§ Order for Second Reading read.
§ Mr. Deputy Speaker (Mr. Michael Lord)
I inform the House that Madam Speaker has selected the amendment in the name of the Leader of the Opposition. I remind the House that there will be a 10-minute limit on Back-Bench speeches throughout the debate.
§ The Secretary of State for Health (Mr. Frank Dobson)
I beg to move, That the Bill be now read a Second time.
The Bill is an important part of the Government's strategy to build a modern and dependable health service to serve the people of this country in the new century. That is what we promised at the general election and it is a promise that we are keeping.
The national health service that we inherited was in danger. It had about it an air of inexorable decline. The Conservatives had introduced a competitive internal market, which set doctor against doctor and hospital against hospital. Their misguided introduction of a commercial approach to health care was a costly failure. It shifted funds from patient care to bureaucracy and corroded both the ethics of the medical professions and the philosophy of working together, on which the health service was founded. It also resulted in a two-tier system for patients.
That the NHS survived owes nothing to the Tory Ministers involved and everything to the hard work of NHS staff the length and breadth of the country. Despite their valiant efforts, the NHS that we inherited was in trouble. Between them, health authorities and trusts had deficits totalling £460 million. Waiting lists were at an all-time high and rising. Capital investment was at its lowest for a decade. The Tory Government had stopped collecting details of pay, so that they could claim that a national minimum wage would bankrupt the NHS. They were not trying to manage the NHS; they had not bothered to find out even how many intensive care beds there were.
As was revealed in the reports that I commissioned into the scandals in Kent and Canterbury and Devon and Exeter, the standard of breast cancer and cervical screening was not being monitored. The Tory Government had paid £33 million in fees to lawyers and accountants to develop a private finance initiative, but not a single hospital had been started. Highly qualified staff were left to work in rundown buildings, often let down by equipment that failed them. There was a shortage of nurses, but, rather than tackling it, the Tories denied that it existed and reduced the number of nurses who were being trained.
Assaults on NHS staff were, so the staff said, getting worse, but the then Government did not do anything about it: they could not be bothered even to collect the figures. The private health care sector, which is so dear to the Tories, went virtually unregulated. Mixed-sex wards continued to make life a misery for many patients. In many parts of the country, NHS dentists virtually disappeared.
39 The development of information technology systems in the health service was years behind that in many other services and industries. NHS computing was best known for scandalous waste on systems that did not work. Nor was there any long-term strategy to make things better.
Health professionals had been ignored. The Tory Government had done little to help the profession's strength and self-regulation to raise standards and to benefit patients. Careers were held back and pay held down by archaic grading systems.
The Tories denied that the increasing wealth gap between the best off and worst off had increased a health gap between rich and poor individuals and rich and poor neighbours. Ministers banned the use of the words "health inequalities."
In deference to their commercial paymasters, the Tories had refused to ban tobacco advertising. They had helped to form a blocking minority to prevent the introduction of a Europe-wide directive to counter the promotion of cigarettes. Millions of pounds were being stolen from the NHS through prescription fraud. Millions of pounds more that were legally owed to the NHS by road traffic accident insurers were not being collected, so the new Government who were elected on 1 May 1997 had a lot to do.
§ Mr. Dobson
No; I will get on.
The new Government had a lot to do, not just to start to put things right, but to lay the foundations for a modern and dependable health service for the new century.
We set out in a White Paper our proposals to create a new NHS. We followed that up with further detailed papers that spelt out how we intended to go about it. We published a 10-year strategy to bring information technology in the NHS up to date. We have spelt out our proposals to modernise social services and mental health services. We have published a Green Paper on how we propose to improve public health.
We have not only said what we intend to do, we have got on with it. For a start, we have invested extra money in the health service. In our first year, we provided an extra £300 million on top of the budget that we inherited. In the year just ended, we invested £2 billion more than the previous Government had planned to spend.
Over the next three years, as announced in the comprehensive spending review, we shall invest an extra £21 billion, giving the NHS a much bigger annual increase than the 3 per cent. per annum for which all the experts and our opponents had called. The three-year settlement will enable the NHS to plan ahead, in a way which proved impossible in the short-term world of annual settlements.
§ Mr. Dobson
As you, Mr. Deputy Speaker, have announced that so many hon. Members—primarily Labour Members—wish to speak in the debate, I should like to get on with it, so that no one will be excluded.
40 In the previous year, £500 million of that extra money was targeted on reducing waiting lists. We promised, by the end of March 1999, to get waiting lists below the figure that we inherited; we did that, and more, by the end of February.
In the year just ended, making good use of the extra funds that this Government found, the dedicated staff of the NHS have carried out an extra 460,000 waiting-list operations, and dealt with 140,000 extra emergency cases and 150,000 extra first out-patient appointments. That is not to mention the tens of thousands of extra people who have needed an out-patient check-up after their in-patient operation. In the coming year, a further £320 million will be earmarked to bring waiting lists down further, and also to deal with many more out-patients and emergencies and to pilot the introduction of booked admissions systems across the NHS.
To help deal with the shortage of nurses, we have implemented the Nurses and Midwives Pay Review Body's recommendations—nationally and in full, for the first time in five years—giving all nurses an increase of at least 4.7 per cent., newly qualified nurses 12 per cent., and 70,000 lower-paid nurses at least 8 per cent. Consequently, two thirds of all qualified nurses are now paid £20,000 or more a year.
We have mounted a very successful national nursing campaign, which has had 53,000 responses. More than 5,000 of the responses were from nurses asking about returning to the NHS. Many of them require refresher courses because they have been out of nursing for more than three years; those courses are being provided free. At least 450 former nurses are already back at work in the NHS because of the initiative that we have taken, and 2,000 extra student nurses are already in training.
We have provided for extra payments for nurses and other professionals at the top of their grade. In consultation with staff representatives, we propose to replace the current rigid grading systems with ones that reward people for the responsibilities that they take on.
§ Mr. Michael Fabricant (Lichfield)
On a point of order, Mr. Deputy Speaker. We heard all that in the Queen's Speech. Are we going to hear anything about the Health Bill itself?
§ Mr. Deputy Speaker
As hon. Members are aware, we are allowed a fairly wide-ranging debate on Second Reading.
§ Mr. Dobson
Opposition Members are so eager to hear our common-sense proposals that they cannot be bothered to hold back for even a moment. They need to know the background to our proposals in the Bill, and that is what they are going to get.
We shall remove the barriers that are holding back the careers of many nurses and other professionals and holding down their pay. We are also negotiating with doctors on a new consultants' contract and providing better conditions for junior doctors.
We promised to sort out the Tory mess in the private finance initiative, and we have. We passed a short Bill to clarify the law, and we have launched the biggest hospital-building programme in the history of the NHS, with 15 new hospitals already being built and 16 more on the way. A thousand GP premises are being modernised, 41 and we are modernising every accident and emergency department that needs it. We are also using lottery money to help provide newer and more reliable equipment, such has scanners and linear accelerators for the diagnosis and treatment of cancer.
All that investment will not only help patients and staff, but create jobs in construction, manufacturing and service industries. We have already diverted funds from the bureaucracy of fundholding into breast cancer facilities. In response to the scandals that arose under the Tories, we have set new standards in breast and cervical cancer screening, and put machinery in place to make sure that those standards are met—something that the trio of former Secretaries of State for Health who are on the Opposition Benches today never managed to get round to.
We have invested £350 million this year in replacing unreliable equipment, both to help patients and to reduce the frustration of staff. With the support of the British Medical Association, we have replaced the divisions between fundholding and non-fundholding GPs with primary care groups, on which all GPs, as well as nurses, the social services and lay members, are represented. I take the opportunity to pay tribute to the medical profession for its voluntary agreement to share decision making in primary care with those other groups.
The Tory amendment refers to the popularity of fundholding, but many fundholders were reluctant participants in the scheme. Even before the Bill has been passed, only 46 of the 3,383 fundholding practices have opted to remain in the scheme. Only 1.4 per cent. have taken what the Tory amendment calls the "popular option". If the Tories think that something chosen by 1.4 per cent. is popular, we can see why they are doing so well in the polls.
The Bill provides for primary care groups to progress to becoming primary care trusts, with wider powers and duties to provide and arrange treatment and care for patients. It will abolish fundholding, and thus reduce the bureaucracy arising from commissioning organisations by replacing them with 481 primary care groups, and replacing annual contracts with longer-term service agreements.
The Bill will give all the national health service organisations a duty of co-operation, in place of the competition that the Tories tried to force on them. It will also require them to co-operate with local councils, and change the law to allow the NHS and local councils to pool budgets and carry further the practical co-operation that they have been putting into practice since the general election.
The legal changes will remove the last obstacles to those bodies working together to provide joint services for local people—for example, helping old people at home to avoid their having to go into hospital unnecessarily, and allowing them to come out of hospital safely when they have recovered.
The Bill will also oblige health authorities, in co-operation with the rest of the health service, and with local councils, voluntary organisations and others, to prepare health improvement programmes to identify the health care needs of their areas and then set about meeting those needs.
Once the Bill becomes law, NHS trusts will be obliged to have in place systems to monitor and improve both the quality of treatment that patients receive and the outcome 42 of that treatment. That obligation has never existed before, and it will augment what the professions have been trying to do. To help them in that process, the Bill also contains provisions to modernise and strengthen the self-regulation of the clinical professions.
What we propose follows extensive consultation with the professions. After Government amendments made in the House of Lords, the Bill commands the support of the relevant professional bodies. Until now, most changes to the arrangements for the self-regulation of health care professions have required primary legislation, which has led to enormous delays and consequent frustration. The Bill will make most changes possible through Orders in Council rather than primary legislation.
The Bill will also make it possible to meet the aspirations of the professions allied to medicine, and bring into the self-regulatory arrangements a number of professions that are not now legally regulated. All matters central to self-regulation will, rightly, remain with the professional bodies—professional registers, standards of education, guidance on professional conduct and fitness to practise.
All our initiatives are intended to improve the quality of treatment and care. The main aim of better training, continuous professional development, the professional revalidation now being introduced by the General Medical Council and clinical governance is not to expose failure, but to reduce the number of problems that arise and to deal with them in good time so that matters can be put right before patients suffer. We want no more Bristol scandals and no more need for public inquiries.
In that spirit, the Bill provides for the establishment of a Commission for Health Improvement to carry out regular independent reviews and investigations and to offer advice and help to health service trusts in their efforts to deliver top-quality care. The system is designed to contribute to improving the NHS.
An amendment was passed in the House of Lords to extend the commission's duties to cover private acute hospitals. They certainly need to be properly regulated, but the Commission for Health Improvement is not designed to do the job. Under the previous Government, private hospitals were treated as private nursing homes for regulatory purposes. At the election we promised to introduce independent regulation of all residential care. When we do that, we shall need to make special—probably separate—arrangements to regulate private acute hospitals. We shall consult on that shortly.
§ Mr. Philip Hammond (Runnymede and Weybridge)
Is the right hon. Gentleman aware that his right hon. Friend Baroness Jay told me, in the presence of her civil servants, that it was no part of the function of the national health service to regulate the private sector?
§ Mr. Dobson
And my right hon. Friend is absolutely right. It is not a function of the national health service to regulate the private health care sector, it is a Government function, and we should distinguish between them here and now. If an NHS body was responsible, the first time that it criticised a private hospital or said that something was wrong, some bleating Tories would leap up and say that it was prejudiced.
At the election, we promised to establish independent regulation of all residential care, and we shall. The body that regulates private hospitals will need to license the
43 hospitals, act as a registrar, have a right of access to carry out regular inspections, publish inspection reports and enforce any licence conditions that have been laid down for the protection of the public. As the Commission for Health Improvement will not have any of those powers, it is unlikely to be suitable for the role. Action is clearly necessary to prevent a recurrence of the situation that, as the right hon. Member for Maidstone and The Weald (Miss Widdecombe) knows, arose in Kent under the Tories when a gynaecologist who had been banned from the NHS for sub-standard work was able to continue to practise at private hospitals.
The Bill also deals with shortcomings in the pharmaceutical price regulation scheme, which sets the price of drugs used by the NHS. Some companies were refusing to comply with the existing scheme. The estimated cost to the NHS was £30 million a year and rising. Under our proposals the scheme will remain voluntary, but the Bill provides powers to make all concerned comply with the terms of the voluntary agreement. That is fair to the taxpayer and to the majority of pharmaceutical companies, which have always met their obligations under the scheme.
§ Mr. Dobson
Before anyone leaps up to defend the pharmaceutical industry, I must point out that the Bill, as amended by the Government in the Lords, meets the requirements of the industry. The reputable companies are satisfied with what we are proposing, because they are as sick to death as we are of the freeloaders who are not playing the game. The Tories support the freeloaders who do not play the game. I am confident that the renegotiated PPRS and the new legal powers will offer a good way forward for that highly successful industry, the NHS and the taxpayer.
§ Mr. Dobson
The Bill provides new powers to help tackle fraud against the NHS by a small minority of patients and practitioners at the expense of the honest majority. It also modernises the framework under which trusts operate. That reflects their status as public sector organisations. High-security hospitals will become NHS trusts.
Our approach is to set quality standards nationally, deliver improvements locally and monitor performance externally. That is why, with the support of the professions, we set up the National Institute for Clinical Excellence, to provide authoritative guidance to all parts of the NHS on the effectiveness and value of new treatments.
We are introducing national service frameworks to set national standards and spell out the models of treatment and care that should be provided in every part of the country for particular conditions or groups of patients. The first national service frameworks will cover coronary heart disease and mental health, followed by one covering the treatment and care of older people and then one covering diabetes.
44 Placing a duty of clinical governance on NHS trusts will help to deliver improvements locally. The Commission for Health Improvement will provide the external monitoring, advice and help that will be needed if targets are to be achieved.
§ Mr. Bercow
I am sure that the Secretary of State would not want in any way to give incorrect information to the House. He said that the pharmaceutical industry was entirely content with his proposals to revise the voluntary scheme. Why, then, is the Association of the British Pharmaceutical Industry objecting to several clauses, and not least to clause 30 because it does not provide explicit criteria or any express requirement of reasonableness?
§ Mr. Dobson
The association said that the changes made in the House of Lords have, by and large, met the needs of the industry, and so they have. [Interruption.] If the hon. yapper wants to do something useful, I suggest that he gets on the Standing Committee and tables amendments to deal with the companies that have not been complying with the terms of the PPRS.
By our extra investment, we are ensuring that the effectiveness of staff is not undermined by out-of-date equipment. We are determined that in future the excellence of staff will be matched by top-quality buildings and reliable, up-to-date equipment and pharmaceuticals. Nothing less will do, for patients or for staff.
We are committed to investing £1 billion in a long-term strategy to provide the NHS with a top-quality information technology system that works, and to develop an electronic record for every patient that can be accessed by all professionals who need to use it. That way, GPs, practice and community nurses, accident and emergency staff, out-patient clinics, hospital specialists and, eventually, even ambulance paramedics can have access to a reliable, accurate, up-to-date picture of the health record of every patient who comes their way.
All those improvements in treatment and care are being developed with resources from the modernisation fund that we established as part of the comprehensive spending review. That fund is financing the rapid development of NHS Direct, a 24-hour nurse-led helpline that has proved an enormous success in the three pilot schemes that have now run for more than a year in the north-east, in north Lancashire and in Buckinghamshire.
NHS Direct now covers roughly 40 per cent. of the country, and by December it will cover 60 per cent. It provides a popular service, especially for older people and young parents. Some 97 per cent. of the users surveyed were satisfied with the service. At my insistence, it offers opportunities for trained nurses who, because of injury, have had to give up work, to use their skills again for the benefit of patients and for their own job satisfaction. I was delighted that several nurses in that group had been taken on by NHS Direct in west Yorkshire, which I visited last week, including one paraplegic nurse in a wheelchair who now feels that there is some purpose back in her life.
§ Dr. Jenny Tonge (Richmond Park)
I appreciate the good intentions of NHS Direct and of the scheme that has been announced today, but the Secretary of State must be aware that it can be difficult to give accurate information without physically examining a patient. Members of Parliament often get complaints from patients who have 45 received misadvice over the telephone from GP deputising services. How does he intend to cover the doctors and nurses who give information, and is he worried that there may be misdiagnoses?
§ Mr. Dobson
All the evidence is that it is possible for the finest, most expert clinician, doctor or nurse to give a misdiagnosis face to face. I do not suggest that it is easy to give a diagnosis over the telephone, and other problems arise from that situation, but diagnosis is a relatively imprecise science, or art, at the best of times. The cover that we provide for NHS Direct staff is the same indemnity that is provided for any employed member of the NHS staff. We will clear up any difficulties that arise from advice being given over the telephone which are discovered when the patient visits a GP.
Some people, including some in the medical profession, expressed doubts about diagnosis over the telephone. In Preston and Chorley, where the scheme has been running for a year, the distinguished director of nursing is using the protocols used by the local NHS Direct scheme for training nurses to work in the accident and emergency department because, she tells me, those protocols are more rigorous than anything that has been used in the past. She knows what she is talking about because she has been involved in the project from the start. I repeat that 97 per cent. of the users are satisfied with the service.
§ Dr. Howard Stoate (Dartford)
The real issue in giving telephone advice is not so much whether it is right or wrong, but when it is appropriate to advise the patient to take other action. I am sure that my right hon. Friend agrees that advice given over the telephone could include a recommendation to the patient to see a doctor face to face, or a decision to send an ambulance to take the patient to an A and E department. Provided the person at the end of the telephone is trained correctly in decision making, there should be no problem.
§ Mr. Dobson
I almost entirely agree with my hon. Friend, but something will always go wrong. Things go wrong in every bit of the health care system and always will, but through training and substantial effort we can keep problems to a minimum. If someone gets through to the nurse, sometimes they are given reassurance and sometimes they are given advice. Sometimes that advice includes a warning to see a doctor straight away and sometimes a warning to attend A and E as soon as possible. Occasionally, the advice is to stay and wait for the ambulance that is being sent. Generally speaking, most of the clinicians in those parts of the country with an NHS Direct scheme are highly satisfied with the arrangements. That is why several areas are asking for NHS Direct to extend its functions beyond the 24-hour line.
§ Miss Ann Widdecombe (Maidstone and The Weald)
No one doubts that even the best diagnosis can go wrong—quod erat demonstrandum. That is not the issue. The issue is whether the Secretary of State accepts—and if not, why not—that if advice is given by somebody who does not know the patient or his history, there is an increased risk of that advice being wrong. The issue is not whether family doctors who give advice face to face are 46 infallible; it is whether there is an increased risk of getting the advice wrong if the person giving it has never dealt with the patient before.
§ Mr. Dobson
Clearly, it is best if the patient is in front of the person giving the advice and that that person has the patient's full medical history and is able to carry out some tests. However, that is not what NHS Direct offers—it provides telephone advice and help and, in some cases, an urgent attention service. In that respect, it is similar to many out-of-hours services where doctors do not have the records of the patients with whom they are dealing.
It might not be ideal, but NHS Direct is immensely popular with the public and it would be best if people did not attempt to run it down, because they are running down a large number of highly skilled people—top-quality nurses, advised in some cases by doctors, and good managements—who have taken this opportunity to provide a new additional service as well as everything else provided by the NHS. In some parts of the country, the service is being extended—at the request of general practitioners, so they obviously have faith in it—to provide a gateway to GP services, social services and mental health services.
As well as taking incoming calls, the nurses can also be used to ring out. Pilot schemes are being introduced in which, during troughs in the number of incoming calls, nurses can ring out to remind patients about out-patient appointments; about the availability of flu jabs; to remind women of appointments for cancer screening; or to check whether a patient, recently discharged from hospital, is okay. Like NHS Direct, all those things go with the grain of what health care staff are already developing locally.
Today, in Birmingham, my right hon. Friend the Prime Minister invited primary care groups to suggest proposals for 20 pilot schemes to develop fast access NHS walk-in centres in towns and cities throughout the country, open from early morning until late at night and at weekends, to provide information—
§ Miss Widdecombe
On a point of order, Mr. Deputy Speaker. I am aware of your previous ruling that Second Reading debates may go wide, but we have now spent a considerable amount of time hearing about issues that are not part of the Bill. The Secretary of State has spent about 10 minutes on NHS Direct and that has nothing to do with the Bill.
§ Mr. Deputy Speaker
I have already explained that the debate on Second Reading can range very widely and I am sure that the Secretary of State will come to the Bill quite soon.
§ Mr. Dobson
The right hon. Lady realises that I shall be moving on to matters that she wants to talk about. However, one of the problems is that she does not want to talk about success stories in the national health service; they deeply upset her. The Tories can never make their minds up. When I stood at the Dispatch Box about a month ago to announce the extension of NHS Direct, they welcomed it, but they have now returned to carping mode.
47 My right hon. Friend the Prime Minister invited primary care groups to put forward proposals for 20 pilot schemes to develop fast access NHS walk-in centres in towns and cities throughout the country, open from early morning until late at night and at weekends. They will provide information and advice and will treat minor conditions without appointment. Some will be located next to existing accident and emergency departments and others will be in shopping centres. They, too, are intended to go with the grain of local developments and we shall work with primary care groups and primary care trusts—[Interruption.]—which are in the Bill, to set them up and run them. The trouble is that the Opposition know so little about the health service that they did not realise that the primary care groups and trusts would be involved.
The Health Bill changes the law to speed up that process. It restores to health professionals opportunities to exercise their clinical judgment, curtailed or taken away by the Tories. It widens the choice open to patients to obtain the most appropriate treatment. it continues the process of reducing unnecessary and expensive bureaucracy in the health service. It will create a stable structure in which a modern and dependable health service can be provided and developed. It puts in place a system for managing the NHS that makes clear who is responsible for quality and performance in every part of the health service. It also makes sure that NHS performance at all levels is properly monitored to secure high standards in every part of the country.
§ Mr. Dobson
Our national health service has served our country for 50 years. It is the most popular institution in Britain, partly because the people working in it do such a good job and partly because it is a practical demonstration of the benefits of working together. British people are not just pleased that the NHS is there to look after them—they gain deep satisfaction from knowing that it will look after all of us.
We promised to stop the rot in the NHS, and we have done that. It is not enough, however, just to save the NHS. We are reversing decline and making sure the service's prospects are bright. The British people want to experience a new, modern and dependable NHS that can give easier and quicker access to the top-quality treatment and care that they need, and that draws on new technology to update the best of the old ways of doing things and to develop new ways of providing what patients need when and where they need it.
That huge undertaking will take a long time to fulfil. It will require leadership and it will depend on professional support. It will require the active involvement of Government, business, local councils, voluntary organisations and individuals, as well as of people working in the NHS. I am convinced that it is the way ahead if we want to make sure that the NHS in the new century will retain, renew and enhance its world renown for fairness, efficiency and quality.
The Bill is sound common sense. Only a fool would oppose it.
§ Miss Ann Widdecombe (Maidstone and The Weald)
I beg to move,
That this House declines to give a Second Reading to the Health Bill [Lords] because it removes choice from both patients and healthcare professionals over appropriate treatment; it removes the highly successful and popular option of fund-holding for family doctors; it imposes unnecessary and expensive bureaucracy and creates further upheaval in the Health Service, which is already under considerable strain; it undermines the competitiveness of the British pharmaceutical industry; and it centralises power in the hands of the Secretary of State, giving him arbitrary authority over the running of the Health Service without sufficient reference to Parliament.I could not help feeling sorry for the Secretary of State for Health as he rose to move the Second Reading. There is so little of worth in the Bill that he had to use his whole speech to talk about matters that have nothing to do with it. His must have been the most inadequate presentation of a Bill that I have witnessed during my time in Parliament.
The Bill, which I, at least, will discuss, does nothing to address the fundamental problems that have existed in our health service since the time of Bevan. We have a three-tier health service. On the top tier are those who receive national health service treatment or who choose to go to the private sector because that is what they want.
On the second tier are those who do not receive NHS treatment, either because of excessive delays—the number of those waiting more than 12 months has doubled since the Government came to power—or because treatment is not available. Those people do not choose to go to the private sector, but can, sometimes at considerable personal sacrifice, choose the private alternative if they have to. In that category, I include people such as those who have sold their houses to buy beta interferon.
§ Miss Widdecombe
I shall go through the three tiers, and then I shall give way.
It is clear that the second tier is being failed, but the third tier is wholly dispossessed. It contains people who cannot receive NHS treatment, either through excessive delays or through unavailability of operations, and who, even if they do not eat, cannot afford to go private.
§ Miss Widdecombe
I shall in a moment.
Not a single thing in the Bill addresses the problems of the totally dispossessed. On the contrary, the Bill will increase the number of dispossessed, because one of its consistent themes is rationing.
I have promised to give way to two hon. Members. Unlike the Secretary of State, I shall have the courtesy to give way to Back Benchers from time to time.
§ Mr. Leslie
It will be a short intervention. Does the right hon. Lady have private medical insurance?
§ Dr. Desmond Turner
There is much truth in what the right hon. Lady says, but does she agree that the reasons 49 for the health inequalities that she has described are inherent in the system of, for instance, fundholding GPs, for which her Government were responsible, and in the structural problems that her Government built into the health service?
§ Miss Widdecombe
The exact opposite is true. I am not claiming and I have never claimed—in the House or outside it—that we created a perfect health service. There are problems in the health service, which the Government would be wise to acknowledge. If the Government acknowledged them, they might address them.
§ Miss Widdecombe
I am already answering an intervention. I was asked whether fundholding increased the inequalities and led to the dispossession that I have been outlining.
That dispossession has been a feature of the NHS under successive Governments, because the NHS has not yet found a way—in my view, it will not find a way until we consider some real innovation—of being able to do it all. However, fundholding enabled a doctor to say to a dispossessed patient, "You may not be able to get that treatment here, but I can send you elsewhere to get it." There should have been a levelling up so that every patient had a fundholding doctor, but the Bill levels down and will ensure that no patients have fundholding doctors. When it comes to a choice of treatment, patients will have a choice of one.
§ Miss Widdecombe
I will presently, but a stack of people are queueing to intervene. I shall address the points as they come.
The Secretary of State is so amused by the plight of the dispossessed that he is sitting there laughing. I hope that the patients who are watching this debate today because they hope that something may come out of it for them will have observed the Secretary of State and those on the Benches behind him laughing, and will understand that nothing that the Secretary of State is doing will help the dispossessed. All that the Secretary of State and his junior Ministers have done in their time in office is to deny that rationing exists.
§ Miss Widdecombe
I said that I would give way presently. I shall not forget the hon. Gentleman. He need not give the impression of a jack-in-the-box; I know that he is in the queue, but he can wait.
As I was saying, the Bill does nothing for the dispossessed. It is well known that the Secretary of State has never yet managed to look me in the eyes when I—oh, he is getting into practice. After the implementation of the Bill, he will have a great deal of difficulty looking the nation in the eyes. In fact, if one looks into the eyes of those behind him, one can already see the beginnings of a terrible doubt about what Labour is doing to the health service. Labour Members' mouths may move in tune with their pagers, but their eyes say something 50 rather different. Their eyes say that they are beginning to realise that the Secretary of State does not have some magic solution to enable the NHS to meet every need. I am careful to say "need", not "demand".
§ Mr. Lewis
I shall address my intervention to the dispossessed on the Conservative Benches. How will the dispossessed or, indeed, anyone else using the NHS benefit from a significant increase in the number of people using private health care, which is the alternative strategy that the right hon. Lady and her party have articulated of late? Roughly what proportion of the population currently using the health service does she believe should be encouraged by a responsible Government to ditch the health service and use the private sector?
§ Miss Widdecombe
If the hon. Gentleman would examine what I am proposing instead of being overwhelmed by his own propaganda, he would find that I am not suggesting what he suggests. Any future Conservative Government will continue to increase in real terms, year on year, spending on the health service. There is no question of using the private sector as a substitute for the health service. I admit that no matter how much extra the Secretary of State, I, or anybody else tries to spend on the health service, it will not be able to do it all. In addition to increased spending on the health service, I want a real injection of fresh, new resources into the health service from the private sector.
§ Miss Widdecombe
Sit down! [Interruption.] Not you, Mr. Deputy Speaker. Labour Members can sit down and stay sitting down while I work through this point. The dispossessed—
§ Miss Widdecombe
Sit! Perhaps it would help if I said that I shall make progress before taking any further interventions. That might save Labour Members a considerable amount of exercise. I ask them to stay seated for a while.
I have already said that the dispossessed are not helped by the Bill. What does the Secretary of State intend to do to assist the dispossessed? According to the Bill, he intends to increase rationing. The theme of the Bill is that we shall have first, as background, a National Institute for
51 Clinical Excellence, which will decide on the availability of drugs according to their cost. If the Secretary of State has any doubt about that —
§ Mr. Austin
On a point of order, Mr. Deputy Speaker. Is the National Institute for Clinical Excellence in the Bill? Is it relevant to our discussion?
§ Miss Widdecombe
The hon. Member for Erith and Thamesmead (Mr. Austin) was not listening. I said — and he will see it in Hansard — "by way of background". I suggest that he listens a little more and talks less, and then he might understand something. The Bill will follow up NICE with CHIMP — the Commission for Health Improvement, which is in the Bill. I have already said that NICE will ration drugs according to cost; CHIMP will implement that policy.
Furthermore, under primary care groups, there will be, for the first time, cash-limited drugs budgets. If cash-limited drugs budgets are not an aid to rationing, I do not know what is. On top of everything else, the Bill prescribes control of drugs pricing, so that some drugs could be squeezed out altogether.
Let us add all that up. There is NICE, by way of background, CHIMP, which is in the Bill, cash limits for primary care groups and control of drugs pricing. Yet, Ministers have denied twice at the Dispatch Box recently that there is rationing in the health service. What will happen is that the number of dispossessed who cannot afford the private sector and who will not get those drugs from the NHS, and who will not get from the NHS other treatments that NICE may decide are too costly, will actually increase, and they will get nothing at all.
§ Miss Widdecombe
No. Will the hon. Gentleman please sit down? He has been told that he will not be successful in his endeavours. I know that doctors like exercise, but I ask him to stay sitting down.
The Government make their proposals against a background of failure and incompetent management of the health service. First, they have said that they are spending record levels on the health service, and that somehow, that will meet all the problems of the health service — that a Secretary of State with a bit of good will and a bit of extra cash is all that we need to address the fundamental issue of squaring need and supply in the health service.
The Secretary of State is very fond of saying that he is spending an extra £21 billion. Let us look at the Treasury Red Book and the Government's own figures, which show that expenditure in 1997 –98 was £ 34.688 billion, and that in 2001–02, it is proposed to be £ 45.179 billion. Most people who have reached even 11-plus standard could work out that that difference is not £ 21 billion, but less than £11 billion; that that less than £ 11 billion represents a real-terms increase of 3.8 per cent.; and that, in the five years preceding those figures, the real-terms increase was 3.8 per cent.
The Secretary of State is very fond of saying that the real-terms increase for the three years from 1998 to 2001 is 4.7 per cent. and is a record, but it is not; because 52 between 1990 and 1993, the real-terms increase was 5.6 per cent. That clearly shows that it is impossible to solve all the problems of the health service on money that has increased less in real terms than has been tried in the past.
§ Dr. Evan Harris (Oxford, West and Abingdon)
I do not doubt the right hon. Lady's figures, but does she accept that the only reason that the Government, during their first term in office, will spend less than the previous Conservative Government's record, is that, for two years, the present Government stuck to the very low, even miserly, real-terms increases in the Conservative spending plans? Further, does she recognise that, as no Government would cut NHS spending in real terms, her commitment — just like the Government's commitment —to raise spending in real terms, which could be just inflation plus £ 1, is generally meaningless?
§ Miss Widdecombe
I am afraid that the epidemic of not listening has broken out on the Liberal Democrat Benches as well. If the hon. Gentleman had followed the years that I was quoting, he would have found that I am quoting Labour's spending plans. Therefore, there is no magic, fresh expenditure that will suddenly change everything, and there is nothing in the Bill that will suddenly change everything — and, what is more, people know that.
What does the Bill do? I suppose that it is very good of the Government to propose in the Bill that fundholding be abolished when they have already abolished it. I suppose that it is very good of them to bother to ask for parliamentary consent after the event, but, first and foremost, the Bill abolishes choice, diversity and flexibility. It dragoons general practitioners into massive collectives. Whether their members like it or not, they will have to follow the patterns of referrals and the patterns set down by the committee governing the collective, and they will not have the choice that they would have had as fundholders.
The Secretary of State tried to say that fundholding was not popular. Perhaps he will tell us, then, why, when we made fundholding entirely voluntary and did not dragoon anyone into it, 60 per cent. of GPs were fundholders, or had applications outstanding to become fundholders, at the time that we left office. If fundholding was so unpopular, why did 60 per cent. of GPs actively join it or want to join it when there was no compulsion, as there would be if the Bill were passed?
§ Miss Widdecombe
No. I have made it clear that I am making progress. [Interruption.] The Secretary of State said at one stage this afternoon that he wanted to get on; by the time that he sat down, we were still waiting for him to get on to the Bill. I have at least tried to address the issues in the Bill. I shall now address some of the background about which the Secretary of State made such a performance in his presentation.
First, waiting lists are not falling. The number of people waiting to see a consultant has increased by 222,000 since the Government came to office. That is not just a statistic because until people have seen a consultant, the urgency 53 of their need for an operation cannot possibly be assessed. The Secretary of State has presided over a situation in which keeping down the list of those waiting to have their operation has been achieved by slowing down the rate at which patients enter the list, and by having a massive increase of nearly 250,000 patients waiting to discover whether they can get on to the list in the first place.
When I raise these matters, the Secretary of State has two or three defences. First, he says, "That may be true, but the numbers on out-patient waiting lists were increasing under the Conservatives." According to figures published by the previous Government — published in exactly the same way as the right hon. Gentleman publishes figures — there were 264,000 people waiting to see a consultant in September 1996 and 247,000 — a fall — in March 1997. From the 247.000 that we left the right hon. Gentleman, he has increased the number to 468,000.
The second defence that the right hon. Gentleman often advances is, "Yes, it is true that the numbers are increasing, but it is also true that we are treating more patients." It is true that more patients are being treated, but it is true also that in 1995 — 96, we Conservatives were treating 4 million more patients than we had been in 1979. The increase was not a few tens of thousands. Even that increase did not solve all the problems. It did not eliminate all the lists and it did not get rid of waiting times. The fact that more patients are being treated under the right hon. Gentleman proves nothing other than that ever since its inception, the national health service has quite regularly increased the number of patients treated. The right hon. Gentleman is not addressing the problem of the increase of 250,000 people who are waiting to see their consultant in the first place.
The third defence is, "The problem has nothing to do with the waiting list initiative", but it has. I shall quote from a letter that has been circulated to all consultants in the Salisbury health care NHS trust from the chief executive, who writes:
Despite having made good progress … waiting list numbers rose … by some 200 more than anticipated.He adds:
To achieve our year end target … we need to reduce our current waiting list numbersby about 500. He states that
"there are only three realistic options".
The first option is:
Reduce the numbers coming onto the list.That is clearly set out. That is the way in which the numbers on lists are reduced. Another option is:
Use of the private sector.That is a commendable option.
If the reduction in the number on waiting lists means that people who have been waiting are being treated by the NHS, that is to be welcomed. I have no doubt that some of the fall will have been brought about in that way. However, if it is being achieved by slowing the rate at which people enter the lists, or by people becoming so fed up that they go to the private sector or so ill that they die before receiving treatment, that is not such a wonderful achievement.
54 Bearing in mind that it was an early pledge to get the lists down to 100,000 below the level that we had left, it has taken the Secretary of State half a Parliament to get down to the level that we left — and with the sort of manipulation that I have been discussing. That is not—
§ Miss Widdecombe
sit down for a moment please. I will not give way for the moment.
That is not a record of which the Secretary —
§ Mr. Deputy Speaker
Order. May I say to the right hon. Lady that it will probably be better if she decides whether to take interventions, and indicates clearly whether she will do so or not, and leaves the rest to me?
§ Miss Widdecombe
Quite so, Mr. Deputy Speaker. I will do that.
That is not a record of which the Secretary of State can be proud.
Similarly, I have in front of me a letter from the Southampton general hospital trust saying straightforwardly that the surgical waiting list has trebled
"since the present Government came to power".
The fact is that there is no magic wand solution that will simply reduce waiting lists. There are many ways of manipulating those lists and the statistics, and there are many ways of triumphantly announcing the statistics, but in the end, if a genuine improvement has not been achieved, patients are being betrayed. Also being betrayed are the doctors and the nurses, who are being obliged to apply distorted clinical priorities to assist that manipulation.
Against that background, I would have hoped that the Government would have had the courage to address in the Bill some of those fundamental problems and to have tried to find new, exciting ways of increasing the resources available to the NHS. The Secretary of State says, very proudly, that the private sector must be regulated, but the House of Lords has forced that upon him, through a Conservative amendment that has applied to the private as well as the public sector the health improvement initiatives that he says he is introducing into the Bill.
The Secretary of State boasts that he will have the biggest hospital building programme in history. We had the biggest hospital programme in history. If he achieves his aspiration to outstrip that, I shall be very pleased, but I shall be even more pleased if he acknowledges that he will do that largely through the private finance initiative, which we introduced and set up. That is the use of the private sector.
§ Mr. Dobson
If the Tories made such a success of the PFI for major hospital projects, why did they never manage to get one started and why, with their agreement, did we have to clarify the law, which they claimed they had clarified previously? They spent £ 33 million on consultants — not medical consultants, but lawyers, accountants and God knows who — and they never got one hospital built. We are getting 15 hospitals built as a result of sorting out the mess we inherited.
§ Miss Widdecombe
First, we built more hospitals than ever before in British history. Secondly, when we set up
55 the PFI, the Secretary of State's party opposed it root and branch, although it has now decided that it is the only way forward. Yes, when we set up the PFI, we had difficulties, which the then Opposition were not willing to help us solve, but we got to a point where they were solved and the PFI was in readiness when the right hon. Gentleman took over.
Why does not the right hon. Gentleman thank us for setting up the PFI? If it is right to use the private sector in that sort of instance, if it is right for consultants to use the private sector to get their lists down and if it is right for certain facilities to be shared with the private sector, why will not he expand that and use the considerable resources of the private sector for the benefit of the NHS?
The problem with the right hon. Gentleman is that his approach to this matter is that of the dinosaur. In every other Department, partnership with the private sector is now a fact of everyday life. In many Departments, it is being extended beyond anything introduced by the Conservative Government. But apparently, uniquely, in health matters, the Secretary of State wants to marginalise the private sector, giving it no major role.
§ Mr. Bercow
In reflecting upon the Secretary of State's attitude to the Bill, is my right hon. Friend not reminded of a former leader of the Labour party and distinguished parliamentarian, Michael Foot, who, in a conversation some years ago, said, "Don't give me facts, they only serve to confuse my arguments."?
§ Miss Widdecombe
I am reminded of many things when I look at the Secretary of State. but mostly I am reminded of desperation — sheer desperation. So desperate is he, that he could not even address the Bill when he came to the House to present it. So desperate is he, that he has to manipulate the waiting lists to say that he is moving towards achieving a pledge that was supposed to be achieved early, but, after half a Parliament, is nowhere near being met.
§ Dr. Wright
I have been listening carefully to the right hon. Lady's remarks and trying to follow them. She gives a terrifying performance. There is certainly something of the fright about her. The right hon. Lady argues that there are dispossessed people whose treatments will be so expensive that the NHS will not be able to afford them. Exactly how will those desperate, dispossessed people be able to obtain treatment somewhere else?
§ Miss Widdecombe
That is the whole point. The whole point of what we are saying is that, if the private sector shares some of the strain with the NHS, the NHS will be freed up to look after the dispossessed. Instead, the Secretary of State wants to keep them dispossessed, and to increase their number and the range of treatments and drugs from which they are dispossessed. That is the 56 Government's policy. I cannot imagine that it is one of which the hon. Gentleman is proud, but at least now he may understand what I have been saying.
§ Miss Widdecombe
It might be for your convenience, Mr. Deputy Speaker, and for the convenience of the House, if I say that I shall make further progress before giving way. Compared with the Secretary of State, who refused to give way almost consistently throughout his speech, there has been a proper debate from the Conservative Benches today.
The Bill sets up primary care trusts, but it does not even contain a definition of one. The noble Baroness Hayman was rather embarrassed in the other place when she had to say that the Government would work out a definition. The Secretary of State has introduced a Bill setting up primary care trusts with no adequate definition of such trusts. I am not surprised that he does not address a Bill that does not even tell us what it is about.
This is a defective Bill, of which we have had a defective presentation by the Secretary of State. The Government have a defective health policy which has resulted in increasing numbers of dispossessed, manipulated waiting lists, longer waiting lists of people waiting to see a consultant and a winter crisis, yet still the Secretary of State tries to pretend that there is something new, modern and vibrant about the declining NHS over which he presides.
I will not say that the Secretary of State's language has been deceptive throughout, because you, Mr. Deputy Speaker, might call me to order, but it has certainly not portrayed an accurate picture. We all remember the right hon. Gentleman standing up in the House in great triumph saying, "I am providing 7,000 extra doctors". Everyone became very excited until he had to admit that they were just the doctors coming through medical school in the usual way, not "extra" at all.
There is nothing extra for any NHS patient in the whole of the Bill. There is nothing extra for any NHS patient in the whole of the Government's health policy. However, there is much less. There is much less choice for a patient's general practitioner to refer outside the area or to particular consultants.
§ Miss Widdecombe
It is true, because whereas a fundholding GP could have decided that course of action for himself, a member of a primary care group will be able to do so only if the committee of that group has established that pattern. The right hon. Gentleman has just given an inaccurate portrayal of what PCGs will do.
We have frequently asked the right hon. Gentleman to guarantee that the choices and services that are now available to patients of fundholders will be available when PCGs are up and running. They are now up and running, and he has still not been able to guarantee that such choices, services and flexibility will be available. Why not? Because quite patently in some parts of the country — the evidence is flowing in — they are no longer available. There is less for NHS patients.
There will be fewer treatments and drugs available to NHS patients when NICE does its nasty, ugly work. There will be less available to patients when pricing policy 57 drives some drugs from the market and when GPs find for the first time that their budgets are cash limited. That is what the Bill provides.
The right hon. Gentleman talks about removing bureaucracy. It will cost £ 150 million to set up the PCG bureaucracy. He talks about cost-effectiveness. I hope that NHS Direct works, but studies currently show that the average NHS Direct call costs — 20 whereas a call from a GP surgery costs £ 3, so there is not even a saving that can be passed on for the benefit of the NHS patient.
This ineffective, defective Bill does not deal with the real problems of the NHS. It does nothing to address the single biggest problem that has eaten away at the NHS from its inception — it was recognised by Nye Bevan himself, but is denied by the Government. The NHS cannot and never has been able to do it all. On top of increased resources from Government — which will always be provided under successive Governments — I want to find fresh ways of putting extra resources, facilities and expertise at the disposal of the NHS for the benefit of patients.
The Secretary of State has sat there and laughed at those patients. He has denied that the dispossessed are dispossessed. He pretends to be spending money that he is not spending, and to be creating extra doctors who are not being created. In the end, he will have to face a reckoning, because the true test of people's satisfaction with the NHS is not Government rhetoric, but patients' own experience. A quarter of a million more patients who are waiting to see a consultant have their own experience. Patients of former fundholders who are now unable to get the same services have their own experience. Patients coming off the lists because they are so desperate that they go private even if they do not want to have their own experience.
Those people know that the Government are not delivering on the NHS. The Secretary of State should come to the Dispatch Box and apologise for what must have been the most insulting performance that the House has witnessed in some years.
§ Mr. Deputy Speaker
Order. Before I call the next speaker, I remind hon. Members that all Back-Bench speeches will be limited to 10 minutes.
§ Mr. Kevin Barron (Rother Valley)
I hope to stick to that time limit, Mr. Deputy Speaker. First, however, let me correct what the right hon. Member for Maidstone and The Weald (Miss Widdecombe) said about the PFI and our attitude when we were in opposition. The Conservative Government made a complete hash of the PFI —
§ Mr. Barron
Will the hon. Gentleman keep quiet for a few minutes? The Conservative Government did nothing at all. They did not set up a single hospital under the PFI. They introduced a Bill —
§ Mr. Deputy Speaker
Order. Hon. Members must use the correct parliamentary language. I suggest that the House should settle down.
§ Mr. Barron
The last Government introduced a Bill called, if memory serves me correctly, the National Health Service (Residual Liabilities) Bill. The Secretary of State and the Minister who were in charge of that Bill are present now. It was in Committee for two or three weeks at the most. We co-operated fully with the Government, and the Bill completed its stages in the House, but when those in the private sector had another look at it, they said, "It is not good enough: you will have to come back with something else."
About three weeks before the general election campaign, the right hon. Member for Charnwood (Mr. Dorrell) offered another Bill to the then shadow health team in the hope that they would endorse it promptly and allow its speedy passage, because the Conservatives could not get anything started with the PFI. In the end, he did not give us that Bill, although we would have gladly taken the matter off his hands, because he did not dare to go public about the mess that the Conservatives had made in regard to the PFI. The present Government have embarked on the biggest programme of building major NHS hospitals for years, because the last Government did not know how to handle the private sector in terms of the PFI.
The Bill makes major changes. I do not know how many Bills providing for structural change in the NHS we have debated when I have been in the Chamber, but there must have been many since my arrival in the House in 1983. It is a great pity that the right hon. Member for Maidstone and The Weald does not understand some of the changes in this Bill; I hope to tell her at some stage what I think is likely to happen.
In fact, I think that the NHS will experience a cultural change. That will not happen overnight — it will take many years — but I believe that aspects of it will challenge parts of the service, although if the service does not change it will not be capable of doing in the next century what it has done in the second half of this one. If it is to retain the admiration and support of its patients and the taxpayer, it must recognise the need for it to change to meet both the expectations of patients and advances in medical science.
Through the media, patients are becoming increasingly aware of new advances on both a national and an international scale. As they become more knowledgeable, they will expect the best treatments that are available. They will want to know more about the latest drug on the market, and how it could affect them. Professionals in the NHS will have to meet those new demands, and the Bill rightly aims to create a more patient-led service.
For the first time, a Government are introducing a statutory duty to implement a "quality of care". It beggars belief that any Member should make it clear from the Dispatch Box that he or she does not recognise the fundamental change that such a duty will make to health care. No one who does not recognise that can have read the Bill properly.
Making quality a driving force for decision making at all levels of the service should guarantee clinical excellence for all patients. I oppose rationing in the NHS, and I hope that every other hon. Member does as well. The Bill will enable us to get rid of it, by ensuring clinical
59 excellence for all patients. The establishment of the Commission for Health Improvement is another step forward, although it was dismissed by the right hon. Member for Maidstone and The Weald, who seems to oppose the idea of clinical improvement in the NHS. That is ridiculous.
Independent assessment of local work to improve quality should have been introduced years ago, and the use of a wide range of expertise and experience to investigate problems is also overdue. It should be welcomed by all who work in the NHS. It is clear — my right hon. Friend the Secretary of State gave a couple of examples — that past performance has been variable. People have been slow to detect and act on lapses in quality, and that is not acceptable.
The introduction of evidence-based national service frameworks should ensure consistent access to services and quality care throughout the country by setting national standards, and defining patterns and levels of care in relation to specific diseases or parts of the service. My right hon. Friend said that coronary heart disease and mental illness would be among the first conditions to be dealt with by the frameworks, which will be based on the Calman Hine model for the provision of cancer care. The recommendations of what was then the Calman committee were published in 1995. The final recommendation states:
The data suggest that the impact of specialised care for common cancers, and probably for many cancers, can increase long term survival by 5-10 per cent., a very important clinical outcome.People reading that report might have thought that the NHS could continue to offer all services in all district general hospitals, as it has for years, but the report made it clear that that should end. I am pleased to say that it has in regard to cancer, but it should end in other contexts as well. We should ensure that our clinicians do the best that they can for every patient, regardless of where the service is being delivered. If Opposition Front Benchers are really concerned about what is happening, or should be happening, in our health service, they will comment on that.
The Bill will provide a new system of clinical governance to ensure that there is continued improvement in NHS trusts and primary care bodies. That is what I look for, as a patient, and what other NHS patients want. We are not interested in arguments about structures.
The National Institute for Clinical Excellence will be clinician-led. It will give a strong lead, in terms of both clinical services and cost-effectiveness. It will issue new guidelines for the NHS, putting an end to all the mixed messages that people receive about new drugs. How many hon. Members have sat in a doctor's waiting room behind a salesman who wants to sell another message about how his drug is better than those that the doctor already has?
The hon. Member for Oxford, West and Abingdon (Dr. Harris) looks confused. Let me tell him that I have sat in my doctor's surgery, and have seen salesmen waiting to sell their drugs. It is about time that there was a better way of conveying information to doctors.
We should be concerned about new drugs and treatments. Those in the NHS should understand the clinical effectiveness of drugs better, so that the decisions that are made are the best for patients. A recognition of cost-effectiveness will not necessarily mean the cheapest 60 treatment: in certain circumstances, it could mean that NICE will recommend the most expensive treatment if that is best for the patient. We should welcome that, however, as should the pharmaceutical industry.
It is clear that some drugs benefit only a small minority of people who suffer from a particular condition. The challenge is to identify those who are assisted by the intervention. Expecting the NHS to pay for expensive products that do not work will just bring the pharmaceutical industry, and the NHS, into disrepute. I think that the industry realises that it must sort that out, although I realise that it will not be an easy task. We all know that beta interferon is likely to help approximately 10 per cent. of multiple sclerosis sufferers, but it is more difficult to identify that 10 per cent. That is the real challenge for the pharmaceutical industry and the NHS — and. indeed, for NICE — and it is a challenge that we should support.
I must say to the right hon. Lady —
§ 6 pm
§ Mr. Kenneth Clarke (Rushcliffe)
The Secretary of State for Health attracted to the Chamber three Conservative Members who are former Secretaries of State for Health. We should all have come here out of sympathy with the Secretary of State because his task is very hard, if it is done properly: to prioritise the service and to produce steady development within finite means when demands are ever burgeoning. I regret to say that we were all drawn here by the fact that, in tackling his task, the Secretary of State is getting into a bigger and bigger mess. We all fear that, in relation to how the health service will perform, he is building up for himself considerable problems in the medium term. Our constituents will all feel that winter by winter, as the crises start to reoccur in the system.
In 10 minutes, I have no time to answer all the points in the Secretary of State's speech, but I do not wish to do so; he sacrificed any sympathy that he might have had from me. He has a standard Opposition-based rant on what the health service was like when he took over. On every occasion he gives an extremely clever, partial and disingenuous presentation of the money that he says that he has, and what he is doing. On each occasion he produces an announcement — today, it was on NHS Direct — to distract the journalists from what the Government are doing. He made only partial references to the Bill.
The reason why the Secretary of State is getting into a mess is that, as he will discover, however skilful the rhetoric, however good the special advisers and press presentation, he may fool people for a bit, but it is what he does to the health service that will come back to live with him. He will find that the Bill will do considerable harm.
I anticipate my criticisms by stating what I welcome about the Bill. It does not reverse the reforms of the previous Government. It does not repeal the internal market or anything like it, although that is not a phrase that I would ever use to describe it. I am glad that the purchaser-provider divide is kept completely intact. No doubt it is regarded as clever that contracts are now described as "collaborative understandings", but they are 61 still there between purchasers and providers. The Secretary of State is even extending the number of NHS trusts on the provider side.
The Bill alters what we used to call in the jargon — it is only jargon — the purchasing side: the commissioning of health care on behalf of the patient. The Secretary of State is moving away from fundholding into new primary care groups, which, as I hope to show, are a wholly undesirable change in the system and will, in the long run, have only adverse effects.
I say in passing — I have no time to say more — that I welcome the fact that elements of quality control are built into the Bill. We began that when we introduced clinical audit into our reforms. When we were in office, we spent our whole time trying to build a more patient-oriented service, and better management of clinical practice and quality, with the support of the best people in the profession.
An attempt is being made to produce further improvement in performance management, although it is being done in an odd way. We have new acronyms and we have new quangos in the acronym-ridden national health service — CHIMP will now join NICE. My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) is right to say that we are not sure what NICE and CHIMP will wind up doing, but they at least are commendable.
Overall, my judgment of the Bill is that it is centralising in its ambitions, which is a serious mistake in such a giant service: the biggest employer and the biggest public service in western Europe. In its changes to the purchaser-provider divide, the Bill is bureaucratic in the extreme. As the hon. Member for Rother Valley (Mr. Barron) said, that will lead to cultural change on the ground. That change will be a stifling of individual initiative by the best go-ahead general practitioners, because that practice will be made more difficult because those GPs will be locked into a group with people who will not want to be as innovative as them.
The best general practitioners will have to proceed at the pace of the slowest as they try to develop the primary care system. The decision-making provisions in the Bill go back to the worst of the old NHS. Slow, expensive decision making will be conducted by the large committees that are being re-established. I fear that they will not function well.
Primary care must continue to develop. Every Minister with responsibility for health knows that developing primary services continues to be one of the major priorities in trying to solve the conundrum of how to meet rising demand out of finite resources. However, like my right hon. Friend the Member for Maidstone and The Weald, I fear that primary care will go through a process of levelling down, rather than levelling up, for quite a period once the primary care groups come in.
I concentrate on the new primary care groups and the end of fundholding; there are other important parts of the Bill about which I have not time to talk. I will not express an opinion on the parts of the Bill that concern the PPRS — the pharmaceutical price regulation scheme — and drug cost provisions. If I did so, I would have to declare an outside interest as chairman of a pharmaceutical wholesale company. 1 make only one comment, which is faintly relevant. One detailed aspect of the primary care groups has been sadly neglected: the role of the 62 pharmacists as a profession. The fact that they will have no real involvement in the new groups is not to the advantage of patients.
Primary care groups are based on the abolition of general practice fundholding. Fundholding was a success. One of the key things that the Secretary of State tried to deny was that we worked to ensure — the best reforms do it — that those who carried out the reforms had ownership of the reforms themselves. The fundholders were volunteers and they were largely enthusiasts.
Almost 60 per cent. of GPs wished to become fundholders. If we had achieved 100 per cent. GP fundholding, as we did with NHS trusts, the Government would never have dared to reverse the policy. They are going to great and unnecessary lengths to reverse it now. It put family doctors in the driving seat in raising the standard of care in their locality. It gave them new and unprecedented influence over the quality of and access to hospital-based services. It enabled them to concentrate on the needs of their own patients. The benefits from the growing number of fundholders were spreading to the rest of the service.
In the short time I have left, I mention specifically what I think are the dangers of the new primary care groups. First, they will level the service down. I will not repeat what my right hon. Friend the Member for Maidstone and The Weald has said. The best fundholders developed set-ups in their practices that were unprecedented in the NHS: physiotherapy in the practice, consultants coming in for special in-house sessions to deal with people in the surgery, better facilities than ever before for minor surgery by GPs. In many cases, after the Bill, those things will be squeezed out in some practices by constraints on the budget of the primary care group as a whole.
A second thing will be lost. Compared with the old fundholders, GPs in the new groups will lack the clout and influence over colleagues in hospital-based and community-based NHS services; those fundholders were such a beneficial influence on behalf of patients.
Practitioners' incentive to achieve efficient practice will be lost in a particular practice because money will be distributed according to historic spending patterns — to practices as a whole. Indeed, the way in which the money is being distributed to the groups rewards the more inefficient practitioners. They will get their historic level of spending, and some more efficient practitioners will be penalised. Under the system, every practitioner will be handicapped by the most difficult GPs in the slowest practices.
The biggest problem in some primary care groups will be that some GPs will simply not be interested in being involved in such management and development of the service. Keen GPs will probably get themselves elected on to the boards, but they will have no way in which to stop the less keen from inhibiting what they can do. That is a serious problem. The cash-limited budgets that will be imposed on those large, almost unmanageable blocks of GP practices will give rise to particular difficulties, especially as prescribing costs will be imposed on the groups, which will have no ability to hold to account those whose prescribing habits start to exceed the budget.
My biggest sadness is that GPs will lose that commitment to their own patients and practice and the incentive to drive improvements, which led to benefits on the ground.
63 I agree with a local GP, Dr. Simon Fradd, who is deputy chairman of the British Medical Association's GP practitioner committee. He says that the policy is equivalent to rationing and will lead to the refusal of service. I also agree with Professor Maynard, the professor of health service management at York university, who says the same: GPs will be put in a position where they will have to ration care. I hope that I am wrong.
I take part in health debates because I want the national health service to survive and succeed. However, the Government's party political rhetoric, the partial presentation of the facts, and Bills such as this one will make things worse.
§ Mr. David Hinchliffe (Wakefield)
I should like very warmly to welcome the main thrust of the Health Bill, particularly its three key provisions on quality of provision, emphasising the role of primary care, and especially the long-overdue abolition of the internal market.
When the history of this phase of the national health service is written, the Bill will be remembered as the end of the privatisation by stealth attempted by the Tories over the past 25 years. I say 25 years because I was working in social services 25 years ago, when Sir Keith Joseph was the Secretary of State and introduced the changes removing the democratic element in health provision from local government to health authorities. His view was that the market had an important role in health provision. Gradually, over the past 25 years, when the Tories were in power, they moved increasingly in the direction of allowing the market to run health care. Current Tory Front Benchers have made it quite clear that they are firmly wedded to the market in health — which is profoundly opposed by most civilised people in the United Kingdom, whatever their politics.
When the Thatcher Government were elected, in 1979, they realised that the British people would not vote for privatisation of the health service — because a vast, cross-party majority of the British electorate support the central tenets of the national health service, as they have done since the service was started in the 1940s. The Tories therefore began the process of privatisation by stealth, with a range of measures that I should like to mention briefly.
The first measure to be introduced, in the early 1980s. was general management. Management concepts were wheeled into the national health service that were totally alien to it. More importantly, people from business were wheeled in, although they had absolutely no knowledge of the NHS. A biscuit manager was brought in as the general manager of my health authority, and the right hon. and learned Member for Rushcliffe (Mr. Clarke) may well recall the consequent problems that we had in Wakefield.
The previous Government created a culture of paying for care. Year after year, prescription charges were hiked way above inflation. The Health and Medicines Act 1988 introduced charges for eyesight and dental checks and for preventive health checks. For older people, there were also tax concessions on private medicine, as the previous Government believed that such an incentive should be 64 introduced to encourage ever more people into the private sector. The hon. Member for Rutland and Melton (Mr. Duncan) nods. He is in favour of people using the private sector.
The previous Government also instituted the wholesale privatisation of community care. I have received computations from the Library showing that, in the 10 years before introduction of the 1993 community care changes,£10 billion of social security resources were pumped into the private residential and nursing home sector. At the same time as there was a huge expansion in construction of private nursing and care homes, there was a deliberate run down of NHS provision for older people.
The Bill will reverse that privatisation process. I therefore believe that, in many respects, the Bill's passage will be a major landmark in making the NHS once again conform to Bevan's vision for it.
The National Health Service and Community Care Act 1990 introduced the internal market. During its passage, several Conservative Members made it clear that they believed that the internal market was only a prelude to moving further towards a market system, in which the vast majority of patients would be expected to have private insurance, with only a state safety net for those without it, as in the United States.
The end result—regardless of what the Tories' reasoned amendment to this Bill states about fundholding—was a two-tier system. In my constituency, I had people who were life-long Tory voters but who objected fundamentally to the fundholding system, which provided them with second-class treatment. The names and addresses of those who came to see me about the way in which the fundholding system operated and impacted on their specific treatment needs are on record.
I praise the Tories for knowing what they believe in and pursuing those beliefs. Although they were absolutely hammered on the NHS at the general election, they still believe in moving us ever closer towards private health care. In every one of her speeches and interviews, the right hon. Member for Maidstone and The Weald (Miss Widdecombe) has said, "Make more use of the private sector." A couple of weeks ago, the hon. Member for Rutland and Melton made a major speech—in which I was given the great honour of a mention or two—the central thrust of which was that, "We can't afford to pay for a national health service. Get people into the private sector."
When talking about moving NHS patients into the private sector, Tory Members fail to deal with one specific difficulty: the private sector is staffed entirely by those who were trained in the NHS. Therefore, the more the private sector develops, the more that the NHS will be denuded of staff. They fail also to appreciate—as the Health Committee is discovering in its inquiries—that the quality of care in the private sector sometimes leaves much to be desired.
I am sorry that the right hon. Member for Maidstone and The Weald has left the Chamber. She mentioned three categories of the dispossessed, but failed to mention a fourth one—NHS patients who wait patiently on a NHS waiting list, until someone from the private sector queue 65 jumps, putting everyone back a place. Those people do not have access to the treatment that they need because of queue jumping by people from the private sector.
§ Mr. Hinchliffe
There is plenty of evidence of it. The hon. Gentleman need not worry, as I could give him plenty of examples.
In the few minutes that I have left to speak, I should like to concentrate on a few key matters. As I said, I welcome the Bill's concentration on the quality of provision. In my own constituency, I have been concerned that, in a minority of cases, patients have had a very raw deal from the health service and not received answers to some of their medical problems.
As I also said, I welcome the Bill's emphasis on primary care. However, I should like to mention one specific concern. I believe that the Bill's vision of involving the social services should go much further, and follow the model provided by Northern Ireland, where there are one-stop shops in general practitioners' surgeries. Northern Ireland's health centres genuinely offer access to child protection, home care, district nurses and various professionals other than GPs. I worked, 25 years ago, as a GP-attached social worker. Gradually, we are returning to that system, which worked so well but was damaged by the reforms introduced in 1974 by the Conservatives.
I hope that one specific aspect of the Bill—on governance of the NHS—will be dealt with in Committee. I have previously raised concerns about the democratic deficit in the health service, and believe that one reason why some patients sometimes misuse the NHS—by not turning up for appointments, for example—is that they lack a feeling of personal ownership of the service. Within the primary care groups, trusts and the overall service, we shall have to consider how to involve patients in the service, as they currently are not.
I have also previously expressed my disappointment at the continuation of the system of appointment of officials which was so discredited under the previous Government. Although those who currently hold appointments usually believe in the health service, we still have to ensure that local people who use the service are involved in decisions on the service's direction.
A key difference between the Government and the Opposition is demonstrated by the Bill's replacement of the duty to compete with the duty of co-operation. It is a fundamental difference between the two sides. I think that the vast majority of people in the United Kingdom—Tories included—believe that the NHS is about co-operation, collaboration and working together. I wish the Bill well in its passage through the House.
§ Mr. Simon Hughes (Southwark, North and Bermondsey)
Almost two years ago today—when we were about 14 days out from the general election—the Labour leader and Labour spokespeople said that there were only 14 days left for the country to decide whether it wanted to save the national health service. Many of us thought then that we could be well disposed towards Labour's commitment to the NHS. We would rather have 66 done what was necessary ourselves, but if we could not be in power, at least Labour would be bold and resolute, and would make flagship proposals to transform our struggling national health service for the better.
§ Mr. Hughes
If the Bill is supposed to be the great, bold, dramatic flagship that the hon. Gentleman implies, he should be sorely disappointed. It is a timid little measure. Although some things in it are timely and welcome—as my colleagues in the other place have said, we support those—there is much more that the Government should and could do. Sadly, none of that is in the Bill.
The Government started off on the wrong tack by saying that their first priority, before any legislation, would be the reduction of waiting lists. There is nothing about that in the Bill, perhaps because the target was wrong anyway. Even if it had been the right target, the bold promise of a 100,000 reduction is still some way off. The figure is down by 50,000 in England, so one in 23 people fewer are waiting; really successful! One in 14 people fewer are waiting in Scotland, and in Wales more people are waiting than when Labour came to office. So far, therefore, there has hardly been a dramatic change.
The Secretary of State said that the Government inherited a health service in deficit, but if we look round the country we see plenty of health authorities that have started the new financial year this month in deficit.
The Secretary of State also said that Labour had inherited a health service in which there were many parts of the country where one could not find a dentist. I was in Cornwall the other day with my hon. Friend the Member for South-East Cornwall (Mr. Breed), and my colleagues there have just launched a campaign to try to get a decent number of dentists almost anywhere in the country. My hon. Friend the Member for Taunton (Jackie Ballard) keeps trying to make it clear to the Government that although everybody identified the lack of dentists as a major issue, there has hardly been any significant change in numbers.
There was nothing in the Labour manifesto about the need for more staff in the health service. There was no commitment to employing more nurses or doctors, although everyone else knew that there was a major crisis. We looked for dramatic responses.
By contrast, some of the things that have happened were not mentioned in the Labour manifesto. NHS Direct must have been dreamed up after 1 May 1997.
§ Mr. Hughes
The right hon. Gentleman, a former Secretary of State for Health, says that the Government inherited the proposal. It certainly was not in the Labour manifesto.
§ Mr. Hughes
Indeed it was, as the right hon. Gentleman fairly says. The 20 walk-in surgeries were not in the Labour manifesto, either.
67 Labour's great commitment was that the two-tier health service would go, and that there would be an end to the internal market. In one sense the two-tier service will go, in that the Bill will end the division between fundholding and non-fundholding. We welcome that. However, a greater concern for most people is the patchwork nature of the health service. People who live in one place have access to treatment that people who live elsewhere cannot get.
That problem has not disappeared, and nothing in the Bill will make it disappear. For someone waiting for beta interferon or in vitro fertilisation, that is the issue that matters. It is no good having a national health service theoretically available to all, if it is not available to all in the place where one lives. That is a multi-tier health service.
The Prime Minister said that the internal market would end, but as the right hon. and learned Member for Rushcliffe (Mr. Clarke), another former Secretary of State for Health, rightly said, that has not happened. The internal market is still here; there are still purchasers and providers. Indeed, there will be more people in that equation. Of course, some of the arrangements will be different, but the internal market will not have gone away.
When the Prime Minister was speaking in the debate on the Queen's Speech, I tackled him about rationing. He said that Labour had proposed the best framework in which to determine priorities. Now, however, although everybody else in the country says that the big issue is how we decide what the NHS should do, how we should pay for it, and why all treatment is not available everywhere, and asks, "Isn't that rationing?" the Government say, "There is no rationing; that is a delusion."
None the less, the Government have made a proposal to deal with the problem that they say does not exist. It is not, of course, to be dealt with by involving the public, because that would be far too dangerous; the public might want to express a view.
When my right hon. Friend the Member for Yeovil (Mr. Ashdown) spoke in response to the Queen's Speech, he set out the view that we hold today, as we did then—the same view as we have formed about the Bill throughout its progress both through the other place and here.
For example, all the professionals in England could have been involved in the process, but only some of them have been invited to the table. In Wales, a wider invitation has been sent out for people to take part in the new Labour NHS.
The Government could also have been bold and followed the logic of all the recommendations from the Select Committee on Health, which is chaired by the hon. Member for Wakefield (Mr. Hinchliffe) and includes my hon. Friend the Member for Isle of Wight (Dr. Brand), about merging health and social services. The logic of that proposal cries out to be heard.
However, there is only one little proposal about health and social services consulting a bit more. They must still keep two separate managements running two separate regimes, offering services that often overlap, although they are charged for differently. There is no proposal to change that, although I can tell Labour Members that, 68 logically, this change will be made. As with much that the Labour party does, the Government will come to the conclusion much later than others who have thought about the subject. For instance, the Select Committee, like the Liberal Democrats, has realised for some time what the right policy is.
There is nothing in the Bill about one of the issues that we have spent much of the last two years talking about: how do we recruit the people to provide a quality health service? We can produce the most wonderful statements about quality, but if we do not have the staff we will not get the quality either.
There could have been extra incentives to recruit people and encourage them to be trainees, or to be undergraduates in nursing, physiotherapy or medicine—but there is nothing in the Bill about that. There is nothing about recruitment and retention, nothing about rationing and nothing about resources.
It might be said that resources are dealt with elsewhere in the parliamentary timetable. That is true, but there could have been something in the Bill that tried to answer the big question about the health service: how do we link the resources with the services that the NHS should provide? Of that there is not a word.
The Conservative contribution, made by the right hon. Member for Maidstone and The Weald (Miss Widdecombe), who is not now in the Chamber, was interesting. As my hon. Friend the Member for Isle of Wight said at the time, sotto voce, there was something of the Barbara Woodhouse of the House of Commons about the right hon. Lady when she instructed everyone to sit down and be quiet as she set out her prescription for the NHS.
As I understand it, there are six Tory criticisms of the Bill. The first is that it removes the choice for doctor and patient to send the patient where they think he or she should go. There is some truth in that criticism, and although the amendment made in the House of Lords was a welcome move in the right direction, it was left pretty unclear what the Government think should happen. We shall press them further on that subject.
The Tories also criticise the end of fundholding. We do not. We think that there should be only one type of doctor's practice, so that people who go to a surgery should not get better or worse treatment, depending on what sort of doctor is there. Such a regime was the legacy of the period when the right hon. and learned Member for Rushcliffe was Secretary of State.
The Tories say that there is unnecessary and expensive bureaucracy. That is a bit rich, coming from them. They set up the most bureaucratic health service that we have ever had, so their criticism is not easy to support. They also say, "We cannot have any more upheaval." That, too, is a bit rich. Apparently Tory upheaval is fine, but if it is anyone else's upheaval, that is not so good. I lived through the Tory health service reforms, such as the creation of the internal market—and the poll tax too—so I am not sure that people will believe what the Tories say about upheaval.
There was another argument about the competitiveness of the pharmaceutical industry being undermined. There is a danger of that happening, and we are alive to it; I shall say more later. The Tories also say that the powers of the Secretary of State are being centralised. That is true. One of the great themes of the Bill is providing more 69 power for the Secretary of State and less power for the patient, less power for the people. That is a fundamental flaw.
Over the past two years many of the things that could have been done either have not been done or have been done too late. Spending plans were on hold for nearly 24 months. Staff pay was staged in year one, and many employees have not caught up in year two. The staffing crisis was not addressed for 20 months. As often happens, the Government have been slow to get up and move.
Then the Government are desperate to be seen to be doing things, even if they have not quite thought through how their actions relate to their other policies. We heard a good example of that today in the statement by the Prime Minister. Only recently have the Government realised that the total waiting time between someone realising that they need treatment and getting it matters. That means not just in-patient waiting time—the time that someone waits to obtain treatment—but the time that they wait to see a consultant in the first place.
The Government have only just realised that we have a terrible staffing crisis in the health service. I am not sure that they will be able to act in time to do something about it. Ideas such as walk-in high street surgeries and NHS Direct are fine as far as they go, but no one has thought through how they integrate with the local health service and work with the other structures, such as primary care trusts and groups, that are being set up; or how to ensure that the new services do not result in doctors, who are in short supply, being attracted away from areas where they are needed and cannot be replaced.
We are in favour of innovation. We are in favour of nurses sharing the leadership of local community health groups with doctors. We are in favour of collaboration among professionals—all of them. We are in favour of co-operatives of doctors doing out-of-hours services. We are in favour of telephone advice in the right place, but as my hon. Friend the Member for Richmond Park (Dr. Tonge) said earlier, we must recognise that it has limited value. We are in favour of more self-medication, including alternative therapies. We are in favour of pharmacies having a proper recognised role. We are in favour of the whole range of NHS services, but there should be democratic accountability.
The Government have missed a great opportunity to bring local health services and local social services together under democratically accountable elected bodies. That would enable the public to participate in decisions, rather than excluding them. The great hidden danger, to which the right hon. and learned Member for Rushcliffe referred, is that those services will be cash-limited and the public will not be able to do anything about it. It is no good giving a lot of money in theory to the health service to be dished out around the country if social services are being stretched and capped and cannot do the job that is expected of them.
There is not a word in the Bill about regional health services. They exist. There are regional health authorities, but nobody elects them or has any say on strategic planning; they are just appointed. The Bill also fails to provide any greater democratic control at national level in the four countries of the UK, which is where the health service will be controlled after May. Recent figures show a worrying trend for the two years the Government have been in office. The number of recognised Labour party 70 people appointed to non-executive posts in health trusts in England has gone up from 8 to 226—an increase from 0.3 per cent. to 9.6 per cent. Needless to say, the other parties are considerably behind.
There are many amendments that we would like the Government to accept, but we fear that they will not. We would like to remove the difficulty of cash-limiting from primary care groups and trusts and make them accountable, but we fear that the Government will not do that. We would like a better balance of the professions in the primary care trusts so that the chair and the majority—or largest minority—of places are not always reserved for doctors if they want them. That is the deal that the Government made to get the proposals past the doctors. We would like to know why the requirements for quality of care do not apply to health authorities and primary care groups as well as to trusts. We want a commission that looks at the quality of care—we have argued for that for years—but it should be truly independent and authoritative and there should be a link between the commission's recommendations and the ability to deliver. It is no good the commission going round the country specifying action that should be taken if the Secretary of State says that the Government do not have the resources to deliver the improvements. The best model would be the prison inspectorate, which is increasingly respected as an independent voice that says what is wrong in the prison service.
We have argued the case for local and health authority mergers. The Government are still fudging the issue on the control of prices for the drugs industry. They are saying that they like the voluntary system, but if it does not work they will introduce a statutory system. The pharmaceutical industry needs to be encouraged because it is a great British industry, but the NHS has an interest in regulating the way in which it is charged for the services that it has to buy from the industry.
On the professions, the Secretary of State has clearly learned a lesson from the debates on the Bill in the other place. Initially he sought all the powers for himself, but there have now been many welcome amendments. All the professions should be regulated. It is a long time since some of them first asked for regulation. For example, psychologists want people to know who a proper psychologist is. We need a system that can bring them quickly into the regulated fold, but we should not change from a system of professional self-regulation without primary legislation. The framework must be clear so that each profession knows where it stands.
A crucial amendment was forced on the Government in the other place to bring the independent health care sector within the remit of the quality control initiatives. The hon. Member for Runnymede and Weybridge (Mr. Hammond) was wrong to say that it should be under the control of the NHS. It should be under the control of the Government. We firmly believe that the private health care sector should be regulated according to the same standards as apply to the public health care sector. We shall resist any attempt by the Government to reverse that welcome change to the Bill. We shall also support the other two major amendments made against the Government, which were to ensure that a majority of a primary care group voted in favour before it became a trust and to ensure the right to refer out of area, which is another name for the existing practice of extra-contractual referrals.
71 There is just one further issue that the Government still resist and I have not heard an explanation from the Secretary of State of why they are being so difficult. There should be clear equal opportunities requirements throughout the NHS, not just on the basis of gender and race, but also on the basis of age. It would be entirely proper to put such a provision in the Bill and we hope that the Government will change their mind.
The Bill proposes changes to create a better quality and more accountable health service. We welcome that, but the Government could have come up with provisions to answer the big questions and meet the needs of the people. Sadly, this short Bill for England, Wales and Scotland is a Bill of missed opportunities in every case. We do not understand why we are legislating for Scotland in April and May of 1999 when from May the Scottish Parliament, which properly wants to run the health service, will take over those powers. We also do not understand why the Government are seeking to impose a system on Wales when the Welsh Assembly is to be elected next month. It, too, will be given responsibility for the health service. The Government want to give the Secretary of State more responsibility for the health service in England when there are plenty of people at local and regional level who are competent to make decisions to meet local needs. We understand that, but we strongly oppose it.
The Government could have introduced a more democratic local health service. They could have introduced a strategic democratic tier for the health service. They could have provided incentives for more people to work for the health service. Above all, they could have owned up to the fact that decisions about resources and rationing have to be made.
We were constructive in seeking to amend the Bill in the Lords, but we remain unhappy because it is weak and timid. We cannot support the Government tonight, but we shall work in Committee to improve the Bill and make it more worthy of the Government's ambitions and objectives and of what the people expect from the health service. By the time it comes back to the House, we hope that the Bill will be bolder and braver than the current very timid measure.
§ Mr. Paul Truswell (Pudsey)
Since the general election, nothing has given me greater pleasure—in the Chamber, at least—than I have now in supporting the Bill. I have been able to view the national health service for some years from a variety of vantage points: as a member of a family health services authority; as a health authority member; as a chair of social services; and as a member of a community health council. In all that time, I never perceived the benefits of the elixir described by the right hon. and learned Member for Rushcliffe (Mr. Clarke).
Primary care groups may have a great deal to learn, but they are infinitely preferable to their GP fundholder predecessors. Unlike GP fundholding, they are inclusive, not exclusive; integrated, not fragmented; co-operative, not competitive. They have the capacity to take communities along with them, on board rather than in tow.
The right hon. and learned Member for Rushcliffe mentioned various senior clinicians of his acquaintance. I refer to only one such person of my acquaintance, 72 Dr. Kingsley Reid, an eminent GP in my constituency and chair of the Leeds local medical committee of GPs. He said that the previous Government made such a mess of the NHS that he doubts the capacity of any Government to repair it.
Senior GPs have welcomed PCGs as an opportunity to put primary care in the front line and in the NHS driving seat. They do not regard everything to do with PCGs as sweetness and light, and there are still concerns about the work load expected of PCG board members and the speed with which the groups may be forced to develop. I am sure that my right hon. Friend the Secretary of State will take those concerns into account.
There are further concerns relating to learning the lessons of GP fundholding. PCGs should not be allowed to advance to the detriment of their neighbours. Whatever defence the Conservative party may have mounted for fundholding, it is a fact that it was promoted on the basis of fear, bribery and, in some cases, turning a blind eye to issues of probity.
Many GPs opposed fundholding but still became fundholders, not because they were hypocrites but because they knew that the Conservative party would do everything that it could to make its ideological baby walk. Someone was clearly going to get a bum deal, and GPs did not want them or their patients to be left holding the nappy.
Those GPs were proved right when the Conservative Government stuffed fundholders' surgeries, if not their mouths, with gold. Allocations of cash to fundholders were based on historic referral and prescribing patterns. It was possible to engage in a frenzy of prescribing and referring in the preparatory year before fundholding, knowing that such activity would form the baseline of the fundholding budget.
Fundholders also received generous extra funding for staff and computers. It may be said that there was a choice, but there was also a great deal of incentive, which came from a levelling down process. Those who were not fundholders' patients suffered the levelling down produced by the system introduced by the right hon. and learned Member for Rushcliffe.
Fundholders were in a privileged win-win position in respect of surpluses and deficits. They were able to keep their savings and leave to the health authority the task of bailing them out when they overspent. [Interruption.] One would not even run a whist drive in Maidstone, or wherever the right hon. Lady's constituency is, let alone a national health service, in that way. [Interruption.]
§ Mr. Deputy Speaker (Mr. Michael J. Martin)
Order. The right hon. Member for Maidstone and The Weald (Miss Widdecombe) has already made a speech. She cannot now make another one.
§ Mr. Truswell
Thank you, Mr. Deputy Speaker, for interrupting our conversation.
When Leeds health authority was seriously in deficit and some of its contracts for routine procedures were running out, the majority of fundholders were sitting on surpluses, many well into six figures. One such surplus was almost £300,000. By the fourth year of fundholding in Leeds, the total surplus amounted to £2.7 million, which roughly equated to the deficit faced by the 73 health authority, which was responsible for purchasing care for those who were not in the privileged position of being patients of fundholders.
Levelling down also took place among fundholders. Having foisted a great deal of riches on the early tranches of fundholding, the Conservative Government discovered a simple arithmetical truth: one cannot continue to give an increasing proportion of people an unfair share of the cake. The early tranches were reduced as new fundholders came in, but those who were not fundholders were still left in the sink.
The fact that fundholding quickly passed its sell-by date was illustrated by the way in which so many different systems grew up. There were total purchasing projects, locality commissioning and multi-funds. Those systems were more in keeping with PCGs than with fundholding.
Another attraction of fundholding was the fact that accountability was relaxed to the point at which it was very flaccid indeed. The definition of what constituted improvements in patient care was stretched to the limit. Several times, our auditors on the FHSA raised serious questions about clinical items such as the purchase of lavish oak furniture and extravagant computer upgrades, especially as the suppliers were linked commercially with the practices concerned. The CHC also raised questions about money being used to resurface car parks. Perhaps, in due course, the National Institute for Clinical Excellence could consider the clinical effectiveness of tarmac, oak and other such items.
We went off to the Kremlin, which is the affectionate title by which the NHS headquarters in Leeds is known, and were told, "Hands off. Go away. We're not interested. Don't you be doing anything to discourage fundholders, now or in the future." That was the Conservative party's approach.
The Conservatives display a slavish adherence to GP fundholding, but they should answer a few questions in defence of that wonderful system. Why, if it was so good, did it perversely have to rely on its shortcomings to attract recruits? Why did GPs have to be bribed with cash, staff and computers, at the expense of other patients and non-fundholders? Why was such a blind eye turned to issues of probity? [Interruption.] The answer can be given in the summing up, so please let us not hear it from the right hon. Member for Maidstone and The Weald (Miss Widdecombe) now.
The only tiers that should be shed in the context of GP fundholding are the two tiers of NHS care to which it gave rise. I can give no better example than the experience of my constituent Kristie Swift. She was suffering from a common ear complaint that required routine surgery. Her hearing was badly affected and her whole educational development was being undermined.
§ Mr. Truswell
A consultant said that he could not treat Kristie that financial year because her GP was not a fundholder, and her head teacher asked me to look into the case because she was so worried about her lack of development.
It turned out that Kristie's GP was in fact a fundholder, and she received her operation long before the end of the financial year, so within a matter of a few weeks, she had been on both levels of the two-tier system produced by 74 the Conservative party, and for good measure she had been the victim of the convoluted bureaucracy spawned by that dynamic duo of the internal market and GP fundholding.
I heard some mutterings about Jennifer's ear. To some extent, that may be pertinent, although this case is 100 per cent. true, not a dramatisation based on what we know in any case to have been a reality. The issue of Jennifer's ear in 1992 concerned the difference as regards access between the NHS and the private sector.
I have described the battle of Kristie's ear. We are not talking today about the division between public and private, but about an NHS that the Conservative party divided against itself. The Bill will help to close that divide and is a welcome stitch in time for our NHS.
§ Mr. Robert Walter (North Dorset)
The NHS is probably the most popular institution in Britain, but judging by the Secretary of State's opening remarks he obviously does not believe that the Bill will be popular. He spent most of his time talking about other health service issues rather than the Bill. Because the NHS is popular, it generates huge concern among those who use it and those who think they would like to use it. It is also one of the few institutions over which the Government have total control.
Members on both sides of the House are committed to the national health service. Despite what the Labour party says, we are committed to making the NHS efficient and effective—but will the Bill contribute to that aim? It is suggested that the Bill will save money through the abolition of fundholding and that it will release scarce resources to be used for patient care. However, primary care groups will probably cost some £150 million a year to administer. Some estimates have put that figure as high as £300 million a year, excluding start-up costs for the new procedure. Ministers have suggested that that money will be recycled, but that is a nonsense. The administration of fundholding costs only £135 million a year, and that is the figure given by the Minister of State to the Select Committee on Health earlier this year. The Secretary of State said earlier that that £135 million has already been used, or recycled, for cancer screening.
The Bill will not abolish the so-called internal market, because there will still be a purchaser-provider balance. The relationship remains intact, although I am sure that Ministers will point to clause 23, which deals with co-operation. It is a motherhood and apple pie clause, which suggests that we will all work together in some great co-operative effort to deliver our objectives. Primary care trusts and health authorities will still buy in services from trusts and local authorities. Level 4 primary care trusts will be able to provide some services for themselves and supply services to other bodies.
The suggestion is that that will abolish the two-tier structure of the NHS. However, the Bill provides for four tiers of primary care, and will allow no choice. At least in the two-tier structure there was some choice. Fundholders and their patients will lose out. If we examine the divisions of care between those in primary care groups at level 1 and those in primary care trusts at level 4, we see a genuine two, three or four-tier effect.
The Bill will not produce a more efficient or effective NHS. In rural areas such as my constituency, the Bill will bring together GPs' practices spread over many miles,
75 which have little in common, other than that when added together they make a unit that suits the civil service maths for a primary care group and, eventually, a primary care trust. Is that an efficient way to run a primary care delivery system? Who will attend the meetings of the board? Will practices send their best GP, the senior partner and the man who is most effective at delivering care on the ground? Or will they send their least effective GP, the man who can be spared from the surgery for half a day to go to a meeting that is possibly some 20 or 30 miles away. When he comes back and tells the practice about the decisions, will the other GPs feel ownership of the decisions, if their least effective man has been sent along as a placeman to sit on the board? It is difficult enough for GPs to work within their own practices, let alone to work with GPs who may be 20 or 30 miles away in other practices. Committee meetings will also be a call on GPs' time, which has not been accounted for in the costs of the Bill.
Abolishing fundholding is a fundamental mistake. Fundholding has received many plaudits from virtually every source other than the Government. The British Medical Association said a couple of years ago that fundholding is
"a good model for encouraging consumer accountability into the NHS … GPs are truly willing to share the decision-making process with their patients."
The Organisation for Economic Co-operation and Development, an external body, stated:
Within the range of services that they are permitted to purchase, GPs do seem to have done a better job of purchasing than district Health Authorities. Fund-holders have been more prepared to diversify providers, challenge hospital practices and to demand improvements.The Audit Commission, a body that cannot be associated with Ministers from Governments of either party, made the most telling observation in March last year, when it said:
Most fund-holders have introduced … improvements, including more services for patients at practice premises, improved communication with hospitals, and more cost-effective drug prescribing.It seems that the wider benefits of fundholding are clear to everyone except the Government. Fundholders have been able to secure shorter waiting times for their patients operations. GPs have managed their practice budgets and have been able to develop new specialist services for their patients. Fundholding has encouraged greater communication and provides a way to involve GPs in the wider planning and management of the NHS. Fundholders have been able to manage their premises budgets, to develop and improve their surgeries and waiting rooms for the benefit of patients. The ability to perform minor surgical procedures in GPs' practices has been developed as a result of that greater autonomy. Because the patient is closer to the centre of decision making, fundholding has encouraged greater accountability in the health service and access to the executive process for patients.
In the time available, I have dealt with the provision for primary care that the Bill contains. It contains other measures, including provision for quality, under NICE and CHIMP. The provisions on drug pricing will be onerous for the supply of drugs to patients, and the Bill also contains provisions on professional regulation. 76 However, it will do little to improve health care in Britain. The provision of primary care will take a step backwards as a result of the Bill. It could have been better drafted to provide efficient and effective control of the NHS and, at the end of the day, the Bill will be seen as unnecessary.
§ Mr. Patrick Hall (Bedford)
I welcome the Bill and the changes taking place in the new national health service. Given the time limit on Back-Bench speeches, I shall comment principally on primary care groups and the context in which they arise. I shall focus on the Bedford primary care group.
Primary care groups have just begun their work. They are sub-committees of local health authorities and will meet in public and conduct their business openly. That is an important fact. At their meetings, they will, de facto, afford community health councils the observer status sought by those councils. There may be some positive purpose in formally recognising the observer status that has been requested, because community health councils are drawn from local communities, local authorities and the voluntary sector, and I ask my hon. Friend the Minister to consider whether that requirement could be included in regulation and to comment on that when he sums up.
The Bedford primary care group covers a population of 145,000 people served by 25 GP practices and 75 general practitioners. I have recently spoken to the chairman of the new PCG about his views and those of his colleagues on the board as to the future prospects for the PCG. He is positive about two aspects. First, he saw the opportunities inherent in an approach to the development and delivery of health care commissioned by people who are in daily contact with patients. That is most important. There are seven GPs, a practice nurse and a health visitor on the Bedford PCG. Those people can see at once what is happening on the ground; they can relate the strategies and plans of health authorities and others to the reality of life in the community.
The second positive aspect is the concept and the practice—as we shall see—of a unified budget. Initially, 40 per cent. of the capitation will be devolved to the area covered by the PCG—£32 million for the Bedford PCG. The official target is that that must rise to 60 per cent. by April next year, but the Bedfordshire health authority and the five PCGs in Luton and Bedfordshire are forming a commissioning consortium, or forum, that has as one of its aims a devolved budget of 100 per cent. by next spring.
The Bedford primary care group sees the new funding arrangements as providing—in the words of the chairman of the new PCG—"an exciting opportunity" for a more cost-effective and holistic approach to expenditure. For example, the new arrangements offer the opportunity to choose to spend more on certain drugs for patients who are still at home, still in the community and at work. Under previous arrangements, that would have overspent the cash-limited drugs budget and the spending would not have taken place. Now that spending can happen and, as a result, money can be saved at the other end of the process—the hospital emergency treatment end. That could represent an overall saving of resources that could be redeployed or reinvested in developments. There would also be a reduction in stress for patients, which would be good for individuals, their families and society.
77 People are enthusiastic about the prospects for the groups—especially the medium and long-term prospects. We realise that when something new starts, there will be short-term problems during the bedding-down process. Fundholders and non-fundholders are now working together on the Bedford PCG board and that is another good feature of the reforms. The former fundholders have some concerns that the new arrangements might make budget decisions more difficult in the short term and that there might be some difficulties in continuing some of the innovations that they introduced in fundholding practices. I acknowledge that—as do the Government. No one is trying to hide that, but the important point is that there is now a greater vision for the greater good, and that is accepted by the Bedford PCG. The benefits should exist for the many, not only for the few—benefits for the whole country, not merely for those patients whose doctors happen to be members of a fundholding practice.
There is a will to make the new system work. It is accepted that the innovations of fundholding should apply to the whole country. I accept that there were innovations in fundholding that benefited some patients, but they should apply to everyone. It is also accepted by many people—including those to whom I have spoken in Bedford—that fundholding could not be the mechanism to deliver the expansion of improved services to all, because of the inherent contradictions in the system. The system had high transaction costs as part of the bureaucratic internal market; it was based on competition, not co-operation and, by its very nature, made planning and long-term thinking difficult. It was inherently destabilising to the national health service.
Apart from the important new duty of quality that has been mentioned by other hon. Members, the Bill also introduces a new duty of co-operation and partnership, not only within the NHS, but outside. There will be partnership with the voluntary sector, local authorities, social services departments and employers—for example, in drawing up health improvement programmes. Consistent with that duty is the need to consult the public. On that subject, I ask my hon. Friend the Minister to agree that community health councils should be consulted by primary care trusts—when that evolutionary step takes place—on significant changes in service, and that CHCs should have the right to inspect premises run by primary care trusts. In respect of the proposed changes to the legislative framework for NHS trusts, it would be reasonable for a requirement to be included that NHS trusts consult the public and CHCs on proposed changes to services or plans to dispose of or acquire sites.
What we are about now, in moving on from fundholding and in the other measures, is levelling upwards, commissioning services that people need. It is about returning to the historic founding principle of the national health service: top-quality medical care, accessible to all, based on need and never based on ability to pay. That historic principle is as important today as it was when it inspired the country 55 years ago. The Bill provides important measures and takes important steps to raise standards, to tackle health inequalities and to take the NHS forward as one of this country's greatest and finest achievements.
§ 7.8 pm
§ Mr. Stephen Dorrell (Charnwood)
In the 10 minutes available to me, I want to concentrate my remarks on the effect of the Bill on the primary care world. I want to 78 follow up some of the remarks made by my right hon. and hon. Friends about fundholding and to pick up a particular question posed by my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe): what do the Government envisage as being the long-term role of a primary care trust? That question is unanswered in the Bill and in its supporting notes.
I begin with a little NHS history. When Enoch Powell was Health Minister in the early 1960s, he made speeches about the importance of making the hospital sector of the health service more accountable to general practice and to people who are in day-to-day contact with patients. That theme was followed up in speeches made by Conservative and Labour Health Ministers through the 1960s, 70s and 80s. If there had been word processors in those days, that text would have been on the word processor. In 1990, those who examined the British national health service started to notice that 30 years of rhetoric about the need to make the hospital service more accountable to general practice was suddenly being converted into action.
The famous aphorism that Christmas cards flowed from general practitioners to hospital consultants was reversed in 1990 when consultants suddenly found a need to send Christmas cards to GPs. The House must ask itself whether it was just a massive historical coincidence that the extra accountability of the hospital service to GPs happened when my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) introduced GP fundholding and the reforms of 1990. Or was there some cause and effect? I believe that there was: my right hon. and learned Friend's reforms, in which I had the honour to play a minor role, strengthened the effective voice of general practice within the NHS, achieving what 30 years of rhetoric had failed to bring about by making the hospital service more accountable to general practitioners, and through them to patients.
The Government continue to make the same speeches about the importance of the secondary care sector being responsive to the wishes of the primary care sector. Ministers apparently believe that the change in the centre of influence of the health service that happened in the early 1990s can be sustained by primary care groups. I wish that I agreed, but I do not.
The key difference between the fundholding regime introduced by my right hon. and learned Friend as an option for all GPs and the primary care groups is that the 1990 regime gave each practice the right to decide where the funds available to support patient care should go. Under the PCG system, groups will be so large that the individual GP will lose the effective right to make those decisions on behalf of patients.
I do not apologise for the fact that when I was Secretary of State I facilitated the coming together in larger commissioning organisations of GPs who wished to do so. The key difference between the range of options mentioned by the hon. Member for Pudsey (Mr. Truswell) and the primary care groups is that a fundholding practice that went into a multi-fund or took part in a larger purchasing co-operative participated voluntarily. If the practice was not satisfied with the decisions taken in the larger co-operative, it could go away and do its own thing better. Under the Government's scheme, participation in PCGs is compulsory.
I have no quarrel with the Government's desire to open the option of purchasing to a wider range of patients. If GPs feel that that is the best way to deliver care to
79 patients, I have no problem with it. However, the key failing of the PCG idea is that participation is compulsory. The authority and power that my right hon. and learned Friend the Member for Rushcliffe gave to individual practices is being taken away and given to a new tier of bureaucracy. If Ministers believe that the Government will go down in history for cutting NHS administrative costs by creating a new tier of bureaucracy in the administration of PCGs, they have a greater faith than I do in the capacity of bureaucrats to cut bureaucratic costs.
My first point, then, is that the PCG weakens the capacity of individual general practitioners to make the structure of the health service account to the needs and wishes of patients. The Bill should be opposed for that reason.
My second theme follows the question put by my right hon. Friend the Member for Maidstone and The Weald. What will be the long-term purpose of the primary care trust, and what, in the Government's vision of the world, is the future of general practice delivered by independent contractors?
The Bill makes it clear that as well as having the authority to regulate the general medical services sector, primary care trusts will have the power to deliver general medical services currently delivered by GPs. Presumably, PCTs are able to deliver those services only by employing GPs. In which circumstances do the Government expect that model to be followed? That is a critical question, and I hope that the Minister will respond to it.
General medical services are one of the great unchallenged success stories of the NHS since its foundation, and that success lies at the heart of primary care. The health service was established on two key principles. First, a GP is a self-employed professional; secondly, he delivers his service as an independent contractor against a national contract, traditionally known as the red book. My right hon. and learned Friend the Member for Rushcliffe rewrote many aspects of the red book when he was Secretary of State, but he did not change that basic principle.
One important change was made to that principle under the previous Government in the National Health Service (Primary Care) Act 1997, for which I was responsible. It introduced for the first time the principle of local contracting, as opposed to the national contract. It also introduced the principle that there could be employed GPs as well as self-employed contractors. Both innovations were made for good reasons, but they were introduced on the basis that participation must be voluntary. Assurances had to be given to the vast majority of GPs that the option of delivering general medical services on the traditional basis would remain open.
When the Government introduce primary care trusts, giving PCTs the power to employ people to deliver general medical services, they must be crystal clear about when the PCT will have the right to employ a GP and about the circumstances in which a PCT will be empowered to deliver services in competition with independent professionals that the PCTs are obliged to regulate—
§ Mr. Ivan Lewis (Bury, South)
I am delighted to support a Bill that reinforces much work already begun to modernise the national health service. The key themes of quality, partnership and accountability define the principles that should underpin an NHS truly fit for the 21st century. The Government have demonstrated their commitment to the NHS by providing — 21 billion over the next three years.
The Bill proves, however, the Government's belief that that commitment is not only about extra resources. In return for our investment, we must make sure that patients in every community up and down the country experience significant improvement in the quality of health care. The Bill also draws a line beneath Tory health policy, which did so much to disfigure the NHS. Competition, inequality of access to services and underfunding combined to undermine public confidence in the NHS, though never public support for it.
Every opportunity should be taken to give people a history lesson about what the previous Government attempted to do with the NHS and to expose the Conservative party's plans for and philosophical beliefs about the future of the NHS. It is interesting that the health service is one of the few areas in which the Conservative party has begun to articulate an alternative policy agenda.
In a recent speech to the Social Market Foundation, the hon. Member for Rutland and Melton (Mr. Duncan) called for a significant increase in the number of people being encouraged—
I assume by the state—to take out private health insurance, and suggested that that policy should be supported by the Government through tax relief. Whenever we make that accusation and claim that that is what the Opposition are saying, they shake their head and deny that they believe that one way to improve quality in the health service is to increase the number of patients using the private sector, so 1 shall quote briefly from a speech that the hon. Gentleman made. He said:
Each and every one of our competitor countries has a larger personal healthcare sector. What becomes clear from looking at other countries is that we are losing out by not encouraging the expansion of personal healthcare. If we are to catch up with others, and deliver the standard of healthcare this country deserves, we need to build a larger public-personal mix. We need to add a thriving personal sector to the public sector NHS we already have.It is perfectly clear from what the hon. Gentleman says that he believes, as a fundamental principle and philosophy, that the way to improve the NHS is to encourage large numbers of people to leave the NHS and use private health care.
On 28 January, the right hon. Member for Maidstone and The Weald (Miss Widdecombe) told the parliamentary Press Gallery lunch:
I think if somebody wants to pay to see their GP, they should be encouraged to do so … The problem with the NHS is that we do not charge for much of what we do.However one dresses up or explains those statements, it is clear that the Conservative party is advocating privatisation by stealth. It is advocating what it did when it was in power—it effectively privatised the long-term care of the elderly and community care. The Conservatives were not brave enough to tell the people of 81 this country that they wanted to privatise the health service because they understood the political consequences of that. We will take every opportunity—
§ Mr. Lewis
No, I am sorry.
The Conservatives spoke about the dispossessed. Whether they did so in the context of health care or in the context of social deprivation, how dare they claim to be the friends of the dispossessed. For 18 years, they created more dispossessed than any Government in the history of this country. They also created a greater gap between rich and the poor than we had ever seen.
I deal now with some specific provisions in the Bill. Primary care trusts will be the natural evolution of the primary care groups, up and running since 1 April. Collaboration and teamwork will replace divisiveness and inequality of access to treatment. The service will undoubtedly benefit from GPs working more closely with other health and social care professionals. We have heard about the fear that GPs who are not very good will hold back those who are innovative and imaginative and who want to make flexible use of resources, but surely bringing GPs together in PCGs and PCTs will mean that peer group pressure will be applied to those who are not doing the job in the way we want and in a way that will enhance the quality of care available to patients. There was much cynicism and scepticism about PCGs before 1 April, but we can all evidence the commitment and work that health care professionals have put in to making them work.
There is also a new emphasis on quality, as exemplified by the establishment of the Commission for Health Improvement and the new statutory duty for quality. These measures will ensure that mechanisms are in place to monitor and evaluate quality at a local level, and to allow for speedy intervention when it is clear that things are going wrong. For too long there has been a disparity of quality depending on where one lives, or perhaps because quality was put to the bottom of the agenda by hard-pressed managers who were weighed down by the bureaucracy of the internal market. The Government are committed to ensuring that quality is the central driving force behind the modernisation and development of the NHS. That common sense dictates that the concept of partnership is the key to securing lasting health improvement and the most effective use of finite resources. At last there is an explicit duty of co-operation between NHS bodies, and between NHS and other local agencies.
When I was first elected to the House, one of the things that horrified me was the fact that health authorities, health trusts and local authorities slated each other in the local media for the difficulties experienced by patients. There was a culture not of collaboration, but of passing the buck and blaming other agencies. There is absolutely 82 no doubt that the new approach to partnership and collaboration is making a real difference in the relationship between the agencies.
We should remember, however, that organisations cannot really have relationships—it is the professionals and other people who work in them who need to develop mutual respect and confidence. The Government are creating a variety of vehicles to enable people from different disciplines to have regular contact and dialogue, and to work collaboratively to ensure that patients get the best possible deal. For example, local health improvement programmes will bring together not only the relevant statutory agencies, but the voluntary sector and carers and users in genuine partnership.
Under previous partnerships, statutory agencies issued draft proposals, and others were asked to comment on them at a final stage. This is about genuine partnership, whereby from the beginning, people from all sectors, including users and carers, identify local priorities and together set about meeting them.
We should also welcome the new pooled budget arrangements between health and social services, and the flexibility that will be given to health authorities to transfer money to social services departments where that is deemed appropriate. Some of us would like a much closer organisational integration between health and social care, but if these developments improve the relationship between health and social care and ensure that users get a seamless service, they will be an important step forward.
In conclusion, the Bill provides further evidence of the Government's commitment to constant improvement of the NHS in response to ever-changing needs and demands. The British people believe in and are proud of their NHS. The Bill will help us to deliver the quality of service that they deserve.
§ Mr. John Horam (Orpington)
It was remarkable that the Secretary of State spent so little time on the Bill. He capped it all by refusing to accept any interventions in the little time that he spent outlining the virtues of the Bill. What we got instead was the umpteenth edition of the Dobson rant. I rather wished that we were in the Senate in America, so that the relevant bit could have been read into the record. It would then have appeared in Hansard, and we could have got on with discussing the real issues rather than listening to the same thing yet again. What we had today does not contribute to the serious health debate that we ought to be having, and which patients and our constituents would want us to have.
As has been said, primary care groups are central to the Bill. As has been agreed, about 60 per cent. of GPs had become fundholders by the end of the last Parliament. Clearly, there are different views, and I dare say that a certain subjectivity entered the debate on the pros and cons of the various alternatives. However, let us consider the objective views of those outside the House, such as the Audit Commission, the Organisation for Economic Co-operation and Development and most doctors. Also, Professor Brian Abel-Smith, a noted adviser to Labour, told the Government, "Whatever you do, don't destroy fundholding—it has been a success." That is the view of independent people.
As the hon. Member for Bedford (Mr. Hall) said, the opportunity was there to accept what was good in fundholding, build on it and deal with the 40 per cent.
83 or so of GPs who had not yet got into the fundholding system. But no, in the spirit of levelling down, the Government had to destroy everything, the good as well as the unproven, and possibly even the bad, and bring in the new system of PCGs.
As my right hon. Friend the Member for Charnwood (Mr. Dorrell), the former Secretary of State for Health, said, the crucial difference is that whereas it was possible for decisions to be taken by one doctor, or at most by two or three in a group, and for doctors to own their decisions and be responsible for them, decisions are now being made by perhaps 50 or 100 doctors in one commissioning group.
I am an economist, and economists are famous for not agreeing, or for finding it very difficult to agree, with each other. I am sure that doctors are much more able, perhaps 100 or 200 per cent. more able, to agree with each other than are economists, but the idea of getting 50 or 100 doctors to agree with each other, with nurses, laymen, administrators, carers and all the others who are rightly in these groups, and with committees and sub-committees of committees is nonsensical. Therefore, although I accept the point made by Labour Members that professional doctors and nurses will try to make the system work—because they want to do so if at all possible and because they have no alternative—no one can get round the fact that it is cumbersome, elaborate and bureaucratic. In addition, it is expensive.
A further point, which was made by my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), is that the system is compulsory. It is compulsory not only in the sense that the Secretary of State says, "You, as a GP, have to join the system", but in the sense that GPs must do so on his terms.
It so happens that my health authority, Bromley, was not particularly strong on fundholding. Quite a small proportion of doctors were members of fundholding practices. As a result, the health authority set up a commissioning system. A small group of GPs and nurses, representing all the GP practices in the health authority area, was formed. The system was developed, and was being put through under the previous Government. Indeed, it was so successful that officials from Whitehall went to study exactly what was happening in Bromley. It was, to some extent, a model of the commissioning proposed for primary care groups.
In conducting such pioneering work, Bromley was well ahead of other health authorities in dealing with questions concerning GP fundholding and practice groups. However, the Government were not content to accept the model, saying that it did not fit into the Whitehall man's view of things. Bromley was told: "You cannot go ahead with that. One group for an entire health authority is not right; you must have three or four"—no evidence was given of why there should be three or four—"groups, scrap all your work and start again."
As a result, Bromley is the last in the health authority queue in the country. Indeed, it is so late in its preparation that it is having to postpone the introduction of primary care groups until 1 July, whereas most are being introduced on 1 April. All the work that was done has had to be done all over again because Bromley's version of it—even though it formed a model used by the 84 Government—was not satisfactory. That shows the extent to which the Government are prepared to accept only the exact model of what they are looking for. That is dictatorial and profoundly unsatisfactory in encouraging local initiative.
While on the question of Whitehall man, the Secretary of State claimed in his speech that, as a result of the proposed measures, financial planning would be better accomplished. All I can say is that financial planning has not been well served in Bromley by the methods that he has so far introduced. For example, money for winter pressures was allocated in the middle of December. Despite Ministers being used to flying by Concorde and going scuba diving during debates on the Budget, they must surely have some grasp of reality. Anybody knows that to allocate money for winter pressures in the middle of December is ridiculous.
As a result, there were huge trolley waits in Bromley hospitals in January. Elderly women—one was more than 80 years old—were on trolleys for many hours as a direct consequence of the trust's inability to plan because the Government failed to take decisions in time and wrapped everything up in red tape.
The perception of the hospital system among ordinary people has been severely damaged by the Government's lack of action and the expectations that they raised. Not only have there been trolley waits on such a scale as never before in Bromley, but waiting lists have not been reduced as the Government promised. Admittedly, Bromley is a particularly good performer. However, the number of people on the waiting list has fallen by only 320 to 6,430—a reduction of a few per cent. Not only that, the waiting list for the waiting list, which is not counted, has grown longer. Not only that, more operations are being cancelled than ever before. That is not recorded either. The possibility of admission to a bed through accident and emergency is now the worst on record.
The entire circumstances regarding waiting times—not merely waiting lists—are considerably worse in Bromley than in any previous year of which I know. That is the consequence of the Government's total failure to perceive the real nature of the problem.
As we are all aware—certainly on the Opposition Benches—it was evident to Conservative Members and to many eminent professionals in the health service that the Labour Opposition had developed no serious strategy for the NHS. The Labour party has demonstrated no serious strategy since it came to power—nothing which can be defined as a serious attempt to deal with the admitted problems of the health service. There is certainly nothing in the Bill to address them on the scale necessary.
Proposing evolutionary, practical, common-sense measures, which have always served the NHS well, will therefore fall to a future Conservative Government, as it always has. As we know, Conservative Governments have handled, looked after and protected the NHS for two thirds of its time. As a consequence, we have today's excellent health service—even though, admittedly, it cannot solve all its difficulties.
When my right hon. and hon. Friends resume power, they will come forward with a set of proposals which, distinct from the concept that the man in Whitehall knows best and the Government's centralised, bureaucratic and red tape-riddled proposals, will be based on a decentralised approach, encouraging and helping local 85 initiatives, trusting doctors, nurses and local managers and creating an atmosphere of co-operation with the private sector, instead of the hate for it that is so often displayed by Labour Members, and was again today. I hope that, when my right hon. and hon. Friends flesh out that package of measures appropriately, they will say, "Vote Conservative—to save our NHS".
§ Mr. John Austin (Erith and Thamesmead)
Although I have no pecuniary or registrable interest to declare, I am a member of the Manufacturing, Science and Finance Union, which incorporates community practitioners and the Health Visitors Association, and represents doctors and a wide variety of other professions in the health service.
I welcome this Bill and its attempts to overcome the obstacles to co-operative working which have been created by the internal market. I do not deny that there were some benefits of past reforms, and it is right that, in their new proposals, the Government have discarded the things that failed and have built on those that worked. In particular, I welcome the Government's commitment to and recognition of the important role of primary care.
The Bill builds on the themes set out in the White Papers: the need to improve the quality of service in the NHS, the need for the NHS to work together and in partnership with local government and the voluntary sector, and devolution of responsibility to a local level in shaping services that are relevant to local needs, enabling local decision making to get the best out of NHS resources, and giving responsibility locally for the promotion of the health of communities.
There has been widespread support throughout the NHS for the creation of primary care groups, which will develop the potential of primary care commissioning without the disadvantages of individual fundholding, which we know has been bureaucratic, divisive and costly. I welcome the abolition of the so-called internal market—a pernicious system which, as the Secretary of State said, set hospital against hospital, and doctor and nurse against doctor and nurse, discouraged the sharing of information and created a two-tier system, providing better services for a few patients at the expense of others.
The market orientation of recent years has done little, if anything, to improve the efficiency of the service or widen the choice available to the majority of patients. The concept of competition has worked against co-operation between different parts of the service. That is why I warmly welcome the Government's approach of replacing competition with co-operation and introducing a new duty of partnership.
I welcome the introduction of health improvement plans, which will provide the framework for commissioning decisions and enable improvements in health to be achieved. That is a clear shift in focus for the NHS toward outputs rather than inputs. Increasingly, we shall be looking at outcomes and what ought to be achieved. But for those health improvement programmes to work, there needs to be a strong community and voluntary sector and carer involvement in consultation on those plans. I hope that the Minister of State will require those plans to be published and full consultation to take place. I hope that in his summing up, he will say how those consultation mechanisms through health 86 improvement boards will work. My concern is that, without that clear guidance from the Department, it may be premature to seek the abolition of the joint consultative committees.
I warmly welcome the Government's promotion of the public health agenda. Health and health care are vitally influenced by poverty, bad housing, poor diet, low expectations, lack of educational opportunity and social exclusion. The Government are tackling all those issues. Many years ago the Black report and more recently the Acheson report have drawn attention to the health inequities across the country due to environmental and economic factors. That is why it is of the utmost importance that we promote co-operative working between health and local authorities, not just between health authorities and social services departments, but with the whole range of local government services—with housing, education, leisure and recreation. As my hon. Friend the Member for Bury, South (Mr. Lewis) said, the Bill provides an opportunity to break down many of the barriers that exist to co-operative working in those spheres.
I want to mention the introduction of primary care groups and the concept of a primary care-led NHS. I have some questions to ask the Minister of State. I emphasise that, in my view, it should be a primary care-led NHS and not necessarily a GP-led NHS.
I want to focus on the contribution of nursing to the modern NHS. I believe that the potential that nursing can offer must be maximised. I welcome the introduction by the previous Government, and the expansion by the present Government, of nurse prescribing. Nurse practitioners are already running outreach health clinics, minor injuries services, family planning and sexual health clinics. Nurses are often the prime professionals involved in health education and health promotion programmes such as those dealing with alcohol abuse, with breast care, with osteoporosis and with testicular cancer. Patients with chronic diseases have benefited from the development of nurse-led care, and it is nurses who act as a resource for many non-health professionals in health education and health promotion programmes.
In my constituency at the Bevan centre, a short-term intermediate care centre providing intensive rehabilitative care and support to patients who would otherwise be blocking far more expensive beds in an acute hospital, nurses, physiotherapists, occupational therapists and other health care workers are providing more relevant quality care and more intensive support than patients could expect to receive in a district general hospital, and at far less cost to the NHS.
The maximum encouragement must be given to innovative developments in nurse and therapist-led care. In that respect, I find it regrettable that only two primary care groups have a nurse as their chair. The Government's arrangements for primary care groups require each PCG to have one or two nurses on its board. Although I acknowledge that that is recognition of the vital contribution that nurses can make to commissioning local health services and of the specific expertise that nurses can bring, I question the necessity to provide for an in-built majority of GPs on primary care groups—and why was the contribution of nurses limited to two?
It is envisaged that primary care groups will develop into primary care trusts. I believe that there is much that we should learn from the lessons of the establishment of
87 the PCGs. In some parts of the country, there were failings in the consultation process by which the primary care groups were established, in that working community nurses and professions allied to medicine were excluded from the consultation or from significant influence. In many areas, the trade unions and professional organisations at local level were not even nominally involved in the consultation. I hope that that will be remedied as the PCGs move to primary care trust status.
The right hon. and learned Member for Rushcliffe (Mr. Clarke) has said that, in some areas, GPs are reluctant to spend time on PCG boards. I can assure the Minister of State that there is no shortage of nurses who are willing to serve and that members of professions allied to medicine would welcome the opportunity to sit on such boards, but have no direct entitlement to do so.
In addition to nurses, who I believe are very important, why should we not include community pharmacists, opticians and physiotherapists, along with other professionals who need to be involved in building the best possible primary care? The voluntary sector, service users and carers all also need to be very much involved in the process.
I understand that the Minister of State, in his letter of 19 February, requires the executive of the level 3 primary care trust boards to have up to seven GPs, two nurses and a professional with public health promotion expertise. I question whether it is right to guarantee a GP majority in that structure—why not have parity between GPs and nurses and other professions allied to medicine?
I have no objection to a majority of GPs if they are the best and most appropriate persons for the job. My concern is that the decision to enshrine a majority for GPs has been taken without justification, and without consideration of a fair selection process to ensure that the best possible persons get the jobs.
I also seek Ministers' assurance regarding the composition of the trust executive board at level 4 primary care trust level—an assurance that membership will be chosen on the basis of clear job descriptions, founded on a clearly defined function of the trust, with the best people getting the job, and not with a reserve majority for any profession.
I also want to mention equity of access. In the debate in another place, reference was made to discrimination on the grounds of age, race or gender. I hope that, in light of the Macpherson report, the Minister will give consideration to putting an equal opportunity commitment on the face of the Bill. I am aware that NICE and the national service framework provide a move forward to equity of access, but I believe that a stress on equality of opportunity is important.
I also want to refer briefly to consultation on changes in service delivery. There is a responsibility on health authorities to consult with community health councils. There is no such responsibility on NHS trusts, and there is none in the Bill, which refers to a responsibility on the primary care trusts to consult community health councils.
Often, CHCs are involved in consultation on health authority decisions when the decisions are already cut and dried. I hope that the Minister of State will consider amending the 1996 health council regulations to ensure 88 full consultation with community health councils. I recognise the importance of the Commission for Health Improvement, but CHCs are also important, and I wonder whether my hon. Friend might consider giving the same right of access and information to community health councils as is given to the—
§ Rev. Martin Smyth (Belfast, South)
I appreciate the opportunity to follow the hon. Member for Erith and Thamesmead (Mr. Austin). He expressed concerns about equality of access to primary care groups. I suspect that one reason why the doctors seem to have had more access than others is that they have the muscle. The harsh reality is that, although we have been told today that the British Medical Association supports the moves, there are deep concerns among some doctors, expressed by the BMA, on the matter. Those doctors are concerned that, having moved to start up the primary care groups, working hard with the support and encouragement of the BMA, they may be forced to move too quickly into the primary care trusts, which will take away some of the local output that they prize.
The hon. Member for Southwark, North and Bermondsey (Mr. Hughes) was surprised that the Bill would legislate for Scotland and for Wales although, in a matter of weeks, Scotland and Wales will be responsible for their own health care—and yet Northern Ireland has been excluded, except in a few particulars. I often wonder whether that was because the draftsmen did not have time to adjust the legislation to suit Northern Ireland, where there is a closer intertwining between health and social services. Did they really imagine that the Northern Ireland Assembly would be running ahead of both Scotland and Wales, when full devolution is not scheduled to occur until next year at the earliest? I regret that, at times, we have had to legislate for Northern Ireland by Order in Council without proper debate in the House, and that things have slipped through that have not been in the best interests of good law or the best service of the people.
Some of the changes are helpful, but I trust that the Government will not follow the procedures that the previous Administration adopted when reforming management. Redundancy payments were made to those who were losing their jobs, who moved into the next district council and obtained similar jobs, having received handouts. About £19 million has already been listed for redundancies but GP fundholders are concerned that there may not be adequate funds for that purpose.
It has been suggested during the debate that the Bill will lead to a reduction in bureaucracy. When we reduce bureaucracy the millennium will be upon us, and I am not thinking of the year 2000. Following the previous round of changes within the NHS, staff moved into different positions. In Northern Ireland we set up boards which were transformed largely into trusts, and many of those who were involved in the change moved into the trusts. I believe that something similar will happen following the Bill's enactment. When we are crying out for money for front-line services, it is not right that we should be paying those who have already been given redundancy money to work in another area of the health service. We should be more careful about how we transfer people from one post to another.
89 I was surprised to hear the Secretary of State proudly saying that the pharmaceutical industry was supportive of the Bill. I am sure that most of us have received the briefing from the Association of the British Pharmaceutical Industry. It is true that it has welcomed some of the improvements to the Bill that were made in the other place, but it still shows tremendous concern about what might happen to one of the few surviving prosperous British industries. I know that we are living in the age of information technology and that that area of knowledge will create many jobs. However, I hope that the Government will not repeat the follies of previous Administrations who reduced the influence of some vital British industries to the detriment of our nation and the betterment of development elsewhere.
I share the Secretary of State's concern about those in the pharmaceutical industry who may not be playing fair. On the other hand, we must be careful that we do not destroy one of the most successful industries in the United Kingdom. I hope that the Government will abide by their own regulations. As I understand it from a briefing and from my knowledge of the situation, the Government were obliged by their understanding of the regulations carefully to specify best regulatory practice. They set forth their principles in "The Better Regulation Guide and Regulatory Impact Assessment".
In his foreword, the Prime Minister wrote that
"no regulatory proposal which has an impact on businesses, charities and voluntary bodies should be considered by the Government without a thorough assessment of the risks, costs and benefits, a clear analysis of who will be affected and an explanation of why non-regulatory action would be insufficient. This requirement applies whenever Ministers or their officials are seeking to clear a new proposal for primary or secondary legislation or a negotiating line that will result in such legislation."
The Association of the British Pharmaceutical Industry said clearly that such an exercise has not been conducted in regard to the Bill. If the Government are expecting others to abide by the law, they should set the example. If it is true that that has not been done, I trust that matters will be taken forward so that those who examine the Bill in Committee can proceed with greater precision.
I left the Chamber for a short time but it is my understanding that the matter to which I am about to refer has not yet been taken up, and that is the concern of Mencap and the correct desire of the Government to integrate services so as to bring professionals together in an efficient way. Mencap feels that there has been insufficient concern to ensure that services for people with learning disabilities are fully integrated with other community services rather than being treated separately with mental health provision. I ask the Minister to clarify the Government's proposals. Mencap would call on the Government to prioritise preventive health care for people with learning disabilities and to incorporate funding into health improvement programme budgets to provide for proper consultation.
We are dealing with the general principles of the Bill, and one of them is co-operation between health professionals. If we are developing care in the community, an important role rests with occupational therapists. For whatever reason, we seem not to have enough of them. If there are waiting lists for hospital appointments as a result of doctors' assessments, occupational therapists must make assessments of what is needed in individual homes and what is needed for 90 individuals personally as aids to enable them to remain in the community. At present, a couple of months pass before the occupational therapist comes along. Thereafter, months pass before the requisite body, be it a housing organisation or whatever, gets on with the job of providing what is needed. I trust that those issues will be considered fully in Committee.
§ Dr. Tony Wright (Cannock Chase)
I have no registerable interest, although I did spend most of this morning in a hospital out-patient department thinking about the Bill. Indeed, I did so yesterday morning as well. Each day brings a new department. As I watched hard-pressed doctors, nurses and administrators, and anxious patients bearing up with quiet fortitude, I asked myself whether the Bill would connect with the situation and experiences that I was observing. Those who are involved would have in their mind, if they were thinking about matters in this way, whether the Bill would make things better. That is all that people want to know. Will their health service become better because of legislation that the House might pass?
I suggest that in two respects the Bill will make things better while a third area might prove to be more troublesome. I believe that our proposals for primary care groups and primary care trusts will make things better. I listened with interest to the argument between those who are passionate defenders of fundholding and those on the Government Benches who want to see the end of it. I speak as someone who was interested in the innovations that fundholding brought, but wanted to see if we could preserve those innovations while removing the inequities attached to them. I saw patients in my constituency benefiting from the innovations that fundholding brought, including the extra clout that it gave to general practitioners within the health care system. I saw also patients not benefiting from fundholding and, indeed, suffering because other people were benefiting from it.
The very proper question is, "Can we retain the virtues of fundholding while remedying its defects?" I think that I am the first hon. Member to use the language of the third way tonight: this is a third way Bill which says that we can try to make universal the extra clout that fundholding brought for some by working, not individually and competitively, but collectively in each locality so that all general practitioners are able to work together to empower themselves. They, in turn, will empower their patients.
The Bill is innovative and does not simply say, "Let's rid ourselves absolutely of all that fundholding involved and revert to a top-down, bureaucratic planning system." It says, "Let's see if we can't devise a more flexible, locally based but collaborative arrangement that would retain the virtues, but remove the iniquities and disadvantages." I think that that is what we are doing.
I am interested that the Opposition prefer other strategies—on the whole, exit strategies. If the Government are, to use the jargon, introducing a voice strategy, then exit strategies such as fundholding and disconnecting oneself from collective provision or assisted places in education are perfectly legitimate ways of thinking about how to manage problems inside public services. They are not, however, systems to which most people in this country feel attached and they do not
91 preserve equity. We want to preserve equity and innovation, which is what the Bill will do and I welcome that without reservation.
The second issue, about which I feel similarly, is the quality agenda. There is not time to say a great deal—other hon. Members have spoken about it—but the neglect of that agenda inside the health service over 50 long years has been extraordinary and, in many respects, criminal. We have talked only about how much money we put into the service, and how we organise and structure it, not about how effective it is clinically.
It has taken the appalling Bristol case to make us see the cost of that neglect. People say, "How could that kind of system continue for so long without anyone knowing about it or, if they knew, without doing anything about it?" It happened because we did not put in place the mechanisms of clinical monitoring and clinical accountability to which the health service should have been subject a long time ago. I pay tribute to all the doctors who work inside the service, but there is no question that the lack of audit and performance monitoring, although widespread in the service, has been particularly acute in the primary care sector.
There has been no clinical monitoring of GPs: the family health services authorities simply paid cheques to doctors and there is huge variation in the clinical performance of GPs. I hope that the primary care groups and primary care trusts will lever up standards and quality right through primary care—not only for those who were able to enjoy the advantages of the fundholding system—and the rest of the system. I would welcome that without reservation, too.
I hope that the Government will take steps to ensure that the measures that the General Medical Council is taking—after some discussion and, in some quarters, resistance—to make sure that there is effective clinical appraisal and reappraisal of all doctors are implemented.
In those two big, critical areas, I support what the Government are doing. The third issue is obvious, but indispensable—money. I represent South Staffordshire health authority, which is in financial crisis. This year, it is running a £7.5 million deficit. We shall talk to the Minister about that and we hope that we will receive assistance, but I do not want to press that point now. My point is that people in this country overwhelmingly want the health service to improve, but we are subject to a permanent revenue constraint. The Opposition say that there will always be such a constraint and that we have to resolve the problem by exploring the private sector, but that is not the position of Labour Members. Nor is it the position of the Government.
Nevertheless, we have a conundrum: most people in this country do not want the health service to stand still financially; they want it to improve and they want more money—a lot more money—to be spent on it year on year in real terms. They know that it is underfunded in relative terms. The time has come to find some kind of dedicated, hypothecated new income stream that can give the NHS a secure funding base so that it does not live from financial statement to financial statement—even from three-yearly financial statement to three-yearly financial statement. That is the real challenge behind the Bill.
92 I believe that in May 1997 the NHS came home—in a real sense, not only in a rhetorical sense. It came home to the people who set it up and it has come home to the people who depend upon it and work in it. The Opposition say, "That home will never be adequate. We have to build new little homes in the garden and make people live in them." However, those of us who want the health service to inhabit that home must ensure that it is secure and that it is not only patched up to keep the water out, but improved in real terms year on year.
§ 8.7 pm
§ Mrs. Virginia Bottomley (South-West Surrey)
It is interesting to speak after the hon. Member for Cannock Chase (Dr. Wright), because his concluding comments reflect a state of frank despair in the area that I represent: it has had one of the lowest funding increases in the country, although it has a low mortality rate but quite high morbidity and very high costs of living. People find that the continual rhetoric of the Government—the spin, the message that money is no problem and the endless new packages and new initiatives—makes their lives more and more difficult.
Before this Second Reading, I decided to revisit my health authority trusts and those taking forward the primary care group. I was struck, with great surprise, by the despair, frustration and, in some cases, fear that they feel. They have been made to feel that it is unacceptable to complain and put their head above the parapet. When my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) mentioned the hospital in Salisbury, I noticed that officials instantly left the Box. I hope—
§ Mr. Deputy Speaker
Order. The right hon. Lady should know better. She should not refer anyone outside the Chamber.
§ Mrs. Bottomley
I stand corrected, Mr. Deputy Speaker, but I hope that the individuals concerned at Salisbury are well. I think that that is an appropriate comment. Southampton was also mentioned, and the Minister of State, the hon. Member for Southampton, lichen (Mr. Denham), has been on the Front Bench for some of the debate.
The hon. Member for Cannock Chase also talked about the tension between innovation and equity. New Labour is almost Soviet in its use of language; it uses words and phrases as though using them makes them true, but there is real tension between innovation and equity. Can the Minister say what is the scope for primary care groups or primary care trusts to take a different view? It is impossible to prohibit post code prescribing and encourage diversity and innovation. Many believe that a problem of the old NHS was that it was risk averse; that it was innovation averse. Growing numbers of people believe that the Stalinist command and control approach, led by Ministers now, makes trust and health authority chief executives and primary care groups think that they will be dumped on, that they will be named and shamed, if they take any risk or innovate.
But over the years, breakthroughs in the NHS have nearly always been achieved by an innovator, such as those at Addenbrooke's and the Southampton teaching hospitals. The first hip operations were not available to 93 all in the NHS; that depended on whether one lived near a teaching hospital. It was always the case that a GP who knew the system and had the contacts in the hospital could obtain treatment for his patients. I do not argue that that is a virtue, but to imply that there was a romantic past with a perfect system of equality is simply not the case. Innovation was the result of developments being taken forward and others wanting to follow.
Fundholding is now dead. The Government have brought an end to GP fundholding. But, for the life of me, I cannot understand how, if a scheme is voluntary, with funding on the basis of comparable funding, there is inequity. If Labour Members had criticisms of the mechanism of the funding, changes could easily be made, but they have substituted a desperately frustrating, bureaucratic collective.
A GP's job is incredibly demanding. I do not blame the hon. Member for Dartford (Dr. Stoate) for abandoning general practice and coming into the House of Commons. To work for 30 years as a GP is extremely demanding. Fundholding gave people a sense of empowerment; of being able to build the plan. It gave them leverage. The GPs whom I most enjoyed seeing were those who said that they would not be a fundholder but would do better. It gave them that empowerment. The worry about primary care groups is that they are frustrating and bureaucratic and move at the pace of the slowest. Every GP to whom I have spoken has repeated that message, even though many were not of my political persuasion. Therefore, I am extremely worried that innovation will be stultified and smothered. I am deeply worried about whether the experience for GPs will be more and more frustrating.
What are the financial and performance criteria for the primary care trusts? I would be reluctant to think that primary care trusts were driven through as a macho symbol for Ministers and I hope that Ministers will be able to be more explicit. The development of a primary care-led NHS is part of the evolutionary approach that the Bill represents. There has not been a great revolution. There has been massive rebadging, relabelling, and amnesia about the past. We have learned to be used to that with the new Labour regime. But the primary care-led NHS was cherished by my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) and many of the rest of us.
A possible way of helping those in my constituency through the gloom in which they currently exist because of the constrained funding for health and social services and the impossibility of taking forward decisions that will cause any amount of noise—keep the system quiet is the message that comes from those who work closely with Ministers—relates to the great hope that Farnham will have a community hospital for the 21st century. It has taken a long time to achieve that. But suddenly the accounting rules for surplus land and buildings under the PFI mean that its costings have been set right back. That was a sudden announcement with no warning and I ask the Minister to take it upon himself to assist the Surrey Hampshire Borders NHS trust to overcome that obstacle. It, to its great credit, has recognised that, rather than pursue a hospital with maternity and surgery facilities, and all the glamorous acute services, the community needs on-going day-to-day care for the elderly and the non-acute patients. It has lowered its expectations, but, after reaching agreement with the GPs, managers and local people, it desperately needs approval and endorsement. It will only have that with ministerial support.
94 I endorse the quality agenda. To return to the comments of the hon. Member for Cannock Chase, it is largely built on the growing recognition of medical practitioners that they cannot be entirely self-regulating. There are responsibilities of clinical governance. That has been a difficult transition. Audit within hospitals is now widespread and accepted and part of the training of junior doctors. The resistance in the early years was extraordinary. It is essential that the duty of quality is extended to the independent sector as much as to the NHS, not least because many publicly funded patients are cared for within the independent sector.
Similarly, the Commission for Health Improvement, which, again, is essentially an evolutionary and sensible development, needs further clarification. It is unrealistic to pay for CHIMP by taking the levy from the hospital that it is inspecting. It must be centrally funded. It must be like the Office for Standards in Education; otherwise, a hospital will have to pay the penalty for its problems and for the inspection.
I would also ask that the health improvement programmes are subject to a duty of consultation in which the voluntary groups must be involved. I speak as a patron of the Carers National Association, but there are many others who wish to see the consultation basis on the same level as that for the National Health Service and Community Care Act 1990.
§ Dr. Desmond Turner (Brighton, Kemptown)
It is nice to follow one of the previous Secretaries of State for Health. It was interesting to listen to them tonight. If one did not know better and simply took what they said at face value, one would wonder why we were having this debate and why there were any problems at all, because we should have a wonderful NHS. But the truth is that we do not. We have a health service which has been labouring under great difficulties—difficulties imposed by limitations of resources and by organisation regimes which have been focused not on patients or medicine but on finance and management. That has not produced the goods.
The opposition that we have heard today has been a mixture of the dreamy and the curmudgeonly, and a curious opposition from the Liberal Democrats who think that this a rather weak little Bill. They are missing rather a lot.
I, too, must declare an interest. I am also a member of the Manufacturing Science and Finance Union and a former medical scientist, and I am excited by the Bill. That is not because I am a sycophantic Government supporter. I am obviously a Government supporter, but I am no one's sycophant. I am excited because the Bill, in addition to the measures that have already been taken, puts us in a position to do something about some of the fundamental failures of the NHS to deliver on standards. It is the question of clinical standards that is most exciting in the Bill.
This country has some of the world's leading scientists in the field of cancer. British scientists have made fundamental contributions to the advance of cancer therapy. We are one of the world's leaders in cancer
95 research. Why, then, do the results of treatment in the national health service lag behind America and every other country in Europe, including Estonia? We have the worst cancer survival rates in the civilised world. How do we manage that? We have the talent, yet we get awful results. That tells me that there is something wrong with the way in which the system is operated.
§ Dr. Turner
No, I am sorry, I have only 10 minutes.
I am not suggesting that those results are the fault of particular individuals, and I do not think that suddenly revising the structure will cure the problem overnight, because it will not—things do not work that way. What the health service has lacked up till now—until the creation of NICE and CHIMP—is a mechanism not only for promulgating best practice, but for ensuring that best practice is acted upon. That is essential.
There is an awful lot of clinical literature, but whether the benefits of that literature are spread into patient care is a matter of chance. It depends on how much time consultants or general practitioners have to read the literature and how enthusiastic and conscientious they are.
§ Dr. Turner
I am sorry, I have only 10 minutes.
Some people are excellent, but not everyone achieves the standard of excellence; otherwise we would not have such awful clinical performance. That fact is inescapable. I hope that the Minister is listening, because the way in which I see NICE making its greatest contribution is in evaluating advances in medical research, evaluating new drugs from an independent perspective and circulating advice throughout the system so that we move towards a genuine evidence-based approach to medical practice. Such an approach has been seriously lacking in our system, and that is largely why we do not achieve the results that we should.
NICE by itself is not the total answer. It cannot be, because there are also questions of clinical freedom and so forth. We need CHIMP to carry out inspections to ensure that research is taken notice of on the ground. If a CHIMP team inspects a hospital and finds that its clinical performance is seriously below par and that consultants are ignoring the guidance of NICE, I would expect an adverse report and something to be done in that hospital to improve clinical outcomes.
There is nothing revolutionary about this measure: it is perfectly logical. We undertake inspections in just about every other public service. We have inspected schools since for ever, and we inspect police forces and fire services. We inspect everything that moves, but we have never inspected the health service until now. It is long overdue, and it will make a very big difference.
There has been much discussion about whether vast sums are being added to health service budgets. We think that a lot of money has been provided. The Opposition opposed the increases in the comprehensive spending review, yet they tell us that they would have funded the health service rather better. I cannot square those two assertions.
96 Having put money into the health service, it is important that we make it count. That is why we need an organisation such as NICE. It should also examine the cost-effectiveness of clinical organisations and the cost-effectiveness of drugs as well as their immediate clinical input. The most expensive drug may, in the long term, be the cheapest. We can get such information only through a serious, in-depth, independent evaluation. We will not get it from the pharmaceutical companies, because they have an interest.
The hon. Member for Belfast, South (Rev. Martin Smyth) was wise to point to the pharmaceutical industry. It is the only industry we have left with a solid research base, and it is inextricably linked with the national health service. It is a multinational industry that can move very quickly. The national health service has a large customer base. That is important, because it gives us the opportunity to negotiate a sharp deal with the drug companies; and it provides much employment for scientists. In return, if we succeed in raising the standards of the health service, we will provide a marvellous shop window for that industry.
I do not find this an insignificant little Bill. It is potentially an extremely important Bill.
§ Mr. David Amess (Southend, West)
This is a truly socialist Bill, in that it represents a triumph for the Secretary of State. It is a triumph of old Labour over new Labour. The Bill is a disaster, and it is a backward step for the national health service. I am astounded that two Labour Members have told the House that they are excited by the Bill, because when I listened to the Secretary of State's speech he did not seem to be excited by it. Indeed, he could not even be bothered to address the House on the Bill.
When Lord Howe responded to the introduction of the Bill in the House of Lords, he said that
"it is a Bill that seeks to undo much of the good resulting from the work of the previous administration…a measure that, far from providing a platform for improvement, will instead be a recipe for inflexibility, inefficiency, lack of choice and, perhaps above all, tight central control of our health service by politicians in Westminster."—[Official Report, House of Lords, 9 February 1999; Vol. 597, c. 114.]
My noble Friend was entirely right.
We all know what the Secretary of State decided to do. He made one little announcement. It was supposed to be a public relations job for the Labour party. He failed to convince me, he failed to convince my constituents in Southend, West, and I think that he failed to convince anyone with a modicum of common sense. The national health service has been worse since we have had a Labour Government.
I think that someone at Millbank pressed the wrong button on the computer. Labour has had the cheek to mail a number of Conservative party members in Southend, West exhorting them to give money to the party in connection with the issue of the health service. First, the Labour party thanks my Conservative party members for voting for it in the general election; then it tells them how their vote has helped to change Britain for the better. That is a laugh. Then it asks my Conservative party members:
Do you want better hospitals with more beds and more nurses to care for the sick?97 We do, but we certainly will not get them from this rotten Labour Government.
Someone sent me a copy of GP. Labour was keen to quote from GP when it was in opposition, but now that the Secretary of State has the top job he dismisses it as a public relations job for the Conservative party. I have read the issue from top to bottom, and the headline reads:
Chaos reigns on eve of reforms".GP had conducted an important survey, which found that 71 per cent. of GPs did not support the reforms, 83 per cent. said that they were "not prepared" for them, 70 per cent. felt that they were not part of a group, 93 per cent. were "worried about GMS funds" and 64 per cent. of fundholders were "suffering financially".
In an article in the same magazine, a doctor said that the health service reforms could prove an Armageddon for general practitioners; and, in its comment section, the magazine said:
Since the much-heralded announcement of the so-called new NHS almost two years ago, in true new Labour fashion there has been more rhetoric than action. Guidance has invariably been late and has been drip-fed to the profession, often missing details on the most vital of ingredients—funding.As we all know, any Labour MP who was honest would get to his feet and say that the Labour party has not delivered on the promise that it gave us on 1 May 1997: it is not funding the national health service properly.
The article continued:
Even as the magical hour for lift-off approached this week, and primary care groups went onto health authority payrolls, some had yet to appoint board members"—certain of my hon. Friends have mentioned that— "and vital decisions were still being delayed by the lack of central guidance.Many Gps have put an immense amount of effort into these reforms, often despite opposing them in principle".I thought that the hon. Member for Erith and Thamesmead (Mr. Austin) talked a lot of sense. I have received a letter; I shall not reveal who it is from, but it refers to undemocratic nurse elections for primary care groups in south Essex. The writer—not a constituent of mine, but someone in Essex—says:
The election process was hijacked so that the nurses were not allowed to nominate or vote for their own candidates. Only Authority backed nominees surfaced from a 'Selection Board'. The local doctors, on the other hand, fellow professionals, ran their own elections with no interference from anybody, and their candidates were accepted. Their process was simple and basic: the nurses had theirs manipulated … this process was abused in South Essex, where nurses found themselves railroaded into accepting candidates in the following manner: All community nurses were invited to meetings jointly organised by the Health Authority and Thameside Community Trust. Here nurses were told quite categorically that a caseload would be a qualifying fundamental requirement, and thus avoid management stooges.The writer told me that, in the event, management stooges were appointed.
This is a dreadful Bill. It is all about imposing a command and control system on our health service. It gives unprecedented powers to the Secretary of State to interfere in every aspect of the running of our health service, right down to the drugs that a family doctor is able to prescribe. As we have heard, the Bill will abolish the popular, successful system of voluntary GP fundholding. I think it is disgraceful that no Labour Member has stood up and asked what will happen to the 98 patients of GP fundholders. Do they not deserve care as good as the care that they received under the system of GP fundholding? The Bill is not about raising standards; it is about levelling down. It is a socialist measure.
The establishment of the National Institute for Clinical Excellence, PRODIGY and the cash-limited drugs budget will put pressure on family doctors to restrict effective treatment on the ground of cost alone.
When Labour was in opposition, it was fond of quoting all the lobbyists. I have had umpteen letters from the BMA, the Royal College of Midwives, the NHS Confederation, the Royal College of Nursing, the Society of Chiropodists and Podiatrists and the Association of the British Pharmaceutical Industry, but, conveniently, not one Labour Member has quoted from the letters. We know why. They have nothing good to say about the Bill.
I did not notice the BMA applauding the Conservative Government, but it says:
The Bill heralds yet more structural change for doctors after nearly a decade of major upheavals in the National Health Service. The BMA will work with Government to try to make these changes work but would ask for no more changes for some time after this. We need a period of stability now in which doctors can concentrate on quality of service to patients rather than structural reorganisation.However, the BMA gave the game away: it is down to money. It says:
It is the responsibility of the Secretary of State to allocate funding for the proposals contained in the legislation, but there will need to be a considerable increase in funding to achieve all the proposals in the Bill, particularly the huge agenda envisaged by CHImp"—what a ridiculous title. It goes on:
Without a significant increase in overall NHS funding, it is inevitable that other parts of the service will see a drop in funding if all these functions are to be carried out. The implementation of the Health Bill cannot be cost neutral.A worried constituent has written to me on behalf of chiropodists. The Royal College of Midwives is anxious that the present system of regulation of midwifery will be
"wholly replaced through secondary legislation. Whilst the Royal College of Midwives supports the replacement of the United Kingdom Central Committee with a new structure, it is most concerned that the Government have not sufficiently clarified the parameters of the successor professional body."
The Bill may be a great triumph for socialism, but it is a very sad day for the national health service.
§ Dr. Howard Stoate (Dartford)
Thank you, Mr. Deputy Speaker, for calling me to speak in what is an important debate.
As a practising GP who continues with a small number of surgeries, I am now a member of a primary care group, so I register that as an interest. For many years, several changes have been imposed on us by the NHS. We have heard much rhetoric about the pros and cons of various aspects of the Bill, but—
§ Dr. Stoate
No, I cannot give way. I have only 10 minutes.
As someone who is a practising GP and who therefore sees those changes day to day, I am in a better position than many to comment on them. Conservative Members
99 have waxed lyrical about the benefits and wonderfulness of fundholding, but I tell a different story; it is a personal story, seen at first hand.
We have learned much from the fundholding experience. I would not wish to leave hon. Members with the impression that fundholding has not done a significant amount of good, because it has. We have to be fair: fundholding has taught us a lot. It showed us a lot about management structures and how GPs and others can develop services in their communities, but it has also created enormous problems. It goes completely against the aims and values that Labour Members share.
We have heard that 60 per cent. of GPs are fundholders. That is true, but I can speak from personal experience and for the many hundreds of GPs whom I know personally. Many of those 60 per cent. went into it not voluntarily or with evangelical zeal, but because they had to. They were forced to by all sorts of chicanery and underhand methods. They felt that they had no choice—go into fundholding, or forget about the new member of staff, the development of the practice, the new computer system. Computers were frequently tied to fundholding: no fundholding, no new computer. Pressure was put on my colleagues in an unhappy and underhand fashion.
No Labour Government could accept the two-tier service that was created and the inequalities that were caused by fundholding. It is to the credit to my right hon. and hon. Friends in the Department of Health that fundholding has now been ended.
Of course fundholding produced excellence. It was bound to. The cards were loaded so much in its favour that it had to produce excellence, but every time a patient was seen more quickly by a fundholding GP and referred to a consultant, a patient of a non-fundholding GP was pushed down the queue. Every time a patient was seen by a consultant from an outpatient clinic in a surgery, it meant that another patient could not be seen because the consultant was in the doctor's surgery, not in the hospital clinic to see people who would otherwise have been seen from the waiting list.
Of course, therefore, fundholding produced good things and seemed to be wonderful, but it did so at the expense of so many other people who were not achieving that type of service.
It is ludicrous to say that we could have made every GP a fundholder. Once there was no longer an inequality and a two-tiered service, there would no longer be a benefit in fundholding, and the whole system would fall down like a pack of cards.
The new NHS will be fairer, distribute resources more equitably and eliminate two-tierism. It will be needs-led, it will integrate health and social services and reinstate strategic planning, and it will emphasise quality and reduce inequality.
Earlier in the debate, the right hon. Member for Maidstone and The Weald (Miss Widdecombe) talked about the dispossessed. I listened very carefully to what she had to say and even tried to intervene on her. I ask her, on her proposals for introducing money from the private sector, which insurance company would take on 100 someone with multiple sclerosis, chronic diabetes or infertility? We would get nowhere by asking the private sector to take on those people.
§ Miss Widdecombe
I am very grateful to the hon. Gentleman for giving way.
Again, there is the confusion that the hon. Member for Cannock Chase (Dr. Wright) showed. Trying to get money in from the private sector is not only about people going and insuring themselves, but about setting up partnerships with the private sector, so that we can benefit from private sector technology, expertise and staffing—as in, for example, St. Peter's hospital in Chertsey, where there is a joint unit, which both partners use and for which the private sector has contributed a huge amount of money. It is a matter of getting additional resources into the NHS, not only of getting people to insure themselves in the private sector.
§ Dr. Stoate
Unfortunately, the private sector will follow that type of policy only if it can make a profit for itself, which is its fundamental motive. The private sector will provide a service, but only if people pay for it through private insurance, or if the NHS puts public money into the private sector—which gets us no further, as we will be back to exactly where we started.
In Dartford, the HealthCare Partnership primary care group has piloted primary care groups. It is already one year ahead of many other such groups, as it was a pilot for the National Health Service (Primary Care) Act 1997 and thus has one year's more experience than most. It has already expressed an interest in moving on to primary care trust status. The group has been successful in developing primary care services, cutting bureaucracy and gaining control over how local resources are best used for local patients.
To scotch the idea that fundholding was somehow a good thing and non-fundholding a bad thing, that group in my constituency of Dartford consisted of fundholders and non-fundholders who voluntary came together to pool their resources and expertise, because they realised that the two-tier service created by fundholding was not in patients' interests. When working together as a primary care group pilot, they were able to demonstrate improvements in bureaucratic costs and in services, and genuinely to make a difference to people in Dartford.
The experience of people in Dartford, and the improved care being offered to them, will act as a template for primary care groups across the country, as they begin to catch up with my primary care group—which, as I said, is one year ahead.
One of the Bill's purposes is to allow the formation of primary care trusts, which will be freestanding organisations either commissioning care—at level 3—or commissioning and providing community services at level 4.
Yesterday, I spoke to Dr. Alasdair Thompson, the chairman of Dartford's primary care group. As I said, the group was started as a pilot under the 1997 Act and is one 101 year ahead in the process. The group has been able to find solutions to many of the challenges and has had much more time to consider its future.
Dr. Thompson gave three main reasons why he believes that it is so important that the Bill's provisions enabling trust status should be passed. The first is that there are limitations in the current process. Although primary care groups have freedom in their budgets, trusts will have much further flexibility in purchasing, in providing community services and in joint working with social services.
Secondly, primary care trusts will be able to develop strategic plans for delivering community health services, based on an integrated approach that is agreed by their work force and signed off by their board. The emphasis on developing community services that are closer to the patient's own environment will make a big differences to local services. The community infrastructure that will be needed to support the new hospital in Dartford—which is the first being built under the private finance initiative scheme—may be developed and managed by the primary care trust. In turn, that will lead to increased professional motivation and better clinical practice.
Thirdly, as freestanding bodies, trusts will have far greater freedoms, within their accountability arrangements, in their use of the unified budget—which is likely to include personal medical services schemes, local development contracts and single—handed vacancies—so that there is scope to develop innovative solutions for future work force problems. as described in the primary care investment plan.
Ultimately, of course, the Secretary of State will approve applications to become primary care trusts. I am looking forward to the day when he will be able to approve the trust application from my own group. It will be up to local health authorities to ensure that the process of application for trust status is wide ranging, and includes as much local opinion as possible. I hope that the Minister will be able to assure GPs that progression to trust status will occur only when a clear majority of local GPs are interested in it.
My understanding is that the Bill will not affect GPs' independent contractor status; I would welcome reassurance from the Minister that that is the case. The House will be aware that independent contractor status has been a great strength of British general practice over the years, and has delivered exceptional value for money and excellent quality primary care. British general practice still represents excellent value for money, and quality envied throughout the world.
GPs now form the majority on primary care group boards, but when primary care trusts are set up, with the increased responsibilities and wider range of skills needed, Ministers may think that no longer appropriate. The current proposals are for lay members to form the majority of PCT boards. GPs and nurses, however, can still form the majority on the PCT executives, which will report to the boards.
Dr. Thompson has asked me to seek reassurance from Ministers that the primary care trust executives, which will largely comprise the doctors and nurses who deliver the services and whose livelihoods will depend on decisions made by the board, will have a clear say in the decisions made by the boards.
102 Primary care trusts will have the freedom, within their accountability arrangements, to allocate resources, develop service arrangements, negotiate incentives and generate income.
The Bill marks the beginning of the process, not the end. It will clear the way for new ways of innovative thinking about how best to deliver top quality primary care for the next century. In my constituency there is already a clear commitment to the process, and I shall finish by quoting from a discussion paper written by my local primary care group as part of its expression of interest in trust status:
The Partnership has taken the view that the philosophy underpinning the establishment of PCGs builds on our partnerships approach to developing health care and to community involvement, which started with joint commissioning with West Kent Health Authority, and continued via the Locality Commissioning group pilot. There is now a greater opportunity for the partnership, as a Primary Care Trust, to further develop our partnerships working as both commissioners and providers of community based services.That was written not by a group of GPs who are disillusioned and dissatisfied, or sorry about the changes that we are making, but by a group that is ahead of the field and has clearly, and voluntarily, shown its commitment first to primary care groups and now to primary care trusts. Fundholders and non-fundholders are working together for the good of the community, and involving nurses, social services and others.
What could be a better template for what the Government propose than what is happening in my constituency? The programme is one of success, and the Bill will achieve what we set out to achieve. I commend it to the House.
§ Dr. Vincent Cable (Twickenham)
I want to draw together two strands from the opening speeches. The Secretary of State made passing reference to the fact that the Government were embarking on an NHS-wide standard-setting exercise focused specifically on the needs of the elderly and the treatment of old people within the health service, and the right hon. Member for Maidstone and The Weald (Miss Widdecombe) spoke on the theme of rationing. The right hon. Lady, as we would expect, made her point in a polemical way, but it would help the debate if we treated the idea of rationing not in a polemical or a pejorative way, but as a simple factual statement of what happens when there is a gap between supply and demand.
Rationing can be done well or badly, fairly or unfairly, and on the basis either of clinical judgments or of arbitrary bureaucratic judgments. I shall pursue that issue, especially in relation to the treatment of the elderly, and the way in which the Government-inspired exercise that the Secretary of State mentioned might work. Clearly, the question is about more than how rationing works. There is a resource issue, too. The gap between supply and demand will vary depending on the resources available, which is why the Liberal Democrats consistently draw attention to the under-resourcing of the system.
Some Labour Members seemed wholly blind to that problem. The hon. Member for Brighton, Kemptown (Dr. Turner), who has now left the Chamber, presented himself as an expert on cancer treatment. I am sure that he is, but he seemed wholly unaware that British funding of cancer services is seriously deficient in relation to that
103 of comparable western countries. That deficiency is reflected in the fact that key chemotherapy drugs are not available to British women in the same way that they are to women overseas.
There is a resources issue, but there is also a deeper question about how rationing is carried out. I shall focus specifically on how it is applied to older patients in the NHS. In principle, care is allocated on a wholly idealistic basis. The codes of conduct of the professions make it clear that clinicians should not discriminate on the ground of age or on any other basis. However, there is a growing concern among elderly people and the organisations that represent them that age is becoming a basis for rationing, often quite explicitly. To some extent, elderly people are bound to feel the adverse effects of the shortage of resources in the NHS because they use it more frequently than others–40 per cent. of the users of the NHS are retired people. However, there is growing concrete evidence of age being used as a rationing criterion.
I gave several examples of that when I introduced a ten-minute Bill some months ago, and it is worth repeating some of them because they are highly relevant to the debate. Rehabilitation programmes for people who have had strokes do not involve a great deal of resources, but a lot of research shows that many health districts and trusts use a specific age cut-off to limit the availability of the service.
Another more understandable example is kidney dialysis. The treatment is very costly and it is widely known that elderly people have great difficulty in getting on to the programmes, although all the medical evidence that I have seen suggests that they are just as likely to benefit as younger patients.
Cancer screening also arouses strong feelings. Active efforts are made to ensure that younger women are screened, but less effort is made for older women, even though the evidence suggests that they benefit just as much from early detection. That is a specific, and probably rather absent-minded example, of age-based rationing.
Drug rationing is at the heart of much of the debate. My final example relates to the drugs available for people suffering from senile dementia. There is controversy about the benefits of some of the new drugs becoming available and clinical trials are continuing, but the balance of evidence that I have seen suggests that if the drugs were widely available they would considerably reduce the damage, inconvenience and great humiliation that people suffer as a result of Alzheimer's. The drugs are severely rationed and there are enormous disparities between different areas.
The process should be more open. I hope that the Government will address the problem. I should like to hear more about what the Secretary of State meant when he said that the Government were embarking on a process of standard setting, experiment and research into the treatment of elderly people in the NHS. Part of the problem is that not enough research has been done.
Several organisations representing elderly people, as well as professional organisations including physiotherapists, have said that it would be helpful if there were a clause in primary legislation that specifically prohibited discrimination or rationing—if we are to use 104 the word—on the ground of age. Decisions should be based purely on professional clinical judgment and the quality of life that could be achieved.
§ Ms Julia Drown (South Swindon)
I welcome the duty of co-operation that will be placed on health authorities and others. The Labour Government are already making a difference in my constituency on that issue. Health trusts and my local social services have made it clear to me that the encouragement that they have been given since the election to get together and work in the interests of local people has made a difference to the services that they provide. I have been pleased to see the good work that is being done locally. I also very much welcome the abolition of fundholding, which not only created a two-tier service, but was incredibly expensive to administer. It is outrageous for the NHS to spend so much money on administering the scheme.
The Conservatives have claimed that GPs became fundholders by choice. I saw the performance objectives of regional health service managers when GPs were being encouraged to take up fundholding. Those objectives, presumably from the Department of Health, clearly stated that the proportion of fundholders in the area had to be increased.
That was a funny way of creating a simple, open and rational choice for all GPs. if one really wanted a fair choice for GPs, one would not give preferential grants to one group—GPs were told that if they became fundholders they would get extra money for computers—and one would not tell health authority managers that they must increase the number of fundholders in their area.
The Labour Government's approach, creating primary care groups instead, strikes me as far more sensible and rational. To reduce the number of commissioning groups from 3,000 to about 500 is obviously a way of reducing bureaucracy, yet ensuring that a much wider group of people in each area can have an influence on the health care that is provided. I congratulate the Government on not limiting the system to GPs. Community nurses and other lay members can have an influence, and that is much better than the narrow focus instituted by the Tories in the fundholding scheme.
I welcome the Bill's emphasis on quality of care and the introduction of the Commission for Health Improvement, but I seek clarification on several points. Users, carers and patient groups want to be sure that their views will be included in discussions on their local health services in the new NHS. I agree with that aim, but will it be best achieved by creating a legal duty or by providing guidance and spreading best practice?
Under the National Health Service and Community Care Act 1990, there is a legal duty to consult various people, but that has given rise to some bureaucratic exercises in which a glossy 200-page brochure has been sent to every single voluntary organisation in an area, many of which simply do not know what to do with it and certainly do not have the time to examine it in any detail. That is not necessarily the best way of achieving real consultation. We must find out what works and ensure that the views of users, carers and patient groups are properly taken into account.
I seek clarification about the membership of primary care groups and trusts. The NHS is much more than doctors and nurses, and one of its great strengths is vivek 105 teamwork, with the input of all the different professions, giving the best patient care to everyone. It is important, if all the needs of all the different areas of the country are to be met, that the membership of the groups and trusts should not be set in stone, but should be able to change and be fluid over time.
Physiotherapists, pharmacists, health visitors, occupational therapists and midwives all have much to add and can greatly influence and improve primary care services. I am not asking for guaranteed places for members of each of those professions, as what works in one place or time may not work so well in another, but we need fluidity to get the best out of primary care.
I seek clarification on the duty of trusts to be responsible for the quality of care that they provide. For me, quality of care is not about producing glossy documents to match the glossy annual accounts that many trusts now produce; it is about listening seriously to patients and users views on the services provided by their local trust and about seriously challenging the results of clinical audit in every single trust.
I hope that the responsibility for providing quality of care will be extended in time to all aspects of the NHS and to the private sector, but I am not convinced that now is the right time to put the details of that implementation into law. It is the right time for the Government to make a commitment to ensure quality of care across the board, whether by the NHS or by the private sector.
Other hon. Members have said that regulation of quality of care should be applied in the same way to the private sector as the Bill would apply it to the public sector. The Health Committee is considering this issue at the moment and I still have an open mind as to the best way forward. There are attractions in having the same body to regulate both the public and the private sector, and some people have suggested that CHIMP should be the organisation that reviews all health facilities. However, significant difficulties would need to be overcome. First, part of the private sector is already monitored by a separate body, and it is proposed that it will be monitored by regional commissions for care standards. Secondly, the private sector does not work in the same way as the NHS. In the private sector, a lead consultant will book a session in a theatre and does not work in a team with junior doctors. That alone suggests that the arrangements should be separate. Thirdly, many patients go to the private sector because they want something different. We would need to think about those issues carefully before we apply the same rules to both sectors.
The last point on which I seek clarification concerns the Government's excellent commitment to getting more women on to the boards of trusts and other public bodies. The aim is for women to make up 50 per cent. of trust board members and 40 per cent. of chairs. I would like to see those figures be even higher over time. However, we could start to change some of the language to try to encourage women to join in. The Bill and its schedules mention chairmen, but we should start talking about chairs. That usage is important, as the Department of Health recognises. When it talks about its aims for appointing women, it talks about chairs, but everywhere else it talks about chairmen. I hope that we can amend the Bill to put that point right, because it is important, especially as most of the staff managed by the boards are women.
106 With those concerns expressed, I wish to register my support for the Bill. It will start a great shift in the NHS's culture, so that staff can co-operate in the interests of patients, and where the quality of service—which is what is important to patients—is seen as important in itself. It shows that the NHS is not just about placing a duty on trusts to cover their financial responsibilities, but about something much more. It will take time to change the culture, but both staff and patients want that change. They do not want the Tories internal market, which treated the NHS like a game of Monopoly. Patients want an NHS in which teams work together to provide what counts—quality patient care.
§ 9.3 pm
§ Mr. John Randall (Uxbridge)
The hon. Member for South Swindon (Ms Drown) mentioned a problem with the terminology of chairmen and chairs. I have spent most of my adult working life selling chairs, and that is where they should remain.
The Bill gives effect to the legislative requirements laid out in the Government's three health White Papers. The Government are presenting it as the centrepiece of an ambitious health reform programme. Ministers have heralded it as offering a radical future for the NHS, promising to improve the quality of health care across the country, eradicating unfairness and reducing bureaucracy. Rather than fulfilling the Government's ambitious rhetoric for the NHS, the Bill will make the health service more inflexible and inefficient, reduce choice and, regrettably, centralise decision making.
I shall concentrate my remarks on the issue of fundholding and the new primary care groups. As we have heard repeatedly this evening, it was the previous Government who introduced GP fundholding. It has been a focus of particular hostility from the Labour party since its introduction in 1990. Fundholding offered doctors greater financial and clinical autonomy, while allowing improvements in patient care. It enabled efficiency savings to be reinvested in the system, resulting in shorter waiting times and the development of new specialist services. Even the Government have come round to acknowledging that. Their White Paper stated that the introduction of fundholding had enabled doctors to
"sharpen the responsiveness of hospital services and extend the range of services available in their own surgeries".
As we have heard this evening, fundholding received the support of many groups, including the British Medical Association and the Organisation for Economic Co-operation and Development. GP fundholding encompassed 60 per cent. of NHS patients. Sadly, the Government have now killed off fundholding despite acknowledging its success, and in the face of widespread support.
The Bill proposes instead to create primary care groups and primary care trusts, leading to the biggest change in the family doctor service since the creation of the NHS. That is despite the promise of the Prime Minister before the election that there would be no great upheavals in the service. The Bill will coerce GPs into the new primary groups whether or not they want to join them. There is the question of the costs associated with these new structures. Initial estimates vary from £150 million per year to more than £300 million per year, without accounting for the new structures start-up costs—at a time when the
107 Government want to save money on bureaucracy and have budgeted for savings. Under fundholding, any extra administrative costs were more than offset by efficiency savings. The new system will be more costly and less efficient.
The Office of Health Economics has predicted that the organisational costs of delivering health care are likely to increase. The Institute of Child Health stated that the cost of developing three to five-year health improvement programmes will more than offset even the most generous assessment of savings made by cutting the number of commissioning bodies. With that background, it is difficult to work out how the Government can claim that their reforms will make substantial savings that will be directed to front-line patient care.
The BMA found that fundholding encouraged accountability and that GPs were truly willing to share the decision-making process. The Audit Commission said that fundholders introduced more services to patients, improved communications with hospitals and were more cost effective in their drug prescribing. The main criticism of fundholding was that it was a two-tier service, but the Government propose to introduce a four-tier service. If two tiers were bad, how can four be good?
The Government's answer to GP fundholding is to have a compulsory system whereby between 50 and 100 GPs are forced into the same group. Under the old arrangements, patients were usually able to choose the fundholding GP, but under the primary care group system, patients will be assigned to a primary care group on the basis of where they live. That contradicts one of the central points of criticism that the Labour Opposition used to make about the operation of the NHS internal market.
The primary care groups became active on 1 April this year and replace the voluntary nature of fundholding with a compulsory approach. GPs will remain able to commission services from hospitals for their patients, but will not be able to act individually as in fundholding. The White Paper stated that PCGs should develop around natural communities, but the boundaries have been fixed by the Department of Health and GPs have consequently been coerced into a designated geographical area. A BMA poll published on 4 February showed that 55 per cent. of GPs would not be willing to take an active role in their local primary care group. It bodes ill for the future of primary care group management if GPs prove to be unwilling to sacrifice time to serve on their boards.
In addition to the lack of enthusiasm for the new PCGs among GPs, the fact that groups, rather than individual fundholders, will make service agreements with trusts means that individual practices will lose the flexibility that previously existed. The Government's hostility to individual practices retaining their autonomy could lead to a loss of the specialist services that many fundholders have developed for their patients.
Under the new resource allocation formula, there will be little incentive for practices to make savings because the bulk of efficiency gains will be made by the whole PCG, not the individual practice. The inefficient will be carried by the group, with the result that the entire group will suffer financially. The direct incentives, which existed under fundholding, to be as efficient and effective as possible will simply disappear.
108 The abolition of GP fundholding will not lead only to financial inefficiencies—according to the BMA, it will lead to substantial regional variations In care depending on where a patient lives. Under fundholding, patients were almost always able to choose a fundholding GP if they believed that they would therefore receive a better service. Under PCGs, that will no longer be possible.
PCGs and PCTs will reduce the freedom of individual doctors to run their own affairs. They are compulsory bodies, and GPs must join them. They will control contracts, and prescribing budgets for individual GPs will be at the mercy of collective decisions. Flexibility will be reduced, with GPs unable to switch patients from one hospital to another without protracted negotiation. That will add pressure to waiting lists and waiting times. There will no longer be the same drive to improve hospital services.
The Bill will result in a far less efficient, more centralised system of health care. It will reverse the shift in the balance of power from the health bureaucracy to the GP that fundholding made possible. It is a very bad Bill, and I shall oppose it.
§ Laura Moffatt (Crawley)
I have waited a long time to stand here tonight, both during the years that I spent in the health service dying to have a Government who really cared about the NHS, and during this evening's interesting debate. I have waited for change not only as a nurse, but as a patient.
As a nurse, I found it abhorrent to have to tick forms saying that some people had the advantage of being GP fundholder patients for whom there would be extra care and would be able to rise up the waiting list. I deplored that practice deeply, and I did not want to have to do it.
As a patient, I have the common nurse's complaint of varicose veins, and have waited for two years for treatment. When I rang the hospital to ask what my chances were of being treated soon, I was told that there had been a huge mistake and that, because I came from a GP fundholding practice, I should have been treated a year earlier. When faced with that sort of thing, I realise how important it is to be here today.
I was interested to hear a former Secretary of State for Health, the right hon. Member for Charnwood (Mr. Dorrell), say that the only way in which to judge who held the balance of power in the health service was by seeing who sent Christmas cards to whom. The concept that we might hold each other in mutual respect—that we might want to send Christmas cards to each other because we value the contribution that each of our colleagues makes to the health service—is completely alien to the Conservatives. They are unable even to contemplate it, but the Bill does so, valuing equally the contributions of everyone in the health service and ensuring that we can all work together.
Goodness knows that difficult decisions must be made to balance the needs of the community against the desire to ensure that we have the best service and to ensure the clinical excellence of services provided. The National Institute for Clinical Excellence and the Commission for Health Improvement are our best opportunity to ensure that we work together.
The duty of co-operation excites me because of my local government background. Was it not local authorities that made sure that we had clean water and that people 109 lived in decent housing? Now, after all the wasted years not being consulted by those involved in health services, they are back next door to their colleagues in the health service, making sure that they are able to contribute to the improvement of the health of all our people. That is the flavour of the Bill.
The Bill is designed to create a new confidence in the NHS, a confidence that we are beginning to build with the staff. We now talk to NHS staff. There was a huge consultation process involving nurses, who were asked what they thought. I have here a fax from just one nurse in my constituency who said, "I want to contribute and write five pages to Frank Dobson about the way that we should move forward." It is crucial that we listen to those people who are committed to the service.
Staff are the health service's greatest asset. As a former nurse who was pleased about the recognition that nurses have just received—a recognition not only of their contribution to the service but in terms of their pay packets—I cannot forget other members of staff who work in the service. I could not have done my job without the people in the laboratories who helped me to get the results of blood tests as quickly as possible so that we could do our work on the wards. We must think about those people now.
It was bad enough when I had to collect a particularly disgusting specimen—I am sorry; I am a nurse, and I always get down to this sort of talk—but I would often think of the poor person who had to open and test it the next day. Some of those people could be earning just £8,000 a year, so I hope that some can be included in a pay review, just as nurses have been. Nurses are very pleased with their recognition, but we cannot forget some of the other NHS staff.
The Bill is about confidence, about how we recognise the value of NHS staff and about how we communicate and work with them. That is why there should be a duty to communicate with the voluntary sector as well as all the other people involved. They understand what is going on, and this is our best opportunity.
I greatly welcome the new regulatory systems and the new systems of self-regulation of many professions allied to nursing. Some are incredibly invasive—for examplee, chiropody involves many sharp instruments and even anaesthetics. Many are not registered or regulated, and I want them all brought into a regulatory system.
It is 20 years this month since I joined the Labour party. I joined because I wanted a Labour Government to do what this Labour Government are doing. I am extremely proud that this new Labour Government have the guts to deal with the issues that we think they should, bringing the NHS back to the people and ensuring that the staff work together, instead of fighting among themselves. We want people to be able to say that we have an NHS of which we can be extremely proud.
§ Mr. Michael Fabricant) (Lichfield
I do not share the enthusiasm of the hon. Member for Crawley (Laura Moffatt) for the Bill one jot, and nor do doctors in my constituency. Instead, I share the views of my hon. Friend the Member for Southend, West (Mr. Amess).
The Bill exemplifies everything that new Labour stands for. Like others before it, it sounds like a major advance, an improvement and a benefit to our people. It is not. In 110 fact—[Interruption.] Gullible Labour Members are actually cheering me. The Bill is rather like the Budget. The Budget sounded great at the time, but a few weeks of analysis has exposed gaping holes both in Labour's arithmetic and in the benefits that it was purported to provide.
The Secretary of State was full of rhetoric. To the gullible on the Government Benches, may I make one thing very clear? The Bill does nothing to abolish the internal market that the Minister so deprecates. It cannot, because even this Government recognise the improvements in patient care that the market has introduced. Instead, there is tinkering with the system, whichwill reduce, not improve, patient care.
At a stroke, 60 per cent. of all patients—the patients who were cared for by GP fundholders, which includes all patients in my constituency, I might add—in this nation will see a reduction in standards of care. The remaining 40 per cent. will not see an improvement either. Changes to the way in which GPs will be funded will put paid to that.
I have news for the Labour Members who have loyally read their party brief. This Bill will go the same way as the Budget: it looks good, but, when one has had a chance to analyse it and see what has not been trumpeted, it is very bad news. It is particularly bad news in Lichfield and Burntwood, where all GPs have been fundholders.
This is nothing to do with levelling up; it is all about levelling down. This is about the Government not being able to resist poking their collective nose into things about which they know nothing: patient care. Fundholding empowered GPs; this little piece of collectivisation puts power back into the hands of Big Brother who, in this instance, does not know best.
I shall air six areas which concern me most. I do not expect the Minister to answer here and now the various points that I-shall put to him, but I ask him to make a note of them. I should be grateful if he would write to me on them because they have been raised with me by doctors who know about patient care.
Although all GPs in Lichfield and Burntwood are fundholders, that is not so nationally. Unlike the proposals before us, GP fundholding was voluntary. Have the Government ever asked themselves why some GPs did not want to become fundholders? It was often because they did not want to become involved in practice management. Not every doctor has the skill required, regardless of whether a practice manager is appointed. Now, as my hon. Friend the Member for Uxbridge (Mr. Randall) pointed out, all doctors will have to join a primary care group—whether they like it or not, but the financial resources are just not there to provide adequate practice management under the proposed scheme.
My constituency is typical. Executive support is quoted to be about £3 a patient, which is far too low for the work required. Even worse, such support does not amount to £3 because it is not ring-fenced. Many primary care groups have not received anything like that level of funding.
The primary care group that covers Lichfield and other towns too has to share a chief officer with another PCG. According to the PCG newsletter published in my area, which was received on 8 April, he is the only permanent member of staff. Furthermore, it is becoming clear that
111 Lichfield practices are sharing other posts, including that of deputy chief officer and a PCG accountant. That level of staffing is wholly inadequate.
Secondly, the situation that I have just described may seriously disadvantage Lichfield and Burntwood, as the other PCG is Tamworth, which has a new hospital, but needs to secure further funding from the PCG. Executive underfunding may lead to Tamworth being favoured by the executive, thus disadvantaging the Lichfield and Burntwood. I do not expect the Minister to answer the following specific constituency question now, but will he assure me that Lichfield Victoria hospital and the Hammerwich hospital will not close as a direct consequence of this Bill and PCGs?
Thirdly, like so much other legislation before the House, there is not enough detail in the Bill. Too many decisions can be made by the Secretary of State, and there is no real information about funding.
Fourthly, the majority of GPs are prepared to assist in fair rationalisation of resources; but, if the system is to be fair, all patients and all doctors should start with a level playing field. I am sure that the Minister and the whole House would agree with that. But—and it is a big but—[Interruption.] It is all very well Labour Members laughing because they have read their Labour party brief, but have they spoken to GPs in their constituencies? Have they actually spoken to fundholders? Have they got off their bottoms and gone back to their constituencies and found out what is really happening on the ground? I think not, Mr. Deputy Speaker.
The most important aspect in Lichfield and Burntwood will be the handling of any overspend by the South Staffordshire health authority for the financial year just ended. My near neighbour, the hon. Member for Cannock Chase (Dr. Wright), raised that point. If the health authority—any health authority—is overspent as at 31 March this year, will that money be sliced off PCG funding for the year 1999–2000?
That is very important because it is not just Lichfield and Tamworth and the South Staffordshire health authority that have an overspend. I notice that the House has now gone very quiet, because hon. Members had not thought of that. If the money were sliced off PCG funding, it would unfairly penalise GP practices—[Laughter.] If hon. Members have thought about it and are finding it so funny, what will they tell GPs in their constituencies? Slicing off the money would unfairly penalise GP practices that are spending within their budget under fundholding. Will the Minister please write to me on that point? Would an overspend of the health authority take money away from the PCGs?
South Staffordshire health authority has ended the year approximately £7 million overspent, as the hon. Member for Cannock Chase said. It is now clear that PCGs will almost certainly not start with a level playing field, as that situation will be carried forward to PCG budgets.
Fifthly, handling all the changes to date has taken an enormous amount of GP time. Do the Government recognise that? Do they understand that the work has not been recognised by proper funding of locum costs while GPs are away from their practices, milling through the paperwork that the change has generated? How do the Government intend to compensate for that? At the moment, no compensation plan is available.
112 Finally, improving the quality of GP services to the community is part of a doctor's philosophy, so many have no problem with the proposals for clinical governance, the Commission for Health Improvement or the National Institute for Clinical Excellence. Both are fine in theory.
Unfortunately, the resources for those initiatives are not forthcoming. It has now been confirmed that South Staffordshire health authority and other health authorities will provide no financial resources for clinical governance, and the only conclusion to be drawn from that is that the aim of most GPs to provide the highest standards of care is not supported by the health authorities—or the Government, who have not funded it properly.
The recurring theme is that the major changes proposed for the NHS will not be supported by special funding. Reliance on NHS staff dedication to continue giving more than they are paid for must come to an end eventually. So many facets of the latest reforms are not funded, despite headline increases of the NHS budget, and staff will become alienated as, once again, they are expected to provide even more for nothing. If the Government truly support their NHS reforms, why is the funding to allow professionals to deliver their vision not available?
A Lichfield doctor wrote to me last night by e-mail—and, just to show my dedication, I tell the House that I received it in my office at 12 minutes past 10 last night. He wrote:
"I am fully prepared to follow NICE advice but for it not to be funded or balanced by telling me which"—9.29 pm
§ Mr. Philip Hammond (Runnymede and Weybridge)
The debate has been distinguished by the participation, from the Opposition Benches, of no fewer than three former Secretaries of State for Health and one former Health Minister. In addition, we have had the benefit of a considered and reasoned debate in the other place, and I hope that the Government will yet take the opportunity to show that they can listen to experience and that they will respond.
I am grateful in particular to my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke) for pointing out that the Bill will not abolish the internal market despite the Government's rhetoric; to my right hon. Friend the Member for Charnwood (Mr. Dorrell) for introducing me to the "Christmas card flow" method of calculating relative power within the NHS—perhaps he predicts that, next year, the Secretary of State will be overwhelmed with Christmas cards—and to my right hon. Friend the Member for South-West Surrey (Mrs. Bottomley) for drawing the House's attention to the fact that the Secretary of State has already succeeded in creating an oppressive climate of fear in the NHS. I am grateful also to my hon. Friends the Members for Orpington (Mr. Horam) and for North Dorset (Mr. Walter) for emphasising, respectively, the importance of the evolutionary, the naturally Conservative, approach to our health service and the meaninglessness and vacuousness of the so-called duty of partnership, which in any event already exists in national health service legislation.
113 I am sorry to say that, with one or two minor exceptions, I have heard nothing from Labour Members showing any original thought. I can only voice my concern for the one or two Labour Members who expressed themselves excited by the Bill. I am grateful to the hon. Member for Dartford (Dr. Stoate) for asking the Minister whether the Government will now accept the Lords amendment requiring the majority of general practitioners in a primary care group to consent before that group evolves into a primary care trust. I look forward to the Minister's answer.
Anyone who listened to the Labour party's pre-election rhetoric, anyone who has heard the extravagant language of the Government's health policy announcements and their re-announcements, and anyone who has been taken in by the creative accounting of the comprehensive spending review, will be asking himself why the NHS is delivering a worse standard of service than it was two years ago. Anyone considering the huge challenges facing our health care delivery system must be struck by the complete inadequacy of the Bill—apparently it is the flagship measure of the Government's health agenda—to meet those challenges.
It is a mean little Bill, driven in equal measure by political spite, the instinctive desire to centralise and the Government's need to put in place by stealth a mechanism to ration NHS care and to shift the responsibility for that rationing away from the Government and on to the shoulders of the medical profession.
The Bill says nothing about the real challenge facing the NHS, which is that of matching supply with demand in the face of dramatic medical advances and huge demographic changes. It says nothing also about the need to develop a broader resource base for health care provision to bring Britain into line with the levels of spending, the quality of provision and the range of choice that are available to the citizens of its European neighbours. The Bill does not mention the issue of rationing or the mechanisms that will be needed for an on-going, open and transparent determination of the limits of availability within our NHS.
The Bill does nothing that will address the deteriorating service that is facing patients. Similarly, it will do nothing for the extra 200,000 patients who are waiting to see a consultant, such as Mr. Tony Wiese, whom I met yesterday in his home at Woodbridge, Suffolk. Mr. Wiese cares passionately about the NHS as a relatively young multiple sclerosis sufferer in the secondary progressive stage of the disease.
Mr. Wiese recently asked his GP to prescribe him a drug that he had been prescribed in 1994 but had abandoned because of side effects. Now that the disease has advanced, quite reasonably Mr. Wiese wants to try it again. His GP told him that he would need an out-patient consultation at his local hospital and she referred him accordingly. On 26 March, Mr. Wiese received the following letter from Ipswich hospital NHS trust:
Dear Mr. Wiese, an appointment has been made for you to attend Dr. Wroe's neurology clinic on Monday 25th September 2000 at 2.30 pm.Mr. Wiese will have to wait 18 months just to see a consultant to obtain a prescription for a drug that has already been prescribed for him once before. That is an 18-month wait for someone suffering from a progressive degenerative disease. Is that the sort of service that the 114 Minister expects to deliver in his modern and dependable new NHS? It is that sort of quality of service issue that the Government should be addressing in this Bill. The Minister might want to think about the specific example that I have quoted as he prepares himself for MS awareness week, next week.
Do not let me give the impression that the Bill does not have a central coherent theme, because it certainly does. However, it is one that is hidden from view. It is stealthily concealed by language and presentation, like the Chancellor's tax rises. It puts in place the mechanisms of a sophisticated but unacknowledged rationing system. Primary care trusts, with their limited range of referral options and the inclusion of prescribing budgets within the cash-limited envelope, will be in the front line of that rationing mechanism. They will operate within guidance issued by NICE based not only on clinical effectiveness, but on cost-effectiveness of drugs and treatments.
The chairman of NICE has already made it clear that he may have to recommend that a drug or a treatment be not made available because of resource shortages. CHIMP will be able to intervene, question clinical practice, demand information and challenge doctors' decisions, but it does not end there. The Bill as introduced in the other place gave powers to the Government to control the medical profession in an unprecedented way, so that they could effectively end self-regulation if they chose.
Thanks only to the vigilance of my noble Friends, that threat has been somewhat diluted, but the loss of choice in referrals, the ominous cloud cast by PCTs over the independent contractor status of GPs and the pincer movement of cash limits on prescribing budgets and NICE guidance enforced by CHIMP will spell the end of the traditional role of the GP as an advocate for his patient. With it will be lost any proxy for the informed consumer in our health care system.
It goes on. The unprecedented powers that the Government are giving themselves to control prices of pharmaceutical products by law can—and, I predict, will—be used by them to force companies not to make available in the United Kingdom drugs that the Government do not want to be available.
So, underlying the provisions of the Bill is a plan for the creation of a comprehensive mechanism for controlling demand and limiting supply of NHS health care by limiting the power and freedom of doctors; removing the choice enjoyed not only by patients of fundholders, but by all patients; controlling what drugs are available in the UK market; and increasing the Secretary of State's ability to direct the health service centrally—all that while denying the existence of rationing.
The Bill does not even begin to address the real and crucial problem of resourcing, which underlies all the other problems faced by the system. So how did the Government get themselves into this corner—centralising in the name of local autonomy, cutting services in the name of levelling up and imposing massive, expensive and unnecessary change on a health service to which, in 1996, the Prime Minister pledged that there would be "no great upheavals" under Labour? They are pinned there by three unwise political commitments, the first of which is the hostile position that they adopted in opposition, on the basis of dogma rather than reason, to the principle of the internal market and, in particular, to GP fundholding.
115 The second unwise commitment is the Government's ill-advised pre-election pledge to cut waiting lists by 100,000—regardless of the cost to patient care in the NHS as a whole and regardless of the distortion of clinical priorities that that entailed. The third—which has been raised to the status of a political creed in itself by frequent, if increasingly unconvincing, repetition by Ministers—is the denial that rationing exists in the NHS.
Thus have the Government inevitably committed themselves to an agenda of centralising control, distorting clinical priorities, reducing choice, creating the mechanisms of organised rationing without ever acknowledging it and dismantling GP fundholding—the foundation on which a truly modern health service could have been built. Indeed, the abolition of GP fundholding—the single most important of the changes proposed in the Bill—ranks with the end of tax relief on private health insurance premiums for the over-60s as an act of pure political spite—an exercise in dogma.
Fundholding worked. Most GPs recognised that, the Audit Commission and the OECD have said so and even the Labour party's own expert advisers recommended that it should not abolish the fundholding system. Fundholding practices have been effective in securing for their patients improvements in secondary provision and delivery of a wider range of high quality primary health care services. They were responsive to the needs of their patients and they would have been quite capable of delivering the Government's health care agenda. Their abolition is purely politically motivated.
Dragooning GPs, independent contractors, into enforced co-operatives, where 50 or 100 of them have to work together, is a recipe for disaster. To remove the practice as the basic unit of the system is to go against the grain of human nature. It will reduce doctors' individual freedom to act on behalf of their patients, reduce the range of services that they can offer and reduce their incentives to improve their efficiency and to demand efficiency from the hospitals serving them.
Of course fundholding was not perfect. The NHS is a large and complex organisation and change takes time to be effective. Fundholding was still in a relatively early stage of its development—Conservative Members would be the first to recognise that—but it offered a basis on which to build. The major objection to it, that it led to inequality between the patients of fundholding and non-fundholding practices, could easily have been addressed by a genuine levelling up—a universalisation of fundholding to ensure that all patients enjoyed those benefits, rather than the levelling down, which is Labour's basic instinct.
On 18 January, the Secretary of State said:
"primary care groups provide incentives for all concerned to 'level tip' to the standards of the best." — [Official Report, 18 January 1999; Vol. 323, c. 594.]
Since then, I and my hon. and noble Friends have sought assurances from the Government that none of the 60 per cent. of patients who had fundholding GPs would lose access to services as a result of the transition from fundholding to PCGs. We have had no answer, and we could not have an answer because those services are already being lost—psychiatric services in Stafford and 116 Leicester, physiotherapy in Luton and Hertfordshire, diabetes and asthma clinics in north London and counselling in Bath, to name but a few.
Therefore, for 60 per cent. of patients, the bottom line is already clear. The Government's reforms have produced an immediate reduction in primary care services. I am still waiting for an explanation of how, even within the apparently elastic confines of new Labourspeak, a reduction in services can be described as levelling up. Instead of seeking to build upon and improve those parts of the primary care system that were demonstrably delivering, and encouraging those that were not to emulate them, the Government chose to sweep them away, replacing them with a structure that looks backwards for its inspiration, not forwards.
One thing that we can be sure about with the Government is that, the more extravagant the claims, the more flamboyant the language, the further from the claims the reality is likely to be. So it is with the reform of primary health care. We are told that primary care is being modernised, that local accountability is being strengthened, but an old-fashioned centrally directed structure is being reimposed. We are told that it is being done in the interests of equality. If that is so, it is the equality of the Soviet era—a levelling down to equal misery for all. The end result is a commissioning system that is less, not more, responsive to patient needs.
In the three hours or so since my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) outlined the Opposition's objections to the Bill, we have heard from Labour Members not a rebuttal of those objections, not a reasoned response to her concerns, but a recital of the Labour party's official dogma. I say this to Labour Members: if the NHS is to be a success in its second 50 years, they must resist the temptation to love it to death. We all share the desire for improved health care delivery. Conservative Members do not believe that the Bill remotely begins to address the issues that must be faced if that is to be achieved.
Of course we object to the way in which the Bill substitutes political control for professional independence, bureaucratic direction for market forces and compulsion for choice, but much more fundamental is the Government's continued refusal to address the resource issue or even to acknowledge that it exists. A Government who genuinely put health at the top of their agenda would be using their flagship health legislation to address that issue, to look forward to the resourcing of our health care system into the 21st century, and, by that test, the Government have failed miserably.
The Bill attacks GPs' traditional role. It attacks all clinicians' traditional professional freedom. It eliminates choice for patients. The end result, whatever the Government's rhetoric, is a highly prescriptive system reversing the trend under the previous Government of devolving power and reverting to the discredited principle that "Whitehall knows best". Behind the rhetoric, the Bill is a recipe for inflexibility, inefficiency, lack of choice and increased bureaucracy. I urge the House to vote for the amendment and deny the Bill a Second Reading.
§ The Minister of State, Department of Health (Mr. John Denham): The right hon. Member for Maidstone and The Weald (Miss Widdecombe) launched 117 a fierce attack in an attempt to divert attention from our success in reducing the numbers on waiting lists. She produced what in some parts of the trade are known as killer facts.
The Official Report will confirm that she told the House that Southampton general's waiting lists have trebled since the election. I can tell the right hon. Lady that the Southampton University Hospitals NHS trust waiting list is now more than 1,000 below the level of March 1997.
The right hon. Lady's second killer fact was the accusation that the chief executive of Salisbury health care NHS trust—I have an interest because I live in Southampton and it is just up the road from me—had written a letter to consultants telling them to stop putting patients on the waiting list. The letter gave three options, and the right hon. Lady mentioned two of them. She said that one option was to reduce the numbers on the list. She did not tell us that the chief executive had said that that risked inconveniencing patients and GPs, that it could expose patients to clinical risk and that it would merely pass the problem on to next year. The other option she mentioned was to use the private sector. That happens in some parts of the country if NHS capacity is full. However, she did not mention the third option, which was to increase NHS capacity, and that is what the Salisbury health care NHS trust did. It treated an extra 500 patients during February and March alone.
The right hon. Lady's speech can be judged on those facts. It was either misleading or just plain wrong. Fortunately, many of the other speeches had considerably greater weight. My hon. Friends the Members for Rother Valley (Mr. Barron) and for Brighton, Kemptown (Dr. Turner) spoke about the importance of the Government's quality agenda. My hon. Friends the Members for Wakefield (Mr. Hinchliffe) and for Bury, South (Mr. Lewis), and the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) talked of the importance of close co-operation between the national health service and social services. They will have noted the important partnership proposals for co-operation, which will enable those two bodies to pool resources and powers.lb/> My hon. Friend the Member for South Swindon (Ms Drown) set out clearly the problems of attempting to apply our proposals for raising quality in the national health service to the independent sector as though the two were exactly the same. My hon. Friends the Members for Dartford (Dr. Stoate), for Bedford (Mr. Hall), for Pudsey (Mr. Truswell), for Cannock Chase (Dr. Wright) and for Crawley (Laura Moffatt) spoke in different ways about the problems that arose from fundholding and the improvements that they envisaged would come from our proposals on primary care. A number of hon. Members spoke of the optimism and achievements of their own primary care groups.
My hon. Friend the Member for Erith and Thamesmead (Mr. Austin) talked about the importance of partnership, and I assure him that health improvement programmes will be published with full details of whom and how they have consulted on the drawing up of those proposals.
The hon. Member for Belfast, South (Rev. Martin Smyth) raised a number of important points. I can tell him that an interim regulatory impact assessment of our pharmaceutical proposals has been produced and is in the Library. A further stage in that process will take place when an agreement has been reached.
118 The right hon. Member for South-West Surrey (Mrs. Bottomley) raised, among other things, some local PFI issues, and I shall look into those matters for her. The hon. Member for Orpington (Mr. Horam) spoke of the achievements of his local hospitals in reducing waiting lists, and I acknowledge his contribution to the debate. We also heard from a number of hon. Members, including the hon. Members for Uxbridge (Mr. Randall), for Lichfield (Mr. Fabricant) and for Southend, West (Mr. Amess), who expressed scepticism about our proposals, although without a great deal of evidence to back up their arguments. I hope to respond to other hon. Members during my speech.
We must remember that when the Opposition were in government, they fostered division and competition in the health service instead of co-operation and collaboration. They failed to establish a framework to ensure that the NHS delivered consistently high-quality services to patients, wherever they lived. Instead of setting out plans to tackle inequalities in health, they hid the information that revealed that such inequalities existed. It was astonishing to hear talk about the "dispossessed" tonight.
When we were elected, we set about tackling the problems. The Bill is a vital part of our modernisation programme, although it is only a part. It introduces the legislative changes that are needed to carry through reforms that are already under way. With the support of general practitioners, nurses and other health professionals, we have already established 481 primary care groups, and the largest hospital building programme in the history of the NHS is in progress. We have also invested a further £2 billion in the NHS, which will receive an extra £21 billion announced in the comprehensive spending review, which will flow over the next three years. Under existing legislation, we have established the National Institute for Clinical Excellence. NHS Direct already covers 40 per cent. of the country, and an extra 2,500 nurses are already in training.
Throughout those changes, we have worked—as we promised we would—with the NHS, with its users, with carers, with professional bodies and with others. They have helped to shape what we have done, and the way in which we have done it. That is why our reforms have been so widely welcomed—why they are seen so clearly as working with the grain of what the NHS, the staff who deliver the service and the public who rely on it want. Their views have shaped the Bill.
Not everything that we want to do can be done under existing legislation. In key areas—in primary care, in quality, including self-regulation, in partnership, in pharmaceuticals and in the tackling of fraud, the Bill provides a legal framework to complete the modernisation of the NHS on which we have already embarked. That framework will put doctors and nurses in primary care at the heart of the new national health service, with the power and influence to shape and deliver the services that their patients need. It will make possible a new, systematic approach to identify, implement and assure best practice and high clinical standards, and will ensure that each part of the NHS works in partnership with every other part, with local authorities, with voluntary organisations and with local communities to deliver effective services, tackle inequalities in health and improve the health of the public.
119 The framework will enable us to tackle fraud in the NHS effectively, saving millions of pounds that can be used to treat patients. It will enable us to secure the best deal for patients, the NHS and the pharmaceutical industry from the billions of pounds that the NHS spends on drugs each year.
As for primary care, fundholding is coming to an end, and with that will come an end to the bureaucratic, costly system that fragmented the delivery of services—a system that gave advantages to some patients, but only at the expense of others. The Opposition claim that fundholding was popular; but after years of persuasion and years of generous management allowances, only 50 per cent. of family doctors ever signed up, and many of those did so with real reluctance. Today, only 46 fundholding practices out of 3,400 in England have hung on to fundholding, while 481 primary care groups are up and running.
Primary care groups will bring real benefits to patients. Better services will be available to all people, regardless of who their GPs are or where they happen to live. The transfer of responsibility that we are bringing about is real. I am told that, at the high point, £6 billion of NHS funding had been transferred to the influence of fundholding practices. Already in the current financial year, £11 billion of NHS funding has been transferred to the responsibility of primary care groups, 83 per cent. of which are operating at level two, doing their commissioning directly. That is a real transfer of resources, enabling practitioners in primary care to shape health services in their local areas in the interests of their patients.
Let me deal with the allegations about bureaucracy. We have heard talk of £150 million. That is the amount that it cost to provide the management of fundholding practices; we are using the same amount to provide primary groups that will cover all practices and all patients, right across the country.
After we were elected, we looked at the books and saw that the Conservative party had planned to increase spending on the bureaucracy of fundholding by a further £30 million. We stopped that. We spent £20 million on cancer services and £5 million on children's intensive care services. I believe that patients agree that that was a better way in which to spend that money.
Under our system, doctors will have greater flexibility of referral. There will be an end to the internal market system of extra-contractual referrals, which denied patients and clinicians choice. GPs, nurses and other health professionals will shape health services to the benefit of all patients.
Throughout the country, as we have urged, primary care groups are protecting services that are delivered cost-effectively at practice level, and levelling them up. Three primary care groups in Calderdale, Kirklees have worked together to develop an out-of-hours service in partnership with NHS Direct. In north Cumbria, extending single practice-based vasectomy and ophthalmology services to other practices—[Interruption.] From a sedentary position, the hon. Member for Rutland and Melton (Mr. Duncan) decries those improvements in services. He does it because he has spent all evening claiming that they would not happen, yet, throughout the country, new services are being developed and existing 120 services that were previously available only to fundholding patients are being made available to all patients. Of course he will heckle: he does not like the early signs of success that are already developing with our reforms.
§ Mr. Denham
The hon. Gentleman is right; it is only the first two weeks. There is much more to come.
§ Some primary care groups—perhaps, in time, many—will want to use the powers in the Bill to go further: to establish primary care trusts that are responsible for almost all the commissioning of health services and, if the case is right, to deliver some community health services as well. Primary care trusts will enjoy new powers and freedoms: powers to invest in general practice, in premises and in information systems; to devise their own incentive arrangements, so that there are incentives to develop individual practices as well as the work of the trust itself; to employ staff to support practices in delivering health care; to use the flexibility that is offered by the National Health Service (Primary Care) Act 1997; to develop clinical governance; to continue professional development; and, at the highest level, to provide community health services, not just to commission them. Those are just some of the powers that primary care trusts will be able to develop locally—at a pace that helps to meet local needs, after widespread consultation.
§ Primary care groups and trusts will help to cut bureaucracy. They will help to ensure that, over the lifetime of the current Parliament, £1 billion that would have been spent on bureaucracy will be spent on patient care, as the number of commissioning bodies is cut from more than 4,000 to fewer than 650 throughout Great Britain.
§ The right hon. Member for Maidstone and The Weald raised again the tradition during the whole 50 years of the NHS of saying, "The NHS is finished. It cannot cope." She said that that situation had existed from the beginning of the NHS. That is true: there have always been those who have decried the national health system. Fortunately, they have not been listened to and they will not be listened to today. If they had been listened to, the NHS would have been destroyed.
§ Question put, That the amendment be made: —
§ The House divided: Ayes 127, Noes 368.124
|Division No. 141]||[9.59 pm|
|Ainsworth, Peter (E Surrey)||Brooke, Rt Hon Peter|
|Amess, David||Browning, Mrs Angela|
|Arbuthnot, Rt Hon James||Bruce, Ian (S Dorset)|
|Atkinson, David (Bour'mth E)||Burns, Simon|
|Atkinson, Peter (Hexham)||Butterfill, John|
|Baldry, Tony||Cash, William|
|Bercow, John||Chapman, Sir Sydney|
|Blunt, Crispin||(Chipping Barnet)|
|Bottomley, Peter (Worthing W)||Chope, Christopher|
|Bottomley, Rt Hon Mrs Virginia||Clappison, James|
|Brady, Graham||Clark, Rt Hon Alan (Kensington)|
|Brazier, Julian||Clark, Dr Michael (Rayleigh)|
|Clarke, Rt Hon Kenneth||McLocughlin, Patrick|
|Clifton-Brown, Geoffrey||Maples, John|
|Collins, Tim||Mates, Michael|
|Colvin, Michael||Moss, Malcolm|
|Cormack, Sir Patrick||Nicholls, Patrick|
|Cran, James||Ottaway, Richard|
|Davies, Quentin (Grantham)||Page, Richard|
|Davis, Rt Hon David (Haltemprice||Paice, James|
|& Howden)||Paterson, Owen|
|Dorrell, Rt Hon Stephen||Pickles, Eric|
|Duncan, Alan||Randall, John|
|Duncan Smith, lain||Redwood, Rt Hon John|
|Evans, Nigel||Robathan, Andrew|
|Faber, David||Robertson, Laurence (Tewk'b'ry)|
|Fabricant, Michael||Ross, William (E Lond'y)|
|Fallon, Michael||Rowe, Andrew(Feversham)|
|Flight, Howard||Ruffley, David|
|Forth, Rt Hon Eric||Sayeed, Jonathan|
|Fowler, Rt Hon Sir Norman||Shepherd, Richard|
|Fox, Dr Liam||Simpson, Keith (Mid-Norfolk)|
|Garnier, Edward||Smyth, Rev Martin (Belfast S)|
|Gibb, Nick||Soames, Nicholas|
|Gill, Christopher||Spelman, Mrs Caroline|
|Gillan, Mrs Cheryl||Spicer, Sir Michael|
|Gorman, Mrs Teresa||Spring, Richard|
|Green, Damian||Stanley, Rt Hon Sir John|
|Greenway, John||Steen, Anthonty|
|Grieve. Dominic||Streeter, Gary|
|Hammond, Philip||Sawyne, Desmond|
|Hawkins, Nick||Syms, Robert|
|Heald, Oliver||Tapsell, Sir Peter|
|Heathcoat—Amory, Rt Hon David||Taylor, Ian (Esher & Walton)|
|Heseltine, Rt Hon Michael||Taylor, John M (Solihull)|
|Hogg, Rt Hon Douglas||Taylor, Sir Teddy|
|Horam, John||Trend, Michael|
|Hunter, Andrew||Tyrie, Andrew|
|Jack, Rt Hon Michael||Viggers, Peter|
|Jenkin, Bernard||Walter, Robert|
|King, Rt Hon Tom (Bridgwater)||Wardle, Charles|
|Kirkbride, Miss Julie||Waterson, Nigel|
|Lait, Mrs Jacqui||Wells, Bowen|
|Lansley, Andrew||Whitney, Sir Raymond|
|Leigh, Edward||Whittingdale, John|
|Letwin, Oliver||Widdecombe, Rt Hon Miss Ann|
|Lewis, Dr Julian (New Forest E)||Wilkinson, John|
|Lidington, David||Winterton, Mrs Ann (Congleton)|
|Lilley, Rt Hon Peter||Winterton, Nicholas (Macclesfield)|
|Lloyd, Rt Hon Sir Peter (Fareham)||Woodward, Shaun|
|Loughton, Tim||Yeo, Tim|
|Luff, Peter||Young, Rt Hon Sir George|
|Lyell, Rt Hon Sir Nicholas|
|MacGregor, Rt Hon John||Tellers for the Ayes:|
|MacKay, Rt Hon Andrew||Mrs. Eleanor Laing and|
|Maclean, Rt Hon David||Mr. Stephen Day|
|Ainsworth, Robert (Cov'try NE)||Beith, Rt Hon A J|
|Allan, Richard||Bell, Martin (Tatton)|
|Allen, Graham||Bell, Stuart (Middlesbrough)|
|Anderson, Donald (Swansea E)||Bennett, Andrew F|
|Anderson, Janet (Rossendale)||Bermingham, Gerald|
|Armstrong, Ms Hilary||Berry, Roger|
|Ashdown, Rt Hon Paddy||Best, Harold|
|Ashton, Joe||Blackman, Liz|
|Atherton, Ms Candy||Blears, Ms Hazel|
|Atkins, Charlotte||Blizzard, Bob|
|Austin, John||Borrow, David|
|Baker, Norman||Bradley, Keith (Withington)|
|Ballard, Jackie||Bradley, Peter (The Wrekin)|
|Banks, Tony||Brand, Dr Peter|
|Barnes, Harry||Breed, Colin|
|Barron, Kevin||Brinton, Mrs Helen|
|Bayley, Hugh||Brown, Rt Hon Nick (Newcastle E)|
|Beard, Nigel||Brown, Russell (Dumfries)|
|Beckett, Rt Hon Mrs Margaret||Buck, Ms Karen|
|Burden, Richard||Foster, Rt Hon Derek|
|Burgon, Colin||Foster, Don (Bath)|
|Burstow, Paul||Foster, Michael Jabez (Hastings)|
|Butler, Mrs Christine||Foster, Michael J (Worcester)|
|Cable, Dr Vincent||Foulkes, George|
|Caborn, Richard||Fyfe, Maria|
|Campbell, Alan (Tynemouth)||Galloway, George|
|Campbell, Mrs Anne (C'bridge)||Gapes, Mike|
|Campbell, Rt Hon Menzies||Gardiner, Barry|
|(NE Fife)||George, Andrew (St Ives)|
|Campbell, Ronnie (Blyth V)||George, Bruce (Walsall S)|
|Campbell-Savours, Dale||Gerrard, Neil|
|Cann, Jamie||Gibson, Dr Ian|
|Caplin, Ivor||Gilroy, Mrs Linda|
|Casale, Roger||Godman, Dr Norman A|
|Caton, Martin||Godsiff, Roger|
|Cawsey, Ian||Goggins, Paul|
|Chapman, Ben (Wirral S)||Golding, Mrs Llin|
|Chaytor, David||Gordon, Mrs Eileen|
|Clapham, Michael||Griffiths, Jane (Reading E)|
|Clark, Rt Hon Dr David (S Shields)||Griffiths, Nigel (Edinburgh S)|
|Clark, Dr Lynda||Griffiths, Win (Bridgend)|
|(Edinburgh Pentlands)||Grocott, Bruce|
|Clark, Paul (Gillingham)||Grogan, John|
|Clarke, Charles (Norwich S)||Gunnell, John|
|Clarke, Rt Hon Tom (Coatbridge)||Hall, Mike (Weaver Vale)|
|Clelland, David||Hall, Patrick (Bedford)|
|Coaker, Vernon||Hamilton, Fabian (Leeds NE)|
|Coffey, Ms Ann||Harman, Rt Hon Ms Harriet|
|Cohen, Harry||Harris, Dr Evan|
|Coleman, lain||Harvey, Nick|
|Colman, Tony||Heal, Mrs Sylvia|
|Connarty, Michael||Healey, John|
|Cook, Frank (Stockton N)||Heath, David (Somerton & Frome)|
|Corbett, Robin||Henderson, Doug (Newcastle N)|
|Corbyn, Jeremy||Henderson, Ivan (Harwich)|
|Cotter, Brian||Hepburn, Stephen|
|Cousins, Jim||Heppell, John|
|Cranston, Ross||Hesford, Stephen|
|Crausby, David||Hewitt, Ms Patricia|
|Cryer, Mrs Ann (Keighley)||Hill, Keith|
|Cryer, John (Hornchurch)||Hinchliffe, David|
|Cummings, John||Hodge, Ms Margaret|
|Cunliffe, Lawrence||Hoey, Kate|
|Cunningham, Rt Hon Dr Jack||Hood, Jimmy|
|Cunningham, Jim (Cov'try S)||Hope, Phil|
|Curtis—Thomas, Mrs Claire||Hopkins, Kelvin|
|Dafis, Cynog||Howarth, Alan (Newport E)|
|Dalyell, Tam||Howarth, George (Knowsley N)|
|Darvill, Keith||Howells, Dr Kim|
|Davey, Edward (Kingston)||Hoyle, Lindsay|
|Davey, Valerie (Bristol W)||Hughes, Ms Beverley (Stretford)|
|Davies, Rt Hon Denzil (Llanelli)||Hughes, Kevin (Doncaster N)|
|Dawson, Hilton||Hughes, Simon (Southwark N)|
|Dean, Mrs Janet||Humble, Mrs Joan|
|Denham, John||Hurst, Alan|
|Dismore, Andrew||Hutton, John|
|Dobbin, Jim||Iddon, Dr Brian|
|Dobson, Rt Hon Frank||Illsley, Eric|
|Donohoe, Brian H||Jackson, Ms Glenda (Hampstead)|
|Doran, Frank||Jackson, Helen (Hillsborough)|
|Drown, Ms Julia||Jamieson, David|
|Dunwoody, Mrs Gwyneth||Jenkins, Brian|
|Eagle, Angela (Wallasey)||Johnson, Alan (Hull W & Hessle)|
|Eagle, Maria (L'pool Garston)||Johnson, Miss Melanie|
|Edwards, Huw||(Welwyn Hatfield)|
|Efford, Clive||Jones, Barry (Alyn & Deeside)|
|Ellman, Mrs Louise||Jones, Helen (Warrington N)|
|Ennis, Jeff||Jones Ms Jenny|
|Etherington, Bill||(Wolverh'ton SW)|
|Ewing, Mrs Margaret||Jones, Jon Owen (Cardiff C)|
|Field, Rt Hon Frank||Jones, Dr Lynne (Selly Oak)|
|Fitzpatrick, Jim||Jowell, Rt Hon Ms Tessa|
|Flint, Caroline||Kaufman, Rt Hon Gerald|
|Follett, Barbara||Keeble, Ms Sally|
|Keen, Alan (Feltham & Heston)||Pickthall, Colin|
|Keen, Ann (Brentford & Isleworth)||Pike, Peter L|
|Keetch, Paul||Plaskitt, James|
|Kemp, Fraser||Pollard, Kerry|
|Kennedy, Charles (Ross Skye)||Pope, Greg|
|Kennedy, Jane (Wavertree)||Pound, Stephen|
|Khabra, Piara S||Powell, Sir Raymond|
|Kidney, David||Prentice, Ms Bridget (Lewisham E)|
|King, Ms Oona (Bethnal Green)||Prentice, Gordon (Pendle)|
|Kingham, Ms Tess||Primarolo, Dawn|
|Kirkwood, Archy||Prosser, Gwyn|
|Kumar, Dr Ashok||Purchase, Ken|
|Ladyman, Dr Stephen||Quin, Rt Hon Ms Joyce|
|Lawrence, Ms Jackie||Quinn, Lawrie|
|Laxton, Bob||Radice, Giles|
|Lepper, David||Rammell, Bill|
|Leslie, Christopher||Raynsford, Nick|
|Levitt, Tom||Reed, Andrew (Loughborough)|
|Lewis, Ivan (Bury S)||Reid, Rt Hon Dr John (Hamilton N)|
|Liddell, Rt Hon Mrs Helen||Rendel, David|
|Linton, Martin||Robertson, Rt Hon George|
|Livsey, Richard||(Hamilton S)|
|Lloyd, Tony (Manchester C)||Robinson, Geoffrey (Cov'try NW)|
|Llwyd, Elfyn||Roche, Mrs Barbara|
|Lock, David||Rogers, Allan|
|McAvoy, Thomas||Rooker, Jeff|
|McCabe, Steve||Rooney, Terry|
|McCafferty, Ms Chris||Ross, Ernie (Dundee W)|
|McDonagh, Siobhain||Roy, Frank|
|McDonnell, John||Ruane, Chris|
|McIsaac, Shona||Ruddock, Joan|
|McKenna, Mrs Rosemary||Russell, Ms Christine (Chester)|
|Mackinlay, Andrew||Ryan, Ms Joan|
|McNamara, Kevin||Salter, Martin|
|McNulty, Tony||Sanders, Adrian|
|MacShane, Denis||Sawford, Phil|
|Mactaggart, Fiona||Sedgemore, Brian|
|McWalter, Tony||Shaw, Jonathan|
|McWilliam, John||Sheerman, Barry|
|Mahon, Mrs Alice||Sheldon, Rt Hon Robert|
|Mallaber, Judy||Shipley, Ms Debra|
|Mandelson, Rt Hon Peter||Short, Rt Hon Clare|
|Marsden, Gordon (Blackpool S)||Simpson, Alan (Nottingham S)|
|Marshall, Jim (Leicester S)||Singh, Marsha|
|Marshall-Andrews, Robert||Skinner, Dennis|
|Martlew, Eric||Smith, Rt Hon Andrew (Oxford E)|
|Maxton, John||Smith, Angela (Basildon)|
|Meacher, Rt Hon Michael||Smith, Miss Geraldine|
|Merron, Gillian||(Morecambe & Lunesdale)|
|Michie, Bill (Shefld Heeley)||Smith, Jacqui (Redditch)|
|Miller, Andrew||Smith, John (Glamorgan)|
|Mitchell, Austin||Smith, Llew (Blaenau Gwent)|
|Moffatt, Laura||smith, Sir Robert (W Ab'd'ns)|
|Moonie, Dr Lewis||Snape, Peter|
|Morgan, Alasdair (Galloway)||Soley, Clive|
|Morgan, Ms Julie (Cardiff N)||Southworth, Ms Helen|
|Morley, Elliot||Spellar, John|
|Morris, Ms Estelle (B'ham Yardley)||Squire, Ms Rachel|
|Mudie, George||Starkey, Dr Phyllis|
|Mullin, Chris||Steinberg, Gerry|
|Murphy, Denis (Wansbeck)||Stevenson, George|
|Naysmith, Dr Doug||Stewart, David (Inverness E)|
|Norris, Dan||Stinchcombe, Paul|
|Oaten, Mark||Stoate, Dr Howard|
|O'Brien, Bill (Normanton)||Stott, Roger|
|O'Brien, Mike (N Warks)||Strang, Rt Hon Dr Gavin|
|O'Hara, Eddie||Stringer, Graham|
|Olner, Bill||Stuart, Ms Gisela|
|O'Neill, Martin||Stunell, Andrew|
|Öpik, Lembit||Sutcliffe, Gerry|
|Organ, Mrs Diana||Taylor, Rt Hon Mrs Ann|
|Osborne, Ms Sandra||(Dewsbury)|
|Palmer, Dr Nick||Taylor, Ms Dari (Stockton S)|
|Pearson, Ian||Taylor, David (NW Leics)|
|Pendry, Tom||Taylor, Matthew (Truro)|
|Perham, Ms Linda||Temple—Morris, Peter|
|Thomas, Gareth (Clwyd W)||White, Brian|
|Thomas, Gareth R (Harrow W)||Whitehead, Dr Alan|
|Timms, Stephen||Wicks, Malcolm|
|Tipping, Paddy||Williams, Rt Hon Alan|
|Todd, Mark||(Swansea W)|
|Tonge, Dr Jenny||Williams, Alan W (E Carmarthen)|
|Trickett, Jon||Willis, Phil|
|Truswell, Paul||Wills, Michael|
|Turner, Dennis (Wolverh'ton SE)||Winnick, David|
|Turner, Dr Desmond (Kemptown)||Wise, Audrey|
|Turner, Dr George (NW Norfolk)||Wood, Mike|
|Twigg, Stephen (Enfield)||Worthington, Tony|
|Tyler, Paul||Wray, James|
|Vaz, Keith||Wright, Anthony D (Gt Yarmouth)|
|Walley, Ms Joan||Wright, Dr Tony (Cannock)|
|Ward, Ms Claire||Wyatt, Derek|
|Wareing, Robert N||Tellers for the Noes:|
|Watts, David||Mr. Jim Dowd and|
|Webb, Steve||Mr. Clive Betts.|
§ Question accordingly negatived.
§ Main Question put forthwith, pursuant to Standing Order No. 62 (Amendment on Second or Third Reading):—
§ The House divided: Ayes 333, Noes 134.128
|Division No. 142]||[10.15 pm|
|Adams, Mrs Irene (Paisley N)||Chaytor, David|
|Ainsworth, Robert (Cov'try NE)||Clapham, Michael|
|Allen, Graham||Clark, Rt Hon Dr David (S Shields)|
|Anderson, Janet (Rossendale)||Clark, Dr Lynda|
|Armstrong, Ms Hilary||(Edinburgh Pentlands)|
|Atherton, Ms Candy||Clark, Paul (Gillingham)|
|Atkins, Charlotte||Clarke, Charles (Norwich S)|
|Austin, John||Clarke, Eric (Midlothian)|
|Banks, Tony||Clarke, Rt Hon Tom (Coatbridge)|
|Barnes, Harry||Clelland, David|
|Barron, Kevin||Coaker, Vernon|
|Bayley, Hugh||Coffey, Ms Ann|
|Beard, Nigel||Cohen, Harry|
|Beckett, Rt Hon Mrs Margaret||Coleman, Iain|
|Bell, Martin (Tatton)||Colman, Tony|
|Bell, Stuart (Middlesbrough)||Connarty, Michael|
|Bennett, Andrew F||Corbett, Robin|
|Bermingham, Gerald||Corbyn, Jeremy|
|Berry, Roger||Cousins, Jim|
|Best, Harold||Cranston, Ross|
|Blackman, Liz||Crasusby, David|
|Blears, Ms Hazel||Cryer, Mrs Ann (Keighley)|
|Blizzard, Bob||Cryer, John (Hornchurch)|
|Borrow, David||Cummings, John|
|Bradley, Keith(Withington)||Cunliffe, Lawrence|
|Bradley, Peter (The Wrekin)||Cunningham, Rt Hon Dr Jack|
|Brinton, Mrs Helen||(Copeland)|
|Brown, Rt Hon Nick (Newcastle E)||Cunningham, Jim (Cov'try S)|
|Brown, Russell (Dumfries)||Curtis-Thomas, Mrs Claire|
|Buck, Ms Karen||Dalyell, Tam|
|Burden, Richard||Darvill, Keith|
|Burgon, Colin||Davey, Valerie (Bristol W)|
|Butler, Mrs Christine||Davies, Rt Hon Denzil (Llanelli)|
|Caborn, Richard||Dawson, Hilton|
|Campbell, Alan (Tynemouth)||Dean, Mrs Janet|
|Campbell, Mrs Anne (C'bridge)||Denham, John|
|Campbell, Ronnie (Blyth V)||Dismore, Andrew|
|Campbell-Savours, Dale||Dobbin, Jim|
|Cann, Jamie||Dobson, Rt Hon Frank|
|Caplin Ivor||Donohoe, Brian H|
|Casale, Roger||Doran, Frank|
|Caton, Martin||Drown, Ms Julia|
|Cawsay, Ian||Dunwoody, Mrs Gwyneth|
|Chapman, Ben (Wirral S)||Eagle, Angela (Wallasey)|
|Eagle, Maria (L'pool Garston)||Jones, Jon Owen (Cardiff C)|
|Edwards, Huw||Jones, Dr Lynne (Selly Oak)|
|Efford, Clive||Jowell, RT Hon Ms Tessa|
|Ellman, Mrs Louise||Kaufman, Rt Hon Gerald|
|Ennis, Jeff||Keeble, Ms Sally|
|Etherington, Bill||Keen, Alan (Feltham & Heston)|
|Ewing, Mrs Margaret||Keen, Ann (Brentford & Isleworth)|
|Field, Rt Hon Frank||Kemp, Fraser|
|Fitzpatrick, Jim||Kennedy, Jane (Wavertree)|
|Flint, Caroline||Khabra, Piara S|
|Follett, Barbara||Kidney, David|
|Foster, Rt Hon Derek||King, Ms Oona (Bethnal Green)|
|Foster, Michael Jabez (Hastings)||Kingham, Ms Tess|
|Foster, Michael J (Worcester)||Kumar, Dr Ashok|
|Foulkes, George||Ladyman, Dr Stephen|
|Fyfe, Maria||Lawrence, Ms Jackie|
|Galloway, George||Laxton, Bob|
|Gapes, Mike||Lepper, David|
|Gardiner, Barry||Leslie, Christopher|
|George, Bruce (Walsall S)||Levitt, Tom|
|Gerrard, Neil||Lewis, Ivan (Bury S)|
|Gibson, Dr Ian||Liddell, Rt Hon Mrs Helen|
|Gilroy, Mrs Linda||Linton, Martin|
|Godman, Dr Norman A||Lloyd, Tony||(Manchester C)|
|Godsiff, Roger||Llwyd, Elfyn|
|Goggins, Paul||Lock, David|
|Golding, Mrs Llin||McAvoy, Thomas|
|Gordon, Mrs Eileen||McCafferty, Ms Chris|
|Griffiths, Jane (Reading E)||McCartney, Ian (Makerfield)|
|Griffiths, Nigel (Edinburgh S)||McDonagh, Siobhain|
|Griffiths, Win (Bridgend)||McDonnell, John|
|Grocott, Bruce||Mclsaac, Shona|
|Grogan, John||McKenna, Mrs Rosemary|
|Gunnell, John||Mackinlay, Andrew|
|Hall, Mike (Weaver Vale)||McNamara, Kevin|
|Hall, Patrick (Bedford)||McNulty, Tony|
|Hamilton, Fabian (Leeds NE)||MacShane, Denis|
|Harman, Rt Hon Ms Harriet||Mactaggart, Fiona|
|Heal, Mrs Sylvia||McWalter, Tony|
|Healey, John||McWilliam, John|
|Henderson, Doug (Newcastle N)||Mahon, Mrs Alice|
|Henderson, Ivan (Harwich)||Mallaber, Judy|
|Hepburn, Stephen||Mandelson, Rt Hon Peter|
|Heppell, John||Marshall, Jim (Leicester S)|
|Hesford, Stephen||Marshall—Andrews, Robert|
|Hewitt, Ms Patricia||Martlew, Eric|
|Hill, Keith||Maxton, John|
|Hinchliffe, David||Meacher, Rt Hon Michael|
|Hodge, Ms Margaret||Meale, Alan|
|Hoey, Kate||Merron, Gillian|
|Hood, Jimmy||Michie, Bill (Shefld Heeley)|
|Hoon, Geoffrey||Miller, Andrew|
|Hope, Phil||Mitchell, Austin|
|Hopkins, Kelvin||Moffatt, Laura|
|Howarth, Alan (Newport E)||Moonie, Dr Lewis|
|Howarth, George (Knowsley N)||Morgan, Alasdair (Galloway)|
|Howells, Dr Kim||Morgan, Ms Julie (Cardiff N)|
|Hoyle, Lindsay||Morley, Elliot|
|Hughes, Ms Beverley (Stretford)||Morris, Ms Estelle (B'ham Yardley)|
|Hughes, Kevin (Doncaster N)||Mudie, George|
|Humble, Mrs Joan||Mullin, Chris|
|Hurst, Alan||Murphy, Denis (Wansbeck)|
|Hutton, John||Naysmith, Dr Doug|
|Iddon, Dr Brian||Norris, Dan|
|Illsley, Eric||O'Brien, Bill (Normanton)|
|Jackson, Ms Glenda (Hampstead)||O'Brien, Mike (N Warks)|
|Jackson, Helen (Hillsborough)||O'Hara, Eddie|
|Jamieson, David||Olner, Bill|
|Jenkins, Brian||O'Neill, Martin|
|Johnson, Alan (Hull W & Hessle)||Organ, Mrs Diana|
|Johnson, Miss Melanie|
|(Welwyn Hatfield)||Osborne, Ms Sandra|
|Jones, Barry (Alyn & Deeside)||Palmer, Dr Nick|
|Jones, Helen (Warrington N)||Pearson, Ian|
|Jones, Ms Jenny||Pendry, Tom|
|(Wolverh'ton SW)||Perham, Ms Linda|
|Pickthall, Colin||Spellar, John|
|Pike, Peter L||Squire, Ms Rachel|
|Plaskitt, James||Starkey, Dr Phyllis|
|Pollard, Kerry||Steinberg, Gerry|
|Pope, Greg||Stevenson, George|
|Pound, Stephen||Stewart, David (Inverness E)|
|Powell, Sir Raymond||Stinchcombe, Paul|
|Prentice, Ms Bridget (Lewisham E)||Stoate, Dr Howard|
|Prentice, Gordon (Pendle)||Stott, Roger|
|Primarolo, Dawn||Strang, Rt Hon De Gavin|
|Prosser, Gwyn||Stringer, Graham|
|Purchase, Ken||Stuart, Ms Gisela|
|Quin, Rt Hon Ms Joyce||Sutcliffe, Gerry|
|Quinn, Lawrie||Taylor, Rt Hon Mrs Ann|
|Rammell, Bill||Taylor, Ms Dari (Stockton S)|
|Raynsford, Nick||Taylor, David (NW Leics)|
|Reed, Andrew (Loughborough)||Temple—Morris, Peter|
|Reid, Rt Hon Dr John (Hamilton N)||Thomas, Gareth (Clwyd W)|
|Robertson, Rt Hon George||Thomas, Gareth R (Harrow W)|
|(Hamilton S)||Timms, stephen|
|Robinson, Geoffrey (Cov'try NW)||Tipping, Paddy|
|Roche, Mrs Barbara||Todd, Mark|
|Rooker, Jeff||Trickett, Jon|
|Rooney, Terry||Truswell, Paul|
|Ross, Ernie (Dundee W)||Turner, Dennis (Wolverh'ton SE)|
|Roy, Frank||Turner, Dr Desmond (Kemptown)|
|Ruane, Chris||Turner, Dr George (NW Norfolk)|
|Ruddock, Joan||Twigg, Stephen (Enfield)|
|Russell, Ms Christine (Chester)||Vaz, Keith|
|Ryan, Ms Joan||Walley, Ms Joan|
|Salter, Martin||Ward, Ms Claire|
|Sawford, Phil||Wareing, Robert N|
|Sedgemore, Brian||Watts, David|
|Shaw, Jonathan||White, Brian|
|Sheerman, Barry||Whitehead, Dr Alan|
|Sheldon, Rt Hon Robert||Wicks, Malcolm|
|Shipley, Ms Debra||Williams, Rt Hon Alan|
|Short, Rt Hon Clare||(Swansea W)|
|Simpson, Alan (Nottingham S)||Williams, Alan W (E Carmarthen)|
|Singh, Marsha||Wills, Michael|
|Skinner, Dennis||Winnick, David|
|Smith, Rt Hon Andrew (Oxford E)||Wise, Audrey|
|Smith, Angela (Basildon)||Wood, Mike|
|Smith, Miss Geraldine||Worthington, Tony|
|(Morecambe & Lunesdale)||Wray, James|
|Smith, Jacqui (Redditch)||Wright, Anthony D (Gt Yarmouth)|
|Smith, John (Glamorgan)||Wright, Dr Tony (Cannock)|
|Smith, Llew (Blaenau Gwent)||Wyatt, Derek|
|Snape, Peter||Tellers for the Ayes:|
|Soley, Clive||Mr. Jim Dowd and|
|Southworth, Ms Helen||Mr. Clive Betts.|
|Ainsworth,Peter (E Surrey)||Burstow, Paul|
|Allan, Richard||Cable, Dr Vincent|
|Amess David||Campbell, RT Hon Menzies|
|Arbuthnot, Rt Hon James||(NE Fife)|
|Ashdown, Rt Hon Paddy|
|Atkinson, David (Bour'mth E)||Cash, William|
|Atkinsone, Peter (Haxham)||Chapman, Sir Sydney|
|Baker, Norman||(Chipping Barnet)|
|Ballard, Jakie||Chope, Christopher|
|Beith, Rt Hon A J||Clappison, James|
|Bercow, John||Clark, Rt Hon Alan (Kensington)|
|Blunt, Crispin||Clifton—Brown, Geoffrey|
|Bottomley, Peter||Collins, Tim|
|Brady, Graham||Colvin, Michael|
|Brand, Dr Peter||Cotter, Brian|
|Breed, Colin||Cran, James|
|Brooke, Rt Hon Peter||Davey, Edward (Kingston)|
|Browning, Mrs Angela||Davies, Quentin (Grantham)|
|Bruce, Ian (S Dorset)||Day, Stephen|
|Burns, Simon||Dorrell, Rt Hon Stephen|
|Duncan Smith, Iain|
|Evans, Nigel||Luff, Peter|
|Faber, David||Lyell, Rt Hon Sir Nicholas|
|Fabricant, Michael||MacGregor, Rt Hon John|
|Flight, Howard||Maclean, Rt Hon David|
|Foster, Don (Bath)||McLoughlin, Patrick|
|Fowler, Rt Hon Sir Norman||Mates, Michael|
|Fox, Dr Liam||Nicholls, Patrick|
|Garnier, Edward||Oaten, Mark|
|George, Andrew (St Ives)||Öpik, Lembit|
|Gibb, Nick||Ottaway, Richard||Page, Richard|
|Gill, Christopher||Paice, James|
|Gorman, Mrs Teresa||Paterson, Owen|
|Green, Damian||Pickles, Eric|
|Greenway, John||Randall, John|
|Hammond, Philip||Redwood, Rt Hon John|
|Harris, Dr Evan||Rendel, David|
|Harvey, Nick||Robertson. Laurence (Tewk'b'ry)|
|Hawkins, Nick||Ruffley, David|
|Heald, Oliver||Sayeed, Jonathan|
|Heath, David (Somerton & Frome)||Shepherd, Richard|
|Heathcoat—Amory, Rt Hon David||Smith, Sir Robert (W Ab'd'ns)|
|Heseltine, Rt Hon Michael||Spelman, Mrs Caroline|
|Hogg, Rt Hon Douglas||Spicer, Sir Michael|
|Horarn, John||Spring, Richard|
|Hughes, Simon (Southwark N)||Stanley, Rt Hon Sir John|
|Hunter, Andrew||Steen, Anthony|
|Jack, Rt Hon Michael||Swayne, Desmond|
|Jackson, Robert (Wantage)||Syms, Robert|
|Jenkin, Bernard||Taylor, Ian (Esher & Walton)|
|Keetch, Paul||Taylor, John M (Solihull)|
|Kennedy, Charles (Ross Skye)||Taylor, Matthew (Truro)|
|King, Rt Hon Tom (Bridgwater)||Taylor, Sir Teddy|
|Kirkwood, Archy||Tonge, Dr Jenny|
|Laing, Mrs Eleanor||Tyler, Paul|
|Lait, Mrs Jacqui||Tyrie, Andrew|
|Lansley, Andrew||Viggers, Peter|
|Leigh, Edward||Walter, Robert|
|Letwin, Oliver||Wardle, Charles|
|Lewis, Dr Julian (New Forest E)||Waterson, Nigel|
|Lidington, David||Webb, Steve|
|Lilley, Rt Hon Peter||Whitney, Sir Raymond|
|Livsey, Richard||Whittingdale, John|
|Lloyd, Rt Hon Sir Peter (Fareham)||Widdecombe, Rt Hon Miss Ann|
|Wilkinson, John||Yeo, Tim|
|Winterton, Mrs Ann (Congleton)||Tellers for the Noes:|
|Winterton, Nicholas (Macclesfield)||Mr. Andrew Stunell and|
|Woodward, Shaun||Mr. Adrian Sanders.|
§ Question accordingly agreed to.
§ Bill read a Second time, and committed to a Standing Committee, pursuant to Standing Order No. 63 (Committal of Bills).