HC Deb 22 March 2000 vol 346 cc981-95 3.30 pm
The Prime Minister (Mr. Tony Blair)

With permission, Madam Speaker, I wish to make a statement.

Yesterday the Chancellor announced funding for the national health service, not just for the coming financial year, but for the three years following. Taken together with this year—the first year of the current comprehensive spending review—it means the biggest sustained investment for the health service: a 35 per cent. real-terms rise over five years, and a real-terms average increase of 6.1 per cent. per year over the next four years. That is a rise of more than double the average under the previous Government.

Yes, there have been larger one-off rises, but never a rise sustained in this way. It means that by 2003–04, NHS spending will have risen to 7.6 per cent. of gross domestic product. That is a huge increase in any terms. In a period of predicted economic growth, it is unique. It comes with an immediate injection this year of £2 billion extra for the UK, which includes the tobacco duty increase of £300 million.

We have done this because we believe in the national health service. We never want to see it broken up, reduced to a rump service for those who cannot afford to pay for private health care. The NHS is a unifying force in this country, and under us it will remain so.

Here is the challenge to us in government and to all who work in the health service, however. Everybody knows that the NHS needed the new money announced yesterday, but everybody knows, too, that the NHS needs fundamental reform if it is to provide the standard of care that people deserve in the 21st century. With the money must come the modernisation. A step change in resources must mean a step change in reform.

In our schools, we now accept that, though more investment is necessary, it is not sufficient. There is a real and often hard debate about standards, performance and reform. No one really believes that the one without the other will work. Now it is time to raise the same debate in the national health service.

This afternoon, I will set out the key challenges facing the health service, the means by which we intend to tackle them and the methods for involving the people who work in the health service in this vital task.

I say to our hard-working and dedicated staff in the health service: "You challenged us to come up with the money. We have done so. It was hard won and hard fought. There were many calls upon it—many places where it might have been spent. We rose to your challenge. Now I ask you to rise to ours. Work with us to make sure that this money is spent well: make sure that the national health service confronts the hard necessities of reform to improve the value that we get for the money that we spend."

Some health authorities and trusts carry out four times more hip replacement operations than others. We need to know why. How is it that some trusts can provide elective surgery for all their patients within six months, while in others one in eight patients have to wait more than 12 months?

In some accident and emergency departments, non-urgent patients are treated within half an hour, while in others there is a four or five hour wait. There are trusts that see nearly 100 per cent. of their out-patients within three months, while others manage less than 60 per cent.

The proportion of operations done as day cases varies from 75 per cent. in some places to less than 30 per cent. in others. There are around 5,000 elderly patients who do not need to be in hospital but are there because of complications between social services and hospitals over their care arrangements.

Some hospitals employ twice as many nurses as others to staff critical care beds. Why is there a twofold difference in the cost of care between the best and the least efficient hospitals? Some hospitals manage without long trolley waits while others have them on a regular basis. Some patients can get a routine GP appointment within 24 hours in some surgeries, but have to wait four or five days in others. The top 25 per cent. of trusts use their consultants twice as productively as the bottom 25 per cent.

There are huge variations in the proportion of patients at risk from heart disease, who get the appropriate drugs to help control their blood pressure and cholesterol. Nurses in some hospitals discharge patients from accident and emergency, and in others they do not. Some hospitals use physiotherapists to help reduce waiting times for orthopaedic appointments; others do not. Links between social services and GPs work well in some areas, but in others are virtually non-existent. Some medical teams are so much better at preventing and managing conditions such as diabetes and asthma than others.

Those are big issues. The reasons for the variations are of course complex. Some of the problems will be because of a shortage of staff and equipment, but some will be the result of poor management and inefficient organisation. Some will arise out of outdated demarcations between professionals within the service. Some will be systems failures, and some will be professional failures. Each of them must be confronted and analysed, and solutions found.

These are the five challenges that I set for the health service. First, there is the partnership challenge for all parts of the health system—GPs, hospitals, their consultants, primary care groups, social services and community health services. How do we work together to end bed blocking, reduce unnecessary hospital admissions and provide the right level of beds and services for each level of care?

Secondly, there is the performance challenge, to ensure that, using information, incentives and inspection, all trusts and primary care groups come up to the standard of the best; that we provide the right support and intervention for those that struggle to provide proper standards of care; and that the systems are in place to identify and root out poor clinical practice.

As a first step towards meeting that challenge, the Secretary of State for Health will later this afternoon give details of £660 million of the extra £2 billion for next year that will be allocated straight away to health authorities, trusts and primary care groups. He will set out how the extra money will be coupled with new incentives to ensure that every pound provides value for money.

Thirdly, there is the challenge for the professions to strip out unnecessary demarcations, introduce more flexible training and working practices and ensure that doctors do not use time dealing with patients who could be treated safely by other health care staff.

Fourthly, there is the patient care challenge. Hospitals and primary care groups should ensure that they all adopt best practice, design out delays and introduce convenient booking systems so that patients with the most serious conditions get treated quickly, and no one has to wait too long for an operation that they need.

Fifthly, there is the challenge on prevention: to balance spending on tackling the causes of ill health with treating illness; to develop a more systematic approach to treating people at risk from chronic diseases; and to persuade more people to play their part in achieving better health by adopting a more healthy life style.

Those are tough challenges. Together we need to find answers. If excellence can happen in one part of the country, I say, "Why can it not happen in all parts of the country?"

In the past two to three years, there has been substantial change and improvement. The internal market has gone. A record number of hospitals have been built. Nurses are returning to the health service. More doctors are in training. There are new services, such as NHS Direct. New standard procedures have just been published for cancer and heart treatment. Casualty departments are being modernised. There is the new Commission for Health Improvement, an Ofsted for the NHS, charged with raising standards in all hospitals, and a new institute to advise on the best treatments and drugs.

But we all know that that has not been enough, and too often the pressure of change has been made doubly painful by the pressure of scarce resources. Now we have a chance to put the extra money to work.

I have set out the challenges, but I offer to meet them in partnership with those in the NHS. In the next few months, the Secretary of State for Health and I will meet and talk to the people responsible for health care in every part of the country. We will consult the leaders of the professions and the health organisations.

For each of the five challenge areas, there will be a dedicated unit to examine the problems and come up with solutions.

Madam Speaker

Order. There are too many conversations taking place around the Chamber.

The Prime Minister

The units will be jointly led by a Health Minister and a key leader from the health service.

The health service is a national health service, and I have therefore invited the First Minister in Scotland and the First Secretary in Wales to join me in a UK-wide group to develop and drive through the reform that we devise.

In addition, for England, a new Cabinet committee chaired by me will be established to agree and monitor the standards of service and improvements that people can expect by the end of the financial year 2003–04.

In July, we will publish a detailed four-year action plan for the NHS. It will outline the improvements that we seek, the changes necessary to achieve them and the timetable for their delivery. That will not complete the journey of renewal for the NHS, but it will take us a long way towards our destination.

It will take tough, often painful decisions about change in order to make progress. However, I want all parts of the health service to sign up to the plan, to feel ownership of it, to agree the priorities we set out, and to help us deliver them. I want the country to unite around it for the future.

However, I do not and will not yield to those who believe that the NHS has had its day. It has not. A modernised health service, not private medical insurance, is the future. The values of the health service are every bit as relevant today as they were 50 years ago, but they have to be applied in a different way, for a different age.

The health service is one of the great institutions that binds our country together. It is one of the great civilising achievements of the 20th century.

It is our task as the party that created the national health service to renew it for the 21st century and defeat the pessimists and the privatisers who would see it dismantled.

Mr. William Hague (Richmond, Yorks)

The media informed us throughout the day that we would hear the Prime Minister's plan for the reform and modernisation of the health service. There was obviously some mistake in their briefing. If all the clichés and waffle that one could express about the health service had been swept into a heap, the result would be remarkably similar to the Prime Minister's statement.

The statement included such concepts as, "We must now all work together"—brilliant idea! The Prime Minister said that we must all match the standard of the best—what a very innovative thought! He suggested that together, we need to find the answers—absolutely inspirational! There will be a new Cabinet committee chaired by the Prime Minister. Wow! A new Cabinet committee! By July, there will even be a timetable for delivery. We believed that 1999 would be the year of delivery, but there will be a timetable for delivery by the middle of 2000. Today, the Prime Minister produced a timetable for a timetable.

To avoid further distortion by the Prime Minister, I make it clear from the outset that we welcome the additional funding for the national health service. We have always provided additional funding for the health service. However, the fact that the Prime Minister has made his first statement in three years about a matter of domestic policy is a clear demonstration of the Government's abject failure. The need to relaunch their policies on the health service clearly shows that they have failed so far.

After three years of mismanaging the health service, the Prime Minister has the nerve to make a statement about professional failures. What about ministerial failures in running the health service in the past three years? Through his statement, the Prime Minister has taken personal responsibility for the health service, from the Secretary of State for Health. We shall now hold him personally responsible.

Does the Prime Minister now accept that the problems of the NHS have become worse since the Government took office? Is it not the case that the out-patient waiting list has doubled, with 250,000 more people waiting to get on the waiting list? Has the right hon. Gentleman forgotten that his promise to take 100,000 people off the waiting list was an early pledge? When he said that, people thought that he meant early in the Parliament, not early in the next millennium.

Now the Prime Minister is launching yet another new initiative, setting out on yet another crusade to save the health service. People remember the Chancellor's £21 billion announcement of two years ago, which turned out to be £3 billion a year, and that the promised improvements did not take place. The right hon. Gentleman may have fiddled the figures before, but now people have figured the fiddles: they know what the Government are up to and they know that the Government have let people down. Will he accept that one reason for the letdown, which must be seriously considered in all those discussions that he is to have, is the way that clinical priorities have been distorted? Will he recognise that that has happened?

The chairman of the British Medical Association consultants committee, Dr. Peter Hawker, says that the Government have tested the tolerance of patients who are waiting even longer for treatment, and the goodwill of Health Service staff by persisting with an initiative that distorts clinical priorities and denies care to people in more acute medical need. That is what the BMA consultants think, so if the Prime Minister is to go around listening to people, that is the sort of thing that he will hear. He had better start thinking about it now. His Secretary of State claims that there is no distortion. Why does he not tell the Secretary of State to wake up, get into the real world and acknowledge that there is distortion? He has to deal with that soon, because is it not the result of such distortion that 160,000 people felt compelled in the past year to pay for their own operations rather than rely on the NHS? That is the situation—the situation that the right hon. Gentleman has created.

Is it not the Government's failure that whether people have money has become more important to their health care under Labour's management of the health system than ever before in the history of the health service? Is that not the classic story of what happens when the system is run by ill-informed and interfering busybodies whose only interest is in newspaper headlines and who produce the exact opposite effect of that which they intend? Can we have a guarantee in the Prime Minister's new, relaunched plan for the NHS to end the distortion of clinical priorities and a guarantee based on waiting times and clinical need? Why does he not set aside all the pride of the past few years and support a guarantee on that along the lines of the patients guarantee put forward by my hon. Friend the Member for Woodspring (Dr. Fox)? Can he not see that there is no point announcing money—[Interruption.] Well, the right hon. Gentleman will find that these points come up from the health professionals, so he had better start listening to them.

Can the Prime Minister not see that there is no point announcing money for the NHS unless we make sure that it gets to the patient being treated? This time, will he get the money into the hands of people who know what to do? The Government's record has not been encouraging; it has been a story of centralisation, with decisions taken further and further away from patients. What is more, have not the people whom he has trusted to take decisions been appointed not on the basis of what they know about the NHS, but on how much crawling and toadying they have done to the Labour party leadership?

Has the Prime Minister read the report of the Commissioner for Public Appointments, who says: It is clear that there have been instances where a person's political association has been a decisive factor in the consideration of their … appointments … Less successful candidates have been brought forward to replace those … identified on merit …? There is evidence to indicate that candidates who declare political activity on behalf of the Labour party have a better chance of being appointed than other candidates. That is the evidence to which the right hon. Gentleman did not respond at Question Time. Can he not see that there is no point in his wringing his hands and gnashing his teeth about people in the health service when he has produced a system of appointments debased, corrupted and contorted by the crony culture that he has built all around him?

Is not that culture also one of the distortion of numbers? Does the Prime Minister realise that no one any longer believes the figures that he presents about the health service? When people hear about the £2 billion, they know that there are already £1 billion-worth of deficits in the health authorities and £200 million of underfunded pay awards. People wonder what will happen with the £2 billion. Unless the Prime Minister can give positive answers to my hon. Friends' questions about health facilities that are closing now, and whether that will change under his plan, the figures that he is reciting will not be believed in the country at large.

Now that the right hon. Gentleman has finally recognised that he is presiding over a permanent crisis in the health service, is it not time to put in place a proper programme of reform? Is it not time that we had health care based on clinical need? It is not time that we had money going as close as possible to the patient? Is it not time that the Prime Minister co-operated with all parts of the health care sector—the NHS and the private sector—in increasing the total resources available for health care? Is it not time that he got rid of his ideological blinkers, his crony appointments and his failed approach based on political priorities?

Is it not true that this statement, which contained so many clichés and so little in actual announcements, is the ultimate demonstration of all mouth and no delivery? Is it not time that the right hon. Gentleman started to deliver?

The Prime Minister

If anyone wants to know why the Tories should not be trusted with the national health service, they need only listen to that contribution from the right hon. Member for Richmond, Yorks (Mr. Hague). The Tories opposed the formation of the health service, and now they oppose the plan to modernise and reform it. It is unbelievable. [HoN. MEMBERS: "What plan?' What we have set out has been welcomed by every group in the national health service, but it is opposed by the Conservative party. As for the health record, we are putting in a 6 per cent. real-terms increase, which is double what the Conservative party put in. The right hon. Gentleman's priorities, which include tax cuts for a few, would mean that the Tories could not possibly afford that sum of money.

We know already that the right hon. Gentleman is opposed to the tobacco duty increase. [HON. MEMBERS: "Oh."] That is right. [Interruption.] So that would be £300 million out of the £2 billion straight away. [Interruption.] Well, the right hon. Gentleman attacked the increase in tobacco duty yesterday, presumably not because he supported it. Let me state the position that we inherited. The number of beds had been cut by 40,000; the number of nurses in training had been cut; the hospital building programme had stalled; waiting lists for in and out-patients were at record levels, and there was a £500 million deficit.

If hon. Members want to know how good the right hon. Gentleman would be at managing the health service, let me point out his record when he was in charge of the Welsh national health service. When he was in charge of the health service in Wales, it lost doctors; it lost 1,200 hospital beds; waiting lists rose by 6,000; 300 nurses, midwives and health visitors were cut; and health spending increases were just a little over 1 per cent. So we know what would happen if the Tories were put back in charge.

The right hon. Gentleman goes on about private health care. We are perfectly happy to co-operate with the private sector, but we oppose forcing people to take out private health insurance. In case the right hon. Gentleman should deny that that is his party's policy—as Tories try to do occasionally—I shall quote his health spokesman. When he explained Conservative party policy, he said that people would look to the NHS to provide them with service when they had serious life-threatening conditions, and would look to their private insurance to help them with those things where the NHS had to ask them to wait. That is why the right hon. Gentleman's health spokesman called the policy a "Trojan horse". It is a Trojan horse.

However, I would have hoped that the right hon. Gentleman could support the process that we have set out today. Having delivered the money, we will now sit down with people in the health service and work out how it is best spent and how we modernise and reform the system. Of course it is right for us to talk to those people before we publish the plan. I make no apology for that; they asked for a promise, and we have delivered it. What the right hon. Gentleman has done today is put himself outside the consensus in the country that recognises that, yes, the health service needs more money, but it also needs to reform and change. We, the party that created the health service, will now work with people in the health service to rebuild it. From today's response, those people now know that the right hon. Gentleman would destroy it.

Mr. Charles Kennedy (Ross, Skye and Inverness, West)

Yesterday's announcement of additional funds for the health service is welcome news indeed. I also agree—as, I am sure, do Members in all parts of the House—that if we want to take the country with us, it makes sense to proceed with a view to the future rather than merely fighting past battles. Does the Prime Minister accept that that process would be assisted if he acknowledged that those of us who have argued for the injection of roughly the sums announced yesterday have not been behaving irresponsibly, as that is now the policy of Her Majesty's Government?

Will the Prime Minister also acknowledge that, in conducting his review, he should be upfront with the profession and the public, and openly admit that waiting list targets have distorted clinical priorities? He has cited the deplorable state of affairs in which 5,000 elderly people are languishing in hospital because no other facilities are available. Does he accept that the position is not helped by the fact that the Government have yet to respond to the findings of the royal commission on long-term care for the elderly, and that that too must be seen as part of the process? The response would be incomplete if it did not take account of those findings.

Will the Prime Minister confirm, given that the review will be rather centralised, that the extra money will find its way down to the regions—to both trusts and health authorities? All too often, extra money announced at the centre is not deployed as effectively as it might otherwise be because of insufficient flexibility locally.

At present many trusts are in deficit, and are having to conduct reviews as we speak. As we heard at Prime Minister's questions, closures are imminent. Given the extra money that has been announced, will the Prime Minister instruct the trusts to put their reviews on hold?

Finally, may I raise the vexed issue of appointments to trusts? A commission is being established for the appointment of Cross-Bench peers. Is that not a good precedent for appointments to NHS trusts? Could they not be dealt with by an independent commission, and could not political fingers be kept out of this particular pie?

The Prime Minister

On that last point, the Secretary of State is announcing our proposals in response to what Dame Rennie Fritchie said.

The findings of the commission on long-term care will be dealt with as part of the comprehensive spending review. Obviously, very important issues are involved. The £2 billion will go down to primary care groups and trusts: my right hon. Friend the Secretary of State for Health will explain how that will happen when he makes his speech.

I think that we must make a distinction. The right hon. Gentleman asked me to put on hold any hospital changes in the country. Of course I do not know the individual circumstances of each case that is put to me, but there will be circumstances in which reorganisation is the right way forward. We cannot freeze health care in exactly the same way for ever. However, there are also areas in which reorganisation will be specifically a result of problems with resources.

The differences between those two cases are exactly what we need to explore with people. Our proposal for a partnership for change, which will lead to the publication of a plan in July, will not work unless people are prepared to make difficult choices as well as easy ones in the health service. It will not work unless people are prepared to accept, for example, that it is important for us to see how elderly patients are best dealt with in the service. What is the right system to ensure that we give them the level of care that they want?

I welcome the right hon. Gentleman's approach in saying that this is the right way: to have the money upfront, and then to say, "Let us sit down with those in the NHS to work out both how we spend the money, and how we make the necessary changes." The right hon. Gentleman's constructive approach stands in very marked contrast with that of the Leader of the Opposition.

Mr. David Hinchliffe (Wakefield)

Anyone who cares about the NHS and its basic principles will warmly welcome yesterday's announcement of the huge funding increase and today's statement: they are in marked contrast with the position of the Conservative party, which appears to have completely given up on the NHS and which wants to push people into the private sector. It is interesting that, during the last Tory Opposition-day debate on the health service, two Conservative Back Benchers were present at the end of the Front-Bench speeches. There is no interest on the Conservative Benches.

May I press my right hon. Friend on three specific points? First, he will accept that, in putting that money into the NHS, we need to make best use of the resources that we have. On that basis, will he look at whether the organisational structure that we inherited from the Conservatives—the internal market, the split between trusts and health authorities—is the best arrangement? There is much evidence nationally of waste as a consequence of that split at local level.

Secondly, my right hon. Friend referred to the relationship between the NHS and social services. Will he look at combining the two organisations, as they are combined very successfully in Northern Ireland?

Thirdly, will my right hon. Friend look at the way—[HON. MEMBERS: "Order."] I will conclude on this point.

Madam Speaker

The hon. Gentleman certainly will.

Mr. Hinchliffe

I will, Madam Speaker.

Will my right hon. Friend look at the way in which, in certain areas, waiting lists are artificially created to cause demand for private treatment by the same consultants who treat people in the NHS locally?

The Prime Minister

I am sure that the items to which my hon. Friend draws attention can be looked at. Of course, primary care groups and trusts are a way of trying to preserve the concept of devolved budgets, which was the one part of the internal market that had some merit, but to get away from the idea of the paperchase for the contract, which did much damage. We want to try to keep that co-operation locally and to keep devolution, but to do away with the vast bureaucratic expense.

Several hon. Members


Madam Speaker

Order. The last questioner was the Chairman of the Select Committee on Health. I will not have further long questions. I ask for brisk questions now. I have today's business to safeguard.

Mrs. Virginia Bottomley (South-West Surrey)

Leading the health service and health care generally must be one of the greatest challenges of our generation. I am not sure that it inspires people to know that politicians are trying to take over all the leadership.

The Prime Minister talks about the professions, but not about health service managers. If all the credit is taken by politicians, but, whenever there are problems, managers are named and shamed, it has a particularly poor effect. "Health Chiefs Face the Sack" is not a helpful headline. The Prime Minister has recognised managers and leaders in industry. Will he please give recognition and support to health service managers in health care?

The Prime Minister

Of course management in the health service is important. The managers are a vital part of the service, but I draw the right hon. Lady's attention to the fact that the NHS Confederation welcomed the extra money that we put in yesterday and the offer of partnership for change. It is simply sad that the Conservative party has set its mind against it.

Dr. Howard Stoate (Dartford)

As someone who still works part-time in the health service, may I say that the vast majority of NHS workers in my constituency of Dartford both recognise and welcome the need for substantive changes in their working practices? What reassurance can my right hon. Friend give to the 1 million-plus people who work in the health service that he recognises their extremely valuable contribution and that he will continue to support them in the way that he has so far?

The Prime Minister

I certainly give that assurance. That is one of the reasons why we put in the additional money. Let us look at just one group in the NHS, the nurses. As a result of the additional staffing pay, we have had a 25 per cent. increase in the number registering for nurse training. We also made a very substantial pay increase—I think the largest that has been made—to 60,000 grade E nurses. We are trying to reward people in the health service better, but we must also look at more flexible working practices and more flexible use of people's working time. We must see how we can improve the quality of life for the staff in the health service, too.

Sir Brian Mawhinney (North-West Cambridgeshire)

Is the Prime Minister aware that, although he is right to draw attention to the service distortions that need to be dealt with, there was one alliterative challenge that he did not include in his list: patient choice. Was that an oversight, or a policy decision?

The Prime Minister

No. I do not know exactly what part of patient choice the right hon. Gentleman is referring to. If he is referring to the split between public and private—

Sir Brian Mawhinney


The Prime Minister

Well, in that case, I am afraid that I am at a loss to know exactly what the right hon. Gentleman's question is dealing with. At least he gave us some welcome for a process that will involve people in the health service. There are no holds barred in that—we shall sit down and talk about all the issues. If the right hon. Gentleman cares to explain at some other time exactly what he means by patient choice, I shall have a look at what he says.

Mr. Win Griffiths (Bridgend)

May I also welcome the fact that the Government are not jumping straight into decisions on how the £2 billion should be spent in the health service? I am also pleased that the Prime Minister said that there will be a joint committee to examine those decisions. The NHS Information Authority produced figures on the 50 most common inpatient treatments and the 50 most common day-case treatments. In Wales, for 22 of the 50 inpatient treatments, costs could vary by more than 200 per cent; for some treatments, costs could vary by a factor of five; and, for 12 of the day-case treatments, costs could vary by a factor of between five and 10. The issue, therefore, is finding the place where treatment can be provided best and most cheaply, and not simply throwing money at the health service and saying, "Get on with it."

The Prime Minister

That is absolutely right. The debate about variations in performance, and how we tackle them, is the debate that I had hoped we would have in the House today. Of course it is right that we need more resources and money in the health service. However, I think that there is a very honest appreciation by the vast majority of people in the health service that some performance variations cannot be explained by social factors, investment or money alone. There are failures in the system that need to be addressed. There is also, of course, really good practice in the health service which could be made universal if we had the right means to do it.

Mr. Kenneth Clarke (Rushcliffe)

Will the Prime Minister concede that the Conservative party has been arguing the case for more money and reform in the national health service for more than 10 years—usually while facing resistance from Labour Members and the bogus claim that we secretly want to privatise the NHS, which he has repeated today. Will he also concede that today's statement shows that the Chancellor did not want to pre-empt his comprehensive spending review for the next four years on the scale that he did yesterday? Did not the Prime Minister, in return, agree that he would take personal responsibility for trying to ensure that the money would be spent better—and did not the cliché-ridden jargon that he produced a few moments ago show that so far he has no idea how to deliver on that?

While we will all keep an open mind until July, when the Prime Minister comes forward with a plan, will the Chancellor ensure that all the money that he announced yesterday—not only the £2 billion, but the current allocation—will be given to the health authorities and trusts that need it, as there is £500 million of financial deficit out there, rather than being kept back in little packages at the centre, in the Department, to be announced and reannounced as gimmicky new initiatives in the next few months?

The Prime Minister

The right hon. and learned Gentleman probably does not agree with the Conservative policy on tax, and at least he is consistent in his view of his own Front Benchers, but the fact is that one cannot possibly have a policy which maintains that, regardless of economic circumstances, one will cut the tax burden the entire time without making swingeing cuts in public services.

The right hon. and learned Gentleman may not be properly familiar with the latest thinking on the Tory Front Bench, but let me point out to him what the Conservative chief health service spokesman—the latest Conservative health spokesman—said. He said: Philosophically we have moved on … Insurance companies could cover conditions that are not high tech or expensive, like hip and knee replacements, hernia and cataract operations, which currently involve long waiting times. We could then leave expensive treatments like cancer therapy to the NHS. I appreciate that that is not the right hon. and learned Gentleman's policy, but that is Conservative Members' policy.

In answer to the right hon. and learned Gentleman's question about the £2 billion, it is important that we get that money down to the front line. As I said, the Health Secretary will be giving details of that in his speech in the debate. However, I think that the right hon. and learned Gentleman, like me, will have to accept that there is no point in my coming to the House to say, "Here are all the details of everything that we are going to do. Now, I am going to go out and have this discussion." It is important to have that debate and discussion within the health service, and then come to the House with the plan. Then people can have a chance to question us on it. Of course we have ideas about how some of the problems should be dealt with, but it is important to have a dialogue and partnership with people. It is unfortunate that the type of one-nation Conservatism that the right hon. and learned Gentleman represents is no longer represented on the Conservative Front Bench.

Mrs. Alice Mahon (Halifax)

I thank my right hon. Friend for his welcome statement on the huge increase for the NHS and his commitment to getting better value for money out of it. I ask him to remind the Opposition that the proposals come on top of the biggest hospital building programme ever embarked on by any Government. Will he join me in paying tribute to the former Secretary of State for Health, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), and to the current Secretary of State, without whose commitment and dedication, we would not be getting a brand-new hospital in Halifax next year, for which we have waited 30 years?

The Prime Minister

I am pleased to do that. It is not merely the hospital building programme, because we have an extra 4,500 nurses now in the health service; more doctors and cardiac and cancer specialists are in training; and every accident and emergency department that needs it is being modernised. We have made many changes already, including getting rid of the old Tory internal market and ensuring that the primary care groups and trusts are put in place. However, as my hon. Friend acknowledged, we must now go further, and we shall be able to go further quicker because of the additional funding that has been introduced. Nobody should be in any doubt about the Tory party's position, which is a desire to demoralise people about the health service so that there is no alternative left to them but the Tories' private health insurance way.

Mr. Nicholas Winterton (Macclesfield)

Yesterday the Chancellor of the Exchequer announced apparently huge additional sums for the health service, which are welcome. Today, the Prime Minister has announced reform and modernisation, and we all hope that that will be successful. However, does the right hon. Gentleman not agree that the NHS is sadly all too often used as a political pawn by all political parties? The people whom we are honoured to represent in this place will not accept that Governments of whatever party are really committed to the health service until they see an improvement in the service they receive. A Liberal Democrat councillor in the Macclesfield borough had a cancer operation cancelled four times because of the shortage of intensive care beds—and people who are waiting in pain for a hip operation should not have to wait so long. Only when such cases are dealt with promptly in accordance with clinical need will people believe that the Government are dealing with the health service as they would wish them to.

The Prime Minister

That is obviously right and I thank the hon. Gentleman for his more constructive attitude. We should be able to reach a stage at which, as a result of the extra money, we can provide the intensive care beds that we need. We have increased the number of intensive care beds, but not by nearly enough, and we accept that. It cannot be done unless the money is put in, but that will only be a start. It is also the case that some acute beds in hospitals are not properly used, so change and modernisation have to happen as well. I hope that, by putting in the money and—for the time being at least—resolving the funding issue, we can get on with talking about the modernisation issue. I hope that the hon. Gentleman and other more constructive members of his party will join in that debate.

Mr. Chris Pond (Gravesham)

Does my right hon. Friend recognise that in my constituency people will prefer the five Ps of his modernisation programme—partnership, performance, professionalism, patient care and prevention—to the two Ps of pessimism and privatisation of the Conservatives, and the 1p that seems to solve all the Liberal Democrats' problems. Is he also aware that, despite the fact that we have a brand-new acute hospital of which we are very proud and which will open soon, some anxiety is still felt in my constituency about the provision of community beds. When he and my right hon. Friend the Secretary of State for Health talk to West Kent health authority and to the primary care group, will they underline the importance of a community hospital, because we have been waiting for one for a long time?

The Prime Minister

I shall certainly do that. One of the important parts of this exercise will be to make sure that we have the right level of care within the system: the right primary, intermediate and acute care. Part of the changes that are necessary will be to ensure that patients are treated at the appropriate level of care, in contrast with what often happens at the moment.

Rev. Martin Smyth (Belfast, South)

I noticed that in his statement, the Prime Minister made no mention of mental health services, although that might be a Freudian slip. Nor did he mention the national health service in Northern Ireland. I assure the right hon. Gentleman that we welcome the increased financial provision; on the other hand, we have to face harsh realities. In respect of private care and clinical priorities, why should a person with a heart condition be told that if he paid £100 he could see the surgeon sooner, then pay that £100 and still be waiting more than nine months later for the urgent treatment that he requires? It is time that we stopped bluffing ourselves that clinical care is a priority.

The Prime Minister

I do not know about the individual case to which the hon. Gentleman refers, but precisely such issues need to be investigated. Change and reform as well as additional resources for the health service in Northern Ireland will be major part of our work.

Mr. David Taylor (North-West Leicestershire)

Following the completely crass and deeply damaging decision by Leicestershire health authority, the status of the most modern, best-located acute hospital in Leicestershire, with the highest reputation, is due to be downgraded. Can my right hon. Friend confirm that before the extra £30 million is allocated to Leicestershire and its health authority, there will be a requirement that such decisions and plans about acute hospital provision will have to include a logical and sane approach to the allocation of resources.

The Prime Minister

Again, I am in difficulty in commenting on individual cases, the circumstances of which I do not know. Of course there will be additional money for the health authorities, but they will then have to look at their own priorities and judge them accordingly. It is important that we do not try to micro-manage every decision that is taken by health authorities around the country, but obviously additional resources will help to make their decision making more open.

Mr. Graham Brady (Altrincham and Sale, West)

In a damning report published this morning, Dame Rennie Fritchie spoke of a disconnection between the purpose of the board of an NHS trust or health authority and the ability of the people serving on it under Labour's policy of systematic politicisation of the appointments process. Given that she has pointed to examples of people appointed to NHS trusts and health authorities other than on merit, will the Prime Minister now identify those who have been appointed ahead of more able candidates and ensure that more able people are put in their places so that there can be progress in the NHS instead of the failure that has occurred under the present Government?

The Prime Minister

I shall simply refer to the following sentence of the Fritchie report: The issue of the politicisation of appointments is not new—the practice of inviting MPs to comment on the shortlists of candidates was first introduced by Conservative Government …

Mr. Dale Campbell-Savours (Workington)

May I express the hope that the very rigid criteria that are used in allocating money for in vitro fertilisation—criteria that vary across the United Kingdom—can now be relaxed as I have a particularly difficult case in my constituency?

The Prime Minister

I think the best thing is that I look into my hon. Friend's point and write to him.

Dr. Evan Harris (Oxford, West and Abingdon)

Does the Prime Minister accept that after 18 years of dreadful NHS Tory rule, he inherited in Oxfordshire operation waiting times that were too high and have got higher; out-patient waiting times that were too high and have got higher; and a mental health trust deficit that has got worse? He also inherited Oseney Court elderly persons' home, which has now closed under new Labour and Cutteslowe Court old people's home which has been closed for financial reasons. Eighteen beds at Abingdon community hospital have now been closed under Labour. Will any of those closure be reversed? Will he apologise to the people of Oxfordshire for the delay in bringing funding to the health service? What does he have to say to Dr. Bob Hoyle, formally a Labour councillor in the heartland ward of Temple Cowley in the constituency of the Chief Secretary to the Treasury, who joined the Liberal Democrats today in protest at Labour's decision to put pre-election tax bribes ahead of health service funding.

The Prime Minister

We have made the largest-ever investment in the health service, and it is being introduced now. This is the right time for that investment, because the Government had to cure the financial deficit that we inherited when we took office. We have done that, and we have gone through two tough and prudent years, as we promised at the last election. We did not break an election promise when we kept to very tight spending plans, we fulfilled one. We knew that we could not inherit a £28-billion borrowing requirement and do nothing about it.

The hon. Member for Oxford, West and Abingdon (Dr. Harris) did not give the full facts about what has happened in Oxfordshire. In fact, more money has been put in than the Liberal Democrats ever asked for, and in-patient waiting lists are down. It is correct to say that out-patient lists are longer, but that is why we must make sure that we put in the necessary investment, which must go along with change and modernisation. In that way, we shall get both in-patient and out-patient waiting lists down. It is also why we must make the extra investment to pay for nurses, doctors and specialists in the service.

However, the process is not helped when Liberal Democrat Members pretend that all the problems of all those public services can be solved overnight, and that there is a limitless amount of money that can be spent. That contention is not true, and it is not responsible. The Government have been determined to avoid boom and bust in the economy, and in the investment in public services. We have been able to put in sustainable investment only because we took the right decisions on the economy. In the end, that is better for the health service and for patients.