NHS (Rationing)

HC Deb 18 January 1999 vol 323 cc580-628

Madam Speaker

I have selected the amendment in the name of the Prime Minister.

4.23 pm

Miss Ann Widdecombe (Maidstone and The Weald)

I beg to move, That this House recognises that rationing has always been a part of how the Health Service manages health care resources; expresses its dismay at the comments of the Right honourable Member for Dulwich and West Norwood denying the obvious fact that rationing exists in the Health Service; expresses grave concern at the proposed changes to be effected by Her Majesty's Government, which through bureaucratic bodies such as a National Institute for Clinical Excellence and a Commission for Health Improvement will force clinicians to carry the burden on rationing decisions; recognises that the availability of modern drugs for conditions such as schizophrenia and MS makes clear the reality of rationing in today's Health Service; recognises the fact that waiting lists are a hidden form of rationing; notes that excessive political concentration upon waiting lists has been largely responsible for the continuing winter crisis in the Health Service, over which Her Majesty's Government appears wholly complacent and unconcerned; and urges Her Majesty's Government to acknowledge the concerns of professional bodies such as the BMA over rationing and embark upon a mature debate on the future of the Health Service. I believe that we need to debate rationing in our health service today more than at any other time in its history. I am greatly encouraged to see that the amendment submitted by the Liberal Democrats is almost the same, word for word, as our main motion. In his endeavours to spin Government reaction before the debate, the Secretary of State for Health told the press that this was some deep-seated right-wing plot. I have many views about the hon. Member for Southwark, North and Bermondsey (Mr. Hughes), but by no stretch of the imagination could he be described as a right-wing plot. Indeed, I would submit that our motion and the hon. Gentleman's amendment are the same in that they strongly reflect the views and concerns of the general public, and their longing for a clear and grown-up debate about rationing.

Our health service is currently embroiled in one of the worst winter crises to hit our hospitals for many years. It is not only the Conservative party that is saying so, but the British Medical Association and the Royal College of Nursing. Now, even the Secretary of State is at last prepared to admit that our hospitals cannot cope with the added pressure that the Government have placed on them.

That sudden rush to accept culpability does not extend to the Prime Minister or his press secretary. Reporting the glad tidings of our Prime Minister's descent on St. Thomas's hospital last week, his spokesman told us that the Prime Minister did not come away thinking that the Health Service is in a crisis. "Crisis? What crisis?" seems to be the attitude emanating from Downing street.

The increasing difficulties being experienced in our health service have underlying causes that are far more serious than the recent flu outbreak, which, I remind the Secretary of State, has at no time escalated to epidemic proportions. He will remember that he claimed that in the absence of such an epidemic or an exceptionally harsh winter, the service could look forward to the winter with confidence. Where is that confidence now? The Government's increased rationing of clinical services, coupled with their pressure on hospitals to force through quick, simple waiting list cases, have been a double whammy against the ability of our health service to cope with the wholly predictable increase in winter pressures.

The Secretary of State will remember, because I have reminded him of it, his party's pledge in 1996 to set up a task force on trolleys and to monitor the number of patients forced to wait for treatment in that manner. The Labour party may have broken its pledge, but not to worry because we have been monitoring the situation that caused so many sleepless nights for the right hon. Member for Camberwell and Peckham (Ms Harman). I have to inform the Secretary of State that the situation is far worse than he could ever have imagined in his complacency.

A patient died, waiting in pain, on a trolley at St. George's hospital in London. His consultant described the conditions as the worst that he had seen in 20 years, with the standard of care being worse than in India. An elderly man died of heart failure in Whipps Cross hospital after waiting over 18 hours on a trolley. A child died from meningitis after being left on a trolley for hours in Rotherham general hospital because there was no bed.

Bodies were stacked up in refrigerated lorries at two hospitals in Norwich and at the Derbyshire Royal infirmary because there was nowhere else to keep them. A patient's body was lost for five days in the grounds of Chase Farm hospital, Enfield, after he had walked out of the ward and fallen into a ditch. At two Portsmouth hospitals, relatives were forced to provide basic nursing care for their loved ones for the first time in the history of our health service.

The Prime Minister has the barefaced cheek to deny that that is a crisis. Perhaps he might have been right if his Government had not closed 679 hospital beds in London alone during 1998, after years of telling us that London needed more, not fewer, beds. It is now clear that such decisions and the obsession with Labour's fiddled waiting list pledge have led directly to the shocking events of the past month.

I wonder if the Secretary of State recalls what Baroness Jay said shortly before last winter? She said: We won't see a return to a situation where people are being helicoptered around the country in search of an Intensive Care bed. I would be only a few weeks out of season if I said, "Ho, ho, ho." What about the shameful case of the elderly patient at Hemel Hempstead hospital? The right hon. Gentleman obviously finds that case funny; we shall find out whether the rest of the House does. The Secretary of State plans to close that hospital's brand new accident and emergency department. That patient was suffering from a potentially fatal respiratory infection, and had to be airlifted 150 miles in agony all the way to Somerset. How can the right hon. Gentleman even attempt to wriggle out of responsibility for much—not all—of that state of affairs?

It is clear that the concentration of resources on waiting lists and the climate of fear that the Secretary of State has created among clinical and managerial staff has harmed other sectors of our health service, led to increased rationing and resulted in this disastrous winter. He will be aware that not just we, but the British Medical Association, which for many months and not only with the wisdom of hindsight, has been claiming that his obsession with numbers on waiting lists—not even waiting times—is distorting clinical priorities. In the words of the British Association for Accident and Emergency Medicine, the principal reason is the emphasis placed on allocating resources to waiting lists, which has resulted in a reduction of beds for emergency cases". Let us take instead the words of the British Medical Journal. The government's emphasis on reducing waiting lists… has caused difficulties in coping with emergency cases". If that is too esoteric for the Secretary of State, let him try the words of a ward manager, nurse Helen Truscott, who works at St. Mary's in Paddington. She said: There is a crisis in the Health Service, but it's not just in the winter, it is now all the year through. A few years ago we would have had some spare beds on the ward overnight. Now we've got patients left lying on trolleys in casualty. If the Secretary of State is in any doubt that that is due to his Government—the Government who gave voters before the election 14 days to save the NHS—all he has to do is listen to doctors and nurses, in whose minds there is no doubt about who is responsible.

I shall now be very kind to the Secretary of State. [HON. MEMBERS: "No."] Yes, I shall. He will remember that, a few weeks ago, I made a promise to him. I said that if he abandoned his ridiculous obsession with raw numbers on lists and instead concentrated on waiting times, and if, in addition, he used not just crude cut-off times but made those times relevant to conditions, as the BMA has asked, I would not gloat but say, "Well done" and support him. I renew that promise today—though more in hope than in faith.

I ask the Secretary of State also to face up to reality. We have been saying for some time that there are no easy solutions of the kind that his party promised in opposition. I go so far as to say that, in opposition, his party deceived Britain. His party said that there was nothing wrong with the NHS other than a Tory Government. It said: "All you have to do is change the Government and we, Labour, will put it all right. The NHS will be able to do it all. It will be able to meet expectations and look forward to endless winters with confidence. All you have to do is vote Labour." Let the right hon. Gentleman look around him at the results of voting Labour. There never were easy solutions. A one-eyed concentration on waiting lists has not helped; nor has the complacently late payment of winter pressures money.

However, such matters are not the cause of deep-seated and underlying problems, which the Secretary of State's Government have persistently refused to acknowledge, always pretending that the health service can do it all and that, somehow, it has a magic wand. They have always pretended that the health service can meet every last demand, provide every new treatment and supply all the very latest drugs—all in the face of increasing demand and accelerating technology.

The Government can have no credibility, given that the Minister for Public Health, who is not present, can stand at the Dispatch Box glibly and fatuously stating that there is no rationing in our health service. I asked her, in perfectly simple terms: Is there rationing, or is there not?"—[Official Report, 15 December 1998; Vol. 322, c. 746.] She replied, "No." She did not qualify her answer; she did not enlarge upon it. "No", she said and sat down, looking as though she had said something wonderful.

Far be it from me to embarrass the Minister, especially when she is not present, but it seems that she is so far out of step with medical opinion that even the normally restrained Doctor magazine felt moved to complain that the Government were like—I quote the editorial—[Laughter.] Well, this is the GPs' view. The magazine said that the Government were like A child hiding under the bedclothes". [Interruption.] I shall repeat that, because Labour Members do not want to hear it. They are going to hear it, and people listening to the debate are going to hear it, because it represents the views of the profession on the absolutely inaccurate statement by the Minister for Public Health.

The profession says that the Government are like A child hiding under the bedclothes…imagining the problem of rationing is a monster that will go away if it refuses to acknowledge it. The editorial said that the right hon. Lady was "embracing a laughable pretence", that the Government's denial made them a "laughing stock" and that the Government should be mature enough to concede that the NHS is not equipped to cope with demand".

Mr. Hilton Dawson (Lancaster and Wyre)

Will the right hon. Lady give way?

Miss Widdecombe

I shall finish this selection; then I shall remember the hon. Gentleman.

Let us find out whether the absent Minister is prepared to stand by those comments. I shall ensure that she gets a copy of Hansard just in case. Does she disagree with Professor Sikora of the World Health Organisation, who says that terminally ill cancer patients in Britain have to pay thousands of pounds for life-prolonging drugs because of lack of cash? It has long been the case that doctors rank cancer cases on the chances of an effective cure or a lengthy prolongation of life. Why do the Government deny that that is rationing?

Dying breast cancer patients are paying £12,000 for a six-month course of Taxol. Patients with cancer of the colon are paying £8,000 for Ironotecan. Lung cancer victims are obliged to find £6,000 for Gemcitabine. Professor Thomas of the university of Surrey says that she has cash disputes with the health service on behalf of patients every two to three weeks.

If the Minister for Public Health does not find the World Health Organisation convincing, perhaps she will listen to the National Schizophrenia Fellowship and the Bethlem and Maudsley hospitals. They tell us that mentally ill patients are being given drugs, developed in the 1950s—such as Haldol—that have crippling side-effects. Even 1970s drugs—such as Clozapine, which is not without its problems—are being rationed. As for obtaining the latest atypical anti-psychotics, such as Risperidone and Olanzapine, those were usually found to be prescribable only in the last resort, when all other drugs had failed.

Surely the Minister for Public Health and the Secretary of State are no longer prepared to make the ridiculous statement that there is no such thing as rationing in our health service. If they are, perhaps they would like to explain that to Mrs. Goldsworth, who has had to re-mortgage her home for £100,000 to pay Frenchay hospital in Bristol for supplies of beta interferon, to keep her out of a wheelchair.

We are not just talking about drugs. Routine operations are no longer available in many health authorities. The Secretary of State knows all about the unavailability of non-acute varicose vein operations. He knows that in some areas, one cannot obtain operations on lipomas and sebaceous cysts, and he also knows that, however much he may like to pretend otherwise, waiting lists are a form of rationing by queue. Until we have an honest—and mature—debate on rationing, we shall never tackle patients' increasing disillusionment with our health service.

Mr. Dawson

I thank the right hon. Lady for giving way. It is important that we should have a mature debate about some of the most serious issues in our country. Will she aid the cause of such mature debate by acknowledging, as gently as she can, the contribution of the previous Government over 18 years to what she calls the serious underlying problems of the national health service? Will she raise the level of the debate so that she does not concentrate quite so much on the difficulties caused to individuals and on trying to take cheap press opportunities by going to hospitals—

Mr. Deputy Speaker (Sir Alan Haselhurst)

Order.

Mr. Dawson

—in the constituency of my right hon. Friend the Secretary of State—

Mr. Deputy Speaker

Order. The hon. Gentleman must sit down when I am on my feet. That is going beyond an intervention and becoming a mini-speech.

Miss Widdecombe

Even the part of the hon. Gentleman's remarks that might be identified as an intervention did not take us very far forward, I regret. He asked me to acknowledge the contribution of the previous Government. I shall indeed acknowledge their contribution: the single biggest hospital building programme in history, a steady increase year on year in real terms in NHS resources, nurses pay up 67 per cent. in real terms, 55,000 more nurses and midwives than we inherited, and millions more patients being treated. That is the contribution that we made. What I have—

Mr. John Heppell (Nottingham, East)

rose—

Mr. Dawson

Will the right hon. Lady give way?

Mr. Deputy Speaker

Order. It would be for the general good, particularly of those listening beyond this place, if the debate were conducted in a sober and serious manner. The hon. Gentleman must not interrupt or reply to his own question.

Miss Widdecombe

The hon. Gentleman may like talking to himself and replying to his own question. He obviously does not like my reply.

Despite that significant contribution, and despite the fact that our national health service is still the envy of the world and that we looked after it for two thirds of its existence, I have never claimed that we had a perfect NHS, or that there were not many problems that we had to confront, for which we had no magic wand.

The essence of my argument is that there have been problems of rationing in the NHS since the time of Bevan. I am trying to get the Government to acknowledge that we are not in some new era in which that does not apply, and that we need some radical and fresh thinking. That is the thrust of my remarks.

Mr. John Bercow (Buckingham)

I am grateful to my right hon. Friend for giving way, as she is developing a powerful case. Does she agree that progress in the health service will be retarded by the Government's creation of a plethora of new bureaucratic bodies, including the advisory committee on resource allocation, the commission for health improvement, the capital prioritisation advisory group, the national institute for clinical excellence and, last but not least, the primary care groups? Does my right hon. Friend agree that Ministers should stop pushing paper and start providing for patients?

Miss Widdecombe

My hon. Friend is right. The deep-seated problems that we face are essentially the problems of a successful service that has expanded vastly, beyond anything foreseen by its founding fathers, and which now has the ability to do what would have been science fiction to Bevan and Beveridge. That very successful service has produced a huge gap between demand and the capacity of supply to keep up with it. I agree with my hon. Friend that no amount of reorganisation, creation of extra bodies or new bureaucratic systems will tackle the underlying problem.

Mr. Simon Hughes (Southwark, North and Bermondsey)

rose—

Miss Widdecombe

I shall give way to the spokesman for the Liberal Democrats. However, because we had, for perfectly sensible reasons, a statement on Kosovo, our time for this debate has been severely truncated. When I have taken the hon. Gentleman's intervention, I shall take no more.

Mr. Hughes

I am grateful to the right hon. Lady. I share with her both the clear view that there is rationing in the health service—I therefore welcome this debate—and the desire for a mature debate across the parties on how we resolve the problems that follow from that self-evident proposition.

I shall ask the right hon. Lady one linked question, which clearly follows, for her. Does she accept that if we are to meet the needs—not the demands—of our people, there will have to be a considerable increase in resources for the health service, which means tax increases, or does she hold to a position that there should be no more tax increases, and that therefore the only way of resolving the problem is for some of the people who currently use the NHS to leave and go to the private health sector, as she argued at her party conference?

Miss Widdecombe

Ah, but there is, in the sensible use of the phrase rather than the Government's use of it, not a third way, but another way, which I shall discuss as I develop my theme.

If we do not have a mature debate on rationing, we shall not be able to tackle the increasing disillusionment with the health service that is felt by patients and those who work in the NHS, and we shall not do much to create a sustainable health service. The NHS last year celebrated 50 years of its existence. I should like to think that there will be celebrations again in 50 years, but that means creating a sustainable service, which cannot be done through wish fulfilment and by burying our heads in the sand, rather than dealing with the real problems.

The Secretary of State must take some responsibility for the existing disillusionment. Labour told people that the health service could do it all. Indeed, he boasted in a television programme in which we both took part that he could make the NHS so wonderful that people "have to be mad" to go private. That represents another 700,000 operations a year which he believes the NHS can encompass, when it cannot even cope with a flu outbreak in winter. Moreover, the right hon. Gentleman has inflated everyone's expectations with his extremely creative accounting in relation to the size of the comprehensive spending review.

Let us consider the matter realistically. The Secretary of State admitted on 16 July last year in response to a parliamentary question that the real size of the increase was not £21 billion, but £10.5 billion. Had we used the same fanciful method of accounting that he uses, whereby sums are double and treble counted, we would probably have ended up spending more than £100 billion. Would anyone have believed such fanciful nonsense? He should stop trying to con people that the health service is awash with money. This winter proves conclusively that it is not.

If the Government are determined simply to use bodies such as NICE and CHIMP to force clinicians to carry the can for rationing decisions, we shall not make much progress. Decisions on clinical priorities should be taken by clinicians, but the frameworks in which those decisions take place should be a matter of public debate and accountability.

The public do not want their intelligence continually insulted by a Government who tell them that there is no rationing, when they know jolly well from their everyday experience that there is plenty of rationing. The fact that the public want more means that we must look for new and imaginative ways of funding some of the modern health care innovations that patients are demanding—the innovations that the Government are finding it impossible to fund by traditional means alone, alongside the core functions of our health service.

I challenge the Government to stop being ideological. They like to speak glibly of bringing down Berlin walls in our health service. At the same time, they dig a grand canyon between the public and private sectors. They cannot bring themselves to accept—I think that the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) has a similar problem—that private medicine has benefits for the entire community, despite the role that the private sector is currently playing to bail out our troubled NHS this winter and before.

Mr. David Hinchliffe (Wakefield)

Will the right hon. Lady give way?

Miss Widdecombe

No, I said clearly that I would not.

We must consider the opportunities—well, I shall give way after all, as I always enjoy the hon. Gentleman's interventions.

Mr. Hinchliffe

On her point about using the private sector, does the right hon. Lady accept that one of the major problems in the national health service relates to staffing levels—shortage of nurses? Will she reflect on where the private sector recruits its nurses?

Mrs. Alice Mahon (Halifax)

And who trains them.

Miss Widdecombe

The hon. Lady calls out from a sedentary position, "Who trains them?" The NHS does most of the training, but what develops, pays for and funds most drugs research from which the NHS benefits? The private sector. The fact is that we need a partnership—[Interruption.] Perhaps the Secretary of State needs a few facts.

The Government's contribution to the medical research budget, which probably comes from the Department for Education and Employment, is £350 million. Any single drugs company spends about £1 billion a year on research, and a lot of the results are not sold for profit because they do not come to fruition.

We have to consider the opportunities—

Mr. Hinchliffe

Will the right hon. Lady give way?

Miss Widdecombe

No, I have had enough—sit down.

Mr. Hinchliffe

Will the right hon. Lady give way?

Miss Widdecombe

No, what the hon. Gentleman said last time was not good enough—

Mr. Hinchliffe

The right hon. Lady has not answered.

Miss Widdecombe

It was not good enough last time, so it will not be good enough this time. The hon. Gentleman has to learn that it is no good shouting from a sedentary position when his Government are considered by the nurses to be one of the worst masters of the health service that they have ever had.

Mr. John Austin (Erith and Thamesmead)

Look behind you.

Miss Widdecombe

Why, are the nurses behind me?

We must consider the opportunities presented by the private sector. If we accept that our health service cannot do it all, we either resign ourselves to ever-increasing rationing—which is happening by stealth—or we look to increase the flows of additional new cash into our health service, through common-sense co-operation with the private sector.

That is not only about private insurance, and it is certainly not about patients paying for what they now receive free. It is about the massive investment in pharmaceuticals, research and clinical technology; the private finance initiative, which the Government resisted for so long, but now boast about, helping to fund our hospitals; and. co-operation—not Labour hostility—between our health service and private medicine.

That can be seen clearly in what the rest of the world spends on health care. Even if we ignore the American model, spending on the private sector in this country lags behind that of other developed countries. That disparity accounts for the much-quoted difference in gross domestic product spent on health. Such nations have recognised that total spending, not only public spending, is what matters.

The Conservative party is committed to year-on-year increases in public spending on health, but we also have the honesty to acknowledge, and the willingness to debate, the facts. I point out to the Secretary of State that, between 1990 and 1993, our percentage increases were greater than what he proposes. That did not solve all the problems of the health service, nor will his spending. However much more we put into the public sector, and we are committed to doing so, public spending has never done it all, is not doing it all and will never do it all.

Until we face that simple fact, and start the debate from that point and forget any possibility of magic wands—[Interruption.] I wish that the Secretary of State would look at me, just occasionally. He appears to be quite incapable of meeting my eyes when I am talking about such things. Indeed, this is a bit like a Wimbledon contest: he looks one way, then the other. He never manages to look at me when I am challenging him. He turns his face from me as he turns his face from the problems in our health service. He has been doing that ever since he took office. He has turned away from the real problems and cannot look them in the eyes.

Let me dispel a few myths. I do not believe, and I have never said, that anybody should be bludgeoned into using the private sector, but I have said consistently that nobody should be made to feel guilty for using it. We should consider the companies and trade unions that have supplied private health care for their employees and members, and the costs and the benefits in terms of health care overall—the totality of funding, public and private, devoted to making patients better. If we do not consider such opportunities and do not ask ourselves about radical new ways of providing for the ever-growing health care needs of our society, not only will this winter of crisis and chaos in our health service be the first of many, but, more important, the health service will become increasingly unsustainable.

I want a thriving health service with state-of-the-art technology, serving the people of this country well 50 years from now as it did 50 years ago. I am afraid that turning that into reality involves rather more courage, and rather more honesty, than the Government are currently prepared to show.

4.55 pm

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

I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof: reaffirms the historic principles of the NHS, that if people are ill or injured there will be a national health service there to help, and access to it will be based on need and need alone, not on ability to pay or who their general practitioner happens to be or on where they live; welcomes the measures the Government has taken, is taking and will take that will ensure that comparable, top quality treatment and care are available in every part of the country through the introduction of new arrangements for spreading best practice, including the ending of the Conservative competition of the internal market, the introduction of local Health Improvement Programmes and Primary Care Groups to put local doctors, nurses and other health professionals in the driving seat in shaping local health care, the introduction of a new Commission for Health Improvement and National Institute for Clinical Excellence, and the creation of new legal duties of partnership and quality to ensure that all parts of the NHS and social services work together to deliver top quality services to all; welcomes the record £21 billion investment to be made in the NHS, including £18 billion for the NHS in England, over the next three years, notes the record 150,000 fall in NHS waiting lists since April 1998 and the 17 per cent increase in the number of new nurse trainees in the period since Labour came to power; and further welcomes the measures that the Government intends to take over the coming year to continue to build a modern and dependable NHS, including the extension of NHS Direct to cover 19 million people, the creation of 26 Health Action Zones covering 13 million people to target areas with particularly high levels of ill health—including cancer and heart disease—and reduce health inequalities, and the targeted investment of £30 million to modernise accident and emergency departments. The right hon. Member for Maidstone and The Weald (Miss Widdecombe) called for a measured and mature debate. Her contribution was to mature debate what Les Dawson's jokes were to political correctness. She talked a lot about rationing, and likes to talk about it, but if "rationing" means merely that there is not an unlimited supply of something, it applies to practically everything in the world.

It is no more informative, mature or considered to talk about health care being rationed than to say that education is rationed because there is not an unlimited supply of classrooms or teachers, or that air travel is rationed because there is not a seat left on the plane someone wants to catch.

Those who want to make great political capital out of the rationing accusation are, by sleight of hand, trying to suggest that something quite different is going on—that each patient is permitted only a fixed ration of health care or a fixed number of operations or drugs, regardless of his or her circumstances. That may apply to some people with private health insurance, and it does, but in the national health service that sort of rationing is not happening, and it never has. In the NHS, treatment is according to individual need, not pre-ordained entitlement.

Why, then, do some patients get new treatments and others not? The very process of innovation means that some places will develop new treatments faster than others, while others will be quicker to follow. That product life cycle is as natural in health care as it is in every other sector. In 1940, penicillin was tried out on mice; within a decade, it had saved millions of lives. At one time, only a few dozen patients had access to hip replacements; they were available only in Wigan and Norwich, where they had been developed. Now hip replacements- are commonplace.

At one time, the only place in the world where it was possible to have a test-tube baby was Oldham general hospital. Now it is possible in every developed country in the world, but not in every part of this country.. Take an even newer technology—cochlear implants—to help deaf people to hear. Thresholds for treatment are coming down as costs fall and as evidence of cost-effectiveness for a wider range of patients becomes available, but there is an eightfold difference in the uptake of this technology between different parts of the NHS in different parts of the country.

Dr. Peter Brand (Isle of Wight)

Does the Secretary of State accept that, in the past, rationing as he is describing it—for the individual—occurred mainly because of the uneven availability of expertise and expected outcomes, whereas today rationing, as I see it, is determined by the availability of resources for people with the expertise to carry out procedures that we know have an effective outcome? There is financial rationing, rather than rationing of ability.

Mr. Dobson

I certainly do not entirely agree with that point, because in many cases there is the question of the necessary spread of expertise. For instance, any old doctor cannot carry out a cochlear implant, so we need doctors with the necessary skills before expertise can be spread as widely, effectively and quickly as we should like.

Miss Julie Kirkbride (Bromsgrove)

I thank the Secretary of State for giving way on that point. A constituent of mine is in the early stages of multiple sclerosis and, as the Secretary of State knows, treatment for multiple sclerosis with beta-interferon is carried out on a regional basis. In the west midlands, 47 patients who attend the same centre have been given beta-interferon for multiple sclerosis. On the same waiting list, with the same doctors, are a further 60 patients—sadly, including my constituent—who have been clinically assessed as needing that treatment, but who are not receiving beta-interferon because the region's health authorities cannot afford it. Will the right hon. Gentleman address that question, which follows up the point made a moment ago by the hon. Member for Isle of Wight (Dr. Brand)?

Mr. Dobson

I shall address that point, because the whole basis of my speech is to explain what we are doing to change the national health service so that we get away from the lottery system that we inherited from the previous Government.

The take-up rate of new treatments, such as Taxol, has been too slow and needs to be speeded up. That time lag is nothing new—it has always existed: there is no new crisis. This is all about how fast patients get extra and better treatments, not about cuts and reductions.

What is new is that the Government are doing something about the problem by putting in place a better-quality system that is better organised for assessing new developments and spreading their use. The speech that we have just heard from the right hon. Lady was the latest round in the endless efforts of the Tory right wing to decry and denigrate the national health service. The Tories have always opposed it. They voted against setting up a national health service, and since then the right wing of the Tory party has taken every opportunity it can to run it down and to suggest that the people of this country would be better off with a different system. The right hon. Lady was at it again today.

The national health service was based on the idea that the best health services should be available to all—the best for all: quality and equality. Despite the damaging reforms of the Tories, the NHS has delivered. Most people in most parts of the country get a good service from the health service. That is why it is popular. It is the most popular health care system in the English-speaking world.

I believe that the NHS is also popular because the people of this country like the idea that it is fair, that it is there not just to look after them but to look after everybody without fear or favour, and that nobody will miss out because he or she cannot afford to pay. They like the idea that, under the NHS, people qualify for treatment because they need it, not because they can pay for it. The people of this country prefer to pay for health care through their taxes rather than pay each time they see the doctor or have a test or go into hospital. Unlike the Tories, the people of this country do not want to abandon that principle, and nor do we.

There is another good reason why our NHS is so popular. It is much more cost-effective and less wasteful than any other system. That relates back directly to the principles on which it was based. Systems in which patients have to pay each time they are treated put off people who cannot afford it. That is not the end of it; those systems cost a fortune to run. Every item must be separately logged so that it can be included in the bill, invoices have to be sent, payments collected and debts pursued. All that paperwork is very wasteful and costly. By not charging patients each time they are treated, our health service is both more fair and more cost-effective. Fairness and efficiency go together.

When the Tories talk about alternatives to the NHS—as they were today—they want to lumber the people of this country with health systems that are less fair, less efficient and more expensive. That is just what one would expect from the party that gave Britain the poll tax and privatised the railways.

No one can deny that the NHS could always do with more resources than it is getting. That has been true for the past 50 years, but it is equally true of every other health care system, which can always do with more. Replacing our system would not eliminate that problem: it would merely add unfairness and extra costs.

The question that every system must address is how to provide a reasonable level of resources for health care and ensure that the services are top quality and are shared out fairly. Unlike the previous Government, the new Labour Government are tackling those issues. From 1 April this year, we will be investing an extra £21 billion in the. NHS—£18 billion in England. We have already made a start on the biggest hospital building programme in the history of the NHS. Not a single private finance initiative hospital was started under the previous Government. Under Labour, work has already started on new hospitals at Dartford and Gravesham, Norfolk and Norwich, Carlisle, Durham, South. Manchester, Greenwich, Bromley, High Wycombe, Amersham, Sheffield, Rochdale, Halifax and Reading, and many more are to follow. Smaller schemes will replace unreliable plant and equipment.

Mr. John Horam (Orpington)

We started all those hospitals.

Mr. Dobson

I am getting some stick from the hon. Gentleman at the back. The last time I saw him was at the sod-cutting ceremony for the hospital that his area is getting.

Mr. Horam

rose—

Mr. Dobson

No, no.

Starting in April, one quarter of all accident and emergency departments are to be renewed, which will make them better for patients and safer for staff. Much more is to be invested in equipment to detect and treat cancer, partly using lottery money from the new opportunities fund. That investment will ensure that more and more people in every part of the country will have access to top-quality hospitals, plant and equipment. The Government are determined to end the health lottery that results in some people in some parts of the country not being treated as promptly or as well as people in other areas.

Poor people are ill more often than others and die sooner. When somebody's span of life is cut short by poverty, that is real rationing. The Tories never talk about that sort of rationing. By opening up greater inequalities in wealth, they opened up greater inequalities in health. We are determined to change all that as part of our commitment to reducing inequalities in health and in health care. That is why, with the support of the health care professions—doctors, nurses, midwives, therapists, laboratory scientists—we are starting to change the NHS for the better by making it easier for the professionals to do their jobs, and to do them as well as they want to do them.

The NHS that we inherited has little or no machinery for identifying best practice and spreading it. That is one reason for the problems over new drugs such as Taxol, beta-interferon and Aricept. We are establishing—with, I emphasise, the full support of the professions—the national institute for clinical excellence. Its chairman designate is Sir Michael Rawlins, professor of clinical pharmacology at the university of Newcastle and consultant at the Freeman hospital and the Royal Victoria infirmary, Newcastle. He is the former chairman of the Committee on Safety of Medicines. His appointment was publicly welcomed by the British Medical Association on the day that I announced it.

The job of NICE will be to appraise new treatments, new drugs and new medical devices, and to issue authoritative guidance to the professionals who wish to use them. That will give individual clinicians more help than they have ever had before when they have to make decisions about the treatment of individual patients. As a result, best practice should be spread much more quickly, and ineffective treatments discouraged. Standards should rise and the same top-quality treatment should be available in every part of the country. NICE will take responsibility for providing the best advice, but each doctor will retain responsibility for the treatment that he or she gives to each individual patient.

Dr. Evan Harris (Oxford, West and Abingdon)

I was interested to hear the details about NICE. Will it consider cost-effectiveness as part of its remit? That may not be unreasonable, because there are limited resources. If so, will it ensure that the Government are associated with advice which it gives to clinicians not to prescribe or treat in a certain way because of problems of cost and not of effectiveness, so that politicians take responsibility for the limitation of treatments because of limited resources?

Mr. Dobson

NICE will certainly consider the cost-effectiveness of alternative ways of treating a particular condition. I hope that everyone would agree that that is sensible.

We must take matters much further. Studies show that the number of people getting important operations, such as heart bypass operations, varies dramatically from one part of the country to another. People in poor neighbourhoods where heart disease is more prevalent are less likely to obtain operations than people living in more prosperous areas where there is less heart disease. People living near major hospitals are more likely to obtain heart operations than people living further away. That cannot be right, and it must be changed. We are therefore placing a duty on each health authority to draw up a health improvement programme to improve health and health care in its area—targeting special effort on the least healthy. For the same reason, NHS regions are to be given more authority to ensure that each and every part of their areas is properly served.

Following the Calman-Hine approach to cancer services—which, to their credit, the last Government introduced—this Government are introducing more national service frameworks, which will spell out how the NHS should deal with other conditions. They will cover the services and treatment that should be provided by primary care and community services, by local hospitals and, where appropriate, by specialist centres. Work is already under way on drawing up the framework for heart disease—led by Professor George Alberti, president of the Royal College of Physicians—and the framework for mental health, led by Professor Graham Thornicroft of the Maudsley hospital. A start has already been made on drawing up a national service framework for treatment and care of the elderly with the appointment of Professor lan Philp from the university of Sheffield as chairman. The next framework will cover diabetes. All that effort is being put into ensuring that services in every part of the country are provided to a universally high standard. That is what the public want, what the professionals want and what the Government are determined to deliver.

As well as launching those initiatives, we shall change the law to place on each NHS trust a duty to promote and deliver top-quality services. Believe it or not, Mr. Deputy Speaker, trusts have no such duty at present; nor have they a duty to work in partnership with the rest of the NHS. In recent times, they have had a duty to compete with one another. We are changing that as well. To help each trust to deliver, we are also appointing a commission for health improvement to carry out periodic inspections, and to give help and advice to those whose performance needs to be improved.

Our modernisation of the system involves new, improved methods of setting standards and spreading best practice, new duties for trusts to deliver those standards, and a national body to ensure that they do. Those are all sensible, practical measures, welcomed by the professions. The Tories failed to introduce them, because such an approach could not be reconciled with the competitive internal market that they introduced—a market that set doctor against doctor and hospital against hospital, and was wasting a fortune in paperwork. In contrast, our proposals for modernising and streamlining the arrangements for primary care will cut bureaucracy. At present, nearly 4,000 fundholding practices and health authorities must negotiate annual contracts with NHS trusts. From April there will be just 481 primary care groups, which will be able to negotiate much longer-term arrangements. The result will be a massive drop in paperwork and bureaucracy.

Miss Widdecombe

The right hon. Gentleman said that the NHS was fair. He is now reading out a list of bureaucratic changes that he intends to make. Can he tell me what is fair about people being obliged to pay for treatment because they cannot receive it from the NHS—because the NHS simply cannot do it all? How will any of the measures that the right hon. Gentleman is describing address the fundamental problem that people are not receiving what they need from the NHS, and that for everyone who pays there is someone falling off the edge who cannot pay, and whom the right hon. Gentleman is letting down?

Mr. Dobson

I am sorry, but the right hon. Lady seems rather to have missed the point—something at which she is fairly smart. All the measures that I am describing are intended to ensure that the lottery system under which certain treatments and drugs are available in one part of the country but not in another is changed. That will enable us to get rid of the anomalies to which the right hon. Lady refers.

The boards of the primary care groups will involve not just local doctors but nurses, social services and lay people. I pay tribute to doctors and their representatives at the British Medical Association for agreeing to the change, which they have accepted because they believe that it is in the interests of their patients. If they did not believe that, they would not have accepted it.

All those changes should help to establish a much more comprehensive service in every part of the country, and generally raise the standard of treatment and care. That is because primary care groups provide incentives for all concerned to "level up" to the standards of the best. Considerable interest is being shown in the opportunity that we are providing for primary care groups to take more responsibilities, and to become primary care trusts. That shows that the changes we are making go with the grain of the more forward-thinking parts of the professions.

As well as changes in organisation, we have embarked on practical measures to improve service to the public in every part of the country. Perhaps the best example is NHS Direct. It is an entirely new service; it does not replace any existing services; it is new; it is additional; and it really works. We introduced NHS Direct in three pilot schemes in Newcastle, Preston and Milton Keynes. It is a nurse-led 24-hour helpline, which people can ring at any time of day or night. The nurses check what people say is wrong with them against protocols on a computer, and then reach professional decisions. Sometimes they call an emergency ambulance immediately; sometimes they make sure that people see their doctors; and, in many cases, they offer advice and reassurance. NHS Direct has been a brilliant success. It has already been extended to the west midlands, it will go on line in south-east London at the end of the month, and by April it should cover 20 million people. According to present plans, it should cover the whole country by next year. It is another practical measure to help patients and the NHS, and to provide a fairer and better spread of the service that the NHS provides.

Since we became the Government, there has been a large increase in the number of people turning to the NHS for treatment. The right hon. Member for Maidstone and The Weald gave the impression that all those people were turning away and going to the private sector. More than 2.5 million more people are being treated this year than two years ago—just over 45,000 more people each week. That is why waiting lists fell by 150,000 between April and November last year.

All that is a result of a massive effort by the staff of the NHS—all the staff of the NHS. We inherited an NHS held back by a shortage of nurses and midwives, which was being made worse by the cuts that the last Government made in nurse training. If they had kept even to the level that prevailed at the time of the 1992 general election, 11,000 extra nurses would have been available to the NHS. We already have 2,500 extra people training as nurses, but it takes three years to train a nurse. We must try to attract back into nursing in the NHS some of the 140,000 qualified nurses who have left—and they have not left since we took office. That is why, unlike our Tory predecessors, we acknowledged to the pay review body that there was a shortage of nurses, which previous Governments had denied. We said that we believed that they should award high increases for the lower grades. I hope that that will mean a settlement that will help to retain the nurses whom we have, attract back some who have left, and persuade more young people to train as nurses.

Unlike the last Government, we are trying to introduce family-friendly employment policies, and have taken new measures to reduce the number of assaults on staff. Like the nurses themselves, we also want to change their pay and promotion structure. The present archaic grading system is rigid; it holds staff back. It needs to be changed to provide more flexibility and more opportunity for career progression. We want to sort out with the profession new ways of working that are good for staff as well as for patients. The same applies to hospital consultants. Contrary to the myth, most consultants work longer hours in the NHS than is strictly required by their contract. A small minority do not. The consultants want to renegotiate the contract; so do we, and we have started negotiating. We want a system that is better for both patients and doctors. I hope that we can get it. A modern NHS needs a modern pay system.

A modern NHS also needs a top-class information technology system. The Tory years in the NHS were littered with multi-million-pound scandals over computer systems that cost a fortune and never worked. We have launched a 10-year strategy, again with the support and welcome of the professions, to invest £750 million to provide the NHS with the IT system that it needs and deserves.

Subject to proper safeguards for confidentiality, we want an IT system where each patient's up-to-date, accurate health records are available at the touch of a button to his or her GP, to a district nurse, to a hospital or perhaps even on a laptop to a paramedic with an ambulance. That would save time and money and lead to much better and quicker treatment.

We want a system that can send test results from the laboratory to the hospital or GP in the blink of an eye. Up to now, all treatment has involved patients travelling to see the professional, or the professional travelling to see them—not any more. In some cases, people will get their scan done locally, while a specialist miles away can look at a screen and give immediate advice to the local doctor or nurse. All that will spread quicker and better practice.

There will be changes not just in relation to medical information. In future, we want people to be able to go to their GP and, from there, book an out-patient appointment if that is what the GP recommends. We are already carrying out some pilot schemes on booked admissions. The lessons will be learned and then the system will be extended nationally. It cannot be done overnight, but it can and will be done.

From next April, when the extra £21 billion starts to kick in, people will see an NHS that is getting better. It will not happen overnight, but it will happen—better-paid staff, new ways of working, new drugs, new treatments, new hospitals, new helplines, new accident and emergency departments, new booking systems, new quality standards, new screening systems, new strategies to reduce inequalities in health, new centres to give equal access to health care.

That will not mean that the resources for the NHS will be limitless. Priorities will still have to be set, but the quality of treatment and care will be raised and there will be a fairer, more standard share-out throughout the country. While the Tories yammer on about extending the private sector and about rationing, we will get on with the job of improving the health service.

5.23 pm

Mr. Kenneth Clarke (Rushcliffe)

I do not think that the Government will be referred to any longer as one of style rather than substance because their style has seemed in tatters since we got back from the Christmas recess. That is revealing failures of substance.

There are two substantial policy areas where the Government are already getting into an important mess. The first is macro-economic policy, of which we will hear more in the coming year. The second is the national health service, which, after less than two years of Labour administration, is already coming under much greater pressure and facing bigger difficulties than most people in the service can remember for a long time. As my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) has said, that is down to the folly of the Government and to the fact that they have wasted their first two years: they have lacked a proper policy and not faced up to what needs to be done.

The debate is short and my contribution must reflect that. I am happy to echo what my right hon. Friend the Member for Maidstone and The Weald said. Contrary to the sneering remarks of the Secretary of State for Health, the shadow Secretary of State happens to combine one of the more combative styles in the House with extremely intelligent content. She took what she described as a grown-up approach to the subject, which is what the public want us to do.

It simply will not do for the Secretary of State to reply by pretending that our criticisms are based on some secret desire to abolish the national health service. I am no more party to some sinister plot to that end with the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) than is my right hon. Friend the Member for Maidstone and The Weald. The fact is that every party wishes to see a better national health service.

The difficulty is that the Labour party came to power with no policy to achieve that. It gave the impression that its election would lead to substantial improvement without more ado. The Secretary of State is desperately trying to find some belief that improvement will come.

The Secretary of State has to get rid of two legacies from Labour's period in opposition. I do not think that he was shadowing health when we came to the election, so it is not his fault that he inherited no files, no policies, no proposals—nothing—but he sticks to the slogans for lack of anything else.

The Secretary of State appeared to believe when he was elected, and he still sometimes implies, that all the problems of the national health service could be solved if only more money were spent. It was clearly the position of the Labour party that the problems that the health service faced before the election were all caused by lower spending than Labour would achieve.

That is total nonsense. We are not looking backwards, but the previous Government always gave higher priority to the NHS than to any other service, as every Government are bound to do. We increased public spending on the service by 1 per cent. of gross domestic product during our period of office. The Labour Government will do that only if they flatten GDP in the next few years.

The Labour party followed up the clear impression that it gave that it was going to spend much more on the service to get it out of trouble with a peculiar approach to public spending in its first two years in office. It thought that it could blame us for the two-year squeeze to which the service has been subjected. It claims that it followed the public spending plans of its predecessors: it did not. It knows that, after the previous Government published each year's public spending plans, they never, in practice, stuck to the first figures that they pencilled in for years two and three of every three-year survey.

Under the previous Government, the public spending round always enhanced spending on the NHS—above what we had first proposed. It is water under the bridge now, but 18 months ago, Conservatives and Liberal Democrats were telling the Labour Government that they would hit a crisis if they pretended to believe that they were simply spending what their predecessors would have spent. They did not even do that.

The Secretary of State sometimes points out that, in the end, the Government put in some extra money for winter pressures last year and so on, but the result was an increase in public spending that was pathetic compared with the expansion of previous years. One of the reasons why we are having a difficult winter, in a year when flu and other epidemics are not exceptional compared with other difficult years, is the fact that the health service has been subjected to a severe squeeze by the present Government in their first two years in office.

Now the Government have committed themselves—again inflexibly—to three years of increases in public expenditure that are not out of line with those that were afforded by the previous Government and that, as my right hon. Friend the Member for Maidstone and The Weald rightly said, are not as good as the best three years that we can point to in the 1990s.

Mr. Heppell

Will the right hon. and learned Gentleman give way?

Mr. Clarke

I will give way just once in my short speech.

Mr. Heppell

From the tone and content of the right hon. and learned Gentleman's speech, it seems that he is suggesting that the Government are not spending enough on health. How does that tie in with the remarks of Conservative Members in the Opposition Treasury Front-Bench team, who say that our spending plans are extravagant?

Mr. Clarke

I joined that debate and I never heard any Conservative Member say that we are spending too much on the NHS. I have joined attacks on the Treasury for the overall level of public spending plans because the Treasury has combined its desirable spending plans on health and education, where what it is achieving is not out of line with what we have achieved, with its failure to apply any strict priorities to other public spending, in line with economic reality. On health, the Government are getting back on track with the kind of increases in public spending that have become almost the norm, on average, for most of the years of the modern NHS.

I will not repeat—the point has been made well in the past week or two—the fact that the other damaging slogan that the Secretary of State stuck to was the ridiculous thing about the number of people on waiting lists. I tire of remembering the number of times that successive Conservative Secretaries of State pointed out to our opponents how fatuous it was to look at the number of people on waiting lists, as opposed to the length of time that people waited for serious treatment.

Not only did Labour use that as a litany in opposition, but it has stuck to it in office. It has distorted the activity of the health service. If we set perverse targets for those responsible for allocating resources, so that they have to speed up treatment of people with comparatively minor ailments when they are under great pressures of rising demand, the health service is that much less well able to deal with winter pressures. That is plainly one of the things that has happened.

The Secretary of State has to come back with the sort of defence that I have heard Secretaries of State use in the past: he says that, each week, 45,000 more people are being treated now than two years ago. We have had 18 years of Secretaries of State saying that—I should hope that they have been saying it.

Demand for national health service treatments is rising rapidly because of an aging population and advancing medical science. The previous Government put more money into the NHS, and the current Government are getting back on track in continuing the increases. If the current Government had not increased the number of patients being treated each week, they would have fallen far short of everything achieved by the previous Government. However, they are distorting priorities by focusing on waiting numbers, as opposed to the local priorities that would have been chosen by health authorities, GPs and trusts.

Mr. Dobson

The right hon. and learned Gentleman has dwelt lovingly on the legacy that we inherited. Will he confirm that, until the NHS reforms that he introduced as Secretary of State for Health were implemented, NHS waiting lists had never risen above 1 million and that, since they were implemented, lists have never been below 1 million?

Mr. Clarke

The idea that my reforms to the NHS caused a sudden increase in referrals is an interesting one. The numbers of people on waiting lists demonstrates the increasing age of the population and advances in the treatments available to the population. It demonstrates also the very varying referral patterns of individual general practitioners, some of whom are far more likely to refer than others. Some consultants are far more likely than others to receive patients.

The numbers on waiting lists are a measure of demand, but they are not a significant one. In the next year or two, numbers may go up or down, and it will have nothing to do with the Secretary of State or with the Government. It is silly to choose numbers as a measure. However, treatment priority and the length of time for which people wait is a very important measure, which we shall be examining.

Dr. Harris

Will the right hon. and learned Gentleman give way?

Mr. Clarke

I said that I would not give way, as I should otherwise speak for far too long.

I shall not engage in great debate with the Secretary of State on NHS reforms—as he has created the tremendous myth that he is abolishing them. Everyone in the NHS knows perfectly well that he is not abolishing the reforms—and breathing a great sigh of relief that he is not.

The previous Government never called the reforms an "internal market". In his speech, the Secretary of State was merely repeating the general election slogans—although he is now two years into responsibility for government—when he talked about "the Government getting rid of competition; being in favour of co-operation; sweeping away the internal market" and all that nonsense. Although he no longer says that simply reducing the costs of bureaucracy will reduce the numbers of people waiting for treatment, all the other slogans have been reproduced.

The Secretary of State is retaining from our reforms what, in the jargon, is called "the purchaser-provider divide". He is therefore retaining a means of dividing providers and those who decide on behalf of the public what treatments should be provided. Unfortunately, he is also inhibiting the providers' choice of where and how service is provided. However, he is retaining the essential elements of choice.

The Secretary of State is retaining—it sounds like he might even make greater use of it—the practice of clinical audit and many other features of our reforms. One of the best boasts that he can make is about the new hospitals that will be opening. He is able to make that boast because he stuck with the private finance initiative, which was denounced by his predecessor as health spokesman when Labour was in opposition. The Secretary of State is now taking credit for new hospitals being produced by implementing a policy that his colleagues fought like mad when they were in opposition. I appreciate why that point should make him raise his eyebrows above his beard, which is much better than mine. Nevertheless, I am grateful for that policy U-turn—he will have to make others.

Rationing is relevant to whether reforms are being made in the NHS, and the public could not care less whether they are Labour reforms or Conservative reforms. The public want a system that functions fairly in response to the ever-changing demands made on it by a modern society.

As my right hon. Friend the Member for Maidstone and The Weald rightly said, rationing exists in every health care system in the world, and is more usually described as a way of making difficult choices, deciding priorities and allocating resources so that they have the greatest effect. The health service must aim to meet every need, but it will never meet every demand, and no health service can. It will help people to understand the difficulty of the term "rationing" if we make it clear that we are talking about how to match finite resources with infinite demand, to ensure that the most important needs are satisfied. Currently, many important needs are going unsatisfied, as our constituents and the press tell us daily.

The Secretary of State is making the big mistake of replacing some of the autonomy given to individual practices and trusts by—as hon. Members have already said—a raft of commissions and advisory bodies and the great committee structure of primary care groups. The nomenclature does not matter, as the groups may boldly go on to be known as primary care trusts and to have even more responsibility. The Government are introducing bureaucracy into a system that needed further improvement; the improvement that was needed was to give individual practices even more control over the resources at their disposal to meet the needs of their patients, allowing greater local autonomy to prevail.

The Government have swept away fundholding, simply because they opposed it. They had the slogan of opposition to a two-tier system. I shall simply cite the survey of health authorities and trusts, conducted last year by the National Association of Fundholding Practices, delivering their verdict on fundholding being swept away. The survey asked whether authorities and trusts believed that practice-based budgets should continue, to which 72 per cent. said yes and 21 per cent. said no. It asked whether they believed that fundholders had made improvements to services, to which 88 per cent. said yes and 2 per cent. said no. It asked whether the actions of fundholders have resulted in improvements for all patients, to which 53 per cent. said yes and 37 per cent. said no. It asked whether authorities found it easier to create change with fundholders or non-fundholders, to which 51 per cent. said that it was easier with fundholders and only 2 per cent. said that it was easier with non-fundholders.

Fundholders have been swept away by dogma, replaced by committees which I hope will work. I do not want the system to grind to a halt in my constituency or anywhere else. However, it is folly to think that committees of 33-odd people—comprising doctors, nurses and laymen but excluding other professions—can reach agreement on an enormous budget, for a locality in which many GPs will wish not to become involved and in which there will be huge disagreements between committee members. The plan will cause rigidity in the system. Our reforms needed to evolve and to be improved, and the commissioning and purchasing side of the system had to be strengthened, providing more power to the elbow of individual GPs.

Miss Kirkbride

Will my right hon. and learned Friend give way?

Mr. Clarke

I am sorry that I cannot give way to my hon. Friend, with whom I am sure I agree. I should like to deal with one point that she dealt with—the matter of beta-interferon and multiple sclerosi.

The Secretary of State already has too many central initiatives. He is slipping back into initiatives for this and that, holding back too much money and trying to run the service by press release rather than by giving greater control to GPs and the NHS. However, he is running away entirely from some difficult issues, which are matters not of local priorities but of clinical opinion.

Such a matter is whether beta-interferon is effective and cost-effective in the treatment of multiple sclerosis. On that, the Secretary of State has said that people should get the treatment if their consultant advises receiving it, while ignoring the fact that in no part of the country does that rule prevail. In my constituency, just as in Bromsgrove, some patients receive it when their consultant recommends it, but others do not because the allocated budget is not large enough.

I have a letter from the chief medical officer saying that the treatment is not satisfactory, that improvements to the quality of life are not sustained, and that more work has to be done. The leading consultant neurologist in my part of the world does not believe that. He believes that published material now shows that the quality of life of patients can be improved. Local spending priorities cannot determine that clinical matter.

We cannot have people saying that we believe one set of clinical advice in Preston, but not in Nottingham. Clear professional guidance from the centre is required. This is a difficult matter that presents hard choices. No rulings have been made on the matter, and the Secretary of State has been only too content to leave it to local health authorities, for them to wrestle with their budgets and to contend with the lobbies. It is an unsatisfactory situation. I do not think that any of the Secretary of State's proposals on the problem will ease it or the many other problems like it in the NHS across the United Kingdom.

I urge the Secretary of State to accept, after two years, that he is no longer in opposition, that it is inadequate to continue to fight the previous general election, and that most of the slogans used in the election were silly and were produced by people who had done little to prepare themselves to meet the demands of the national health service. The slogans are quite valueless when applied to the problems faced by the NHS in the first difficult winter under this Government.

The amounts of money that the Secretary of State will provide will be more satisfactory from next April onwards, and more in line with the increases made by the previous Government in the early 1990s. I do not have any confidence that he has the first idea of how to apply sums intelligently. He is responding to pressures, repeating political slogans and facing each headline and winter as they come along, trying to do the best with what he has, to persuade everyone that the service is getting better. The NHS requires clearer policy than that. My right hon. Friend the Member for Maidstone and The Weald is to be commended on urging him to produce one, to give some serious thought to the problem and to stop thrashing about, as he has been doing, putting the NHS into crisis.

5.40 pm

Mr. David Hinchliffe (Wakefield)

The right hon. and learned Member for Rushcliffe (Mr. Clarke) began by saying that the flu problems that the NHS has faced in recent weeks were not exceptional. That may be true in his part of the country, but in the north-west of England and in Yorkshire we have had some serious difficulties. I did not realise how bad things were—despite my entire constituency office staff of three people going down with the bug—until I saw my local newspaper for the first week of January. Reports of deaths normally occupy two or three columns, but for that week they stretched to two full pages. That shows the severity of the crisis that the NHS has faced. My neighbour, who is a nurse in the local hospital, told me that on her ward—one ward alone—10 people were absent. One of those was on maternity leave, but the rest were down with flu. We should not underestimate how serious the problem has been.

Today's debate is on an Opposition motion. I believe in the importance of constructive opposition in a democracy. I have the privilege of chairing the Health Committee, in which some excellent Opposition Members play a constructive role. In the past three weeks, the Opposition, led by the right hon. Member for Maidstone and The Weald (Miss Widdecombe) and her colleagues, have been opportunistic and destructive. Her comments today about bodies placed in refrigerated lorries—

Mr. Philip Hammond (Runnymede and Weybridge)

It is true.

Mr. Hinchliffe

It may be true, but what do health managers do when faced with the scenario that I have described, with so many deaths that the reports cover two full pages in my local newspaper? What do they do when people are dying and there is no way of dealing with it? I praise NHS staff for the work that they have done in recent weeks in my area and elsewhere, despite the negative comments that we have heard from the Opposition today and throughout the Christmas and new year period.

The right hon. and learned Member for Rushcliffe talked about the intelligent content of his colleague's comments from the Opposition Front Bench. I must have blinked, because I did not notice any intelligent comments. I have listened carefully to the Opposition's policies and arguments since the election. In debates and at endless Question Times we have heard attack after attack from the Opposition Front Bench on the Government's failure to meet their waiting list target. When the Government start to meet their waiting list target, all of a sudden the Opposition shift their tack and say that the crisis in the NHS over Christmas is the fault of the waiting list initiative. I am sorry, but we made an electoral pledge, rightly or wrongly. The people to whom I made that pledge have a right to evaluate whether we are meeting it. I am pleased that the Government are doing so—and doing so well.

What would the Conservatives have done? I have listened carefully to what the right hon. and learned Member for Rushcliffe believes to be the constructive comments from the Opposition Front Bench. The only proposal that we have heard from the right hon. Member for Maidstone and The Weald is to put people into the private sector. That is the only answer that the Tories have to the current problems in the NHS.

I asked the right hon. Lady a relevant question. I acknowledge that we have staffing problems in the NHS. I have done the rounds with other colleagues on the Select Committee, meeting nursing staff, doctors, ancillary workers and others employed by the NHS to find out their thoughts on the current staffing level problems. One thing has come over loud and clear: we are short of nurses. Many wards are desperately short of nurses. One reason for that is that many nurses have gone to the private sector. The right hon. Lady's answer to the problems of the NHS—the crisis, as some are calling it—is to get people into the private sector. The increased demand in the private sector will draw ever more nursing staff and doctors from the NHS. What nonsense. Is that the best that she can do after 18 or 19 months in opposition? It is disgraceful.

The Select Committee will soon be reporting on the regulation of the private sector. In the evidence that we have taken so far from people in the private sector and outside, we have heard serious concerns about the quality of care that it provides. The right hon. Lady might want to reflect on why the quality of care in the private sector is so much worse than that in the NHS.

Miss Widdecombe

I am on record as having said for some time that the private sector should be regulated. If it is to play an expanded role, it must be regulated. I have called on the Secretary of State to consider that, because those in the private sector tell me that when they raise the issue with him, he will not meet them because he says that he has nothing to do with the private sector.

Mr. Dobson

They are liars.

Mr. Hinchliffe

My right hon. Friend the Secretary of State and I have many things in common. We use the same pork pie shop in Yorkshire, as may be apparent. I support him ideologically in many ways because he believes in the NHS and its ethos, as I do. The right hon. Lady did not respond to my intervention—[Interruption.] She intervenes on me, then talks to her colleagues when I am responding. I wanted to know her response to my important point about her key policy initiative of moving people into the private sector. What would the impact be on nursing staff levels in the NHS?

Miss Widdecombe

I was talking with my colleagues because we thought—we may have been mistaken—that we heard the Secretary of State call those in the private sector liars. If he did, I am sure that those concerned will be interested to read that.

The hon. Gentleman has so vastly misunderstood my policy that I cannot put him right in the space of an intervention. A nurse is trained to nurse. Is it less valid for her to assist someone who happens to have paid for their operation than to assist someone who has not?

Mr. Hinchliffe

This is the third time that I have put my point to the right hon. Lady, but she has not responded. My central point is that if she wants to push people into the private sector, she must accept that nursing and medical staff in the private sector will come from the national health service. She would worsen the circumstances of people in the national health service. That is her policy and it is disgraceful.

Dr. Harris

rose—

Mr. Hinchliffe

I have given way several times. I want to carry on because there are others who want to speak.

The right hon. Lady's other policy, presumably, is to return to the anarchy of the internal market. The right hon. and learned Member for Rushcliffe plays down the anarchy of the internal market. [Interruption.]

Mr. Deputy Speaker (Sir Alan Haselhurst)

Order. I appeal to the right hon. Member for Maidstone and The Weald (Miss Widdecombe), who has already made a significant contribution to the debate.

Mr. Hinchliffe

The right hon. Lady wants to return to the competitive, cut-throat environment of hospital versus hospital and doctor versus doctor. I am proud that the Government are abolishing the internal market and getting back to basics in the NHS.

I commend the Government on a range of initiatives. My right hon. Friend the Secretary of State can be proud of the impact that the investment that he has managed to win for the NHS is having in areas such as mine and the contribution that it has made to easing the serious problems that we have faced over the past few weeks. However, I am sure that he agrees that money is not the only issue. No one has said that it is just about money. How the money is used is important.

I have taken a close interest in the NHS over many years. I was concerned about the gross waste of scarce resources caused by the internal market. The Government are getting back to investing money in patient care. I welcome the abolition of the internal market, the way in which the Government are putting the fragments back together and the new statutory duty of partnership that the new Bill will introduce when it comes before us in the next few months.

I welcome the way in which the Government have launched the winter pressure initiative. Members of the Select Committee have seen excellent examples in various parts of the country of people working together to address the difficulties in the NHS and social services, and numerous positive initiatives have alleviated the acute difficulties that have faced the NHS in recent weeks.

I want to address one or two areas where positive developments are needed within the NHS under the new Labour Government. Recent experience has shown that, as a matter of urgency, we must address staffing levels because, at ward level, there is simply no slack in the system. If—as in the case in which my neighbour was involved—a ward has 10 people away for various reasons, there will be serious difficulties. We must build some slack into the system.

We must look at how we ensure that nurses are attracted back to the NHS. It is partly about pay, but it is not just pay—as my right hon. Friend the Secretary of State has recognised. A range of issues concern nursing and NHS staff over and above pay, and I hope that the Government will address those in the next few weeks and months.

I would like to see substantial changes in primary care. In my part of the world, constituents have attempted to contact their GPs over the Christmas and new year period. Obviously, the GP surgeries have not been working and people have had difficulty accessing advice and help. I recognise that NHS Direct will make a substantial contribution to solving those difficulties. However, it concerned me that many of those who have tried to get hold of the deputising services in my part of the world have been told that there would be a five or six-hour wait for the service. They have, therefore, presented themselves to accident and emergency units, causing great stress in the hospital sector—stress that could be resolved by more flexible primary care arrangements.

My hon. Friend the Member for Dartford (Dr. Stoate)—a GP—is looking at me and I know that he works hard, as do many GPs who deserve their holidays. However, it is possible, with the provision of primary care groups, to ensure that we create different arrangements over holiday periods so that people can access GPs to get a basic prescription and do not need to present themselves to accident and emergency units.

It will not surprise Ministers that I want to raise my concerns about the need for further improvements in the relationship between the NHS and social services. The Select Committee produced a report last week which may or may not meet with the approval of Ministers—but I hope that they will listen to some of the points that the Committee picked up.

One key area, with direct relevance to the kind of problems that we faced over Christmas, is the way in which one element of local authority or health services does not recognise the impact of expenditure on another element, so that additional money spent in one sector can impact on saving more money in another sector. I welcome the way in which the Government are moving towards pooled budgets, but they should look seriously at the way in which charges for domiciliary care and care in the community are preventing people from releasing and making available acute beds. That factor must be analysed in detail by the Department of Health.

The picture that we on the Select Committee get, and that I get personally, is that there are tremendous experiences of joint working across the country. Staff want to work together, but—in many areas—are prevented from doing so by the current statutory framework.

In conclusion, I recognise that we have made great progress, and I do not recognise the picture presented by the Opposition. There are many achievements of which the Government can be proud in the short time that we have been in power. We can debate rationing, waiting lists and waiting times—the shorthand for what is happening in the NHS—until the cows come home. However, the key issues of health—morbidity, illness and mortality—are not even mentioned in either the Tory motion or the Liberal Democrat amendment.

I am pleased that the Government are addressing fundamental public health questions of the kind to which my right hon. Friend the Secretary of State referred—such as why poorer people are often more ill than others. The Government are doing something about that, and they can be proud of their policies and their results. I wish the Government well in their future initiatives.

5.55 pm

Mr. Simon Hughes (Southwark, North and Bermondsey)

This debate was triggered when, at the last Health Question Time before Christmas, the Minister for Public Health came up with the unequivocal statement—as the right hon. Member for Maidstone and The Weald (Miss Widdecombe) said in her introductory speech—that there was no rationing in the NHS.

The hon. Member for Wakefield (Mr. Hinchliffe), the Chairman of the Select Committee on Health, has just said that there are other hugely important issues, especially concerning the quality of care. However, today we have, quite rightly in our view, taken one of the issues that has underlain the health service throughout its existence, as the right hon. and learned Member for Rushcliffe (Mr. Clarke) stated. We are trying to tease out of the Government, and the Secretary of State, the admission which everybody outside knows is true—namely, that there is rationing, and that it is nothing to be ashamed of. Only if we get past our initial hesitation at using the "R" word can we have an honest debate.

The Minister for Public Health is in her place. She, together with the Secretary of State and her ministerial colleagues, must accept that it is no good coming to the House with an amendment to a Conservative motion that does not deal with the point of the motion—nor with the amendment that my party tabled, which accepts the proposition in the motion.

From the moment that the Government came to office, and during the whole 18 years of the previous Administration, it has been understood that one of the biggest and growing issues in the NHS has been how, as the right hon. and learned Member for Rushcliffe said, we reconcile growing needs with the resources that might be available at any one time.

We have very little difference on the general thrust of the Conservative motion, as the right hon. Member for Maidstone and The Weald said, but we do have four detailed points of difference. The right hon. Lady has heard me say before that I always welcome conversions, and we observe the fact that Tory Front Benchers have converted—they are now owning up to the fact that there is rationing, something the previous Conservative Administration never did. I appeared with the right hon. Member for Charnwood (Mr. Dorrell), her predecessor as Opposition spokesman, when he was Secretary of State for Health, in television studios before the last election—together with the then Labour spokesman, the right hon. Member for Islington, South and Finsbury (Mr. Smith). Never did the word "rationing" pass their lips. The Conservative conversion is welcome.

We do not want to be overly critical of the national institute for clinical excellence and the commission for health improvement, the bodies that the Government are proposing—which we will debate, no doubt, in the health Bill later this year. However, we certainly do not think that, suddenly, they will be the answer. Unless, once they have formed a view, they are given the power to impose that view, all they will do is give advice, recommendations and suggestions—the rationing decisions will still be left to the practitioners. Do they use a drug costing £1,000, or not? Do they treat seven people, or one? Do they carry out this or that practice, or not? We have not heard from the Government whether they will make the NICE recommendations compulsory. If they do, the Government could then accept the ownership of the decisions, which would be much fairer on the practitioners—the people in the front line, or, as people always describe them, the gateway to the NHS.

Mr. Clive Efford (Eltham)

The right hon. Member for Maidstone and The Weald (Miss Widdecombe) gave the example of a number of people who purchase expensive drugs for themselves because they are not available to them through the NHS. Does the hon. Gentleman accept that rationing will inevitably lead to two classes of patient in this country—those who can afford to buy drugs in the private sector and those who cannot? Does he accept that rationing will mean that people cannot access services? Does he accept that the fact that implicit rationing is occurring in certain areas does not absolve the Conservative party of the responsibility for bringing us to this situation?

Mr. Hughes

I would happily spend a lot of time criticising the previous Administration, but it is not productive—the Labour party is in government, and constructive opposition is about trying to make the Government do what is right.

Mr. Efford

Answer the question.

Mr. Hughes

I can easily answer the question. There is a huge amount of rationing now. The former Minister of State—now the Chief Secretary to the Treasury, the right hon. Member for Darlington (Mr. Milburn), who was recently promoted to the Cabinet—effectively admitted that in the autumn, when he said that one of the objectives of the Government was to make sure that, in future, someone in one part of the country would not have a request for treatment turned down which would be granted in another part of the country.

Rationing by postcode is general in many areas of life. My mother, who lives in Hereford, told me a few years ago that she was told by someone at the local eye hospital that she would have to wait for a year or a year and a half for a simple cataract operation, with the prospect of deteriorating eyesight. The same person told her that if she was willing to pay she could have the operation tomorrow. There is a two-tier health service: the 13 per cent. with private health care can generally buy their care tomorrow.

When, in the past, my hon. Friend the Member for Isle of Wight (Dr. Brand), a general practitioner, was an outside adviser on health to our party, we argued that we could end the two-tier health service only by working out what it was necessary to make the NHS do everywhere in order to give everyone the same access to treatment.

Dr. Brand

This morning, I met two simple examples of rationing. A man who had very imperfect cosmetic surgery carried out on the NHS now has to wait 14 months before seeing a consultant about a revision operation. That is rationing—the man, who is on benefit, cannot go to work until that work has been carried out, so he has to go privately.

I saw a man of 62 who desperately needs Viagra—as does his wife. I have been told that I am not allowed to prescribe it under the NHS, so I broke my terms and conditions of service this morning by issuing a private prescription, to save him the expense of having to see another doctor privately for exactly the same service.

Those are clear examples of rationing and of a lack of guidance to the poor sods such as myself who have to meet not the demands, but the needs of patients.

Mr. Hughes

In our previous NHS debate just last week, the Secretary of State called my hon. Friend an hon. and learned colleague, because he is a general practitioner. I hope that Ministers will learn the lesson that he teaches today. I hope that next week, if not this week, Ministers will acknowledge the self-evident truth that there is rationing in the health service, just as the Secretary of State earlier acknowledged the self-evident truth that there was a crisis and a staff shortage in the health service. Then, we could get on with the debate.

Mr. Efford

Will the hon. Gentleman give way?

Mr. Hughes

No; I have already given way once to the hon. Gentleman.

Mr. Dobson

Under his definition of rationing, can the hon. Gentleman name anything that anyone wants that is not rationed?

Mr. Hughes

The Secretary of State drew a comparison with education, which he said was rationed, but the reality is that, for those of school age who require education, it is not rationed. Schools and classes are available, so the situation is completely different.

Mr. Dawson

Will the hon. Gentleman give way?

Mr. Hughes

No, I am dealing with the Secretary of State's point.

The reality is that the positions in health and in education are not comparable. At the moment, the patient to whom my hon. Friend the Member for Isle of Wight referred could not get the treatment he needed, just as my mother could not. I have constituents with multiple sclerosis who cannot get treatment. That is rationing. It is not the same in other walks of life. There is a difference between what one needs—to be cured, so as to be able to get back to work and pay taxes, thus contributing rather than drawing from the state—and what might be desirable extras.

The rather academic and cautious beginning to the Secretary of State's speech did not draw the right parallels. We are talking about treatments that the national health services acknowledges people need for their good health, but that are not available at all, are available only after a year or two or three, or are available in place A but not in place B.

Dr. Harris

The Government take the limited view that either there is no rationing at all or everything in the world is rationed. The British Medical Association, the King's Fund, the health economics departments at York and Birmingham, the Patients. Association and every political party other than the Labour party recognise the truth—the Government are sticking to their point in splendid isolation.

Mr. Hughes

That is true. I challenge the Secretary of State to do what I did this morning: I went to my filing cabinet and, looking back only two years, I turned up cutting after cutting from professional bodies and reputable journalists making the case about rationing.

In 1996, the BMA held debates entitled "Hard Choices in Health Care" and "Rationing and Rights in Health Care". The latter was initiated by the Institute for Public Policy Research, a think tank that the Government recognise as valid. In March 1998, The Daily Telegraph said: Test-tube baby choice depends on your postcode. The Independent said: MS sufferers denied costly 'wonder drug' … People with MS still face a postcode lottery on new treatments. The situation is unfair and unacceptable. Chris Ham, a very well-known health expert, wrote about the case of child B and said that the issues involved were oversimplified.

Every health journal, almost every month, provides an example. Viagra was the most controversial and topical instance last year. A couple of months ago, my hon. Friend the Member for Richmond Park (Dr. Tonge) introduced a debate about audiology services in the health service, which are unavailable in some places. They are not high-profile services, but for the deaf or hard of hearing they matter a great deal. Everyone outside the House is calling on us to face up to the issue and do something about it.

Clearly, there is and always has been rationing. There are many relevant examples showing rationing by delay, by cost—through prescription or other charges—or by unavailability, as with in-vitro fertilisation or treatment for MS sufferers. No amount of clinical effectiveness institutes, health improvement commissions or primary care groups will alter that fact. Indeed, the primary care groups are worried that, in the future, they will have to carry the burden of the decisions on rationing.

The King's Fund, a very reputable organisation, published a report using figures from the British social attitudes survey, which showed that in 1983, 29 per cent. of people supported limiting the NHS to people on low incomes while 64 per cent. opposed it, but that by 1996 the number of people supporting a safety-net-only service had gone down. Most people want a comprehensive health service and they want the Government to face up to questions about what should be included in it and how it should be funded.

Mr. Bercow

The hon. Gentleman justifiably invokes public opinion. Is he aware that the King's Fund and the relevant economist at the York university centre for health economics calculate not only that primary care groups will probably be ineffective, but that they will cost £150 million?

Mr. Hughes

I am being tempted away from the issue of rationing. To replace the present structure with primary care groups certainly will not have a nil cost and they will have their own bureaucracy. There will always be a management cost for the health service, but I do not want to get into the debate about whether the present structure is better than what the Government intend to implement. I want rather to concentrate on the fact that we must get over the hurdle, or blockage, in the Government's mind that is preventing us from taking a long-term view.

The Government have admitted that the NHS is in crisis, but we are not being truthful about the whole story until we accept the other half of the equation. Just as health service pay is rationed—it will be rationed by the present Government, as it has been by every previous Government and will be by every future Government—so drugs and treatment are rationed. There is an equation between the money that goes into the kitty and the service that can be delivered.

I was not surprised by a briefing from the BMA for this debate that I received on Friday. It was blunt about the hard choice that the House and the Government will have to face. It said: The Government face two options…if the public and politicians want a comprehensive health service, with everything available on the NHS, the Government must provide considerably more resources to the NHS, over and above the Comprehensive Spending Review Allocation. The right hon. and learned Member for Rushcliffe used to be Health Secretary and what he said was absolutely right. We have done the figures: the amount of money that his Government devoted to the NHS always went up, and the Conservatives always provided more than predicted in the spending plans. As a result, this Government's announcement of an extra £21 billion will mean that only £1 billion extra a year will be available, compared with the final spending plans drawn up by the previous Administration.

Mr. Hinchliffe

What would you do?

Mr. Hughes

The Government must respond to the public demand for a debate about what the NHS should do. They must not act in a way that no doctor ever would in response to a patient: they must not say, "I see you're ill, oh health service. I'm terribly sorry, but I'll come back in two years with a remedy. I won't do anything for the time being because some inherited rule says we can't treat the problem immediately."

The right hon. Member for Maidstone and The Weald was right in her identification of the great problem which has been compounded by the Government. They came- to office promising to save the NHS in 14 days—that looked a bit optimistic even to the most naive people—but then they phased the first pay award, which had a wonderful effect on morale. People left the health service because of this Government's actions; that did not happen only under the previous Administration.

Moreover, the Government inherited the Tories' spending plans and kept to them for two years.

Mr. Hinchliffe

Will the hon. Gentleman give way?

Mr. Hughes

Let me finish the point. There was a bit of extra money—

Mr. Dobson

Twice as much as you promised.

Mr. Hughes

Not twice as much as that, which in any case was considerably more than the Government had suggested would be provided. The Government kept to the Tory spending plans until last July, and now have provided just about enough money, for the final three years of the Parliament, to allow the NHS to keep its head above water.

The Cabinet will study the pay review body's report in 10 days' or two weeks' time. I suspect that the decision will be made behind closed doors and will not be brought to Parliament for endorsement. Even if the Cabinet do not phase the award—

Mr. Dobson

There are no Liberals in the Cabinet.

Mr. Hughes

No, that is true, and the Government might face a really hard time if there were.

When the Cabinet studies the review, I hope that it will not do what the Tories sometimes did on similar occasions. They used to say, "Fine, you can have a big pay rise, but it's all got to be funded out of existing resources and the money that has already been allocated." That tactic meant that people might be paid more, but the money available elsewhere in the health service fell.

Mr. Gareth R. Thomas (Harrow, West)

I agree with the hon. Gentleman that there is a need for a mature debate about health, but does he recall the publication last autumn of a new Liberal Democrat consultation document on the subject? That document contained no costings and it appears that none will be supplied until just before the next general election. How can my constituents believe that the hon. Gentleman really wants a mature debate when he is not even prepared to attach financial costs to his plans?

Mr. Hughes

The hon. Gentleman has not been in the House long, so I do not criticise him if he is not aware that we have costed every alternative Budget that we have produced since my hon. Friend the Member for Gordon (Mr. Bruce) has been our Treasury spokesman. We costed every item in our manifesto before the election. In our conference health service debate last year, members of the Liberal Democrat party accepted that rationing existed in the NHS and that the right way forward was to define what the NHS does, work out how much it costs and then decide how to pay for it.

We have never ruled out raising taxation or abolishing prescription charges and other charges. The Labour Government should be a bit braver and respond more to the public mood. They should understand that people feel deceived and disappointed by two years of hesitancy, with NHS staff still so badly paid. If the Government were to realise that what we propose is in accord with what people want, perhaps they would not be in such difficulty over the matter.

Finally, I can tell the right hon. Member for Maidstone and The Weald—and those who speak on health in this House for all the other parties from all over the country—that the Liberal Democrats stand ready to implement the offer that I made to the Secretary of State. We believe that, in health as in other areas of public life, there should be a debate outside this House. That debate should involve professionals in the service, not just politicians and patients.

A forum should be established in which the long-term future of the health service is debated. The late John Smith set up the Borne commission—not on a narrow partisan basis—to look at social justice issues. The present Government have just announced a royal commission on the future of the other place. That is a proper way to gather opinion from all other sources.

We believe that such consultation should be conducted about the health service. I hope that, in the near future, the Secretary of State will respond with two announcements to today's call for a mature debate. First, he must admit that rationing exists; and secondly, he should promise that the health service of the future will be built on the views and experience of all concerned. In that way, perhaps, he can ensure that the pressure of so many crises in the health service can be alleviated, and that patients and staff who feel that too little progress has been made after two years of a Labour Government will no longer be so disillusioned.

6.15 pm

Mr. Ivan Lewis (Bury, South)

As this is an Opposition day debate, it is entirely appropriate to contrast 18 months of this Government with 18 years of the previous Administration. Sometimes it gets forgotten that the Conservatives had 18 years in which to fix the national health service. Throughout that period, they had to persuade the public continually that the service was safe in their hands. People drew the usual inference from such continual persuasion: they were not convinced that the NHS was safe in the Tories' hands.

The legacy left by the Tory Government to my right hon. Friend the Secretary of State and his colleagues on the Front Bench is not in dispute, even—I am sure—by the hon. Member for Southwark, North and Bermondsey (Mr. Hughes). That legacy was one of underfunding and low staff morale: it included an internal market more concerned with ideology than patient care and so obscene that it ended up costing the taxpayer billions of pounds in money spent on bureaucracy rather than on improving patient care.

The suspicion will always linger that the Opposition's agenda for the national health service—evidenced in debates such as this about rationing—is one of undermining public confidence as a precursor to arguing for privatisation. Tory Members may claim that that description is too dramatic, but we should remember what they did to community care and to dentistry—they privatised both, saying that there was no other option.

Dr. Brand

Will the hon. Gentleman give way?

Mr. Lewis

Not yet. If the Tories had been allowed to continue undermining the health service, I have no doubt that further privatisations would have followed. That would have been entirely consistent. Whenever this debate is held, the House should remember that Conservative Members are the most passionate advocates—and users—of the private health care system. Such people clearly have an interest in privatising more of the NHS.

The debate about rationing is another attempt to persuade the public that the NHS cannot be expected to meet their needs and to prevent people from having any great expectations of the service. That deliberate attempt to undermine public confidence is in clear contrast to the Government's approach. The Government have made massive extra investment in the health service, in return for its modernisation so that it is fit for the 21st century. They have not just thrown money at the problem, nor have they repeated the same old mistakes that have been made before. They have made the money available, and in return have demanded an improved quality of care.

The Government have committed themselves to an extra £21 billion in investment in the health service. People who talk about the private finance initiative should recall that the Tory PFI hospital building programme never got off the ground. Since this Government came to power, they have built hospital after hospital.

Waiting lists are falling. That was a clear election commitment, and the Government will be able to demonstrate at the next general election that that pledge has been met. The Government are also tackling the problem of clinical accountability, and not before time. For 18 years, general practitioners and hospital doctors were allowed to be laws unto themselves, but the Government have said that that must come to an end. The Government have promised, where clinicians do not deliver the quality of care that we expect and need, that they will act in the interests of patients.

Primary care groups have replaced divisive GP fundholding, and health action zones will ensure a more cohesive and integrated approach to the delivery of health and social care. All relevant agencies—health services, social services and other local authority services, along with the voluntary sector—are co-operating in the treatment of patients and in the introduction of an ambitious public health strategy for the first time in this country. That is very important.

Some Labour Members would like the Government to go one step further, in line with the recent Health Committee report on the relationship between health and social services. The report states that: the problems of collaboration between health and social services will not be properly resolved until there is an integrated health and social care system". At least health action zones are a step in the right direction.

Health problems cannot be solved within the Department of Health or by Health Ministers alone; there is a broader agenda. Social exclusion policies will tackle the root causes of poverty, family breakdown and, ultimately, ill health. Gone are the futile policies of the Conservative Government, who did not merely ignore but denied the link between poverty and ill health.

Mr. Bercow

I am sure that the hon. Gentleman would not chunter on about primary care groups without first troubling to do his homework on their cost. Will he tell the House what he estimates to be the additional annual cost to the NHS budget that is created by the establishment of primary care groups?

Mr. Lewis

We are talking about significantly reducing bureaucracy, and devolving power and resources from health authorities down to GPs and the people who are closest to patients. It is nonsense to talk about extra costs when the policy is designed to reorganise the way in which money is spent in the health service and to ensure that it is spent more cost effectively and as close to the patient as possible. There can be no doubt that the overall objective of the Labour Government's health reforms is to achieve a significant reduction in the money spent on bureaucracy, which will allow money to be redirected to patient care.

The Government cannot turn around overnight 18 years of neglect and undermining, and no one—neither the public nor health care professionals—expects them to do that. Our objective is to be able to face the British people at the next election and say that we have not only met our pre-election pledges on the health service but have considerably surpassed the objectives we set ourselves before the election to modernise the NHS. We do not want merely to claim that the NHS is safe in our hands, for the NHS is the embodiment of all that the Labour party believes in. The Labour party created the NHS and it is entirely appropriate that the Labour party is charged with the responsibility of modernising it.

6.22 pm

Mrs. Marion Roe (Broxbourne)

Rationing exists in the national health service. In a cash-limited system, it cannot but exist and it is sheer folly to suggest that it does not. Rationing has existed since the health service began, with general practitioners controlling access to services and treatments, and hospitals manipulating their waiting lists. Demand has always outstripped resources and provision. The words spoken in the House by the Minister for Public Health when she said that rationing simply does not exist within the NHS must hang heavily, like an albatross around her neck. The Health Committee, of which I was Chairman for five years, recognised the existence of rationing in its inquiries into priority setting in the NHS. It produced reports on the drugs budget and on purchasing in 1994 and 1995, so this is not the first time that such issues have been debated.

The Conservative Government recognised the bottomless pit of demand and used the reforms of the 1990s to address it. They created a fundholding system that put GPs at the centre, providing care for a population they knew. It enabled GPs to set priorities and to identify those in greatest need, and so provided a bespoke health care service that was sensitive to the individual. Resources could be used flexibly and cost effectively, so many more patients could receive care. As a result of Conservative policy, many more staff were employed. The Conservative Government concentrated on waiting times, not on waiting lists, and in less than four years, they reduced from more than nine months to less than four months the average time that patients had to wait before being admitted to hospital. Sadly, that good work is being undone and patients now wait ever longer for admission.

We now have a Government who, with the greatest respect, are deceitful and duplicitous: they deny that rationing exists while taking steps to conceal the shortcomings of their own policies. There is cynical manipulation of patients through the waiting list money being hurled at the system by the Secretary of State. Waiting lists are the tap that turns health care on and off, but under the current system, there is no logical method for selecting patients from the waiting list. Managers rearrange cases so that if the Government want a number of patients treated, they get that number of patients treated, often without consideration being given to the severity of patients' condition or the distress that failure to be selected may cause.

A facile scattergun approach has been adopted—one that takes no account of the time that people spend waiting and fails to recognise that need should be the key determinant of care. In the pool of patients waiting to be fished out for treatment, Government initiatives encourage the rescue of those in shallow water—the patients most easily treated, who occupy a bed for the shortest time—to ensure rapid turnover. The patients in the deepest water are often left longest and some drown while waiting.

How have the Government approached the problem of infinite demand and finite resources? They have come up with primary care groups, which are a rag bag of ideas, hastily cobbled together. They force GPs to relinquish personalised care and give up valuable clinical time to undertake management roles for which they are neither trained nor enthusiastic. They are inadequately funded, rely on good will for their operation and are supplied with a mass of guidance—often contradictory—within which to operate.

Let us take health service circular 1998/139, entitled "Developing Primary Care Groups". Paragraph 52 states: The ability to offer patients the individual care they require has been and remains the cornerstone of general practice. The new system will continue to allow individual GPs to decide what is best for the patient, whether, for example, to prescribe drugs or refer patients to hospitals in the light of their clinical judgment. The freedom to refer and prescribe remains unchanged. The best bit is: Patients will continue to be guaranteed the drugs, investigations and treatments they need". The Government are clearly saying that there is to be no rationing—but wait, what about the next paragraph?

Paragraph 53 states: Primary care groups will be expected to live within their budgets. Where a group is forecasting an overspend it must work with its host health authority to manage the position in-year". So, there is to be rationing after all, with guidance telling GPs, "Give patients whatever they need, but don't spend money doing it." What a devious philosophy. We know that more than one third of health authorities are overspent.

Only a confused Government bent on folly could believe that rationing could be abolished and money saved by fragmenting the service, destroying management and delegating the operation of the system to inexperienced doctors. Already the evidence is beginning to appear. The Government suggest that inequity must be tackled by levelling up, but what is really happening? The first decisions made by fledgling PCGs are to scrap in-house clinics to save money and to reduce GP practices' drug budgets to save money. That is not levelling up; it is dumbing down.

Survey after survey of medical professionals shows conclusively that rationing is preventing patients from getting the care they need. Only last week, a survey in Doctor magazine revealed a damning indictment of the Government's policies and made a laughing stock of their denials. Of respondents, 97 per cent. believe that rationing is inevitable, 79 per cent. say that services or treatment have been withdrawn and 20 per cent. said that patients had suffered as a result of rationing; most serious is the fact that one in 20 said that patients had died as a result. In my constituency, infertility treatment is a thing of the past, plastic surgery is extremely difficult to obtain and even hip pain is no longer an indicator for a joint replacement.

We do not need denials of rationing: we need a fair and effective mechanism for managing rationing. We need mature debate, not meaningless rhetoric. We do not need the Government's retreat to the magical, mystical modernisation fund which they claim will do so much, yet has been spent five times over in successive health circulars. The health professions recognise it and the public accept it: the evidence is clear. When citizens' juries, focus groups and individuals are presented with the facts, they can understand complex medical and case-mix issues. They can arrive at sensible decisions about who gets what.

Rationing is not a job for managers: they do not have the knowledge and it invites public disapprobation. GPs may be the best option, but they are increasingly uncomfortable with that demand. The Doctor magazine survey showed that 80 per cent. of doctors recognise that rationing is a cause of friction between them and their patients. Increasing complexity makes decisions more difficult, and many doctors say that that is not why they entered the medical profession. Other GPs may use rationing as a political tool. It would not be difficult to break the bank and stay within ethical and contractual responsibilities.

Mr. Dawson

Why should the term "rationing" be used in relation to the health service when it is applied to no other area where infinite demand will always be met with finite resources? Does not "rationing" have pejorative overtones?

Mrs. Roe

That word has been used for many years to describe the budgetary dilemmas that certain doctors and hospitals face. We should use the term "rationing" and be open about it. In Health Committee meetings, we used the word "priorities", but we also referred to "rationing" because it meant something to the people who were giving evidence.

Dr. Brand

Will the hon. Lady give way?

Mrs. Roe

No, I will not give way any more as I am under a time constraint.

The Government's disordered and ill-thought-through approach must be replaced by a wider debate involving the consumers. As the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) has already said, the most controversial questions must be addressed if we are to make such a debate meaningful. We must certainly ask why the Government have not recognised the key inefficiencies of the NHS that the previous Government tackled. Where is the cost-effective management, clinician innovation and progress? In short, we must replace rationing with rationale, rhetoric with responsibility and words with deeds.

6.33 pm

Dr. Howard Stoate (Dartford)

I have listened to the debate with great interest as it is about an area that is dear to my heart. In opening the debate, the right hon. Member for Maidstone and The Weald (Miss Widdecombe) called for a mature and adult discussion of the future of the health service. It obviously takes at least 18 years for Conservative Members to reach maturity, because that is the first that we have heard of anything approaching an adult and mature debate. Unfortunately, I am afraid that Opposition Members have failed in that endeavour this afternoon. They expressed a desire to discuss the mature issues of the day, but spoiled it by using soundbite politics and rhetoric that is designed to scare rather than inform people.

I was a doctor throughout the 18 years of the previous Government, and never once did I hear mention of the word "rationing"—it never crossed the Government's lips. It was not an area for discussion. There are real debates to be had, and I would like to enter into genuine, meaningful and mature debates about the health service. We must consider what we can expect of the health service as we enter the next millennium. There is no question but that expectations are changing. People expect and deserve better health care, better services and improved life expectancy—and that is what they should receive.

Health possibilities change daily. We can now operate on babies in the womb and talk about the possibility of replacing brain cells in people with Parkinson's disease. Ten years ago, such procedures were science fiction. We now rely far more on evidence-based medicine that enables us to back up our decisions with meaningful science. I shall concentrate on the issue of rational science in my speech today.

No system in the world will ever meet every need that is placed upon it—and we cannot pretend that it will. However, when we decide to prioritise in a particular area, our decision must be backed by sound science. We have heard much this afternoon about media hype regarding the NHS crisis. The NHS has always been under pressure. I have endured 20 winters as an NHS doctor, and every year there has been a problem with the availability of NHS beds, people on trolleys and waiting lists. However, the reality is that my health authority experienced one bad day this year and that difficulty was ameliorated tremendously because the winter pressures money allowed social services teams to care for people in their own homes. The Government said that we would provide assistance, and that is what we have delivered.

Mr. David Maclean (Penrith and The Border)

rose—

Dr. Stoate

I am sorry, there is no time to give way.

I shall give an example. My hon. Friend the Member for Wakefield (Mr. Hinchliffe) mentioned that I am a general practitioner. I saw a patient—a lady with a breast lump—on 4 January. She had just noticed the lump, which I suspected might be cancerous. I faxed a letter on the same day—4 January—to the consultant in charge of my local breast unit. On 7 January, the senior consultant saw my patient and carried out a needle biopsy and a mammogram. The results were inconclusive, but the lump is probably not malignant. Those results were arrived at only three days after I referred the lady to a consultant. She has been booked in to have an operation next week to remove the lump because we want to be on the safe side when managing a patient's condition.

That is the reality of what the health service can deliver because this Government have put money into breast cancer treatment, just as we promised we would. Patients do not have to wait two weeks for an opinion: they can get one in three days during a so-called "NHS crisis". That is the reality of what the Government can do. The truth is that, while we need to debate priorities in the health service, we will not hear such dialogue from Opposition Members. We need to examine the public's priorities and what people would like to see from the health service in the next few years. As medical knowledge progresses, attitudes must change accordingly.

I shall give another example. A few years ago, a lady who suffered from menstrual pain was likely to undergo a dilatation and curettage. That operation was carried out thousands of times a year on the national health service. However, it is not done any more because medical evidence has shown that it is useless and, in most cases, achieves nothing. Using evidence-based medicine, the operation has been phased out of the health service. That is one result of a mature debate about how medical science has progressed, and attitudes and clinical science have changed.

I want organisations such as the national institute for clinical excellence to be able to review world literature about what constitutes best medical practice. That would enable the best medical treatments to be passed on to all clinicians in the field. It would ensure that useless operations and procedures were abandoned and that good operations and useful procedures were enhanced. In that way, money could go a lot further and be used to treat many more patients more effectively within the constraints of any publicly or privately funded institution.

That is the sort of dialogue that I wish to have. We must consider how best medical knowledge and practice can be used to inform debate in order to help those in difficult situations. That is the sort of issue that we should consider in Parliament. We need proper, rational, adult debate rather than sterile soundbites and competitions to discover who can score the biggest political points. That does not help the situation. The people want their NHS to deliver services for them. They want to know that best practice and clinical governance is ensuring that the best medical knowledge from throughout the world is focused on their personal medical needs. That is what the Government are doing and that is why I am proud to support this Government.

6.38 pm

Mr. Alan Duncan (Rutland and Melton)

We are having this debate today because, if one cares about the national health service, the first thing that one should do is tell the truth about it. In the three hours or so of debate today, it has become apparent that the Government refuse to tell the truth about the most fundamental and simple point governing any policy that will shape the future of the NHS. It seems that they have fallen into the trap of believing their own publicity; so much so that the Secretary of State—who, I am sure, will return to his place in a moment—spoke to a motion that bore no relation whatever to the one that we tabled. I was confused, but only because I could not work out whether his contribution was neanderthal or palaeolithic. It was a smokescreen of bluff and fundamentally intellectually dishonest. What a contrast it was to the contribution of my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke). [Interruption.]

We welcome the Secretary of State back to the Chamber. For his benefit, I point out that I am recalling the barnstorming contribution of my right hon. and learned Friend the Member for Rushcliffe, who carried out radical surgery on the Secretary of State, but, I fear, will not have cured him of his lamentable condition. Similarly, my hon. Friend the Member for Broxbourne (Mrs. Roe) was absolutely right in what she said.

We are trying to establish a simple point that every schoolchild will realise is true. We have no prospect of making any progress in having a sensible debate on the national health service unless we understand the basic pattern of demand and supply in a massive endeavour that is financed out of general taxation and free at the point of sale.

Mr. Hinchliffe

Free at the point of delivery.

Mr. Duncan

Yes, free at the point of delivery. [Interruption.]

Mr. Deputy Speaker (Mr. Michael J. Martin)

Order. We must have order in the Chamber.

Mr. Duncan

I do not mind acknowledging the first sensible contribution that the hon. Member for Wakefield (Mr. Hinchliffe) has made today.

This is key stage 1 economics, which the Secretary of State and all the Ministers beside him—particularly, given what she said before Christmas, the Minister for Public Health—refuse to admit. There cannot be equilibrium in a system that does not have a pricing structure unless there is infinite funding of a system that faces infinite demand. That is so simple and obvious that there seems to be no point in the Minister for Public Health and her colleagues on the Government Front Bench denying it. The right hon. Lady and the Secretary of State are committing us to a sterile debate that will bedevil the future of health care in this country.

Dr. Brand

Does the hon. Gentleman agree that it is particularly important to acknowledge that rationing exists because the previous Government denied its existence and therefore managed to privatise long-term care and dentistry?

Mr. Duncan

We never denied the existence of rationing. That is why we introduced measures such as the private finance initiative, which the Secretary of State is now at last adopting, even though he lampooned and derided it in opposition.

We have been drawn into a sterile debate, which, as the hon. Member for Southwark, North and Bermondsey (Mr. Hughes) pointed out, takes us into a meaningless auction about who is spending more. We compare percentages and amounts, which are rolled up into gross figures by the Secretary of State to reach his figure of £21 billion. However, there is no point in any of that unless there can be a sensible debate about how the health service is funded and about the fact that there is rationing in the service, always has been and always will be.

This sterile debate only brings politics in disrepute. The Secretary of State is guilty of that. He always looks around and chats to his ministerial team when he is being mentioned in the House, as he was so rudely doing when my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe), the shadow Health Secretary, mentioned him this afternoon. There is rationing and, if the Secretary of State does not believe that, I will give him the latest example of the fiasco that is his waiting list policy—a form of rationing if ever there was one.

I have a letter from a doctor at a hospital in Leeds, which says: Due to the enormity of my in-patient waiting list, I am unable to see new patients requiring operative intervention for a considerable period of time. As my current waiting time for surgery is in excess of 18 months, I am now not going to be in a position to see new patients until my waiting time for surgery drops below nine months. There is therefore going to be an inevitable delay of several years before I am likely to be able to see your patient. If that is not rationing, what is? If the Secretary of State is not prepared to admit the condition of the health service, which he is making worse, I do not know what the world will think of him.

The Secretary of State derided Doctor magazine.

Mr. Dobson

Yep.

Mr. Duncan

The right hon. Gentleman says, "Yep". I think that is his word for "yes". An article in Hospital Doctor magazine, entitled "How rationing splits you and the patient", contains a box headed "Squaring up", which says: Many doctors try to be honest with patients about clinical rationing". When will the Secretary of State square up and be equally honest with the patients whom he is cheating day in and day out?

If there is no rationing, why is a whole edition of Doctor magazine devoted to the issue? It says that its exclusive research, carried out with Hospital Doctor—which the Secretary of State also derides—is the biggest survey yet of doctors' experience of rationing and that the results offer compelling evidence that the Government must acknowledge that rationing is an everyday reality in the national health service. That statement is made not in black and white but, more appealing to the Secretary of State, in red and white. Perhaps he can at least admit the basic fact that the health service is now facing rationing.

The Secretary of State has promised a statement on Viagra, although we have not yet received it.

Mr. Dobson

indicated assent.

Mr. Duncan

The right hon. Gentleman nods. Where is it?

Mr. Dobson

It is coming up.

Mr. Duncan

It is coming up. The Secretary of State makes a quip, with a smile on his face. I hope that we can get some answers, because many people want to know if they will be prescribed Viagra on the national health service or whether there will be an extension of the rationing that he says does not exist.

The Conservative party is interested not only in the national health service, but in all health care in the country. We are prepared to admit that there is rationing in the NHS and to consider the public-private mix that might improve health care overall.

We have listened today to backward, old-fashioned old Labour comment about the private sector. If Labour Members want to stick to those old nostrums and deny people in Britain the health care that could better be delivered to them if those Members were not so luddite in their attitude, so be it. People will soon realise that Labour's approach is so backward-looking that it is denying people the health care that they could otherwise receive. There is too much old-fashioned dogma. The Secretary of State will not admit the basic fact that rationing exists, so his policy will run further into the sand, and health care in this country will have been hindered and hampered by the wilful ignorance of this deluded Government.

6.48 pm

The Minister of State, Department of Health (Mr. John Denham)

The Opposition called today's debate on the pretext of talking about what they call rationing. Labour Members are happy to discuss the speed, availability and effectiveness of treatment on the national health service. Indeed, I shall spend most of my few minutes at the end of this debate talking about that.

It is clear to anyone who has listened to the debate how right wing and out of touch Tory Front Benchers are. I stand willing to be corrected, but I listened to the contribution of the right hon. and learned Member for Rushcliffe (Mr. Clarke), who was full of praise for the right hon. Member for Maidstone and The Weald (Miss Widdecombe), who spoke from the Front Bench, and he singularly failed to endorse the right hon. Lady's ideas for the future of private medicine in the health service. The right hon. Lady's speech and those of other Conservative Front Benchers have made it clear that, for them, today's debate has not been about improving the national health service.

Mr. Kenneth Clarke

We spent the past 18 years being accused of secretly plotting to privatise the health service and, before we go down that curious path again, I point out that we are no more guilty of it now than we were before. To all Conservatives, it is self-evident that a healthy private sector relieves the pressures on the national health service. That is not inconsistent with wanting a better NHS consistent with all the fine principles on which it is based and which we all endorse. It is a great pity to hear old Labour's arguments so faithfully trotted out whenever we discuss the NHS when Labour is now charged with the responsibility of government and ought to be discussing what is happening now.

Mr. Denham

It is very interesting to hear the right hon. and learned Gentleman; he still has not endorsed what his right hon. Friend the Member for Maidstone and The Weald said. As for the old Labour argument, I wonder whether the right hon. and learned Gentleman agrees that The national health service is not intended to be a safety net, a guarantor of a minimum standard to those who can afford better private care. It is intended to use taxpayers' funds to provide access to the best of modern clinical practice, and to do so on the basis of the patient's clinical need and without regard to his or her financial circumstances. That is not what we heard that from the right hon. Lady. Those are the words of the previous Conservative Secretary of State for Health, the right hon. Member for Charnwood (Mr. Dorrell).

Today's debate has not been about improving the NHS. As my hon. Friend the Member for Wakefield (Mr. Hinchliffe) said, it has been about giving up the ghost on the NHS. The Conservative argument is not that the NHS is coping, but that it cannot cope—not today, not tomorrow, not ever. Even Baroness Thatcher thought that she should claim that the NHS was safe in her hands. The right hon. Member for Maidstone and The Weald had no such reservation.

Mr. Andrew Lansley (South Cambridgeshire)

Will the hon. Gentleman give way?

Mr. Denham

No, I have only very limited time, and have already allowed a considerable intervention.

We heard a softening-up job—softening up of the public for a Tory party that does not believe that the job of making the health service work is worth the candle. People have been warned. The right hon. Member for Maidstone and The Weald would have done well to listen to the right hon. Member for Charnwood, when he said: I believe that those who argue that the national health service is unaffordable have fallen victim to an old law. Every difficult and intractable question has an answer that is simple, obvious and wrong. A better summary of the right hon. Lady's speech I cannot imagine.

The main claim that the right hon. Member for Maidstone and The Weald made was that there is rationing in the NHS. I shall point out, as others have, that, if she believes that, she must also say that there was rationing under the 18 years of Conservative government; yet the previous Government never talked about it.

Miss Widdecombe

It says so in the motion—as the hon. Gentleman would know if he read it.

Mr. Denham

The right hon. Lady made no mention of that when in government, despite the considerable opportunities to do so. Indeed—there is some sense in this—the previous Government said: Budgets will always be finite while demand is potentially open-ended. There will always be a gap between all we wish to do and all that we can. Setting priorities is a fact of life. I agree. There has been a need to set priorities in the health service from the beginning. There is such a need in every health service in the world. The challenge is to set those priorities properly, sensitively and effectively; to ensure that every penny that the NHS has is used to treat patients to the best effect.

Mr. Lansley

Will the hon. Gentleman give way?

Mrs. Angela Browning (Tiverton and Honiton)

Will the hon. Gentleman give way?

Mr. Denham

No, I have made it perfectly clear that I am not intending to do so. [Interruption.]

Mr. Deputy Speaker

Order. The hon. Member for Tiverton and Honiton (Mrs. Browning) should calm down. The Minister is not giving way.

Mr. Denham

I am not intending to allow interventions because I want to make my points on priorities in the NHS.

This Government, as my hon. Friend the Member for Bury, South (Mr. Lewis) has reminded us, are investing record amounts. We put in an extra £2.25 billion in our first two years in office. There will be £20 billion more over the next three years. I found it strange that the hon. Member for Broxbourne (Mrs. Roe) complained that we were throwing money at the system. We are investing far more in the health service than any other party promised or contemplated in this Parliament.

Clinical judgment is at the heart of decision making in the NHS. But, to make the best use of that money, people working in the NHS and those taking decisions in it need to know what works and what does not. They need to be aware of the costs of what they do and the most cost-effective and clinically effective way of doing it. The NHS needs to be organised, so that decision making is effective and reflects national and local interest. The most damning indictment of the past 18 years of Conservative government is that the Tories failed in that key task. That is why, all too often, there are differences and variations in the health service that the Tories left behind.

It is true that patients with the same need will not always receive the same treatment. Some patients do not do so because the internal market was designed to set doctor against doctor, patient against patient, hospital against hospital. That was the entire logic of the internal market—each fundholding practice focusing only on the needs of its own patients; each trust focusing only on the patients sent to it.

Of course, in such a system, everyone has been working to do their best—GPs for their patients, hospitals for the people who are sent to them. However, doctors and nurses in every hospital know that they could see fewer patients with less severe conditions if the links between primary and secondary care were better. Doctors in every GP practice know that their work load reflects the failure to tackle the roots of ill-health and health inequalities in the wider community—in work, in provision for young children and through social exclusion. Yet those professionals are without the power to influence the way in which problems are tackled. We will abolish the internal market, replacing division and competition with co-operation and partnership. We shall improve primary care, ensuring that the whole service works together to tackle health inequalities.

The internal market is not the only problem. When hard-pressed doctors do not always have the latest information and analysis to hand, some patients will receive treatment that is not the most clinically effective and cost-effective.

Mr. Kenneth Clarke

Will the hon. Gentleman give way?

Mr. Denham

I have already given way to the right hon. and learned Gentleman. [Interruption.] Conservative Members do not want to be told why, in the health service that they have created, there are variations in treatment and access to treatment in different parts of the country.

One of the reasons for such variation is that there is no organisation that brings together in one place the best, evidence-based assessment of the latest treatment, drugs, surgical procedures and new technologies. As a result, despite the best efforts of professionals in the NHS, some patients do not receive the most cost-effective and clinically effective treatment. Some receive treatment that costs money but does not work well, or of which the risks may outweigh the benefits. When that happens, money is wasted—money that could have funded treatment for someone else. The organisation that could provide that information does not exist. Nor have we effective ways of getting information to those who need it. The national institute for clinical excellence will do that job, getting that information to doctors.

With total predictability, the Conservative party opposes such a proposal. It would rather that doctors worked without the latest information and patients received second best. It would prefer taxpayers' money to be wasted on ineffective treatment. It would rather that patients waited longer to benefit from proven advances in medical science.

Some patients do not receive comparable treatment because the NHS bequeathed by the Tories has lacked the tools to analyse how to manage services effectively. It has lacked the encouragement to work together to tackle inequalities in health provision. The Tories' health service could not measure the difference between a really well-run hospital and a poorly run one. We know the cost of seeing a consultant in every hospital, but not whether people get better having done so. Nor do we know whether there is fair access to services, or what patients and carers think of the services that they receive.

We shall introduce better performance measures—counting the things that count for patients. The commission for health improvement will oversee the quality of care in hospitals. We are setting out national service frameworks to define the standards that everyone should be able to enjoy. We will ensure that patients have better information, so that they can make the best use of the NHS. By April, 40 per cent. of England will be covered by NHS Direct—telephone advice from nurses 24 hours a day.

The message from the Opposition is clear: the Conservative party has given up on the NHS. We reject its pessimism; so do the British public. There has always been a need to set priorities in the health service, and our priorities are clear. We are funding extra nurses. We are training more doctors. One in four accident and emergency departments will be modernised in the coming year. Our priorities are making available money for winter pressures; investment in modernisation; better information; less waste, and co-operation instead of competition. And the principles remain the same: that if people are ill or injured there will be a national health service there to help: and access to it will be based on need and need alone, not on ability to pay".

Question put, That the original words stand part of the Question:—

The House divided: Ayes 169, Noes 336.

Division No. 34]	[7 pm
AYES
Ainsworth, Peter (E Surrey)	Clark, Rt Hon Alan (Kensington)
Allan, Richard	Clark, Dr Michael (Rayleigh)
Amess, David	Clarke, Rt Hon Kenneth (Rushcliffe)
Ancram, Rt Hon Michael	Clifton—Brown, Geoffrey
Arbuthnot, Rt Hon James	Cormack, Sir Patrick
Ashdown, Rt Hon Paddy	Cotter, Brian
Atkinson, Peter (Hexham)	Cran, James
Baldry, Tony	Davey, Edward (Kingston)
Beith, Rt Hon A J	Davis, Rt Hon David (Haltemprice)
Bercow, John	Day, Stephen
Beresford, Sir Paul	Dorrell, Rt Hon Stephen
Body, Sir Richard	Duncan, Alan
Boswell, Tim	Duncan Smith, Iain
Bottomley, Peter (Worthing W)	Emery, Rt Hon Sir Peter
Bottomley, Rt Hon Mrs Virginia	Evans, Nigel
Brake, Tom	Faber, David
Brand, Dr Peter	Fallon, Michael
Brazier, Julian	Flight, Howard
Brooke, Rt Hon Peter	Forth, Rt Hon Eric
Browning, Mrs Angela	Foster, Don (bath)
Bruce, Ian (S Dorset)	Fowler, Rt Hon Sir Norman
Burns, Simon	Fox, Dr Liam
Burstow, Paul	Gale, Roger
Campbell, Menzies (NE Fife)	George, Andrew (St Ives)
Cash, William	Gibb, Nick
Chapman, Sir Sydney (Chipping Barnet)	Gill, Christopher
Chidgey, David	Gillan, Mrs Cheryl
Chope, Christopher	Goodlad, Rt Hon Sir Alastair
Clappison, James	Gorman, Mrs Teresa

Gray, James	Ottaway, Richard
Green, Damian	Page, Richard
Greenway, John	Paterson, Owen
Grieve, Dominic	Pickles, Eric
Hague, Rt Hon William	Prior, David
Hamilton, Rt Hon Sir Archie	Randall, John
Hammond, Philip	Redwood, Rt Hon John
Harris, Dr Evan	Rendel, David
Harvey, Nick	Robathan, Andrew
Hawkins, Nick	Robertson, Laurence (Tewk'b'ry)
Hayes, John	Roe, Mrs Marion (Broxbourne)
Heald, Oliver	Rowe, Andrew (Faversham)
Heath, David (Somerton & Frome)	Russell, Bob (Colchester)
Heathcoat—Amory, Rt Hon David	Sanders, Adrian
Hogg, Rt Hon Douglas	Sayeed, Jonathan
Horam, John	Shephard, Rt Hon Mrs Gillian
Howard, Rt Hon Michael	Simpson, Keith (Mid-Norfolk)
Howarth, Gerald (Aldershot)	Smith, Sir Robert (W Ab'd'ns)
Hughes, Simon (Southwark N)	Smyth, Rev Martin (Belfast S)
Hunter, Andrew	Soames, Nicholas
Jack, Rt Hon Michael	Spelman, Mrs Caroline
Jenkin, Bernard	Spicer, Sir Michael
Johnson Smith, Rt Hon Sir Geoffrey	Spring, Richard
Jones, Nigel (Cheltenham)	Stanley, Rt Hon Sir John
Kennedy, Charles (Ross Skye)	Streeter, Gary
Key, Robert	Stunell, Andrew
King, Rt Hon Tom (Bridgwater)	Swayne, Desmond
Kirkbride, Miss Julie	Syms, Robert
Laing, Mrs Eleanor	Tapsell, Sir Peter
Lait, Mrs Jacqui	Taylor, Ian (Esher & Walton)
Lansley, Andrew	Taylor, Matthew (Truro)
Leigh, Edward	Taylor, Sir Teddy
Letwin, Oliver	Townend, John
Lewis, Dr Julian (New Forest E)	Tredinnick, David
Lidington, David	Trend, Michael
Lilley, Rt Hon Peter	Tyler, Paul
Lloyd, Rt Hon Sir Peter (Fareham)	Tyrie, Andrew
Llwyd, Elfyn	Viggers, Peter
Loughton, Tim	Walter, Robert
Luff, Peter	Wardle, Charles
Lyell, Rt Hon Sir Nicholas	Webb, Steve
McIntosh, Miss Anne	Wells, Bowen
MacKay, Rt Hon Andrew	Welsh, Andrew
Maclean, Rt Hon David	Whitney, Sir Raymond
Maclennan, Rt Hon Robert	Whittingdale, John
McLoughlin, Patrick	Widdecombe, Rt Hon Miss Ann
Madel, Sir David	Wilkinson, John
Major, Rt Hon John	Willetts, David
Malins, Humfrey	Willis, Phil
Maples, John	Wilshire, David
Mates, Michael	Winterton, Mrs Ann (Congleton)
Mawhinney, Rt Hon Sir Brian	Winterton, Nicholas (Macclesfield)
May, Mrs Theresa	Yeo, Tim
Michie, Mrs Ray (Argyll & Bute)	Young, Rt Hon Sir George
Moss, Malcolm	Tellers for the Ayes:
Nicholls, Patrick	Mr. John M. Taylor and
Oaten, Mark	Mr. Tim Collins.
NOES
Abbott, Ms Diane	Beckett, Rt Hon Mrs Margaret
Ainger, Nick	Begg, Miss Anne
Ainsworth, Robert (Cov'try NE)	Bell, Martin (Tatton)
Allen, Graham	Bell, Stuart (Middlesbrough)
Anderson, Donald (Swansea E)	Benn, Rt Hon Tony
Anderson, janet (Rossendale)	Bennett, Andrew F
Armstrong, Ms Hilary	Benton, Joe
Ashton, Joe	Bermingham, Gerald
Atherton, Ms Candy	Berry, Roger
Atkins, Charlotte	Best, Harold
Austin, John	Blair, Rt Hon Tony
Barnes, Harry	Blears, Ms Hazel
Barron, Kevin	Blizzard, Bob
Battle, John	Boateng, Paul
Bayley, Hugh	Borrow, David
Beard, Nigel	Bradley, Keith (Withington)

Bradley, Peter (The Wrekin)	Flint, Caroline
Bradshaw, Ben
Brinton, Mrs Helen	Flynn, Paul
Brown, Rt Hon Gordon (Dunfermline E)	Follett, Barbara
Browne, Desmond	Foster, Rt Hon Derek
Buck, Ms Karen	Foster, Michael Jabez (Hastings)
Burden, Richard	Foster, Michael J (Worcester)
Burgon, Colin	Foulkes, George
Butler, Mrs Christine	Fyfe, Maria
Caborn, Richard	Gapes, Mike
Campbell, Alan (Tynemouth)	Gardiner, Barry
Campbell, Mrs Anne (C'bridge)	Gerrard, Neil
Campbell, Ronnie (Blyth V)	Gibson, Dr Ian
Campbell—Savours, Dale	Gilroy, Mrs Linda
Canavan, Dennis	Godman, Dr Norman A
Caplin, Ivor	Godsiff, Roger
Casale, Roger	Goggins, Paul
Cawsey, Ian	Gordon, Mrs Eileen
Chapman, Ben (Wirral S)	Griffiths, Jane (Reading E)
Chisholm, Malcolm	Griffiths, Nigel (Edinburgh S)
Clapham, Michael	Griffiths, Win (Bridgend)
Clark, Paul (Gillingham)	Grocott, Bruce
Clarke, Charles (Norwich S)	Grogan, John
Clarke, Eric (Midlothian)
Clarke, Rt Hon Tom (Coatbridge)	Gunnell, John
Clarke, Tony (Northampton S)	Hall, Mike (Weaver Vale)
Clelland, David	Hall, Patrick (Bedford)
Clwyd, Ann	Hamilton, Fabian (Leeds NE)
Coaker, Vernon	Hanson, David
Coffey, Ms Ann	Heal, Mrs Sylvia
Coleman, Iain	Healey, John
Colman, Tony	Henderson, Doug (Newcastle N)
Connarty, Michael	Henderson, Ivan (Harwich)
Cook, Frank (Stockton N)	Hepburn, Stephen
Cook, Rt Hon Robin (Livingston)	Heppell, John
Cooper, Yvette	Hesford, Stephen
Corbett, Robin	Hewitt, Ms Patricia
Corbyn, Jeremy	Hill, Keith
Corston, Ms Jean	Hinchliffe, David
Cousins, Jim	Hoey, Kate
Cranston, Ross	Home Robertson, John
Crausby, David	Hoon, Geoffrey
Cryer, Mrs Ann (Keighley)	Hope, Phil
Cryer, John (Hornchurch)	Hopkins, Kelvin
Cummings, John	Howarth, George (Knowsley N)
Cunliffe, Lawrence	Howells, Dr Kim
Cunningham, Rt Hon Dr Jack (Copeland)	Hoyle, Lindsay
Cunningham, Jim (Cov'try S)	Hughes, Ms Beverley (Stretford)
Dalyell, Tam	Humble, Mrs Joan
Daryell, Keith	Hurst, Alan
Davey, Valerie (Bristol W)	Hutton, John
Davies, Rt Hon Denzil (Llanelli)	Iddon, Dr Brian
Davies, Geraint (Croydon C)	Illsley, Eric
Davies, Rt Hon Ron (Caerphilly)	Jackson, Ms Glenda (Hampstead)
Dawson, Hilton	Jackson, Helen (Hillsborough)
Dean, Mrs Janet	Jamieson, David
Denham, John	Jenkins, Brian
Dismore, Andrew	Johnson, Alan (Hull W & Hessle)
Dobbin, Jim	Johnson, Miss Melanie (Welwyn Hatfield)
Dobson, Rt Hon Frank	Jones, Barry (alyn & Deeside)
Donohoe, Brian H	Jones, Mrs Fiona (Newark)
Doran, Frank	Jones, Helen (Warrington N)
Dowd, Jim	Jones, Ms Jenny (Wolverh'ton SW)
Drew, David	Jones, Dr Lynne (Selly Oak)
Dunwoody, Mrs Gwyneth	Jowell, Ms Tessa
Eagle, Angela (Wallasey)	Keeble, Ms Sally
Eagle, Maria (L'pool Garston)	Keen, Ann (Brentford & Isleworth)
Efford, Clive	Kelly, Ms Ruth
Ellman, Mrs Louise	Kemp, Fraser
Fatchett, Derek	Kennedy, Jane (Wavertree)
Field, Rt Hon Frank	Khabra, Piara S
Fisher, Mark	Kidney, David
Fitzpatrick, Jim	Kilfoyle, Peter
Fitzsimons, Lorna	King, Ms Oona (Bethnal Green)
	Kingham, Ms Tess

Kumar, Dr Ashok	Pickthall, Colin
Ladyman, Dr Stephen	Pike, Peter L
Lawrence, Ms Jackie	Plaskitt, James
Laxton, Bob	Pollard, Kerry
Lepper, David	Pond, Chris
Leslie, Christopher	Pope, Greg
Levitt, Tom	Pound, Stephen
Lewis, Ivan (Bury S)	Powell, Sir Raymond
Lewis, Terry (Worsley)	Prentice, Ms Bridget (Lewisham E)
Linton, Martin	Prentice, Gordon (Pendle)
Lloyd, Tony (Manchester C)	Prescott, Rt Hon John
Lock, David	Primarolo, Dawn
McAvoy, Thomas	Prosser, Gwyn
McCabe, Steve	Purchase, Ken
McCafferty, Ms Chris	Quin, Ms Joyce
McCartney, Ian (Makerfield)	Quinn, Lawrie
McDonagh, Siobhain	Rammell, Bill
McDonnell, John	Rapson, Syd
McGuire, Mrs Anne	Raynsford, Nick
McIsaac, Shona	Reed, Andrew (Loughborough)
	Reid, Rt Hon Dr John (Hamilton N)
Mackinlay, Andrew	Robertson, Rt Hon George (Hamilton S)
McNulty, Tony	Robinson, Geoffrey (Cov'try NW)
MacShane, Denis	Roche, Mrs Barbara
Mactaggart, Fiona	Rooney, Terry
McWalter, Tony	Ross, Ernie (Dundee W)
McWilliam, John	Rowlands, Ted
Mahon, Mrs Alice	Ruane, Chris
Mallaber, Judy	Russell, Ms Christine (Chester)
Mandelson, Rt Hon Peter	Ryan, Ms Joan
Marek, Dr John	Salter, Martin
Marsden, Gordon (Blackpool S)	Savidge, Malcolm
Marsden, Paul (Shrewsbury)	Sawford, Phil
Marshall, David (Shettleston)	Sedgemore, Brian
	Shaw, Jonathan
Marshall—Andrews, Robert	Sheerman, Barry
Martlew, Eric	Sheldon, Rt Hon Robert
Meacher, Rt Hon Michael	Short, Rt Hon Clare
Meale, Alan	Simpson, Alan (Nottingham S)
Merron, Gillian	Singh, Marsha
Michie, Bill (Shef'ld Heeley)	Skinner, Dennis
Miller, Andrew	Smith, Rt Hon Andrew (Oxford E)
Mitchell, Austin	Smith, Angela (Basildon)
Moonie, Dr Lewis	Smith, Rt Hon Chris (Islington S)
Moran, Ms Margaret	Smith, Miss Geraldine (Morecambe & Lunesdale)
	Smith, Jacqui (Redditch)
Morgan, Rhodri (Cardiff W)	Smith, John (Glamorgan)
Morley, Elliot	Smith, Llew (Blaenau Gwent)
Morris, Ms Estelle (B'ham Yardley)	Snape, Peter
Mountford, Kali	Soley, Clive
Mullin, Chris	Southworth, Ms Helen
Murphy, Denis (Wansbeck)	Spellar, John
Naysmith, Dr Doug	Squire, Ms Rachel
O'Brien, Bill (Normanton)	Squire, Ms Rachel
O'Brien, Mike (N Warks)	Starkey, Dr Phyllis
O'Hara, Eddie	Steinberg, Gerry
Olner, Bill	Stevenson, George
O'Neill, Martin	Stewart, David (Inverness E)
Organ, Mrs Diana	Stewart, Ian (Eccles)
Palmer, Dr Nick	Stinchcombe, Paul
Pearson, Ian
Pendry, Tom
Perham, Ms Linda

Stoate, Dr Howard	Walley, Ms Joan
Strang, Rt Hon Dr Gavin	Wareing, Robert N
Stringer, Graham	Watts, David
Stuart, Ms Gisela	White, Brian
Sutcliffe, Gerry	Whitehead, Dr Alan
Taylor, Rt Hon Mrs Ann (Dewsbury)	Wicks, Malcolm
Taylor, David (NW Leics)	Williams, Rt Hon Alan (Swansea W)
Temple—Morris, Peter	Williams, Alan W (E Carmarthen)
Thomas, Gareth R (Harrow W)	Wills, Michael
Timms, Stephen	Winnick, David
Tipping, Paddy	Winterton, Ms Rosie (Doncaster C)
Touhig, Don	Wise, Audrey
Trickett, Jon	Wood, Mike
Turner, Dennis (Wolverh'ton SE)	Woolas, Phil
Turner, Dr Desmond (Kemptown)	Wray, James
Turner, Dr George (NW Norfolk)	Wright, Dr Tony (Cannock)
Twigg, Derek (Halton)
Twigg, Stephen (Enfield)	Tellers for the Ayes:
Vaz, Keith	Mr. Kevin Hughes and
Vis, Dr Rudi	Mr. Clive Betts

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith, pursuant to Standing Order No. 31 (Questions on amendments), and agreed to.

MR. DEPUTY SPEAKER forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House reaffirms the historic principles of the NHS, that if people are ill or injured there will be a national health service there to help, and access to it will be based on need and need alone, not on ability to pay or who their general practitioner happens to be or on where they live; welcomes the measures the Government has taken, is taking and will take that will ensure that comparable, top quality treatment and care are available in every part of the country through the introduction of new arrangements for spreading best practice, including the ending of the Conservative competition of the internal market, the introduction of local Health Improvement Programmes and Primary Care Groups to put local doctors, nurses and other health professionals in the driving seat in shaping local health care, the introduction of a new Commission for Health Improvement and National Institute for Clinical Excellence, and the creation of new legal duties of partnership and quality to ensure that all parts of the NHS and social services work together to deliver top quality services to all; welcomes the record £21 billion investment to be made in the NHS, including £18 billion for the NHS in England, over the next three years, notes the record 150,000 fall in NHS waiting lists since April 1998 and the 17 per cent increase in the number of new nurse trainees in the period since Labour came to power; and further welcomes the measures that the Government intends to take over the coming year to continue to build a modern and dependable NHS, including the extension of NHS Direct to cover 19 million people, the creation of 26 Health Action Zones covering 13 million people to target areas with particularly high levels of ill health—including cancer and heart disease—and reduce health inequalities, and the targeted investment of £30 million to modernise accident and emergency departments.