Health and Social Care Bill

HC Deb 10 January 2001 vol 360 cc1080-125

Order for Second Reading read.

Mr. Speaker

I should inform the House that I have selected the amendment in the name of the Leader of the Opposition, and that there is a 15-minute limit on Back-Bench speeches.

3.35 pm

The Secretary of State for Health (Mr. Alan Milburn)

I beg to move, That the Bill be now read a Second time.

When the Government came to office, our first job was to stabilise the national health service. Decades of neglect, coupled with years of failed reforms, had left the NHS with neither the investment nor the fundamental changes that it needed. [Interruption.] If the hon. Member for Mid-Worcestershire (Mr. Luff) thinks that that is so funny, perhaps he will explain why, when this Government came to office, the health authority in his area of Worcestershire had built up debts of £12 billion under the previous Conservative Government. Would he like to stand up and explain why that was? The truth is that the internal market imposed on the health service by Conservative Ministers had failed patients and disempowered staff. It created a lottery in care and failed to raise standards.

In our first two years, the Government laid the foundation for fundamental reform in the national health service. The internal market—tough on finance but soft on quality—has now gone. In its place there is a new emphasis on raising standards. Doctors and nurses know patients' needs best, and they are now in the driving seat to shape local health services, controlling about £20 billion of NHS spending every year.

Secondly, after decades of under-investment, we have supplied the new resources that the NHS needs. For years, the NHS budget rose by just 3 per cent. a year. In the previous Parliament, it grew by even less. In the final year of the Conservative Government, NHS spending actually fell in real terms. Cuts for the short term did lasting damage for the long term. There were cuts in the numbers of nurse training places, of beds and of GP trainees, and there were cuts in spending on buildings and on equipment.

For 18 years, the Conservatives short-changed the national health service. Their failure to invest then is the root cause of NHS problems now.

Mr. Peter Bottomley (Worthing, West)

Will the Secretary of State give way?

Mr. Milburn

There are too few doctors, nurses and beds. If the hon. Gentleman has a convincing explanation, I look forward to hearing it.

Mr. Bottomley

While the Secretary of State is talking about such matters, will he say at what stage he or his junior Ministers decided to abolish community health councils, and why they did not consult on that decision?

Mr. Milburn

As the hon. Gentleman would expect, I shall come to the matter of community health councils. However, as far as consultation is concerned, I know that under the Conservative Government it tended to be merely a period of time rather than a meaningful exercise. The hon. Gentleman will recall that last year the Government embarked on the largest consultation ever undertaken in the national health service. He cannot claim not to have heard about it, as he and other Conservative Members were busy criticising it.

We consulted the British people and NHS staff, and we received a quarter of a million responses. We assessed what action, in terms of policy and investment, needed to be taken to turn the service around. That required both new resources and new reforms.

Mr. Graham Brady (Altrincham and Sale, West)

Will the Secretary of State say how many of those quarter of a million replies called on him to abolish community health councils?

Mr. Milburn

There were many different views as to the best way to ensure that the voice of patients could be enhanced within the national health service. If the hon. Gentleman wants me to demonstrate the range of the responses received from various organisations with regard to CHCs, I should be happy to oblige.

For example, Marianne Rigge is the director of the College of Health, of which the hon. Member for Altrincham and Sale, West (Mr. Brady) might know. It is responsible for providing patients with information about waiting times, for example, and is an extremely reputable organisation. She said: The College of Health welcomes the new statutory duty for public involvement and consultation by health authorities, primary care trusts and NHS trusts. We also welcome the creation of Patient Forums as statutory bodies. Claire Rayner is involved with patients' associations, and she said: I welcome the proposals put forward by the Government which will allow patients to influence directly the services they receive. The NHS Confederation supported the proposals, and the Local Government Association stated: The proposals are an important contribution to a more patient centred and locally accountable NHS. [Interruption.]

Mr. Speaker

Order. I do not expect the hon. Member for Worthing, West (Mr. Bottomley) to shout down the Secretary of State. That is just not acceptable.

Mr. Peter Bottomley

I apologise for causing you to rise, Mr. Speaker. However, I was not trying to shout the Secretary of State down, but to encourage him to answer the specific question that he allowed me to ask. I asked when he decided to abolish community health councils, and what consultation was held on that. He was not answering that question.

Mr. Speaker

I would not have expected the hon. Gentleman to shout encouragement to the Minister either.

Mr. Milburn

The hon. Gentleman should know better. The fact that he did not receive the answer he wanted does not mean that it is not the right answer.

Step by step, the Government are putting right what the Conservatives did wrong. In just five years, the NHS will grow by a third in real terms—that is the biggest growth that it has ever experienced. Capital budgets that fell by an average of more than 2 per cent. a year in the last Parliament are growing by an average of 8 per cent. a year in the current Parliament.

Of course it takes time for resources to produce results, but after decades of neglect the NHS is moving in the right direction. Waiting lists that rose by 400,000 under the last Government have fallen by more than 130,000 under this Government. Hospital bed numbers that were cut by 40,000 under the Conservatives are now rising again with Labour.

Mr. Roger Gale (North Thanet)

Will the Secretary of State give way?

Mr. Milburn

I will in a moment. I have already given way two or three times.

Cancer and cardiac services that had been shamefully neglected are now receiving the investment that they need: they will receive an extra £450 million in the next year alone. Nurse numbers, cut in the 1990s, have risen by 16,000 under this Government.

Mr. Gale

Given his extravagant tirade of abuse against the last Government and his equally extravagant claims for the present Government, can the Secretary of State explain why the private nursing and private residential care sectors are in almost as much despair as farmers? Can he explain why nursing homes in east Kent are closing at a rate of almost one a week? Can he explain why we have lost more than 200 beds since April? Can he explain why hospital beds are being blocked by patients who should not be there, and why operations—although he claims that the situation is improving—are being cancelled daily?

Mr. Milburn

The hon. Gentleman asks for an explanation of what is happening in areas including his own. As he will know, it is true that some nursing homes are closing—[Interruption.] Of course that is true, and of course some residential homes are closing as well, largely because of changes in property values in the hon. Gentleman's area.

Those nursing home closures, however—and the reduction in the number of beds—have been more than compensated for by the extra money that we have invested through our social services spending. The question for the hon. Gentleman, and for the Opposition health spokesman, the hon. Member for Woodspring (Dr. Fox), is this: if the Conservative party is so concerned about closures of care homes and bed blocking in hospitals, will it now commit itself to matching our increases in social services expenditure? That is a simple question, requiring a yes or a no.

Mr. Stephen Day (Cheadle)

Perhaps the Secretary of State can answer my question—that is what he is here for. He constantly tells the House of the "neglect" of the NHS that took place during the 18 years when the Tories were running it. The NHS, incidentally, was safer for longer in our hands than under Labour: the Tory party has run it for more years than Labour ever has. Does the right hon. Gentleman accept that there was a 70 per cent. real-terms increase in the NHS budget between the election of a Conservative Government in 1979 and the regrettable election of his party in 1997?

Mr. Milburn

If I were the hon. Gentleman, I really would not start giving facts and figures about investment in the NHS. For nearly 20 years, the Conservatives increased NHS spending by about 3 per cent. in real terms. That was not enough to enable the NHS to keep pace with changes in technology and treatment, let alone modernise services for patients. It left the NHS in the state in which it is today. Hon. Members on both sides of the House acknowledge that there are too few beds, too few nurses and too few doctors, that not enough patients are being treated, and that there is not enough investment in cancer and cardiac equipment. Over five years, we are doubling that investment.

If I were the hon. Gentleman, I would look at what the Conservative Government did in the last Parliament. In their last year in office they cut NHS expenditure, cut capital budgets, failed to invest, and cut the number of nurse training places. A little less bleating from the Conservatives would not come amiss.

Today, the NHS is a service in transition. It is true that too many patients still wait too long for treatment, and it is true that more staff are still needed. There is a long way to go, but progress is taking hold. None of that happened by chance; it happened because of the choices that the Government made, and they were the right choices for Britain. We chose to get the public finances back in order to give the country economic stability after years of instability. A strong and growing economy is now providing the foundations for strong and growing public services, not just for one year—it is not a one-off—but for year after year after year of sustained investment. That is what the NHS needs, that is what the Government are delivering, and that is what the Conservatives would cut back.

Investment on its own, however, will not deliver the goods for patients. The NHS needs sustained reform to run alongside the programme of sustained investment. The fundamentals of the NHS—its principles, fairness and the commitment of its staff—are sound, but major changes are needed if it is to meet the aspirations of the public, staff and patients for services that are faster, fairer and more convenient.

The sustained investment that we are making provides the best ever opportunity fundamentally to redesign the health service around the needs of its patients. The NHS plan that we published last July sets out the essential reforms necessary to transform the way in which the NHS works. They address many of the underlying weaknesses that have bedevilled the NHS for decades, such as old-fashioned demarcations between staff, barriers between services, the lack of clear incentives to provide encouragement for better performance, over-centralisation of decision making and the fact that patients lack real power inside the system. The Bill addresses those fundamental problems which have for too long held back the NHS from realising its full potential.

First and foremost, the Bill is about devolving power from the centre to the local—from the NHS executive and the Department of Health to front-line clinicians, local hospitals, primary care groups and, above all others, patients themselves It transfers the oversight of local primary care services. Let us not forget that in all the discussions about hospitals that inevitably take place in the House—[Interruption] There must be something happening, Mr. Speaker, because all the Opposition's bleepers have gone off at once. No doubt someone from their Front Bench I as gone too.

The oversight of local primary care services—the primary point of contact for patients with the NHS—will be transferred from national quangos to the local health service. The House knows that in the past few years we have strengthened systems of accountability and inspection in the health service. The Bill goes further and offers more support to doctors and better protection for patients. Let me emphasise one important point: the overwhelming majority of doctors do a brilliant job for the NHS, and I believe that it is in their interests, as well as those of the patients, for the few problem doctors whom patients en counter to be dealt with fairly and quickly.

The NHS tribunal system is responsible for deciding whether an individual GP can remain practising within the NHS when concerns have been raised about his or her performance. That system has failed. It has not acted swiftly enough to suspend GPs or remove them from NHS lists when they pose a real risk to patients. The Bill abolishes the tribunal. Its role will be devolved to local health authorities, allowing them to take urgent action when there is a local cause for concern. There will, of course, be a right of appeal to an independent body.

Together with other measures that we are taking, such as the annual appraisal of all doctors, the Bill will provide extra safeguards for patients, including a requirement that previous convictions and judgments by regulatory bodies be reported to the local authority. The new system will be faster, fairer, more flexible and offer better protection for patients.

Dr. Peter Brand (Isle of Wight)

I welcome anything that will speed up the control of unsatisfactory doctors, in particular the idea that the disqualification or suspension of a doctor by one health authority will be valid for all other health authorities. However, I am concerned that there is no parallel provision for doctors who are approved to serve on the list of one health authority automatically to be included on the list of other health authorities. That will make life extremely difficult for locums and others.

Mr. Milburn

The hon. Gentleman is aware that, particularly where there are GP shortages, local patients and local health services rely disproportionately on locums. The truth is that, hitherto, we have not had an appropriate structure to ensure that they are capable of providing services of the highest standards to patients. As we all know, there have been unfortunate incidents involving locum GPs.

The vast majority of locum GPs, like the vast majority of permanent GPs, do a first-class job, but some do not. We cannot allow such people to slip through the net, which is why there are proposals to ensure that every health authority list not only includes full-time GPs who work permanently for a practice, whether single-handed or group practices, but registers for the first time locum or temporary family doctors. I believe that that will make a substantial difference, certainly in assuring the public that those from whom they receive care and treatment are always of the highest quality, wherever they come from and whether they be temporary or permanent.

Dr. Brand

Perhaps I did not make my question completely clear. The issue is that a disqualification by one health authority disbars a person from working in all health authorities. An approval by one health authority surely should allow a person to be approved automatically by all other health authorities. The Bill does not make that clear.

Mr. Milburn

If the hon. Gentleman wants to be a member of the Committee and wants to go into those issues in detail, he will have an opportunity to do so—there is an offer he cannot refuse. The Bill says that to practise in any health authority, a locum has to be on the list of one health authority. I hope that that will get the balance right in ensuring that We provide proper safeguards for patients but do not over-bureaucratise the system, and that my remarks offer him the reassurance that he wants.

Dr. Howard Stoate (Dartford)

I am grateful to my right hon. Friend for giving way.[Interruption] There is a doctors' lobby going on, I am afraid, and the doctor will see the Secretary of State now.

My right hon. Friend rightly says that certain parts of the country have to rely too heavily on locum doctors. Will he clarify the point about the Medical Practices Committee, which is able to oversee the number of GPs across the country to ensure equitable access to services for patients? If that committee is abolished as the Bill proposes, how will he ensure that there remains a good spread of GPs and that that spread will be overseen centrally to ensure that pockets of real shortage do not exist next door to pockets of relative plenty?

Mr. Milburn

My hon. Friend speaks as more than a locum GP—he is an expert GP on those issues. On the question of the Medical Practices Committee, the Bill proposes to establish yet another quango and devolve that down to the local health services. The Medical Practices Committee is supposed to ensure an even distribution of GPs between areas, but the truth is that it has failed to do its job properly. Hon. Members have only to look to Barnsley, Sunderland and some inner-city areas to realise that those places are not over doctored, but under doctored. It is entirely right and proper that the people who should take decisions about whether they need to recruit more GPs should be these responsible for overseeing the provision of local health services, rather than some national committee that has simply failed to do the job.

I offer my hon. Friend this reassurance: the Department of Health and the NHS executive must and will ensure that there is oversight to get the incentives in the right place, particularly through the new personal medical services contracts. That will ensure that we recruit family doctors to the areas where they are needed most.

Mr. David Chaytor (Bury, North)

Will the new powers for health authorities include one to monitor in detail the performance of individual doctors? I speak as one of the few Members—perhaps the only one—whose family was registered at one of the group practices where Dr. Shipman formerly worked, so I have a close interest in the matter. It is surprising that I am here, in view of the circumstances. At a very early stage in the Shipman case, there was well-documented local evidence of malpractice, which was not picked up and not formally fed into the system. Will the health authorities' new powers change that?

Mr. Milburn

I think that they will do so. As my hon. Friend knows, there is a raft of measures to strengthen the safeguards that he seeks. Some of those measures are contained in the Bill and require new legislative powers, although others can be introduced under existing powers.

The most important of the measures that we are taking, apart from the establishment of the Commission for Health Improvement and the new National Clinical Assessment Authority, is the introduction of a requirement for all doctors, whether family or hospital doctors, to undergo annual appraisal. Many people would expect similar arrangements to exist in other industries and other parts of the public sector. Although such measures can be controversial, the provision enjoys a great deal of support not only among patients and patients' organisations, but in the medical profession. There is now a recognition that things cannot continue as they have done.

We must be careful with the assumption that there is a raft of doctors who go around killing their patients, as that is not the case. We must be clear about Harold Shipman and his crime. He was a cold, calculating and evil killer who manipulated the system and abused trust in the most callous way imaginable. The Bill deals with poor performance and with spotting problems early on. That is what we must deal with.

I remind my hon. Friend the Member for Bury, North (Mr. Chaytor) of what happens every time the cases in question arise. There is a recurring pattern. Everybody knows that there is a problem, except, of course, the patients themselves. It is gossiped about by managers and clinicians in the local health service, but nobody does a damn thing about it. That is what we must change. Such change is difficult, controversial and will not always enjoy support, but I say to my hon. Friend that it is the right thing to do. Things must change and move on. In my three and a half years in the Department of Health, I have found that a big sea change has also occurred in the medical profession, which now recognises that these matters must be hammered out jointly between it, the Government and patients' organisations. That process is in the interests of the profession and of patients, and the Bill is a big step forward in that respect.

The Bill contains other measures that will improve services for patients. Not least among them is the formation of local care trusts. The Bill gives local health and social services the power to form new care trusts, bringing their services together under one organisation to provide more seamless care for patients. In the overwhelming majority of cases, care trusts will be formed as a result of agreed local decisions between health and social services. In the rare case in which either service is failing patients, however, the Bill provides powers to compulsorily form a care trust.

As hon. Members from all parties know, the truth is that local services, which often serve markedly similar populations, have different levels of performance. Some are good, a few are bad and all could be better. That lottery in care is not good enough. It was made worse by the fragmentation associated with the internal market, but no one should believe that a return to old-style, centralised command and control can deliver for the NHS in the 21st century. The NHS is too large and too complex an organisation to be micro-managed from Whitehall. What is needed instead is a combination of clear national standards so that patients know that they can expect a quality service, regardless of where they live. Local responsibility should determine how best to meet those standards.

Rev. Martin Smyth (Belfast, South)

I appreciate the Secretary of State's remarks, but does he accept that there is some concern about the division that may still remain between health care and social care, and about the definition of nursing care? Will guidance be provided to ensure that the trust will pay for health care? I should also like to check another point now, to avoid intervening later. I take it that clause 60, which deals with prescribing rights, brings Northern Ireland into line with the rest of the United Kingdom, especially in respect of nurse prescribing.

Mr. Milburn

Yes, it does, and I hope that that is welcome. The provision will extend the right to prescribe to nurses and other health professionals such as pharmacists. That will make for better and faster services for patients and will reduce pressure on the family doctor service.

The hon. Gentleman's first point concerned health care, social care and funding. I shall deal in a moment with the royal commission's recommendations and with the part of the Bill in question. When we have hammered out agreement on the definition of free nursing care, we will expect that, if the go ahead is given to free nursing care for the individual patient, it will be funded by the local health service.

What is needed today in the NHS is a combination of clear national standards with responsibility for local delivery. For exceptional circumstances, where services persistently fail, the Bill proposes new powers to replace failing management teams and to bring in new leadership. The more that standards rise and modernisation takes hold, the more that devolution can take place. The concept of earned autonomy, which was outlined in the NHS plan, has gained widespread support within the NHS. The Bill seeks to enshrine it through a new performance fund, which will rise to £500 million a year. The best performers will be free to spend those extra resources without strings attached; others will have to earn the right to that flexibility.

The views of patients will, for the first time in the NHS, help to determine the cash that local services receive. That seems to me to be right. The relationship between the patient and the service must fundamentally change. For too long, patients have been too much talked at and not enough listened to. When they have had an immediate problem with a service, they have not always been able to have it addressed quickly. The complaints system is discredited; few rights of redress have been available. The patient's voice does not sufficiently influence the provision of services. Local communities and local democracy are poorly represented in NHS decision-making structures. The culture is more of the last century than of this century: that must now be reformed.

Giving patients new powers is one of the keys to unlocking patient-centred services. The Bill will strengthen the way in which we involve patients in the NHS. It will give patients more say than ever over how their health service works for them—but that, too, requires fundamental reform.

I know that there are concerns in the House about some of the proposals, most notably about the abolition of community health councils. We listened very carefully to the arguments that were put to us and took action when drafting the Bill to respond, most notably by strengthening still further the independence of the new structures that we propose.

The first major change to make local health services more accountable to the local communities that they serve involves giving new powers of scrutiny over the local NHS to those elected by the local community—to the local council. On democratic grounds, I believe that that is right. Health authorities will have a duty to consult local authorities on proposed major changes to service development. Scrutiny committees in the local authority—formed on an all-party basis—will be able to refer contested proposals to the new independent national reconfiguration panel if they think that the plans are not in the interests of local people.

Mr. Hilton Dawson (Lancaster and Wyre)

I welcome the renewed role of local government in scrutinising vital health services. Will my right hon. Friend assure me that, where a shire council and a district council have different functions, both will be involved in scrutiny at district level, which is crucial?

Mr. Milburn

There are two points on that issue. First, the lead will probably be with the social services authority. In some cases, that will be in the old so-called district councils, as in my area of Darlington, which has a unitary council, and in others it will be in county councils. We will ensure the involvement of district councils.

Secondly, we will work very closely with the Local Government Association to ensure that appropriate guidance is given to local health services and authorities. Council boundaries form a patchwork quilt— some local health services cross many local authority boundaries—so we shall have to ensure co-ordination. I believe that that can be addressed through guidance.

Mr. David Hinchliffe (Wakefield)

On democratising the health service and the relationship between it and social services—I support my right hon. Friend's desire to achieve that—why not simply shift the health authority function to local government and deal with the job lot in one go?

Mr. Milburn

My hon. Friend has been extremely consistent on this point, and I have been extremely consistent in resisting it down the years. I do not believe that that is what the national health service needs. It has had years of structural and organisational upheaval. Of course we need to change the structures when that is appropriate, but our emphasis now is not just on the structures but on incentives and on breaking down barriers between services and staff. That is precisely what the NHS needs.

I do not believe that the best way forward is for the NHS to have a local government takeover. Incidentally, I do not believe that the best way forward for local government and social services is to have a national health service takeover. When services work together on the ground—the new care trust will provide a model for that—partnership among organisations is enhanced and the service to patients is enhanced and more seamless.

I am sure that, like me, my hon. Friend meets the most vulnerable people in his constituency surgery who find the current system byzantine. It must change, and it must be made easier. We must have more seamless services, better co-ordinated planning and more consistent assessment of people's health and social care needs. That is precisely what our proposed reforms will do, including the care trusts.

Mr. John Bercow (Buckingham)

Will the right hon. Gentleman give way?

Mr. Milburn

I shall give way to the hon. Gentleman, and then I shall make some progress.

Mr. Bercow

On 31 October last year, an early-day motion was tabled that rightly celebrated the work of the community health councils. Does the Secretary of State recall the letter that shortly thereafter was sent by the Prime Minister's agent, Mr. John Burton, which said "Tony agrees with every word of the motion. Tony would certainly like to add his congratulations to the work of the community health councils over the past 25 years, and he wishes them every success in the future"? Had the Prime Minister at that stage already decided to scrap those community health councils, or did he stumble on that stupidity only at a later stage?

Mr. Milburn

I was looking for a reasoned argument from the hon. Gentleman, but more fool me. I am not privy to the Prime Minister's correspondence, but of course many community health councils have done a good job—some have and some have not. We should not be conservative about this issue. We should consider what is needed from the patients' point of view. No organisation has a God-given right to exist. Governments do not have a God-given right to exist. Community health councils do not have a God-given right to exist. MPs do not have a God-given right to exist.

If the hon. Gentleman looks at the problem from the patients' point of view, what do they need? If they are in a hospital or in a primary care setting and they have a problem—heaven knows, people encounter problems in the national health service—they need somewhere to go to get it nipped in the bud before it becomes serious or it engenders a serious complaint. They need a complaints system that is accessible, open and independent. If they have a serious complaint, they need help through the complaints system. They also need a form of inspection and accountability so that they are able to assess how well the local health service is performing. We are putting all those measures in place.

Mr. Simon Burns (West Chelmsford)

Will the right hon. Gentleman give way?

Mr. Milburn

I shall make progress, but I shall give way to the hon. Gentleman in a second.

The Bill establishes entirely new, independent and statutory patient bodies in every part of the country. Every NHS trust and every primary care trust will have a patients forum made up of individual patients and representatives from patients' groups and voluntary organisations. Patients forums will not be managed by the trust, they will not be funded by the trust and they will not be answerable to the trust. The Bill makes it clear that it is the other way round. NHS trusts will have to answer to the patients forums.

The forums will be wholly independent. Unlike CHCs, which are partly appointed by the Department of Health, members of each new statutory patients forum will be appointed independently by the new independent NHS appointments commission. Furthermore, every patients forum will have the power to appoint a non-executive director to the trust board. For the first time, patients will elect a patient to the governing bodies of local health services as of right. For the first time, too, a patients' organisation, the forum, will be able to monitor, review and inspect all aspects of local health services from the patients' perspective. It will be able to visit and inspect every place in which patients are treated—hospitals, nursing homes, private health care, and, for the first time, all primary care settings.

Mr. Clive Efford (Eltham)

I am grateful to my right hon. Friend for his reference to the involvement of the voluntary sector because, in my experience as a former member of a CHC, it provides enormous expertise and insight into the way in which the NHS operates, which has allowed it to be an effective patients' advocate. How will patients be selected for the patients forums? At the moment, they appear to be self-selecting. How patients become part of the forums is a bit of a mystery to me.

Mr. Milburn

There will be two points of entry to the patients forums, but only one organisation responsible for the appointments, which will not be me, other Ministers or the Department of Health but the completely independent appointments commission. I hope that that deals with the concerns that are being expressed about independence.

As we all know from our constituencies, extremely good local patient and voluntary organisations do a brilliant job, whether they be the local branches of the Alzheimer's Disease Society or the Multiple Sclerosis Society. It is right and proper that we should give such organisations the opportunity better to influence local health services. Therefore, they will be represented, as of right, on the patients forums.

The second group of people who will be represented is simple and straightforward—the patients who have previously used the health service. That is reasonable. We all use local health services, but the people who really count are the patients themselves, so it is right and proper that they should have an opportunity to put themselves forward to the independent appointments commission, which will make a decision and try to achieve the right balance between different interest groups, genders, races and so on to ensure that every primary care trust and NHS trust has an organisation that it can be legitimately said is standing up for and properly representing the needs of patients.

Mr. Burns

If the forums and patient advocacy liaison services will be so independent and reflective of the wishes of local people, can the right hon. Gentleman reassure the Parliamentary Secretary, Lord Chancellor's Department, the hon. Member for Wyre Forest (Mr. Lock), that they will have more effect and influence than community health councils and other local people on the changes to Kidderminster hospital, which are so deeply unpopular?

Mr. Milburn

I thought that the hon. Gentleman intended to make a serious point. I am happy to have a serious debate about some of these issues. He will know, having dealt with such matters as a Minister in the Department of Health, that local service changes are always under way in the NHS, and rightly so. Some are more controversial than others. At the moment, a contested local service change will land on my desk, and, ultimately, Ministers have some responsibility for ensuring that the right decisions are made. In future, an independent reconfiguration panel, comprising clinicians, managers and patients, will assess whether a decision is in the best interests of the local NHS and patients. That will be a much more coherent way to make decisions and it will help to take some of the silly party politics out of such issues.

Dr. Brand

I welcome the greater independence that is now being proposed for patients forums. Although patients are important, are not people important before they become patients, and communities too? Are we not at risk of handing over an important function to a special interest group? Is the Minister not designing a scheme for a national illness service, rather than a national health service? Are not we likely to lose the public health input, which is so important and was available through community health councils, and especially through their local authority membership?

Mr. Milburn

I thought that the Liberal party was committed to the idea of democratising the national health service. Does the hon. Gentleman oppose the idea that we should transfer the extremely important function of monitoring on behalf of the local community how well the local health service is performing from an unelected body—the community health council—to an elected body that, in the end, has to face the crucial test, doing what we do every few years, which is to stand for election? That seems to me to be precisely the right thing to do.

The patients forum will also oversee the work of the patient advocacy and liaison services, which will provide an entirely new tier of service in the NHS: someone to sort out problems within hospital or community services on the spot, be they poor communication, worries about cleanliness or discharge arrangements.

PALS will be placed in every trust to have the knowledge and clout to sort out problems for patients before they escalate into serious complaints. To safeguard against their "capture" by NHS trusts or primary care trusts, the independent patients forum will be able to recommend that a patient advocacy service be taken out of the trust and be run independently from it.

The fourth element of the new system will be an effective complaints procedure. The existing complaints system is being reviewed and I want the new system to be much more independent than the old. It is likely, for example, that when necessary it will be fully independent of the NHS body being complained about, unlike in the current system. In addition, there will now be an independent advocacy service commissioned in each area to support complainants. Some have suggested that there would be particular advantages if the services were provided by a local authority. There is merit in that argument, and we will be very happy to consider it further in Committee.

To ensure that there is a strong voice for patients nationally as well as locally, we are working with voluntary and patient groups, including the College of Health and the Long Term Medical Conditions Alliance, to explore how best to form a national patients' organisation to act as an independent umbrella body for NHS patients. The feasibility work is being funded by my Department, and I expect that when it is completed in March the Department will in turn provide the funding needed to establish and run the new national patients' organisation.

Ms Debra Shipley (Stourbridge)

As the long title of the Bill says that it is intended to make provision in relation to the supply or other processing of patient information will my right hon. Friend consider favourably a small amendment to allow my constituent Marian Jordan to register her late husband's name on her son Daniel's birth certificate? As the law stands, birth information—and therefore medical history—is inaccurate by omission. I might add that such a commitment was given by my hon. Friend the Minister for Public Health in August.

Mr. Milburn

We have agreed the policy, I am told—so it must be right. I know that my hon. Friend the Minister for Public Health has agreed the policy, and I will be happy to chase it up. Clearly, if we can make progress on it, we should do so.

Helen Jones (Warrington, North)

Will my right hon. Friend clarify the role of the independent appointments commission? I am concerned that large parts of constituencies such as mine remain under-represented throughout the health service. Will the commission actively seek applications from unrepresented groups and areas rather than simply appointing from among those who put themselves forward?

Mr. Milburn

That is obviously the right thing to do. Before 1997, women and people from black and ethnic minority backgrounds were under-represented on trust and health authority boards. We changed that precisely because Ministers operated to a clear set of guidelines that increased the ethnic and gender mix on those boards. We can give precisely the same guidance to the independent appointments commission.

It is important to recognise that, for too long, decision making in the national health service has been behind closed doors and that all too often it has resembled a secret society rather than a public service. We have to open it up to all sections of society because the national health service does not serve just one part of the community; it serves the whole community and we must have a means of decision making that properly reflects all interest groups.

The changes proposed in the Bill respond to many of the concerns expressed about the abolition of community health councils. The Standing Committee will allow further detailed consideration, but I believe profoundly that the reforms will give more power to patients in the health service and more independent scrutiny than ever before.

Mr. Paul Burstow (Sutton and Cheam)

Will the Minister give way?

Mr. Milburn

I must move on. I have been speaking for about 40 minutes and I now want to refer to the royal commission.

The steps that we are taking to make the funding of long-term care fairer are also important. From October this year, with the consent of Parliament, nursing care will be free at the point of use and fully funded by the NHS. Residents in nursing homes will, in future, be treated in the same way as people who are being cared for at home, with NHS services and equipment being provided according to need, not ability to pay. This is indeed an historic step. It is long overdue. It will make a huge difference to thousands of older people.

By 2004, we will be spending an extra £1.4 billion on those reforms and on new services for older people. New intermediate care services, for example, will promote independence and allow more older people to stay at home for longer, in many cases avoiding altogether the need for them to enter residential care

We could, of course, have chosen to spend the money instead—as I think the Liberal Democrats suggest—on implementing the royal commission's recommendation that all personal care, as well as nursing care, should he free. I believe that this would not have improved front-line services in any way, shape or form—[Interruption.] The hon. Member for Sutton and Cheam (Mr. Burstow) is nodding. Perhaps he should look again at the Liberal Democrat amendment, which, thankfully, has not been selected.

Not one more older person would have received any extra care or support to remain independent for as long as possible. Nor would it have benefited the least well-off, as seven out of 10 people in residential care already get all or some of their personal care costs paid for. Instead, it would have locked in place the existing range of often inadequate services that have been the frequent subject of criticism from many older people.

I know that these are hard choices, but in future our priority must surely be to develop a wider range of services that will meet the health and social care needs of our society much more effectively than in the past. That is what the NHS plan does and what this Bill supports.

Mr. Hinchliffe

I welcome the steps that the Government have taken to go part of the way towards what was recommended by the royal commission. My concern relates to how we distinguish between personal care and nursing care in a practical sense. For example, if in a care or nursing home a care assistant, supervised by a qualified nurse, bathes an elderly resident, is that social care or nursing care?

Mr. Milburn

It would depend on the assessment—

Mr. Burstow

Ah!

Mr. Milburn

I had managed to get only four words out. If the hon. Gentleman would allow me 40 words, I would provide an explanation. It would depend on the assessment of the case. First, the royal commission accepted the premise that we could differentiate between nursing care and personal care. Secondly, we are going further than the royal commission recommended, not least in spending more money on this package of measures. We are also going for a wider definition of free nursing care. As my hon. Friend is aware, we have had discussions with the Alzheimer's Disease Society, with our colleagues in Scotland and with the Royal College of Nursing to come up with a definition of free nursing care that provides some consistency, but which also must afford some flexibility.

Each patient has different and individual needs. We need flexibility to ensure that the needs of the individual are taken fully into account, consistent with the national framework that we are trying to hammer out with voluntary organisations, patient organisations and clinical organisations.

Mr. Burstow

I am grateful to the Secretary of State for giving way. Will he confirm that the definition in the Bill means that it is not an assessment of the need for nursing care but who provides it that will determine whether such care is free? If a dressing is changed by a care assistant, that must be paid for; if it is changed by a nurse, it is not.

Mr. Milburn

No, that is not the position. A proper assessment will be made by the nurse. Who can make the assessment for free nursing, other than the nurse? My hon. Friend the Minister of State is not going to do it; I am not going to do it; officials and bureaucrats are not going to do it—nurses are going to do it. If I know nurses, they will make an assessment based on the health needs of the patient. That is precisely what we shall have. Where a nurse makes an assessment, it will be properly funded by the local health service. I gave that commitment before the Select Committee on Health and I give it before the House.

I read with some amazement the Opposition's reasoned amendment and its reference to free nursing care as a "modest" change. That change that will benefit 35,000 people. It will save them on average £5,000 a year. It is a change so modest that it was resisted year after year by the Conservatives when they were in government.

The truth about today's Conservative party is that it has neither the inclination nor the conviction to support such changes in the NHS. The Conservatives do not have a credible programme either for reform of health and social care services or for investment in health and social care services. Instead, they have a programme of cuts to damage public services.

Mr. Burns

Rubbish.

Mr. Milburn

The hon. Gentleman says that is rubbish. The Conservatives' programme would repeat the decades of damage to social services that they inflicted during the 1980s and the 1990s.

Mr. Burns

Rubbish.

Mr. Milburn

I have questioned the hon. Member for Woodspring on this matter before and he has refused to answer. I shall give him another opportunity to answer. In a moment or two, when he speaks, will he give a clear commitment to match our spending on social services? If he does not—if he cannot—his crocodile tears on bed blocking and care homes will be clear to the whole House.

Health and social services—as the Bill makes clear—go hand in hand; we cannot have one without the other. Any failure to match our increases in social services spending will bring more bed blocking in hospital, less rehabilitation in the community and more old people once again paying the price for the Conservatives' failure to invest.

The Bill is about investment in and reform of health and social services—after decades of under-investment and failed reforms in those services. Just as the first post-war Labour Government in the last century created the NHS, so the first Labour Government in this new century are now busy rebuilding it. Just as the Conservatives opposed the creation of the NHS then, so they oppose its modernisation now.

Today, with this Bill, we make progress on free nursing care, progress on patient power, progress on primary care and progress on patient protection. We make progress on implementing the NHS plan—not just to save the NHS from its enemies, but to secure it for a whole new generation.

The Labour party stands firmly on the side of the NHS. We are on the side of its principles and on the side of its staff. In our heads and in our hearts, we know that care based on need and not on the ability to pay is the right way forward for Britain. Today, with this Bill, we modernise the NHS so that it can improve the health of our nation—all of our nation—across the whole nation. I commend the Bill to the House.

4.24 pm

Dr. Liam Fox (Woodspring)

I beg to move, To leave out from "That" to the end of the Question, and to add instead thereof: this House declines to give a Second Reading to the Health and Social Care Bill because, although it contains some welcome provisions including the modest changes relating to nursing care, it increases still further the powers of the Secretary of State, reinforces the central bureaucracy and entrenches the micro-management by Whitehall of the National Health Service which so demoralizes NHS staff, is likely to worsen problems of recruitment and retention of medical and nursing staff and, by abolishing Community Health Councils, removes the only effective and independent voice which local communities have in health care. I begin by making a personal apology to the House. No Member would purposely mislead the House, but I did so inadvertently at Question Time yesterday and I want to correct the record. Yesterday, I said that the number of patients waiting for appointments—the waiting list for the waiting list—had gone up by 55,000 under the Labour Government. I should have corrected that, because the number has gone up by 188,000 under the Government—[HON. MEMBERS: "Ah!"] I do not want the record to underestimate the amount of misery caused to patients by the Government.

That is the background to the current debate. The Secretary of State said that the Government came to office to stabilise the NHS. In fact, more people are waiting than were waiting previously and clinical priorities have been distorted through the waiting list initiative. Last week, a consultant from a major London hospital told me that he had been told to stop carrying out so many hip replacements and start completing more minor procedures that would bring down the waiting list more quickly. That is ethically unacceptable.

There is greater public dissatisfaction with the lack of cleanliness in our wards. There has been an increased number of hospital-acquired infections and consequent unnecessary deaths. There are failures in public health policy—in tuberculosis—and there is an unacceptably and dangerously low level of immunisation against common illnesses such as measles. The Government say that they are proud of "The NHS Plan", but it took them six months to bring it to the House of Commons to have it debated. It is part smokescreen, and only part reform.

Dr. Stoate

rose—

Dr. Fox

I shall give way to the hon. Gentleman, but must warn him that I shall do so only once, so he had better make use of it.

Dr. Stoate

I am, grateful. The hon. Gentleman talked of clinical priorities. Does he believe that the fast-tracking of suspected cancer patients, who can now see a consultant within two weeks, is a distortion of clinical priorities?

Dr. Fox

It is obviously right to treat the sickest patients first. Quite wrong, however, are the examples of which we have heard from up and down the country of patients whose cancer surgery has been postponed because more minor cases are being treated. That is an unacceptable ethical distortion, and it happens up and down the country regularly.

The Bill is aspirational, if undeliverable in many ways, but it is, fundamentally, the wrong approach to the problems. Despite what the Secretary of State has said, the Bill is not a decentralising, but a centralising Bill. It is all about micromanagement of the NHS from Whitehall. It is impossible to run an organisation that employs almost 1 million people from behind a single Minister's desk. The more micromanagement that we attempt, the poorer morale becomes for those at the front line in the national health service.

The Bill perpetuates the myth of a one-size-fits-all structure for health care. There is no single blueprint. Forcing primary care groups to become primary care trusts, and then forging them into being care trusts implies that some magical Whitehall blueprint can work in all parts of the country. It will not. We must allow systems to develop that are fit for the purpose required in their locality. We need to move from a managed health care system to a regulated one. We need an outcome-based system with investment directed accordingly.

We need less power in the hands of the Secretary of State. We need depoliticisation with an independent appointments body established in legislation. We need more decisions to be made by doctors, not taken by hospital managers on the orders of Ministers. We need authority to match responsibility for the nurses on our wards, and a return to what we might call matron's values of discipline and cleanliness. We need an expansion of the private sector, with incentives to create more capacity. We need to maximise the use of the voluntary sector, and patient choice and competition between providers must be recognised as good, not something to be deprecated.

In considering the effectiveness of the Bill, we must return to first principles. We need to examine the functions of the NHS and whether the Bill will improve them. The first function of the NHS is as a funding mechanism for the provision of health care free at the point of use. By any measure, the NHS must be regarded as, at the least, a highly qualified success in that area. Costs are controlled, it is relatively efficient and there is no wealth barrier to access. Funding is relatively even across the country; we could all name areas in which it is slightly higher or lower, but it is relatively even.

The Government, to their credit, have shown commitment to funding the NHS. United Kingdom spending on health fell behind what was then the common market average in 1963, so that during almost my entire life—and certainly my life as a working doctor—our spending had been historically behind that of continental Europe. The simple truth is that we only get what we pay for, irrespective of whether funding comes via taxation or insurance. I do not believe that there is any benefit in shifting the funding basis of the NHS to insurance.

The second function of the NHS is that of the delivery of health care, which is where the NHS falls down. Its delivery is poor. Our outcomes are unacceptable. The chance of surviving stomach cancer in the United Kingdom for five years is only about a quarter of the chance in Germany and the chance of surviving lung cancer for five years in the United Kingdom is half of the chance in Germany. Life expectancy in this country—the world's fourth biggest economy—is 19th in the world, similar to that in Turkey.

There is widespread public dissatisfaction with the delivery of health care under the NHS. That is why, since the Government came to power, 450,000 uninsured people have paid directly for procedures to be carried out privately. I have no problem with that if they can afford it and it is their choice. Choice is a good thing; in addition, the burden on the NHS is off-loaded, which is welcome. However, people should not have to pay with their life savings for life-saving surgery. Until we tackle the deficits in NHS delivery, the problem will remain, but I do not believe that the measures described by the Secretary of State will necessarily improve matters.

Mrs. Linda Gilroy (Plymouth, Sutton)

I am following with great interest the theme that the hon. Gentleman is beginning to set out, especially the part about insurance. Does he agree with the following remark made by the right hon. Member for Maidstone and The Weald (Miss Widdecombe)? She said: If someone wants to pay to see their GP, they should be encouraged to do so ‖ The problem with the NHS is that we do not charge for much of what we do.

Dr. Fox

It is not our policy—nor, under my stewardship, will it ever be—to charge for access to general practice, for the very reasons that I have mentioned of access to care and barriers of wealth. I hope that that is perfectly clear.

In the delivery of our health care system, we need to use private capital. We need to develop the private health care sector to supplement delivery, whether that provision is funded via the NHS or from another source, such as private personal insurance or company-based insurance. The Government have made some progress in that respect, and it is only reasonable that we should welcome that. Under the Government's concordat, primary care trusts are allowed to buy health care for patients directly from outside private sources and are, therefore, able to bypass NHS provision entirely. I welcome that freedom for doctors and patients.

Mr. Milburn

indicated dissent.

Dr. Fox

The Secretary of State shakes his head—is he saying that that is not so? It is the case in the concordat. I know that he has spoken to Labour Back Benchers about NHS doctors buying NHS treatment in the private sector for NHS patients, but they can, in fact, buy treatment entirely outside the NHS. I think that that is a good thing and that the element of competition is to be welcomed.

Mr. Bercow

My hon. Friend's attitude to private health care has always been thoroughly sensible. Does he recall the interview given to the Health Service Journal by the Chairman of the Select Committee on Health, the hon. Member for Wakefield (Mr. Hinchliffe), in which, by contrast, the hon. Gentleman had the temerity to abuse all professionals working in the independent health care sector, likening them to illegitimate children? Was that not a disgraceful insult, both to people working in the private health care sector and to illegitimate children? Does it not provide evidence of the profoundly ideological, dogma-ridden, backward-looking, socialist approach of the Labour party?

Dr. Fox

Sometimes, I wish that my hon. Friend would speak his mind a little more clearly. He describes the experience of many Labour Members who have to endure a permanent "Groundhog Day" whereby they wake up in the morning natural socialists, but have to go to bed born-again Blairites. The Bill is full of parallels. However, I am sure that the hon. Member for Wakefield (Mr. Hinchliffe) will prove more than capable of paraphrasing his previous comments when he speaks in the debate, as no doubt he will.

Mr. Hinchliffe

That intervention has appeared in almost every health debate of the past two years and it is getting rather boring. I think that the hon. Member for Buckingham (Mr. Bercow) is aware of the context in which I made certain remarks in respect of the private health care sector. I did so after a sitting of the Health Committee in which a man described how, in a private hospital, he had had to lay out his wife's body because of the lack of care in that hospital. I admit to having been extremely angry and to using possibly intemperate language, but if the hon. Gentleman had sat through what the Committee sat through, he would have shared our shock and concern.

Dr. Fox

I do not wish to intrude on a private dispute between two colleagues. However, it is always wrong to extrapolate a general situation from individual cases. I am sure that the hon. Gentleman would wish to retract his comments if they were disparaging about all the dedicated professionals who work in the private sector.

I welcome Government developments in two other areas. They have taken up the private finance initiative, which was developed under the previous Government, and advanced it. We have seen a great deal of capital investment as a result. Clause 4 in part I makes provision for the Government to use private investment to improve the premises for primary care. It would be hypocritical and wrong of the Opposition not to welcome Government proposals when we would like those provisions to be advanced.

There is widespread agreement on other areas of the Bill. There are some measures about which we would like to see more detail and some with which we disagree. I shall begin with the good news for the Secretary of State about those parts of the Bill with which we agree. I draw particular attention to the widening of the franchise for prescribing. Again, the pilot for that was started by my right hon. Friend the Member for South-West Surrey (Mrs. Bottomley), when she was Secretary of State for Health. Certainly, with the restrictions on manpower and the length of training for those who work in health care, there is a need to use all health care personnel at the ceiling of their training and ability. I therefore welcome the extension of the right to prescribe to the nursing profession and pharmacists. Indeed, some of the Government's ideas which we would like to explore in Committee very much echo our own ideas on prescription-first medicines and allowing pharmacists to re-prescribe, once the initial prescription has been given by a doctor.

Most hon. Members will understand my own experience as an asthmatic, unable to get an inhaler on a Saturday morning when I was running my constituency surgery. I phoned my doctor and got the receptionist, who was probably a sad loss to the SS—[Interruption.] She happens to be a good friend of mine. I was not allowed to see my GP that morning, and was told that I could not get an inhaler for my asthma. When I asked why not, I was told that I had to go and see the doctor. When I said that I was a doctor, the receptionist said that that did not matter. I said that I had run out of inhalers and could become dangerously asthmatic over the weekend. However, I was told that I still could not have an inhaler. I said that I can write prescriptions for other people, but I was told that I still could not have an inhaler. I said that I was a member of the Royal College of General Practitioners, but I was told that I still could not have an inhaler.

That is nonsense. Simply taking out common prescriptions, such as those for asthma, would stop about 30 million repeat prescriptions going across doctors' desks. That is a sensible policy and if the Government intend to take that forward, expand it and create a new category of medicine in prescription-first medicines—or whatever they want to call it—they will have the Opposition's support. That common-sense measure is long overdue because we have greatly over-regulated prescribing in this country. We could give a good deal more discretion to other professionals.

The Government see potential in personal medical services. I believe that the days of the Red Book in medicine are numbered. There is a limit to how long we can continue with general medical services. We need to move to a quality agenda, and PMS allows us to do that. However, we need to avoid excessive centralisation and control. We need a duty to consult on changes to PMS in the Bill, in the same way as we have a duty to consult on GMS. I hope that the Secretary of State will give us that assurance. Perhaps the Minister of State, the hon. Member for Southampton, Itchen (Mr. Denham), will provide it when he winds up.

Likewise, we welcome the proposal on supplementary lists for locums, part-timers and other employees. The hon. Member for Dartford has already mentioned locums, and the proposal is essential to protecting patients. We could all give examples of horror stories—either anecdotally or from our own experience—of what is happening in locum services throughout the country and what has happened in individual cases in the past. I therefore welcome the proposal.

I also welcome the concept of the need to reward excellence. The Bill includes a proposal to increase funding for those who excel in health care, which makes a great deal of sense. However, how does that fit with the Government's education plans, in which they say that giving money to the se who are failing, rather than those who are succeeding, is the best way forward? We look forward to the Minister describing the thinking behind that proposal in Committee.

I welcome the Government's decision to make all nursing care free, and we shall match that. Workability has been mentioned, and there are problems with defining exactly what matters will fall within which category. There is also a danger of creating perverse incentives. Nurses on the ground carrying out the kind of decision making that the Secretary of State described could be forced to claim that some services that might otherwise objectively be deemed social care were nursing care, to qualify for payment. Great care will have to be taken in Committee to ensure that that does not happen.

Mr. Dawson

It is good to hear the hon. Gentleman welcoming so much of the Government's work to put right the mess that pus party left behind. Given that he is accepting so much of what is on offer today, will he move on from the medical model and give the House an assurance for which he was asked earlier? In the highly unlikely—in fact, amazingly unlikely—event of his ever being in a position to do anything about it, will he give an assurance that a future Conservative Government would fund the social services element of these matters to the same extent as this Government?

Dr. Fox

I should like to give the hon. Gentleman a lesson in verbal efficiency. I can confirm that our funding proposals relate not only to the NHS budget, but to the Department of Health's budget, which we see increasing from £45.285 mill ion in 2000–01 to the full £59.011 million in 2003–04 including the personal social services funding via the Department of Health and the funding for the Food Standards Agency.

The Secretary of State talked about the balance between local and central Government. I would caution him that he should go back and look at the Red Book figures on funding. They show that the balance between local and central Government in the funding for personal social services changes quite markedly in that period. The Department's funding rises from £713 million to £2,247 million in a period in which the standard spending assessment funding only goes up from £8,693 million to £9,962 million. In the interests of clarity, that means that the balance of power between local and central Government falls dramatically towards centralised Government. This is a centralising measure; it is in the Red Book, and those in Labour local authorities might be alarmed at the consequences.

The Parliamentary Under-Secretary of State for Health (Yvette Cooper)

Has the hon Gentleman cleared his remarks about matching the Department of Health funding with the shadow Chief Secretary to the Treasury, who said on "Newsnight" that his party was committed only to matching the funding for hospitals?

Dr. Fox

Of course I have cleared them. I have given as clear a statement of policy as I can possibly give. When we give the Labour party a clear statement of our policy, we are immediately told that that is not what we really mean, and that we must mean something else. The hon. Lady should have used up her credit on interventions in a more constructive way.

Mr. Edward Leigh (Gainsborough)

Will my hon. Friend give way?

Dr. Fox

Of course.

Madam Deputy Speaker (Mrs. Sylvia Heal)

Mr. Christopher Chope.

Mr. Leigh

No, I am Edward Leigh, Madam Deputy Speaker. I am sorry—I have only been here for 18 years.

Despite what my hon. Friend says, will he make it absolutely clear that many people believe that we cannot take the debate forward simply by both sides trying to up the ante in terms of matching funds? Many Conservative Members believe that, if we are to deliver a quality health service, we have to increase private sector involvement while keeping the principle of health care being free at the point of demand. We should, for example, increase private sector involvement in capital projects, and we must make that clear.

Dr. Fox

I do not see the matter as a choice between the two systems. There is a case For improving the functioning and the funding of the NHS as well as encouraging the private sector and ensuring that the services are available to a wider range of citizens in our society. By operating the two systems together, as most European countries do, we might achieve the health outcomes, survival rates and cure rates enjoyed in those countries. It has perhaps been our failure not least in the Conservative party, to make the case for the growth of both the private sector and the NHS, and that has meant that we have not been able to make the progress with outcomes in this country that we might otherwise have made over recent years.

We require more detail on parts of the Bill. The first relates to the abolition of the Medical Practices Committee. I hope that the Secretary of State will accept that the MPC works quite well at present. It controls the number of doctors in each area to a reasonable degree. This is a hugely centralising proposal once again. Moving away from capitation as the sole basis for remuneration is inevitable—that is the way that medicine is going. We should open the way for quality to be more matched by income. However, if we are to abolish the MPC, we should have an independent review mechanism, not just the view of an omnipotent Secretary of State. I do not mean that as a compliment in case the right hon. Gentleman interprets it as such.

In this place we have a boundary review commission to ensure an even match between representatives and the electorate. It would be reasonable to expect, within a certain time frame, a review of how the abolition of the MPC is working in terms of how many patients there are to each doctor across the country. That would be a sensible safeguard to include in the Bill.

I have reservations about confidentiality. We need to protect patient privacy, give clear guidelines to doctors about disclosure and keep the flow of information going for such things as the cancer registry. The provisions are too loosely drawn and leave too much discretion for the Secretary of State. The British Medical Association is worried about the potential conflict between the ethical position of doctors and the law if doctors are forced to disclose information that they believe would be disadvantageous to their patients. We need to tighten up those provisions in Committee.

The approach to the declaration of gifts for doctors is too bureaucratic. Obviously, we need to control excessive gifts to the medical profession, and we require transparency. We will put down amendments in Committee that will liken the treatment of doctors with that of Ministers. I fail to see why Ministers who make the policy for doctors should be allowed to keep gifts to a higher value than they allow for the doctors. It will be interesting to hear the Minister talk about that in Committee.

On the proposed traffic light scheme, rewarding excellence is fine, but the success or failure of this policy will depend on what is currently ill defined—the so-called initial amount of the settlement. It will depend on whether the criteria set are reasonable and whether the targets are fair and attainable. Again, this is a hugely centralising measure—it requires transparency in a way that we cannot currently envisage and the concept of earned autonomy. In other words, doctors will be given some freedom to do what they want only if it is earned under the conditions set down by the Secretary of State. "Earned autonomy" is indeed an Orwellian phrase.

We also have practical worries, as do many medical groups, about the practicalities of recruitment and retention for hospitals which are graded as "red light". How will they go about attracting staff? Will that not make it more difficult for them to recruit and retain staff?

We also require a properly independent body for national health service appointments. The Bill goes in the opposite direction—it gives the Secretary of State more power over recruitment; it allows him to fire those who work in the NHS and replace them with those he chooses. We need an independent body—one that is specifically independent of the Secretary of State—if we are to stop political gerrymandering.

The area of the Bill on which we disagree most profoundly with the Government is the abolition of community health councils. Three things are perfectly clear: there was no consultation on the abolition of CHCs, there was no consultation on the decision since the abolition, and none of the dialogue on patient empowerment has dealt with the abolition of CHCs. The decision was made in advance and no consultation took place.

I reiterate what my hon. Friend the Member for Buckingham (Mr. Bercow) said. The Prime Minister's agent said that the right hon. Gentleman agrees with the motion praising CHCs, congratulates them on the work that they have done and wishes them every success in the future. To be wished every success in the future by this Prime Minister means looking for one's P45. I would be quaking if I were the Secretary of State, come the reshuffle. It is absolute nonsense and profoundly dishonest to claim that there has been any consultation on the abolition of the CHCs.

There is a strong case for reform. We had a very good debate in Westminster Hall in which there was strong agreement on both sides of the House on the need for better standardisation and resourcing. However, we are being asked to accept that, effectively, any body that is under the auspices of the trust and that feels strong enough will be able to criticise it, or that any body in local government will be independent enough to do so. That will be made all the more difficult as Labour has been appointing local government people to health board trusts.

In other words, the Government are asking us to accept that Labour party cronies in local government will be capable of criticising Labour party cronies who have been appointed to the health boards. That is nonsense. As Dame Rennie Fritchie pointed out in her damning indictment of the Government's handling of the position, between 1997 and 1999, 284 Labour councillors were appointed to NHS trust positions, compared with 23 Conservatives and 36 Liberal Democrats. These are the bodies that the Government tell us will be independent of party and able to act independently on behalf of patients. They must think that the public were born yesterday.

We will fight to retain the CHCs. If the Government do not give ground on this, I warn the Secretary of State that we will fight to defeat them in another place, even if it means the loss of the Bill in its entirety.

Mr. Bercow

My hon. Friend will recall that the Prime Minister was all over the shop at Prime Minister's Question Time when he replied to a question from my hon. Friend the Member for Eddisbury (Mr. O'Brien) on that very subject. Does my hon. Friend recall that the Prime Minister—wriggling out of the situation as best he could—subsequently wrote on 20 November to my hon. Friend, saying that the community health councils were to be abolished subject to legislation? He went on to say that that better described the consultation to which he alluded at Question Time. Is that the nearest we get to an admission of error and an apology from the Prime Minister?

Dr. Fox

That is the closest that we get with this Prime Minister to any definition that remotely resembles the truth as the rest of the country would understand it. I am sure that my hon. Friend the Member for Eddisbury (Mr. O'Brien) will contribute to the debate and perhaps he will expand on that matter. It does not surprise me, however, because I believe that the Prime Minister would say anything to get through Prime Minister's questions irrespective of the trouble stored up for later. To cope with the questions from the Leader of the Opposition on beds in the community, he started to count beds in people's homes simply to make more. In effect, he conjured up 30 million extra NHS beds overnight. I no longer believe anything that he may say.

The Government have shown that they are committed to the increased funding for the NHS. I made it clear that we would match that funding, both for the NHS and, in the wider Department of Health budget, for personal social services. I hope that that has been absolutely clear.

In presenting the Bill, the Government have shown no grasp of the wider picture: how to maximise capacity, decentralising properly the model of health care, deal effectively with an ageing population, prepare for using new medical technologies to their best advantage, and maximise the use of the private and voluntary sectors. They talk about decentralising, but the Bill would bring far more power to the centre. It places too much trust in bureaucrats and too little in health professionals. It gives too much emphasis to management from the centre and too little to patient choice. They may be well intentioned, but they have failed to grasp the real problems of the health service. This is, par excellence, a missed opportunity.

4.58 pm

Mr. David Hinchliffe (Wakefield)

This is a wide-ranging Bill containing a huge number of different elements that would implement significant and important parts of the national health service plan. It contains many positive measures, but also some that need to be given further thought, as hon. Members on both sides of the House have argued in interventions. I particularly welcome the continued efforts to encourage joint working between the NHS and social services, building on the important provisions in the Health Act 1999, which I also strongly welcomed.

To reiterate what I said in an intervention on my right hon. Friend the Secretary of State, I have long had a personal preference, as he made clear, for placing the health authority function in local government—where it was, to some extent, until the Conservative party removed it way back in 1974. In a number of ways, reverting to that arrangement would deal with certain key matters of concern that arise in the Bill.

For example, we could tackle the false division between health and social care. That fundamental problem has faced both major parties for many years. In my view, it would also unite the public health function. I am speaking in advance of any conclusions that the Select Committee on Health may reach with regard to public health, but I have long believed that it is more sensible to locate the public health function in local government than in health authorities, where it is separated from the central drivers of public health, such as the housing function.

Returning to the arrangement that obtained before 1974 would also democratise health and make possible democratic scrutiny at local level. I know that my right hon. Friend the Secretary of State firmly rejects that idea, and we differ over the point, but I will continue to argue for what I consider to be a sensible course of action. I hope that I may yet succeed in convincing my right hon. Friend. However, even if the Government are not going to move in the direction that I prefer, the proposal for care trusts is a welcome step forward. The policy will address some of the problems at local level, and I will support it strongly.

I am worried about a number of elements in parts I and IV of the Bill, and I hope that the Government will consider them further. Of particular concern are the proposals in clauses 7 to 14, regarding scrutiny and complaints. It is not often that I agree with the hon. Member for Woodspring (Dr. Fox), but I feel that there has not been adequate public consultation and discussion in respect of some of those proposals. Although the NHS plan contains some important and positive proposals, I get the distinct impression that the proposals regarding CHCs and scrutiny were something of an afterthought.

I am also concerned because the Bill introduces proposals regarding the wider issue of complaints before the project team in the Department of Health has completed its evaluation of complaints procedures. Clearly, the measures in the Bill—which will probably go into Standing Committee next week—have a bearing on the complaints procedures. The Government have put the cart before the horse, and it would be more sensible to await the departmental team's report before examining complaints procedures.

My right hon. Friend the Secretary of State knows that less than two years ago, the Health Committee considered in detail the handling of adverse incidents in the health service. We met hundreds of patients for whom things had gone wrong, and we were impressed by the extent of the suffering that health service incompetence had caused them. For example, some people had lost family members—although that was rare. The difficulties that people faced were made far worse when they tried to obtain some explanation or redress by making a complaint.

Members of the Health Committee met people who had been treated by Richard Neale, Christopher Ingolby and Rodney Ledward. They had been at the sharp end of some pretty difficult treatments, and I want to pass on some of the key messages that those people communicated to us about what scrutiny and complaints procedures should do, and how the Bill should go about changing those procedures.

Any complaints procedure must be independent, and must be seen to be so. The current system is not independent, as Ministers know. The procedure must be simple to understand, so that people have access to it and will know where they must go when they have a difficulty with a particular service. It also needs to be transparent and comprehensive. It must cover primary, secondary and tertiary care, and care in the community—all the areas in which treatment may have been given.

I appreciate that further thought has probably been given to some of the proposals in the Bill, but I am worried that the proposed system will not be independent, as it should be. The patient advocacy and liaison services will be trust-based and non-statutory. They will clearly be regarded as part of the health trusts, whether or not they are in fact.

In addition, as the Bill stands, the independent advocacy proposals will be commissioned by the health authority. I accept the remarks that were made earlier, but all hon. Members will have experience of complaints directed at us that also relate, directly or indirectly, to the policies and practices of the complainant's health authority. I have received complaints against a trust for difficulties that have been blamed directly on the health authority. It is wrong to suggest that the Bill's proposals for independent advocacy should be commissioned by a health authority that may be the subject of a complaint.

I accept that the Government are giving the matter further attention, and considering the possibility of advocacy relating to scrutiny of local government. That is a welcome step. I met the Minister of State earlier this week, and we had a very happy discussion. I appreciate the fact that he has listened to some of my concerns.

Dr. Brand

Does the hon. Gentleman agree that many complaints are appropriately dealt with internally, either within primary care or within the hospital trust sector? Patient advocacy and liaison services can be very helpful in the reaching of an agreed conclusion, but sometimes patients and carers will not be satisfied with an internal arrangement. In those instances we require a separate system, not run by a trust tribunal—or, indeed, serviced by PALs.

Mr. Hinchliffe

I entirely agree. The hon. Gentleman sat through the same evidence as I did, and the message was loud and clear. The patients whom we saw wanted complete independence and fairness, and I do not think that the proposed system offers the independence and fairness that I would like to think the Government want.

I feel that what is being proposed is somewhat clumsy and confusing. If I were a patient with no knowledge of the structure of the health service, rather than a Member of Parliament involved in health policy, I would like to know who did what in the complaints process. The Bill specifies a range of agencies and other bodies that I, as a patient, might or might not need to consult: the trust, the district health authority, PALS, the independent local advisory forums, the patients forum, the scrutiny committee, the National Clinical Assessment Authority, the ombudsman, and various professional regulatory organisations. People are baffled by the complexity of what is on offer now, and I think that we are making the system even more complex. I hope that it will be simplified in Committee, so that it makes sense to patients.

I also feel that what is proposed would fragment the scrutiny and complaints function. The patients forums and PALS will relate to just one element in the service—a trust. As I have said, many complaints that I—and, I am sure, other Members—have dealt with relate to more than one element. They may relate to primary care, secondary or tertiary care, and community care. It must be possible to look at the whole process, rather than focusing on only one aspect. I hope that that too will be considered in Committee.

I hold no particular brief for community health councils. I became a member of a CHC in 1974, and served as its vice-chair. I worked for many years on that CHC, which I considered to be a good one. I know, however, that the effectiveness of CHCs varies. Some are excellent, but some have not done the job required of them, and the voice of patients has not been heard. Such CHCs have been the poodles of local trusts and health authorities. They have not stood up to be counted on occasions when patients' views should have been expressed loudly and clearly at local level.

Nevertheless, I am not convinced that the new system will be better. Indeed, it may be worse. I am sorry to say that, because I welcome much of what the Government have done on health, and warmly commend Ministers for introducing so many positive measures, especially with regard to the relationship between health and social care. I feel, however, that further consideration is needed.

Shortly before Christmas I wrote to the Secretary of State suggesting a possible compromise. My suggestion, which may or may not have been helpful, was that we beef up the membership and powers of CHCs. I suggested that their powers should be extended to cover complaints in the context of primary care, and that—as the Health Committee proposed—they should have an advocacy function. If the Secretary of State wants a link with local authorities, he could easily increase the proportion of local authority appointees on local CHCs. That proportion is currently one third; the Secretary of State could make it a majority. Many Labour Members—they will not speak today, and they are not among the "usual suspects"—are deeply worried about what is being proposed. I hope that I have made my point constructively, and that the Government will consider the issue in Committee.

I genuinely welcome the Government's attempts in part IV to rectify the long-term care shambles that the Conservatives left them. I was amused yesterday to see the Leader of the Opposition launch his "Where has all the money gone?" campaign. It made me think about the amount of money that was sunk into private institutional care between 1981 and 1993, when community care changes came into effect. Some £10 billion was thrown at gross over-provision of private institutional care, when people were crying out for investment to support them in their homes. Tory MPs bleat about empty private care homes, but that is utter hypocrisy. They are empty because we provided too many beds, and the Government—thank goodness—are ensuring that people do not end up in institutional care.

We are supporting people in the community. That is a positive step, and the Government can be satisfied with that achievement. I think that we should look to Denmark, where housing-with-care schemes have replaced institutional care. The Government are right to emphasise in the Bill the need to restore and support older people's independence. I strongly welcome the new investment in community care.

I also welcome the proposal for free nursing care, but I regret the failure fully to implement the royal commission's proposal. We have not completely addressed that issue, and a difficult situation will develop. The royal commission's definition of personal care offered a sensible answer to the social nursing care issue that has dogged successive Governments for many years. The Government can develop assessment processes and local protocols until the cows come home, but I do not think that it will ever be possible to draw a clear boundary between personal care and nursing care. The previous Secretary of State admitted that, and I would I have to agree.

Today I received a letter about personal care and nursing care from a nursing home in West Yorkshire. Mr. Andrew Makin wrote about the specious and probably resource-led division between these two ideas … it is an entirely artificial and unnecessary construct … there is no such thing as a distinction between nursing and personal care in a care setting. All care is directed at the well being of the client in an holistic sense, which by all modern accepted definitions is a nurse's role. Nursing looks at all the facets of a person's care and does not draw theoretical divisions between different aspects of it. I entirely agree with him. He has summed up the problem. If the Bill is not amended, I believe that there will be huge disputes about where the line is drawn locally. I have looked in the Bill for procedures to resolve disputes, but I cannot see them, and problems will arise.

To conclude, I want to reinforce the fact that the Bill contains many positive proposals. I hope that other matters will be addressed in Committee. The Government have shown their willingness to listen to concerns, and I hope that they will continue to listen and amend the Bill in Committee, so that it makes more sense on Report.

5.13 pm

Mr. Nick Harvey (North Devon)

The Bill gives effect to many provisions in the NHS plan, which was published in July last year. We welcomed the plan because it made a valuable contribution to the renaissance of the NHS, and we appreciated the investment that the Government pledged. However, we had reservations about specific aspects of it. Similarly, although we welcome some of the Bill's provisions, we have reservations.

At the outset, however, let me restate for the record the Liberal Democrats' absolute commitment to the founding principles of the NHS. We believe that it should be comprehensive, free at the point of delivery and paid for by general taxation. We do not think that it should be supported by induced contributions from people who have to pay for themselves, either directly or through insurance contributions.

We have significant reservations about three aspects of the Bill. First, it provides for free nursing care, but does not take up the royal commission's recommendation for free personal care. Secondly, although we welcome the fact that it creates care trusts that bring together social care and primary and community health care, we have some misgivings about how that will be achieved. Thirdly, we are concerned about the abolition of the community health councils—and, more specifically, about the manner in which their functions will be distributed.

However, we agree with many of the provisions in the Bill and believe that they will make a valuable contribution to the continuing progress and development of the NHS. We welcome the commitment to ensuring that more funding gets through. I disagree with the comments of the hon. Member for Woodspring (Dr. Fox) about the so-called traffic light system—one of the mechanisms by which additional funds are provided. The Government's approach does not seem entirely unreasonable, although I have some reservations about specific aspects. Their proposal is far more sensible than any equivalent idea that has been considered in the past.

Rewarding areas that have done especially well with extra funds will increase existing inequalities. Conversely, rewarding areas that have done badly gives an incentive for everybody to try to achieve a red light. As I understand it, the strength of the proposed system is that the funds will go through come what may, but more strings will be attached to what must be done with them in "red light" areas.

My specific misgiving is that the Government seem to want to predetermine the proportion of trusts, primary trusts and authorities that fall into each category. That approach does not seem ideal. Surely it would be better to work on the basis of merit. The obvious ideal is that everybody should have green light status, so I am not sure that preconceived notions about the proportion for each status will create the incentives that we seek. Nevertheless, the idea is worth working on.

The Liberal Democrats also welcome the provisions for greater use of nationally agreed terms and conditions for NHS staff. One of the especially adverse aspects of the internal market was local trusts' arrangement of their own contracts. I hope that the Bill will ensure the rolling back and ending of those arrangements. I make a particular plea for practice nurses, who are not—in a manner of speaking—currently part of the NHS. but are employed directly by general practitioners. It would be useful if they, too, could be incorporated into a national framework.

We welcome the opportunity that the Bill provides for modernising GP contracts, on which I agreed with the general tone of the hon. Member for Woodspring. I hope that compulsion will not be necessary, but an overhaul is undoubtedly needed. I hope that the Bill provides a framework for ensuring that that happens in a constructive way.

The Opposition's reasoned amendment refers to the new powers of the Secretary of State to intervene. I confess that I was mildly astonished to discover that he did not already have such powers. If he does not, and is to be given new powers to make interventions from the centre, they must be exercised with great care. I hope that the trigger point for the powers will be the discovery, through one of the various checks introduced by the Bill, that a hospital, trust or primary trust has been failing and requires such intervention. I am slightly worried that the Secretary of State seems able to make such interventions almost on a whim. Perhaps that matter can be probed in further detail later during the Bill's passage.

As for health service resources in areas with too few GPs, I understand that the Medical Practices Committee may be seen to have had its day, but I thought that the Secretary of State was rather too harsh about it. Although it has not by any means delivered a perfectly even distribution throughout the country, I am sure that things are a great deal better than they would have been without it. If the new arrangements are to be based on a market in which health authorities bid in accordance with the resources available to them, there is a serious risk of mayhem. I hope that we will hear about the mechanisms for performing the functions now exercised by the Medical Practices Committee. We welcome the extensions of prescribing rights, and pharmaceutical pilots. The requirement for GPs to declare gifts, on a similar basis to that which applies to other doctors, is right even if it will discomfit some pharmaceutical companies.

As the Bill progresses, we shall need to define in rather more detail proposals for scrutiny and assessment of doctors. We have welcomed much of what the Government have done to date to address the issue of patient safety, especially in the wake of the tragic circumstances surrounding the Shipman case. In addition to further modernisation of the General Medical Council and the creation of the Commission for Health Improvement, the Government have proposed the creation of the National Clinical Assessment Authority. The Bill proposes that the role, authority and responsibility of health authorities should be extended, particularly with regard to the list system. Clearly, interaction between the various bodies will be crucial if they are not to duplicate each other's work—and, which is perhaps more important, if practitioners are not to fall between the remits of those bodies. We shall certainly want to probe the matter further as the Bill progresses.

The hon. Member for Wakefield (Mr. Hinchliffe) spoke persuasively and convincingly about personal care. The Bill leaves many unanswered questions, and many opportunities have been lost to improve welfare and rights, particularly those of older, disabled and mentally infirm people. Above all, it means that hundreds of thousands of older people will have to pay for the essential help that they need in their daily lives to dress, take meals and bathe.

The Government's proposals to distinguish personal and nursing care are likely to be almost impossible to administer in practice. No one chooses to leave home, abandon independent living and seek long-term care in a residential setting. That choice is imposed on people by necessity, and it is unfair and iniquitous for the state to penalise people for it.

Mr. Dawson

I follow the hon. Gentleman's remarks, but I am slightly disturbed about where they seem to be leading. Is he seriously saying that entering residential care cannot be a positive choice for an older person?

Mr. Harvey

Of course it can, but it should—and, I hope, usually would—be the last choice. There should be a commitment to fulfil the adage of Florence Nightingale, who said originally that everybody's hospital should be their home. I would have thought that there is a commitment across the political spectrum to provide help in a person's home where at all possible.

That was why I was mystified by the Secretary of State's saying that our policy of implementing in full the recommendations of the royal commission somehow ran contrary to, and was in conflict with, the Government's proposals to expand intermediate care. I remind the House that the royal commission recommended that all personal care should be provided free, whether in a domiciliary context or a residential home. I would have thought that provision of both services was essential, and that the overriding objective in all cases should be to preserve independent living.

The hon. Member for Wakefield has already alluded to some of the anomalies that will arise. He rightly pointed out some of the difficulties that will occur in practice. It seems impossible that we will reach a definition of nursing care when we are told by the Secretary of State that neither he nor the Minister of State, the hon. Member for Barrow and Furness (Mr. Hutton), will hand one down, but that it will be determined by nurses on the ground. That will be impossible to administer. There does not seem to have been any rational debate about what constitutes nursing care. I am also very sceptical that such care will be provided within the Government's estimate of £420 million over three years. That seems most improbable; I think that the bottom-line cost of providing free nursing care will be considerably more than that.

Dr. Brand

Is there not a risk that nurses will have a closed budget for this service, and will be asked to become gatekeepers and rationers of services?

Mr. Harvey

I am sure that that will happen, and we will have the same spectre as we have now, but on a wider scale. Social services directors warn us that as the financial year goes on and budgets get thinner, their funds run out and it is not possible to give the care that should be given. That leads to a fairly crude system of rationing. That is why the measure will prove difficult in practice.

The proposal leaves some aspects of health care to be paid for, when in other settings it is free.

Mr. Philip Hammond (Runnymede and Weybridge)

Given that the hon. Gentleman is inside the big tent, can he help me to clear up some confusion? The Secretary of State spoke earlier of nursing care in nursing homes being provided by NHS nurses with NHS equipment. Is it the hon. Gentleman's understanding that NHS nurses will be put into private nursing homes, or will the NHS fund the nurses that are already there? That is an important distinction. The Secretary of State said "providing" rather than "financing".

Mr. Harvey

It has not been my understanding that the nurses in question will have to be NHS nurses, but I confess that it is a long time since I have been in any sort of tent, so I could not really say. No doubt the Minister will make the point clear at the end of the debate if he sees fit to do so.

We are concerned that some aspects of health care will be paid for in one context, but not in another—whether that be physiotherapy, incontinence pads, which the NHS does not currently supply to nursing homes, or the practice of GPs charging for call-outs to residential and nursing homes and those costs being passed on to residents. The Government's desire to maintain this wholly artificial, wrong and illogical division between the two categories of patient is inconsistent with the provision in the Bill to bring together primary and community health care and social care. As they are bringing those organisations together in one, they have the opportunity to get rid of the artificial divisions and distinctions once and for all. If we entrench this completely artificial division in legislation, the opportunity will be missed.

We are concerned that older people and others will no longer be able to establish under what legislation services are being provided, and thus whether their care should be free, as an NHS service, or charged as a social service. The Bill provides the opportunity to clarify that once and for all. It is entirely reasonable that people are expected to make their own financial provision for their accommodation, the roof over their head, the food they eat, heating and so on, but it is wrong that people who are suffering from chronic long-term conditions will have to pay for their personal care, whereas others with acute conditions will enjoy a different degree of financial support and will have the services they receive paid for under the Bill. It would surely be right for the same treatment, often given in the same establishment and by the same staff, always to be provided free. This is a missed opportunity to iron out some of those anomalies at a time when the organisations are changing.

The care trusts are welcome. The Liberal Democrats have long campaigned for and supported the bringing together of health and social care. The formation of primary care trusts provides a context in which to do that which is different from any that we have considered in the past. If they are to be brought together into the care trusts, we have some reservations, especially about accountability. The role that local government could play should be considered further, and smoked out.

I agree with the hon. Member for Wakefield that it would be more logical for public health to be vested in the hands of local authorities rather than health authorities, because so much of the public health agenda is influenced by issues outside the health service, such as housing, transport, job opportunities and a variety of other social issues. To some extent, the Government acknowledge that by having local authorities play the part that they do in health improvement programmes. In the Bill they propose to take that role further by giving local authorities a significant role in scrutiny of primary care trusts—and also, presumably, the wider care trusts, when they come in—and NHS trusts. It would be logical to take that a little further by using local authorities as a mechanism to hold all those bodies more democratically to account.

In future, all trust boards will be more independent, in the sense that their composition will be handled by the new commission, and I welcome that. The Secretary of State is right to have relinquished that power. I listened with some amazement to the hon. Member for Woodspring talk about the number of Labour councillors who have apparently been appointed to the trust boards. Perish the thought that the previous Conservative Government would have stuffed the boards full of their appointees. Those people were independent business men, not Conservative councillors; they had taken the precaution of losing their seats first, so they were ex-Conservative councillors.

It is no good knocking the matter around on a party political basis. Nothing happening now is any different from what went on under the previous Government. That is why the Secretary of State is right to have put things on an independent basis, and it is right that he should have relinquished that power in order to do so. [Interruption.] I am sorry that the Tories do not like what I am saying, but they should look in the mirror and see what happened under their Government.

Mrs. Virginia Bottomley (South-West Surrey)

rose—

Mr. Harvey

I give way to the right hon. Lady, who I think was one of the leading culprits.

Mrs. Bottomley

I hope that the hon. Gentleman will withdraw that comment when he considers the evidence. I was responsible for the appointments of Baroness Hayman, Baroness Dean and Dame Rennie Fritchie, quite apart from Julia Neuberger and Baroness Thomas. Dame Rennie Fritchie was a leading health service regional chairman under the previous Government. If the situation then was as the hon. Gentleman describes, it is surprising that she should have written quite such a critical report. Will the hon. Gentleman investigate for himself the truth of his statements?

Mr. Harvey

I shall be more than happy to do what the right hon. Lady suggests and look at the evidence. If by any chance I find that what I have said is incorrect I shall certainly withdraw it, but I sincerely doubt whether that will be the case. We all have recollections of such matters. I well remember, in my constituency, how each time one particular Conservative councillor lost his seat on a further tier of local government, he was rewarded with another place on some quango or other—including the local health care trust.

The final issue to which I shall refer is the abolition of the CHCs. I recognise the successful role that CHCs have played in many communities in the past 25 years, but it is important not to have too starry-eyed an idea about how successful they were across the board They were good in some areas and not so good in others Everyone to whom I have spoken in the CHC movement in the past few months has recognised that there was a need for major reform of the whole function.

We must be wary of throwing the baby out with the bath water, but the Government have tabled some proposals and we must address those and consider what merits they have and how they might be improved. The Government's proposals have improved somewhat since the original blueprint put forward last summer.

To consider the individual components for a moment, the patient forums were originally to have been supported and staffed by employees of the trusts that they were supposed to be monitoring. We now learn that they will be set up on a completely independent footing, and that must be a significant improvement. However, the Secretary of State was wrong to dismiss quite so firmly the point made by my hon. Friend the Member for Isle of Wight (Dr. Brand).

If the forum is to consist of representatives of patient groups with particular concerns about particular conditions, and a cross-section of patients who have used the service in the preceding year, it will not really represent the wider community and those who have not recently been health service users. The CHCs have made that point in recent representations. It is right that those who have recently used the service should be represented, but there should be a slightly wider focus and remit.

Most CHC chief officers to whom I have spoken have been candid about the fact that the handling of complaints has been one of the weakest areas of CHCs' performance. They have not felt that they have had adequate funds for the task, and it has often been the poor relation when they have had to prioritise.

Having heard the Secretary of State's speech, I am still not entirely clear about what the new system is to be. The patient advocates are within the hospitals and the trusts; as my hon. Friend the Member for Isle of Wight said, they sort out the problems that are appropriate for sorting out within the organisation. However, I understand that if a patient still has a fundamental complaint, there will then be an independent complaints procedure.

I understand that the Secretary of State is awaiting the report that he commissioned, and perhaps he will say more about that presently. He suggested in his speech that it might be possible for local authorities to provide the service, area by area. The criticism of the Government's plans to replace the CHCs that has rung truest with me is that the component parts that they want to introduce, although each has a certain logic, do not really hang together.

If the scrutiny role is to go to local government, why not also give it the responsibility for commissioning the independent complaints procedure, area by area, and for funding, staffing and supporting the patients forum? Then at least the three essential component parts would be together. Local government could fulfil the scrutiny role on the basis of the information gathered from the patients forum. That could begin to solve some of the problems of fragmentation that form the strongest case against the Government's proposals.

We are talking about local government ceding its traditional role in managing social services to what is essentially a health service body—the care trust. Giving local government a good deal of responsibility for defining what provision there ought to be in a community, and for monitoring what goes on, would therefore be a significant way of remedying what might otherwise be deficiencies in democracy and accountability in those trusts.

We welcome many of the proposals, but we have some major reservations.

Mr. John Burnett (Torridge and West Devon)

My hon. Friend talks about local government having a greater say in such matters, and refers to public health issues. He will be aware that a survey by the Department of the Environment, Transport and the Regions and West Devon borough council of the incidence of radon in properties on Dartmoor with private water supplies was published yesterday. Does he agree that that should precipitate immediate research on the problem?

Mr. Harvey

I am aware of that, because the issue affects my constituency, too. If local government had responsibility for public health, and had the wherewithal to undertake the necessary research, it would be able to make a valuable impact on public health issues at community level. That is another example of why it would be better to give it a greater role.

In conclusion, the Bill contains many measures with which we agree, and others about which we have major reservations. We do not feel able to support its Second Reading today, but doubtless it will proceed to Standing Committee, where Liberal Democrats will do what we can to amend the Bill along the lines that I have suggested.

5.40 pm

Mr. John Austin (Erith and Thamesmead)

First, I apologise to the hon. Member for Woodspring (Dr. Fox) for missing the opening couple of sentences of his speech as I was in the Lobby voting.

Like my hon. Friend the Member for Wakefield (Mr. Hinchliffe), I greatly welcome many of the measures in the Bill, which addresses some of the inequities in health service provision, emphasises primary care and addresses the crucial issue of the joint working of social services and health authorities.

In relation to the primary care trusts, I recognise that the changes in the allocation of cash-limited and non-cash-limited funds to health authorities and PCTs could in time help to tackle the unequal distribution of GPs across the country. The Government are right to redress the situation in under-doctored areas and improve GP services in some of the most needy and deprived areas. However, if they are to succeed, guarantees are needed to ensure that additional funding is spent on primary care services and not diverted into secondary care. I hope that, in his reply to the debate, my hon. Friend the Minister can give such guarantees.

While I fully understand and support the Government's intentions to drive up standards in the NHS, I have some reservations about how the green, amber and red traffic light system will work. I have similar reservations about the way in which Ofsted has labelled some schools as failing and the impact that that has had on morale and the recruitment and retention of staff. To label an organisation as failing can have adverse effects. I am much more in favour of using carrots rather than sticks. Although I can see how the green and amber traffic lights would work, I have some reservations about the red ones.

In his speech to the Royal College of Nursing in May last year, my right hon. Friend the Secretary of State described his vision of the NHS as: A health service of all the talents. He described a service which liberates nurses, not limits them, and said that an NHS that was patient-centred must be nurse-centred too. He outlined Labour's plans to put nurses at the centre of the modernisation of the NHS, stating: nursing values are health service values. Caring. Compassionate. Professional. Dedicated. The needs of the patient at the core of all we do. I share that view, as I am sure my hon. Friends do, but we must also value other professions working in the health service and ensure that their role and contribution is not overlooked or taken for granted. That means recognising their value and reflecting it in their pay and conditions and their role in policy making.

A health service of all the talents will require the involvement of all relevant staff, not just in service delivery but in planning and policy formulation and in management. It means involving all the relevant professions on working groups, taskforces and committees.

I deal now with the staff terms and conditions elements in the Bill. I welcome the new powers to be given to the Secretary of State to make regulations about the terms and conditions of staff. Most staff in the NHS are employed according to nationally agreed terms and conditions, most professional staff coming within the terms of the pay review body. The Secretary of State and the Minister will know of my concerns about staff who are outside the pay review body, such as medical laboratory scientific officers whose pay has fallen way behind that of nurses and other professions allied to medicine that are within the purview of the pay review body. They will recall my early-day motion 68, which was supported by right hon. and hon. Members on both sides of the House.

I wish to be one of the first to join my hon. Friend the Member for Bolton, South-East (Dr. Iddon) in welcoming the Secretary of State's recognition of a long-standing problem that was ignored for so long by the previous Administration and yesterday's announcement of substantial pay increases to some of the lowest-paid professionals who provide an essential diagnostic and preventive service as well as playing a key role in treatment.

I want to mention briefly some of the positive changes in the NHS that have occurred under the Secretary of State and his predecessor, my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), especially with regard to the nursing profession. My right hon. Friend the Secretary of State has recognised that, in the past, a nurse had narrow career options, and that in order to advance the only paths were to enter nurse education and the realms of management.

There is no problem with those choices: we need able nurses in management and we should welcome the increasing number of nurses who make it as chief executives in the NHS. Equally, nurse education needs some of the best nurses to ensure that the next generation of nurses is adequately skilled. It has, however, been frustrating for good clinical practitioners who want to remain with their patients. Since the Halsbury report of 1974, the profession has sought genuine opportunities for a clinical career grade—a desire wholly ignored by previous Governments, but which the Labour Government have taken on board, providing nurses and the nursing profession with a real chance to break new ground in building solid options for a clinical career.

One group of nurses mentioned earlier—practice nurses employed by individual GPs—are not technically part of the NHS, although they clearly work in and for the health service. Their terms and conditions should be brought within the remit of the NHS.

Dr. Brand

Does the hon. Gentleman agree that those practice nurses should not lose out by being brought into the framework of the NHS? In my experience, practice nurses have much better and more flexible employment opportunities than some of the nurses employed directly by the NHS.

Mr. Austin

That is so and it is all to the good. However, in many cases practice nurses are at a disadvantage compared with their colleagues.

The issue of practice nurses is a key part of the Bill. Yesterday, my hon Friend the Member for Wythenshawe and Sale, East (Mr. Goggins) described an excellent example of the role that practice nurses are playing in his area. There are examples of initiatives of nurse-led practices under the Government's innovative personal medical services pilots where a nurse is actually responsible for managing the practice and employing a salaried GP—leading to a better service for patients and freeing up time for the GP to see those patients who need to consult a doctor. Why cannot those nurses legally be principals in their own right?

I welcome what the Government have done in the Bill to extend nurse prescribing. I was among the first to criticise Opposition Members, but I pay tribute to Baroness Cumberlege who pioneered the concept of nurse prescribing. None the less, it was the Labour Government and my right hon. Friend the Secretary of State who developed and extended that concept.

I welcome the PMS initiative. I am pleased that all the schemes submitted by Bexley in the recent wave have been approved. However, I have written to the Secretary of State about some anxieties that were expressed as to whether sufficient growth funds to support the additional salaried GPs and nurse practitioner posts will be available. I await his reply with interest.

The Minister of State, my hon. Friend the Member for Southampton, Itchen (Mr. Denham) will be aware that I first joined the CHC in the area where I lived in 1974 as a local government nominee, having been elected to the local council in three successive elections. At the time, I worked in a neighbouring borough for a local voluntary organisation and registered charity. Some years later, when my term of office on the CHC in the area where I lived expired, I was appointed to the CHC in the area where I worked, having been chosen in an election process involving all the local voluntary organisations with an interest in health—including Mencap, MIND, the Multiple Sclerosis Society and the Association of Disabled People—as well as general interest groups, such as residents and tenants associations and ethnic minority organisations.

In speaking of CHCs, the Under-Secretary, my hon. Friend the Member for Birmingham, Edgbaston (Ms Stuart), has referred to a democratic deficit in the NHS. In reality, until now CHCs have been the most democratic and accountable part of the NHS; they are not directly elected—although some of their members are appointed from local authorities—but are an innovative experiment in representative democracy. That experiment has worked and it has worked in the interest of patients.

Some people have pointed out that not all CHCs worked well. I could say the same thing about hon. Members. I venture to suggest that my appointment, first as a democratically elected local councillor nominated by the local council, and subsequently as the choice of a consortium of voluntary and community organisations serving the community, made me a more democratic choice and more accountable to the community that I served than any of the health authority and trust board members appointed under the patronage of the Secretary of State.

We need no lessons in democracy and accountability from Opposition Members. With my colleague, my hon. Friend the Member for Eltham (Mr. Efford), I also served for a period on my local health authority. He chaired the social services committee, and I was one of his predecessors. The right hon. and learned Member for Rushcliffe (Mr. Clarke) removed all local authority and elected representation from health authority boards, and the right hon. Member for South-West Surrey (Mrs. Bottomley) was the Minister of State at that time. My hon. Friend and I were replaced on the health authority by a computer salesman and a double glazing salesman, after which the health authority got into some dodgy financial deals, some of which I suspect to have been not exactly lawful. That left the authority with a substantial financial loss.

I also served for two years as chair of the Association of Community Health Councils for England and Wales. It will not surprise anyone, therefore, that I have grave reservations about the proposals to abolish CHCs, notwithstanding the assurances that I received from the Minister of State, my hon. Friend the Member for Southampton, Itchen, this morning. I believe that the Secretary of State went further in his statement this afternoon.

Mr. Hammond

The hon. Gentleman has referred to two clearly identifiable individuals, and may have put the suggestion into some minds that those people were guilty of some impropriety. Would he confirm, for the record, that that was not his intention?

Mr. Austin

I did not intend that implication as far as those two individuals were concerned, but I stand by my assertion that the financial scams in which the health authority became involved were unlawful. They certainly led to financial losses.

I am aware that the proposal to abolish CHCs followed consultation on the national plan. I welcome both the consultation and the plan, but it was general consultation—there has been no specific consultation on the proposal to abolish CHCs or on their replacement. CHCs had some weaknesses, and some of the Bill's proposals address that. The Welsh Assembly has decided to consult widely on patient advocacy and support, including the future remit of CHCs. It is likely that local health councils will continue in Scotland. The Welsh Assembly may, of course, reach conclusions different from those arrived at in England—that is what devolution is all about. However, England should be entitled to the same consultation as Wales, and I urge the Secretary of State to adopt a similar procedure in England.

Time does not permit me to go into detail on the roles of patient advocacy and liaison services and patients forums, but I welcome additional resources for advocacy and dealing with complaints.

The CHCs were not resourced for or charged with the responsibilities of dealing with complaints, but that is what they have done, effectively, in most cases. CHCs have proved themselves capable of organising, servicing and supporting patient forums. As they have been so successful, I would apply the adage, "If it ain't broke, don't fix it."

There are faults in CHCs, and remedies are needed, but where they have failed—or, perhaps, not been as successful as they might have been—it has generally been because they have lacked resources or statutory powers. They are tried and tested and, above all, they are trusted by patients as champions of the users of the NHS. Will my hon. Friend the Minister consider keeping CHCs, placing PALS within them, and giving them the responsibility for servicing, supporting and co-ordinating the work of patients forums?

I served for 24 years as a local councillor, so I welcome the scrutiny role being given to local government. Local authorities have a duty to care for the general well-being of their areas. Although Greenwich borough council was neither a health nor an education authority, when I was leader it set up health and education advisory committees. We thought it right that the local authority and its elected representatives should scrutinise providers. I welcome the new scrutiny role, but do not see it as a substitute for the scrutiny of the CHCs.

Under the Bill, the power to veto, or refer to the Secretary of State or an independent body, closures or major changes in services will transfer from CHCs to the scrutiny committee of the local authority. The Minister may say that that addresses the democratic deficit. Increasingly, however, patterns of service and service delivery are determined jointly by health authorities and local authorities. A local authority is much less likely to comment adversely on service provision that it has been responsible for planning or delivering. The joint working of NHS and local authorities and the creation of care trusts, which I welcome, strengthen—not weaken—the case for monitoring by an independent body such as the CHC.

I echo the points made by my hon. Friend the Member for Lancaster and Wyre (Mr. Dawson) about areas that have two tiers of local authorities. District councils have a vital role to play—

Madam Deputy Speaker

Order. Time is up.

5.55 pm

Mrs. Virginia Bottomley (South-West Surrey)

I appreciate the opportunity to speak on Second Reading. Aspects of the Bill are undoubtedly constructive and positive and will help to build better health care and greater confidence. Other aspects are more doubtful and will need careful scrutiny in Committee. Further elements are, frankly, wrong-headed, and I hope that the Government—although they are not given to listening—will think again.

I shall comment on the Government's style of stewardship of the national health service and the gap between their perceptions from the political bunker, advised by political appointments made by the Department of Health and No. 10 Downing street, and the reality experienced by people who use or work in the health service. One of the advantages of being a Back Bencher, and one associated with health care in many manifestations over many years, is that one has the time to listen and to learn what really concerns people.

I shall start with the positive points, and I am grateful to the hon. Member for Erith and Thamesmead (Mr. Austin) for paying credit to Baroness Cumberlege. If ever there were a champion of the cause of nursing and nurse prescribing, it is my noble Friend. I am pleased to see such an extension of nurse prescribing in the Bill.

Like my hon. Friend the Member for Woodspring (Dr. Fox), I am pleased by the Bill's more constructive attitude towards the relationship with the independent sector. At last, that provides recognition that pragmatism rather than political dogma is taking a higher priority. The Government have spoken in a paltry manner about and to the independent sector. They have had an obsession with the ownership of the means of production in health care, which is quite unlike their attitude in other parts of the public sector. Even now, they harbour some reactionary prejudices in that regard.

The fact is that the independent sector delivers much excellent care. I have not used it, I hasten to say, but if we are to meet people's rising expectations of health and social care, we shall have to use the independent sector. There must be more scope to allow people to put their hands into their own pockets to purchase services and treatments that the NHS is not, despite its justice and integrity, able to provide. For the Government to say anything else is unhelpful and irresponsible.

Let me turn now to matters that I hope will receive further scrutiny in Committee. There are real questions about confidentiality of patient information. I am concerned about comments made by the British Medical Association. In the running of cancer registers, issues arise about patient information being made available and the degree to which that might be extended to other areas.

The confidentiality of patient information in the NHS is a fundamental principle. With that in mind, I mean to draw to the House's attention a matter that I regard as being extremely serious. In my constituency, there is a patient who is a chronic schizophrenic. I have had contact with him for 12 years, and he suffers great distress and, frankly, poor service. He is being treated with anti-psychotic drugs, but he believes that his condition is influenced by satellites. Whatever the House's view on that, I felt that, as his Member of Parliament and after repeated and urgent entreaties, it was right that I drew the matter to the attention of the Prime Minister.

I leave it to the House to imagine my horror when, on 28 December, I was contacted by Mr. Guy Adams of The Daily Telegraph who told me that he had received a tip-off from No. 10 that I was wasting time, raising questions about UFOs. I regard that as the most shocking breach of patient and constituent confidentiality. It is all the more extraordinary that, having raised with the Prime Minister questions about the growing inequity in health services in this country since his stewardship began, and having written to the right hon. Gentleman after a Prime Minister's Question Time last summer, I should receive, five months later an inadequate reply from a parliamentary secretary.

The correspondence I received from No. 10 consists of a photocopied letter from a correspondence secretary. That paints an extraordinary picture of the priorities of the Prime Minister and his office and their view of the courtesy due to Members of Parliament, and it insults one of my constituents who suffers a long-term and chronic condition. I should not have dreamed of raising his case in the House—even now I hope that it will not come to his attention—had not someone in No. 10 brought it to the attention of The Daily Telegraph. I have spoken to the parliamentary commissioner and written to Sir Richard Wilson, but I thought that as the Minister takes an interest in mental health policy, he might like to investigate the matter further himself.

The Standing Committee will have to give further consideration to other aspects the Bill, such as the clauses relating to the royal commission on long-term care. I have no Front-Bench responsibilities and can offer my views as one who has been a Minister and considered the issue. Bedlam is already breaking out about the different proposals for England and Scotland for the funding of long-term care. In my view, Christine Hancock is right to say that the proposals are unworkable. The greatest injustice we could do to elderly people would be to imply or pretend that their long-term care was to be funded; that would be to mislead them when, in fact, the service available to them was to be inaccessible or entirely lacking.

The Government should try to disregard the political timetable that always occupies first place in their thoughts—which is not surprising, given that from the word go the Prime Minister has made it clear that his only thought as Prime Minister is re-election, not public service. On this issue, the right step for the Government may be not to please the interest groups, but to take the braver decision that it is not affordable to please the interest groups. It might be more responsible fully to achieve the priorities that they have set than to open up a new wish list of policies, initiatives and constructs.

I say that because the gap between the Government's rhetoric and the reality on the ground appears to be growing all the time. People working in the health service in my area say that they feel beleaguered, oppressed, undermined and tyrannised. I live in a red-light district— an area in which the care available to my constituents has been deteriorating. I have raised the issue repeatedly with Ministers.

Although in the localities of the Secretary of State for Health and the Prime Minister only one person in 66 waits more than a year for treatment, my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) will confirm that in West Surrey one person in eight waits more than a year for in-patient treatment. That is not an adequate service in this day and age. Ministers dismiss the issue and talk about long-standing financial difficulties. I acknowledge that such difficulties exist, but I have constituents living on social security in West Surrey who have to wait more than a year for treatment at eight times the rate of the constituents of the Prime Minister and the Secretary of State. If Ministers care about the lottery of funding and the health care lottery, they cannot continue to be so indifferent to the problems in West Surrey.

Ministers have taken steps to make themselves even less accessible to Members of Parliament and those who represent localities. The new body, the national reconfiguration panel, is presumably another attempt by Ministers to wash their hands of the problems with which they do not want to become involved. I have described how impossible it is to gain the attention of the Prime Minister: even though he does not hesitate to launch the NHS plan, he has no interest in hearing, about reality from Members of Parliament—even those who have been in the House as long as he has.

In their centralising, authoritarian manner, the Government are removing regional chairmen. In my judgment, regional chairmen have performed a valuable role. They are not part of the management line on which the Government repeatedly turn the screw, and they do not belong to the tribes of nurses, doctors and professions allied to medicine. They have a degree of independence and Ministers are well advised to listen to them, but their post is to be abolished.

That abolition takes place alongside another about which the House is almost unanimously concerned—that of community health councils. For the past year, my local health authority has survived in crisis. Despite a deteriorating service, ministerial pressure has forced the health authority to say that it will close most of the community hospitals. It is community health councils which, with distinction, responsibility and rigour, have argued the case and developed a rational consensus on a more sensible way forward.

Will Hutton, not known as a great Conservative thinker, has said: the National Plan paid lip service to the idea that accountability had to be improved and decision-making delegated. Health Secretary Alan Milburn has proved the great centraliser. That issue causes me great concern. Devolution to NHS trusts—much misportrayed by the Labour party, which we in our business have to accept—allowed genuine delegation to those people who were most involved and closest to patients. Now, trust chief executives and regional directors up through the line have less room for manoeuvre and less freedom to speak. That greatly worries those who work in the service. I say that because, having been forced to develop the extremely unappetising proposals I have described, the chief executive of my local health authority, who is an honourable and sincere person, is now leaving the health service, and the chief executive of the community trust most involved has left the service on sabbatical. If the Government's bullying of people in the service results in the loss of talented individuals, it will be a great shame for the NHS.

Another aspect of the culture over which the Secretary of State presides, and of which there has been no mention, is Nigel Crisp, the new chief executive. Conservatives believe that politicians do not own the NHS but act as stewards. The Government should show more respect and concern for those working in the service. I am worried about reports from the medical profession that the Government are fuelling doctor hostility and suspicion. Doctors live under great pressure and face very high expectations from patients and the public. The degree to which they are subjected to unfair pressure and intimidation from the current team of Health Ministers should cause us all alarm and concern. I am sure that Government Members are aware that the reports are widespread.

There are growing expectations of health care, and the Bill includes sensible measures. However, I hope that in Committee the Government will think again and temper their rhetoric with the reality and delivery of care as it affects all our constituents from day to day.

6.10 pm

Mr. Patrick Hall (Bedford)

I welcome the wide-ranging reforms promised in the Bill as they advance the prospect outlined in the NHS plan of a health service in which the patient is to be the most important person and in which NHS institutions are open and accountable, better to serve the patient and the wider community.

That is a truly radical approach, requiring nothing less than the transformation of the service. Until now, for more than 50 years, the NHS has done a good, worthy and cost-effective job for the people of Britain. However, those people have had to fit in with the NHS, rather than the other way round. That has been the dominant culture, and still is. That unacceptable state of affairs has gone on for too long and needs to change. In my view, it represents a poor appreciation of the concept of public service. I am delighted that the Government understand that and are prepared to take on ambitious reform.

Given my role as chair of the all-party parliamentary group on community health councils, I should like to concentrate on part I of the Bill, which deals with the abolition of CHCs and the establishment of structures for patient empowerment and greater public accountability. Reference has already been made, in this debate and earlier, to the manner in which the planned abolition of CHCs was announced last summer. That could and should have been handled much better.

There is one overriding reason for that: if the new proposals that replace CHCs are to work, it is essential to harness the skills, experience, knowledge and good will of as many as possible of the 700 staff and 5,000 volunteers who work for CHCs in England. I know that the Government are engaged in the process of talking to those people, and they now recognise that point. Making the system work is the overwhelming will of the majority of people in this country.

As I said in the Adjournment debate on the future of CHCs on 28 November, a key question is whether the proposals for the new system of patient empowerment and community involvement provide the necessary mechanism to make things work and, more important, whether they do so better than CHCs. That question was behind early-day motion 1103, which was tabled in my name last October and was re-tabled as early-day motion 109 in the current Session. The hope was, having laid down the gauntlet last July, that the Government would work with others to fill the many gaps in their outline proposals. I welcome Ministers' willingness to engage in that process. They and their officials have worked hard with many people from CHCs, patients groups, voluntary organisations, research institutions and others to address those matters, and continue to do so. As a result, a fuller, clearer and more reassuring picture is in the making, but it is still far from complete.

That is the difficulty that we face. Today, we are debating the general principles of a Bill that deals with only part of the new structures. It includes, for the first time, a statutory duty on health authorities and trusts to consult on changes in service delivery, which is extremely good. It abolishes CHCs and sets up patients forums for every NHS and primary care trust. It places scrutiny of local NHS plans and the ability to refer contested proposals to the Secretary of State in the hands of local council scrutiny committees.

The only truly new body in the Government's proposals to appear in the Bill is the patients forum. Other bodies are not mentioned directly. I do not see how we can debate those matters effectively and answer the question that I have just posed unless we discuss patient advocacy and liaison services, independent local advisory forums and how the existing Commission for Health Improvement is to play a part.

In addition to the five bodies that I have just mentioned, Ministers have talked about health authorities commissioning citizens advice bureaux or other bodies— we have heard today that they could include local authorities, which is an interesting and welcome move— to perform the key role of offering independent advocacy services to handle patients' complaints. That is a welcome recognition of the fact that PALS are not suited to that task. However, that means that there will be another organisation, making a total of six, only two of which are included in the Bill and only one of which—the patients forum—is genuinely new. Several matters relating to the membership and powers of patients forums will be dealt with by regulation, so we might not get the detail until the Bill has completed its parliamentary stages.

In considering those aspects of the Bill, there is a strong need for a clear vision of the bigger picture. I do not mean that every detail should be included in the Bill and, of course, there should be flexibility. However, there is surely a need to demonstrate some detail, such as national standards for training, resourcing and sharing good practice. If that is not done, we could end up with a system that displays the patchiness of performance that has been cited, rightly, as a key weakness of CHCs.

I therefore urge the Under-Secretary to respond to our debate by addressing the need for sufficient detail, to enable us to scrutinise the whole picture, not just what is in the Bill. We must tease out the details of issues involving PALS, independent local advisory forums and the Commission for Health Improvement, and how everything fits together. We must consider how those are to be resourced, supported and integrated, both locally and nationally, to provide a coherent, workable and joined-up system. To do that, it would be helpful if draft regulations and guidance were made available when the Bill is considered in Committee. Will my hon. Friend the Minister give me an assurance that that will be done?

It is proposed that one patients forum will be set up for every trust, charged with a duty to monitor, review and inspect the provision of health services from the patient's perspective. It is a relief to have heard today that the forums will be funded by health authorities, not the trust to which they are attached. That gives them every chance to be independent, which they need to be. There is a radical proposal in the requirement for the forums to elect a representative to serve as a non-executive director on the trust's board. However, would there be a conflict of interest? To whom would the extra new non-executive director be accountable? Would it be the patients forum or the trust's board? After all, a trust's board is a corporate body that expects collective responsibilities and confidentialities to be respected. Would that compromise the independence of the forum?

Mrs. Caroline Spelman (Meriden)

I know that there is a time constraint, but does the hon. Gentleman accept that there might be a conflict of interest if the patient has a complaint against the health authority that is funding the forum?

Mr. Hall

That needs to be worked out. The money has to come from somewhere, and it has to come from the public sector. After all, CHCs are funded through regional health authorities, and it is sometimes possible to trace policy back to the regions. Such issues should be examined thoroughly in Committee so that we can see the full picture. That is a perfectly fair point, although it is preferable to remove the patients forum from the direct management and financial responsibility of the trust to which it is attached. I hope that the hon. Lady agrees with that. I am not saying that a healthy tension between a non-executive director from the patients forum and the board on which he or she sat would not work. However, the status of that non-executive director needs to be clarified.

The proposal for local council overview and scrutiny committees is one of the best in the Bill. It is a welcome initiative that will confer a new and important role on local government. However, that role will only be as good as the information and advice that councillors receive. Councillors will need to be well informed to engage constructively in debate about the local health scene, and to decide whether to refer proposed service changes with which they do not agree to the Secretary of State. They will need easy access to independent, reliable sources of information as well as to the official views of the health authorities and trusts, which brings us back to the point about the integration of new structures.

What will happen in parts of the country such as Bedfordshire with two tiers of local government? What will happen to a trust covering a wide geographical area? For example, the Bedfordshire and Hertfordshire ambulance trust covers two county councils, one unitary district and 13 ordinary district councils. How is that trust to be held to account?

There is a great deal at stake in these matters. The transformation and modernisation of the NHS is an ambitious and desirable goal. I wish it well, and I would like to assist in that process. However, there remains much more to be done before the system that replaces community health councils can be seen to be credible and capable of bringing about the improvements for the patient and the community for which most of us are looking.