NHS Plan (Hansard, 27 July 2000)

§ The Prime Minister (Mr. Tony Blair)
With your permission, Madam Speaker, I should like to make a statement on the national health service plan.
The NHS was the greatest achievement of the post-war Labour Government. It was based on one solid founding principle: health care should be given on the basis of people's needs, not their wealth. Some objected to that principle then, some would like us to abandon it today, but this side of the House will never abandon what was one of the greatest civilising acts of emancipation this country has ever known. Our task is instead to provide both the money and the reform to make the health service and its founding principle live on and prosper in the 21st century.
As to investment, in March we took a profound decision as a Government. We had sorted out the public finances. Debt service payments were down. Spending on unemployment benefits was down. It was the tough decisions that we took on the economy that gave us the opportunity to make this historic commitment to the national health service—an average real terms increase in spending of 6 per cent. Over five years, the NHS will grow by a third in real terms, the largest ever sustained increase in its funding.
The plan shows how that money will make up for years of underinvestment. Over the next four years, it will provide 7,500 more consultants, a rise of 30 per cent.; 2,000 extra general practitioners; 450 more GP trainees and more to come after that; in time, 1,000 more medical training places each year—on top of the 1,000 already announced—a 40 per cent, increase since 1997; and more than 20,000 extra qualified nurses, to add to the 10,000 extra already in post, making 30,000 extra in total.
For decades, the NHS has failed to invest sufficiently in modern building and equipment. The plan will mean 3,000 GP premises modernised and 500 new one-stop primary care centres; 250 new scanners for cancer and other illnesses; modern information technology systems in every hospital and GP surgery; 100 new hospital schemes in the next 10 years; and 7,000 more hospital beds in hospitals and intermediate care, including the first increase in general and acute hospital beds in 30 years. That is only possible because we are making this historic investment in our NHS.
Caring better for NHS staff will mean better care for NHS patients. That is why the plan sets out new facilities for staff, starting with 100 on-site nurseries and money for individual training for all staff—not just the professions, but the support staff as well. Our task is to tackle not simply years of underfunding, but years of low morale.
We know that money alone, however, is not the solution. Over the past few months, I and my right hon. Friend the Secretary of State for Health—to whose work in drawing up the plan I pay tribute today—have had scores of meetings with NHS staff and professionals, visited hospitals and GPs, and spoken to providers and users of the NHS. Because the issue of funding has been alleviated, at long last, people have been able to lift their heads and look at the system in which they operate.
The NHS staff are magnificent. They are the greatest asset that the health service has. They are indeed the basis of the trust that the British people put in the NHS, but, 1257 in truth, they have been, and often still are, working flat out in a system that is still organised as it was in the 1940s. Today, patients and staff alike expect and demand a wholly different type of service for the new age in which we live.
What is extraordinary is that this is the first time that any Government have looked long and hard at all aspects of the NHS: the absurd demarcations between staff that keep patients waiting; the splits between social services and the NHS that make life misery for many elderly people; the consultants' contracts, largely unchanged since 1948, the issue of private practice and NHS work left unresolved; GPs' contracts being based too much on quantity, not quality; and a standoff between the private sector and the health service that is not in the interests of NHS patients—all difficult issues, all a relic from 1948, all addressed in this plan today.
Each of those issues is faced up to and fundamental reform proposed. The aim is clear: to redesign the health service system around the needs of the individual patient.
First, the role of nurses will be radically enlarged and old barriers to modern working removed. A qualified nurse has had at least three years training. It is wrong that, in many places, nurses are unable to make and to receive referrals, to admit and to discharge patients, to order tests, to run clinics and to prescribe drugs. Those old rules will be swept aside and nurses in every hospital will have that opportunity.
Secondly, let me say something about general practitioners. The vast majority do a superb job, as we all know. They are highly respected, and rightly so. We should never allow the publicity given to the few exceptions to undermine the excellence of GPs' reputation. Butagain—their contract is outdated and inflexible. GPs can do more—they could even do some of the work that is currently undertaken by consultants—and they should have far more freedom in respect of how they use the money that they have.
We aim over time, without compulsion but with clear incentives, to move GPs to a new system of contractual arrangements. The personal medical service contract will reward doctors on the basis of quality of care as well as on the basis of patient numbers, and will give doctors far more flexibility to innovate and change. [Interruption.] This will not be the old two-tier system.
There will also be more salaried doctors. Taken together, the changes I have announced will be the most significant changes in the way in which GPs operate since 1948, and will literally be able to transform primary health care in this country.
Consultants do an extraordinary job for the national health service. Their expertise and immense skill are key to its future. That is why we are increasing consultant numbers by a third, and giving leading clinicians a greater role in the setting of national standards. Again, however, the consultant contract has remained largely unchanged since 1948, and, although most consultants work extremely hard for the health service beyond their contractual commitments, there is no proper management of their time. We will ensure that all consultants have proper job plans setting out their key objectives, tasks and responsibilities; that has never happened before. Moreover, consultants' performance will be regularly reviewed.
1258 Above all, however, we want to reward most those who make the most commitment to the national health service. First, to encourage high standards of performance and use of the new national service frameworks, we are giving consultants, along with others, access to part of the new £500 million performance fund, which will give extra money to those who meet the highest standards of service. Secondly, we will merge the existing distinction awards and discretionary points schemes, and increase their funding. By 2004 we will increase the number of consultants receiving superannuable bonus from less than 50 per cent.—the present number—to about two thirds, and will double the proportion of consultants who receive annual bonuses of £5,000 or more.
Thirdly, we are offering a deal to new consultants. From now on, once a person is newly qualified, that person will be contracted to work exclusively for the NHS for the first few years of his or her service.
Again, those will be the most substantial changes to consultant contracts since 1948.
The next major reform is to remedy the extraordinary situation that means that at any one time thousands of older people are in the wrong place for their needs. They are stuck in hospital, when they could be cared for better in their own homes. For the first time, social services and the NHS will, in every area, use pooled budgets and new arrangements that will ensure that they work together for the good of the patient. When local councils and primary care trusts want to go further and merge into a single organisation, we will enable them to do so by creating new care trusts delivering one-stop care with a unified budget. When partnerships persistently fail to deliver, we will require local health and social services to join in a new care trust.
I thank Sir Stewart Sutherland, who chaired the royal commission on long-term care, and the other members of the commission. A full response is published alongside the health plan.
Today, we are correcting a major injustice in the system. The NHS provides nursing care free of charge for people living in their own home or in hospital. Until now, however, nursing provided in a nursing home has been charged for. That will now change. From October 2001, subject to parliamentary approval, nursing care in nursing homes will be treated as nursing care elsewhere in the NHS—free at the point of use.
Additionally, we are investing in a major expansion of intermediate care prevention and rehabilitation services for the elderly: by 2004, spending on those new facilities will increase to £900 million per year. We shall also, as the commission proposed, expand respite care, benefiting 75,000 carers and those for whom they care.
Taken together, the package amounts to an extra £1.4 billion per year for older people. That is more investment than the royal commission itself called for.
Next, there is a series of reforms aimed at preventing ill health and improving the nation's health, including measures to reduce smoking and improve diet. Central to that are measures to reduce health inequalities. The truth is that the gaps between the health of the poorest and the health of the better off in our society are completely unacceptable in modern Britain. Moreover, it is children who pay the biggest price for those gaps. That is why programmes such as sure start, enhanced maternity grants, 1259 increased child benefit and the new deal for communities are so vital, and why we should fight so hard to protect them against those who would abolish them.
Next, we shall reform treatment of the most serious illnesses, such as cancer and heart disease. Until now, there have been no national standards for treatment of those illnesses, and the availability of treatment has often been patchy—some people get drugs, others do not; some people are seen quickly, others are not. For each of the main conditions, therefore, there will be a national framework of standards specifying minimum standards of access and the care to which patients are entitled.
The framework for cancer, for example, will entail maximum waiting times that cover not only referral to diagnosis, but diagnosis to treatment; a big expansion in cancer screening and cancer specialists; and an end to the postcode lottery in prescribing cancer drugs. Additionally, 400,000 patients will benefit every year from new equipment for diagnosing and treating cancer. The framework for coronary heart disease will entail an extra £230 million per year by 2004; a 50 per cent, increase in cardiologists; and shorter waits for heart operations.
The national service frameworks will reflect a fundamental change in the relationship between central Government and the local NHS. The centre will do what it must do: set standards, monitor performance, support modernisation, put in place a proper system of inspection, and, when necessary, correct failure. The new Commission for Health Improvement will inspect and report on hospitals, primary care groups and primary care trusts. That information—like information on schools from the Office for Standards in Education—will be available to the public.
If necessary, the worst performing trusts will have new management put in. In future, the 3,000 non-executive board members of trusts and health authorities will be appointed not by the Secretary of State, but by an independent appointments commission. There will also be a new independent panel to advise the Secretary of State on proposed reorganisations of local hospitals and health services.
There will be maximum devolution of power to local health professionals. Over time, primary care groups will move to being primary care trusts, offering minor surgery, physiotherapy, diagnostic tests, and even minor operations in the local primary care centre. For all PCTs, health authorities and hospital trusts, there will be a new system of what is called "earned autonomy" that will radically reduce the amount of central intervention where performance is high. Patients put their trust in front-line doctors, and so do we.
The best performers will be given greater freedom and flexibility, and all will have access to additional funds tied to clear outcomes in performance. That will include a new framework—a concordat—with the private sector. There should be, and will be, no barrier to partnership with the private sector where appropriate—as the private finance initiative hospital building programme has shown. Where the facilities of the private sector can improve care or help to fill gaps in capacity, we should use it, but let me make one thing clear: we will never permit people to be forced out of the health service for non-urgent care. That would destroy the national health service. Where the private sector is used, it will be fully within the national health service, free at the point of use to the patient.
1260 We also examined in detail alternative methods of funding the health service. We concluded that the proposals of some to expand health care through tax incentives for private health insurance were massively inefficient and would take vital resources out of front-line national health service care; and that moving entirely to a continental European type of social insurance system, while less inequitable than many other suggested alternatives, would cost an extra £1,000 to £1,500 per employee per annum. We also estimated that, through the health service, administrative costs are hugely reduced compared with other systems. We were therefore confirmed in our view that what the national health service required was not dismantling but modernisation.
At the heart of the reforms is the idea of redesigning the system round the patient. Too often, whatever the quality of actual care, the patient is catered for in dirty wards on rundown premises, with standards of food and basic amenities far below what would be tolerable in other services. Part of the reforms is designed to remedy that. Clean wards and better hospital food will become central to trusts' work, with new resources to back it up.
That will get under way now. By 2002, 95 per cent, of mixed sex wards will have gone. NHS Direct will be available in all parts of the country. In time, we aim to have the ability to link all parts of the system through technology, so that one call will put the patient immediately through to the right place.
By 2005, booked appointments will have taken the place of the old waiting lists. As a first step, by April 2001, all hospitals will be using booking for two of their major conditions. By 2003–04, two thirds of all appointments must be pre-booked.
By 2004, there will have been an end to long waits in accident and emergency; people will get an appointment with a GP within a maximum of 48 hours; and, if an operation is cancelled on the day it is due to take place, other than for medical reasons, patients will get another one within 28 days or have their treatment funded somewhere else. Patients will also have more say and more choice, with a patient advocate and forum in every hospital to give them immediate help with sorting out their complaints, and a voice in how the hospital is run.
Over time, these changes, plus the money and the staff, will allow waiting times to come down substantially. By 2005, the maximum waiting time for an out-patient appointment will be three months, and for an in-patient appointment six months rather than the present 18, with urgent cases being seen the most rapidly.
Average waiting times will, as a result, also come down: from seven to five weeks for out-patients and from three months to seven weeks for operations. There will be reduced waiting times for all conditions—not just some—and our eventual objective, provided that we recruit the staff and make these reforms, is to get the maximum waiting time for any stage of treatment down to three months by the end of 2008.
There are many other proposals for change set out in the plan. It will mean, over time, radical change in the health service, but I emphasise to the country that it will take time. Some changes will be fast, but others are crucially dependent on new investment in staff and facilities coming through. Staff are crucial to this process. Uniquely, the principles that underpin this plan command 1261 the wide support of professions and staff across the NHS, as will be seen from the signatures to the principles at the start of the plan.
There is another cause for optimism: at every level of the health service, there are examples already of where change and reform have made a difference. We know that the plan is achievable because somewhere in the health service it is already being achieved. The challenge has been to remove the outdated practices and perverse incentives that have prevented the best from becoming the norm. I make it clear to all NHS staff: we will carry on with the same system of co-operative working and partnership that has characterised the past four months. This is the beginning, not the end, of that process.
The challenge is to make the NHS once again the health care system that the world most envies. Now, with the money going in, the reforms can follow so that we can proclaim loud and clear that the idea of decent health care based not on wealth or position, but on need and suffering, is not an old-fashioned principle that has had its day; it is, rather, a timeless principle that this generation has found the courage to reinvigorate for the modern world. That is what we set out in the plan, and I commend it to the House.

§ Mr. William Hague (Richmond, Yorks)
I thank the Prime Minister for his statement, but warn Labour Members that in announcements from this Government, there is always a huge difference between the announcement and the facts—[Interruption.] I shall say what some of them are in a minute. There is also a vast gulf between the announcement and what really happens.
We agree with the Prime Minister that the staff of the NHS are indeed its greatest asset. We welcome what he said about changes to the role of nurses and his apparent acceptance of the need to use the private sector when it is of benefit to patients—which comes after years of hypocritical attacks on us for advocating the same idea. However, the importance of looking at the fine print is shown on even a cursory reading of the Prime Minister's statement. Will he confirm that when he refers to 7,000 extra beds, he is including beds in the private nursing sector? He talks about funding nursing care. Will he confirm that the Press Association has been briefed that it will not include dressings and catheters, which will be counted as personal care and not as nursing care? When he says that he will not have a two-tier system of GPs, will he confirm that what he has just advocated involves some of them being salaried and some not, and some providing personal medical services and some not; so how can he lecture others about a two-tier provision? Will he confirm that an extraordinary number of the targets in his four-year plan will not be met for eight or 10 years, if at all?
Will he confirm that, in the fourth summer of his premiership, he has now made a long statement on health to the House without a single mention of the waiting list initiative that has been the centrepiece of his policy for the past three years? Is that not a stark admission of his total failure on health for the past three years?
We all remember that before the general election the Prime Minister said that we had 24 hours to save the NHS—now it is 10 years and a four-year plan. Three years on, the waiting lists to see a consultant are up by 154,000; 80 per cent, of health authorities have more 1262 patients waiting more than a year for operations; the number of cardiac bypass operations has fallen for the first time in a quarter of a century; one fifth of people diagnosed with curable lung cancer are inoperable by the time the treatment begins; the nursing profession is facing its most severe shortages for a generation, and 140,000 NHS patients were forced to pay for private care in the last calendar year.
As the Prime Minister's own adviser summed it up so well: TB has not delivered. He said that he would improve the NHS but instead things have got worse. People will judge today's plan against that background of mismanagement and failure.
Of course, selective extracts of the plan were leaked to the newspapers in advance. How extraordinary it is that the Government complain about leaks, when most of the leaking is authorised by the Prime Minister himself. It was therefore already known that the plan would contain more targets even though the current targets have not been met, and more pledges even though the current pledges have not been met. The only difference between the contents of this statement and the pledges in the Labour manifesto of four years ago is that the Prime Minister has set the targets so far in the future that he will not be held to account for whether or not they are met.
Yesterday, the Prime Minister conceded that the next Conservative Government would spend the same as this Government on health. The real debate is about how that money is spent. That is the debate about this plan. We will judge the national plan on whether it really extends patient choice, on whether it really puts clinical priorities ahead of political priorities, on whether it really breaks down barriers with the private sector and on whether—[Interruption.]

§ Mr. Deputy Speaker (Mr. Michael J. Martin)
Order. There is far too much shouting in the Chamber. Hon. Members should calm down.

§ Mr. Hague
We will judge the national plan on whether it really devolves power away from Whitehall to doctors, nurses and other health professionals. The Prime Minister has a tendency to use words such as "choice" and phrases such as "putting the patient at the centre", but not to deliver in reality. People will naturally be sceptical.
Will the Prime Minister say whether the Government have at last abandoned their disastrous waiting list initiative, of which he made no mention in his statement? Will he assure the House that the plan means that the sickest patients, such as those with cancer or cardiac problems, will be treated first, as we have long proposed?
Secondly, for all his talk—[Interruption.]

§ Mr. Deputy Speaker
Order. It is not good for the Deputy Speaker to interfere, but I appeal to the House. We must be quiet. The Leader of the Opposition is entitled to a hearing. Hon. Members do not have to agree with what he says, but he is entitled to a hearing.

§ Mr. Hague
Secondly, for all the Prime Minister's brave talk, the plan appears to create a medical apartheid between the private and public health sectors, by prohibiting NHS consultants from working in the private sector. Is the right hon. Gentleman aware that it is not 1263 general practice for people to do that in the first five years that they work as consultants? Will he say whether the period of a "few years" to which he referred amounts to fewer than five years? If the period is less than five years, the provision will make no difference. If it is more than five years, it will surely risk reducing the number of consultants working in the national health service. Will not that risk adding to the waiting list?
How does that square with the Prime Minister's stated aim of working with the private sector on problems such as cancelled operations? Should not maximum waiting times include a commitment to use the private sector if the NHS cannot deliver?
The Prime Minister talks about patient power, and says that he will set up a lot of new patient advocacy quangos. However, what is he actually going to do to give patients a real choice about which hospital they are treated in? The director of the College of Health has said: Patients have less choice now than ever in the National Health Service's history. Would not the best way to drive up standards be to restore the right of GPs to refer patients to the hospital of their choice—a right abolished by this Government last year?
The Prime Minister said that the Government would pay for nursing care but not for personal care. Will the right hon. Gentleman define those terms, and say how they differ from one another? How much of the care needed by an Alzheimer's patient is the former, and how much the latter?
As well as the rhetoric, the reality of reforming the NHS has to be about patient choice, trusting the NHS professionals, partnership with the private sector, and getting rid of political interference. Instead, is not today's statement the final admission by the Prime Minister that he has broken every promise that he made on health in the past three years? Three years into his Government he has had to start from scratch. Given that absolute failure in the past three years, should he not be assured that the British people will judge him not on what he promises that his plan will achieve, but on what it is likely to deliver?

§ The Prime Minister
I think we saw that the moment he got on to policy, the right hon. Gentleman did not have a great deal to say. When he is making his jokes and his witty remarks, he can just about do it, but when it comes to serious policy, he really does not have a clue.
First, let me remind the right hon. Gentleman that his party was in power for 18 years when many of these things were being done. Let me also deal with a few of the facts. He was rather coy about mentioning some of them at the Dispatch Box, such as his extraordinary remark the other day that there are 14,000 fewer nurses in the health service under this Government. He did not mention that today, perhaps because he knows that there are 10,000 more today.
Another thing that the right hon. Gentleman did not mention—as I have the answer, I will give it to him anyway—was the nonsense about spending £200 million on the euro. Madam—Mr. Deputy Speaker—[Interruption.] We are back to that. Mr. Deputy Speaker, the costs on the euro are negligible in the national health service. No money is being spent on the euro in the national health service—the money is being spent on the patients in the national health service.
1264 The right hon. Gentleman says that waiting lists have gone up under this Government. Let me again give him the figures. It is true that waiting lists—in-patient and out-patient—had been rising for years when we came to office. We have brought down the in-patient list by more than we promised at the election. It is correct that out-patient lists have gone up; it is correct that they are coming down now. But they were rising year after year after year when the previous Government were in office.
We do not have to argue about the theory—let us argue about the facts. The right hon. Gentleman was in charge of the health service in Wales under the previous Government. What did he do then? The number of general practitioners was cut, he cut 1,200 hospital beds, the in-patient waiting lists went up by 6,000, and he cut by 300 the number of nurses, midwives and health visitors.
Since we came to office, let me tell the House what we have done in the right hon. Gentleman's constituency. There is the £3.3 million scheme for the conversion of the Friary in Richmond to a community hospital and primary care centre, operational since 23 March 1999. Northallerton health services accident and emergency department has received £600,000. Some £500,000 has been spent on intensive care beds and £180,000 on out-patient modernisation. Shall I tell the right hon. Gentleman what those improvements have in common? They were delivered by us and they would never have been delivered by him. [Interruption.]

§ Mr. Deputy Speaker
Order. We must have some calm in the Chamber. [Interruption.] Order. We are talking about the health service, so we should all watch our blood pressure.

§ The Prime Minister
The right hon. Gentleman said that I conceded yesterday that the Conservatives would match us on health spending. They will not match us on health spending. The right hon. Gentleman has £16 billion worth of cuts to find. He has £1 billion more to find for private medical insurance. He has to find the extra money on tobacco duty, which he refused to support, which makes a £300 million hole in his funds straight away.
What is clear from everything that the right hon. Gentleman has said today, and from what his health spokesman has said, is that on the NHS, the Conservatives are more extreme than ever. They do not believe in the health service—they never did. They would not invest in the health service—they never did. They do not understand the health service—they never did. [Interruption.]

§ Mr. Deputy Speaker
Order. Hon. Gentlemen should not be shouting. [Interruption.] Order. I am not responsible for the answers of the Prime Minister. Hon. Gentlemen must be quiet.

§ The Prime Minister
I will repeat what I said. Conservatives do not believe in the health service—they never did. They would not invest in the health service—they never did. They do not understand the health service—they never did. [Interruption.] The problem with the service is that, for 35 of its 52 years, it was run by a 1265 party that did not care enough about the national health service. Well, this party does, and it will be our pleasure to rebuild it. [Interruption.]

§ Mr. Deputy Speaker
Order. I realise that it is the end of term, but the hon. Member for Lichfield (Mr. Fabricant) must behave. If he cannot calm himself, he will have to leave the Chamber.

§ Mr. Charles Kennedy (Ross, Skye and Inverness, West)
There is great symbolism in the fact of this prime ministerial statement today, and the House of Commons, as a whole, should welcome that fact. Is it fair, therefore, to acknowledge that, in the carefully crafted words of the Prime Minister today early in his statement—when he said that the plan shows how the money will make up for years of underinvestment—those years of underinvestment included the first three years of his Administration?
Secondly, when the Prime Minister says—[Interruption.] I hope that Labour Back Benchers will give me the courtesy of attention, because I am attempting to question the Prime Minister on what he said, as opposed to coming up with a pile of pre-prepared, jingoist and simplistic soundbites, paying no attention to the detail involved.
When the Prime Minister says that, for decades, the NHS has failed to invest sufficiently in modern building and equipment, he should say not that the NHS has failed to invest, but that we have failed to invest. It is the responsibility of the public in terms of the decisions taken at the ballot box, as well as of the Government of the day. Having listened to the Leader of the Conservative party, I am sure that we will have our legitimate differences across the Floor of the House when it comes to public services generally and the health service in particular, but none of us wants to return to the 18 years that preceded the development that we are acknowledging today.
Can the Prime Minister properly clarify whether the national plan includes the provision of personal care for those in long-term care, as was recommended by the royal commission? If it does not, let us be clear what that means in human terms. It means, for example, that a person suffering from dementia would be expected to pay for being bathed, fed and clothed. That is an issue of basic dignity that should be of concern to us all. It is vital that the Prime Minister should be able to confirm that.
In passing, could the Prime Minister confirm how many of those groups—including, for example, those concerned with Alzheimer's—who put their names to the NHS plan have not put their names to the Government's response to the royal commission on long-term care? That is a significant consideration, and one that the House needs to hear about. Will every mental health patient be given an absolute right to an assessment of their needs and treatment?
The Prime Minister was silent today on the issue of dentistry. What, if anything, are the Government proposing later this year with regard to that? All of us know, at a constituency level, the real difficulties people are having in even getting registered with a dentist, never mind getting or affording the treatment that follows.
1266 Finally, Madam Speaker—I mean Mr. Deputy Speaker: you are not in danger of calling me "love", I hope—

§ Dr. Evan Harris (Oxford, West and Abingdon)
Nothing wrong with that, Charles.

§ Mr. Kennedy
Following what he said during Business questions, my hon. Friend says that there would be nothing wrong with that.
Finally, Mr. Deputy Speaker, Sir, I welcome the report and confirm the commitment of my party—and our whole political and philosophical tradition—to the thinking that led to the formation of the national health service. We want the national plan to succeed: that is in all our interests. If the promises it contains are delivered, there will be better to come for the health service. I share the Prime Minister's hope that better is to come. The whole nation wants that.

§ The Prime Minister
On the right hon. Gentleman's point about underinvestment, I accept that we did not get as much money into the health service as we should have liked during our first two years. However, that happened for the simple, clear reason that we had to make sure that we reduced the enormous deficit in the public finances. If we had not done that, we would not have stabilised the economy, achieved growth and avoided the recession that many predicted. We would not, in fact, have been in a position now to achieve sustainable increases. The right hon. Gentleman is also, of course, right to refer to a failure by Government to invest.
On personal care, the right hon. Gentleman is right. We have committed ourselves to nursing care; but have decided that it is better to spend £900 million on intermediate care rather than making all personal care free. It will be up to the nurse on the ground to decide the difference between nursing and personal care. I am informed—but will get the precise details for the right hon. Gentleman—that seven out of 10 of those who receive personal care will also receive some support.
I will also check the details on mental health, but think it correct to say that people will have the right to have their needs assessed. On dentistry, the position is as I set it out last year. By the end of September 2001, everyone will have access to an NHS dentist.
There are many elements in the plan, and to list them all would detain the House even longer than I have done. I thank the right hon. Gentleman for his general support, and for the constructive way in which he has approached the issue. To Conservative Members, particularly those who object to what I have said, I say that it would have been easier if we had had something of the same constructive approach from the right hon. Member for Richmond, Yorks (Mr. Hague).

Several hon. Members
rose—

§ Mr. Deputy Speaker
Order. It is obvious that I cannot call every hon. Member who wants to speak. The briefer the questions are, however, the more I will be able to call.

§ Mr. David Hinchliffe (Wakefield)
I warmly welcome the Prime Minister's statement. The strategy that he has outlined is in marked contrast with the ragbag of a fragmented internal market that we were left by the 1267 previous Government. I pay tribute to my right hon. Friend the Secretary of State for Health for his efforts. He deserves much credit for the imagination that went into the plan. I welcome the proposals about consultants' contracts and private practice.
I have one or two detailed questions about the statement. My right hon. Friend will understand that there is some unease on the Labour Benches about the proposed relationship with a private health care sector that has consistently undermined the NHS's basic principles since 1948. Will he say a little more about the proposed concordat? Is it a temporary arrangement, and will it last as long as some of the mental health arrangements with the private sector? If the NHS is short of capacity, why do we not buy capacity on a long-term basis from the private market?
Finally, on long-term care, I warmly welcome the proposals about the relationship between health and social services, which has concerned me for many years.
Picking up on the point made by the leader of the Liberal Democrats, my right hon. Friend answered the question about the definitions of social care and nursing care by saying that the decision would be left to the individual nurse. Does the plan offer a clear definition of those two areas, one of which is means-tested and one of which is free? Otherwise, will there not be some inconsistency in the interpretation of that division?

§ The Prime Minister
On the last point, I will write to my hon. Friend as I do not want to mislead him in any answer I might give about some of the distinctions, which are complicated. Essentially, we had to choose whether we would fund all personal care in the way that the Sutherland commission anticipated, or whether it was better to use the same amount of money for a range of intermediate care projects. We decided that it was better to do it in the latter way.
I have no doubt that the debate and discussion will continue on the matter, but the commitment of £1.4 billion overall is significant. Of course, the commitment to free nursing care is intended to remove what otherwise has been a basic anomaly in the way in which we have dealt with the long-term care system.
As for the private health care sector, for me the key distinction is between that sector developing or delivering a service within the national health service and people being forced out of the NHS altogether. It would probably be prohibitively expensive to buy out all the private care as my hon. Friend suggests. However, it is also clear that if hospitals can buy in some capacity for the treatment of particular patients—obviously, this happens now to an extent—it is important to have that flexibility for the patient.
On consultants' contracts, the important thing is that, obviously, consultants will carry on with their private practice, but it is right that we contract new consultants to the national health service for the early stages of their careers, provided that we ensure that they are properly and adequately rewarded—[HON. MEMBERS: "HOW long?"] As to the number of years, that is precisely what we can now sit down and discuss with them. [Interruption.] 1268 People would complain if we imposed that on them, therefore it is sensible to discuss it with them. In the plan, we say that about seven years is a sensible time.

§ Mr. Nicholas Winterton (Macclesfield)
I welcome the Prime Minister's statement about the NHS for the future and the plan that he has put to the House. I am sure that he would accept from me—my credentials in support of the health service are, I think, well known—that the proof of the pudding is in the eating. Clearly, people will want to see how the reforms and the plan unwind. Will he assure me and the House that doctors and consultants will have total clinical freedom and that the pressures of bureaucracy put on them by central Government in respect of waiting lists will be removed?
I warmly welcome the additional responsibilities that the right hon. Gentleman is giving to the nursing profession, which could save the health service a great deal of money. Please will he be a little more forthcoming, however, about what is nursing and what is social care when dealing with long-term care for the elderly? To my mind, that matter is critical. Does he not feel that he is putting a great deal of pressure on the nurses who have to make that decision?

§ The Prime Minister
Probably, it is best that nurses make that decision, as they will be able to assess what care they, as nurses, need to provide. It is probably better to leave that decision to them, obviously with some flexibility, rather than to draw up such tight rules that they would cause more trouble rather than help.
As for consultants, of course they will have the power to determine priority cases. I make no apology for saying, however, that we are trying to get as many consultants as possible to consider new and different ways of working. Every stage of the health service that I have seen in my visits of the past few months convinces me that, by fairly simple changes that are not rocket science, the way in which patients are treated—from the time they first see their GP to the time that they have their operation—could be hugely simplified. Basic protocols and frameworks can be drawn up to allow that to happen.
Obviously, it must be for individual consultants to decide these matters, but it is frustrating when one sees that some practices in the health service have literally abolished waiting lists and times, but that those practices are not universal within the service. That is what we will try to do through the new performance fund. Certainly, I pay tribute to the hon. Gentleman's own commitment to the health service.

§ Mr. Dennis Skinner (Bolsover)
Does my right hon. Friend appreciate that while he, our right hon. Friend the Secretary of State for Health and others have been touring hospitals to devise this plan, many people have been attending hospital because they had to? During the past 15 months, I have been on a steep learning curve in the NHS. Most of those with whom I sat in queues during those months would give my right hon. Friend seven or even eight out of 10 for today's announcement. By any stretch of the imagination, this is a big day not only for the NHS but, more important, for all those people who have had to use it over the years. People left hospital searching for the blue in the sky—sometimes they never saw it. Today's announcement means that a lot more 1269 people will leave with a smile on their faces, in the knowledge that the health service has been improved—not perfection, but made one hell of a sight better.

§ The Prime Minister
I thank my hon. Friend. I hope that he is right. It will take time, but I am sure that we can do it.

§ Mr. Tim Boswell (Daventry)
As one TB to another, perhaps we can agree to overlook the adviser's memo that suggested that the Prime Minister had failed on the health service.
Will the right hon. Gentleman explain to my constituents how his announcement today will bring them a better health service when, during the past three years, successive announcements made by various Ministers have achieved a local situation in which waiting lists are at best static, the waiting list to get on the waiting list has doubled and the district general hospital is full at the height of the summer?

§ The Prime Minister
I can explain how it can become better. No doubt, the hon. Gentleman needs in his constituency more hospital staff and better facilities. That is precisely what this investment gives us. If we achieve better working between social services, primary care services and the hospital service, that too will improve the situation. I have not come to the House today to say that everything in the health service is perfect; of course it is not—otherwise we would not need this plan. I hope that we can work to achieve the changes.
I point out to the hon. Gentleman—although I am not sure whether he is too much in agreement with much that is said by Opposition Front-Bench Members—that if he considers—[Interruption.] I am sorry, I may have dealt the hon. Gentleman a career blow. I did not mean to do that; I am sure that he is wholly in agreement with Opposition Front-Bench Members. [HON. MEMBERS: "He is a Front-Bench Member."] That is even better—I am afraid I missed that.
If the hon. Gentleman analyses what the Conservatives have promised financially, there is a big division—that is a real issue for Opposition Members. With the strength of the economy, we can either put more money into our essential public services or not. His party have chosen not to do so. My right hon. Friend the Chancellor announced additional spending of 3.3 per cent. The Leader of the Opposition and the shadow Chancellor said that it should be less than 2.25 per cent. That is a fact. On my arithmetic, that means that one third comes off the spending figure. If the Conservatives are going to take a third off health spending, heaven help the law and order, transport and education services.

§ Ms Joan Walley (Stoke-on-Trent, North)
I thank my right hon. Friend the Prime Minister and the health team for all their hard work and leadership in dealing with the legacy of underfunding from the Tory years. In Staffordshire, we have already shown that, with modernisation, we can improve ambulance services. With the extra 6 per cent., we can deal with the existing underfunding.
My constituents are right behind my right hon. Friend in wanting something to be done about long-term care beds and community care for the elderly. Will he 1270 personally take an interest in the Edwards report and ensure that there is a pilot project in north Staffordshire to address funding in long-stay beds and social services with the new pooled budgets?

§ The Prime Minister
On the point about long-stay beds and community care, the additional money that we have announced today should help in part.
As for what has happened already in the health service, it is important to recognise that the position in the health service varies in different parts of the country; however, by the end of this year, for example, all the accident and emergency departments that need modernising will have been modernised, and that will make a significant difference. Therefore, I think that the money is already slowly beginning to have an effect, but obviously the additional funds cannot come in over a period of years.

§ Mr. Andrew Rowe (Faversham and Mid-Kent)
First, everyone would agree that improvements in the use of social services are desirable, but is the Prime Minister comfortable with the proposition that, inevitably, under his plans social services will revert to the kind of medical model that was deserted nearly 50 years ago? Secondly, is the right hon. Gentleman comfortable with the emasculation of the local authorities, which is happening so fast under his Government?

§ The Prime Minister
That is a new tune from the Conservative party. I do not accept the proposition on the social services and medical model, but certainly, judging by the work that I saw and the people to whom I spoke in the health service, one of the main problems is the lack of proper co-ordination between social services and local hospitals and primary care groups. As a result, very often large numbers of people—particularly elderly people—end up in the wrong place in the system. Having a pooled budget enables those bodies to look at these things together, and obviously it is then up to them to decide whether they want to go for a local care trust, which would mean a unified budget.
In some parts of the country people already have a pooled budget, and that has had a significantly better impact. Indeed, I think that in different parts of the United Kingdom, such as Northern Ireland, that has been a tradition over many years. The absence of proper co-ordination between the two parts of the service has caused distress to a great many patients over the past few years.

§ Angela Smith (Basildon)
Is my right hon. Friend aware that one of the pilots for testing the system of pre-booked appointments was actually at Basildon hospital in my constituency? Is he further aware that through the efforts of the staff at the hospital, who were pleased to change the way in which they worked, and who, through their effort and commitment, have really made the system succeed, patients all over the country have reaped the rewards of that? The response that I am getting is excellent. Will my right hon. Friend congratulate those members of staff?

§ The Prime Minister
A former chief executive of the hospital is playing a leading role in that project. The importance of the booked appointments system and the fact that it is already in use in certain parts of the country 1271 show again how things can be done. The importance of that system is that it literally ends the whole concept of waiting. In order to get there, of course, there must be a sufficiently low maximum waiting time—the system of booked appointments cannot work if waiting times are very extended. However, the system is working in certain parts of the country and the plan sets out a detailed list of ways in which it can be improved.

§ Mr. John Maples (Stratford-on-Avon)
One of the things that I believe bothers all our constituents is the length of time that they sometimes have to wait to get an out-patient appointment with a consultant. The Prime Minister announced that he wanted that maximum wait to be reduced to three months. That would be a welcome, although not desperately ambitious, target. Can he explain why it will take him until 2008 to achieve it?

§ The Prime Minister
Waiting times will start to come down a long time before that, and three months will be the maximum wait; the average will be far less. The explanation for which the hon. Gentleman asked is a perfectly simple one. For years, there have been insufficient staff and consultants in the health service. We have to expand the numbers, but that will take time. However, the other thing that we can do in the meantime is to change the system.
Consultants to whom I spoke over the past few months said that up to 40 per cent, of their time was spent unnecessarily seeing patients, because some of that work could be done by either GPs or nurses, or, in the case of back injuries and so on, patients could be seen by other qualified professionals. So, lots of changes in the system are necessary, but it will take time to get there. The changes will be seen almost immediately, but it will take some years to get the system fully sorted out.

§ Mr. Win Griffiths (Bridgend)
This is a very welcome statement and my hon. Friend the Member for Bolsover (Mr. Skinner) was absolutely right in everything that he said. Will my right hon. Friend confirm that the figures that he gave on consultants and other NHS staff were related specifically to England? If that is the case, can he confirm that it means that in Wales there will be between 375 and 400 extra consultants, to bring the health service up to a standard of which the Welsh people can be very proud?

§ The Prime Minister
Perhaps I should have pointed out that the Joint Ministerial Committee has met with people from the devolved Administrations of the United Kingdom, and it is of course for them to decide how they make progress, but I understand that they will all be publishing, in the not-too-distant future, their own version of how this money can be used and what they can get for it.

§ Dr. Evan Harris (Oxford, West and Abingdon)
Is the Prime Minister aware that early this week, the chief executive of the Oxford Radcliffe said that he was ashamed of the severe bed crisis at the Radcliffe? Of course, the chief executive has not had the opportunity to put in early extra resources. Will the right hon. Gentleman 1272 apologise for his Government's decision to opt for tax cuts in the first two years rather than investment in the health service?
Until that money, which is much welcomed, comes through, there will be a need to recruit nurses and doctors. Will the right hon. Gentleman promise not to pillage developing countries for their trained doctors and nurses?

§ The Prime Minister
First, we are putting in more beds. Secondly, the criticism of us in our first two years, especially from the Conservative party, has often been that we were too hard with people in clearing the financial deficit and so on, but we had to achieve a balance and I think that we got it right.
As for the hon. Gentleman's last point—an important point—we do not intend to try to take doctors from developing countries where they are urgently needed, but we will, where necessary for short-term reasons, recruit doctors from developed countries.

§ Mrs. Rosemary McKenna (Cumbernauld and Kilsyth)
I welcome the statement. In all plans, the devil is always in the detail. However, I think that, for the very first time, we have a Government who are committed to a holistic approach to health. Allied to other policies, that will make a fantastic difference to those people who are unable to afford health care of any other kind.
Can my right hon. Friend say how this will be dealt with in the devolved Administrations, and Scotland in particular, and will it be discussed in the Joint Ministerial Committee?

§ The Prime Minister
It will be discussed in the Joint Ministerial Committee. Obviously, it is for the devolved Administrations to decide how best to make progress. There will be changes; they will want to do it in their own way, but I think that they broadly accept the basic outlines of what we are doing.

§ Mr. David Curry (Skipton and Ripon)
The Prime Minister's statement raises the prospect of really large consortiums spanning health and social services. Where does he expect the management to come from for those? How will he maintain accountability for those services if social services then effectively become managed from the health side of that equation? Is he aware that when elderly people put themselves in residential care but run out of money to pay for it, they become the responsibility of the local authority, which is not funded for those people? That is a cause of bed blocking, and if the Prime Minister does not address it he will not tackle one of the big dislocations between health and social services.

§ The Prime Minister
It is for that reason that we are putting more money into social services as well. I agree that we need to deal with that problem.
In relation to the consortiums that will run health services locally, we have to develop a cadre of managers to do that, but the primary health care trusts that I have seen in action so far give us significant cause for optimism. They have far greater flexibility; they are able to span across primary care groups; they are able, for example, to have their own physiotherapists; they are able to make far better use of practice nurses; and they get economies of scale. That will mean that we have to 1273 develop, over time—a specific centre is being established as part of the plan—a cadre of leaders, managers and executives who can do that. That gives us the best of maximum devolution without the difficulty of the old internal market system, namely, that there was too much competition between local bodies.

§ Mr. Kevin Barron (Rother Valley)
The announcement today that the national health service will be more patient focused should be warmly welcomed by everyone in the House and outside. My right hon. Friend has just made an announcement about the next five years' investment in the national health service. Will he confirm that that will be invested in the national health service and not elsewhere within health care in this country?

§ The Prime Minister
Yes, that is indeed an investment in the national health service.

§ Mr. Peter Brooke (Cities of London and Westminster)
In the light of today's announcement, when that notable health care authority Brian Abel-Smith advised the Labour party that individual GP fundholding was a good initiative that should be made universal, why did the Government interpret and implement that advice by making fundholding collective rather than individual?

§ The Prime Minister
We received advice from many other people that it was not such a good idea. That brings me back to what was said earlier about patient choice. For doctors who were not fundholders, there was a huge restriction of choice. The benefit of an internal market was the devolution of power downwards, but the problem was the competition and the two-tier system that arose. Through primary care groups and trusts, we have tried to extend the notion of local devolution, but on a co-operative rather than a competitive basis.

§ Dr. Howard Stoate (Dartford)
Does my right hon. Friend believe that public funds should be used only for the benefit of NHS patients? If so, is that view shared by the British Medical Association, the Royal Colleges of Nursing, of Physicians, of Surgeons and of General Practitioners, the NHS Confederation and others?

§ The Prime Minister
It is, indeed, one of the principles that all the bodies to which my hon. Friend refers have signed up. It is an important principle. People are perfectly free to take out private medical insurance, but it should not be subsidised by the taxpayer.

§ Mr. David Tredinnick (Bosworth)
The Prime Minister talked about alternative funding, but said nothing about alternative and complementary medicine. Given that a quarter of the population have used some form of complementary medicine such as homeopathy, herbal medicine or channelled energy, what is he doing to make sure that such treatments are available in the NHS? Can he confirm that he and his immediate family have at some stage used some forms of complementary and alternative medicine?

§ The Prime Minister
I am not going to go into the latter point. On the former point, certain forms of complementary medicine are already available on the NHS. The plan does not specifically deal with the issue.

§ Ann Clwyd (Cynon Valley)
I am the only Member who was a member of the royal commission on the NHS, 1274 which was set up by a Labour Government, but unfortunately reported to a Tory Government. Its recommendations were ignored until this day. For those members who worked hard during those three years, it will certainly be a vindication of our efforts to find so many of our recommendations implemented in the plan.
My right hon. Friend was right to criticise the Leader of the Opposition, who left the health service in Wales in a total mess. In constituencies such as mine, we have a third-world health service as a result. I am certain that if Nye Bevan were alive, he would be standing up and cheering on this day.

§ The Prime Minister
There could be no better compliment than that.

§ Mr. Simon Thomas (Ceredigion)
I warmly welcome the principles behind this plan for England and I hope that we shall see similar principles reflected in a short time in Wales. May I draw the attention of the Prime Minister and his hon. Friends to early-day motion 885, which deplores the lack of treatment for eating disorders in some areas of England and all of Wales? About 60,000 people a year, especially young women, suffer from eating disorders at any one time. There is a lack of specialist treatment throughout England. It is a postcode lottery. Can the Prime Minister confirm that the plan will end discrimination in England so that we can look forward to a similar thing happening in Wales?

§ The Prime Minister
Child and adolescent mental health is dealt with in the plan, and that will obviously have an impact on the issue of eating disorders.

§ Ms Julia Drown (South Swindon)
I welcome the new NHS plan. It is a brave and radical plan. The reason why the Opposition respond with talk of leaks is that they were practised in that in government whereas they were not practised in understanding the NHS.
My right hon. Friend mentioned that primary care groups would move into primary care trusts. If a primary care group feels that it is best for patients that the PCG remains a group, will it be allowed to do so? He also talked about the importance of breaking down demarcations in the health service. Does the plan address the need to break down demarcations between health and social services so that all the people in the teams can meet people's needs as quickly and efficiently as possible, and so that we avoid the farce that many of our constituents face of being assessed once, twice or three times to obtain the basic care that they know they need?

§ The Prime Minister
On the first point, we want primary care groups over time to become trusts, as I think that many of them will want to do. I have detected in the groups to which I have spoken in the past few months an increasing enthusiasm for the idea of PCTs. They have seen in neighbouring areas that trusts have worked well, but obviously we have to work in consultation with the doctors.
As for budgets for social services, the important thing is that many of the matters to which my hon. Friend rightly refers and which greatly inconvenience people will disappear as a result of the new measures that we have 1275 announced, the pooled budgets that are available and, in time, if that is what people want, the creation of local care trusts.

Several hon. Members
rose—

§ Mr. Deputy Speaker
Order. I know that hon. Members will be disappointed not to be called, but this is a matter to which we shall return, and we must move on to the main business.