. Anyone who is a connoisseur of such matters should read Hansard, in which he talks aboutmaking this country No. 1 in… electronic commerce".—[Official Report, 24 November 1998; Vol. 321, c. 36.]Anyone who has any idea about what is happening in the world will understand that, in electronic commerce, the Americans are light years ahead of anything that is happening yet in this country. The world has shrunk in recent decades. It is ludicrous to pretend to the House that introducing legislation on electronic commerce will enable us to close the gap between this country and north America.
Perhaps even more naive is the hostility with which the Government approach the previous Government's record. Britain has a position of strength in electronic publishing relative to parts of Europe, but that is because, in the 1980s, we made all the difficult decisions to privatise and deregulate, all of which were ruthlessly opposed by the Labour party. We know exactly where the heart of the Government lies—in yesterday's ideas and yesterday's solutions. Although they understand that most of those are out of date, unfashionable and unpopular, they are edging back, in their legislative proposals, to the practices, assumptions and policies that failed the country so dismally in the past.
Today's debate centres on the health service. I listened with great care to the opening speeches. Two fundamental weaknesses emerged in the case advanced by the Government. The first was brilliantly exposed by my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe), when she made the point that, to reduce waiting lists, the Government are dealing with the easy cases. Of course that is desirable, and I have no complaint about it, but if, in the broad spectrum of health care, a mercifully small number of cases are relatively serious and a huge number can be coped with quickly, the easy, cheap way to get the plaudits of the crowd is to deal first with the easier cases.
When my right hon. Friend made that point, there was no flicker of recognition by the Secretary of State that she had stumbled on the essence of what he is doing, which is to preside over a rise in the number of more serious cases. The heart of my right hon. Friend's case is that the Government are in the business of levelling down. They are pandering to numeracy and the case that is being argued about statistics, but they ought to be preoccupied with the quality of the service.
My right hon. Friend made an important point that contradicted the Secretary of State's case, which was that the Government have talked to doctors, and, of course, many are hostile to what they are doing, but—he used a 351 quotation—they have decided to co-operate. Doctors will always co-operate. They are passionate in the pursuit of health and the interests of their patients. They will not let anyone down, whoever are the Government of the day.
Under the system of fundholding introduced by the previous Government, we tried to put doctors into a position of power as close to decision-making as possible, so that they could judge their patients' best interests. That was not popular with the great baronies of power—the vested interests of the unions and bureaucracies. We all know that they never want front-line people to be given the power to exercise individual discretion.
The Secretary of State's case was that doctors did not need to worry, because the Government will set up primary care committees, and doctors can elect the majority of their members and even be the chairman. If I were a doctor, I would shudder at that prospect. What does it mean? Doctors will have to become involved in the politics of the health service. Instead of dealing with their patients in their practice, they will have to go to committee meetings, stand for election and sit on the committee with people from different pressure groups, which all have a political agenda. That is enormously time-consuming. If one has the stomach for it, one may prevail, but the vast majority of doctors did not go into the medical profession to become politicians.
Having regard to some of the politicians who have done so well on the left of politics as experts in the manipulation of committees, I do not blame doctors for not wanting to spend their valuable time trying to advance the interests of their profession by the bureaucratic process of negotiating their way through a labyrinth of committees.
In any human activity, including medicine, one has to make difficult decisions. It is essential that we trust people to experiment, make decisions, explore alternatives and exercise initiative. That was happening under the fundholding arrangements, which is why doctors were voluntarily adopting them. That flexibility will now be replaced by a centralist system that will gradually impose the will of the Department of Health on the medical profession. That will not succeed. It will lead to trouble. Ministers will get into an appalling mess when things go wrong, and they will be hauled to the Dispatch Box to account for a myriad of errors that are not their immediate, personal responsibility, but, the politics of the system being what it is, they will be in the firing line.
The vast majority of people think that the health service is a fantastic achievement. They thought so under the previous Government; they think so under this Government; and they will go on doing so, but the Secretary of State's proposals will politicise the service.
As the Secretary of State knows, I have to explain to my constituents why a hospital will be closed. No hospitals in my constituency were closed when the Conservatives were in power. [Interruption.] No, they were not. The Secretary of State has generously agreed to receive a delegation of my constituents so that they can listen to a Labour Minister explaining why this munificent Government, with all their extra money, are threatening to close a hospital.
§ Miss Widdecombe
One of many.
§ Mr. Heseltine
One of many, as my right hon. Friend says. She was generous enough not to make that point at great length in her opening speech, but I suspect that my colleagues will want to make it.
§ Mr. Dobson
The right hon. Gentleman brought a delegation to see me. I have agreed to receive other Conservative Members who represent parts of Oxfordshire. They will tell me that they want to keep their hospitals open, and that the right hon. Gentleman's hospital should close.
§ Mr. Heseltine
As the right hon. Gentleman has spent his life trying to explain the conflict about priorities in the health service, he should not be surprised about that. That is the legitimate responsibility of a Member of Parliament. He should be concerned by the fact that I am not the only hon. Member from Oxfordshire who has made a representation about a proposed hospital closure—my colleagues also face hospital closures. Why did the Secretary of State read out a long list of new hospitals that will be constructed, but make no reference to the fact that hospitals in Oxfordshire are threatened with closure? I find that extraordinary, when so much extra money is apparently available.
§ Miss Widdecombe
Is my right hon. Friend not also surprised that that should be happening when, before the general election, the then shadow Secretary of State for Health said that the Labour party had no plans for a programme of hospital closures?
§ Mr. Heseltine
No, I am not a bit surprised. That is exactly what I would have expected of the then Labour Opposition. They said anything to con the people into believing that they had miracle solutions. Having got into government, they have had to face up to reality, which for my constituents means facing hospital closure.
§ Dr. Harris
Will the right hon. Gentleman give way?
§ Mr. Heseltine
No, I shall not.
The wider issue is not merely one of trying to stifle individual initiative in the health service and remove competitiveness—those themes run through the Gracious Speech. There will be trade union reform. The Government use charming words about a new partnership between managers and employees. If one genuinely wants higher-quality industrial relations, one must create such partnerships. That is the aim of Investors in People, an excellent programme that the Government support. The one way to bring it juddering to a stop is to bring the unions back into the process. Once the unions are in charge, there is another career pattern and another range of motives—and all of us know exactly what happened when they were involved in the process before.
The union leader wants to enhance his own reputation. Where he can, he wants to create the impression that he is fighting for the lads and lasses in the factories, but, before long, there are tensions between managers and union representatives. Discussions take place behind closed doors; the union representatives leak what was said, to the disadvantage of management; the process festers, and the situation deteriorates. The union leader then becomes part of a national chain. People want to climb the union ladder. To do so, they have to be seen to 353 be fighting local battles. The more battles they can fight and the more rows they can create, the more they attract the activists in the union chain who can promote them to national leadership.
There is thus an agenda quite different from that of the company whose interests the representatives were first elected to serve. That process has gone from this country. We have excellent industrial relations and increasing productivity, and we are more competitive than ever before, but what is to happen now? The unions are to get their privileges back. It is a retrograde step, which will prejudice our recovery and our progress towards increased competitiveness.
The story is the same in local government. We are told that we are to have more modern local government. There is a great case for that, and I am the first to say it. We cannot get councillors of the calibre we need. No party finds it easy to recruit men or women of the calibre required to command the scale of resources involved in local government. Councillors do not have the experience necessary to challenge the bureaucracies on which they have been elected to serve.
One would have hoped that the Government would tackle the problem. I have no doubt that we must move towards the introduction of directly elected chief executives who are paid an income corresponding to the level of their responsibilities. That should be done as a matter of urgency. It would create a far greater sense of local accountability. The Government are committed to the experiment, but does it appear in the Gracious Speech? No, and why not? It does not appear because it is a complicated idea. Instead, we understand that compulsory competitive tendering is to be ended. The challenge of balancing services and their value and cost is to be removed from the marketplace, and CCT is to be replaced by what is known as best value.
Best value is another classic example of this Government's public relations skills. Who can possibly be against best value, but how does one decide what it is? Who decides? One has only to ask that question in the Government's presence to know exactly who is going to decide. The people who are administering the systems will decide, and will do so in cahoots with the unions and the direct labour organisations.
That is transparent, but what will the consequence be? The consequence will be a monopolistic regime from which the chill of private sector competition is eliminated, under which costs go up, restrictive practices are tolerated, and the abuse of the democratic process, characteristic of Labour's long-held monopoly over local government, is perpetuated.
The Government talk about raising standards in education. I go along with that. The quick and easy way to do it is to start sacking some head teachers in Labour authorities where the standards are unacceptable. How many head teachers have been removed since the Government came to power? Why have the Government not done anything? They have the power, and they tell us that they want higher standards. They have been in office 18 months, so what is holding them back? It is the rhetoric of a broad, happy, smiling body of people running the country in everyone's interest that prevents them from challenging the vested interests of the power groups on which so much of their political support depends.
354 If anyone is looking for the worst housing conditions in the country, I can tell him where to find them.
§ Mr. Patrick Hall (Bedford)
§ Mr. Heseltine
The hon. Gentleman probably represents some of those very places. The worst housing conditions are to be found in the urban constituencies that have been represented for the longest time, at municipal and national level, by Labour politicians. The conditions in which many people live in public sector housing are scandalous, and the worst scandals are to be found where the Labour party is in charge. How can one begin to argue that that situation should be tolerated under a system called best value? It has nothing to do with "value" and nothing to do with "best"; it is simply about paying off the unions for the support they gave the Labour party in the general election.
§ Mr. Heseltine
The hon. Gentlemen should relax. I listened to the Secretary of State for a long time, so I hope that hon. Members will be kind enough to listen to what I have to say.
The situation is even worse, because the problem does not end with the elimination of the competitive challenge in local government. We are now to have a whole new tier of local government. There are menaces inherent in that. To begin with, it is a menace in itself.
We all know about Labour's desperate position in Scotland. Labour has decided that the only way to deal with its problems there is to pander to Scottish nationalism by pretending that devolution will change something. Once there is devolution in Scotland, there has to be devolution in Wales, although the Welsh do not want it. Then we have to think about what to do in England, and we now have a ludicrous scheme for a mayor in London and, before we know where we are, we are witnessing the regionalisation of England.
The first step is to get rid of English Partnerships, which is an extremely effective weapon to bring about the regeneration of stress areas. No one is keener on that than I or the Government in which I served. English Partnerships is being broken up into regional development agencies. I know exactly what will happen. The advice given to the Secretary of State will be clear. He will be told that strategic thinking is needed—along with academics and unionists, this, that and the other—to create a plan.
By the time the Government seek re-election, the regional development agencies will have been set up, a fortune will have been spent on consultants, many urgent decisions will have been delayed, and a plan will have been produced. The moment a plan has been produced, there will be an election, and whoever becomes Secretary of State will say that he does not like the plan, and wants to have another look at it.
The essence of urban regeneration and regional renewal is site-led. One has to have local projects and policies to deal with specific problems. It is not about a concept for the north-west of England, for example. There is no such thing as the north-west of England, as is clear to anyone 355 who lives there or knows that part of the country. Manchester does not get on with Liverpool; Preston is a long way north—
§ Mr. Nicholas Winterton (Macclesfield)
Don't forget Macclesfield.
§ Mr. Heseltine
Macclesfield leads the bunch.
The way to rejuvenate such areas is to have a macro-economic policy for growth and stability, and then to stimulate local communities. That is why I believe in directly elected chief executives. However, we are to have these great bureaucracies inserted between national Government and existing local government. That means more delay and more cost.
My final point is a chilling one. I am a European. I believe that this country's best interest is served by our playing a leading role in the European Community as it is now emerging. I have believed that for 40 years, and I believe it today as profoundly as ever. We have to fight within Europe for the United Kingdom. However, there is another European agenda, which is a federalist one. It wants to bypass the nation state.
Federalists want to bypass the nation state because they realise that, if they can regionalise Europe, they can exercise a much more pervasive influence from Brussels and through the European Parliament than they will ever be able to do if the nation states are the building blocks of Europe. What the Government are doing—I doubt whether they have even thought that this is what they are doing—is creating a blueprint that brings this country into line with a potentially regionally governed Europe.
It is as sure as night follows day that the Labour party will lose to the nationalists in Scotland. The nationalists will go to Brussels, and Brussels will pay them, as it pays the Irish, to bring about an artificial, short-term prosperity in that country. That is what will happen. The Welsh will say, "If it is good enough for Scotland, why isn't it good enough for us?"
By that time, people in the north-west, the north-east and the south-west will be saying, "What about these lousy regional development agencies? They have no teeth. They are just talking shops dominated by the Treasury in London. We need directly elected regional assemblies, and then we'll be able to go to Brussels, like the Scots and the Welsh, in order to try to get our handout." This place will become increasingly unimportant, as the power is shifted, with the money, towards a regional process in Europe.
Many other European countries are already ideally suited to such a concept. The German lander are a very obvious example, as are the great departments of France. Italy, as a state, was put together only just over 100 years ago. One can see how that concept of Europe is fed by what the Government—wittingly or unwittingly—are doing in breaking up the United Kingdom's coherence.
I see this Government as very much the successor of the Attlee Government of 1945—a Government of big ideas, who nationalised the Bank of England, introduced punitive taxation and nationalised the commanding heights of the economy. It took us 50 years to get rid of those ideas and to restore prosperity to the British people. This Government are on a different journey, but the consequences could be as bad.
§ 5.1 pm
§ Ms Bridget Prentice (Lewisham, East)
I welcome the remarks of my right hon. Friend the Secretary of State for Health, particularly on raising standards in the health service, which, sadly, have been eroded over the past 18 years. In his absence, I should like to make a plea to him through my right hon. Friend the Secretary of State for Social Security. If we must listen to the right hon. Member for Maidstone and The Weald (Miss Widdecombe) speak at such a decibel level, will he guarantee hearing tests for us all afterwards to check whether we have gone deaf?
The theme of the speech of my right hon. Friend the Secretary of State for Health was modernisation, not just in the health service but throughout areas in which the Government are trying to make changes. I want especially to address another area in which we can help to create a healthy society: youth justice. If my right hon. and hon. Friends will bear with me, I shall speak on that aspect of the Queen's Speech, despite the theme of today's debate.
I say in passing to the right hon. Member for Henley (Mr. Heseltine) that he clearly does not understand what best value is about. Labour local authorities are quite prepared to ensure that their communities receive the best service, regardless of where it comes from. If he wants to see that in practice, he is welcome to visit my authority of Lewisham.
Two years ago, there was a serious problem with young people causing mayhem in Downham, a part of my constituency. The local police, the council, teachers, community workers and youth workers got together to consider ways in which they could try to solve the problem. A few months before the election, my right hon. Friend the present Home Secretary visited Downham, with me, to see what was being done, and was told that, despite being very proactive, the police were constrained by the length of time that it took to get young people through the courts. I therefore particularly welcome the part of the Gracious Speech that refers to modernising the youth justice system.
Not only do court delays affect the young person who is charged: they have a detrimental effect on the victims, and create frustration and pessimism throughout the community. At the moment, a court can do very little—in fact, nothing—to guarantee the attendance of boys and girls between the ages of 10 and 16. If they fail to attend, the first sanction at the disposal of the court is remanding into local authority accommodation. If they fail to attend a second time, their files are marked "No appearance", and a warrant is issued. The defendant must then be arrested, and the process repeated. In other words, bureaucracy moves very slowly. The young person has the opportunity to commit further crimes, and the local community suffers as a result. The only other option would be for the local authority to apply for a secure accommodation order, although, as we know, they are very few and far between and costly. Local authorities are therefore reluctant to do so.
I encourage my right hon. Friend the Home Secretary in his Bill on youth justice either to instigate further, better and stricter bail conditions for young people that youth magistrates are able to implement quickly, so that young people who break such conditions are brought back to court much faster, or to implement section 60 of the Criminal Justice Act 1991, which has not yet been brought into force, but which provides the courts with 357 directed, secure remands. As a result, young people who continue to fail to attend court or to comply with set conditions can be prevented from committing further crimes, to the great benefit of the courts, the agencies that support communities, and the witnesses, all of whom are concerned to bring about a much speedier conclusion.
Will my right hon. Friend the Secretary of State for Social Security pass on my concerns about the youth justice system? I welcome the fact that it is to be modernised, although we must ensure in the Bill that, when a young person is arrested, it does not take six months or longer before he is brought to court. By imposing more stringent bail conditions or bringing into use section 60 of the 1991 Act, we can ensure both that the young person does not end up with many offences to be taken into consideration and that witnesses and victims see the matter being dealt with quickly.
The work on the Downham estate, where the community has worked together and youth workers especially have acted as a preventative team, targeting young people who they believe are likely to commit offences and working with them, has made life much better. It is important to underline that youth workers do not take the view that they should not make value judgments of the young people with whom they deal. In fact, that is their raison d'etre. We must consider such matters in the youth justice Bill, so that young people are dealt with quickly and effectively, the courts have the strength and power to implement proposals, and communities benefit.
§ 5.8 pm
§ Mr. Simon Hughes (Southwark, North and Bermondsey)
I should like to take up two of the comments of the hon. Member for Lewisham, East (Ms Prentice), who is a near parliamentary neighbour. I support her plea for speedy youth justice, and I hope that it is heeded. I, like her, have some experience of the failure of the system. Young people understand far more if they are dealt with quickly. I disagree profoundly, however, with her motto, "Come to Labour authorities to see good value". Lewisham may be wonderful, but if Southwark were ever held up as a model local authority, many in this Chamber would be hugely surprised. Sadly, in many respects, Southwark is not yet a good Labour authority—or a good authority at all. The sooner that we have good quality services in Southwark, the sooner that my constituents will be happy.
When William Beveridge produced his report in 1942, he made it clear that a national health service was the precondition of a good welfare state. It is therefore appropriate that this debate links welfare and the health service—and logical that we debate health first and welfare later. I am sad to note that no health Minister is currently present, although the Secretary of State for Social Security is here.
Today is Thanksgiving day in the United States. We all give thanks for our good health, and hon. Members have often joined hands in giving thanks for the national health service. As the 50th anniversary year nears its close, we give thanks as loudly as ever. Let me say to the Secretary of State for Health—although he is not present—that none of us intend to criticise those in the health service who are trying to do a very good job.
The Minister for Public Health has just arrived. May I ask her to convey some information to the Secretary of State? On one occasion during the past year and a half, 358 I have misrepresented someone's position. Two weeks ago, we had an exchange about South Devon healthcare trust. The trust used the phrase "pending lists" rather than referring to waiting lists, and I suggested that people on pending lists were not included in waiting-list figures. I was corrected, and I apologise to the trust and those who work for it. I say, unreservedly, that we should always give accurate information, and if we make mistakes we should admit to them.
I hope, however, that, as a consequence of our debates about waiting lists and waiting times, a common form of wording will be introduced. I also hope that a common system will be introduced for the publication of figures relating to out-patient and in-patient waiting times, so that the statistics are objectively valid and can be checked and there is no massaging of statistics, either by Government or by those trying to criticise Government. A senior member of the staff of the King's Fund called for such a system only earlier this week.
Today's debate coincides with the launch of the Acheson report, whose commissioning by the Government we welcomed. Like the Black report before it, it sets out a range of measures—thirty-nine steps—to reduce health inequality and improve public health. It is important for the nations of the United Kingdom to understand that, even with the best health service in the world, the sickness service—for that is what the NHS is—will be of relative rather than better worth unless we improve public health.
I applaud the appointment of a Minister for Public Health, and, like the current Minister, I want us to have a public health service that is as effective and integrated as possible. I shall make a couple of positive observations first, and then issue a couple of promptings that will be constructively critical of the position that the Government have reached over their first 18 months in office.
We all remember the section of the Labour manifesto entitled "We will save the NHS", in which the Labour party made a welcome commitment. It stated:Smoking is the greatest single cause of preventable illness and premature death in the UK. We will therefore ban tobacco advertising.Sadly, there was a blip—a glitch, or hiatus—last year. Regrettably, unless the Government bring the date forward, the manifesto commitment will not be fully implemented until 2006, which, especially in the light of the Acheson report, may be far too late. I hope that tobacco advertising will be banned much earlier than that.
The manifesto made another commitment in the next sentence: toestablish an independent food standards agency.Many people, not just politicians, regret the absence of a measure for that purpose in the Queen's Speech. The public regularly express strong views about the need for better food standards.
It is a case of "not yet" for the banning of tobacco advertising, and for the food standards agency; and, sadly, there are to be free eye tests—but not dental checks—but not for all. Both used to be available to all, but the Tories abolished that, and the Labour Government are reintroducing free eye tests only for pensioners. That is a shortfall, and I hope that the Government will think again.
As my hon. Friend the Member for Newbury (Mr. Rendel) pointed out in an intervention—I hope that he will catch your eye later, Mr. Deputy Speaker—less help 359 will be given to widows and disabled people. It was announced in the Queen's Speech that their benefits would be cut. We shall have further debates about that, but it clearly will not help to reduce inequality for those in these categories concerned.
The commitment to reduce inequality also contains no commitment to redistribute wealth, which means taking from the well-off as well as giving to the less well off. The Government have policies to improve the conditions and wealth of the less well off, but they have resolutely set their face against collecting more from the better-off. Some of us believe—and our party voted to this effect at its conference—that there should be redistribution of wealth as well as an increase in the wealth of those at the bottom of the league.
These are important issues. I am glad that the debate has begun again, 20 years after the Black report. I hope also that the Minister will persuade her colleagues that we should debate public health and inequalities in health, on the basis of Sir Donald Acheson's excellent recommendations, in Government time and relatively soon, after we have all had time to read the report.
I want to raise a couple of other matters that do not relate to the NHS Bill. I know that the Minister, like me, is committed to ensuring that our efforts and resources are directed as much towards mental as towards physical health. I look forward greatly to the Government's announcement about its mental health policy. My health authority, Lambeth, Southwark and Lewisham—the largest in the country in terms of population—gave me its figures this morning. In a population of about 750,000, 100,000 people suffer from mental illness—roughly one in seven. That is not unusual in urban areas, and, indeed, other parts of the country.
In terms of mental health, a person may be fine one year, but not the next. It might be us one day, and someone else the following day. People need to know that resources, support and, where appropriate, drugs that they may need are considered a priority by the Government. I am not saying that the Government do not understand that, but we must continue to remind each other that our duty to those with mental illness is as great as our duty to those with physical illness.
Let me now raise a matter that is also in the domain of the Minister for Public Health. It is appropriate that it should be raised this week. There is still a battle to be waged against HIV and AIDS. We have been waging that battle, but we have not won it. The Terrence Higgins trust has told the Minister, who responded in a recent interview, that although the prevalence of HIV in this country is relatively low—22,000 cases—there are still 2,500 new diagnoses each year. Of those cases, about 1,500 are men—often gay men—and young people form a high proportion.
We must spare no effort. Perhaps there is some complacency because, owing to vaccines and therapies, people with HIV do not necessarily look as though they will automatically die of AIDS. Unless we continue the attack with publicity, information and education, as well as funds—an attack that may have to be very hard-hitting—we may not be able to win the battle. I hope that winning it will remain a high priority, and that we realise that such action is our duty in this country as much as in other parts of the world.
360 Two Bills were proposed in the Queen's Speech, the NHS Bill and a supplementary Bill relating to charges. I believe that services and staff in the NHS are more important to people outside than structures. The Government say that they will abolish the two-tier NHS. Under the Tories, people were given either fast or slow treatment, depending on who their GPs were. That practice is to be abolished, which we welcome; but in some areas there will be a three-tier NHS caused by rationing. There will be some treatment for some people, and private treatment, or no treatment, for others. The Government have yet to grasp that nettle.
The Government say that they will abolish the internal market. They must be careful, because that is not actually true. The purchaser-provider split will remain—we accept and support that—but the internal market will also remain: reduced, yes, remaining yes, and abolished, no. Let me give an example. If a primary care group is able to choose where to send its patient, there is choice and therefore, to an extent, a market. What will happen to what were called extra-contractual referrals? I understand that they are not being abolished, but are merely being renamed. Let us not delude people into believing that the system has been completely changed.
The Government say that they will reduce bureaucracy. That may happen, and the Government say that they will maintain their £1 billion cost reduction target; but it is another case of "not yet". According to this week's newspapers, 500 new managers will be appointed under the new proposals. I am not against additional managers but let us not pretend that bureaucracy will be reduced if there are to be more.
The Government talk about established primary care groups. We think that that is a flawed and second-best proposal, which we shall seek to amend and improve. A radical and sensible Government would have merged health and social services authorities, and would have done so under democratic control. A radical and self-confident Government would not have given in to doctor influence over the composition of primary care groups, which delivered them a majority and the chair in every instance. A sensible and democratic Government would not try to rush changes through now. They would have a start date later than next April to enable proper scrutiny of the proposals and the concept embodied in the proposed legislation to ensure that it is up and running properly and not rushed to meet an artificial target.
We are in favour of health improvement plans, but they should be led by democratic local health authorities and social services authorities. That is where the debate can take place.
We support the raising of standards as we support the health improvement commission. It is not as radical a concept as that which we have proposed in the past, when we said that there should be a national inspectorate of health and social care.
We support the idea that it is necessary to deal with people who are not up to the job. However, let us not confuse having a go at people who are not up to the job with having a go at those who are overstretched in trying to do their job because there are not others to help them do the job. The patient needs an NHS contract to know what service, standard and speed he can expect, but there must be the staff to deliver the service and the money to deliver the staff.
361 We are in favour of reducing inequalities but that means equal access to health care throughout the length and breadth of the United Kingdom. Access cannot be available in one area and not in another. We shall achieve greater equality only if we face the fact that in some areas patients are not receiving treatment at all. There is rationing, as the right hon. Member for Maidstone and The Weald (Miss Widdecombe) said, as there has always been. The sooner that the Government own up to the R word, the more realistic the debate will be.
It may be inappropriate to ban effective but expensive drugs, and we must ensure that everything we do is effective. That has not always happened in the past. Statutory control of drug prices is a large and complicated issue, but our gut reaction would always be to support it. However, the objective should be a reduction of unnecessary drug use in Britain; there should not be drug rationing where drugs are needed. Some people, including those who are mentally ill, often need drugs that at present they do not receive because they are told that they cannot be afforded.
§ Mr. Nicholas Winterton
Will the hon. Gentleman give way?
§ Mr. Hughes
I will not give way. I would like to do so but I was told that if my remarks were brief one of my colleagues might be able to catch the eye of the occupant of the Chair later. If I am not brief, that will not be possible.
Reserve powers to increase regulation of the professions are important. We support absolutely the registration of all the professions that are allied to medicine, or waiting to be registered—for example, psychologists, chiropodists and physiotherapists. I hope that Ministers will introduce such proposals in forthcoming legislation so that all the relevant bodies can be registered. If someone sees a plaque on a door bearing the word "Chiropodist", he should be confident that that person is a real chiropodist, not a would-be chiropodist. There are many professions that are disadvantaged by pirates and rogues.
There is a difficult balance to be struck in regulating the professions. The General Medical Council and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting have been making every effort to get it right. I support their efforts. We should examine whether auditing practice can ensure that we deliver the best quality people. The hon. Member for Lewisham, East and I have constituencies that share the same health authority, which has a minority of poor doctors. Getting rid of poor doctors is an almighty difficult job, and that is not acceptable. For every poor doctor there is a much higher risk of mistreatment. We must be willing to introduce reserve powers although that might not happen now.
There is a problem with amending the Road Traffic Act 1988, and that is not because necessary legislation has not been on the statute book. We have had that legislation since the 1930s. What is the logic in levying money from insurance companies where the victim successfully claims compensation after a road accident but not where someone claims after an industrial accident or makes a claim after falling over in his local park or on the pavement, or makes a claim against someone else? We are talking of a charging mechanism, and if we are to 362 consider charging an insurance company or others, we must consider all the circumstances and not some of them. My right hon. and hon. Friends and I will be critical and will scrutinise carefully the charging proposal. We are not yet persuaded.
My colleagues and I have been engaged in a bit of a discussion recently about what collaboration there should be between Liberal Democrats and the Government. For a long time we have put a proposal to the Government, which I hope will be accepted with or without closer collaboration before the close of the 50th anniversary of the NHS. We propose that there should be a standing conference on the national health service, which should be separate from this place and from party politics, where we could debate how we might recruit and retain the staff that we need. That is necessary because we have a staffing crisis. We could debate how we might raise and spend the funds and resources that we need. We have an underlying resource crisis. We could debate also how we might face rationing, because we have a rationing crisis too.
We believe that the three Rs—it is technically four if recruitment and retention are taken separately—are the crucial issues for the health service, as my right hon. Friend the Member for Yeovil (Mr. Ashdown) said the other day. If we can secure the best structures, staffing and quality outcomes for the NHS against the background of best public health, whatever our parties, we shall be serving the patients and the people of Britain best. That is the challenge, and we shall be a constructive opposition for the rest of the Parliament to ensure that the Government do as well as possible to respond to it.
§ Mr. Patrick Hall (Bedford)
I shall concentrate on the national health service, but I was fascinated by what I thought to be a new policy initiative on education that came from the right hon. Member for Henley (Mr. Heseltine). I think that the right hon. Gentleman said—the record will show whether this is the position—that the best way to improve education would be to sack head teachers.
The Conservatives have a difficulty in debating education, but nothing like the difficulty that they face when it comes to the NHS. We saw that in the performance of the right hon. Member for Maidstone and The Weald (Miss Widdecombe). It struck home to me that it must be a most difficult task for any Conservative to criticise the Government about the NHS. Despite the right hon. Lady's undoubted abilities as a parliamentarian, she failed to offer any real criticism. She did not even attempt to defend the Conservative Government's record. Perhaps that is why she resorted to so much sound and fury rather than concentrating on content.
One of the key ingredients in the Queen's Speech is the Government's continued commitment to the NHS. We have heard especially about a Bill to end the highly divisive and destructive internal market together with general practitioner fundholding. There is evidence from throughout the country that those policies have led to a two-tier health service which has not served the British people well. We have heard that there will be a Bill to replace that division with a system that will enhance collaboration and co-operation and introduce negotiated 363 agreements and longer term planning, which is the foundation upon which a decent health service needs to be built.
§ Mr. Nicholas Winterton
I am grateful to the hon. Gentleman, a Member of the Government's party, for giving way, unlike the Liberal Democrats, who do not find time to give way. I am interested in what the hon. Gentleman is saying about general practitioner fundholding. Clearly, there have been abuses of fundholding, which have caused considerable problems for certain hospitals, where, for no real reason, doctors have referred their patients from many miles away, thus putting departments in district general hospitals in some jeopardy.
Would the hon. Gentleman agree that GP fundholding has brought benefits as well, and that many of the services that have been developed in doctor's surgeries and community health centres have taken the pressure off hospitals? That has been of benefit and people have been able to obtain treatment close to home rather than having to go into their district general hospital.
§ Mr. Hall
Certainly there have been some initiatives of benefit. The Government want to see a system in place whereby those benefits can be available to all patients, to all people in the United Kingdom and not only those whose GP happens to be a fundholder. The hon. Gentleman talked about some fundholders referring patients to certain hospitals without a good reason. I think that the reason is clear. They realised that by making those referrals they might secure faster treatment for their patients. I do not blame them for trying, but that is not the way to run a comprehensive national health service. Most people agree that we need our hospitals and community services to work together to share new ideas for the benefit of all, and not to be engaged in the useless paper-chase of extra-contractual referrals and annual contracting, which was a key feature of the NHS under the internal market.
Under that system, a good idea developed in one hospital had to be defended in that hospital because if it was shared with other, competing hospitals, that could undermine the contractual position of the original hospital. That is not the way to go forward.
§ Dr. Harris
I understand what the hon. Gentleman says about ending competition and improving collaboration. That is clear, but could he define what features make up the internal market, as opposed to the two-tier system, and as opposed to competition rather than collaboration, and could he explain what features of the internal market will be abolished by the proposed Bill?
§ Mr. Hall
It is well understood that the internal market generated an excessive paper-chase and the diversion of resources from front-line patient care into unnecessary bureaucracy. Of course we need management and administration, but that must be directed towards a clear purpose.
On the latter part of the hon. Gentleman's question, we shall have to wait and see what is in the Bill. I do not have the advantage of prescience. With him, I shall examine the 364 Bill to make sure that the objectives that he and I appear to share are delivered. There is no evidence to suggest otherwise. A clear message has come from the Government about what has happened under the internal market, and that system will be changed. [Interruption.] I hope that all hon. Members will assist us in trying to achieve that, in the interests of the NHS.
Whatever the Leader of the Opposition may have said on Tuesday and whatever the right hon. Member for Maidstone and The Weald may have said today, no one in my constituency, including those working in the NHS, would defend the system devised by the previous Conservative Government. They do not want to retain that system; they want it changed. There is no public support for continuing with the internal market.
The Conservatives are the last people who should complain about red tape coming before patient care. That was one of the inherent disadvantages of the internal market system. Under the internal market and under the Conservatives' stewardship of the NHS, the health service was almost drowned in red tape.
§ Miss Widdecombe
If there is no support for our system and so much support for the Government, why does opinion poll after opinion poll show that 68 per cent. of the public believe that the Government are getting it wrong on the NHS?
§ Mr. Hall
That is an interesting use of statistics. If that is the case, why does opinion poll after opinion poll show support for the Conservative party as low as it has ever been, and show considerable support for Labour in government? Whether Labour is in government or in opposition, poll after poll shows that, with regard to the NHS, the British people trust Labour more than any other party. That has been an unmoving fact for some decades.
I welcome the devolution of power in the NHS to the local level through the establishment of primary care groups. As the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) said, there will of course be a need for the management and administration of primary care groups, but there is a world of difference between investing money to manage those structures effectively, and putting money into the management of the internal market. There is a difference between doing something for a good reason and doing it for a bad reason.
§ Dr. Peter Brand (Isle of Wight)
In his scrutiny of the legislation, will the hon. Gentleman consider another aspect of the internal market, which served patients and is now at risk? I refer to the concept of resources following patients. We have had an assurance that members of primary care groups can still refer patients anywhere in the country—that practice has been enshrined in the NHS since its inception—but we have had no assurances that the trusts to which patients are referred are obliged to accept those referrals. If there are no resources attached to a referral, it is quite likely that the referral will not be accepted. Will the hon. Gentleman help to make sure that there is a mechanism to ensure that patient choice is retained?
§ Mr. Hall
I will, indeed. One of the principal effects of the greatest ever additional investment in the NHS—the investment of £21 billion over three years—will be to 365 widen and deepen patient choice and make the NHS work for patients. I am glad that the hon. Gentleman adopts a constructive position on the Government's performance on the NHS.
Primary care groups represent a superb opportunity for greater accountability in the NHS and more openness between the NHS and the British public. The role of lay members on the PCGs is important. The methods of selection must be open and credible. It is crucial that there should be support for that one lay person, or possibly two people, depending on the size of the primary care group. If there is only one lay member in a large body, his or her views may be swamped. The Government must deal with the question of how those people are to be supported.
A mechanism for such support already exists in the form of community health councils, health councils and their equivalent in Northern Ireland. Will my right hon. Friend the Secretary of State consider allowing community health councils, health councils and their equivalent to enjoy observer status on primary care groups, with speaking but not voting rights?
I hope that the confidentiality clauses introduced by trusts under the previous Government in an attempt to gag whistleblowers will be scrapped. It is time for that system to end. Confidentiality clauses are a feature of organisations that are in competition with one another; they have no place in the new, co-operative, open national health service. I hope that my right hon. Friend will consider the matter and act to take the fear out of whistleblowing, so that never again do we experience the ill and the harm that was done in the Bristol babies case—one of a number of examples.
Another welcome aspect of the Queen's Speech in relation to the NHS was the proposed commission for health improvement. Not only will that oversee performance in clinical practice in order to raise standards, but it will enable community health councils and whistleblowers to report suspected problems to that they can be examined in a wider setting.
I warmly welcome the potential offered by health improvement programmes addressing not only clinical matters, but public health issues such as sickness and illness prevention, health promotion, and tackling health inequalities—the exciting agenda raised by the excellent Green Paper on public health, and before that in the Black report which, after months or years of suppression, was eventually published under the previous Government. It argued that education, income and housing are closely intertwined with health.
Those matters can be addressed only by a co-operative partnership across the board—NHS trusts, primary care groups, dentists, opticians, pharmacists, local councils, employers, utilities. The list goes on because health is affected by so many interconnecting forces.
The prospects for the NHS reinforce the universal entitlement to full and free treatment at the point of need for all the people. That is the founding principle of the NHS, and we are now at a point where we see that principle being reinforced and taken forward for the decades ahead.
It was the British people's strong support for that principle which prevented the previous Government from undermining the NHS even more than they did. The Government's support and belief in that principle lies 366 behind the excellent features in the Gracious Speech on the NHS which will help us to build a new NHS to serve the British people in the many years ahead.
§ Mr. Michael Fabricant (Lichfield)
I do not know whether doctors in Bedford feel the same as doctors in Lichfield, but there is no enthusiasm whatever for primary care groups among general practitioners in Lichfield. I shall quote later from GPs in my constituency who have e-mailed me on that matter in the past 24 hours.
First, I want to address the Queen's Speech. The Prime Minister and the No. 10 Downing street policy unit seem to have difficulty in determining exactly what the third way is—or the "troisième voie", as the Prime Minister put it at the Assemblée Nationale in Paris recently. The third way, or the middle road, as the Prime Minister puts it, sounds suspiciously like the caring capitalism of my right hon. Friend the Member for Henley (Mr. Heseltine). Privatising the Queen's flight, air traffic control and other organisations is following in Margaret Thatcher's footsteps, not Attlee's. While we should welcome the Prime Minister's apparent conversion, I think that he sees that this is no road to posterity.
The Prime Minister, like others before him, wants to be remembered. He realises that following a well-trodden path is no road to posterity. As we know, the Labour party is heavily into marketing so, to use a marketing term, the Prime Minister has to product differentiate the Labour Government from previous Conservative Governments. Therefore, the Prime Minister has decided to tinker, without thinking through the consequences. His big idea is to tinker with the constitution and, as we shall see later, to tinker with the NHS.
The Prime Minister will tinker with devolution, even though it may mean the Labour party in Wales and in Scotland splitting away from new Labour. That is a real possibility for the Labour party. Conservative Members will be watching that space with considerable interest when it comes to the elections for the Scottish Parliament and if, as we all believe at the moment, the Scottish National party wins.
The Prime Minister will tinker with the other place, although a Chamber of placemen is even less democratic than the status quo. Why cannot he wait for the royal commission on the other place to report back first?
The Prime Minister will tinker with our voting system, even though Israel, New Zealand and Italy all seek to adopt a first-past-the-post system—the very system that the Prime Minister is now trying to abolish.
As I said just now, not happy with tinkering with the constitution, the Prime Minister now wants to tinker with the health service. This Government of soundbites maintain that the internal market is somehow destructive. We have heard that from the hon. Member for Bedford (Mr. Hall) and from other Labour Members. They criticise the internal market, but it benefits patients. Let us remember what it was like before the internal market.
In 1990, the King's Fund centre published "Health Care UK", its annual review of health care policy. The paper 367 addressed the lack of efficiency within the NHS compared with other Government Departments. The centre, a neutral body, asked:Why should so little have been achieved within the NHS not just during the 1980s, but in the previous decades?
§ Mr. Stephen Hesford (Wirral, West)
Will the hon. Gentleman confirm that the 1990 review was carried out after 11 years of a Tory Government and that that is why there was no progress in the NHS? It was under your Government. It was your tinkering—
§ Mr. Hesford
It was the hon. Gentleman's Government after 11 years.
§ Mr. Fabricant
The hon. Gentleman spat it out eventually. Unfortunately, he was preparing his intervention before he had heard the full quote. I repeat:Why should so little have been achieved within the NHS not just during the 1980s, but in the previous decades?I said that, but the hon. Gentleman was not listening. The report describes the huge leviathan of the NHS, the biggest single employer in the United Kingdom since 1948, as being incapable of efficiency withsimultaneous centralising and decentralising tendencies interfering with the thorough-going implementation of either.That could not have been a Conservative party report because there is no way that such a report would use a ghastly phrase such as "thorough-going" with a hyphen.
The report went on to detail how cumbersome the NHS was. Its efficiency was almost as bad as that of the BBC, yet just four years later, after the introduction of the internal market, the same King's Fund centre was writing a different story. In a paper entitled "Evaluating the NHS Reforms", it stated:In many areas of hospital operations, trusts had significantly lower costs than non-trusts, particularly in ward unit costs and in areas associated with administration and management.Let us be absolutely clear about this history lesson. The money saved is money that can be spent on patients and beds instead of on waste.
In 1989, a report in The Guardian—hon. Members know that it is my favourite newspaper—gave an example of the waste and bad management that existed. It stated:Health authority beds have patched fences, walking sticks have been spotted in vegetable plots smothered in runner beans, and bed hoists have been seen raising engines from cars. Sheepskins have moved from beneath the bedridden elderly to the pride of place in front of fireplaces.Equipment is haemorrhaging at a cost of £1,000 a week.That is in one health district. The paper also stated:Officials calculate that a quarter of their £56,000 of home-care equipment goes over the garden fence each year.In 1988, the same paper, The Guardian, citing an example of waste, before our reforms and the introduction 368 of the so-called evil internal market—which, incidentally, the Government are not getting rid of, simply giving it a different name—stated:Responsibility for equipment is split between health, social services, and the artificial limbs and wheelchair authorities. Supply is a muddle: social services fit one type of hoist, the health authority another … Multiple sources for some items, the lack of others, and informal rationing which means long waits, all create confusion for disabled people and their carers.They often have to accept what's on offer, instead of choosing the equipment that would best suit their needs.… Research shows that up to 50 per cent. of equipment can go unused.
§ Dr. Whitehead
The hon. Gentleman is being a little selective in his trip down memory lane. In 1983, the Conservative Government introduced the Griffiths reforms to introduce general management into hospitals to solve precisely the problem that he has just described. Is he not therefore describing the failure of the Conservative Government to get to grips with the NHS?
§ Mr. Fabricant
The hon. Gentleman raises a perfectly reasonable point. Policies evolve—after all, who would have thought that the Labour party would be into privatisation? The Labour party has evolved. In 1983, we tried to do something with the leviathan—and yes, you are right, it did not work. That is why we brought in the internal market. That works, and that is why the Labour party is not getting rid of it. Don't believe your pager—
Mr. Deputy Speaker
Order. It is the hon. Gentleman who is now forgetting his second and third persons.
§ Mr. Fabricant
You are absolutely right, Mr. Deputy Speaker. That goes to show how important it is to have debates and interventions. It shows also that one can get emotionally concerned—as I am—about the welfare of people of this country, and not about spin-doctoring.
Who are the Government kidding? Does the Under-Secretary of State for Social Security, the hon. Member for East Ham (Mr. Timms), want to return us to the old shambles? The Minister—whom I know from the previous Parliament—is a sensible man and does not want that. Let us hear no more soundbites about the internal market setting nurses against doctors, and all the other claptrap that we have heard over the past hour or two.
The latest proposals from the Government involve tinkering with the GP fundholding practices, and that is what I want to concentrate on now. The proposed changes have serious consequences for my constituents in Lichfield. Every GP in Lichfield has chosen to be a fundholder; not one has shown any enthusiasm for the Government's proposals. That is not because Lichfield doctors—or any other fundholding doctors in the UK—are greedy, as the Government try to make out in an attempt to demonise them. It is because my local doctors firmly believe that GP fundholding practices benefit their patients.
As a local doctor said to me last night,Fundholding had its faults but at least GPs were in the driving seat of improving patient care.He believes that primary care groups will worsen the treatment of patients. While PCGs give GPs the responsibility for looking after their patients' interests—in theory, at least—they will lack the power to have any 369 significant impact. The Government will point to the higher tiers of the new system, culminating in level 4, where the primary care trust will be responsible for all services to patients—like the health maintenance organisations in the United States, which the Government are attempting to copy.
On paper—like all soundbites—it seems like a good idea, but not for Lichfield, and not for the rest of the country. Let me explain why. Leaving aside the high management costs of HMOs, GPs will be locked into underfunding. Let us cast our minds back to the introduction of fundholding. This history lesson puts things in context.
Hospital consultants were using the media time and again to say that the NHS was not providing a service to individual patients. The then Prime Minister, Margaret Thatcher, personally announced on television a review of hospital services, out of which grew the purchaser-provider split to generate efficiencies for the benefit of patients. Until then, hospital consultants had huge power at health authority level, and the authority was responsible for providing hospital services.
As community services did not have the power to influence health authorities, proper development of community services, with a fair share of resources, did not happen. However, the purchaser-provider split could be killed at birth, as the consultants and health authority executives were the same people. Why would a hospital become a self-governing trust and take all the risks when paying lip service to the reforms was all that was required? Many hospitals would have remained under health authority control, so there would be no purchaser-provider split. From this, GP fundholding was born.
Let me give the House a local perspective. In the main, patients from Lichfield are sent to three main hospitals—Good Hope in Sutton Coldfield, Burton hospital and Stafford hospital. Lichfield doctors tell me that the services provided by Good Hope hospital used to be "atrocious"—their word. GP representatives on teams and authorities were merely tolerated, and were usually ignored. Fundholding empowered their voices.
By good fortune, and through the skill of the family health services authority—then chaired by a good friend of mine, Philip Jones—seven local practices were selected in the first wave of fundholders in the UK. Suddenly, local GPs controlled half of Good Hope hospital's budget for elective services. A marked improvement occurred at Good Hope for the benefit of patients as a direct result of the introduction of fundholding practices.
At Burton hospital, where the service was adequate prior to fundholding, most of the business came from Burton and south Derbyshire. With little impact from fundholders, the consultants retained their power. Only when a consortium of practices around Burton formed the Burton fundholding group did change for the better occur—change driven by doctors, caring for their patients at community level. These successes have been duplicated up and down the land.
§ Mr. Patrick Hall
What the hon. Gentleman has just described—which applied to small parts of the country, and certainly not to the whole country, under GP fundholding—can now apply to the whole country. That is the difference between the Government's proposal and 370 the Opposition's proposal. Why does not he want the benefits that he has just described, regarding the balance of power, to apply to the whole country for all patients?
§ Mr. Fabricant
A sensible question, if I may say so, from the hon. Gentleman. On paper, it would seem to be a good idea—make fundholding compulsory, give it a different name and take away one or two of the powers. However, it will not work like that. If it did, I would be voting with him—but it ain't going to work like that.
The Government—and the hon. Member for Bedford—have recognised that fundholding has been a success, but they argue that it is a two-tier system with the patients of fundholding GPs benefiting because they have more money. The Government argue that the system is fine for fundholding patients, but not for ordinary patients. As the hon. Gentleman says, the Government have said, "Let us change the name to primary care groups and make membership compulsory. There will be a single tier and everybody will be happy." That is not the case.
Two fatal flaws in Labour's logic are dogging the Government—just as they have dogged previous Labour Governments. First, the Government ignore the fact that some GP practices are more skilled than others in management. It is not a question of whether they have more money or not—it is a question of whether they have the inclination to be involved in the management of practices. The second mistake in Labour's logic—a mistake that has been a common thread since 1948—is that the Labour party persists in the belief that dragging down to an equality of mediocrity is better than allowing excellence. We have seen that with the Government's aim to abolish the remaining grammar schools—we are now seeing it with fundholding.
I shall now be more specific. Primary care groups are not the same as fundholding practices—despite what the hon. Member for Bedford might think. All partners in first-wave fundholding practices had to agree to enter the scheme. One veto from one doctor in the practice blocked their joining the fundholding scheme. With PCGs, every GP is compulsorily a member of the PCG.
The boundaries of the group are arbitrary. For example, in Lichfield—I am sure that this will be duplicated in other parts of the country—if practices had a choice, they would join with certain practices in Tamworth, where there are like-minded GPs with whom they have worked for years. Instead, they have been bundled in with Burntwood. However, that is not the main point. In fundholding, each practice was responsible for funds for its own patients. With PCGs, the budget is for all practices in the group, with the implication that every GP has corporate responsibility for the spending of GPs in other practices.
In fundholding, the budget was set for planned procedures—this is the most important point, which has not been picked up yet—with the budget for emergency procedures remaining with the health authority. The new PCG scheme will result in practices having to fund unpredictable emergency treatment. Will the doctors in the House be so pleased with the changes if we have a bad winter and more people go to accident and emergency departments, and their budgets are cut accordingly? I suspect not. The budget for first-wave fundholders was set according to the hospital, drug and staff expenditure in the year before anyone had even coined the idea of fundholders.
371 A Lichfield GP wrote to me. He said:Will I be able to convince the Chancellor that my practice needs extra funding for winter pressures or waiting list monies to reduce the number of my patients on waiting lists? I am sure you know the answer to that question, and you will understand the attraction to the Government of PCGs. South Staffs Health Authority is about 13 per cent. underfunded so the playing field is not level; hence a multi tier NHS. Where you live may still determine the service you get. In addition to the 13 per cent. underfunding inherent in the budget calculations, there is also the thorny question of how to deal with overspends run up by health authorities by the end of this financial year. Will the Treasury write off these debts or will PCGs be forced to take on board these debts as a first charge on next year's funds?I do not know whether the Minister will be able to answer that question, but it would be helpful to receive a letter from the Department. The letter from the GP continues:Unlike fundholding if it goes wrong we cannot pull out.What about the management skills needed by GPs? First-wave fundholders had to demonstrate management skills to be accepted on the scheme, but PCGs are compulsory. There has been no assessment of whether the skills are available countrywide. Are the Government aware that management skills are not part of GP training? Perhaps the Government feel that management skills are not needed because of the appointment of general managers, but the overall sum available for the manager and his team, for reimbursing GPs for the cost of locums in their absence on PCG business and for an honorarium for GP advisers is a measly £3 a year per patient registered with the practices in the PCG. The formula is obviously insufficient for Lichfield, Tamworth and Burton and for other areas.
Will the Lichfield team be able to deal fairly when Tamworth GPs will want to protect their Sir Robert Peel hospital? Could the Victoria hospital in Lichfield be threatened in such a scenario? As development at the Victoria has involved portakabins for several years, I would like to know whether Premier Health now favours Sir Robert Peel over the Victoria?
With fundholding, savings made by practices could be carried forward for up to four years, so GPs did not have to waste money by rapidly spending any surplus in the last month of the financial year. Savings had to be accounted for and the spending of savings had to be approved by the health authority. Improvement in care or facilities for patients was paramount. It was prudent to keep a reserve for future years' hospital care, as a practice could have an unusual imbalance of expensive procedures.
The Government have said nothing about what is to happen to PCG savings. If savings are not carried forward, where is the buffer for extraordinary years? The question is especially pertinent now, as for the very first time, the Government are making GP budgets pay for unpredictable, emergency work. It is a fundamental question: if the weather is bad, will GPs have their budgets slashed? The Government should tell the truth.
§ Mr. Nicholas Winterton
My hon. Friend reflects the concern of GPs throughout the country. I spoke earlier of the benefits brought by GP fundholding, but admitted that there had been abuses. My hon. Friend is outlining some of the problems with the Government's proposals, but 372 how would he amend GP fundholding to reduce the abuses and the problems that were created for some hospitals and hospital trusts, while preserving the many benefits that it brought for patients, putting as it did the GPs on an equal footing with the hospital consultants, who had hitherto dominated the health service?
§ Mr. Fabricant
I would like to extend fundholding. I would not make it compulsory and I would provide better training so that all GPs would have the ability and the financial wherewithal to manage their own practices, as happens with the 55 per cent. of practices that are currently fundholding. Eventually, by voluntary choice and ability, all practices in England and Wales would be GP fundholding practices. We should certainly not say, as the Government do, that the extraordinary budget—for emergencies, for illnesses in winter and cardiac arrests—should come out of the GPs' budgets.
§ Mr. Fabricant
I am coming to my conclusion, and I know that others want to speak.
The measures will not help community care. They are all about party dogma. I end not with my words, but with those of my Lichfield doctor. In an e-mail that he sent to me last night, he said:Like the 'new' arrangements for the House of Lords,"—I will have to sign this doctor up to the Conservative party if, as I believe, he is not already a member; his words provide a better ending than any that I could possibly write. He said—I repeat his opening words—Like the 'new' arrangements for the House of Lords, the new NHS seems to be words with no substance. Sorry, that is unfair; circulars describing the new NHS arrive almost every day. The comparison is only valid as nobody seems to know how either will work!!
§ 6.8 pm
§ Dr. Howard Stoate (Dartford)
As the only general practitioner on the Government Benches, it is up to me to inject some common sense into the debate, following some of the arguments that we have heard from Conservative Members. I am sorry that the right hon. Member for Maidstone and The Weald (Miss Widdecombe) is not here, because I want to take issue with much that she said. I am afraid that, as usual, she displayed a tendency not to let the facts get in the way of some damn good rhetoric. It is important to consider in more detail some of what she said.
The right hon. Lady spoke about GPs having referral rights taken away from them by primary care groups. The record will correct me if I am wrong in supposing that she said that, under the new primary care group arrangement, GPs will lose referral rights to the hospital of their choice.
Some years back, under the fundholding arrangements—I hasten to add that I have never been a fundholder or accepted the necessity for fundholding— a patient came to see me and I diagnosed a particularly rare and unpleasant form of leukaemia. I knew that there was only one hospital in the land that could offer her any hope of decent treatment; I contacted it and spoke to the consultant. I said that if the woman was to have any 373 chance of survival she should be in his unit. He said that he entirely agreed, that it was a very rare case and that he would like to see the patient immediately.
The consultant asked me to send the patient along, but then said, "Hang on a minute, you're a fundholder, aren't you? You do have a contract with this hospital, don't you?" Oh, dear. Of course, the whole thing then fell flat on its face and it took another 12 hours to sort out whether I could have an extra-contractual referral on an emergency basis. That was all to the great detriment of my patient, who subsequently died.
I would argue that fundholding has not been a great success because it has led to a two-tier service and undermined doctors' ability to send patients where they choose, causing great distress and difficulty.
§ Dr. Brand
I am grateful to the hon. Gentleman, who has just described my fear that the new arrangements will mean that all patients will be treated in the same way as patients of non-fundholding GPs. I am sure that he has read the executive letters issued by the Department of Health and I hope that he is clear, because I am not, on how we can retain the ability to refer patients in the situation that he describes. A speedy response between clinicians is essential for an effective national health service, and managerial systems must not get in the way. Fundholders cut out a lot of the rubbish and I hope that primary care groups will be able to do the same.
§ Dr. Stoate
Fundholding took out some of the nonsense, but it should not have been there in the first place. Before 1990, a GP had the right to refer a patient to any hospital in the land. The previous Government created the mess and it needs sorting out. GPs who were not members of fundholding groups did not have the right to choose to whom they referred their patients and that caused great distress and difficulty for many people.
I wish to tell the House about experiences I have had in my constituency. I take issue with the hon. Member for Lichfield (Mr. Fabricant), who seems to think that all the doctors in his area are opposed to primary care groups. He gave the game away when he said that he would send a membership form for the Conservative party to one local doctor, who seems to be a ripe candidate for joining. The hon. Gentleman's experience differs from mine.
§ Mr. Fabricant
The doctor is not a member of the Conservative party. In Lichfield, every GP is a member of a fundholding practice—it works for them and, more importantly, for the patients. I do not know how the hon. Gentleman can talk about fundholders when he has never bothered to become one. Does he not think that his patients might have benefited?
§ Dr. Stoate
I never bothered to become a fundholder because I was sure that it was not right for my patients. The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) claimed that we would spend huge amounts on bureaucracy under the new system of primary care groups. Currently, there are 4,000 commissioning groups of varying sizes and we intend to replace them with only 600 primary care groups. Huge savings will be made in bureaucracy.
§ Mr. Simon Hughes
Those two statements are not necessarily logically connected. If fundholders 374 are abolished, there will be fewer commissioners, but the new primary care groups will have to employ staff—they are all now advertising for chief executives. Some 500 extra managers will soon be appointed and nobody, in the professions or the management, has claimed that the first few years of the new system will result in any net reduction in managers.
§ Dr. Stoate
I shall enlighten the House on that point. As the hon. Gentleman knows, fundholding practices employ fundholding managers. They employ members of staff to shuffle bits of paper around, to sign off completed patient episodes, to sign off patient treatments and to ensure that patients have been seen by the right consultants. That involves thousands of pieces of paper. Every fundholding practice has a member of staff, sometimes several, to deal with that. A primary care group will contain an average of 50 GPs covering 100,000 patients, and one level of bureaucracy will cover all of them.
§ Mr. Hughes
One member of staff?
§ Dr. Stoate
No, but one level of bureaucracy. We will no longer need single pieces of paper for every completed episode of patient care. We will sweep away that nonsense of a bureaucracy that never taught anyone anything about patient management and never contributed to patient care, but snarled up the system with thousands of pieces of paper. That will lead to huge savings.
Nobody has yet put forward a sensible argument against a primary care-led NHS. Our changes will mean that local doctors, nurses, and members of social services departments who understand the local needs of local patients will set up local services to meet those needs. What could be more sensible? That has to be the way forward, not the hugely bureaucratic system we now have.
Change is threatening, and the hon. Member for Lichfield described the fears and doubts of some of his local GPs. I do not decry those fears, because they are genuine. Nobody easily votes for change—other than to get rid of the previous Government, when people voted with alacrity for change. Many GPs have expressed their concerns to me because I am the only GP who sits on the Government Benches and I tend to be the focus for GPs' concerns and anxieties. I do not wish to patronise them by saying that their doubts and fears are unfounded, because in many cases they are not.
In the interests of good debate, I wish to point out some of the genuine fears of GPs. For example, fundholders have spent much time and energy setting up new clinics and services for the benefit of their patients. Good luck to them. They have sometimes succeeded in pushing at the boundaries of medical care and making some treatments very effective. Some genuine innovation has flowed from fundholding and I do not seek to minimise that. Fundholding GPs do not want to see those benefits lost and they are anxious that the clinics they have set up continue to provide good care for their patients.
Non-fundholders are anxious to ensure that they have enough time, energy and expertise to make the new primary care groups work. I do not seek to minimise those fears, either. Other fears include overspending and what will happen if the money runs out. Some people are concerned that if they take time out of their practices to 375 sit on primary care boards, their partners will have to pick up the slack. If a doctor is out of the practice for half a day a week, somebody else has to see the patients and that can cause tensions in partnerships. We must face up to those problems in an adult way, instead of with rhetoric and loud voices. Those fears are not merely moaning from a privileged interest group that has always had its own way. That is a patronising and simplistic view. It is also wishful thinking, because GPs have raised real issues that will not be solved without careful consideration and thought.
This morning I contacted Dr. Alasdair Thomson, the GP chief executive of the Dartford, Gravesham and Swanley HealthCare Partnerships Project and chair elect of the new primary care group. The project was initially set up as a pilot scheme, covering 220,000 patients with 116 GPs, 70 per cent. of whom are fundholders. They have worked with non-fundholders, voluntarily, to set up the project, which is a precursor of primary care groups. The project has followed, almost exactly, the model that will be followed by all PCGs. It has blazed the trail for PCGs, faced up to the difficulties I have described and found solutions.
The project is enthusiastic about its work. I was due to meet Dr. Thomson this evening to discuss his group's plans, but I felt it was more important to take part in the debate. We intended to discuss the project's seemingly unquenchable thirst for innovation. I am sure that Ministers will be delighted to hear that the subject of tonight's meeting was whether the project should express an interest in becoming a primary care trust at the earliest opportunity. The project is convinced that it is of real benefit to the local communities.
Dr. Thomson sent me a progress report today, which explains what the group has achieved and how that has benefited its patients. The report states that the project was set upas a Locality Commissioning Group Pilot in September 1997.… Since the publication of the White Paper … the GPs have been working in partnership with West Kent Health Authority, Kent Social Services Department, Trusts, particularly Dartford and Gravesham Acute Trust and Thames Gateway NHS Community Trust and the Community Health Council to develop services which are more responsive to local needs.The progress report continues:The pilot status has given us a head start in developing partnership working, bringing together organisations in Health and Social Care and in particular, tackling the 'Berlin Wall' culture.This has enabled … GPs from very different types of Practice in Dartford, Gravesham and Swanley (Urban, Single Handed, Rural) to come together in a specific forum to raise issues and solve problems which directly relate to local health needs.It allows GPs to become directly involved in commissioning decisions and service development of local trusts. In particular, GPs are looking at ways in which to bridge the gap between fundholding and primary care groups. For example, equity of patient access to in-house clinics is one of the difficulties that we have considered, and they have found the way around that problem.
GPs have also formed new service review groups to develop local services in conjunction with trusts. So far, there has been success in urology, anticoagulant therapy, radiology and ultrasound, and dermatology. That is 376 exactly in line with the Government's proposals in the new Bill. Our primary care teams—GPs, practice nurses, practice managers, district nurses and health visitors—are working together with social services care managers to develop elderly care services in the community. That way of working has been piloted at six GP sites in the district, and it is ready to be rolled out across the entire group. It has also allowed the commissioners, the health authority, social services and GPs to work together with providers to improve mental health services in the locality.
Perhaps more excitingly, the groups are also working with the health authority pharmacists and pharmaceutical advisers to draw up guidelines on the most rational and cost-effective prescribing. The report sent to me this morning asks, "What's gone well"? It responds:Groundswell of support from all organisations, particularly around partnerships working.A belief that we can tackle local issues better.A head start in developing management structures to cope with the new PCG agenda.GP involvement in the Commissioning process.A foundation to enable us to start to tackle issues in Primary Care and the concept of Clinical Governance.That is not a bad record for a group that set itself up voluntarily, and which is a mixture of GP fundholders and non-fundholders who have demonstrated a year ahead of everyone else that they have tackled most of the problems head-on in a way that has met local need.
More importantly, the group has also improved local services for patients in a way that would have been undreamt of a couple of years ago. That is the reality of what happens when we work towards primary care groups. The reality is not the rhetoric that we have heard this evening, but the fact that real GPs treat real patients in real situations, making real improvements in care. It is not about some GPs fighting against others for scarce resources. All the GPs in the area are working together to improve resources for all patients. That must be the way forward. I commend what the Government are doing to roll the programme out to the entire country.
§ Miss Anne McIntosh (Vale of York)
I am delighted to participate in the debate on the Gracious Address. I am afraid that I do not share the enthusiasm of the hon. Member for Dartford (Dr. Stoate) for primary care groups. I have consulted almost every practice in Vale of York over the past six months and I do not believe that primary care groups will work. In two or three years time, we shall have to come back with more proposals. I am no gambler, but I predict that the proposals will not work.
I was disappointed to hear the Secretary of State for Health say that he was removing a tier of bureaucracy. One of the grounds that general practitioners offer for being whole-heartedly against the proposals is that primary care groups will add another tier of bureaucracy. In North Yorkshire, there will be something like seven chief executives—recruitment adverts have gone out over the past two months—and they will cost, I imagine, between £20,000 and £30,000 each. I am not medically qualified. I cannot handle the sight of blood, so I went into another noble profession, the law. However, my father, my brother and my uncle have between them served between 80 and 100 years in the health service. The money intended to pay for chief executives in North 377 Yorkshire will be multiplied across the country and will total at least £1 million. In my view, and in the view of GPs who have written to me, that money should be spent on patient care, hospital treatment, the training of midwives or an increase in nurses' pay, to which the Government claim to be committed.
Do the Government intend to honour their commitment to raise nursing salaries? We all know that morale in the nursing profession is at an all-time low. In my surgery within the past month, I met a police officer and his wife, who is a nurse. The police officer believed that the Government did not have the money in this year's budget to make good the promised increase. The nurse was keen to extract a commitment that the Government would make good their promise, particularly through a big one-off pay increase that would bring nurses to the level that the profession justifies. Perhaps the Minister might tell us later whether the Government are committed to that increase.
I received a press release today from North Yorkshire health authority. It relates to the future of the Duchess of Kent hospital, in the constituency of my right hon. Friend the Member for Richmond, Yorks (Mr. Hague). The hospital is in Catterick, but it attracts patients from Vale of York. The thrust of the press release is that the immediate future of the hospital is secure. It is not to close for, I imagine, the foreseeable future. General practitioners are being asked to run it, which is welcome. In my experience, many GPs are well qualified to do operations, especially small ones, and I hope that that will work successfully at the hospital.
However, North Yorkshire health authority and I, with the support of my right hon. Friend the Member for Richmond, Yorks, are trying to extract a promise from the Government. The hospital was budgeted for in the Ministry of Defence budget, but it has become a direct drain on national health service resources. This year, it will suffer a shortfall of £500,000. I have taken every opportunity to write, to ask questions or to raise the matter on the Floor of the House. I have tried to extract from the Government a promise to make up that £500,000 shortfall. The short-term future of the hospital has been secured. In view of that fact, will the Government assure the House and my constituents that the money will be forthcoming?
The Minister for Public Health, the right hon. Member for Dulwich and West Norwood (Ms Jowell), who is not in her place, kindly replied to my Adjournment debate within the past month on the question of health among those living near overhead line transmissions. I referred in particular to power lines in Vale of York and other parts of North Yorkshire. Would the Under-Secretary of State for Social Security, who is here, convey to the right hon. Lady the fact that I am concerned about the important work being undertaken by Bristol university and Professor David Henshall, which I know she values and which is making a major contribution to the debate. The Electricity Association has intervened at the highest level at the university—the vice-chancellor—to try to stop that work. The right hon. Lady committed herself, when she replied to my Adjournment debate, to making more studies available. That work could prove conclusively that health risks exist, and that leukaemia may be formed—cancer is certainly formed—among those living close to overhead lines.
378 My constituents share my regret about the Government's knee-jerk reaction to a minuscule risk when they banned beef on the bone. A much greater and clearer risk exists from power lines, but the Government are not so quick to react to the very serious health concerns of those living underneath or near overhead lines. I urge the Government to assure me that they will make a similar knee-jerk reaction to that problem. I did not agree with the decision to ban beef on the bone, but the Government must be consistent. If they react with a knee jerk to one health scare, they must do so again for another scare that affects a much larger number of people.
Finally, the link between health, welfare and food hygiene in livestock farming is compelling and serious and I must place on record my concern about the apparent lack of communication in many instances between the Department of Health and the Ministry of Agriculture, Fisheries and Food. The banning of beef on the bone was just one example of that.
The Minister may or may not be aware that two proposals are decimating turkey production. I speak with heartfelt concern for Moorland Turkeys, a large company based in Vale of York near Thirsk. The Government's proposal to ban the sale in butchers' shops of turkeys that have not been eviscerated—in common parlance, that means with their giblets—is already causing great concern and has affected turkey production. A number of turkey factories, not least some owned by Moorland Turkeys, have closed. Production had to be halted because of that proposal. That was another knee-jerk reaction. There is no consequential health risk from such sales about which we need to worry. I wish that the Government would stop damaging food production in that way.
Another Government proposal affects turkey production. Health checks are to be made on turkeys and vets are to be present during their processing and slaughter. It costs £40 per hour for a vet to be present. I realise that that matter is probably the responsibility of the Ministry of Agriculture, Fisheries and Food, but the two Departments should talk to each other. There is no co-ordination between them. That sort of knee-jerk reaction is threatening to put turkey producers out of production, as other schemes have already done for beef producers and others.
I shall leave the Government with a thought on a matter that I raised with the Minister of Agriculture, Fisheries and Food yesterday. I am convinced that this country has the highest food hygiene and production standards. Producers need to be reassured that imported food products have to meet those same high standards before they are sold in our stores.
§ Mrs. Ann Cryer (Keighley)
Today's subjects of health and welfare in the debate on the Queen's Speech and our legislative programme for the coming year are subjects close to my heart, and, for good reasons, the hearts of many of my constituents.
I congratulate my right hon. Friend the Secretary of State on moving to the abolition of the wasteful national health service internal market, so that co-operation, rather than competition, will become the motivating force. I am also extremely pleased by our move away from general practitioner fundholders. In Keighley, the Aire Valley health consortium three years ago led the way towards 379 primary care groups, which include all the practices in Keighley—large, small, rural and urban and, more particularly, Asian doctors, who give an excellent service to their community but tend to work alone. The situation there is similar to that described by my hon. Friend the Member for Dartford (Dr. Stoate) in relation to his area.
I look forward to fairer provision, regardless of which part of the town one lives in. Nationally, the provision of primary care in the health service will, I trust, be first rate for all, and will be according to a patient's physical and mental condition, not their postcode.
Many of my constituents are more than happy with the existing administration of the Airedale national health service trust. Airedale general hospital at Eastburn is the biggest employer in my constituency and serves an area north as far as Bentham in the dales, west as far as the constituency of my hon. Friend the Member for Pendle (Mr. Prentice) in east Lancashire, east as far as Leeds, and south as far as Bingley, in the constituency of my hon. Friend the Member for Shipley (Mr. Leslie). Airedale hospital is extremely well regarded by all the communities that it serves. The staff of the excellent special care baby unit were delighted to be visited by my right hon. Friend the Secretary of State earlier this year. That visit was regarded as recognition of the magnificent service given by a dedicated team of carers at all levels and in all specialties.
Recognising the special place that Airedale hospital holds in the hearts and minds of the people of my constituency and the many communities that I have mentioned will, I trust, persuade my right hon. Friend that to merge the Airedale and Bradford NHS trusts would be extremely unpopular and ill advised—in fact, not even worthy of consideration. I hope that those will be the final words on that subject.
I believe that my commitment to universal benefits is known to my right hon. Friend the Secretary of State for Social Security. It may be very old Labour indeed, but universal benefits, available to all with the benefit clawed back where necessary through taxation for those on high incomes—provide the safety net of welfare benefit provision, in particular for the most vulnerable people who are often unaware of their entitlements and simply do not know their way around the system. I am particularly pleased that child benefit will remain universal and that it will continue to increase, although I still mourn the loss of the enhanced rate for single parents.
I am sure that none of us can take exception to the idea of providing support for those who need it most while helping those who can work back into work. Certainly, extra support for families charged with the lifelong task of caring for children born with spina bifida, Down's syndrome, cerebral palsy and other chronically disabling disorders must be welcomed by all. Most of us who have been asked for some form of help by such families know of the dedication of the parents involved.
We are also aware that some incapacity benefit claimants have jobs in the black economy but, judging from my experience as a Member of Parliament and a member of the social security appeal tribunal for nine years, those are the rare exceptions and certainly not the rule. One of my abiding memories is of a man who was 380 reduced to tears before the tribunal when he graphically described how a Department of Social Security doctor asked him to kneel, but when he said that he could bend his knees only so far, the so-called doctor pushed down on both his shoulders until his knees reached the floor. He had cried out with the intense pain, but he was thus declared fit for work. I trust that our justified enthusiasm for helping people back to work will not put claimants into that sort of painful and degrading situation. No doubt our constituents will tell us if unnecessary pressure is put on those with a genuine illness and we will in turn make Ministers aware of such cases.
By and large, the changes in widows' benefits are an improvement for many, in particular bereaved fathers of young children. The doubling of the lump-sum payment will help many people with the enormous costs encountered on bereavement. However, the universal nature of the benefit long term will disappear, and for many people it will do so at a time when finding a job will be difficult.
I hope that my right hon. Friend the Secretary of State has taken into account the many people of my generation and some younger who have taken time off full-time paid work—in my case from 1964 to 1974—to care for our children. In our case, the Government did not give national insurance contribution credits for that period. I understand that that happened only from the mid-1980s. Therefore, were I not in the fortunate position of having the long-term widow's pension, my retirement pension would be much reduced when I reached 60, owing to the lack of contributions for 10 years. With the approval and generous support of my party and of the people of Keighley and Ilkley, I look forward to at least a second term in this place, in which case I shall be working until the age of 65. Even so, I would still be on a much-reduced state retirement pension as a result of those 10 years out of paid, full-time work. I hope that the new arrangements for widows take that into account so that widows at the age of 60 will have a full pension regardless of contributions.
For one or two items in the Gracious Speech I should have preferred the promise of legislation to that of draft Bills—for example for the strategic rail authority and freedom of information. Given my age, impatience may be understandable. I am pleased with much of the legislative programme and much in the speech of the Leader of the Opposition made me happy to be a Labour Member.
§ Mr. Archy Kirkwood (Roxburgh and Berwickshire)
I am pleased to follow the hon. Member for Keighley (Mrs. Cryer) and I congratulate her on her compassionate speech. I would not have expected anything else, knowing her family background, if I may put it that way. Perhaps I can do a deal with her and create a pincer movement. If she approaches the Government from an old Labour point of view and I from a Liberal Democrat view, we might reach our goal in the end.
I have always supported the Government's approach to developing social security and to planning welfare reform in so far as they believe that that must be done across Government Departments. If ever anybody wanted evidence of the need for that, they would find it underscored in the Acheson report, the independent 381 inquiry into inequalities in health. It is inadequate to try to implement social change simply by using the Benefits Agency and the Department of Social Security. I have always taken that view, and after the election I encouraged the Government in that direction.
I support what the Government have been doing—and certainly much that has been done to introduce work as a way out of welfare. Obviously that is the right way forward. Nevertheless, I am worried about the fractured way in which some social security policy is beginning to unfold. There is concern that the Department may have lost some momentum in evolving a coherent set of long-term policies. The Queen's Speech provides an opportunity for us to tease out from Ministers the Government's long-term vision and strategy for our social security policy. By that I mean, not just for the next 12 months, but for the next five or 10 years. As we all know, policies that we put on the statute book must stand the test of time and, hopefully, withstand changes of Government, if there is to be any stability in the system.
Although this matter is not solely for the Department of Social Security, I am worried at the way in which the policy is being deployed. The Treasury is involved. The Prime Minister is now chairing a Cabinet committee. The social exclusion unit, which I welcome, is in on the act. The Department of the Environment, Transport and the Regions is now looking after housing benefit. The Treasury introducing a working families tax credit. All those initiatives can be considered individually and found to be good or bad, but I would have expected the Government's programme for a second term—I appreciate that it takes time for a new Government to get into their stride—to give more of a hint at the long-term strategy. I am nervous that that is absent from the Queen's Speech and I should be pleased to be guided on that.
I fully accept the clearly adumbrated principles in the Loyal Address of work, security, fairness and value for money. No one could argue with that. On the detail of the proposed welfare reform Bill, I hope that the Government can assure us that reform of disability benefit will be implemented only after proper consultation with the pressure groups involved. I am anxious that the pension sharing and divorce measures—the Select Committee that I have the privilege to chair has just completed what I hope is a valuable report on the matter—do not get lost in the totality of the stakeholder pension provision reform. If the measures are tacked on in some clauses to a Bill that focuses in other directions, there is a danger that the Standing Committee may wish it through with one or two amendments because the Select Committee thought that it was not a bad idea. The measures are more important than that. Their implementation may benefit from slightly more delay than the Government currently envisage. We were certainly grateful to have the opportunity of pre-legislative scrutiny and I hope that it will prove to have been of value to the measure when it comes before the House.
The working families tax credit is a good idea in principle. However, some thorny implementation problems remain to be addressed. In particular, the previous Chairman of the Select Committee is rightly credited with having identified fraud as a major issue in social security policy. This is the first new benefit that the Government have come up with, yet I cannot see any design attempts at its gestation phase to make it proof against fraud. The Government have rightly made an issue of trying to wring fraud out of the system. This is the first 382 benefit of whose implementation they have been in sole charge, yet there is no evidence that they have taken steps in gremio to make it harder to defraud the system. If that turns out to be the case, that will be a shame.
The social exclusion unit is an exciting idea. To build a unit into the whole process at No. 10 based in the Cabinet Office and reporting directly to the Prime Minister is an extremely good idea. How will the unit be held accountable to the House? I do not ask that in any carping way, but because it straddles Departments, there is no Select Committee with a unique responsibility for monitoring its work. It is to cover a vast range of Government activity from the DETR, the Department of Social Security, the Department for Education and Employment, the Department of Health, the Cabinet Office, the Home Office, the Treasury and the Department of Trade and Industry. That is a huge brief and the work is important. The unit is to report directly to the Prime Minister, but how can Members follow and understand what it is trying to do? Following the Cabinet reshuffle names of responsible Ministers are being considered and have yet to be announced, but the Government have a duty to say clearly how the House can get access to the work of the unit.
That is true, too, of the DETR task forces. There are 18 policy action teams, all with so-called champion Ministers assigned to them. I am in favour of inter-departmental working, but I am worried that it may become incoherent and that it may not be effectively scrutinised by this House. I hope that Ministers will consider these criticisms in the positive, constructive spirit in which they are made.
The Green Paper on success measures is a brave idea. It is brave of a Government to say that they will set success measures in social security, because the Government can be tested against them. There has been some well-directed criticism to the effect that some of the measures are ill-defined and impractical at the draft stage. That consultation process is now over, but we have not yet heard what the Government will make of that consultation process and what improvements they want to introduce. It is important that we do not lose momentum. I am disappointed in particular that there are no criteria for measuring a reduction in poverty. That is a significant omission. I am sure that the hon. Member for Keighley would agree, knowing her concern about these matters. If success measures for welfare reform and social security are to be meaningful, some benchmarks against which to test poverty must be included. I put it no higher than that.
I notice that the Queen's Speech did not refer to a proposed pre-legislative scrutiny stage for the draft child support Bill. The previous Ministers at the Department gave an undertaking to the Select Committee that we could examine a draft Bill on child support. This is too big an issue to get wrong twice—and I do not need to say that twice. It is a tough challenge for the Select Committee, but we look forward to it. I hope to be told that that point was omitted for brevity's sake and that there will be no going back on the undertaking.
The Secretary of State's recent statement on changes to bereavement provision elicited a number of responses from hon. Members on both sides of the House about the future of the contributory principle. I talked earlier about trying to get a better idea of the Government's strategy. If we do not get some idea of what the Government have in mind for the social insurance principle, we may move 383 by default to an American system where everything is means-tested. There may be an argument for that but I would not want it to happen by default.
I remind the Minister that the Government Actuary's quinquennial review of the national insurance fund provides an opportunity for a debate. If the Government have challenging ideas, I for one am willing to sit down and work them through. If there are radical changes in the Government's mind, I would rather have them out in the open so that we can have a proper debate rather than having it all done by default.
I am worried about two big issues that concern the modernisation of information technology. I know that the Minister is an expert—I nearly said an anorak—on IT. The two projects are private finance initiatives. NIRS2, the national insurance recording system installed in Newcastle by Andersen International, is suffering serious delay and major technical difficulties. In October, the Department admitted that the computer database had collapsed, resulting in underpayments of up to £100 a week for some pensioners. That is a serious matter and casts doubt on the PFI. If we are going to get into that sort of trouble, perhaps we should reconsider it. I would like some reassurance on that.
I believe that the Horizon programme, which put Benefits Agency technology into post offices, is teetering on the brink of collapse. If so, it is another PFI project that is years behind time and suffering escalating costs. The Government have an opportunity to enhance the ICL scheme by going for smart cards rather than magnetic strips. Something must be done. A statement must be made soon or people will think that the Government are reneging on the contract. I do not want to go scaremongering in that direction but I fear not that delivery of the modernisation programme—a key part of Government policy—will be prejudiced but that the post office network will be prejudiced. I am sure that the Government know that that is a double whammy of enormous political significance. The silence of Ministers is deafening and the more that it continues, the more those of us who watch these things will worry.
To return to my first point, I hope that Ministers can reassure the House, now that we are nearly two years into the Parliament, that they have a long-term view of where their reform and modernisation proposals will be in 10 years. I hope that they will use the Queen's Speech debate to make that clear to those hon. Members who are interested.
§ Dr. Ashok Kumar (Middlesbrough, South and Cleveland, East)
It is a pleasure to follow the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), and to praise his work on the Select Committee and the seriousness with which he approaches the subject. I agree with him about the work of the Child Support Agency. I have had to deal with about 250 cases, and I have real problems to sort out.
It has been pleasant to listen to the Loyal Address debate. I even enjoyed the ranting of the right hon. Member for Henley (Mr. Heseltine), who accused the Government of following in the footsteps of Clem Attlee's Government. I am delighted to plead guilty, 384 because that Government had great successes. It was the jewel in the crown of Labour Governments, and I am proud to be associated with them.
§ Dr. Kumar
They were elected in 1950 as well. The hon. Gentleman must wait.
This has been an inspiring week for Labour Members. Today's debate is on health and welfare. Within that framework, I want to raise the needs and desires of disabled people; but first I have some general comments on the Loyal Address. I hope that the message has gone home to the British people that, unlike the Tory Government, this Administration know what they want to deliver, and refuse to be pushed off course. Labour fought the general election on a manifesto with 177 commitments, 63 of which have been met. The Gracious Speech contains the bones of legislation that will enable the Government to deliver on more.
We are committed to improving educational standards and ending the two-tier national health service, with the help of reform and the financial support of £40 billion announced earlier this year. We are committed to fairer asylum and immigration laws, and to introducing more, and fairer, protection for people in the workplace. We are committed to securing greater social justice by lowering the age of consent. As a democratic socialist, I welcome all those commitments as part of the big picture of creating a fairer society. I hope that the reforms—there are plenty of them in the Loyal Address—will unite all who believe in progressive values on change in our society.
The Loyal Address and the Government's programme was described by David Halpern in the New Statesmen as an attack on the lazy and lucky: the people who by birth have been handed the right idly to dictate the country's democratic programme, and the people who were in the right place at the right time when the spoils of monopoly and privatisation were handed out. By contrast, the beneficiaries of the Government's programme are those less fortunate: those who were unable to share in the greedy spoils of the past 18 years, and those who were the victims of discrimination.
I have been a campaigner against discrimination. I know from direct personal experience what it is, and what it feels like. I came into politics and the Labour party as a vehicle to fight discrimination. As a former chair of a local authority equal opportunities committee, I am acutely aware of the discrimination faced by disabled people. It is sometimes overt, too often covert. That is why I give three hearty cheers for the Bill that will set up the disability rights commission.
I was astonished to hear the right hon. Member for Richmond, Yorks (Mr. Hague), who represents the constituency that neighbours mine to the south, praise the initiative. If that section of the Gracious Speech is so praiseworthy, as it is, it will be asked why in the past 18 years his party did not introduce legislation with the same proposed powers and duties. Why did his party take great pleasure in killing several private Member's Bills that would have introduced measures that we are beginning to implement?
I was a Member of Parliament in 1992, when the Conservatives killed the private Member's Bill promoted by Alf Morris, now Lord Morris. The culprit on that 385 occasion was the then Conservative Member for Kingswood, who was subsequently defeated in the 1992 general election by my hon. Friend the Member for Kingswood (Mr. Berry). Yesterday, my hon. Friend spoke eloquently about disability issues, although he underplayed his own praiseworthy contribution to campaigns on those issues. I shall be gracious to the Conservatives and concede that, under intense pressure from outside this place, they did finally enact legislation; but, although well-meaning, it turned out to be toothless.
Having referred to pressure from outside, I should pay tribute to the campaigning work of organisations that represent the disabled. Much of the legislation that we shall enact originated with those organisations and their members' direct experience. The questions I pose to the Conservatives here are those which many of my constituents who are disabled or who care for the disabled will put to the right hon. Member for Richmond, Yorks. They will also put them to those representatives of the Conservative party who undertake the grim and gruesome task of trying to sell the Conservative party in the local elections next spring.
Let me now turn to broader issues. The disabled in Britain are a large community: if we count all those receiving the state benefits that are due to disabled people, we arrive at a figure of 5.14 million people—the equivalent of the population of a large city such as Birmingham. However, there are others whose personal occupational circumstances do not allow them to receive benefit, as well as those who are on the borderline between disability and long-term illness. If we add them, the total is more than 9 million people.
Discrimination comes in many ways. Loose thinking sees it only in terms of access to employment, but it is far more complex than that. In the terms used by the consultation paper that was the precursor to the setting up of the disability rights commission, discrimination can coveraccess to goods, facilities, services and premises.That is a wide-ranging definition. Disabled people often face multiple forms of discrimination, including discrimination in gaining access to buildings—often important ones such as railway and bus stations, local council offices and, it has to be admitted, Government Departments and agencies, many of which are still inaccessible, despite all our attempts to adapt them.
Disabled people often have difficulty in accessing services. They find it difficult to gain personal mobility by means of private or public transport, such as buses and trains, and—just as important—in terms of vocational and non-vocational training and other education opportunities. The ability to gain access to goods is also important, as many disabled people need special foods, medicines and clothing—goods that are often hard to obtain, and which might not be available at the right place, at the right time and in the right quantity.
Another issue that we should consider is whether many aspects of current legislation covertly discriminate against the disabled. I am thinking of simple things such as standards of highway and pavement design, food packaging and building regulations, and the design and layout of official forms and publications and of shops, libraries and post offices. Those are issues that the disability rights commission must be allowed to tackle.
386 The commission must be able to take direct action against those who directly and overtly practise discrimination against the disabled. It must be able to help disabled people through complex legal proceedings, and so enable them to gain what is rightfully theirs. Such support will often require partnership with other advocacy bodies and organisations—the work of the commission must not be ring-fenced.
The state, in its local and national manifestations, is the body that has the greatest impact on the disabled and their needs. We should not attempt to hide the fact that discriminatory practices have been discovered within state agencies and institutions. The disability rights commission should have unfettered freedom to probe the state and hold it to account when it has been guilty of discrimination. The Government must see the commission as the lead advisory body when drafting legislation that will have an impact on the lives of disabled people.
The commission must have the resources to support a truly capable conciliation service—one that has the clout to broker agreements and ensure that they are fully implemented. It must also have the resources to conduct and commission deep and far-reaching research into social and economic issues affecting disabled people. It must have the ability to institute and monitor codes of good practice, and to examine existing codes in order to determine how applicable they are to the needs and rights of the disabled.
I hope that Ministers will bear in mind some smaller issues later this year, when we debate the nuts and bolts of the Bill to set up the disability rights commission. The first is who has the last word on the content of codes of practice. Currently, codes issued by bodies such as the existing equality commissions and the National Disability Council are subject to ministerial approval and may be rejected by the Secretary of State. The consultation paper on the setting up of the disability rights commission proposed amending that, so that the Secretary of State can modify codes, rather than having to reject them outright. In some ways, that gives more power to the Secretary of State. The proposal requires clarification, and perhaps amendment, so that there is a common playing field for the various equality commissions.
Other potentially contentious issues include the concept, floated in the consultation paper, of having the power to charge for direct personal services to an individual in matters of legal representation. Given that the majority of disabled people depend to some extent on state benefits, such a proposal might be seen as threatening, and might deter people with genuine cases from seeking advice. In addition, greater clarification is needed of the relationship between the proposed rights and roles of the disability rights commission and those of the other equality bodies, and of the suggestions made in the Human Rights Act 1998 about the establishment of a human rights commission.
A general point, which is applicable to all areas of the Gracious Speech, relates to the bodies and agencies that will be established to control and run our new initiatives. Those will often take the form of a new or adapted non-departmental public body—in plain English, a quango. Many of us dislike quangos, and would prefer public affairs to be run by democratically elected bodies, but we know that, in the real world, that aim is not 387 always achievable. If quangos have to be set up, they must be as transparent as possible, and be seen as directly representing the interests of the people they serve.
It is important that as many as possible of the people who serve on the disability rights commission should have direct experience of the issues and problems affecting disabled people. A substantial number of those who serve on the new commission must be disabled themselves. In that context, it would be an interesting experiment in the development of a truly pluralist society if those who wanted to serve on the commission and who were registered disabled were subject to a ballot by members of disabled groups throughout the country. However, that does not mean that it should not be examined as a principle to aim for, in terms both of the composition of the disability rights commission and of other bodies that serve a specific client group.
I am proud to be a member of an Administration that has sought to see the benefits flow to the many, not the few. I am also proud to be a member of an Administration that has ensured that those most disadvantaged by virtue of their disability are allowed to make the most of their innate talents, initiatives and abilities. That has been recognised by the groups and organisations that represent those with special needs.
There are such groups in my constituency. The Redcar and Cleveland access forum has told me of its joy at the measures. Its secretary, Jocelyn Holmes, said:Not all disabled people are able to call on qualified help and advice—but now we will have a body that will have the power of law behind it so as to speak for all of us.There is popular support for the measures, both nationally and certainly in my constituency. That has been our message, and that is the substance of the Gracious Speech.
The establishment of the disability rights commission is a key milestone in the Government's long march towards a fairer and more equal society, and it is a step that I know many of my constituents welcome warmly.
§ Mr. Robert Syms (Poole)
This debate excites many passions, particularly when discussing health, for the simple reason that most of our constituents care deeply about these subjects. They value the national health service and the people who work in it. It is fair to say that, apart from a few cases, the vast majority of people receive good treatment from conscientious staff who work extremely hard. This year, as we celebrate the 50th anniversary of the national health service, it is worth reflecting on the prosperity of the nation, the national diet and the contribution of the NHS. Its founders would be surprised by how healthy, robust and successful we are as a nation.
As a Conservative, I am perfectly prepared to give credit to the Attlee Government for founding the NHS, if the Labour party is equally prepared to acknowledge that Conservative Governments have administered and nurtured it for 35 of its 50 years—or nearly 70 per cent. of its history. If all the dire headlines and the jibes thrown across the Chamber during the last Government and previous Governments had been true, we would not now be valuing what many hon. Members on both sides of the House have called the "jewel in the crown".
388 My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) made a very good point: total health spending is vital. The Government started off badly by abolishing tax relief for over-60s private health insurance—a measure which encouraged people to put a little more of their own money into their health care. There is a real problem with public expectations that cannot be addressed through the Exchequer. If we can use the tax system to encourage people to invest a little more of their own money in their health care—and there is every evidence that they will do that—we will be able to provide a better service for all.
I do not intend to go into the details of the Government's proposals, because I have a feeling that I may spend many hours doing so later this Session. However, I must mention GP fundholding. That system has been in place for seven years, and nearly 60 per cent. of patients are covered by some 15,000 fundholders. GP fundholding has proved a success, because, by and large, decisions are taken nearer to the patients. It has empowered many GPs. I accept that there were no GP fundholders in many areas, but I believe that the solution was encouraging more GPs into fundholding rather than abolishing the system.
GP fundholding was voluntary, and, as many of my hon. Friends have pointed out, the system of primary care groups is coercive because people have no choice: it is a form of conscription. For that reason, the Government's proposals contain deficiencies—many of which we will undoubtedly test later this Session. One of the key differences is size. The Government propose increasing the size of groups to hundreds of thousands of people, or to 30,000 or 35,000 in rural areas. Frankly, that structure is too large.
Grouping together 50 or 100 doctors will cause difficulties. It is often hard to encourage doctors to work together—although they are very worthy people. I questioned a Yorkshire GP about this matter when the Select Committee on Health considered it, and he said that the regional groups would subdivide. That is perhaps an acknowledgement that, in rural areas, the Government are trying to create an edifice that is far too big.
I turn now to issues involving the national institute for clinical excellence. We are moving towards evidence-based medicine, which is good. However, doctors sometimes prescribe treatments that are not fully tested; some trial and error is involved. I think that we will get into difficulty if the institute provides guidance that doctors do not wish to take in the interests of their patients. Doctors may be put under professional or financial pressure to follow those guidelines. There must be a balance in this area between sensible guidance and audit, and sensible conduct on the part of medical professionals.
Earlier in the debate, we discussed moving away from self-regulation to more intervention by Government. The British Medical Association is aware of terrible abuses within the medical profession. Mention has been made of the fact that it is difficult to get rid of bad doctors and consultants, because their colleagues in the profession are not always prepared to stand up and be counted.
I served on a regional health authority some years ago that forced a particular consultant to take early retirement. Although other doctors refused to work with him, they would not put anything in writing, because he was 389 a colleague. Actions such as forced early retirement benefit the patients, but cost the national health service a lot of money. It is a question of balance. I shall be interested to examine the Government's proposals in detail when they introduce a Bill.
Mention has been made of reclaiming sums from insurance for accident victims. Like many other hon. Members, I have constituents who have suffered accidents and, as a consequence, cannot work. That often leads to financial problems, such as falling behind with the mortgage. That is not always the best time to try to get money from people, unless it can be done efficiently and cost-effectively. If a new agency is to be established to try to get money from insurance companies via patients, it must do so efficiently and effectively. We must test its success pound for pound.
In their publication "Our Healthier Nation", the Government stated that stroke and heart disease would be one of their four main priorities. However, the Stroke Association was a little exercised when the "national priorities for health" guidance, which was sent to chief executives of health authorities, failed to mention it. The Stroke Association viewed that as either simply an omission or a change in the Government's priorities.
The association is concerned because stroke is the third largest killer in this country, and the main cause of severe disability. Some £2.3 billion of resources from the health and social services budget is devoted to addressing that problem. It is not an exciting side of medicine—there is no fancy machinery—but the Stroke Association does valuable work improving people's thought processes and encouraging them to talk again and holding group sessions for stroke victims two or three times a week. That provides some respite for partners and carers who bear the brunt of caring for stroke victims.
Lord Skelmersdale issued a press release a few weeks ago to the effect that he would seek a meeting with the Secretary of State in order to gain a reassurance that strokes remain a high priority within the NHS. I hope that the message has got through to Richmond house, and that that assurance will be provided. My constituency on the beautiful south coast is rather more elderly than some, and, although there are young stroke victims these days, the elderly are particularly vulnerable to strokes.
Because it is reliant on blood products, the haemophiliac community gets really scythed down whenever anything goes wrong with them. In the last Parliament, the Government took the correct decision to compensate haemophiliacs with HIV.
As the Minister of State no doubt knows, there has been a campaign for compensation for the many haemophiliacs who contracted hepatitis C through NHS blood products. It is a great pity that, despite the campaign, the Secretary of State provided a written answer in July, only two days before the beginning of the summer recess, to say that the Government were not persuaded of the argument for compensating people with hepatitis C. Some of them will die, and they are concerned about looking after their families. They are finding life difficult. That issue needs to be reconsidered.
There has recently been a statement about Creutzfeldt-Jakob disease. If that is causing problems with blood products, it will affect haemophiliacs more than any other group, and they will experience problems first. I welcome the Government's decision to spend £30 million on blood 390 products, of which I know there is a shortage. That is a belt-and-braces approach, but we cannot take any risks with blood products, particularly for communities such as haemophiliacs.
I hope that, during this Parliament, I and other Members on both sides of the House can persuade the Government that sufferers from hepatitis C, who have difficult lives, deserve compensation to enable them to adjust to their problems.
§ Helen Jones (Warrington, North)
I shall address my remarks to the decisions on the health service and the announcements about that in the Gracious Speech.
I am conscious that I and others of my generation are children of the NHS; I was born into the NHS and I have never known anything else. We are therefore probably the most fortunate generation in this country's history. We have never had to fear the consequences of illness or worry about how to pay the doctor, as our mothers and grandmothers did. We have been able to benefit from huge advances in medicine and surgery without worrying about the size of our pay packets. It is precisely because my generation has benefited so much from the health service that we have a duty to protect and extend it so that others might benefit in their turn. That is our aim in this Session. We are working for nothing less than the modernisation and improvement of the health service to make it, once again, the envy of the world, because for the people whom we represent, nothing less is good enough.
The previous Government paid lip service to that duty but did not carry it out. We all remember them saying that the NHS was safe in their hands. I am sure that General Custer said the same to the 7th Cavalry. He probably said, "Stick with me boys and you'll be all right." Far from safeguarding the NHS, the Conservatives set about damaging it. They introduced a two-tier health service in which doctors and nurses were competing against one another not for patients' benefit but to satisfy their accountants. When the Conservatives left office, inequalities in health had grown so much that people in social class V had a mortality rate three times as high as those in social class I. So much for one-nation Conservatism.
The Conservative party's response—which we heard again today—was not to consider how those problems could be tackled, but to encourage more and more people to use private medicine and to subsidise that through the tax system. This afternoon, Conservative Members have talked not about providing good public services, but about how they could provide a route out of such services for those who could afford it.
The right hon. Member for Maidstone and The Weald (Miss Widdecombe) would no doubt tell us that such measures provide freedom of choice. They do, but what freedom is there for people in Bewsey in my constituency, which is the most deprived ward in north Cheshire, who, however hard they worked and saved, would never in a million years be able to afford private medicine? What choice is there for people who require geriatric nursing, long-term mental health care or other services that the private sector hardly touches? Those people rely, and always will, on good public services. We are determined that we will meet their needs and tackle the health inequalities that so disfigure this country.
391 In common with some of my hon. Friends, I still have on my bookshelf a samizdat copy of the Black report. The then Prime Minister, now Baroness Thatcher, did not like its conclusions, so she sought to suppress it, but health inequalities do not go away if we ignore them. They have got worse, as the Acheson report has revealed today. We are tackling those inequalities. We have appointed the first Minister for Public Health and changed the direction of the NHS so that it will not only treat illness but promote good health.
The north-west needs that change of direction more than most regions. Its mortality figures are the worst of any regional office area and they are much higher than those for England and Wales as a whole. In 1995, the last year for which I have complete figures, two thirds of all deaths were from circulatory problems and cancers, many of which were preventable. Those are not only figures on a balance sheet; they represent people suffering pain. It is the duty of Governments to tackle that.
The same inequalities are perpetuated in my constituency. Bewsey and two other wards—Poplars and Hulme—form part of the most deprived health district in my area. Their residents have higher rates of debilitating long-term illnesses and higher rates of cardiac surgery, but there is less uptake of preventive medical treatment such as child immunisation and cervical smear tests. They are poorly served in the quantity and quality of primary health care services. For example, they have a lower provision of health visitors than their needs would suggest. They have the lowest proportion of district nurses per members of the medical practice population aged over 65. They even get fewer knee and hip joint replacements than those living in the more affluent areas nearby.
If ever there was an argument for the Government's health improvement programmes and the use of primary care groups, it is evident every time that I go home. It is clear that, in the past, money and resources have not been allocated according to need and have not worked to improve health. That is precisely what the Government's programmes are designed to do. They will ensure that doctors and nurses, working in primary care groups with other agencies, deliver health improvement programmes.
§ Mr. David Heath (Somerton and Frome)
I agree with much of the hon. Lady's speech. Does she not agree that it is a shame that primary care groups will essentially be general practitioner groups and will not sufficiently include other health care professionals, such as dentists, optometrists and pharmacists? They should be involved; they could provide business skills and would contribute to the holistic approach that she is advocating.
§ Helen Jones
I do not agree with the hon. Gentleman's view that primary care groups will consist of only doctors. They will include doctors and nurses, who will have the right to work with other health care professionals. We have heard much about bureaucracy. The hon. Gentleman's suggestion would add further layers of bureaucracy to the NHS. For my constituents, the programme is not an optional extra; it is vital to their well-being and, in some cases, to their lives.
I welcome that change in direction, but I say to my right hon. Friend the Minister of State that we must also change direction in other areas of the NHS. Mental health 392 has been neglected for far too long, and care in the community has been introduced without the necessary back-up services. I know that there are differences of opinion on that matter in the House. Care in the community can work well, but it is not a cheap or easy option. It needs to operate alongside a range of services such as help lines, counselling and 24-crisis intervention teams, which work well in many areas and which help to meet the spectrum of people's needs.
We also need to consider innovative projects such as the Gatehouse assessment centre in Warrington, where there is a dedicated and enthusiastic team of staff who have created a multi-disciplinary way of working. They offer a range of physical treatments but also relaxation classes, health education counselling and even aromatherapy. More important, they have developed a system of clinical nurse assessment which has been validated and which has been proved to work well. It is that kind of forward thinking and multi-disciplinary approach that we need to encourage across the health service, not only in respect of mental health.
We want staff to be able to use and develop their skills; in return, they have to be accountable for what they do. We recognise that the vast majority of people are happy with the treatment that they receive, but when things go wrong—which, tragically, they sometimes do—it is important that mistakes are acknowledged and put right straight away. The commission for health improvement and the plans for clinical audit will have a major part to play in raising standards and in making sure that we learn from mistakes and that people get the most effective treatment. However, that by itself will not be enough.
The Select Committee on Public Administration, of which I am a member, has already heard too much about a reluctance by some doctors and trusts to admit mistakes, to acknowledge patients' need, or even to give simple information. They are a minority, but they have to realise that such attitudes have no place in a modern health service. Sir Lancelot Spratt died a long time ago. Consultants can no longer play God, and administrators and chairmen of trusts have to be accountable.
§ Mr. Iain Duncan Smith (Chingford and Woodford Green)
Matron is still with us.
§ Helen Jones
I take that for granted.
While we require accountability on the part of staff, we must make sure that they are registered and regulated properly. The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) mentioned this in passing. I hope that the review of the Nurses, Midwives and Health Visitors Act 1997, which the Minister is carrying out, will not only ensure stricter checks on the registration of nurses but will examine how we can protect the title of nurse. It is a mystery to me why people cannot call themselves midwives unless they are registered midwives, but can call themselves nurses so long as they do not claim to be registered.
I hope that we shall also make sure that if people are removed from the nursing register, they are not able to get jobs elsewhere in the health service or in social services, perhaps as a health care assistant or in some other capacity where they are still working with vulnerable people.
The NHS has moved on and developed new techniques and skills, but our systems of registration have not necessarily caught up with them. Let us consider the 393 example of operating theatre practitioners. They do not have to be registered—there is only a voluntary code. However, their jobs are often interchangeable with those of theatre nurses. In fact, trusts often advertise for a nurse or an OTP. Certainly, nurses and OTPs have the same access to sensitive equipment and controlled drugs yet, if an OTP abuses his position, he cannot be removed from a register, unlike the nurse working alongside him, and is quite free to get a job elsewhere.
The public deserve better from us, just as they need us to examine the way in which we register people practising as psychotherapists and physiotherapists and the restrictions that we place on them as to whether they can call themselves psychotherapists and physiotherapists. The good and conscientious staff working in the NHS deserve that protection. Their standing should not be damaged by charlatans who should not be practising.
There is much that needs to be done. This is a period of great change and great opportunity. I am pleased that we now have a Government who will tackle the various difficulties. As I said, like most of my generation, I am a child of the NHS. Perhaps our generation was in danger of taking the NHS too much for granted. However, after the last 18 years, we will not be in danger of doing that again. Because the NHS has been under attack, we have learned how precious it is. I hope that the Government will ensure that the NHS returns to the principle of its founder, who clearly said that private charity is no substitute for organised justice. It is organised justice and equality of health care that we want in the NHS, and I hope that the Government will ensure that that is what we have.
§ Mr. Simon Burns (West Chelmsford)
Like the hon. Member for Warrington, North (Helen Jones), I, too, am a child of the national health service, but I also had the privilege of being a Health Minister. This is the first time since 2 May last year that I have contributed to a debate on the health service. That was a deliberate decision, and I want to take part in this important debate because of my concern about what I believe to be a glaring omission in the Queen's Speech. That glaring omission is the absence of anything positive and concrete to deal with the problem of hospital waiting lists.
I am delighted that my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) is present. She has done a great deal of work in the past few months to highlight the problems suffered by our constituents as a result of rising waiting lists. I share a district health trust area with my hon. Friend the Member for Maldon and East Chelmsford (Mr. Whittingdale), who is as concerned as I am about what is happening in the Mid-Essex hospital trust area. Sadly, the Minister for Public Health has had to leave the Chamber, but I am delighted that the Secretary of State for Social Security is present. I shall put to him several questions to which I hope he will have the courtesy to respond when he winds up the debate. My constituents desperately want answers to them.
When the Secretary of State for Health opened the debate, he was very dismissive of my intervention in respect of hospital waiting lists. My constituents will be extremely disappointed that he sought to brush aside my valid point by saying that he did not know where the figures came from and so was not prepared to say anything about them.
394 The figures came from written answers sent to me by the Minister for Public Health on 22 October and on 9 and 17 November. Therefore, the figures that I shall cite, which illustrate my concern about the lack of action proposed in the Queen's Speech, have not been dreamed up by the Conservative research department to embarrass the Government. They are figures put into the public domain by the Department of Health and the Minister for Public Health, so I assume that even the Government will accept that they are accurate and honest.
As I said, I am concerned about hospital waiting lists in the Mid-Essex hospital trust area and about the lack of any measure to tackle that problem in the Queen's Speech. Let me share with the House the scale of the problem facing my constituents.
During the general election, a little plastic credit card was circulated. It had on it a photograph, taken by Lord Snowdon, of the right hon. Gentleman who is now the Prime Minister. On the back of the card were several irrevocable pledges on which I think the Prime Minister wants his Government to be judged. One of them was that they would reduce waiting lists.
It goes without saying that, since early 1991, my right hon. Friend the Member for Huntingdon (Mr. Major), the former Prime Minister, targeted money each year specifically to bring down waiting lists. We started by eliminating lists of those waiting for more than 24 months. Waiting times were then brought down to under 24 months, then 18 months, and then, for non-emergency treatment, to between 12 and a maximum of 18 months.
During the election campaign, all hon. Members and their opponents had six weeks to canvass. I vividly remember my Labour opponent and the Labour party at large throughout the country saying, "Elect new Labour. We pledge to bring down waiting lists"—not increase them. The campaign was so frenetic that Labour created the perception and raised the expectation that, under new Labour, people would be able to walk into their local hospital on the day that a problem was identified and surgeons would queue up to treat them. The country believed that, if there were a Labour Government, waiting lists would fall and non-emergency hospital treatment would be available infinitely more quickly.
What happened? From day one of this new Labour Government, hospital waiting lists for non-emergency treatments have risen inexorably. My constituents cannot turn up at Broomfield hospital and immediately have the operation that they need. Funnily enough, they are put on a waiting list. Let us consider what has happened to those waiting lists. So that nobody thinks that the Conservative research department is painting a terrible picture, I add the caveat that the following figures are from the Government.
On 31 March 1997, the number of people in the Mid-Essex hospital services NHS trust area waiting 12 months or more for non-emergency hospital treatment was 104. The latest figures that the Government have produced are for 30 September 1998—after 18 months of a new Labour Government, under whom, apparently, there would be no problems with hospital waiting lists. They show that 1,155 people are waiting. The Secretary of State for Health suggested that the country should be thanking him for what he is doing on hospital waiting lists. Nobody on a list in my constituency has anything to thank him for.
395 The Secretary of States says that waiting lists are coming down, so people might think that the peak has been reached and that the number of people waiting fell to 1,155 on 30 September. Not a bit of it. On 31 August, a month before, 1,063 people were waiting. Month after month, hospital waiting lists in the Mid-Essex area have increased dramatically, in utter contravention of pledges and promises given on the doorstep during the election campaign in West Chelmsford and throughout the country by the Prime Minister down to the most junior new Labour Back Bencher.
§ Mr. Fabricant
I want to probe my hon. Friend. Does he think that Labour candidates deliberately misled and lied to the electorate, or were they just naive?
§ Ms Ann Coffey (Stockport)
Think about it.
§ Mr. Burns
Given my anger at what has happened to my constituents, I am thinking, first, that I do not want to use unparliamentary language and secondly, that even Labour politicians are basically decent human beings. I think that they were spun out of control by the prince of darkness and spin doctors in Millbank because they were desperate to get into power. They saw an emotive issue and milked it for all its worth.
Over the past few months, my right hon. Friend the Member for Maidstone and The Weald has highlighted the fiddle that has been going on in an attempt to remedy the political damage caused by the Government's appalling waiting lists. The Government cannot fiddle figures in my constituency for a very simple reason: the number of people waiting for 12 months or more for hospital treatment has risen so dramatically. Nobody can dispute that; even the Government have produced figures to show it.
Let us get under the skin of the figures: let us consider the numbers of people who are waiting to see a consultant following a GP visit—even before they are put on a waiting list for hospital treatment. They, too, are appalling. On 31 March 1997, the number of such people waiting between 13 and 25 weeks in the Mid-Essex area was 481. By 30 June this year—the last month for which figures for this category are available—the figure had escalated to 1,348. In March 1997, 74 unfortunate people were waiting 26 weeks or more to see a consultant, but by 30 June this year, the figure was 256. In only 14 months of a Labour Government, even the number of people waiting for more than 13 weeks to see a consultant rose from a maximum of 555 to 1,604. That does not suggest that new Labour is honouring its pledges to the people of the Mid-Essex area.
The total number of people waiting in Mid-Essex for hospital treatment for any period of time was 8,391 on 31 March 1997. The latest figure, 18 months after the Government came to power, having pledged to bring down waiting lists—unlike, apparently, the previous Government, who did reduce waiting lists—was 11,615. I repeat that those are not my figures.
In written answers, the Minister for Public Health happened to say—I welcome this—that North Essex health authority is working with the waiting list task force to see what can be done to meet its target of reducing 396 waiting lists by 31 March 1999, which is almost two years after the Government came to power. That intrigued me; nowhere in the answer did it say what the target was. I thought, "Wonderful!" I thought that the Government must be so concerned that, according to the Sunday papers last weekend, the area has the highest waiting lists in the country, and so embarrassed about breaking their pledge that they are pouring loads of extra money and expertise into the area so that fewer people will have to wait than did when they came to power. I tabled some more questions. Hon. Members can imagine my disappointment when I discovered that that was not so.
I welcome any target that reduces waiting lists so that fewer people have to wait—and wait for less time—for hospital treatment. However, the Government's target is very modest: to reduce the figure from 11,615 to 9,738—about 1,400 people more than when they came to power. What sort of target is that?
I pray that we do not have a hard winter. As anybody who has worked or been involved at ministerial level in the health service knows, the winter crisis period is the most worrying time for the Government of the day and the NHS. If there is a harsh winter, the number of illnesses and of people needing operations rises dramatically. That is regrettable, and can throw even the best-laid plans for treating more people more quickly. Even if we ignore that consideration, however, the Government's target for waiting lists in Mid-Essex is incredibly modest. It is still the case that significantly more people are on the waiting list than when the Government came to power.
It is ironic that a Government and a Prime Minister who have made such a deal—day after day—about keeping their promises have not kept their promises to my constituents who are ill and need non-emergency operations and other hospital treatment. More and more of them are having to wait longer and longer under new Labour.
Let me say one more thing on this subject. I wonder what the West Chelmsford Labour party thinks. We have not heard a dicky bird from it on this subject over the past 18 months. I understand how ashamed it is, but one would have thought that its candidate at the last election—who happens to be a consultant in psychiatry in the Mid-Essex community and mental health trust working at Broomfield hospital, which is at the heart of the health trust area—might have had something to say. He made a big deal—citing his medical background when talking to my constituents on the doorstep and in his literature—of the fact that his party's Government, like a new Jerusalem, would cure my constituents' problem. The irony is that their problem is infinitely worse under his party's Government than it ever was under my party's Government. Under my party's Government, waiting lists were reduced in the Mid-Essex hospital trust area.
I realise that the Secretary of State who will reply is responsible for social security rather than health, but, because the Secretary of State for Health was not prepared to discuss the issue earlier, I ask him to give me some answers when he winds up the debate. I do not want to hear the usual platitudes about what the Government are doing.
I would be grateful if the Secretary of State would listen for a minute, rather than talking to the Whip about—presumably—an entirely different matter. He might then be able to give a specific answer to my questions. 397 Why have my hospital waiting lists lengthened? Why is the target for reducing them by March next year 1,400 higher than the target set by the Government when they came to power? Why has this happened under new Labour, which promised to reduce hospital waiting lists?
Let me now pick up an important point made by the hon. Member for Warrington, North. She spoke knowledgeably about mental health, and implied that, like me, she considered that for too long mental health services have been the Cinderella of the NHS. They have been underfunded and pushed aside by Governments of all political parties—
§ Mr. Burns
As I said, it happened under Governments of all political parties. Let me reply to the hon. Member for Stockport (Ms Coffey). Over the past five years, mental illness has been given much more recognition, and much more priority. More and more money was channelled into it as the Government tried to help to change attitudes, both in the medical profession—where, sadly, the wrong attitudes still obtained—and outside it. They wanted to break down the barriers, and to end the prejudices afflicting mentally ill people. I am sorry that the Queen's Speech contained no specific measures to deal with that, but I recognise that the Department and the relevant Minister are examining the whole subject of mental health.
I hope that arrangements regarding patients in the community will be tightened. I am not saying for a moment that caring for such patients in the community is the wrong policy, but I think that the policy should be improved in certain respects. One example that we have seen over the last few days showed, tragically, that something must be done—not, I hope, in a party political way. I look forward to hearing an announcement from the Department of Health. I hope that the Department will come up with a framework allowing people of all political persuasions to work together to improve the medical care and physical well-being of mentally ill people.
It is equally important for much more to be done—by us, using our positions of responsibility, but also by the medical profession and the voluntary sector—to end the horrendous prejudice that affects the mentally ill. Everyone sympathises with someone who has appendicitis or flu, telephoning and sending flowers and good wishes. The awful thing about our society is what happens to those with mental health problems. This tends to be forgotten.
All too often, because of the prejudice that they know to exist, relatives will try to hide the fact that a member of the family is suffering from a mental health problem. Far too few people will telephone, show genuine interest or send flowers. Mental illness is a stigma: it is something that must be brushed under the carpet. People suffering from mental illness are suffering through no fault of their own, like people suffering from flu. The barriers that have built up are unacceptable in a society that is heading towards the millennium.
I look forward to the Government's announcements, and hope that they will tackle many of the problems that desperately need to be tackled in the next few months.
§ Dr. Alan Whitehead (Southampton, Test)
I am pleased to see that the hon. Member for Lichfield (Mr. Fabricant) is present, and sad to see that the right hon. Member for Henley (Mr. Heseltine) is not. Both made interesting speeches. The hon. Member for Lichfield spoke of the recent history of the national health service, which is an interesting subject, although I did not agree with all that he said. He assumed that a background of common sense existed; I can only put it like that.
In what could kindly be termed a wide-ranging speech, the right hon. Member for Henley concentrated on best value in local government, and a number of associated issues. He demonstrated comprehensively that he had signally failed to understand the first thing about what the Government are saying about best value, assuming that his prejudices of many years ago still hold true. In discussing GP fundholding and best value in local government, both speakers implied that what they had suggested—suggestions that preceded the two proposals in the Gracious Speech—was common sense, and that the Government's proposals were, in some way, deeply ideological.
Interestingly, the right hon. Member for Maidstone and The Weald (Miss Widdecombe) could hardly contain herself before, after a few minutes, claiming that the GP commissioning bodies that the Government propose were aimed to collectivise the profession. It seems that Opposition Members are saying that they have adopted a commonsense position and that the Government are attempting to introduce ideology into the provision of public services. My view is that the contrary is true. The Government are attempting to undo the damage that was inflicted by the previous, deeply ideological, Government by the Acts that they introduced, which brought about compulsory competitive tendering, general practitioner fundholding and the internal market in the health service.
By way of evidence, I shall read a brief quotation from 1993 from William Waldegrave. I shall be interested to see whether anyone on the Conservative Benches nods when I read it. The right hon. Gentleman said:The key point is not whether those who run our public services are elected, but whether they are producer-responsive or consumer-responsive. Services are not necessarily made to respond to the public by giving our citizens a democratic voice, and a distant and diffuse one at that, in their make-up. They can be made responsive by giving the public choices, or by instituting mechanisms which build in publicly-approved standards and redress when they are not attained.If any Opposition Members are thinking to themselves that that sounds perfectly fine and a reasonable argument, that demonstrates why the Conservative party so comprehensively lost the 1997 election and why it is so far out of touch with what the public these days are thinking.
The quote suggests, as have some of the contributions to the debate, that Opposition Members are still thinking about public services as if they are cans of pineapple—as if we can buy and sell them. They seem to think that they can be obtained off the shelf and that if they prove to be defective they can be taken back and the shop will replace them. They seem to think that it is all about customers going into stores and buying commodities.
I suggest that public services are not capable of being boiled down to the whims of the market. However, that is the course that the previous Government took in the 399 public service areas that we are discussing. Those who required good public services in both health and local government had foisted on them GP fundholding and compulsory competitive tendering. Those policies arose from the assumptions that the market is always superior to the public service ethos; that competition would of itself sort out any problems that might arise; and that both would inevitably produce a better service.
Those who have argued that the Government would wish simply to remove the internal market from the health service and from local government should understand that the issue is not that competition is never right for public service provision. If, for example, I wish to organise the purchase of some textbooks or some roughbooks for a school, I can think of no better method than to specify what I require, obtain tenders and opt for the cheapest one, provided that it meets what my specification sought to achieve. That tender would win. However, as competition attempts to deal with issues that become ever more complex, it becomes increasingly apparent that we cannot apply it on the basis of one size fits all to the public service.
That is what happened in local government with compulsory competitive tendering. Whatever the circumstances were, the previous Government slapped on competition. That is what happened in the health service. The previous Government attempted systematically to introduce crude competition in the quasi-market that they sought to establish throughout the health service. Similarly, they introduced GP fundholding to try to make GPs subject to the market in the way in which they dealt with their patients and in organising their own practices.
It is interesting and instructive to examine the claims that were made against these systems and compare them with the outcomes. It was claimed that competition itself would solve the problems. We were told that GP fundholding would make more efficient use of services; break down bureaucracy; liberate doctors to enable them to take better decisions; and ensure better care for patients. We were told also that CCT would save us money and improve services at the same time. It is clear, a few years on from both those deeply ideological impositions, that there is no evidence overall that that has happened.
That is not to deny that many GPs have made a success of their fundholding practices within the terms within which they were required to work. Nor do we decry the idea that many local government employees have worked hard to win and hold the contracts that they were asked to bid and compete for in local government. However, if we look—
§ Mr. Eric Pickles (Brentwood and Ongar)
Does the hon. Gentleman therefore believe Sir Jeremy Beecham, the head of the Local Government Association, when he said that there can be no doubt that compulsory competitive tendering brought much benefit to local government, increased efficiency and reduced costs? Is Sir Jeremy wrong in that assessment?
§ Dr. Whitehead
I was referring to the original claims which were made by those who instituted CCT. They talked about huge savings and huge increases in services. I have emphasised that many council workers have 400 worked hard, with their local authorities, to ensure that, within the terms presented, to them CCT was a success in that services and efficiencies were maintained.
Several studies, particularly that of the London business school, have demonstrated, among other things, that if we take into account the transactional costs of CCT—those things that were taken out of the equation when the original claims were made by Government as to the successes that CCT would introduce—it is not possible to identify the savings that the previous Government suggested. Furthermore—
§ Mr. Pickles
§ Dr. Whitehead
I ask the hon. Gentleman to bear with me while I make my point. I shall then let him intervene again.
If a service is removed from local government and taken into the private sector for contracting, there is strong evidence that costs arise once there is not a public sector yardstick against which the private sector can compete. Consequently, private sector cartels have arisen in the long term in CCT provision. There is strong evidence that there are such cartels among CCT providers. That is evidence that refutes the claims made by the original proponents of CCT.
§ Mr. Pickles
Sir Jeremy Beecham is a respected figure in local government and a respected member of the Labour party. Is he right or is he wrong? Yes or no?
§ Dr. Whitehead
I was attempting to set out for the hon. Gentleman the fact that the claims originally made by the Conservative Government about CCT have proved not to be right in practice. The result of the long implementation of CCT is that a number of things have changed. Sir Jeremy Beecham was reflecting that fact. If we examine the overall results of both fundholding and CCT, it is apparent that the results have been destructive in terms of public service delivery and ethos. Fundholding has introduced buying and selling into what should be a straightforward relationship between the doctor and his or her patients. Fundholding has led to a two-tier NHS, and the idea that the patients of those who did not opt for what Conservative Members assured us was a voluntary move to fundholding are not treated in the same way as fundholding doctors' patients.
Fundholding has undoubtedly led to a large increase in bureaucracy, not only within GPs practices, but because transactions outside GP practices have had to be accounted for within the internal market that has been created within the NHS. It has led to additional duties for doctors. They have had to run what, in effect, are small businesses, when many of them wanted to ensure that they delivered the best possible medical service to their patients.
Fundholding has led to decisions on patient lists and on drug availability that set the market and doctors' clinical judgments against each other. Although the evidence points in many directions, the suspicion remains that in some cases, in order to balance the books, some fundholding practices appear to have attempted to remove from their lists patients who proved to be costly, awkward or difficult. All those outcomes contradict the basic idea of what a doctor's relationship with his or her patients should be.
401 Compulsory competitive tendering has led to the effective casualisation of much of the local authority labour force. It has made local authorities unable to respond effectively to the needs of their communities once contracts were fixed. If the material circumstances changed, if the local authority wished to take a different role in its relationship with the community, or if the community made different requests of the local authority, nothing could be done, because the contract had been given out and that was the end of the matter.
CCT deeply damaged the democratic process, as it was unclear who was responsible for a particular service. I know of many instances in which members of the public experienced great frustration when they went down to the town hall to complain and were passed on, properly, to a contractor who they did not believe had anything to do with the service. When they sought redress, they were told that the contract had been given out, the matter was the contractor's responsibility and they must deal with the contractor.
As I said earlier, CCT led to the development of large transactional costs as the client side monitored the process of tendering and policed its outcome, whether or not the internal labour force won the contract or the contract went out to an external organisation.
All those destructive effects will be avoided through the measures announced in the Gracious Speech. The development of primary care groups will enable various professionals—not just doctors but, as we have heard, nurses and some specialties—to become involved at local level. We know that the multifunds—forerunners of primary care groups that were set up in Southampton—brought in specialist clinics to allow the participation of various specialties at immediate ground level, enabling them to co-operate to provide a better service.
Instead of competing, GPs and other primary health carers will be able to collaborate in the running of services. Resources overall will be used to best advantage. Best value will allow local authorities to engage in the method of service delivery most suited to the service, the area and a productive dialogue with the local community. Any business man understands that much better results will be obtained from a long-term relationship with a contractor, whoever that may be, by growing and altering the contract according to how he wants the service to develop, as opposed to the regime of the brown envelope, which destroys everything that has been achieved and makes it necessary to start all over again.
Local government will be reconnected to local communities. Before a service is decided on, local government officials will have to discuss with the community what the targets are and how the service should be delivered. The local authority will be required to justify to its community and to the Audit Commission—a fact that was apparently unknown to the right hon. Member for Henley—what the service will comprise.
I congratulate the Government on introducing these measures, which demonstrate that at last we are out of the dark tunnel of dogma which, for the past decade and a half, has plagued the provision of much-needed services. The measures will restore to public service professional pride in providing good services, using all the skills and imagination that we know public service professionals possess. The public will get good services from 402 management that is responsive to the needs of the community. The Gracious Speech represents a good day for public service and demonstrates that the Government are determined to make sure that what works best for the community will form the basis of their legislative programmes in the future.
§ Mr. David Rendel (Newbury)
Welfare reform is heralded as one of the central measures of this year's Queen's Speech, and has been heralded as one of the Government's principal measures, so I am rather concerned that there was nothing in the speech about some of the most important aspects of welfare reform.
One example is the issue of compulsory second-tier pensions, which I believe is still unresolved in the Government's mind. As my hon. Friend the Member for Roxburgh and Berwickshire (Mr. Kirkwood) pointed out, there is no mention in the Queen's Speech of the Child Support Agency. I hope that that was an unfortunate omission.
Where are the means of tackling poverty, social exclusion, and health and income inequalities? Other hon. Members have noted that those are also omitted from the Queen's speech. I would have expected the Government to begin to tackle those issues.
The Liberal Democrats support the principle of welfare reform because we believe that the current system contains a number of significant deficiencies. It traps people in benefit, yet it fails to deliver effective help where it is most needed, not least because of the sheer complexity of the benefits system. As we have heard, there is the continuing problem of fraud and the waste of money that it causes.
However, we reject the argument, to which the present Government and the previous one were happy to subscribe, that there is a spending crisis in social security. We should never forget that in Britain we spend rather less on social security than most of our competitor countries in Europe. The real problem of welfare spending is not that we are spending too much overall, but that not enough of the money reaches those in greatest need.
The Secretary of State's answer is to repeat the phrasework for those who can and security for those who cannotso often that it is beginning to sound like a mantra. He must grasp the nettle and make the basic philosophical decision, which he and his Government do not seem to have made yet, whether to extend means testing, with all the associated disincentives to work and to save, or whether to focus purely on getting people back into work. His Government will not make real progress with welfare reform unless and until he and they make that decision.
I shall deal with the Bills proposed in the Queen's Speech. The publication of the Bill to introduce the working families tax credit will, I hope, clear up many of the detailed concerns that we and others still have. The Liberal Democrats are concerned that the Government still does not know how they will deliver the credit. For example, how will it work for someone who has several employers?
Although the principle may be laudable, where is the evidence that tax credits are a positive work incentive? Evidence given to the Select Committee suggests that the Government are acting on a hunch. Tax credits have not 403 always worked in other countries. I was surprised to discover that the Tories oppose the measure. After all, they planned to introduce a similar credit in the 1980s, but failed to do so when they could not overcome the arguments about purse-into-wallet transfers and the large burden on businesses. Sadly, the Labour Government have not solved those problems either. It is sad that they have taken up a failed Tory policy, but it is ridiculous for the Tories to claim that they want nothing to do with it.
On the cuts in benefit that will result from some of the measures in the Queen's Speech, the changes to incapacity benefit are a clear example of the Government's gradual abandonment of the contributory principle. Means-testing incapacity benefit claimants who have occupational pensions simply punishes those who have made provision for their future. Do we want to provide such a disincentive to saving? The cuts involved, which represent a real loss of cash to people who may have considerable medical problems, are huge. Let us compare that with what the previous Secretary of State said.
On 28 March 1997, following a meeting with the all-party disablement group, that group and the then Secretary of State issued a joint press release which stated:The savings to incapacity benefit would come through getting more people into work, not through reducing the level of incapacity benefit, or entitlement to it.What a contrast that is.
§ Mr. Vernon Coaker (Gedling)
My experience in some of the mining communities in Nottinghamshire and elsewhere is that incapacity benefit was used as a convenient way of getting people out of mining jobs without sacking them. If that was one of the ways in which incapacity benefit was used, it is not unreasonable to consider how it works and to see whether that can be improved.
§ Mr. Rendel
Looking at the way in which the benefit works is different from cutting it off from those who need it.
My next concern is the decision to restrict the severe disablement allowance to those disabled before the age of 20. That measure will cause great financial hardship for students and others who have become disabled after the age of 20, who, legitimately, have not been in a position to pay any national insurance contributions and thus obtain incapacity benefit. There will be several in that position. Even if the Government do not reverse the measure, I hope that they will at least think of increasing the age limit at which that cut-off comes so that those who have not yet reached the stage of earning and paying national insurance contributions are not hampered by the measure.
If the Government go ahead, that is another area in which they will be forcing more people on to means-tested benefits. That reform alone will force 70 per cent. of those previously eligible for severe disablement allowance on to means-tested benefits. Furthermore, despite the Government's claim to be women-friendly, the measure will penalise a disproportionate number of women who comprise some two thirds of those who claim that allowance.
404 More welcome is the measure to extend to widowers the benefit that currently goes to widows. There is no case for discriminating between women and men in this area, and it is therefore of little credit to the Government that they had that change of mind only when forced to do so by a case in the European Court.
There are aspects to the changes to widows benefit about which I am concerned, as I hope all hon. Members are. Not least is the fact that the Government seem so desperate to make savings that they will penalise the recently bereaved. In particular, to limit the new bereavement allowance to just six months is far too short. Losing a spouse is about the most traumatic of all life events, and those who do so unexpectedly in middle age need a decent period of adjustment before they can be expected to stand entirely on their own feet again. It can be difficult for widows who are not working at the time of an unexpected bereavement, suddenly to have to re-enter the job market successfully, and the measures make no real allowance for that.
A widow wrote to me recently expressing her concern about the changes and how they erode the contributory principle. She said:After 24 years of marriage, my husband died leaving me a widow at 50 … I was absolutely devastated. There is just no way I could have gone back to teaching and frankly would have had no chance of being employed at that age, having been out of touch. My widow's pension of £90 per week was an absolute lifeline. My husband had, after all, paid all his NI contributions and SERPS all his life and was to receive no pension in return, due to his early death.We welcome the provision of a one-stop shop as part of a single gateway to benefits. The current system fails to deliver effective help to many people precisely because of the complexity of claiming different benefits with different rules from different offices. But a gateway can be one of two things. It can open up access to the land beyond, or it can be used to close off a bottleneck and to prevent access. We will welcome the gateway if it opens up access to benefits, but not if it is used merely as a mechanism for denying benefits to claimants.
While the measure has the welcome effect of narrowing the possibilities for fraud in the system, we are concerned that, by refusing benefit until an interview has taken place, many vulnerable people may be left without money at a time when it is most needed. The introduction of the element of compulsion may well undermine any good will towards the welfare-to-work schemes and discourage co-operation.
The establishment of a disability rights commission is welcome, but long overdue. The Liberal Democrats have been calling for such a commission for many years, and we hope that the Government will give it the power that it needs to do a good job and to ensure that real progress is made.
I come now to what is missing from the Queen's Speech. We still await the Green Paper on pensions. We have been waiting for it for many months. There are some who think that we will be earning our own pensions before it is published. The problem seems to be that the Government remain determined to postpone a decision on whether to introduce compulsory second-tier pensions.
Will the Secretary of State make it clear to the Chancellor, who I believe is the current stumbling block, that there is a significant difference between compulsory 405 savings put into a fund for an individual's own retirement, and compulsory taxation used for current Government expenditure. The Chancellor needs to appreciate that crucial difference.
We are also disappointed that there is no mention of a draft Bill to reform the Child Support Agency. That may be because the Government intend to take more time to listen to the concerns being voiced about their proposals. I hope so. Will the Secretary of State assure me that the draft Bill will go to the Select Committee on Social Security this Session, despite the absence of any such pledge from the Queen's Speech? It is important that we have the opportunity to put right the wrongs associated with the current Act, and that we are not simply expected to go along with the Government's plans.
What about the 6 million carers in the United Kingdom who provide support worth around £34 billion a year? Despite manifesto commitments, there is no mention in the Queen's Speech of the introduction of a citizenship pension, which would help those carers who cannot make provision for their own second-tier pensions.
One point which has not so far received much attention is the size of this year's proposed cuts in benefits, which is far greater than those which were threatened last year. Last year's smaller cuts were, for the most part, reversed by the previous Secretary of State, in many cases before they had even taken effect, although not in the case of the lone parent benefit cut. This year's cuts amount to a much larger sum—some £1.25 billion.
I look forward once again, I hope, to enjoying the support of Labour Back Benchers in trying to reverse some of the cuts, as we did so successfully last year with the enormous revolt against the cut in lone parent benefit. Perhaps this time we can overturn some of the proposals before the Government get themselves so hopelessly stuck in a corner that they find it difficult to get out without embarrassment, as they did last year.
Health and social security are both areas where there are major differences between the Liberal Democrats and the Government. I can assure the Government that they will have our support on matters on which we agree, but my team will most certainly oppose the Government whole-heartedly on matters on which we do not.
§ Mr. Stephen Hesford (Wirral, West)
There are a number of reasons why I feel moved to speak tonight—
§ Mr. Pickles
Because you were told to do so by the Government Whips.
§ Mr. Hesford
I have not sat here as long as I have for that reason. Opposition Members may laugh, but I notice that no shadow health spokesmen are present at the moment. None of those hon. Members whose speeches I intend to examine in a moment is present.
There are a number of reasons why I need to speak on health matters. It is the 50th anniversary of the NHS—an important event for this country. In my constituency in the summer, I was honoured to welcome current and past hospital and community service staff to an event. The thousands of local people who turned out at the fair based around that event showed that the British people have the well-being of the NHS in their hearts.
406 Another reason why I wish to speak on health matters concerns what the electorate were telling me prior to the election. I represent a constituency that was not a Labour seat before the election—indeed, it had never been a Labour seat until the election. One of the reasons it became a Labour seat for the first time was that previously lifelong Conservative voters told me that the NHS was not safe in the hands of the Conservative party.
The subject of the debate shows the genuine divide between the Government and the Opposition, and the debate has been illuminating for a young Back Bencher to behold. I have altered the nature of my speech to deal with the manner of the Opposition in this debate on the Gracious Address. I will not take the mock horror and concern that the right hon. Member for Maidstone and The Weald (Miss Widdecombe) showed when her hon. Friend the Member for West Chelmsford (Mr. Burns) was talking about increasing waiting lists—and, more importantly, neither will my constituents. Nobody was fooled.
The fact that the right hon. Member for Maidstone and The Weald was chosen to lead on health for the Opposition demonstrates without qualification where the Tory party stands on the health service. The tenet of her rant—I hope that that is parliamentary language, Mr. Deputy Speaker—was to put the frighteners on. What was her purpose in trying to do that to my constituents, including the many who were previously lifelong Tory voters? She knows that, at the last election, the Tories were spotted on health, and had come to the end of their tether.
The right hon. Member for Maidstone and The Weald said that the Government's proposals—which I welcome, and to which I hope to return—would cause top-to-bottom turbulence. She and other Opposition Members were showing selective amnesia, and should think back to the absolute turbulence caused by the reforms of the previous Government. In an intervention on the hon. Member for Lichfield (Mr. Fabricant), my hon. Friend the Member for Southampton, Test (Dr. Whitehead) pointed out that, in 1982–83, the Conservative Government tried to reform the NHS. The hon. Member for Lichfield had to accept that those reforms failed.
The general public—and, no doubt, some hon. Members—will have a longer and less selective memory than Conservative Members. They will recall the sad case in Birmingham around 1986–87, when a baby died because it could not gain admission to the right hospital at the right time. That caused consternation in the Conservative party and was the cause of the National Health Service and Community Care Act 1990, which forced fundholding and the internal market upon us. It was politically expedient. My hon. Friend the Member for Southampton, Test used the words "ideologically driven," and he was right.
It is a bit rich for the right hon. Member for Maidstone and The Weald to say that we are the cause of the turbulence. Not at all. The electorate asked us to sort out the health service, and that is what the proposed legislation will be about. Other hon. Members have referred to that matter, and I hope to return to the subject.
The right hon. Lady attempted to frighten my constituents by saying that people are still on trolleys. Whether or not that is the case—the right hon. Lady was able to give only two examples—the general public 407 and hon. Members know who invented that process. From where did we inherit that problem? If a few hospitals are still in that situation—I will not comment on the right hon. Lady's examples—it is because, after 18 months, we are still trying to get at the backlog that was created under the previous Government. Their arguments will not wash.
The right hon. Lady was selective in her use of statistics, which was not very sophisticated. She said that, in a British Medical Association opinion poll, 55 per cent. of general practitioners stated that they did not want anything to do with the running of primary care groups. Any scrutiny of that sentence gives it away—all it means is that many in the profession do not want to be on the boards. It does not mean that they do not agree with the primary care group proposal. The House will know that PCG boards will not be large and, by definition, not many GPs will be able to have anything to do with their running.
The right hon. Lady talked about levelling up and not levelling down in the context of GP fundholding. She attempted, and failed, to make the point that GP fundholding was designed to improve services for everybody. What happened in practice? The right hon. Lady and the hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) can have no hiding place on this topic. Fundholding has been in place for seven years, and during that time just over half our GP practices went for, or said that they intended to go for, fundholding.
Where was the ringing endorsement after seven years? Why was there a delay in practices switching to fundholding? Why did the Conservative Government have to change the rules time and again to try to get people who were not really willing partners to join in? By the end of the seven years, there were four different versions of GP fundholding. Many GPs have told me that they signed up to the last wave only because there was an unconvincing inevitability about it. They did not want to do it, but they felt that they had to.
There was no levelling up because, crucially, fundholding created a two-tier system, setting GP against GP and making planning difficult. The system was expensive and bureaucratic, and patients in one part of my constituency could do this, that and the other at the local hospital, while those in another part could not. That had to be ended. The Government will end GP fundholding, and not before time.
Conservative Members, unlike my constituents, do not understand the significance of the general election result—it meant that the Conservatives could not and cannot be trusted on health. I shall give a brief history of the Tory philosophy on the NHS. In 1945 and 1948, they voted against it. In the early 1950s, having returned to power, they set up the Guillebaud committee to consider the funding of the health service. That Tory Government expected the committee to say that the funding could not be afforded out of general taxation and to recommend another form of funding—in other words, a dismantling of the NHS.
§ Mr. Quentin Davies (Grantham and Stamford)
Will the hon. Gentleman give way?
§ Mr. Hesford
No, I want to make progress.
408 To the surprise of the then Tory Government, the committee said that funding out of general taxation was the best form of funding and that the health service gave very good value for money. Let us fast forward to 1997. What was the state of affairs on funding? The figures that we inherited show that in 1999–2000—[Interruption.] Conservative Members may laugh, but these are their figures, showing that there would have been a real cut in NHS funding if the Tories had returned to power.
The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) asked the right hon. Member for Maidstone and The Weald about funding the NHS with private money, and the hon. Member for Poole (Mr. Syms) seemed to say that it was Tory policy. If my analysis is at all correct, the divide between the Conservative and Labour parties is such that, if the Tories had won at the general election or were—inconceivably—to win at the next one, there would be only a safety net. The NHS would not be funded out of general taxation to be there at the point of need, without requiring payment. My constituents—they realised this at the general election—would be left with a safety net that dealt only with emergencies, geriatric care and mental health: the services that the private sector does not like.
My constituents saw through the Tories at the general election and they see through them now. Tory scare tactics will not work. The Tory party is in desperate need of publicity. It is for others to decide whether the right hon. Member for Maidstone and The Weald is seeking publicity for herself and whether her party is seeking credibility because it has no profile. Tory tactics did not work at the general election and they will not work at the next one.
§ Dr. Peter Brand (Isle of Wight)
We have been promised changes in the benefits system. I make a plea for a change in attitude in the benefits system delivery. As a GP, and now as a Member of Parliament, I have been amazed by the insensitivity shown by some of those who administer the system. The medical division of the Benefits Agency seems hellbent on giving people just one point less than they need to qualify on the all work test. The staff should realise not only the anxiety that is created for their clients—and my patients—but the danger into which they sometimes put them.
Over the past 18 months, I have seen three cases of that. One was a man who used to work as a builder's labourer, who had no other qualifications. He had had one heart attack and coronary grafting, and he still had unstable angina. A doctor from the medical department of the Benefits Agency found him fit for some sort of work. The agency withdrew that classification only when I asked it which doctor would represent it at a coroner's court should the man drop dead because of the advice given by the agency.
The same happened to a man who had worked as a gas fitter. He had an unstable neck, surgery had failed, and he was becoming paralysed from the waist down, but he was considered to be fit for work. That is clearly nonsense, and shows the insensitivity and the poor clinical skills of some of the doctors employed.
Most recently, last week, I saw the husband of a lady who suffered from Alzheimer's disease, who had just had an application for night-time attendance allowance 409 turned down. The lady became severely confused day and night, and she was taking a small dose of tranquilliser four times a day. The written report from the adjudication officer suggested that she could be adequately sedated at night so that she would not be a problem. That report was written by someone without medical or nursing qualifications, as far as I could see, and it is not their role to give advice that is dangerous as well as incorrect.
I am concerned that the trend in the medical division of the Benefits Agency seems to have worsened since it has been externalised. I urge the Government to review the decision to privatise that aspect of the agency's work. We have heard much today from Labour Members about the dangers of private medicine and privatisation, but I was surprised that the Government have continued the policy of externalising an important medical input into many people's lives.
I am not against private medical services, because they have a role to play. However, I am concerned that the development of an NHS with core services that excludes certain aspects of medical care may, overtly or more subtly, drive people to the currently unregulated private sector. Examples of such services include cosmetic surgery, counselling and psychotherapy, slimming clinics and infertility clinics. The best recent example is probably the treatment of erectile dysfunction—the great Viagra story—which is a wonderful illustration of the fact that the present regulations do not make sense if we want to deliver the best treatment for patients in the NHS.
The Secretary of State for Health has issued an edict, not backed by any regulation, that Viagra shall not be available on the NHS. The people who execute his edicts have taken it a stage further. For example, my local director of public health wrote me a letter saying that, if I prescribed Viagra on the NHS, he would take every step possible to recover the cost of the prescription from me personally. No regulations exist that allow him to do that. He could take me to a tribunal only for irresponsible prescribing, but Viagra is a licensed drug with a proper purpose.
We are dealing with a bit of bullying and bluffing, but that story illustrates an important point. Technically, I cannot prescribe Viagra, which is a useful drug, on a private prescription for my patients. The official advice is that I should see the patients, and then send them to see someone else to get the prescription. That is not in the interests of the patients or of efficiency.
It is hard enough for patients to come and explain that they have a problem, and they want to sort it out with a doctor they know. If we drive them into the private sector, we will cause problems. We have seen how awful some of the clinical outcomes of cosmetic surgery are, and we have seen the irresponsible behaviour by many slimming clinics. We must consider the regulations, and, even if the NHS is not prepared to pay for certain treatments, ensure that those treatments are still available through the NHS, so that patients are supported while their treatment is carried out.
It is not a problem to suggest that some treatments, such as life-style drugs, should be paid for. People are prepared to pay for such treatment, as the clinic at Euston 410 station shows. One can get Viagra from the Euston clinic if one is prepared to pay £120 for a consultation and a few pills.
§ Mr. Coaker
It is more than that.
§ Dr. Brand
I hear it is more expensive. People used to go to King's Cross to get advice on erectile dysfunction from the shops round there, but they now go to Euston station. The present regulations do not make sense, and I hope that the forthcoming legislation will address the issue of what may be prescribed through the NHS, even if the NHS does not pay for it.
§ Mr. Vernon Coaker (Gedling)
It is a good job that we do not always take everything that happens in the House personally. I saw the Whip talking to you, Mr. Deputy Speaker, and I thought that I would be told that I was no longer needed.
The Gracious Speech contained much to be commended on health and welfare. Although we all recognise that the primary care group proposals present certain problems, they are radical because they will bring together doctors and nurses with health visitors, community workers and housing workers to tackle health inequality. That will be complemented by the setting up of health action zones.
The hon. Member for West Chelmsford (Mr. Burns) made some good points about mental health. He is not in his place at present, and I should be grateful if his hon. Friends could pass on my remarks to him. Families find it difficult to seek help, but the individuals who suffer from mental health problems often wish to hide the fact. The more all of us—this is not a party political issue—can talk about some of the difficulties that mental health problems cause many people, the better. All ages, from young people—as I know from my teaching experience—to old people, can suddenly develop a mental illness. It is a huge problem. Everyone will agree with the points that have been made about mental health.
I will focus on welfare reform, which is a huge issue. I was pleased to see the Chairman of the Select Committee on Social Security here, as I very much enjoyed my first meeting yesterday. It was a purposeful meeting, at which we tried to build a consensus, which is often more helpful than the inevitable ping-pong—in which, no doubt, I shall myself engage later. I commend the Government for grasping the nettle of welfare reform. Ask anyone whether the welfare state works. Few people, if any, would answer that it does. Most accept that reform is needed.
The problem, of course, is identifying what reform we need, and how to go about it. That is difficult. The welfare state was set up 50 years ago, and longer ago in some parts of the system. During that time, there have been huge changes. People live longer now. The retirement ages are 60 and 65, and people often stop work before that. Working patterns have changed, and people move in and out of work. More women work. Many people care at home for long periods, and they are unable to contribute towards benefits. The welfare state is important to us all, but it needs fundamental change.
The welfare state was not initially set up as anything more than a safety net. Now, however, some people live off the welfare state. That has become a life style. I do 411 not believe that that sort of dependency was what the architects of the welfare state wanted, or thought desirable. Without engaging in fundamental change, we may damage some of the central planks of society.
Change, of course, is difficult. Modernisation is difficult. The Government are often accused, even by people who support me in my constituency, of not modernising with principle, but I think that they have very clear principles. They are grappling with difficult issues in trying to modernise according to those principles. That is not easy.
I do not believe that the Secretary of State sets out to make people poorer. I do not believe that he sets out to make life worse for disabled people, or that he sets out to attack the sick. However, when we listen to some of the debate on welfare reform, those accusations seem to be made. In my view, people who want no change, and who have a vested interest in keeping things as they are, attack my right hon. Friend and those who try to change the system in order to undermine the real changes that are needed.
The Gracious Speech offered a beginning. It did not cover everything. I accept that, and the hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) may well say in a moment that some matters were missed out. However, the Queen's Speech contained a large number of measures, others have already been enacted, and more are on their way. The important thing is that the Government are determined to reform the welfare state in a principled way.
We must ensure that those who need help receive it, but we must also face the fact that, without fundamental change, the people who are poor now will be poor in 20 or 30 years' time. One of the most depressing things at my surgeries—this must be so for all of us, of whatever party—is that I see people who are desperately poor, and I know that their children will be in exactly the same situation in 20 years' time. That is immensely frustrating and emotionally sad, for want of a better way of putting it. If we continue to defend the welfare state as it is, we condemn those people to that future. In reality, the welfare state fails them.
We must have a more mature debate on many of these issues. Otherwise, we are arguing about defending the poor, the sick and the disabled, but using them as party political pawns, and doing nothing to help them. My right hon. Friend the Secretary of State and the Government have started to grasp some of those very real nettles, in the face of determined opposition even from some Labour Back Benchers. That nettle has to be grasped.
A number of other measures mentioned in the Gracious Speech are important, and should command widespread support. The establishment of a disability rights commission is long overdue, and I think that everyone will welcome it. We look forward to finding out exactly how it will work, and the way in which the idea will be developed.
The shake-up of disability benefits is also important. We have enacted legislation to ensure that people with disability must be included. We must try to encourage them and consider what they can do. The fact that someone is in a wheelchair or has a disability does not mean that he or she cannot contribute. Indeed, 412 their contributions are often fantastic. I am sure that many people with disabilities could floor me when it comes to using information technology and such like.
Surely we should be asking how we can use their talents and abilities, and bring them into work, so that we can create a better society. It is a shame that, when we talk about such matters, the debate often degenerates into an argument about whether the Government are trying to force people who are terminally ill or can do hardly anything to go out to work, as if that were the real aim of the reform, when it is nothing of the kind.
The single gateway—the idea of compulsory interviews for benefit—is another important reform. For too long, people have got benefits passively. If they have fitted set criteria, they have received benefit. The gateway is a means of making the system more proactive. It will be concerned with the totality of someone's needs, whether those are child care or training, as well as with benefit. That is a positive way forward.
The measures to try to make work more rewarding and to show that going to work can be attractive, both for the individual and for the pay packet, are important. The working families and disabled persons tax credits, as well as the child care tax credits that go with them, are important ways to move the debate forward and they will help more people.
Again, there will be practical problems with implementation. Issues remain to be resolved and difficult problems to be overcome, but that does not mean that the concept is wrong. One can argue whether it is a good or a bad idea, but often people say, "It is a good idea, but this is the problem with it." Let us overcome those problems if we think that it is the right way forward.
I am delighted with many of the measures in the Gracious Speech. It is important that the Government are determined to reform the welfare state, not so that people who are in genuine need are excluded, or as an attack on the poor, the needy or the sick, but to ensure that, when we debate this issue again in five, 10 or 15 years—as we undoubtedly will—we will have started to attack poverty and social exclusion. If we merely defend the existing welfare state and the system as it stands, we are condemning many people to remain in poverty and socially excluded. Sometimes we need to be more mature in debate, and to get behind the real issues underlying welfare reform. We need to join the Government to ensure that we build a more equal society. We shall achieve that not just by redistributing wealth from the rich to the poor, but by ensuring that everyone has access to opportunity and can make the most of those opportunities. That is the way to offer real prospects of inclusion in society and to enable people to make the most of their abilities. That is the way to tackle social inequality and exclusion.
§ Mr. kin Duncan Smith (Chingford and Woodford Green)
This has been a long and fascinating debate. I am sure that the Secretary of state will agree that, as ever, we are in the peculiar circumstance of both winding up and leading off on a completely separate debate—linked but different. Obviously, I want to talk about welfare reform and social security in particular, and I expect that the secretary of State will want to do the same, but clearly some of the contributions from both sides of the House require, rightly, some reference.
413 My right hon. Friend the Member for Henley (Mr. Heseltine) made a powerful, fairly broad-ranging speech, much in character. He is a man who has been noted in the past to prefer the broadsword to the rapier. In this case it was a fistful of broadswords, and dynamic, too. It was nice to see him back after a short absence from the Chamber.
The hon. Member for Southwark, North and Bermondsey (Mr. Hughes), who is not in his place, made several points. Of most interest to this side of the House was his point about how there has always been rationing in the NHS. [Interruption.] Here he is. He spoke boldly about rationing, and reaffirmed, I think from a sedentary position during my right hon. Friend's speech, that there has always been rationing. He said that we must recognise to what extent that has been the case, rather than play games around it. That was a powerful point and well made.
My hon. Friend the Member for Lichfield (Mr. Fabricant) made a good speech. He was proud to announce that all his area was covered by GP fundholders, and believed that they were proud of it. I would be, too. I have a large number of fundholders in my constituency, and I know that the system has worked. The Government should build on that system rather than tear it down, but that is a record for another day.
My hon. Friend the Member for Vale of York (Miss McIntosh), before she departed to talk about turkeys—I do not intend to follow her down that road, and would have some difficulty in recognising how we got there—made the important point that much of the change to the commissioning process will add to bureaucracy and create the costs from which the Government say they will save money. That in turn will create problems. She made the point particularly well.
As ever, I listened with great interest to the speech of the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), the Chairman of the Select Committee on Social Security, whom I see in his place. He is one of about three Members who referred to social security and welfare reform during the debate. He had to, the hon. Member for Newbury (Mr. Rendel) had to as well, and the hon. Member for Gedling (Mr. Coaker) did, although he did not have to—I shall come to him in a second.
Among other points—I shall come to them in the course of my speech—the hon. Gentleman spoke about working families tax credit and means testing. Powerfully, he asked the serious question: where are we going on means testing? I think that there is clarity now; he says that there is not. I shall be interested to hear what the Secretary of State says in reply.
My hon. Friend the Member for Poole (Mr. Syms) made a powerful plea for haemophiliacs to be treated specially, particularly those who suffer from hepatitis C. I hope that the Secretary of State listens to that heartfelt point.
The Member for Warrington, North (Helen Jones) said that she was a child of the health service. Most of us would admit to that, and proudly so. She seemed to want to attack the Conservative Government on their process of spending on the NHS. She glossed over the fact that health service spending in real terms fell under the previous Labour Government for the only time in its 50-year history.
414 My hon. Friend the Member for West Chelmsford (Mr. Burns) made a detailed speech, giving chapter and verse. He asked a series of questions—I know that Ministers who were present will have taken them down and passed them to the Secretary of State for answer; I hope that he has them—about how waiting lists have risen inexorably in his constituency. I thought that he spoke powerfully. Perhaps his most powerful point concerned mental health. On that, the hon. Member for Gedling (Mr. Coaker) made an excellent speech, showing that he cares about welfare reform. He said that he agreed with my hon. Friend that mental health is seen as a Cinderella, and should be treated more seriously.
I agree with the hon. Member for Gedling in one sense: no one should accuse the Secretary of State—as some did in the previous Parliament—of being out to crush people into poverty. No one in the House could or should be accused of wanting to do that. There are clear differences about approaches to solving problems, to which I shall come in a moment. I do not make such a charge. Whatever the Secretary of State is doing is done in good faith. He believes that he is right. He is wrong, but we will hear more about that dispute in due course. I do not believe that there is a hidden agenda to produce more poverty.
Only three hon. Members spoke on social security and welfare reform, mostly on the same aspect. It is worth quickly reminding ourselves—I do it endlessly—what the Prime Minister said before and just after the general election. On 7 April 1997, he said:as we get the welfare bills down… then we can release more money into education and health and the services where we really want them.After the general election, he said:I have asked Ministers at the Department of Social Security to look in detail at how we can make far-reaching reforms that tackle insecurity and poverty as well as reducing the social security bills.It is not fair to judge the Government on someone else's agenda; we must judge them on their own, and find out when they will meet their pledge or whether they will meet it at all.
We must start by asking exactly what the Government took over in budgetary terms that underscored the Prime Minister's commitment. His commitment was based on what was clear in the Red Books then and now: the budget for social security as a proportion of gross domestic product was falling. In the last financial year, it fell by 1 per cent. Over three or four years, the budget was on a downward trend. The Government admit that, and it is in their Red Book. The social security budget was stable in the short term, and, to all intents and purposes, under control.
When we set the Government's forecast for social security spending against what they set themselves as a target, we see that, in the first year in which their policies really come into effect, 1999–2000, the budget leaps by 5 per cent., and that it goes up over the following three years in their general spending programme, pushing social security spending up to around 13 per cent. of GDP by the end of the Parliament. That does not cover falling growth rates. If the growth rate falls below one 1 per cent., the figures will go up, because, as the Secretary of State knows, it is a demand-led budget.
The total increase over three years to the end of the Parliament is £37 billion, which matches health and education spending, calculated in exactly the same way. 415 That does not fit with the Prime Minister's rhetoric when he first took over and made those serious pledges. We must consider what the Government have done to arrive at this position.
First, there are the Government's proposals, some of which have already been implemented, relating to the spend-to-save programme. The problem is that much of that is already beginning to fail. Let us remind ourselves what the Chancellor said in 1997:Central to Labour's medium-term approach to public spending must be radical reform of the welfare state… to unlock the possibility of reducing social security costs".Like the Prime Minister, the Chancellor links social security costs to other spending. However, when we look at what the Chancellor and the Prime Minister have allowed to happen, we see that they have presided over an increase in spending.
There is the £5 billion for the new deal, including the new deal for lone parents, which was raised through a windfall tax. We are now discovering, bit by bit, that the programme is failing to achieve its objectives. The cost per job, as stated in the press today, across all programmes is about £11,000; and the forecasts for the next three years suggest that that is likely to be the case until the end of this Parliament. In addition, about 25 per cent. of those who enter work through new deal programmes are out of work again within six months. It is clearly not a fully sustainable programme, but it is an expensive one, which is beginning to fail.
The second part of the equation, which has yet to be implemented but is included in the Queen's Speech, is the working families tax credit. As the Government admit, that is clearly set to increase spending by £1.5 billion a year. The Government tried to move that figure out of the social security budget and into accounting adjustments, but no one, including the House of Commons Library, believed that that was the right way to go about things, so that sum has been put back in, and we can see that it raises social security spending, not lowers it.
The Labour manifesto stated:And because efficiency and value for money are central, ministers will be required to save before they spend. Save to invest is our approach, not tax and spend.Yet when have the Government ever given us their targets for savings, in line with that manifesto pledge? Perhaps the Secretary of State for Social Security will enlighten us. How and when will the Government cut the cost of welfare, and by how much? That is important, because it was a manifesto pledge, so I should like to know how they will do it. Perhaps the Secretary of State can tell us.
If there are no targets—no departmental targets, no Treasury targets—how can the voters who elected the Government in 1997 have any confidence that the money they are spending under the spend-to-save programme is money well spent? Without targets, spend to save will rapidly become an incomplete equation—or, more likely, a case of spend to tax. That is the exact opposite of what the manifesto promised.
The spend-to-save strategy clearly implies that the Government must save more money than they spend on their new programmes. If they spend £5 billion on the new deal and a further £1.5 billion per year on the working families tax credit, surely the Secretary of State 416 agrees that they will save at least that amount during the lifetime of this Parliament before moving on to fight another election—or perhaps they do not believe that they will save anything. The Secretary of State should tell us that much at least, as he leads off for his Department in the Queen's Speech debate.
However, I recall the Under-Secretary of State for Social Security, the hon. Member for Wallasey (Angela Eagle), stating during our last Social Security Question Time:The working families tax credit… is not intended to create … jobs."—[Official Report, 16 November 1998; Vol. 319, c. 593.]That is not what the Government have been telling us, and it certainly is not what they have been telling the general public: the Government were going to save money, because people would be going into new jobs because of what the Government were spending money on. That is now clearly not the case.
Instead, the working families tax credit begins to offer us the prospect of increased regulation on informal family child care; and it will further erode the status of single-earner couples.
§ The Secretary of State for Social Security (Mr. Alistair Darling)
I apologise for interrupting the hon. Gentleman's flow, but will he answer the following question: I know that he is against and would scrap the working families tax credit; does it follow that he would oppose the disabled persons tax credit?
§ Mr. Duncan Smith
No, not necessarily—it depends to a great extent on what the proposals are. If the disabled persons tax credit works out to be pretty much the same as the working families tax credit, we shall oppose it. We shall decide what to do when the right hon. Gentleman produces the details, as his hon. Friends have asked him to do. My simple point is that the proposals for the working families tax credit will result in effects that are exactly the opposite of what the right hon. Gentleman thinks will be achieved. It is clear that the WFTC will strike at the heart of families and supporting families, and create problems for them; it certainly will not improve their situation.
I said that nothing in the WFTC will help the single-earner household. We have seen from the figures—I shall cite them in a moment—that the WFTC will create greater problems. The Chairman of the Social Security Select Committee, the hon. Member for Roxburgh and Berwickshire, referred to the likelihood of increased fraud, partly because employers will know which employees are receiving the credit, as will their colleagues. That will lead to stigma and increased costs. Most businesses do not want that to happen.
The Secretary of State will have to address a whole range of issues. The WFTC is not likely to work. We believe that it will fail, add cost, create no new jobs and, ultimately, raise social security spending—which is not one of the Prime Minister's declared aims. Behind the failing programme of spend to save—to which the Secretary of State is now pledged—screened by the rhetoric and the rising costs, lies a much clearer agenda. I disagree slightly with the Chairman of the Committee on this point. This is the dog that does not bark—but different from Labour Back Benchers, who spend most of 417 their time not barking about anything. It is the debate about means testing that the Government simply refuse to have.
The Committee Chairman was quite clear: he is concerned about the way the matter is drifting. I do not think that it is drifting: I believe that the Government's agenda is to move to a means-tested system, in which the contributory principle is thrown away and people become wholly dependent on the state to meet their needs. That is not a constructive agenda for the future. It does not deal with the real issues of dependency or family breakdown, which it will accelerate.
Let us examine the way in which the Government propose to deal with the state pension. The extension of pensioners' minimum incomes is nothing more than a con trick. I have talked to many pensioners—including those from the pensioners parliament—and many of them say that they have spotted the trick, and they do not like it. The Government have just repackaged existing benefit, and have not dealt with the real issue of improving pensioner incomes. They have reinforced the natural disincentive to save that is present in the means-tested system for existing pensioners or those approaching pension age.
The Government say endlessly that, if people are going to save big, that is fine. However, if they are not going to save big, they should not bother to save at all. For example, the Government's proposal makes a saving of £9,000 an irrelevance—a person might as well not have bothered to save at all. People would be better off redeclaring and redefining their lives on to income support. They should not put money away for a rainy day, because they will suffer if they do. However, the person who does not save will benefit.
The Government clearly intend to means-test the state pension. Let us clear up that matter once and for all. The Conservative party has said that we will not means-test the state pension after the next election. Will the Secretary of State match that commitment, so that we may have a proper debate? I give him the opportunity to intervene now. He does not wish to do so, so he has finally admitted that the Government wish to retain the option of means testing the state pension.
The Secretary of State must admit that his inaction makes our case. If he did not believe in it, he would rule it out now. However, nothing would surprise me from a Government who spent their first few weeks in office discovering ways of taxing pensioners an extra £5 billion a year. Damaging pensioners' savings is no way of resolving these matters.
The hon. Member for Newbury also referred to means testing, and to the severe disablement allowance. I hope that the Secretary of State will say once and for all what will happen to severely injured people over the age of 20 who have not had the chance to build up their contributions, and who will now not be eligible for severe disablement allowance or incapacity benefit. They will experience a real-terms cut in their income. The hon. Member for Newbury raised a reasonable point, and I hope that the Secretary of State will respond to that tonight, or write to us.
The Government have a means-testing agenda. They view the system as a balloon, and believe that they can get rid of much of the cost by pressing down on it to make it thinner. They fail to realise that their action makes the 418 balloon expand at either side, as people find their way into other parts of the system. That distorts spending. Increasing means testing may reduce costs in the short term, but in the medium and long term, costs will balloon, and there will be changes in people's behaviour.
Those changes will create confusion and chaos. For example, the working families tax credit will attack single-earner couples. I said that the difference between single-earner couples and lone parents will be made more stark by the working families tax credit. If a single-earner couple and a lone parent each earn £15,000 a year, the couple will receive next to nothing from the WFTC, and the single parent will receive about £70 a week more. That creates a position of divide and rule, it causes chaos for those who want to provide for themselves and to save, and it creates disincentives for those who are able to do so.
As many Labour Back Benchers are now beginning to discover, the Secretary of State's changes to widow's benefit mean that many widows will lose their entitlement. Readjusting the benefit was a way for the Government to save money. I am surprised that Labour Members did not realise that when the Secretary of State made his speech on the subject, but he dressed up the measure more cleverly than his predecessor might have done. Its effect has now been spotted—it is another extension of means testing.
I said a year ago, before the Secretary of State was in his post, that every Member of the House would want to support welfare reform, as long as the Government abided by four principles. First, reform must strengthen the institution of the family, rather than breaking or undermining it, which the Government are doing. Secondly, any change must strengthen personal responsibility, and break the dependency culture. The working families tax credit certainly does not do that; it will add 500,000 to the benefit regime. Thirdly, reform must strengthen alternative provision of welfare and break the state monopoly of provision. The Government have made no far-reaching proposals on that. Pensions come into that category. Fourthly, reform must protect those in genuine need.
The Queen's Speech contained many proposals, all of which we were already aware of and which are mechanistic. There was nothing new or unexpected, and nothing to tackle the big issues. For example, what will happen to housing benefit when the working families tax credit is implemented? No change is proposed. I remind Labour Members that, back in March, the previous Secretary of State for Social Security, the right hon. Member for Camberwell and Peckham (Ms Harman), said:we are reviewing the interaction of housing policy and housing benefit and we will bring forward proposals… shortly."—[Official Report, 19 March 1998; Vol. 308, c. 1436.]We have heard nothing. There has been no Green Paper, and no proposals on housing benefit. That creates a huge problem.
There have been no proposals—only leaks—on child benefit. Most importantly, we have heard nothing on pensions. The Government have spent 18 months fiddling around on pensions, and still have no proposals for reform.
The Queen's Speech, no matter what the spin or what friendly journalists write, reveals that, 18 months after the election, the Government have balked at their own targets 419 for welfare reform. Even the Prime Minister recognises that. He has changed his language to match the changes that he would like to make to Labour's pledges. In 1997, he said that Labour's aim was tostart reducing the very high welfare and benefits bills we pay in this country so that we can get the resources into education and health that we need".That is not happening, so, at the Mansion House earlier this month, the Prime Minister said:People often say the aim should be to cut welfare bills. But they forget: some welfare spending… is good and necessary".I remind the Government that it was the Prime Minister who said that Labour would cut welfare bills. He set the target, and the Government now want to change the rhetoric. As my right hon. Friend the Leader of the Opposition said on Tuesday, it seems that they are a Government who govern to win elections, but do not win elections to govern. Nowhere is that more true than in this regard. Redefining their pledges and rewriting history will not work. The Prime Minister will and must be judged on the pledges he gave.
The Government's heavy reliance, rhetorically and politically, on welfare to work merely masks the failure of their big picture. It is not as if there is no vision; it is simply that, after 18 months, we can see what that vision is. The Government's big idea is means testing and more means testing. It is not radical—[Interruption.] The Secretary of State for Social Security smiles in agreement. It is good to have that confirmation. All he will do is chase the error.
Pensioners, widows, the disabled and families were all led to believe that the Government had a programme for reform which was structural and which would sort out the dependency culture. Far from it—what they are doing will increase it. It is a matter of great sadness to all in the House because the Queen's Speech was a golden opportunity for proper reform to deal with structural dependency. We offered the Government support for proposals that would tackle the problem, but they have thrown it away. In any event, very few such proposals have been forthcoming.
There is also reason to be angry because the Queen's Speech marked the moment when it became clear that the Government's agenda—no amount of spin can change this—for the next three years is means testing, means testing and more means testing. We have been warned.
§ The Secretary of State for Social Security (Mr. Alistair Darling)
It comes as some surprise to us and, I suspect, to the whole country, that the Conservatives are now against means testing. I do not remember one occasion in the past 18 years when any of the then Ministers said from the Dispatch Box that they were going to end means testing. Means testing has always been part of the welfare state. It is not the only part, by any means, but it is one way of ensuring that help can be got to those who need it most.
I shall deal with welfare reform, the contributory principle and means testing shortly. However, like the hon. Member for Chingford and Woodford Green (Mr. Duncan Smith), I want to cover some of the other points made in this debate which covered health 420 and welfare, although I agree with the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) that the two are inextricably linked.
The right hon. Member for Maidstone—
§ Miss Widdecombe
And The Weald.
§ Mr. Darling
And The Weald as well.
Until now, I had been spared the sight of the right hon. Member for Maidstone and The Weald (Miss Widdecombe) in full flow. I did not see the video of her at the Tory party conference, but I have had the opportunity this afternoon to see something of a rather tormented and demented miniature Hattie Jacques.
As I listened to the right hon. Lady talk about waiting lists and berate us on our record on the treatment of cancer and so on, I found it odd that she did not allude to the fact that she and her party oppose the £21 billion investment that we are putting into the national health service over the next three years. The shadow Chancellor, who, I assume, speaks for the whole of the Conservative party, has made it clear that all our public spending—our £40 billion on health and education—is a mistake. The criticism that the Tories make of us falls apart when one remembers that the Tories oppose every extra penny that we are investing in the health service.
§ Mr. Quentin Davies
Will the right hon. Gentleman give way?
§ Mr. Darling
In a moment.
Given that the Tories want to cut £21 billion of investment, it is not surprising that, to get around the gap that that leaves in the health service, they have to emphasise the importance that they attach to increasing private health provision. It is another example of how they are drifting further from the mainstream into the right wing of politics. I do not think that the hon. Member for Grantham and Stamford (Mr. Davies), to whom I am about to give way, believes in that nonsense. He spent 18 years in the wilderness on the Tory Back Benches because he does not believe that. How on earth can he justify speaking for the Conservative party which is against the investment that most people want?
§ Mr. Davies
The right hon. Gentleman affords me rather more seniority than I can claim. He either has not understood or pretends that he has not understood the force of criticism from the Conservative Benches. Of course we are not against spending money efficiently on health and education. The Labour party came to power promising to pay for that incremental expenditure through social security savings, but he and his predecessor, the right hon. Member for Camberwell and Peckham (Ms Harman), have fundamentally failed to deliver them. Indeed, as my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) pointed out, he is allowing his budget to increase out of control. That is the criticism that we are making.
§ Mr. Darling
The hon. Gentleman is most clearly wrong. He should listen to the shadow Chancellor, who has made it abundantly clear that the Tories oppose our additional investment. He says that such investment is 421 irresponsible and cannot be justified. As one half of the Tory party is telling us that, the spending half is saying that we ought to be spending more.
§ Miss Widdecombe
Can the right hon. Gentleman name one occasion on which I have said that Labour should be spending more?
§ Mr. Darling
The right hon. Lady has been shouting that she wants us to be spending more. When I looked into the Chamber during debates following the Budget last year, I heard her say on many occasions that we were not spending enough. She has been complaining about waiting lists and cancer treatment, yet she belongs to the same Front-Bench team as the Shadow Chancellor, who is against additional spending.
§ Mr. Duncan Smith
Will the right hon. Gentleman give way?
§ Mr. Darling
I will later on—not just as the moment.
We are investing £40 billion more in health and education. The Bill that will shortly be before the House, which will abolish the internal market, ensure that the NHS is universally available and get rid of competition and the false market that the Tories tried to create in the health service, will be welcomed by most people.
We are able to make such investment and to restructure and reform the welfare state because we are doing so from a sound economic base. Over the past two years, we have taken steps to end boom and bust—the instability of the economy that we inherited—to ensure that we can plan ahead. We gave the Bank of England independence and, as a result, we have the lowest long-term interest rates for 35 years. The Conservative party is against not only our long-term investment, but one of the key planks of our strategy for economic stability.
§ Mr. Darling
I would be delighted to give way shortly.
The hon. Members for Chingford and Woodford Green and for Grantham and Stamford criticised our approach to welfare reform. We said during the election campaign that we would cut the bills of economic failure, and we are doing so. Through the new deal, we are getting people, who were written off by the Conservative party, into work. We also said that we wanted to reform and restructure the welfare state so that it meets the needs not of post-war Britain, for which, fundamentally, it was designed, but of the next two to three decades and beyond.
The rate of increase of social security spending in this Parliament will be half that of the previous Parliament. That is because not only have we been cutting the bills of economic failure by getting people into work, but we have taken steps in the Department to ensure that we pay benefits to the people for whom they are intended. We are taking more care to ensure that we have evidence before we pay benefits in the first place.
The Conservatives must come to terms with the fact that, because we are in the business of fundamentally restructuring the emphasis of the welfare state, concentrating more on preventing failure in the first place rather than picking up the bill after it, we will be 422 successful in restructuring and reforming the welfare state, so that it delivers the support and active help that we require to get people into work.
§ Mr. Darling
I will in one moment. The hon. Member for Chingford and Woodford Green wants to intervene, too. If the Tories believe that our increased spending on pensions, family support and disabled people is wrong, which area of spending would they cut?
§ Mr. Duncan Smith
The right hon. Gentleman seems to be giving way to me. That is fine, but two or three of us had lined up to intervene. [HON. MEMBERS: "He said, `Chingford and Woodford Green'.] Yes, I was and still am the Member for that constituency.
The right hon. Gentleman said that spending over the lifetime of the current Parliament would be half the amount of our spending when we were in government. He is wrong. If he looks at the figures for the first year of the present Government—figures that, as he knows full well, were set by the last Government—he will see that they fell by 1 per cent. If he takes those figures out of the equation, which is quite right—every other commentator will do the same—he will see that the spending that he predicts, even in good times, will grow by nearly 3.5 per cent. in the current Parliament. That is not half what our spending was.
§ Mr. Darling
Taking numbers from any selected year will produce a different answer. Moreover, the hon. Gentleman ignores the fact that social security spending was increasing by some 10 per cent. in the early 1990s. In any case, he did not answer the question. He says that we are spending too much on social security—on pensions, families and the disabled. He did not explain something else either. The Conservatives oppose the working families tax credit, which will help people on lower incomes and lower the barriers preventing people from getting into work; furthermore, they want to introduce a transferable tax allowance that will cost £4 billion a year. They must finance that before doing anything else—and, of course, such action would disproportionately benefit the better-off. We want to ensure that poorer people who have been trapped on benefit get into work: that is part of our fundamental reform of the welfare state.
§ Mr. Darling
I will in a moment, but I want to make some progress. I want to deal with a point made on behalf of the Liberals. At least, I think that it was made on their behalf; I discerned two or three different lines of thought during the evening. I refer to what was said about the Government's overall approach to poverty.
The House will know, because my right hon. Friend the Secretary of State for Health referred to it earlier, that the Acheson report on inequalities in health was published today. When I heard that the Conservatives had named today for a debate on health and welfare reform, I realised that they were more cunning than I had thought: they knew that the report would be published today, and they wanted to make something of it.
423 Perhaps it is not so surprising that the Conservatives did not mention the report, which is a damning indictment of their 20-year stewardship of the economy; but our response may show how this Government, with our approach to welfare reform generally and our economic approach, are beginning to tackle the inequalities. We have mentioned the working families tax credit, the sure start programme, the extra money for child benefit, help for families—one of the tests that was set by, of all parties, the Conservative party—the extra money that we are investing in communities that have been run down for years, and the minimum wage, which will address the problem of poverty. Across the board, the Government are tackling inequalities, in economic and health terms and in terms of welfare reform—a topic to which I particularly wish to return.
§ Mr. Simon Hughes
I do not dissent from what the Secretary of State has just said, but have he and the Government a target for reducing the gap between the richest and the poorest within a normal parliamentary term of five years?
§ Mr. Darling
People want not just a commitment, but action. We know that poverty exists in every corner of the land. We know that there are inequalities and a lack of opportunities, and, right across the board, we have emphasised the need to tackle the problem. We will tackle it through, for example, the new deal.
The Conservative party has accused us of spending some £11,000 per job. The hon. Member for Chingford and Woodford Green said that that was in the press today, but it was in the press because he told the press.
The Conservatives have priced the new deal in the manner of someone trying to price the cost of a new car on the basis of its first few weeks of operation. In fact, the cost is about £1,000 per job. The Conservatives are happy to ignore the success of the new deal: the fact that some 30,000 young people will have been given work. When they criticise us, it should be remembered that they would do absolutely nothing for a whole generation—a generation that was written off under their Administration. The new deal has been extremely successful in getting people—sometimes they have been in extremely difficult circumstances—back into work. That is something that any civilised Government should do for good economic and social reasons.
We set out the principles that will govern our welfare reform in a Green Paper which was published earlier this year. In answer to the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), the success measures there set out were responded to and overwhelmingly endorsed. I published the results of the consultation and I think that a list of responses has been made available in the Library.
Over the past 18 months, we have made progress in reforming tax and benefits, including child benefit. There are further reforms to come, including to the Child Support Agency, for example. I say to the hon. Member for Newbury (Mr. Rendel) that we are proposing to introduce more than 20 Bills in the coming Session, which will be shorter than the previous Session, which was quite long. We cannot legislate for everything in the first or even second year of the parliamentary term. We have been 424 elected for a five-year term and we are consulting on the CSA proposals. The Government will bring forward legislation as soon as we can. However, as I understand it, the Liberal party is against the concept of the CSA. That being so, I am surprised at its anxiety to get a new or improved version of it on the statute book.
§ Mr. Kirkwood
Is pre-legislative scrutiny still planned by the Government?
§ Mr. Darling
I certainly hope that we shall have an opportunity for pre-legislative scrutiny of the Bill. That is an extremely important part of some of the changes that we have made to the way in which Parliament works. Indeed, a number of measures were announced in the Queen's Speech, to which I hope other Bills will be added. The disability rights commission, to which my hon. Friend the Member for Middlesbrough, South and Cleveland, East (Dr. Kumar) referred, is an important part of our reforms.
I welcome the fact that so many Members have supported our approach on the single gateway. It is a complete change of culture for the Departments of Social Security and for Education and Employment. It is surely right that everyone should have the opportunity to know what options may be open to them if they come out of benefit. It is an example of how the culture and approach of government is changing. We are not merely reacting to problems but, ending a situation in which someone simply receives benefit and no help. I think that, overwhelmingly, people now believe that the Government must have a different approach to get people back into work.
§ Mr. Darling
The right hon. Lady has been containing herself for long enough. I shall certainly give way to her. Having done so, I want to talk about disability and bereavement issues, which some of my hon. Friends mentioned.
§ Miss Widdecombe
I am grateful to the right hon. Gentleman for at last giving way. He may have thought that as a result of delaying giving way for 10 minutes, I had forgotten what he was talking about, but I have not.
As I am sure that the right hon. Gentleman would not knowingly or willingly mislead the House, I can conclude only that he is the victim of his own propaganda. I have never, either from the Opposition Dispatch Box or from a sedentary position, called upon the Government to spend more. I have said that they are claiming to be spending vastly more than they actually are by using a rather quaint form of accounting. If they really were spending all that money, what on earth is their difficulty about funding such things as keeping open community hospitals? I have said that. The supposed conflict between myself and my right hon. Friend the Member for Horsham (Mr. Maude), the shadow Chancellor of the Exchequer, is a figment of the Prime Minister's imagination, which the Minister is trying to perpetrate. Will the right hon. Gentleman apologise?
§ Mr. Darling
I take it from that that the right hon. Lady is confirming my suspicion that Conservatives do not want to spend the £21 billion that we shall invest in 425 the NHS. If the Conservatives want to go into the next election promising to cut £21 billion from the health service, that is fine by me. I am quite happy to put up with that problem.
§ Mr. Darling
No, I will not. I want to deal with disability and bereavement benefits, which hon. Members have raised.
First, I turn to disability and a point raised by my hon. Friend the Member for Keighley (Mrs. Cryer). We are determined to ensure that disabled people have the opportunities that are available to others. We are determined also to ensure that no one asks anyone who is disabled to do anything that is unreasonable. I entirely take my hon. Friend's point that people with disabilities sometimes have quite substantial difficulties and that we must take account of that.
I want particularly to deal with two points on incapacity benefit. One is in reply to the hon. Member for Newbury and his complaint that we are taking into account people's occupational pensions. I remind him that we are ignoring the first £50 and introducing a taper of some 50 per cent. Given the rise in the amount of insurance that people now have, it is not unreasonable that there should be a better and fairer balance between their contribution and the contribution from the state. If we were designing a system from scratch, I am sure that we would not ignore that.
The hon. Gentleman and others spoke about the principle of means testing. The welfare state has always had a mix of contributory benefits and means-tested benefits—benefits paid on the basis of need. We are extending some aspects of disability and bereavement benefits. We are extending some of the benefits available to those who are most severely disabled—for example, we are extending the mobility allowance component of disability living allowance to three and four-year-olds. For the severe disablement allowance, we have dramatically increased the amount of money that will be available to people disabled from birth or very early on.
We have also made changes in widows bereavement benefit. The choice was whether to extend it to everyone, at a cost of £250 million a year, or to continue with the absurd situation where 40 per cent. of the women who receive the benefit are in the top half of the income bracket, whereas a man on low income with young children gets nothing. When faced with these difficulties, we must make difficult choices. We must ask ourselves what approach we would take if we were starting from scratch. My approach is unashamedly to do more for people who need it most. That is what I was elected to do, and that is what I am determined to deliver.
§ Mr. Rendel
I accept entirely that the doubling of the initial lump sum will help people who need it very much. 426 However, the Secretary of State is arguing that he could not afford to do anything other than he has done, yet he also tells us that £500 million will be saved. He could easily have created a fiscally neutral change to widows benefits and still allowed the bereavement allowance to go on for much longer than six months.
§ Mr. Darling
We are spending a great deal more in the first five years because we are extending the scheme. In future there will be savings. I am determined to ensure, as my hon. Friend the Member for Gedling (Mr. Coaker) said, that the welfare state is affordable and manageable over the next 20 to 30 years. I know that additional needs will arise that we must deal with. The great thing about being a Liberal is that one need not bother about any of these things. One can pick and choose—take the good things and ignore the rest.
In the time available, I shall deal briefly with pensions. The Green Paper on pensions was promised before the end of the year. If there has been any delay, that is entirely my fault. I want to ensure that when we publish the Green Paper, it is the right solution to the pensions problems that we will face over the next 20 to 30 years. Right hon. and hon. Members will see that it is. The reason that it is not mentioned in the Queen's Speech is that it will be in the Green Paper.
The debate has been instructive, as it has shown clearly the divide between the Government and the Conservative Opposition. First, we are determined to reform the welfare state and provide more help for those who need it most, to carry on encouraging people who can work to get into work, and to change the whole emphasis of the welfare state in a way that never happened during the past 18 years. The welfare state will help people to get into work and provide security for people who cannot work. The Conservatives never tackled that task.
The second point that shows the distinction between us is that we believe that where investment is necessary, in the health service and in education, we will make the necessary investment. We have created a secure economic platform which allows us to build for the future and plan for the years to come. My right hon. Friend the Chancellor of the Exchequer has made sure that we have that secure future, which is enabling us to invest record amounts in the health service. Most people believe that that was long overdue and much needed.
The Government are determined to modernise the institutions of Britain. We are determined to provide opportunity for individuals. The Queen's Speech represents another major step forward in the Government's second Session. We have much more to do in the coming years, but we are well on the way to delivering our manifesto promises.
Debate adjourned.—[Mr. Kevin Hughes.]
§ Debate to be resumed tomorrow.