HC Deb 27 October 2003 vol 412 cc82-133
Madam Deputy Speaker (Sylvia Heal)

We now come to the motion on the effect of Government targets on the provision of heath care. I must inform the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.

7.16 pm
Dr. Liam Fox (Woodspring)

I beg to move, That this House notes that the Government's obsession with target-setting now pervades almost every aspect of healthcare; believes that the volume of centrally set targets and the way in which these have been imposed is having a detrimental effect on clinical outcomes, since the welfare of the patient becomes a secondary consideration to the achievement of the target; further believes that the imposition of these targets is seriously demoralising the professional staff within the NHS, diverting them from spending time with patients to additional paperwork and bureaucracy; is appalled that pressure on managers to achieve targets has led to distortions in reporting on performance, so that the public has no confidence in claims that are made about achievements in the NHS; and calls on the Government to do away with their reliance on the target-setting culture, to re-invest the money saved on bureaucracy into front line medical care and to trust doctors, nurses and other professional staff to get on with their jobs with minimal interference, in the interests of all of their patients.

I must say at the outset how bizarre it is that the Secretary of State for Health has not attempted to stay to hear a debate on such an important health issue. I understand that he recently visited the United States to learn about the benefits of its health system. It seems that he is rather more interested in that than in what happens in this House or the national health service.

The debate revolves around the question of what targets actually are. Most of us would regard targets as quality benchmarks and something against which we could monitor progress. Most of us would say that targets relate to the application of best practice and that they are aspirational. Yet, under the new Labour Government, targets have become something quite different. They have become direct commands in the health care system. They are ministerial diktats meaning that strategic health authorities and primary care trusts are simply the delivery arm of Whitehall acting on ministerial instructions.

Under the full lexicon of new Labour, we hear of "earned autonomy", which is a wonderful oxymoron, meaning "You can do what you like as long as it's what we tell you to do." We are told that PCTs control 70 per cent. of the budget, but they merely handle 70 per cent. of the budget. That is rather like saying that bank clerks control millions of pounds because they handle millions of pounds, although they have no discretion in what to do with the money. Part of the myth perpetrated by the Government is that they are decentralising the service.

The problems with targets fall into several distinct categories: their effect on patients and clinical priorities; their effect on integrity and trust in the system; their effect on non-acute services; and their effect on recruitment and morale. Let me begin by talking about the effect on patients and clinical priorities, because all hon. Members will be aware of stories that have been circulating widely about distortions in the system. In September, the BBC broke a story about what was happening in Leeds. It said: Managers at Leeds Teaching Hospitals NHS Trust say they will only accept referrals from GPs if they are sure patients can be seen within 17 weeks … The trust has now written to GPs in Leeds to tell them it will not accept new patients if it means it will breach the outpatient waiting time targets set by the government. In a letter to GPs, the trust warned that patients will have to go elsewhere. It said: We will accept a referral only when we have the capacity to see the patient within the maximum waiting time—which is currently 17 weeks for outpatients by 31 March 2004. We may be unable to accept a referral from your practice. The trust had the nerve to say: This is not all about waiting times … This is about managing the number of people coming into the trust and improving planning. So patients are referred to where it is convenient for the system to see them. In other words, the system is not there to service the patients; the patients are there to service the system. That has been the great cultural corrosion under new Labour.

Rather more recently, on 13 October this year, the United Lincolnshire Hospitals NHS trust said about the suspension of specialist pain services in Lincolnshire: The Local Primary Care Trusts and the United Lincolnshire Hospitals NHS Trust has reached an impasse in negotiations regarding funding of the county-wide specialist pain services. The service has been suspended because capacity of the service is insufficient to meet a growing demand. Faced with an unwillingness on the part of the Primary Care Trusts to invest, and a likelihood of breaching monitored waiting times for new outpatients, a decision was made to suspend the service. In other words, if a trust cannot make the targets, it can give the service up entirely and not breach Government guidelines. What sort of ethical basis is that for running a system?

The consultants at the centre of the problem said that the decision was taken without consultation with clinical personnel and, apart from continued access for patients with cancer pain, is not based on clinical need but rather financial and political criteria. In their letter, the consultants also said: There have been a number of instances where pain clinics in the UK have stopped accepting new patients as a means of managing waiting lists, with the recent nationwide survey revealing four clinics spread across the country currently not seeing new patients"— not because the patients did not need to be seen, but because it was politically inconvenient for the managers to have to report to Ministers that they could not meet their targets. So the statistics came first and the patients came second.

Hugh Bayley (City of York)

In my health authority area in North Yorkshire, the number of out-patients waiting longer than 13 weeks has fallen over the past five years from more than 5,000 to 1,000, a fivefold reduction. The figures for the area represented by the hon. Member for Woodspring (Dr. Fox) will be similar. Does he think that we should get rid of the out-patient waiting time target? If not, precisely which targets does he suggest the NHS should abandon?

Dr. Fox

I do not believe that the service should be forced to work to centrally driven targets determined by Whitehall. It should be up to clinicians to determine which patients are treated, and the priority of that treatment, in their locality. There will need to be a different balance of services in different parts of the country. To attempt to run the service in a one-size-fitsall target-driven culture designed in Whitehall will be catastrophic, as it is in many of the areas I mentioned.

Several hon. Members


Dr. Fox

I shall give way in a moment.

Let us consider what happened in Oxford, for example, where we saw the obscenity of patients sitting in ambulances, queuing by the accident and emergency departments so that they did not breach the four-hour waiting time for accident and emergency. The Government's Commission for Health Improvement ambulance trust review said: One of the reasons for long delays in A&E departments accepting patients from waiting ambulances may be their own need to achieve a target that no patient should wait more than four hours from arrival in A&E to admission … This illustrates how targets set for one service may work against good cooperation between services. It is not possible to micro-manage a system as complex as the NHS from behind a Minister's desk in Whitehall. It is not possible to design a set of targets and criteria that will allow professional people to exercise their judgment appropriately.

Mr. Mark Hendrick (Preston)

How can a Government determine whether the taxpayer is getting value for money from their health care if the Government do not set the targets? Does he not accept that hospitals throughout the country do not have inexhaustible capacity? If a hospital cannot meet the need in the locality, it is feasible that that patient may have to be treated elsewhere.

Dr. Fox

The hon. Gentleman raises two important points and he betrays what is at the heart of the new Labour problem. First, he says that the Government have to set targets to get value for money, but there is no concept of what is appropriate for the patients. The most important thing is not the system but what matters to the patient. Secondly, he mentions patients going elsewhere. It is Conservative policy that patients should move anywhere they want to inside the NHS. Naturally, any policy is constrained by capacity, but patients should be able to exercise that choice themselves. Instead, they are moved around for the convenience of the administrators. That has nothing to do with what patients want or what is good for them. In that scenario, the system comes first and the patients come a very poor second.

The Secretary of State for Health (Dr. John Reid)

I thank the hon. Gentleman for clarifying his remarks. Will he confirm that for the 1,500 people who were waiting more than 26 weeks in his constituency for a consultant's appointment and who have now been completely taken off any list—no one in his constituency is waiting more than 26 weeks—as a result of our objectives in driving forward those targets, he would abandon all the targets and objectives and we would return to the situation that prevailed before the Labour Government?

Dr. Fox

The Secretary of State's question reminds me of what happened to some of my constituents when the Bath Royal United Hospital NHS trust told them that only two patients were waiting more than 18 months anywhere in the country. We were inundated with calls all afternoon from people wanting to know who the other person was. As far as the patients were concerned, many had been waiting for that time, and I intend to deal with the accuracy of the figures.

The Secretary of State does not understand that activity is being driven by the numbers, not by the clinical importance of the conditions affecting patients. It is not acceptable to get numbers down if it means that the sickest patients might wait longer than those with less important conditions. What is absent from the Government's approach is the idea that the most appropriate people to make decisions for patients are the clinicians who look after them. We all want lower maximum waiting times across the board. That is a universal aim. We want to ensure, however, that that does not result in a clinical distortion by which some of the sickest patients have to wait longer.

Mr. David Hinchliffe (Wakefield)

Will the hon. Gentleman give way?

Dr. Fox

Of course I shall give way to the hon. Gentleman in a moment.

One set of Government figures reveals the flaw in the Secretary of State's case. Their targets for seeing cancer consultants are, on the surface, laudable and sensible, but they are about gaining access to a consultant in the first place; they say nothing about when a patient will receive treatment. So let us consider what has happened in cancer treatment.

According to Department of Health figures produced in September, waiting times for cancer treatment increased in most cases between 1999 and 2002. [Interruption.] The Secretary of State says, "No, they have not", so let us look at them. Between 1999 and 2002, the average waiting time for treatment for cancer of the oesophagus was up 14.3 per cent.; for cancer of the stomach, it was up 20 per cent.; and for brain cancer, it was up 66.7 per cent. The Government have met their targets for how quickly a patient can see a consultant, but they have increased the length of time before patients receive treatment. What is the point of that?

Mrs. Joan Humble (Blackpool, North and Fleetwood)

The hon. Gentleman does not mention breast cancer treatment or the initial referral. Constituents of mine have had almost immediate access to both the initial consultation and treatment. Those women would have died but for that development. They welcome the targets because they are the direct beneficiaries of them.

Dr. Fox

But if the consequence of all patients who are suspected by their GP of having breast cancer being seen within a maximum waiting time—which, again, on the surface, seems fine—is that the consultants who should be treating those with proven breast cancer are having their activity redirected, there is no clinical gain. It is a question of what is sensible and what is appropriately judged by clinicians.

With the best will in the world, politicians cannot create a system that is both specific and sensitive enough to deal with individual patients. It is nonsensical if the patients get a maximum waiting time to see a consultant but the waiting time for treatment is lengthened, because that is what will make the difference to the clinical outcome for the patient.

Dr. John Reid

With great respect to the hon. Gentleman, who has practised medicine, I say to him that the whole point is that, unless patients are seen early by a consultant, those clinical judgments cannot be made. When we took power, people waited weeks and, in some cases, months to see a consultant, even when the doctor had identified a suspected cancer. Now 98.5 per cent. of all people diagnosed with a suspected cancer see a consultant within two weeks.

That early appointment is important precisely so that the consultant can then decide, according to their clinical assessment, in what order treatment should occur. But patients have to be seen first, and under the last Conservative Government, even when people had been diagnosed, they waited weeks and months; now they are seen within two weeks. That is the point.

Dr. Fox

The Secretary of State is right: that is the point. The point is that it is not how quickly patients are seen that matters for their clinical outcome; it is how quickly they are treated. According to the Government's own figures, the waiting time from being seen to being treated is going up. It is being elongated by the fact that consultants have targets for seeing new patients, not follow-up patients, and there is no Government target for the length of time before treatment.

I recently attended a meeting with CancerBACUP at which a cancer consultant said that his hospital was making very good progress with cancer doctor numbers. He said, "We now have extra consultants, which is a good thing, except for how we did it. We delayed the retirement date for our outgoing consultant from 31 March to 1 April, brought forward the recruitment date of our new consultant from 1 April to 31 March and gave one of our retired consultants one session a week. As we were measured on 31 March, we had three consultants. Of course, we really have only one, but on paper we have three." It is that sort of statistical manipulation that is so damaging to morale, integrity and trust in the system.

Mr. Hinchliffe

The hon. Gentleman may have had some contact—in a professional capacity, I hasten to add—with the genito-urinary medicine clinic in Bristol, which I, as a member of the Health Committee, visited a little while ago. We were told that it was turning away 500 people a week because it simply did not have the capacity to treat people with serious infections and sexually transmitted diseases. The Committee, with the support of its Tory members, put forward the view that in such circumstances patients should have access to treatment and care within 48 hours; they should not be turned away to go and infect other people. To their credit, the Government acceded to that request. Were they wrong to do so when we have such a crisis in sexual health?

Dr. Fox

That is a very good question because it goes back to what we mean by a target, as I said at the outset. It is fine for the Government to say, "This is what we regard as best practice and it is aspirational", but using targets as a means of forcing activity on the system—an activity designed on a one-size-fits-all basis—does not really work in the real NHS. That is the problem that we are identifying in this debate.

The targets and the way in which they are interpreted also have an effect on the trust and integrity in the system. In June 2003, in a damning condemnation of the culture of targets, the Audit Commission said: Local managers must want to improve patient care via meeting targets—not manipulate things to theoretically meet targets without real gain. For example, practices such as offering appointments at short notice and restarting waiting times if patients cannot attend comply with DH guidelines, and allow some trusts to achieve targets, but would not be considered fair by patients. Similarly, cancelling high numbers of operations the afternoon before the due date means that the commitment to rearrange within 28 days does not apply, and the Plan target can be met—but again, this is not acting in a way that patients would think fair. Such trusts have lost sight of the real priorities, which are about improving the NHS for patients, not just meeting Government targets. In practice, the target culture nurtures target-oriented behaviour.

Looking at the accuracy of the figures that Ministers are so fond of quoting, the Audit Commission said: A number of trusts were found to be operating in ways that seemed weighted away from the interests of patients. These include the practice of offering appointments to patients at short notice and then, when they are unable to attend, recording this as a 'patient cancellation' and resetting the 'clock' measuring their waiting time to zero. The chairman of the commission said: You're about to breach the target, you then tell the Department to phone up 50 per cent. of the people on that waiting list and offer them, surprisingly, admission within the following two weeks, to which of course large numbers say 'Two weeks? I can't do that.' At which point they're told, 'I'm terribly sorry, you have to go back to the beginning of the waiting list" and hence the target is met. That is fine if one thinks that the most important thing in the health care system is meeting the targets, but as the Audit Commission clearly said, it does nothing to help patients.

When the all-party Public Administration Committee reported on the Government's measurements, it said: The danger with a measurement culture is that excessive attention is given to what can be easily measured, at the expense of what is difficult or impossible to measure quantitatively even though this may be fundamental to the service provided (for example, patient care …) There is the further danger that the demands of measurement may be so consuming of time and effort that they detract from the pursuit of a service's underlying purpose. The measurement culture is also in danger of threatening standards. That is a Labour-dominated Committee.

Mr. Ian Liddell-Grainger (Bridgwater)

As a member of the Public Administration Committee, I should point out that we went on to say that we had found numerous cases where figures were being blatantly fiddled and people were lying to cover up the culture that my hon. Friend has just mentioned. Does he agree that that is happening?

Dr. Fox

The interesting point, following further investigation of the details, was what the culture meant to patients in those situations. In May 2002, the Bath Royal United Hospital trust found that more than 2,000 out-patients waiting more than 13 weeks for a consultant appointment had disappeared from official lists—at that time the trust reported just 22 such outpatients. A lot of patients who were genuinely waiting were not, on paper, waiting at all.

In autumn 2002, after a strategic health authority investigation, the Good Hope Hospital trust in Birmingham found that 30 inpatients had waited over 15 months for treatment and six outpatients had waited longer than 26 weeks for treatment, but those figures had not been correctly recorded. In March 2003, the strategic health authority for South Manchester University Hospitals trust found that long waiters—those who had been waiting longer than 18 months—were simply excluded from returns, and other patients were being inappropriately redesignated from the acute waiting list to the planned admissions list.

We all know from our constituency mailbags that those are not unusual cases. Ministers will say that they are isolated examples and that the managers in question must be sorted out because they have no place in the NHS. Those managers are merely carrying out the tasks that they know are required of them by central Government in the target culture. It is no use Ministers saying, "It has nothing to do with us," because managers know that if they fail to meet their targets or they breach the Government guidelines, they will get a phone call from someone in the Department of Health telling them how they ought to be running their hospital and which patients ought to be seen. That is simply not acceptable.

Earlier this year, we had the great accident and emergency farce. The figures published by the Department showed that the proportion of patients in England who spent less than four hours in A and E had risen to 82.4 per cent. Those were wonderful figures—we would all love to think that patients did not wait in accident and emergency—and they were released on 20 June. However, the BBC programme "Panorama" and the British Medical Association showed that they were nonsense and did not accord with what was happening in the real world. According to the BMA, two thirds of accident and emergency departments in England established special arrangements during the monitoring period, which they knew about in advance. Preliminary results from a questionnaire sent to accident and emergency staff found that the temporary use of medical and nursing staff was the most common tactic, followed by staff working double or extended shifts. Fourteen per cent. of respondents were aware of routine surgery being cancelled so that extra beds were available that week. The majority believed that efforts to meet the Government's targets distorted clinical priorities in accident and emergency.

It is nonsensical to operate a service by saying, "We know you're going to be measured this week. If you can meet the targets that week, whatever you have to do to do so is fine. The Government will be able to tick a box and say that we've met the targets." In fact, that distorted activities in other areas and other patients suffered. Nobody believed that the exercise was genuine or sustainable and, of course, the following week, things went back to what they were before. It is an Alice in Wonderland way to run a health service, and results in a culture of distortion and deceit.

Other services damaged by that culture are the non-acute services and the services for which the Government do not have a centrally driven target. The Prime Minister keeps telling us that public services are about "schools and hospitals", which betrays a great deal of ignorance of what happens in the health service, as most of our health care is provided not in hospitals but in the community. The obsession with acute hospital targets means that, far too often, too little attention is given to other services. My hon. Friend the Member for East Worthing and Shoreham (Tim Loughton) will talk about the effect of targets on primary care in his winding-up speech. but while Ministers have developed obsessive-compulsive disorders about hips, knees and cataracts, mental health services have continued to deteriorate. The so-called sexual health strategy is a disaster. I am sorry that the hon. Member for Wakefield (Mr. Hinchliffe) has left the Chamber, because it would have been interesting to learn from him just how bad things have got for the GUM clinic in Bristol. The Government's immunisation strategy is in tatters, and infectious diseases such as tuberculosis have reached record levels. While diabetes becomes ever more prevalent, screening and care constantly lag behind that trend.

We also need to consider the effect of targets on staff morale, recruitment and retention. If there is one thing that shows the Government's lack of understanding of the complex way in which the health service works it is their absurd star rating system, which is designed to demoralise people, tells us nothing of any value about hospitals, and ought to be scrapped. When the star ratings, in their crude way, are applied to hospitals, they often create a misleading picture. Hospitals are treated as single units, not a complex interaction of services. Just because a hospital has a poor gynaecology service does not mean it will have a poor cardiology service. Just because it has an excellent ear, nose and throat service does not mean that it will have an excellent orthopaedic service. The star rating system does not tell patients anything of any value, but it can, in many cases, have a demoralising effect on staff in those hospitals. The chairman of the BMA, Jim Johnson, said: Nobody should use star ratings to judge how well a hospital is doing. They measure little more than hospitals' ability to meet political targets and take inadequate account of clinical care or factors such as social deprivation. It is grossly unfair on staff working in low-rated trusts that public confidence in them is being undermined". The Times carried out an investigation in May and found that a third of English hospital trusts with the highest mortality rates were the best performers in Government ratings. To put that in context, we might consider the high level of hospital-acquired infections and what the Government's figures tell us about the relationship between infection and cleanliness. Fourteen of the 20 trusts in England with the highest levels of hospital-acquired infections received the Government's top rating for cleanliness. It is nonsense for a trust to get the top rating for cleanliness while, at the same time, putting patients at the highest risk of getting a hospital-acquired infection. What on earth does that tell patients and doctors about the quality of the service?

David Taylor (North-West Leicestershire)

Would the hon. Gentleman care to tell the House about the links between levels of hospital-acquired infections and the outsourcing arrangements in place at many of those hospitals, a good number of them dating back to the period when his party was in office?

Dr. Fox

That is one of the most absurd arguments that I have ever heard. If a trust has contracted-out cleaning, but the hospitals are filthy, why pay the contractors? It should get someone else in to do the job. One of the biggest problems with hospital-acquired infections is simply cultural. Transmission of infection between patients has nothing to do with expenditure but a great deal to do with washing one's hands. For a doctor or nurse to wash their hands after seeing one patient and before seeing the next does not require a Government grant. It is part of the culture of the system—it is not helped by any Government target and is good practice for professionals who deal with patients. It does not require Government intervention, but it does require a bit of thought about patient care.

One area where morale has been particularly hard hit is general practice. Medeconomics, the specialist health magazine, reported in September this year: There are now fewer GPs per patient than five years ago. In 1997 there were 54.3 GPs for every 100,000 people, compared to 54.1 in 2001. Figures published this month show that the number of vacancies has gone up. More than two thirds of GP vacancies were unfilled for more than six months, and the number of such vacancies has increased by 31 per cent. since 2002. Dr. John Chisholm of the BMA's general practitioners committee said: We are not surprised by this increased vacancy rate … in England. Indeed it matches the findings of our own GP vacancy rate survey … The upward trend is a matter of great concern. Finally, targets have another cost. A target culture breeds bureaucrats in the same way as micro-organisms breed in a culture dish. If a target is set, it must be monitored, the results of that monitoring passed to someone else, and so on. Co-ordinators have to coordinate other co-ordinators, and the gap between decision making and delivery is filled with an ever-growing volume of interference, control and obstruction. It is no wonder that more people joined the Government payroll in the past year than work in the European Commission—there are hundreds of posts in monitoring units, delivery units, assessment teams and co-ordination groups. The overall number of public sector workers has risen by 0.75 million in the past five years so that they now account for one in four of the work force. It is little wonder that the Government's extra spending and our extra taxes have not resulted in clear benefits for patients.

Targets are not about patients but about politics. The NHS is being run to suit the spin of the Government machine, not the clinical needs of patients. Political expediency is given priority over the need for care. New Labour has corroded the integrity of the NHS. It has put statistics before patients, demoralising NHS staff—the staff I trained and worked with, who are becoming increasingly difficult to recruit. This is no longer about the health of the public but about the political health of the Government. And they told us that things could only get better.

7.48 pm
The Secretary of State for Health (Dr. John Reid)

I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof: welcomes the Government's record extra investment in the National Health Service; supports the Government's policy of linking investment to reform; notes that setting targets and monitoring performance against them are a vital part of the accountability process; welcomes the Government's determination to devolve power in the health service to the front line backed by three-year allocations of money to NHS organisations and clear delivery targets for the next three years; welcomes the positive effect of the right targets on staff morale, motivation and standards; welcomes the increases in capacity and workforce numbers, the greater availability of new and better drugs, the shorter waiting times and the greater choice available to all patients; notes that expenditure on NHS management as a proportion of the total NHS budget is falling; and supports the Government's commitment to a high quality NHS, responsive to the needs of patients, available to all free at the point of need. Well, now we know. We knew before tonight that the Conservative party was committed to reducing the amount of money in our health service, diverting money from the NHS to subsidise people who could afford to go private. However, now we know two other things. We know that the Conservatives oppose the increase in NHS staff numbers—the hon. Member for Woodspring (Dr. Fox) revealed that in the last part of his speech—including extra doctors and so on. The Conservative spokesman gave a pledge that our targets, which have resulted in extra doctors and nurses, reduced waiting times, increased finance, and made sure that there are more operations for more people, who get them more quickly, will all be scrapped under a Conservative Government. That pledge is significant, and it is a dividing line to which I shall return. It is ironic that the Opposition, who regard themselves—on what basis has never been clear to me—as competent in a managerial and business sense should argue that there should be no centrally set targets whatsoever. It is one thing to argue sensibly for a balance between devolution of operational capability to the front line, which I fully support, but, on the other hand, it is something else entirely to argue that there should be no drive or strategic objectives set from the centre. It is an extraordinary statement from any party that claims to have any knowledge of any organisation, public or private.

It is ironic that the debate is taking place on the very day that the Leader of the Opposition set Wednesday as a target date for his opponents, who have a target of 25 letters being submitted. It is ironic that today we are debating a Conservative motion deploring targets. [Interruption.] I am sorry. The hon. Member for Woodspring (Dr. Fox) is getting frustrated. I hope I have not kept him away from letter writing or from composing a personal manifesto. He has a chance to shine tonight and I hope he takes it, because perhaps greatness awaits. I know that there is some scepticism about his opportunities and his chances, but the Opposition are running out of options, so he must have some chance of greatness in the coming period.

We make no apology for targets in pursuit of excellence. Targets bring—

Mr. John Bercow (Buckingham)

Useless windbag.

Dr. Reid

I take it very badly that such an eminence grise of the House complains about my contributions. We await the day when the hon. Gentleman is standing at the Government Dispatch Box, but it may be a considerable time before any of the Opposition arrive on the Treasury Bench.

Targets bring focus, delivery and accountability. They are foreign to the Opposition because they also bring equity, which has never been a prime objective of the Conservatives. Of all the presentational aspects tonight, the one that grieves me most, though it is not unexpected, is the way that the efforts and achievements of 1.4 million staff who treat 1 million patients every 36 hours have been demeaned and condemned by the Opposition spokesman.

Dr. Fox


Dr. Reid

I shall give way in a moment. Every improvement that has taken place in the national health service has been brought about because of the determination and commitment of those who work in it. To hear every single improvement disparaged as the result of lying, fiddling and cheating by the NHS staff says more about the party that makes those allegations than about the NHS staff. I give way to the hon. Member for Woodspring if he wishes to withdraw half of his speech tonight.

Dr. Fox

It is a great pity that the Secretary of State must resort to such tactics and puts into our mouth words that were never there. It is especially disgusting, if I may say so, that he tries to suggest that we would denigrate the work of staff in the NHS. As I just said, they are the staff with whom I trained and worked. Unlike the Secretary of State, I have worked in the NHS. It is the staff who are keeping the NHS afloat, despite Government interference. The right hon. Gentleman might want to ask himself why the Opposition trust the professionals to exercise their judgment on patients, but he does not.

Dr. Reid

Every one of the words that I quoted was taken from the hon. Gentleman's speech—he can check Hansard: "fiddling", "cheating" and "lying". I could have gone further. He referred, at least by implication and possibly explicitly—we will read it in Hansard—to managers as micro-organisms being spawned. Not only did he use such language, but in almost 36 minutes he could not bring himself to admit that there had been any achievements or improvements by NHS staff.

I admit there are some deficiencies—I shall come to them later in my speech. I know the size of the challenge that we were left by the previous Government. I will not pretend that everything is all right, but an NHS whose every achievement is condemned by the Opposition is not an NHS that will march in the street for the return of a Conservative Government.

As anyone involved in any organisation, public or private, knows, targets bring focus, concentration of effort and delivery, as they drive effort and ingenuity towards achievable ends. Targets bring accountability because they not only distil the priorities of the public, but set the criteria by which promises can be measured. They bring a degree of equity because, for the first time, they provide the public with an equal right to access, and a right to judge whether the politicians are assisting in delivering an improved service, as they promised. Targets provide a degree of equity, not a privilege that only a few can buy—a point to which I shall return—but a right for everyone.

People want to know how quickly they can see a GP or how quickly they can have an operation. They want to know that we are doing all we can to reduce those times, and they want to know whether we are succeeding in reducing those times. The abolition of all those targets, as promised tonight by the Conservatives, would deprive the NHS of the drive and the resources to better the service that it gives, and would remove from the public any indication of whether the Government and the NHS are improving at all.

Furthermore, the absurd separation and implied dichotomy between the time that one has to wait, often in pain, for an operation, and the quality of the service that one perceives oneself as having received is a separation and dichotomy that can be made up only in the minds of those who, like some Opposition Members, have never had to wait for an operation because they have found other ways to jump the queue and get it quickly.

Mr. Andrew Turner (Isle of Wight)

Where is the equity that the right hon. Gentleman has guaranteed to deliver, when constituents of mine have to travel three hours in each direction and spend £90 to get three children to an NHS dentist?

Dr. Reid

There is a distinct lack of equity in that situation. I assume the hon. Gentleman is referring to the Isle of Wight. I have no hesitation in saying that we have a mountain to climb in NHS dentistry. We have a huge challenge in respect of public health issues. Sexually transmitted diseases present us with a major challenge. All these things are true. I do not claim tonight that everything in the NHS is as it should be. I say to the House that things in the NHS are vastly improved over what they were six years ago, in every conceivable direction.

Dr. Fox

On the point made by my hon. Friend the Member for Isle of Wight (Mr. Turner), the Government have been in office for six years. In 1999 at his party conference, the Prime Minister specifically promised that within two years no one would be denied access to an NHS dentist. What went wrong?

Dr. Reid

We are trying, in circumstances not of our own making—in circumstances that we inherited—to improve almost every aspect of our health service, which was left under-invested, underfunded and in decline over a period of almost 25 years. Only last month we put another £35 million into NHS dentistry to try and improve the position that the hon. Member for Isle of Wight described.

There are many in the House who, from a position of authority and commitment to the NHS, could criticise us for not doing enough, but the Conservatives are the last people entitled to do so, since their policy is to reduce public expenditure as a whole and, even from that reduced amount, to divert money from the NHS to subsidise those who can already afford to jump the queue by going private, through the patient passport.

Mr. Bercow

Will the right hon. Gentleman allow me?

Dr. Reid

Of course, and I will listen with a view to learning from the hon. Gentleman how great men should speak.

Mr. Bercow

I am grateful to the right hon. Gentleman for giving way. May I clarify his position, for the avoidance of doubt? In response to my hon. Friend the Member for Woodspring (Dr. Fox), the Secretary of State's attitude is that if the Prime Minister makes a promise in 1999 to be delivered in 2001, and in 2003 it still has not been delivered, that is the fault of a Government who left office in 1997. Is that his position?

Dr. Reid

No, I did not say that. If we make a promise and fail to deliver on it, we should say from the Dispatch Box, "We have not delivered on that promise. We continue to try to do so." But it is not irrelevant to explain to people that although we have free will, we do not, as an old philosopher said, operate in circumstances of our own choosing: those circumstances were largely created by the Conservatives. In this party, we suffer from the great disadvantage of knowing that when our leaders make a promise, they are liable to have to answer, a few years hence, on whether it was delivered. The Conservative party has the good fortune to change its leaders every so often, so none of them can ever be held accountable for anything, let alone promises that they made 24 hours ago. [Interruption.]

Madam Deputy Speaker


Dr. Reid

Thank you, Madam Deputy Speaker. As you know, there is a great deal of nervous energy among Conservative Members at the moment.

Is the Conservatives' problem that we have set targets or—for them, it is a bigger problem—that we are meeting those targets?

Mr. Hendrick

Does my right hon. Friend agree that the state of NHS dentistry is due not to the resources that are being ploughed in or the commitment of the Prime Minister, but to the fact that it takes six years to train a dentist?

Dr. Reid

Any fair and balanced person would accept that the Conservatives' introduction of a contract that alienated the whole dentistry profession has had long-term consequences. That is why, despite the comments of the learned doctor, the hon. Member for Woodspring, I take some small and modest satisfaction from the fact that doctors and consultants gave us an overwhelming vote in acceptance of the contracts that we proffered. That is because they achieve a balance between giving central direction and setting strategic objectives and recognising the flexibility, independence, integrity and professionalism of doctors and consultants, so that they can contribute towards a general corporate effort that recognises their individual contribution and autonomy in so doing. We are achieving a great deal in that respect, despite the nay-sayers.

I wonder why Conservative Members decided to decry not only the targets, but all the achievements and improvements of the past six years, which, for all their partisan comments, they must know are going on. The answer lies in what the hon. Member for Woodspring is alleged to have said at his party conference—that if the Government were to succeed in improving the national health service, in line with the plans that I set out, the Conservatives would be politically "flummoxed". I am not sure that that was the word that he used, but I remember that it started with an F. He is probably right. His party is in a state of complete flummox—indeed, I would go so far as to say that they are well and truly flummoxed.

The truth is that the investment that we have put in, the systems reform that we are carrying out and the strategic objectives and targets that we have outlined have had a dramatic effect on the health service. Unlike the hon. Member for Woodspring, I shall try to give a balanced picture. I have already accepted that in some areas we have not made the advances that we should, but it is reasonable to point out that in 1997, when we took office, there was no standard waiting time to see a GP—no objective had been set—because so many people were waiting too long. Now, nine out of 10 people can be seen within 48 hours. In 1997, when the hon. Gentleman's party had been in power for some considerable time, more than 30,000 people were waiting for operations: last month, there were 31. That is the result not of lying, cheating and fiddling managers, but of a huge, determined effort by NHS staff, increased capacity and changes and reforms in the system. Making that reduction from 30,000 to 30 is surely an achievement by the NHS that even the most grudging Conservative spokesman should be prepared to flag up and offer an accolade.

I remember the days, not that long ago, when Conservative Members wondered aloud whether they would be able to give a guarantee that no one would wait more than two years for an operation. Now, almost no one waits for more than a year. By March next year, I hope that no one will wait more than nine months; by the following year, I hope that no one will wait for more than six months. Those are the targets that I set. Let me say, because it is relevant to one of the cases that was mentioned, that even if we achieve a six-month maximum wait, it will be six months too long for me. We should be aspiring to give people what anyone with large amounts of money would demand—that is, an operation within weeks, sometimes days. I take some satisfaction from the fact that seven out of 10 patients are admitted for treatment within three months of joining the in-patient waiting list. More than 90 per cent. of people—almost double the rate under the Conservatives—are seen, diagnosed and treated within four hours in accident and emergency departments. It is simply not true, as the hon. Member for Woodspring implies, that the achievement of that target was a one-week wonder.

Dr. Fox

It was.

Dr. Reid

The hon. Gentleman repeats the calumny. In fact, it has been maintained for five months consecutively. It is not one week's effort by a bunch of fiddling and lying staff, but a sustained effort from March until now. Indeed, I can tell the House that in August, the last month for which we have figures, the average was 90.3 per cent. We should celebrate that achievement by NHS staff, not decry them at every opportunity.

Although such successes do not completely transform the health service—we will be years in that job—they remind us of the horrific mess that the Conservative party made of it when it was in power. I am not in the least complacent. We have further work to do to improve access to accident and emergency, GPs and practice nurses. Yes, on occasion people have used methods that none of us would condone to achieve targets or to pretend that they have done so. I recently condemned those methods in front of an audience of 500 or 600 GPs, saying that they are not only unwanted, but deleterious to the whole service, as well as patients. However, they are not the norm. The hon. Member for Woodspring implied that the Audit Commission's report says nothing but that all the targets had been met only by wholesale cheating and lying. That is a complete misrepresentation. I recommend that he and his hon. Friends read it again to get a more balanced picture.

Of course, we have to shorten the waits for admission to hospitals even more than we have done already. As I said, we want to achieve nine months next year and six months in the year after that. But nobody is helped by an Opposition who have clearly broken away from the post-war consensus and, in pursuit of their political objectives, claim that the NHS is incapable of improvement. Another aspect of that argument is to say that the volume of targets and their rigid centralised structure stifle local innovation.

Again, the truth, when it is pushed too far falls into error, as Nye Bevan said. I agree that there has to be a balance between central objectives and local decentralisation, and operational autonomy at the front line. Surely we would all agree with that. However, claiming that any centrally set objectives and targets are nothing more than a stifling of all local autonomy is different. That is similar to saying that the only way in which to run a business or a concern is along the lines of an anarchist convention, whereby everybody has to decide what they want without any central objective being laid out strategically.

It is simply not true that the volume of targets in the national health service is so immense that it stifles all local initiative. The Department of Health has a budget of more than £60,000 million and 62 targets. That is roughly one target for every £1,000 million that we spend. No reasonable person would consider that to be excessive. Of course, if doctors genuinely believed that there was a contradiction of their oath or an undermining of their clinical position, we would discuss that with them and, if that was inadvertently happening, be prepared to reconsider. We did that with the accident and emergency services when doctors said that reaching a 100 per cent. target would remove the necessary clinical decision making and autonomy. Of course, we were prepared to change.

Our success has been maintained only because we have combined central targets with power and resources that are devolved to the front line to give health professionals and managers the freedom to innovate in pursuing the objectives and targets.

Mr. Stephen McCabe (Birmingham, Hall Green)

Clearly, it is true that no reasonable person would take the view of tracking the money that my right hon. Friend outlined. However, someone who is on tape at a closed Conservative party meeting, telling people that his strategy is to talk down and run down the NHS as a pretext for dismantling it would have to ridicule targets. He would need the ensuing chaos to achieve his ambitions.

Dr. Reid

Exactly. In such straitened times, we are all obliged to help the Conservative party. First, I advise Conservative Members that if they want to call emergency debates, they should not choose the subject of the health service. Secondly, if they choose it, they would do better to change their policy. The hon. Member for Woodspring may believe that he is ploughing a furrow towards the leadership of the Conservative party, but he is digging a grave for the party in the country because his animosity towards the national health service and all the improvements is so difficult to hide that it is obvious to everyone.

David Taylor

Will the Secretary of State acknowledge that perhaps he has been a little unfair to the Conservative party? Our NHS framework for mental ill health might benefit from some of the targets that the Opposition have set themselves in trying to reduce the number of people who suffer from chronic panic attacks to below 25. Is not that an admirable target?

Dr. Reid

If I have been unfair to the Opposition in any way, I am sorry. Although our team of Ministers maintain above all that NHS priorities are those of the public and the Government, and that fulfilled targets make a genuine difference to people's lives, we would be the first to accept that we sometimes fall short. One example has been mentioned tonight and we have much work to do on that. We also fall short in other cases. However, even when we fall short of 100 per cent. success, the significant improvements mean that people are hugely better off than they were under a Conservative Government.

The Opposition celebrate every time we fall short. That happened earlier this year, when we had hoped that, by March, nine out of 10 patients who wanted to see a doctor would be offered an appointment in 48 hours. We fell short of that, as one or two newspapers noted, and the Opposition celebrated our failure to reach the 90 per cent. target. We fell short; we achieved only 88 per cent. success. We therefore missed by a fraction. However, the achievement remained a huge stride forward from the position that we inherited from the Conservative Government whereby only half the patients were seen by a doctor in 48 hours. Even when we miss the target marginally, there is a vast improvement for the people who matter—the patients.

What exactly motivates the Opposition to keep raising such subjects? They cannot be doing so to add to the coherence and motivation of their troops, who have little love or respect for the NHS. Is it right for the Opposition to complain that we have more than 55,000 extra nurses? Is that a rightful complaint for a responsible Opposition to make? Should we really consider nearly 14,000 more doctors towards our target as a great failure? Is it truly a cause for regret that in 2000–01, there were nearly 300,000 more in-patient operations than in 1996–97, when the Conservatives left office? As I said earlier, 98 per cent. of those unfortunate enough to be suspected of having cancer can now see a specialist in a fortnight—half as many again as when the Conservatives were in power. Are all those achievements truly a source of disappointment to the Conservative spokesman?

Dr. Fox

Since the Secretary of State wants to give the balanced picture this evening, I ask him the following question. If there are 14,000 extra doctors and it takes five years to train a doctor and the Government have been in office for six years, how many began their training under the previous Government?

Dr. Reid

Some did and some have come from abroad. Yet as the hon. Gentleman pointed out, we have more vacancies than ever. Let me explain that conundrum. [Laughter.] I am trying to be helpful to the laughing cavalier, the hon. Member for East Worthing and Shoreham (Tim Loughton), who obviously finds it difficult to hold two concepts in his head at the same time. He finds it difficult to understand how we can have more doctors than ever and more vacancies. The answer is easy. We have more doctors but we have created more posts than ever. That should not be a cause for complaint.

The application of targets for quicker access to cancer treatment has helped to cut death rates from cancer in this country by nearly 9 per cent. Does the hon. Member for Woodspring believe that the figures are being fiddled by people not dying when they should? No one can question the figures. We have cut deaths from cancer by nearly 9 per cent.

Let us consider coronary heart disease. No patient now waits longer than nine months for heart surgery, compared with 2,700 in March 1997. Does the hon. Gentleman believe that those 2,700 people view targets as a mistake? Does that apply to those who have been helped because targets for quicker access to treatment for coronary heart disease has cut mortality rates by almost 19 per cent. in the past three years?

The details that I have outlined should be cause for celebration. We should raise the roof because the efforts of NHS staff have reduced cancer deaths by 9 per cent. and coronary heart deaths by 19 per cent. To my knowledge, that significant figure has not been replicated anywhere else in the world.

Why do the Conservatives need to misrepresent the position? Why do they have to run down the successes of the NHS instead of presenting a balanced picture? They have to do that to justify their plans to run down the NHS. They need to create the illusion of irredeemable failure inside the NHS to justify their craving to subsidise private health care outside the NHS. What they plan is simple: it is not a patient passport for the many, but an exit visa from the NHS for the few who are well off.

More to the point, that exit visa will be paid for by the rest of us with longer waits, more distress, fewer operations, fewer doctors, fewer nurses and no targets, as the Conservatives have confirmed tonight. There will be no standards by which we will drive our health service. As always, the Conservatives have contrived, after great thought, to abandon their so-called compassionate conservatism—a contradiction in terms if ever I heard one—and return to the old policy for the few to be paid for at the expense of the many. [Interruption.]

The hon. Member for Woodspring shouts, "Rubbish." The suggestion that our old folk should find almost £2,000 if they want a quicker cataract operation or over £5,000 if they want a quicker hip operation could have come only from the Conservative party in this country. The idea that anyone who needs an early bypass should get it early by virtue of their ability to pay over £9,500 is completely in tune with the Conservatives' philosophy and completely out of tune with the sentiments of people in this country.

The Tories' policy is not a matter of increasing choice for the many; it is cheque-book choice for the few, which they have come back to as ever. Our answer is to reduce waiting times for everyone by investing, reforming and driving the NHS in partnership with its patients and staff. It is to deliver better care, more quality and more operations for more people more quickly than ever before.

The Conservative answer is diverting investment from the NHS into the hands of those privileged enough to be able to afford the purchase of priority treatment while extending the waiting times for the others. [Interruption.] The hon. Member for Woodspring asks about the diagnostic and treatment centres, where I am purchasing in the private sector in bulk and delivering free for every single person in this country. I am not asking people to buy earlier operations by spending their own money if they have it or to wait longer if they do not. That is the difference between him and me. I will not be constrained by dogma.

I will be prepared to deliver health care wherever it can be provided, always provided that it is built on the foundation of the NHS of equal access to health care free at the point of need, but the hon. Gentleman and his party, driven by dogma, can come only to the one solution, which is to divert money from the NHS to the few people who can afford to pay the other half of the costs of the operation in the private sector. That is less choice for the many and the cheque-book choice of earlier operations for the few, subsidised by the taxpayer.

I thank the hon. Gentleman for tonight; I thank him for what he did. He has provided us with the real dividing line in British politics, which will run from now to the general election. That dividing line is between those of us on the Labour Benches who believe in a national health service free at the point of need and those on the Tory side who believe in subsidising those who can afford to pay for health care and the privileged few in this country. I tell the hon. Gentleman this: when it comes to that choice and that great dividing line, the vast majority of the people of this country will be on our side.

8.24 pm
Mr. Paul Burstow (Sutton and Cheam)

As I listened to the debate unfold and to the arguments about target setting in the NHS, it increasingly came into my mind that perhaps the biggest target we are debating is the Conservative party. That is our difficulty tonight: there are many distractions that have resulted in many choosing to be elsewhere and not to listen to the valid criticisms of targets that have been made by Conservative Front Benchers.

I will try to deal with those points, but first I want to place on record my party's appreciation of the NHS and its staff for delivering better health care for the vast majority of our citizens. The hard work of front-line staff deserves to be applauded, but all too often—perhaps inevitably—that does not happen in these debates. As constituency Members, we receive correspondence from constituents who had bad experiences of the NHS. That distorts our impression of what is happening in the NHS, but the truth is that the public are strongly committed to the principle of health care free on the basis of need, as are the Liberal Democrats.

Many who have experienced acute hospital care, in particular, in the NHS are seeing a difference as a consequence of the extra investment that is going in. That is extra investment that the Liberal Democrats had the courage and conviction to vote for, and to argue for at the general election. We are delighted that, at long last, that extra investment is arriving and beginning to bear fruit. We hope that it will continue to bear fruit in developing patient care.

Tonight's debate is about targets. Reference has already been made to the Audit Commission report, which, earlier this year, rightly shed a strong light on some darker and more disturbing aspects of the target-setting culture that the Government have introduced, not just in the NHS, but right across the board in public services. The debate is a welcome opportunity to discuss the targets and the damage that they can cause to the way in which priorities are set and the way in which health care needs are being met.

It is perhaps worth stressing that there is nothing new about target setting in the NHS. Indeed, the Conservatives, when in government, started it a long time ago—one has only to think of the patients charter—and their ideas continued through to their 1997 manifesto and to their 2001 manifesto with their patient guarantee proposals. However, under Labour, target setting has been developed into a pervasive and corrosive tool of ministerial control of every aspect of the way in which the NHS delivers care.

Performance in the NHS needs to be measured—of course it does—and the Secretary of State is absolutely right to say that he should be setting strategic goals for the delivery of health care, but the reality is that we are not setting strategic goals for our health care system or for the health improvement outcomes that we wish to see for our population. We are micro-managing detailed aspects of health care delivery. That is not strategic management but detailed micro-management.

The targets should be evidence-based and they should be outcomes-focused, but to my knowledge the Government have never published any systematic research evidence of the efficacy of the targets that they have set to date. Indeed, I wonder whether the Secretary of State, even at this stage, would be prepared to subject all the 62 targets that he has in place to evaluations and appraisals by the National Institute for Clinical Excellence. Perhaps then we would see whether they really deliver a clinical benefit and better outcomes for the patient. Will he make that offer tonight? Perhaps NICE could look at those targets.

Dr. Reid

I am not sure that NICE would be the appropriate body to survey all the targets but, as far as I can see, an almost endless array of bodies already examines them, inside and outside Government. I am continually making representations to those bodies, through the Health Committee, the Public Accounts Committee, the Audit Commission and, now, the Commission for Health Audit and Inspection. I assure the hon. Gentleman that the target results are not hidden under a bushel. I could write to him listing the bodies to which we must supply answers.

Mr. Burstow

I look forward to receiving the letter, in which I hope the Secretary of State will also cite the evidence base underpinning each target. The Liberal Democrats have raised that on a number of occasions, but today we have been given no answers to satisfy us or many people outside.

The Public Accounts Committee has examined target setting, not just in the context of the health service but more widely. In a recent report, the Committee said: What we found, however, is that these very laudable aims are in many cases not being fulfilled nor widely recognised as such by those on the front line whose job it is to deliver them. This is not least because of the lack of proper integration between the building of an organisation's capacity through what we call 'the performance culture' and tracking quantitative achievement in the public services through the 'measurement culture'. The result has been tension between those charged with centralised responsibility and those who are responsible for dispersed delivery of public services. That is at the heart of this debate. I think that all hon. Members believe that performance management in the NHS must deliver the very best care for the population, but targets do not do that. Targets measure quantifiable items, which are the easiest things to measure. That is the fundamental weakness, and I am sure that we shall hear more about it when the Conservative spokesman winds up the debate.

Dr. Fox

The Secretary of State asserted that patients cannot possibly determine the quality of services offered to them without Government targets. Does the hon. Gentleman agree that that is completely untrue? There is a world of difference between measurements, best practice, and the centrally, rigidly driven targets—in effect, management commands—used by the current Government.

Mr. Burstow

What matters is whether we are making a difference to the health care outcomes of individual patients. I am talking about not just their experience of the system, but whether it adds years to, or saves, their lives. That is what this should be about, but unfortunately the targets being set all too often do not deliver it.

Mr. Hendrick

Will the hon. Gentleman give way?

Mr. Burstow

I will give way shortly, but I hope that the hon. Gentleman will bear with me for a while. I suspect that I shall say several things on which he will want to comment.

Of course we need a performance culture in the NHS. What gets in the way is the measurement culture identified by the Public Accounts Committee—what could be described as a targets and tick-box culture. Too many of the current targets seem to be based on the findings of focus groups, and on process and experience—although experience matters—rather than on patient outcomes. Ministers talk, as the Secretary of State has tonight, about devolution and earned autonomy, but behind and belying all that is the talk of targets. NHS trusts can do whatever they like, provided that they hit the targets. That is the constraint. That is the straitjacket in which the NHS is being required to operate, and in which foundation trusts will be obliged to operate if they ever come into being. It gets in the way of innovation, initiative and clinical judgment. If I may put it simply, what gets measured gets done.

Accident and emergency waiting times are a case in point. That target, which has been mentioned by Members on both sides of the House today, is based on a snapshot taken over a single week. It happened in trusts in my area, and I should be more than happy for the Secretary of State to say something about it when he writes to me. The NHS knew that it was happening, so operations were cancelled, and beds were freed as a result. Agency staff were brought in to increase capacity during that week.

Dr. Reid

I think that the hon. Gentleman has been genuinely misled by some of the reporting. Yes, there was a snapshot target that was published, but the level of 90 per cent. and above has been maintained in every month before and after that. I can send him the figures, if he wishes, and publish them. The week of the snapshot produced the highest level—I think that it was 92 per cent.—but it has now been 90 per cent. for five months. That was not a one-off.

Mr. Burstow

I look forward to the Secretary of State's letter. Perhaps he will also explain the methodology used for the capture of the information, so that we can be confident that it uses a reliable measure. I must say that the analysis that I have read of the way in which the scheme has operated so far told us nothing, except that the best time to go to an A and E department was while the snapshot was being taken. If the Secretary of State can provide the information, I will more than happily acknowledge the achievement, if it is an achievement.

Another example is the target on GP access time, which is even worse in some ways. It is a classic political target. Of course, we all want to see our GP more quickly when we are unwell—no one would dispute that—but the target does not measure that. It measures the time until the first appointment. It makes no difference if the first offered appointment is inconvenient and cannot be kept. The box gets ticked, the target gets hit, but it misses the point completely, and that is the problem with the targets that are being set.

The cancer diagnostic waiting time target—the two-week wait—is a classic case of piecemeal target setting that fails to improve cancer survival rates because it fails to look at the whole patient pathway. Of course, it is stressful to have to wait a long time for a cancer diagnosis. I have no doubt about that but, as The Lancet has reported, diagnosis followed by a long wait for treatment does not help a person's chances of surviving cancer.

Currently, there are few published statistics, although we have heard some of them mentioned tonight, on the time it takes from diagnosis to treatment, except in the case of breast cancer, for example. Such selective publishing of performance data serves only to reinforce the impression that targets are a proxy for delivery, and that they are designed to capture headlines, not to do the important job of saving lives and improving the quality of patients' lives.

On its own, speeding up diagnosis diverts resources from treatment. It is a wasteful and dangerous approach in isolation because those targets distort priorities and get in the way of whole-systems thinking and person-centred care. That concern is expressed by clinicians, not just politicians.

Targets can be misleading. They can give the public a false sense of comfort, whether it is the overall star ratings or the patient environment action team inspections. Those are often presented by Ministers as dealing with issues of cleanliness and hygiene, yet cleanliness is just one of the 19 categories in the PEAT standards. The scoring system is such that a hospital rated badly on cleaning could still get a green light from the scheme. Indeed, the scoring for cleanliness is self-assessed and audited by the NHS trust itself—hardly an objective and independent measure of what has been done on the ground. There is no role for Commission for Health Improvement audited inspection.

It came as no surprise that so many green light hospitals topped the league for methicillin-resistant staphylococcus aureus, or MRSA, infections. Just last year, a report by the Commission for Health Improvement said this about an inspection that it did in West Dorset General Hospitals NHS trust: The trust has experienced a substantial increase in MRSA infections in the last three years. The infections have led to further problems including ward closures. The trust identified a number of risk factors for MRSA infection, but reports that there was only limited success in instituting control measures, primarily because of resource issues. Staff told CHI that the increase in activity and the pressure on meeting targets has resulted in staff not having the time to get the basic infection control procedures in place". Because of targets, they do not have the time to deliver essential basic good standards of hygiene in a hospital; that is targets putting lives at risk and helping to increase the chances of people getting sicker, not better, in hospital.

It is time that the Government's obsession with target setting came to an end. To be genuinely responsive to patients and to local community needs, the NHS must be free to determine local priorities. Of course, performance should be measured and compared, but it should be measured on ill health prevention and health outcomes achieved: the years added to a person's life and the lives saved should be the yardsticks against which NHS performance is measured. However, because the measurement culture is so dominant and what is easy to measure tends to be what gets measured, the focus is always on acute care.

I believe strongly that the balance in our health care system needs to shift from disease treatment to disease prevention. Unless much more is done to tackle the root causes of ill health, the costs of health care will continue to climb. When it comes to debating whether health care costs will increase and what the drivers behind that will be, the tendency has been to assume that health care costs will rise as a consequence of a growing elderly population. The Government are to be applauded, because their Wanless inquiry into health care expenditure comprehensively debunked that myth. It is not old age that is going to drive up the costs of the NHS bill. What will be the real driver behind increased health care costs over the next 50 years? It will be the rise of chronic diseases: diabetes—particularly type 2 diabetes—coronary heart disease, arthritis and the many other chronic health conditions that are the direct consequence of the obesity epidemic emerging in this country and across the world.

The challenge is to build a public health service that is capable of leading a revolution in health care, and which tackles the causes of ill health, rather than just treating its consequences. Poverty, poor environment, bad housing, poor diet and lack of exercise are the roots of many chronic diseases in the UK today. That is why Liberal Democrats argue that the health service ought to be commissioned locally by local government, not just bringing health and social care together, but creating the opportunity to tackle those root causes of poor health. That is why we reject the Conservative proposition that a national quango needs to take responsibility for the national health service. We think it wrong to remove from political accountability day-to-day control of the NHS in that way. We reject the idea that we should allow an unelected, unaccountable quango to take charge of the NHS.

Today's debate is really about the Conservatives' proposition and their analysis of the health service. It is a chance—at least, it should be—to showcase their new health policy, but we did not hear a great deal about that. We heard a lot of analysis, but not much prescription. In fact, their new policy, the centrepiece of which is the patient passport, needs to be showcased as much as possible. On this occasion, the Secretary of State is right: it is not so much a passport as an exit visa from the national health service. It would allow those who can afford to go private to withdraw from the NHS 60 per cent. of the NHS cost of the operation.

That figure is an important one to keep in mind, but in truth we are not talking about 60 per cent. of what the patient has to pay, because private operations—surprise, surprise—cost more than they cost within the NHS. Let us consider a hip replacement—just the sort of routine operation for which someone might opt to go privately. A hip operation in the NHS costs some £4,356. The same operation in the private sector can cost up to £9,000; indeed, some say that it can cost a little more. Sixty per cent. of the NHS cost is £2,614, but that is just 29 per cent. of the cost of going private; the rest has to come from the individual's pocket.

Tim Loughton (East Worthing and Shoreham)

I regret that the hon. Gentleman is playing the bogus figures game with the ones that the Government came up with. If he had visited hospitals in the independent, not-for-profit sector, he would know that that the price paid to those hospitals is much lower than the tariff that he suggests; indeed, in some cases it is equivalent to the NHS headline figures. Would a Liberal Democrat Administration—God forbid—commission no operations outside the NHS, not even the 250,000 that this Government are commissioning but misleading us about, in terms of the figures that they are paying?

Mr. Burstow

What we would not do is to try to palm off the passport idea as a golden opportunity to liberate people, giving them the chance to receive health care quickly. In reality, they would still have to pay huge bills, at the expense of our national health service itself.

Mr. Hendrick

Why is the hon. Gentleman against targets if he is genuinely in favour of measuring performance? Without targets, there is no benchmark. He talks about outputs, but we also need inputs. We obviously need quality care, but we also need some form of target to deal with patient numbers; without it, we cannot determine whether the outcomes are effective. The Liberal Democrats say that they are against targets and against the Conservatives' patient passport, but what would they do to improve the health service?

Mr. Burstow

As I said—I am more than happy to amplify the point a little—we propose genuine, democratic local control of health care commissioning. We believe that health care commissioning is best done in the context of local government, in which there is the opportunity not just to integrate health and social care commissioning, but to look across the piece and address environmental health, housing and a range of other factors that are the real underlying causes of health problems. That is the agenda that we want to move on to, because we believe that it is the way to secure better health outcomes in the long run.

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


Mr. Burstow

I see that the Minister is becoming very alert. That is not a good reason to give way, but I will nevertheless give way to him.

Mr. Hutton

I am very grateful. I am following the hon. Gentleman's argument closely and giving it the respect that it is due. I understood what he said about local government, so can I take it that, if there were to be a Liberal Democrat Secretary of State for Health, no national targets would be set for the NHS?

Absolutely, because national targets of the sort produced by the Government are input and process-driven, not outcome-led, so they do not make a difference. What we want in respect of national priority setting and strategic goals is to move the focus of our health care system to public health. As to the current process targets, I am happy to go on the record and repeat what my colleagues have consistently said for a long time in critique of the Government's approach. If that gives the Government any form of succour, they are suckers to take it that way.

Tim Loughton


Mr. Burstow

I give way one more time to the Front-Bench spokesman.

Tim Loughton

I am terribly grateful. We are starting to get at the beginnings, but only the beginnings, of a Liberal health policy. Is the hon. Gentleman saying that if Liberal Democrat councillors are put in charge of health policy locally, everything will be rosy? Why does he not trust professionals in the health service to determine the medical objectives that need to be followed? Many professionals will be on a national body, but at arm's length from political control, as we have suggested. Apparently, the hon. Gentleman wants more, not less, political control.

Mr. Burstow

The reality is that I am prepared to trust the patients and the people, and to achieve that through local democracy rather than through the central autocracy proposed by the Conservatives. It is interesting to see that the Conservatives dare to criticise an exposition of Liberal Democrat policy when they did not have the courage to outline any of their health care policies in the debate tonight—[Interruption.] It is a great pity that the shadow Secretary of State did not take that opportunity. It is also a great pity that he is not in his place to take up the challenge later.

In setting out the Conservative health care policy in early October—it seems a long time ago when so much water and so many leaders have gone under the bridge since—the hon. Member for Woodspring (Dr. Fox) identified the fact, as reported in the Daily Mail on 7 October, that 300,000 people currently had operations in the private sector. That is entirely right, but the number is important: 300,000 people opting to go private. In the same article, he took the example of a hip operation as the basis for working through the proposals. If 300,000 are already opting to go private and, under a Conservative Government, they could claim a contribution to a third or less of their private bill, what would that do for the NHS budget? We should remember that this is before a single extra NHS patient opts to use their patient passport at all. Without a single extra operation being performed, the Conservative policy would cost the NHS at least £900 million a year—possibly more, depending on the types of operation done in the private sector under the policy. That is taxpayers' money leaving the NHS with not a single extra operation being performed as a consequence.

Where will the extra £900 million come from? Typically for the Conservatives, we have heard no detail, no costings and no proposals for how the policy would be rolled out in practice—[Interruption.] If the detail exists, I wish that Conservative Front Benchers had taken the opportunity to outline it. It has certainly not been put into the public domain—[Interruption.] It is no good the hon. Member for East Worthing and Shoreham (Tim Loughton) protesting from a sedentary position that there is detail, and then not publishing it. That hardly amounts to a Conservative policy. Can he now provide some detail?

Tim Loughton

The hon. Gentleman should know that, for the last few weeks, our party has talked an awful lot about the patient passport. Considerable detail has come out. We are about to produce some rather interesting costings on how it will work. If he would be more patient, he might be pleasantly surprised. Perhaps he will now tell us how much extra in local council tax—the latest invention of the Liberal Democrats—it will cost us all, again before a single extra operation is done, to install all the extra managers and political bureaucrats that he wants to introduce into the NHS.

Mr. Burstow

I am afraid that the hon. Gentleman protests too much. We should wait to hear the details of the Conservatives' policy, then have a good belly laugh when they come out, because they will not add up. The Conservatives have not yet outlined how they are going to carve this £900 million out of the NHS budget to pay for their policy. That money will not add a single operation, private or public. That is the charge that the Conservatives must answer when developing their policies and selling them to the public.

The Conservatives would have us believe that they want to reform the national health service. I cannot criticise their motion in terms of its analysis of many of the flaws in the Government's approach, but the Government's amendment is much too self-serving and self-congratulatory to deserve the support of the Liberal Democrats tonight. From what I have heard of the Conservatives' policies, and of the details that they have outlined bit by bit during the exchanges that we have just had, we certainly would not wish to demonstrate our support for them in the Lobby. The Conservatives say that they favour reform, but what did they do when they were in office? They ran the national health service down and, in opposition, they are now all about abandoning it. That is not the solution that this country wants.

8.51 pm
David Wright (Telford)

Before I was elected to the House, I spent some 13 years working in the public sector. Much of that time was spent working under a Conservative Government who brought in a whole raft of indicators and targets for local government. We struggled with them a bit at the time, but that Government were right to build up those targets and to increase the amount of information that was collected relating to delivery. Therefore, it is interesting that, in this debate, the Conservatives seem to have performed a complete volte face. Originally, they tried to approach the issue from the perspective of placing a business emphasis on the management of public services and, as I have said, they were probably right; yet they now seem to have changed their position and to be considering abandoning responsibility for key targets in the health service.

How can we manage a service of the scale of the NHS without targets? If we cannot measure it, how can we manage it? I assume that the Conservatives will not be using targets in future debates, yet their Front-Bench spokesman's opening speech used a whole raft of targets to try to illustrate how badly the health service was doing. Indeed, without such information, he could not have delivered his speech. Throughout my time in local government, I particularly enjoyed the contribution to management theory of Tom Peters, who said: Get hard data. Get it quickly. That's the key. That is the key to managing in business, and it also applies to the health service.

The Conservatives' attack on targets completely misses the point. Labour Members have said all along that targets are not an end in themselves, but a vital mechanism by which we can improve our health service and increase accountability. Of course we must decentralise control of the health service, so that bureaucracy and form filling are reduced, but that must be balanced by the need for national standards. Patients should get the same guarantees of basic quality from the NHS wherever they live in the country, and national targets help us to drive up performance and standards where necessary. The Government are, of course, bringing in proposals for foundation trusts for those hospitals that reach the very highest standards. We are trying to improve national targets across the board, and when they are achieved the trusts will give greater freedom and flexibility to local managers to set targets and priorities. I very much welcome that initiative.

The public want to know how their money is being spent and what the results are. The main focus is, of course, on acute services, although target setting through primary care trusts is also delivering significant improvements in community-based health care.

Sir Sydney Chapman (Chipping Barnet)

The hon. Member for Sutton and Cheam (Mr. Burstow) said that during the 18 years of Conservative government, we ran down the national health service. Would the hon. Member for Telford (David Wright) like to confirm that when we returned to office in 1979, expenditure on the health service was £8 billion, and that when we left in 1997 it was £42 billion? In the light of that, does the hon. Gentleman agree that, despite what he says, especially on targets, we are trying to get rid only of the contradictory targets that lead to a worse health service and that the whole emphasis should be on what we want to produce—a better managed national health service?

David Wright

I appreciate the hon. Gentleman's intervention. Undeniably, there were real-terms increases in health spending throughout the 18 years of a Conservative Government, and that resulted in improvements in services. However, services, including drugs and health care, have become more and more expensive over the years. I think that when the hon. Gentleman has heard my remarks he will acknowledge that we have made significant increases in health spending. I shall return to his point later.

In his speech, the Secretary of State outlined the progress that we are making nationally and gave some of the headline figures on health care. I want to tell the House how we are doing in Telford and Wrekin and in Shropshire. During the past three years, there has been an increase in investment of £25 million in capital developments and new service initiatives at the two main acute hospitals in Shropshire—the Royal Shrewsbury hospital and the Princess Royal hospital in Telford. In addition, £19 million has been invested in moving services from the barracks-style buildings on the south site at the Royal Shrewsbury and opening new facilities to replace them in both Telford and Shrewsbury. In 18 years of a Conservative Government, we saw no progress on the Copthorne south site; progress has occurred only since the Labour Government were elected.

Last year, trauma and orthopaedic clinics, a new X-ray department and an endoscopy unit were opened at the Princess Royal. In 2001, a new maternity unit was opened and the hospital has also created a new clean air theatre. A new gymnasium and a refurbished fracture clinic have been opened recently. The accident and emergency department has been fully refurbished. Future investment will deliver a range of new facilities for haematology and chemotherapy treatment; there will be day surgery theatres, a dermatology unit and a satellite renal unit.

There has been tremendous progress in capital investment. The Opposition often accuse us of putting in the cash while not securing delivery, so what is that investment delivering on targets? More patients are being treated more quickly and in better buildings than ever before. Between 1997–98 and 2002–03, the total number of cases seen by the two hospitals rose by about 12 per cent. to 433,000. That includes elective surgery, emergency in-patients, out-patient attendances and accident and emergency attendances. Even with that increase, in-patient and out-patient waiting lists fell dramatically. No in-patient is waiting more than 12 months and the total size of the list has fallen by 34 per cent.

By March 2003, no out-patients were waiting for more than 28 weeks and the number of people waiting for more than 13 weeks fell by more than 36 per cent. between 1998 and 2003. In the words of the chief executive of the trust, Neil Taylor: Year on year activity is increasing, with the number of referrals from GPs and emergency cases going up, but our lists have been going down. The length of time that people are waiting for an operation has been significantly reduced. We should trust NHS staff to know their business, although I know that that kind of performance and improvement in the delivery of targets is not what the Opposition want to hear. I am sorry about that.

Alongside that success in acute services, the PCT is making major progress in planning and delivering community-based services. In my constituency, two brand new GP surgeries have opened, in Dawley last year and in Oakengates this year. There has also been a large refurbishment at one of the most popular surgeries in the town. Resources allocated to the PCT will increase by £40 million to £152.9 million a year by 2005–06.

Chris Grayling (Epsom and Ewell)

Is the hon. Gentleman aware that at least one PCT in Shropshire has been forced to use money allocated in this year's budget for the consultants' contract to help to bridge its financial gaps, such is the state of the financial predicament it faces? As a result, now that the consultants' contract has been approved, that PCT will struggle to afford to pay for it.

David Wright

There are problems with acute services following the merger of two large hospital trusts, and there is certainly a need for us to invest more heavily in new and developing services on those two sites and in the consultants' contract. We also have some problems with the maternity services provided at Oswestry. So things are not all rosy, and I was going on to say that we have some problems and we can always do better. For example, the PCT does not receive its calculated fair share of resources at the moment. I hope to secure an Adjournment debate on that very issue in the next few weeks. The new junior doctors' hours are a cause for concern in relation to staffing capacity and funding, particularly in accident and emergency services. However, the number of student doctors in this country has risen by 50 per cent. since 1997.

In general, the picture is very good. There are more doctors and nurses working in the NHS now than at any time in the past 15 years, so there is an impressive pace of change and significant progress is being made. Increased resources and capacity, coupled with reforms to the NHS, have already had a direct and positive effect on the quality of treatment that NHS patients receive in Telford and Wrekin and Shropshire.

The question that the Opposition have to answer is that, if targets really are having a detrimental effect on clinical outcomes", how do they explain the facts that I have outlined in relation to Telford and Wrekin and Shropshire and the improvements that have been made to our local NHS? The use of targets has contributed to those improvements, but we have always been clear that they are a means to an end—a better health service for all—and not an end in themselves.

I shall briefly consider the Opposition's proposals for the NHS and what their targets are. The Opposition have clearly decided to tear up the post-war consensus on health. Even Lady Thatcher, in the years that the hon. Member for Chipping Barnet (Sir Sydney Chapman) mentioned earlier, did not attempt to do what the Conservative leadership plans to do to the health service. They no longer believe in the fundamental principle that NHS health care should be available to all, free at the point of need.

In fact, the patient passport is a Trojan horse for privatising the service. The only people who will be able to benefit from it are those who can already afford to pay for private medical treatment. The vast majority of patients will not be able to exercise any choice under the Tory proposals because, if they want to exercise that choice, they will have to pay to do so.

Tim Loughton

The hon. Gentleman obviously has not read any of the proposals. Everyone would benefit from the patient passport, without any coercion to pay a penny, by being able to exercise choice and gain access to any NHS hospital in the country. That would be much more widespread than the bogus choice that the Secretary of State for Health is peddling. I want to make it absolutely clear that not a single person would be coerced into paying a single penny for any treatment in the NHS. Labour Members must stop peddling this nonsense.

David Wright

The problem is that if people wanted to jump the waiting list, they would have to pay more money. The problem with the patient passport is that if people wanted health care, they would have to pay for it in addition to what they are currently paying through general taxation. If hon. Members visited the people who live on the estates that I represent, they would find that they could not afford that expense. They want a high quality NHS, funded from general taxation and free at the point of delivery, and I am very proud to stand up for those principles this evening.

The Opposition's plans would cost the NHS about £2 billion to enable the minority of patients to go private. The battle lines are drawn in relation to the NHS, and I am confident that the people of Telford are on the side of the Government.

9.4 pm

Mr. Ian Liddell-Grainger (Bridgwater)

The targets cover a multitude of sins, but I have specialised in one issue. I am a member of the Public Administration Committee, as is my hon. Friend the Member for Chipping Barnet (Sir Sydney Chapman), and the Committee considered all the targets, not just those in the health service. The first thing we discovered was that there is a great raft of targets in the NHS. In fact, the Government announced the 62 targets during a Select Committee sitting. We had no idea—even though the Select Committee is Labour dominated—that that was going to happen. Those 62 targets are set at the top level, but by the time that they reach down to GPs on the ground, they can have multiplied because there are targets on targets. We discovered parts of hospitals that create targets for other targets, for consultants, doctors and anyone who works in the NHS.

The Committee went to Bristol to look at what was happening there—Bristol was chosen for no particular reason other than that it was fairly close to London and it has a good train service. What we found was startling. We expected to see only the top management, but we found ourselves in a room that was filled with people who worked in Bristol hospitals. The problem was that they all wanted to talk about targets to a Select Committee—I do not quite know whether they all understood what a Select Committee did, but that is not the point. They all said the same thing—that targets were damaging health care in this country. They said that they were damaging it for different reasons: some said that it was because they are confusing; some said that it was because they are not achievable; some said that they did not have the money to achieve them; others said that they had had no clear steer from the Government on what to try to achieve. Others, more worryingly, said that they were being bullied to hit targets, that they were being forced by managers into a position in which they had to berate staff to hit targets, and that ambulances were going around car parks where, at the end of the month, patients were being left on trolleys without wheels so that they could be counted as beds, not trolleys. We also discovered that people needing eye tests were not being given the chance to have them because a target had to be hit at the end of the month. Up to 1,000 patients had been taken off a list relating to eye conditions—those suffering from glaucoma, diabetes and so on—because the target could not be guaranteed to be hit. That cannot be right.

When we started to investigate further, nurses told us that they would start to take action—Ian Bogle made some famous statements to which I shall refer later—because they simply did not have the ability to achieve the targets. The point has been reached at which targets are being created in the health service that are not achievable and that the staff do not want to achieve, and the detrimental effect on patients and staff is out of all proportion to what they are trying to achieve.

The star rating system for hospitals is also a problem—Bath is the other prime example in the west country of a hospital that was in a terrible state. It could not achieve the star rating because it could not hit the Government's targets. Why? Because its expertise is not what the Government were trying to target—in that case, cancer. The same was true of my local hospital in Taunton, Musgrove Park, which is not a cancer specialist hospital, although it must still try to hit cancer targets. However, that is not what it is known for or good at.

When the permanent secretary at the Department of Health came to talk to the Committee, his view was that the targets system had to be streamlined. That is fine—all targets need to be streamlined—but that is not what is happening. When it starts from the top and the permanent secretary sets out what we must try to achieve, five or 10 years later—and some of the targets extend for up to a decade—the targets bear no relation to what they set out to do in the first place.

The Public Administration Committee—another member of which, the hon. Member for Pendle (Mr. Prentice), has just joined us in the Chamber—said that it was detrimental to have more than five targets. Lord Browne of BP said that no more than five to 10 targets should be set, and that we should expect to fail to meet two to three of them. People should not be forced down a particular line when they cannot hit targets. Lord Browne is a fairly astute character to say the least—he was certainly an impressive witness in front of the Select Committee—and his view is that an organisation cannot work on 62 targets; it must quarter the number, and if it does not it will cause instability. In an organisation such as BP, which is not national but international, we can imagine how that would be magnified.

I want to talk about more local issues. Somerset Coast primary care trust, which is in my constituency, has three small hospitals: Minehead, Williton and Bridgwater. Our problem is that they supply one major hospital, Musgrove Park in Taunton. There is no straightforward bus service from any of those hospitals to Taunton. If people have to see a consultant, they have to rely on an ambulance car service, the one ambulance that is based in west Somerset, or a bus. The bus may or may not get people to the hospital in time, but they know that they must spend the whole day there, whether they like it or not.

When people get to the hospital in Taunton, they sometimes discover that the consultant cannot see them. That might happen because there is a problem at the end of the month—it is funny how problems build up toward the end of each month. Cancellations occur, people cannot be fitted in, or machines break down. People then have to wait at the hospital because they have difficulty getting back from there.

In west Somerset, wards have to be shut periodically to allow staff to be transferred to the main hospital in Taunton to ensure that targets are hit. That happens regularly and we accept it because we have no choice—people in rural areas do not have a choice because where else can they go? We have paired up with hospitals in Dorset. People who go to the next main hospital from Taunton have to get to Poole or Bournemouth. I drove down to that area on Friday night and it took me more than two hours. The sort of roads that people have to use make it difficult to get there. How can transferring people by car to a hospital in Bournemouth hit targets? Surely the common-sense approach would be to transfer people from Somerset to Bristol or Exeter, but that is not happening.

A further problem is the general practitioner service in rural areas. I have been to see all my local GPs and they are an extremely good bunch who work hard. However, they cannot recruit replacements for retiring GPs, although they have tried. They cannot find GPs who are willing to set up home in rural areas. The opposite was true in the old days, but there are now fewer GPs in the area. One of my local rural surgeries, which has four or five doctors, has been continually advertising for a GP, but it cannot find one—that cannot be right. The problem is that if one GP retires in a place such as Bridgwater, 3,000 extra patients have to go to a different surgery for what is called "the time being". However, that does not happen for "the time being" because the problem has still not been resolved, although the PCT and the strategic health authority have tried extremely hard to address it. The situation has arisen because they are trying to hit targets, but it is not working. Doctors say that they must keep pushing people through, so they do not want to refer people to other services. We need doctors to start at the beginning with the patients whom they have. All the lists for doctors in the east of my constituency are closed, so some people cannot get a doctor.

For some unknown reason, the headquarters of our mental health service is in my constituency—I do not know whether that says anything about the constituency's hon. Member. The head of the service has moved on, which is fine, but we are left with a massive problem. We have lost bed after bed after bed. We cannot look after people with mental health problems from Bridgwater or Somerset. Worse still, in order to hit targets, people from outside our area are being referred there, and they take up the beds that we have left. That happens because areas such as Bristol that have too many patients have been told that they must hit targets, so they push people down the road and send them out to places such as Somerset, Dorset, Wiltshire and Gloucestershire. That cannot be right. We are losing beds because we do not have the money to pay for them, yet our area's people cannot get beds because of draconian measures from the centre to hit targets. The system is badly wrong.

We are trying to resolve the long-term effect of targets on old folk. One of the towns in my constituency has the highest proportion of elderly people in the county. However, so many care beds have been lost in my area that doctors are forced to refer patients to hospital for overnight stays. A person cannot get a bed in an emergency because we do not have sufficient beds to take up the slack.

Members of the PAC know how many beds have been lost in long-term and short-term care. If doctors cannot put old people into a care place overnight, they refer them to hospital, but hospitals do not want them because they take up extra beds. The hospital's attitude is, "We don't want them because it does not work for our targets", so those people are pushed out again. In my constituency, more and more people have been put back into the community too quickly and without adequate care and back-up. To judge by the letters I receive, the situation is getting worse.

The figures show that the level of care in the community has dropped dramatically. Again, that may be the result of a target. All I know for certain is that people are coming back into my community and are not getting the care they need to ensure that they are properly looked after. The situation in accident and emergency departments is also worrying. Don Mackechnie, an accident and emergency consultant, said: I am appalled to see how A&E departments have been forced into taking extraordinary measures for a week-long period just to meet political targets. Old people are being pushed into those departments because there is no choice. That cannot be fair.

The targets are political. They are targets for targets' sake. When we wrote the PAC report, we said that it is not possible to use targets as a means in themselves. That does not work, as has been proven over the past five years. A good target is a target that is achievable, but we cannot break the organisation that we are trying to get the best out of in the process. If we break the organisation, we get what happened in Bristol—deceit, difficulties and problems of low morale. I do not know where the doctors will come from, but they will not want to enter a service in which they are berated because they cannot hit a target. Political targets have one use only, which is to try to ensure that the money that is supposedly being pumped into the health service gets there. I tell the Minister that it is not and it is going wrong.

9.16 pm
Mr. Adrian Bailey (West Bromwich, West)

We need to be clear that the Opposition motion is not just about targets. By proposing the abolition of targets. they are making it clear that they oppose the planning of public resources, performance management and public accountability. Above all, they oppose policies that they thought appropriate when they were in government.

I was interested in what the hon. Member for Woodspring (Dr. Fox) said about the inadvisability of centrally driven targets. Those of us with long memories may remember the statement by the then Secretary of State for Health, the right hon. Member for South-West Surrey (Virginia Bottomley), when she introduced the White Paper on targets, which included targets on coronary heart disease, stroke, cancer, mental illness and AIDS. She said: In each of these key areas we have set challenging but achievable targets … In other areas, more development and research will be needed before national targets can be set. What we are proposing are not short-term measures. The strategy will grow and develop … The White Paper identifies other possible target areas for the future. This underlines the fact that it represents a beginning, not an end. Furthermore, she said:

"The NHS management executive will require health authorities to build the target-setting approach into all levels of local activity. The strategy will be central to the work of the NHS."—[Official Report, 8 July 1992; Vol. 211, c. 335-37.]

We can only marvel at where the Tories were when in government and where they are now in opposition.

The policies on targets adopted by this Government are consistent with that approach, with one significant difference: under the Tories, the NHS was starved of fund, but under Labour targets are backed up by consistent, sustained and record investment. One reason the Tories do not want to hear about targets is that they know that the target-setting culture and the performance indicators that underpin it demonstrate just how far we are going and just how much progress has been made with the extra investment from this Government.

The current NHS targets are not figures plucked out of the air; they arose from research and consultation with interested bodies. They relate to the milestones and objectives of the NHS plan, which, in turn, was determined following the widest public and patient consultation exercise ever conducted in the service.

I consulted my trust, Sandwell and West Birmingham Hospitals trust, to find out its experience of targets. Its response was that targets are very useful in a number of areas. The first is planning. Trusts now have clarity about public and Government expectations, and that allows them to examine their services, to plan clearly and to deploy their expanding resources accordingly. It enables them to prioritise and to invest in those areas of the service designed to meet those priorities.

Targets help with staff morale. Demonstrating improved performance against targets and communicating that to staff and local communities provides a boost to staff morale and is good for both recruitment and retention. Dedicated NHS staff who do a good job like to know that their efforts are formally and publicly recognised. I acknowledge that there is a danger in that, in those hospitals not reaching targets, there is a potential for lowering staff morale. However, my experience of NHS staff is that their commitment to the public is such that they would always welcome ways to improve management and planning so that they may serve the public more effectively. Without NHS targets and performance indicators, there is no way in which staff can know what they can achieve.

Targets help the local community. Trust performance indicators are keenly reviewed by groups and individuals who can then argue their case from a more informed position than before. They also provide a clear, shared framework for discussion between the primary care trust and the hospital trust about the deployment of their increased funding. PCTs are better able to account to local people and GPs the basis for their decisions and priorities.

Targets also help in expanding NHS capacity. Where trusts are in negotiation with building contractors and commercial banks for private finance deals, the management of risk is an essential part of those negotiations. Where the private sector can see that a trust is high performing, and therefore a lower financial risk, it enhances the prospect of private sector funding. Without financial targets, that source of financial reassurance would be lost.

Targets have also helped performance. By setting standards high and targeting efforts to pull the worst performers up to the highest standards, the NHS has already raised standards throughout the country. We have already discussed a clear example of that: the 90 per cent. of people who visit accident and emergency departments and are treated and discharged within four hours of arrival. The geographical variations in that service have virtually been eliminated.

The motion has nothing to do with red tape, bureaucracy or the perversion of clinical priorities in the NHS. The profound change in the Conservatives' policy since they were in government has everything to do with their desire to undermine and privatise the NHS. It is part of a wider strategy to reduce public funding and increase private practice. It signals the end of any Tory aspiration to improve the nation's health care through the NHS. By removing targets, the Tories are removing incentives for improvements and ending the possibility of an informed dialogue between local communities and local health care providers. By removing targets, they are reducing funding for the NHS and hiding the consequences. The so-called patient passport would deprive the NHS of an estimated £1 billion. Tax relief on private medical insurance would cost another £1 billion, which would pay for 16 hospitals, or 80,000 nurses, or 25,000 consultants, or 30,000 GPs. A funding deficit on that scale would devastate the NHS's ability to meet future public expectations.

By removing targets and performance indicators, the Tories hope to disguise the full extent of the failure of their policies to deliver the service that the public want. Their policy is designed to assist a minority of the better off who can afford private treatment while shortchanging the great majority who depend on a publicly funded NHS free at the point of delivery. This debate is not just about targets but about the future of the NHS. Removing targets is an essential prerequisite for the privatisation process supported by the main Opposition party. There is a clear choice between the Government's vision of a well funded, better focused NHS, sensitive to the needs of a well informed local community and the Tory sabotage of an underfunded NHS haemorrhaging money to the private sector, unable to meet local need and with no means for the public to measure that deterioration. I am confident that the public and the great majority of people who work in such a dedicated way in the NHS will back the Government.

9.26 pm
Dr. Richard Taylor (Wyre Forest)

In the three minutes available to me I shall make just one crucial point. I want to pick up a phrase in the Government amendment about the House welcoming the positive effect of the right targets and ask whether we have got the right targets. In 2002 and 2003, nine key targets dictated the outcome of the star ratings. In addition to those nine key targets there were a large number of items with a clinical or patient focus. Sadly, an analysis of the 2002 ratings shows that the patient focus, particularly in the six points in the inpatient survey, bears no relation to the star rating that the trust received. The results of in-patient surveys of three-star trusts could be as low as those for no-star trusts. The balanced scorecard approach, which I have tried to get lots of people to explain, does not seem to take that into account. The 2003 ratings awarded by the Commission for Healthcare Audit and Inspection did not appear to take account of the patient focus. The clinical focus had little influence, and neither did the staff survey.

The targets that we should be aiming at should include patient satisfaction because, as has been mentioned by the hon. Member for Sutton and Cheam (Mr. Burstow), we cannot yet measure patient outcomes reliably. I was interested to read in today's papers that Aston university in Birmingham is to undertake a comprehensive poll of NHS staff for the Commission for Health Improvement and the Commission for Healthcare Audit and Inspection. I hope that staff opinion will be taken into account more in performance ratings in future. I appeal to the Minister to push for staff surveys and patient surveys to be taken into account. Why does nobody take into account the full inspections of hospitals that are undertaken by all the royal colleges for accreditation? They examine the performance of a hospital in detail and could add tremendously to the value of measures such as star ratings.

I finish by pointing out that targets are to be aimed at. When he missed a target, even Robin Hood was not penalised or shot directly. I do not believe that targets should be enforced to such an extent that trusts are penalised for not hitting them.

9.30 pm
Tim Loughton (East Worthing and Shoreham)

We have had a good debate with some interesting contributions. It is a shame that we could not hear more from the last speaker, the hon. Member for Wyre Forest (Dr. Taylor), with his professional experience. He is right. The debate should be about the right targets, which the Government are trying to weasel out of. A target is to be aimed at. It should not drive the entire service and rationale of the NHS, as it does, with all the intimidating tactics that are used.

We had some interesting contributions from Labour Members. The hon. Member for Telford (David Wright), who has momentarily disappeared, says that targets help to drive up performance and standards. It is not the targets that do that; it is the professionals and resources in the health service that drive up the performance and standards. That is the fundamental misconception of Labour Members, which is why the debate is so essential.

My hon. Friend the Member for Bridgwater (Mr. Liddell-Grainger), when not erroneously suggesting that we should put down elderly people, is a distinguished member of the Administration Committee, and gave us the benefit of the experience of people in business, who know what targets are all about. He gave the example of Lord Browne, the chief executive of BP Amoco plc, saying that any good business would have between five and 10 targets, but under the new formula announced by the Secretary of State earlier this evening, there is one target in the NHS for every £1 billion of expenditure. If that principle were applied to business, BP would have many hundreds of targets, making it completely unmanageable. It would be absurd.

The hon. Member for West Bromwich, West (Mr. Bailey), I fear, reflected the topsy-turvy world in which Labour lives, saying that staff to whom he had spoken in his constituency verily embrace the target culture and welcome it, and that it has helped with staff morale. He ought to get out more and speak to real people who will give him real answers, not the answers that he wants to hear to the warped questions that he might be asking.

We make no apology for returning once again to the subject of the Government's obsession with targets and performance tables, and, most crucially, the bureaucratic baggage that attaches itself to such a system, which is so deeply ingrained in the Government's mindset, but nowhere more extensively and damagingly than in respect of health care. The Government have a target for everything, but know the ultimate value to the health of a patient of nothing. They pursue a policy that has as its primary objective the health of the national health system, rather than the health of the patients whom it exists to serve.

As the Audit Commission stated in its June report, too many targets and indicators risk obscuring where the real priorities lie. There are targets for reducing maximum waiting times for out-patient appointments, reducing to four hours the maximum wait in accident and emergency, guaranteeing access to a primary care professional within 24 hours, reducing substantially the mortality rates, achieving a maximum wait of four months for out-patient appointments, achieving a maximum wait of nine months for in-patients—the list goes on and on.

There is one good target that has been achieved, according to a report in Hospital Doctor. The radiology department at the Ealing hospital trust has successfully reduced the wait time for a barium enema from 19 weeks to four weeks. The reduction has been achieved by local people using their ingenuity and local expertise in that hospital, rather than relying on some centrally driven bureaucratic target that the Secretary of State has told hospitals to achieve.

There are so many targets and so much measuring to be done, but the Secretary of State would be well advised to listen to an old farming adage: the pig does not get any fatter the more you weigh it. That is what all the targets are about. Individually, they all sound perfectly reasonable objectives, and none of us would not want to reach a state of improvement in health care generally, characterised by such worthy aspirations. Taken in their entirety, however, the cumulative effect of placing so much importance on these targets, completely suppressing the professional skill and judgment of doctors and nurses, is often to distort clinical outcomes; to create problems down the line for patients who do not fit neatly into the target priorities; to place intolerable pressure on intimidated managers to claim that targets have been met, irrespective of whether that is borne out by the evidence; and completely to demoralise the health professionals who came into the NHS to treat patients and to make them better. The outgoing chairman of the British Medical Association, Ian Bogle, describes it as the suffocation of professional responsibility by target-setting and production line values that leaves little room for the professional judgement of individual doctors or the needs of individual patients … The auditing of every bowel movement on every ward in every NHS hospital would be a fitting memorial to Alan Milburn"— the former Secretary of State— now that he has decided to spend more time with his family". We have heard many examples of the target culture distinctly distorting clinical outcomes. The experience of the Bristol eye hospital was related to the Public Administration Committee by its clinical director, Dr. Richard Harrod: The waiting time targets for new outpatient appointments at the Bristol Eye Hospital have been achieved at the expense of cancellation and delay of follow-up appointments. At present we cancel over 1,000 appointments per month. Some patients have waited 20 months longer than the planned date for their appointment. That is on top of all the problems that are being caused by the delay in funding the National Institute for Clinical Excellence-approved treatment for wet form age-related macular degeneration, which, after undergoing the second-longest approval process of any treatment, is still being delayed to the extent that some 3,000 people risk going blind as a result.

An estimated 2 million patients are effectively being banned from making GP appointments under the advance access scheme because it would hinder GP surgeries in meeting the Government's 48-hour waiting time targets. That particularly affects elderly and disabled people who have to make special transport arrangements.

On mental health, Dr. Matt Muijen, director of the Sainsbury Centre for Mental Health, has expressed concern that the targets for mental health services mean that many patients are being neglected at the expense of high-profile areas. He states: The trend I am beginning to see is that fewer people get better care. People who are high risk are getting good care but there is a big group of people who just need ongoing care. What about the people who fall through the cracks? … We certainly know an awful lot of places where they have to close down hospital beds to fund crisis teams. Research carried out by the Conservative health team over recent months with the mental health trusts shows that, in practice, many of the new systems that the Government boast about rolling out are not happening—their claims are not being met.

There has been a big increase in the number of operations cancelled less than 24 hours before they are due to happen. That is a result of targets that give wrong priorities to clinical problems. Last year, 70,000 such operations were cancelled. There has been an increase of 4,627 in emergency readmissions to hospital after hospital treatment, often because people are discharged too early owing to pressure on management to meet targets elsewhere in the hospital. As my hon. Friend the Member for Woodspring (Dr. Fox) said, there is serious doubt about the accuracy of the data that are produced supposedly to attain those targets—the star rating of hospitals. James Johnson, the new chairman of the BMA, says: Nobody should use star ratings to judge how well a hospital is doing. They measure little more than hospitals' ability to meet political targets and take inadequate account of clinical care or factors such as social deprivation. In May, a survey in The Times showed that only 15 per cent. of primary care trusts in England believed the 2003 star ratings to be accurate. People involved in health care do not take the figures seriously, let alone the patients.

Hugh Bayley

Does the hon. Gentleman realise that, like the NHS, every private hospital chain sets targets for cleanliness, timeliness of treatment and patient privacy? Why are the targets that are clearly necessary to maintain standards in the private sector not necessary to maintain standards in the NHS?

Tim Loughton

Independent hospitals have a different definition of targets. The standards must be met, and it does not require 62 different targets for those independent hospitals and other treatment centres to produce high quality health care. It does not require dozens, scores and hundreds of managers to investigate targets and whether they have been achieved. Why can independent hospitals do it when the NHS has to have ever increasing targets and people to administer them? That is the genuine difference.

Dr. John Reid

Will the hon. Gentleman give way?

Tim Loughton

If the Secretary of State will give me a minute to make some progress, I shall readily give way.

The position is not helped by the ridiculous spectacle of hospital trusts drafting in extra staff for the accident and emergency tests at the end of March. Let us dispel the myth that the Secretary of State has promulgated. At the end of March, the Commission for Health Improvement inspections for the star ratings were done in one week, whatever may have happened since.

Dr. Reid

Particular ratings were put out, but since March we have also maintained the statistics on the achievements in accident and emergency. They have consistently run between 87 per cent. and more than 90 per cent. for months.

On administration in the private sector, does the hon. Gentleman realise that 25 per cent. of the United States' expenditure, which is 15 per cent. of gross domestic product—that is twice what we spend, but it does not cover 43.5 million people—goes on administration. In the NHS, less than half that percentage is spent on administration.

Tim Loughton

That is why we do not hold up any experiences in the United States' system as examples that we want to follow. The Secretary of State has been in the United States investigating those systems. We have based many of our policy points on the experience in continental Europe, where things have been done differently. I am surprised that the right hon. Gentleman is so afraid of the experiences of our partners in Europe.

Most wasteful is the diversion of time and resources from dealing with patients to paperwork, inspection reports and bureaucracy. For example, at the end of September last year, there were 158,000 whole-time equivalent NHS infrastructure support staff in England. That is an increase of 12 per cent. since the Government came to power. There are 31,000 whole-time equivalent NHS managers—an increase of 44 per cent. since 1997. It is not surprising that the extra manpower is required when it has been revealed that NHS hospitals are answerable to no fewer than 36 separate regulators out of the Government's total of 108.

The Better Regulation Task Force found that the number of regulators has mushroomed, with nine more promised, yet no one in Government takes responsibility for whether they operate effectively or should exist. David Arculus, chairman of the taskforce, said: If you are running an organisation like a hospital, these people impinge on almost everything you are doing, and 36 different regulators make it very difficult when you are trying to deliver a service. How right he was. As the Public Administration Committee said: The danger with a measurement culture is that excessive attention is given to what can be easily measured, at the expense of what is difficult or impossible to measure quantitatively even though this may be fundamental to the service provided". Where is the evidence that the Government's discredited target culture, which now pervades every part of the NHS, is achieving improvements that could not be better achieved by preserving the autonomy of our health professionals locally? It could be achieved by putting clinical considerations first, by trusting doctors to get on with their job, and by not undermining their judgment and overwhelming them with paperwork, box ticking and bureaucracy. It could be achieved credibly and convincingly so that patients can trust the information that they are given about NHS performance and not constantly having to question its veracity.

The new Secretary of State promised a new broom and a new approach when he succeeded the arch-centralist, the right hon. Member for Darlington (Mr. Milburn). On 7 September, in The Observer, he stated: Targets and objectives are a necessary spur. But they're not an end in themselves—the end is the best possible medical care. What has changed since he took over? What targets have been abandoned so far, and not simply as a result of the Government's failure to achieve them?

The Government should have only one target in health—to improve the health of the whole nation and the quality of the clinical and social outcomes for all patients when they come into contact with all aspects of health care. They should be prioritised purely on medical considerations. Implicit in that is doing away with a raft of targets and the target mentality, which makes the goal the achievement of targets, not the health of the patient and trust in health professionals to deliver it. We must stop treating patients as statistics, whose importance and access to appropriate health care is determined purely by whether their early treatment would be a help or a hindrance to achieving the target, regardless of the clinical effect on the patient. That is the real dividing line between a Government stuck in a Stalinist time warp and—from the Conservatives—bright, imaginative and fresh ideas relevant to health care for all in the 21st century.

This Government stand for more targets, more all-pervading bureaucracy, more demoralisation of staff and more money for maintaining the health of a system, rather than that of the patients it exists for, micro-managed by a transient Secretary of State in Richmond house. Under the Conservatives, the health service would put patients first, give all patients real choice and power to access the whole of that system, put the quality of care ahead of the number of boxes ticked, and trust the professionals to deliver without the dead hand of the Secretary of State hovering menacingly over their every move. That is the real dividing line which we will enthusiastically set out to the British people ahead of the next election; it is one that I relish.

9.45 pm
The Minister of State, Department of Health (Mr. John Hutton)

I have to say to the hon. Member for East Worthing and Shoreham (Tim Loughton) that it is not terribly sensible to refer to transient leaders, given the turmoil in his party. I want briefly to return to that theme, as he would anticipate.

This has been a useful debate, because, as the hon. Gentleman said in his closing remarks, it has helped to highlight the differences between both sides of the House in relation to the NHS. The hon. Member for Woodspring (Dr. Fox) made another of his characteristic speeches. By that I mean that he spoke for half an hour, but could not bring himself to mention any of his party's policies in relation to the NHS. Having read them, I perfectly understand why.

The hon. Gentleman shared with us the illuminating insight that the Tory Administration's targets for the NHS were always aspirational. That is certainly true, because the Tories never managed to meet any of them. He also confirmed, very helpfully, although I am not sure that the hon. Member for East Worthing and Shoreham took exactly the same line, that under a Conservative Administration—if ever there were to be one in the near future—no national targets would be set for the NHS. That will be of serious concern for taxpayers and for patients.

The basic thrust of the speech made by the hon. Member for Woodspring was to deny that any progress has been made in the NHS, which is the view of the hon. Members for East Worthing and Shoreham and for Bridgwater (Mr. Liddell-Grainger). In the process, NHS managers were accused of systematic dishonesty. Those are serious allegations. If that is the hon. Gentleman's view, I am sure that at some point he will want to come to the House and to Ministers with their substance. We look forward to receiving those allegations—

Mr. Liddell-Grainger


Mr. Hutton

I will give way in a moment, because I want to come to the hon. Gentleman's speech.

We warmly welcome the hon. Member for Sutton and Cheam (Mr. Burstow) to his new responsibilities, and I am sure that he would want me to pass on to the hon. Member for Oxford, West and Abingdon (Dr. Harris), for whom I have a great deal of respect, my very best wishes and the best wishes of all Members of the House to him and to his partner.

I am grateful to the hon. Member for Sutton and Cheam for his support for the work of the NHS and its staff—that is very welcome—but he is quite wrong to characterise targets as not being related to improved outcomes for patients. I am sure that, with hindsight, he will want to go away, perhaps consider some targets that we have set this year and reflect on whether he was right to make that allegation. In fact, that also goes for the two Conservative Front Benchers who contributed.

I shall give the hon. Gentleman four examples in which we can say clearly that those targets are about improving health outcomes, which is the point and purpose of the work that we are doing: first, reducing the rate of smoking in the population—there is a clear evidence base for that, and it will improve the healthy lives of millions of people in Britain—and, secondly, increasing the proportion of patients who receive thrombolysis within 60 minutes of asking for professional help. Three years ago, only 38 per cent. of patients received thrombolysis within 30 minutes; now that figure has been doubled to 76 per cent. That will help to save lives.

It is quite wrong to say that that target is unrelated to health outcomes. Neither is that the case with the targets to reduce the rate of untreated psychoses in the population and to require all the hospitals to have a dedicated stroke service by 2004. All those targets are about improving health outcomes for the people of this country and the evidence base for that, which the hon. Gentleman wanted, is very sound and fully set out in all the national service frameworks to which they relate.

Mr. Burstow

I am grateful to the Minister for giving way, because the Department of Health's June 2003 "Review of Early Thrombolysis" states: In quarter 4 of 2002/03, 48 per cent. were treated within 20 minutes". That does not achieve the target of 75 per cent.

Mr. Hutton

I did not catch the hon. Gentleman's first few words, but I can tell him that I gave the right figures on thrombolysis. Perhaps he and I should correspond on the subject.

The point I should make to the hon. Gentleman and his colleagues is that these targets are about outcomes. They are not arbitrary political targets. Targets only become arbitrary political targets for the Tories when we set them; that is not what they are when the Tories set them. I do not think that the irony of that will be wasted on the wider population.

The hon. Gentleman helpfully confirmed that under the Liberal Democrats there would be no national targets for the NHS, but there would be strategic national goals. I am sure that at some point he will want to explain to us what those will be.

I congratulate my hon. Friends the Members for West Bromwich, West (Mr. Bailey) and for Telford (David Wright) on their very effective speeches. Not everything is perfect in the national health service, and we do not claim that it is, but not everything is as hopeless and desperate as Opposition Members proclaim it to be for their own party-political reasons. That balance has been signally lacking from all the contributions we have heard from Conservatives today.

I am particularly sorry to say that in relation to the hon. Member for Bridgwater. I do not know how many GPs were practising in the NHS in his constituency in 1997, although I know that last year three more joined the NHS there. That is progress. It is not the case that, as the hon. Gentleman seemed to be trying to argue, there has been no progress in his constituency. [Interruption.] I listened carefully to what he said, and he did not mention any progress. Perhaps in a future debate he will have the good grace to talk about progress, but he did not manage to get round to it today.

The hon. Members for Woodspring and for East Worthing and Shoreham both used the Audit Commission report to suggest that it made the case against targets. It does not do that at all. It says The overall picture is one of good progress. It is clear that setting national standards and developing action plans are powerful tools for improving services to patients, and holding organisations to account for their performance. Making more efficient use of resources is an important part of meeting targets, and is the key to long-term progress. Its key finding was that the majority of trusts were making progress, performing well against the main targets and managing resources adequately. In particular, the huge effort put into reducing waiting times for outpatient appointments and for hospital inpatient treatment was paying off". Any objective person listening to the speeches of the Opposition Front Benchers must have thought that they were referring to an entirely different report.

The debate has served at least one useful purpose in highlighting the difference between Labour Members who want the NHS to expand and who believe in the principle that care should be free at the point of use, and Opposition Members who do not want and believe those things. We want to put extra investment into the NHS; they want to cut that investment. They want to take money directly from the NHS, as my hon. Friends have pointed out, to subsidise the cost of private medical insurance. That is the policy of the hon. Member for East Worthing and Shoreham, although he now seems to be denying it.

We say that NHS patients should come first. We want choice for every NHS patient, so that we can continue to cut waiting times and make the most effective use of our hospitals and new treatment centres. The Conservative party wants to introduce top-up vouchers for those who can afford to have private operations and treatment.

The policies that the Opposition want us to pursue are not new policies; they are just more extreme versions of failed Tory policies of the past—even more Thatcherite, even more unfair and even more damaging.

Tim Loughton

Can the Minister tell us why he thinks that last year 300,000 people, most of them not wealthy, using their own life savings—three times as many people as when his party came to power—opted out of the NHS to seek private operations, having already paid tax? Does he not think that those people are now owed more respect, care and help—and why did they have to do that in the first place?

Mr. Hutton

They did it to avoid long waiting times. I think that everyone understands that. The hon. Gentleman must surely understand it. The answer, however, is not to take money out of the NHS, but to increase investment in the NHS. I am astonished that the hon. Gentleman does not seem to be able to grasp that basic fact.

None of these Tory policies is based on reason and fairness. They are based on prejudice, and on pure political opportunism. They will not benefit the many; they will benefit the few. They are riddled with inconsistencies and contradictions. It is impossible to say, as the Conservatives have tried to say again tonight, that spending decisions in respect of the NHS will be made by an independent non-political body, and to announce in the same breath that £2 billion will be taken from NHS budgets to fund their policies on vouchers and private medical insurance. What a load of nonsense!

The NHS needs investment and reform if it is to meet the health care needs of our modern society. We have set a course for both. The record investment will see spending on the NHS grow in real terms by nearly 50 per cent. by 2008, building over 100 new hospitals and employing 55,000 more nurses than in 1997, and that is due to rise further still to 70,000 by 2008, employing more doctors—20,000 more consultants and GPs by 2008—and replacing cancer screening equipment at an unprecedented rate. Forty-two per cent. of MRI scanners, 63 per cent. of CT scanners and half of all linear accelerators are brand new—all purchased in the past three years.

The NHS is now doing 1 million more operations and elective admissions a year than when the Tories were last in power. Nearly 2 million more out-patients were seen last year compared with 1997. That is why out-patient and in-patient waiting lists are falling—and fast. Waiting times to see a consultant or a GP, the public's No. 1 priority, are coming down, too. All that is made possible by the extra investment and reforms we are making. All that is at risk from the cuts and policies proposed by the Conservative party.

For each of those statistics, and here I agree with the hon. Member for East Worthing and Shoreham, a real difference has been made to the lives of many of our fellow citizens and their families. They are not just figures. Deaths from coronary heart disease are falling. If one listened to the hon. Member for Woodspring, one would have thought that cancer survival rates were falling—they are rising rapidly. That has all come about because the NHS has been focused on shortening the length of time that patients have to wait before their treatment begins, on making the new drugs available more quickly and on improving cancer screening.

In truth, that is only half the story. The investment on its own is not enough if the NHS is to become the service that Labour Members wish it to be. There is, of course, still a lot to do but clear national targets and objectives have ensured that the reforms are focused on patients' priorities: reducing waiting, improving services in cancer, coronary heart disease, mental health and services for older people. Those are not arbitrary targets but real progress in crucial areas where the NHS needed to improve the service that it offered patients.

That is the course that the House should stick to. The alternatives on offer would take us precisely in the wrong direction, with no guaranteed minimum waiting times for treatment in hospital, in accident and emergency or in a GP's surgery, no commitment to recruit more doctors and more nurses, no promise even to maintain levels of spending, no national standards, unfairness built into the system at every level, with the inevitable return to the lottery of care that we saw under previous Tory Administrations.

The only sure thing is that things would get worse in the NHS if the Conservative party ever returned to office. If we took the advice of Opposition Members this evening, there would be no benchmarks against which taxpayers or patients could judge progress and that, of course, is how the Conservatives want it because they want to talk down the NHS and so pave the way for their pay-as-you-go health care market.

There is a choice before us tonight, as there will be for the British people at the next election. I am looking forward to that contest, too. We will propose the extra investment and the reforms that will help the NHS to provide faster, better-quality treatment with real choice for patients in the best possible environment. The Tory alternative is a smaller NHS, with cuts in investment and tax subsidies for those who can afford private treatment. For the Conservatives, there is no sense of direction other than backwards, no purpose—we have seen it clearly tonight—other than to undermine the NHS and the values that it stands for. The choice that they face this week is either to continue with a failing leader, or to bring back the failed leaders of the past. I think that I speak for all my right hon. and hon. Friends when I say roll on that next election.

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

The House divided: Ayes 132, Noes 333.

Division No. 338] [9:59 pm
Ainsworth, Peter (E Surrey) Fallon, Michael
Amess, David Flight, Howard
Ancram, rh Michael Flook, Adrian
Arbuthnot, rh James Forth, rh Eric
Atkinson, Peter (Hexham) Fox, Dr. Liam
Bacon, Richard Gale, Roger (N Thanet)
Baldry, Tony Garnier, Edward
Barker, Gregory Gibb, Nick (Bognor Regis)
Baron, John (Billericay) Gillan, Mrs Cheryl
Bercow, John Goodman, Paul
Beresford, Sir Paul Gray, James (N Wilts)
Blunt, Crispin Grayling, Chris
Boswell, Tim Green, Damian (Ashford)
Bottomley, Peter (Worthing W) Grieve, Dominic
Bottomley, rh Virginia (SW Surrey) Gummer, rh John
Hammond, Philip
Brady, Graham Hawkins, Nick
Brazier, Julian Hayes, John (S Holland)
Browning, Mrs Angela Heald, Oliver
Burnside, David Heathcoat-Amory, rh David
Burt, Alistair Hendry, Charles
Butterfill, John Horam, John (Orpington)
Cameron, David Howard, rh Michael
Chapman, Sir Sydney (Chipping Barnet) Howarth, Gerald (Aldershot)
Hunter, Andrew
Chope, Christopher Jackson, Robert (Wantage)
Clifton-Brown, Geoffrey Johnson, Boris (Henley)
Collins, Tim Key, Robert (Salisbury)
Conway, Derek Kirkbride, Miss Julie
Cormack, Sir Patrick Knight, rh Greg (E Yorkshire)
Curry, rh David Laing, Eleanor
Davies, Quentin (Grantham & Stamford) Lait, Mrs Jacqui
Lansley, Andrew
Davis, rh David (Haltemprice & Howden) Leigh, Edward
Lewis, Dr. Julian (New Forest E)
Djanogly, Jonathan Liddell-Grainger, Ian
Duncan, Alan (Rutland) Lidington, David
Duncan, Peter (Galloway) Loughton, Tim
Duncan Smith, rh Iain Luff, Peter (M-Worcs)
Fabricant, Michael Mackay, rh Andrew
Maclean, rh David Spicer, Sir Michael
McLoughlin, Patrick Spink, Bob (Castle Point)
Malins, Humfrey Spring, Richard
Maples, John Stanley, rh Sir John
Maude, rh Francis Steen, Anthony
Mawhinney, rh Sir Brian Syms, Robert
May, Mrs Theresa Tapsell, Sir Peter
Mercer, Patrick Taylor, Ian (Esher)
Moss, Malcolm Taylor, John (Solihull)
Norman, Archie Taylor, Dr. Richard (Wyre F)
O'Brien, Stephen (Eddisbury) Taylor, Sir Teddy
Osborne, George (Tatton) Turner, Andrew (Isle of Wight)
Ottaway, Richard Tyrie, Andrew
Page, Richard Viggers, Peter
Paice, James Waterson, Nigel
Paterson, Owen Watkinson, Angela
Prisk, Mark (Hertford) Whittingdale, John
Redwood, John Widdecombe, rh Miss
Robathan, Andrew Wiggin, Bill
Robertson, Hugh (Faversham & M-Kent) Wilkinson, John
Willetts, David
Robertson, Laurence (Tewk'b'ry) Wilshire, David
Roe, Mrs Marion Winterton, Ann (Congleton)
Rosindell, Andrew Winterton, Sir Nicholas (Macclesfield)
Ruffley, David
Sayeed, Jonathan Yeo, Tim (S Suffolk)
Selous, Andrew Young, rh Sir George
Shephard, rh Mrs Gillian
Shepherd, Richard Tellers for the Ayes:
Simpson, Keith (M-Norfolk) Mr. John Randall and
Soames, Nicholas Mr. Mark Francois
Abbott, Ms Diane Campbell, rh Menzies (NE Fife)
Ainsworth, Bob (Cov'try NE) Campbell, Ronnie (Blyth V)
Allan, Richard Caplin, Ivor
Allen, Graham Casale, Roger
Anderson, rh Donald (Swansea E) Cawsey, Ian (Brigg)
Armstrong, rh Ms Hilary Challen, Colin
Atherton, Ms Candy Chapman, Ben (Wirral S)
Atkins, Charlotte Chaytor, David
Austin, John Clapham, Michael
Bailey, Adrian Clark, Mrs Helen (Peterborough)
Baird, Vera Clark, Dr. Lynda (Edinburgh Pentlands)
Baker, Norman
Banks, Tony Clarke, rh Tom (Coatbridge & Chryston)
Barrett, John
Barron, rh Kevin Clarke, Tony (Northampton S)
Battle, John Clelland, David
Bayley, Hugh Clwyd, Ann
Beith, rh A. J. Coaker, Vernon
Bell, Stuart Coffey, Ms Ann
Benton, Joe (Bootle) Cohen, Harry
Berry, Roger Coleman, Iain
Best, Harold Colman, Tony
Blears, Ms Hazel Connarty, Michael
Borrow, David Cook, Frank (Stockton N)
Bradley, Peter (The Wrekin) Cook, rh Robin
Bradshaw, Ben Corbyn, Jeremy
Brake, Tom (Carshalton) Cousins, Jim
Breed, Colin Cryer, Ann (Keighley)
Brennan, Kevin Cryer, John (Hornchurch)
Brooke, Mrs Annette L. Cummings, John
Brown, rh Nicholas (Newcastle E Wallsend) Cunningham, rh Dr. Jack (Copeland)
Bryant, Chris Cunningham, Jim (Coventry S)
Buck, Ms Karen Cunningham, Tony (Workington)
Burden, Richard Davey, Edward (Kingston)
Burnett, John Davey, Valerie (Bristol W)
Burnham, Andy David, Wayne
Burstow, Paul Davis, rh Terry (B'ham Hodge H)
Cable, Dr. Vincent Dawson, Hilton
Caborn, rh Richard Dean, Mrs Janet
Cairns, David Dhanda, Parmjit
Calton, Mrs Patsy Dobbin, Jim (Heywood)
Campbell, Alan (Tynemouth) Donohoe, Brian H.
Doran, Frank Illsley, Eric
Doughty, Sue Irranca-Davies, Huw
Dowd, Jim (Lewisham W) Jackson, Helen (Hillsborough)
Drew, David (Stroud) Jamieson, David
Eagle, Angela (Wallasey) Jones, Jon Owen (Cardiff C)
Eagle, Maria (L'pool Garston) Jones, Lynne (Selly Oak)
Ellman, Mrs Louise Jowell, rh Tessa
Etherington, Bill Joyce, Eric (Falkirk W)
Field, rh Frank (Birkenhead) Kaufman, rh Gerald
Fisher, Mark Keeble, Ms Sally
Fitzpatrick, Jim Keen, Alan (Feltham)
Fitzsimons, Mrs Lorna Kemp, Fraser
Flint, Caroline Khabra, Piara S.
Flynn, Paul (Newport W) King, Ms Oona (Bethnal Green & Bow)
Follett, Barbara
Foster, rh Derek Kirkwood, Sir Archy
Foster, Don (Bath) Knight, Jim (S Dorset)
Foster, Michael (Worcester) Kumar, Dr. Ashok
Foster, Michael Jabez (Hastings & Rye) Ladyman, Dr. Stephen
Lamb, Norman
Foulkes, rh George Lammy, David
Gapes, Mike (Ilford S) Lawrence, Mrs Jackie
Gardiner, Barry Laws, David (Yeovil)
George, rh Bruce (Walsall S) Lazarowicz, Mark
Gerrard, Neil Lepper, David
Gibson, Dr. Ian Leslie, Christopher
Gidley, Sandra Levitt, Tom (High Peak)
Gilroy, Linda Lewis, Ivan (Bury S)
Godsiff, Roger Lewis, Terry (Worsley)
Goggins, Paul Linton, Martin
Green, Matthew (Ludlow) Lloyd, Tony (Manchester C)
Griffiths, Jane Llwyd, Elfyn
Griffiths, Nigel (Edinburgh S) Love, Andrew
Griffiths, Win (Bridgend) Lucas, Ian (Wrexham)
Grogan, John Luke, Iain
Hain, rh Peter McAvoy, Thomas
Hall, Mike (Weaver Vale) McCabe, Stephen
Hall, Patrick (Bedford) McCafferty, Chris
Hancock, Mike McCartney, rh Ian
Hanson, David McDonagh, Siobhain
Harman, rh Ms Harriet McDonnell, John
Harris, Tom (Glasgow Cathcart) MacDougall, John
Harvey, Nick McFall, John
Havard, Dai (Merthyr Tydfil & Rhymney) McGuire, Mrs Anne
McIsaac, Shona
Healey, John McKechin, Ann
Heath, David McKenna, Rosemary
Henderson, Doug (Newcastle N) Mackinlay, Andrew
Henderson, Ivan (Harwich) McNamara, Kevin
Hendrick, Mark McNulty, Tony
Hepburn, Stephen MacShane, Denis
Heppell, John Mactaggart, Fiona
Hermon, Lady McWalter, Tony
Hesford, Stephen McWilliam, John
Heyes, David Mahon, Mrs Alice
Hill, Keith (Streatham) Mallaber, Judy
Hinchliffe, David Mallon, Seamus
Hodge, Margaret Mandelson, rh Peter
Hoey, Kate (Vauxhall) Mann, John (Bassetlaw)
Holmes, Paul Marris, Rob (Wolverh'ton SW)
Hood, Jimmy (Clydesdale) Marsden, Gordon
Hoon, rh Geoffrey Marshall, David (Glasgow Shettleston)
Hope, Phil (Corby)
Hopkins, Kelvin Marshall-Andrews, Robert
Howarth, rh Alan (Newport E) Martlew, Eric
Howarth, George (Knowsley N & Sefton E) Meacher, rh Michael
Meale, Alan (Mansfield)
Hoyle, Lindsay Merron, Gillian
Hughes, Beverley (Stretford & Urmston) Michael, rh Alun
Milburn, rh Alan
Hughes, Kevin (Doncaster N) Miliband, David
Hughes, Simon (Southwark N) Miller, Andrew
Humble, Mrs Joan Mitchell, Austin (Gt Grimsby)
Hurst, Alan (Braintree) Moffatt, Laura
Hutton, rh John Moore, Michael
Iddon, Dr. Brian Moran, Margaret
Morley, Elliot Smith, rh Chris (Islington S & Finsbury)
Morris, rh Estelle
Mountford, Kali Smith, Geraldine (Morecambe & Lunesdale)
Mudie, George
Mullin, Chris Smith, Jacqui
Munn, Ms Meg Smith, John (Glamorgan)
Murphy, Denis (Wansbeck) Smith, Sir Robert (W Ab'd'ns & Kincardine)
Murphy, Jim
Naysmith, Dr. Doug Soley, Clive
Norris, Dan (Wansdyke) Squire, Rachel
Oaten, Mark (Winchester) Steinberg, Gerry
O'Hara, Edward Stevenson, George
Olner, Bill Stewart, David (Inverness E & Lochaber)
Organ, Diana
Osborne, Sandra (Ayr) Stewart, Ian (Eccles)
Palmer, Dr. Nick Stinchcombe, Paul
Perham, Linda Stunell, Andrew
Picking, Anne Sutcliffe, Gerry
Pickthall, Colin Tami, Mark (Alyn)
Pike, Peter (Burnley) Taylor, rh Ann (Dewsbury)
Plaskitt, James Taylor, Dari (Stockton S)
Pollard, Kerry Taylor, David (NW Leics)
Pond, Chris (Gravesham) Taylor, Matthew (Truro)
Pope, Greg (Hyndburn) Teather, Sarah
Prentice, Ms Bridget (Lewisham E) Thomas, Gareth (Clwyd W)
Tipping, Paddy
Prentice, Gordon (Pendle) Todd, Mark (S Derbyshire)
Prescott, rh John Tonge, Dr. Jenny
Primarolo, rh Dawn Trickett, Jon
Prosser, Gwyn Turner, Dennis (Wolverh'ton SE)
Purchase, Ken Turner, Dr. Desmond (Brighton Kemptown)
Quin, rh Joyce
Quinn, Lawrie Turner, Neil (Wigan)
Rapson, Syd (Portsmouth N) Twigg, Derek (Halton)
Raynsford, rh Nick Tyler, Paul (N Cornwall)
Reed, Andy (Loughborough) Tynan, Bill (Hamilton S)
Reid, rh Dr. John (Hamilton N & Bellshill) Vaz, Keith (Leicester E)
Walley, Ms Joan
Rendel, David Ward, Claire
Robertson, John (Glasgow Anniesland) Wareing, Robert N.
Watson, Tom (W Bromwich E)
Robinson, Geoffrey (Coventry NW) Watts, David
Webb, Steve (Northavon)
Rooney, Terry White, Brian
Ross, Ernie (Dundee W) Whitehead, Dr. Alan
Ruane, Chris Wicks, Malcolm
Ruddock, Joan Williams, rh Alan (Swansea W)
Russell, Bob (Colchester) Winnick, David
Ryan, Joan (Enfield N) Winterton, Ms Rosie (Doncaster C)
Sanders, Adrian
Savidge, Malcolm Woodward, Shaun
Sawford, Phil Woolas, Phil
Sedgemore, Brian Worthington, Tony
Shaw, Jonathan Wright, Anthony D.(Gt Yarmouth)
Sheerman, Barry
Sheridan, Jim Wright, David (Telford)
Simon, Siôn (B'ham Erdington) Wright, Tony (Cannock)
Singh, Marsha Tellers for the Noes:
Skinner, Dennis Mr. Nick Ainger and
Smith, Andrew (Oxford E) Paul Clark

Question accordingly negatived.

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

The House divided: Ayes 290, Noes 167.

Division No. 339] [10.14 pm
Abbott, Ms Diane Atherton, Ms Candy
Ainsworth, Bob (Cov'try NE) Atkins, Charlotte
Allen, Graham Austin, John
Anderson, rh Donald (Swansea E) Bailey, Adrian
Armstrong, rh Ms Hilary Baird, Vera
Banks, Tony Foster, Michael (Worcester)
Barron, rh Kevin Foster, Michael Jabez (Hastings & Rye)
Battle, John
Bayley, Hugh Foulkes, rh George
Bell, Stuart Gapes, Mike (Ilford S)
Benton, Joe (Bootle) Gardiner, Barry
Berry, Roger George, rh Bruce (Walsall S)
Best, Harold Gerrard, Neil
Blears, Ms Hazel Gibson, Dr. Ian
Borrow, David Gilroy, Linda
Bradley, Peter (The Wrekin) Godsiff, Roger
Bradshaw, Ben Goggins, Paul
Brennan, Kevin Griffiths, Jane (Reading E)
Brown, rh Nicholas (Newcastle E Wallsend) Griffiths, Nigel (Ediburgh S)
Griffiths, Win (Bridgend)
Bryant, Chris Grogan, John
Buck, Ms Karen Hain, rh Peter
Burden, Richard Hall, Mike (Weaver Vale)
Burnham, Andy Hall, Patrick (Bedford)
Caborn, rh Richard Hanson, David
Cairns, David Harman, rh Ms Harriet
Campbell, Alan (Tynemouth) Harris, Tom (Glasgow Cathcart)
Campbell, Ronnie (Blyth V) Havard, Dai (Merthyr Tydfil & Rhymney)
Caplin, Ivor
Casale, Roger Healey, John
Cawsey, Ian (Brigg) Henderson, Doug (Newcastle N)
Challen, Colin Henderson, Ivan (Harwich)
Chapman, Ben (Wirral S) Hendrick, Mark
Chaytor, David Hepburn, Stephen
Clapham, Michael Heppell, John
Clark, Mrs Helen (Peterborough) Hermon, Lady
Clark, Dr. Lynda (Edinburgh Pentlands) Hesford, Stephen
Heyes, David
Clarke, rh Tom (Coatbridge & Chryston) Hill, Keith (Streatham)
Hinchliffe, David
Clarke, Tony (Northampton S) Hodge, Margaret
Clelland, David Hoey, Kate (Vauxhall)
Clwyd, Ann (Cynon V) Hood, Jimmy (Clydesdale)
Coaker, Vernon Hoon, rh Geoffrey
Coffey, Ms Ann Hope, Phil (Corby)
Cohen, Harry Hopkins, Kelvin
Colman, Tony Howarth, rh Alan (Newport E)
Connarty, Michael Howarth, George (Knowsley N & Sefton E)
Cook, Frank (Stockton N)
Cook, rh Robin Livingston) Hoyle, Lindsay
Corbyn, Jeremy Hughes, Beverley (Stretford & Urmston)
Cousins, Jim
Cryer, Ann (Keighley) Hughes, Kevin (Doncaster N)
Cryer, John (Hornchurch) Humble, Mrs Joan
Cummings, John Hurst Alan (Braintree)
Cunningham, rh Dr Jack (Copeland) Hutton, rh John
Iddon, Dr. Brian
Cunningham, Jim (Coventry S) Illsley, Eric
Cunningham, Tony (Workington) Irranca-Davies, Huw
Davey, Valerie (Bristol W) Jackson, Helen (Hillsborough)
David, Wayne Jamieson, David
Davis, rh Terry (B'ham Hodge H) Jones, Jon Owen (Cardiff C)
Dawson, Hilton Jones, Lynne (Selly Oak)
Dean, Mrs Janet Jowell, rh Tessa
Dhanda, Parmjit Joyce, Eric (Falkirk W)
Dobbin, Jim (Heywood) Kaufman, rh Gerald
Donohoe, Brian H. Keeble, Ms Sally
Doran, Frank Keen, Alan (Feltham)
Dowd, Jim (Lewisham W) Kemp, Fraser
Eagle, Angela (Wallasey) Khabra, Piara S.
Eagle, Maria (L'pool Garston) King, Ms Oona (Bethnal Green & Bow)
Ellman, Mrs Louise
Etherington, Bill Knight, Jim (S Dorset)
Field, rh Frank (Birkenhead) Kumar, Dr. Ashok
Fisher, Mark Ladyman, Dr. Stephen
Fitzpatrick, Jim Lammy, David
Fitzsimmons, Mrs Lorna Lawrence, Mrs Jackie
Flint, Caroline Lazarowicz, Mark
Flynn, Paul (Newport W) Lepper, David
Follett, Barbara Leslie, Christopher
Foster, rh Derek Levitt, Tom (High Peak)
Lewis, Ivan (Bury S) Rapson, Syd (Portsmouth N)
Lewis, Terry (Worsley) Raynsford, rh Nick
Linton, Martin Reed, Andy (Loughborough)
Lloyd, Tony (Manchester C) Reid, rh Dr. John (Hamilton N & Bellshill)
Love, Andrew
Lucas, Ian (Wrexham) Robertson, John (Glasgow Anniesland)
Luke, Iain (Dundee E)
McAvoy, Thomas Robinson, Geoffrey (Coventry NW)
McCabe, Stephen
McCafferty, Chris Rooney, Terry
McCartney, rh Ian Ross, Ernie (Dundee W)
McDonagh, Siobhain Ruane, Chris
McDonnell, John Ruddock, Joan
MacDougall, John Ryan, Joan (Enfield N)
McFall, John Savidge, Malcolm
McGuire, Mrs Anne Sawford, Phil
McIsaac, Shona Sedgemore, Brian
McKechin, Ann Shaw, Jonathan
McKenna, Rosemary Sheerman, Barry
Mackinlay, Andrew Sheridan, Jim
McNamara, Kevin Simon, Siôn (B'ham Erdington)
McNulty, Tony Singh, Marsha
MacShane, Denis Skinner, Dennis
Mactaggart, Fiona Smith, rh Andrew (Oxford E)
McWalter, Tony Smith, rh Chris (Islington S & Finsbury)
McWilliam, John
Mahon, Mrs Alice Smith, Geraldine (Morecambe & Lunesdale)
Mallaber, Judy
Mandleson, rh Peter Smith, Jacqui (Redditch)
Mann, John (Bassetlaw) Smith, John (Glamorgan)
Marris, Rob (Wolverh'ton SW) Soley, Clive
Marsden, Gordon (Blackpool S) Squire, Rachel
Marshall, David (Glasgow Shettleston) Steinberg, Gerry
Stevenson, George
Marshall-Andrews, Robert Stewart, David (Inverness E & Lochaber)
Martlew, Eric
Meacher, rh Michael Stewart, Ian (Eccles)
Meale, Alan (Mansfield) Stinchcombe, Paul
Merron, Gillian Sutcliffe, Gerry
Michael, rh Alun Tami, Mark (Alyn)
Milburn, rh Alan Taylor, rh Ann (Dewsbury)
Miliband, David Taylor, Dari (Stockton S)
Miller, Andrew Taylor, David (NW Leics)
Mitchell, Austin (Gt Grimsby) Taylor, Dr. Richard (Wyre F)
Moffatt, Laura Thomas, Gareth (Clwyd W)
Moran, Margaret Tipping, Paddy
Morley, Elliot Todd, Mark (S Derbyshire)
Morris, rh Estelle Trickett, Jon
Mountford, Kali Turner, Dennis (Wolverh'ton SE)
Mudie, George Turner, Dr. Desmond (Brighton Kemptown)
Mullin, Chris
Munn, Ms Meg Turner, Neil (Wigan)
Murphy, Denis (Wansbeck) Twigg, Derek (Halton)
Murphy, Jim (Eastwood) Tynan, Bill (Hamilton S)
Naysmith, Dr. Doug Vaz, Keith (Leicester E)
Norris, Dan (Wansdyke) Walley, Ms Joan
O'Hara, Edward Ward, Claire
Olner, Bill Wareing, Robert N.
Organ, Diana Watson, Tom (W Bromwich E)
Osborne, Sandra (Ayr) Watts, David
Palmer, Dr. Nick White, Brian
Perham, Linda Whitehead, Dr. Alan
Picking, Anne Wicks, Malcolm
Pickthall, Colin Winnick, David
Pike, Peter (Burnley) Winterton, Ms Rose (Doncaster C)
Plaskitt, James
Pond, Chris (Gravesham) Woodward, Shaun
Pope, Greg (Hyndburn) Woolas, Phil
Prentice, Ms Bridget (Lewisham E) Wright, Anthony D. (Gt Yarmouth)
Prentice, Gordon (Pendle) Wright, David (Telford)
Primarolo, rh Dawn Wright, Tony (Cannock)
Prosser, Gwyn
Purchase, Ken Tellers for the Ayes:
Quin, rh Joyce Mr. Nick Ainger and
Quinn, Lawrie Paul Clark
Ainsworth, Peter (E Surrey) Heath, David
Allan, Richard Heathcoat-Amory, rh David
Amess, David Hendry, Charles
Ancram, rh Michael Holmes, Paul
Arbuthnot, rh James Horam, John (Orpington)
Atkinson, Peter (Hexham) Howard, rh Michael
Bacon, Richard Howarth, Gerald (Aldershot)
Baker, Norman Hughes, Simon (Southwark N)
Baldry, Tony Hunter, Andrew
Barker, Gregory Jackson, Robert (Wantage)
Baron, John (Billericay) Johnson, Boris (Henley)
Barrett, John Key, Robert (Salisbury)
Beith, rh A. J. Kirkbride, Miss Julie
Bercow, John Kirkwood, Sir Archy
Beresford, Sir Paul Knight, rh Greg (E Yorkshire)
Blunt, Crispin Laing, Mrs Eleanor
Boswell, Tim Lait, Mrs Jacqui
Bottomley, Peter (Worthing W) Lamb, Norman
Brady, Graham Lansley, Andrew
Brake, Tom (Carshalton) Laws, David (Yeovil)
Brazier, Julian Leigh, Edward
Breed, Colin Lewis, Dr. Julian (New Forest E)
Brooke, Mrs Annette L. Liddell-Grainger, Ian
Browning, Mrs Angela Lidington, David
Burnett, John Loughton, Tim
Burnside, David Luff, Peter (M-Worcs)
Burstow, Paul Mackay, rh Andrew
Burt, Alistair Maclean, rh David
Butterfill, John McLoughlin, Patrick
Cable, Dr. Vincent Malins, Humfrey
Calton, Mrs Patsy Maples, John
Cameron, David Maude, rh Francis
Campbell, rh Menzies (NE Fife) Mawhinney, rh Sir Brian
Cash, William May, Mrs Theresa
Chapman, Sir Sydney (Chipping Barnet) Mercer, Patrick
Mitchell, Andrew (Sutton Coldfield)
Chope, Christopher
Clifton-Brown, Geoffrey Moore, Michael
Collins, Tim Moss, Malcolm
Conway, Derek Norman, Archie
Curry, rh David Oaten, Mark (Winchester)
Davey, Edward (Kingston) O'Brien, Stephen (Eddisbury)
Davies, Quentin (Grantham & Stamford) Osborne, George (Tatton)
Ottaway, Richard
Davis, rh David (Haltemprice & Howden) Page, Richard
Paice, James
Djanogly, Jonathan Paterson, Owen
Doughty, Sue Prisk, Mark (Hertford)
Duncan, Alan (Rutland) Pugh, Dr. John
Duncan Smith, rh Iain Redwood, rh John
Fabricant, Michael Rendel, David
Fallon, Michael Robathan, Andrew
Flight, Howard Robertson, Hugh (Faversham & M-Kent)
Flook, Adrian
Forth, rh Eric Robertson, Laurence (Tewk'b'ry)
Foster, Don (Bath) Roe, Mrs Marion
Fox, Dr. Liam Rosindell, Andrew
Gale, Roger (N Thanet) Ruffley, David
Garnier, Edward Russell, Bob (Colchester)
Gibb, Nick (Bognor Regis) Sanders, Adrian
Gidley, Sandra Sayeed, Jonathan
Gillan, Mrs Cheryl Selous, Andrew
Goodman, Paul Shepherd, Richard
Gray, James (N Wilts) Simpson, Keith (M-Norfolk)
Grayling, Chris Smith, Sir Robert (W Ab'd'ns & Kincardine)
Green, Damian (Ashford) Green, Matthew (Ludlow) Soames, Nicholas
Grieve, Dominic Spicer, Sir Michael
Gummer, rh John Spink, Bob (Castle Point)
Hammond, Philip Spring, Richard
Hancock, Mike Stanley, rh Sir John
Harvey, Nick Steen, Anthony
Hawkins, Nick Stunell, Andrew
Hayes, John (S Holland) Syms, Robert
Heald, Oliver Tapsell, Sir Peter
Taylor, Ian (Esher) Widdecombe, rh Miss
Taylor, John (Solihull) Wiggin, Bill
Taylor, Matthew (Truro) Wilkinson, John
Taylor, Sir Teddy Willetts, David
Teather, Sarah Wilshire, David
Tonge, Dr. Jenny Winterton, Ann (Congleton)
Turner, Andrew (Isle of Wight) Winterton, Sir Nicholas (Macclesfield)
Tyler, Paul (N Cornwall)
Tyrie, Andrew Yeo, Tim (S Suffolk)
Viggers, Peter Young, rh Sir George
Waterson, Nigel
Watkinson, Angela Tellers for the Noes:
Webb, Steve (Northavon) Mr. John Randall and
Whittingdale, John and Mr Mark Francois

Question accordingly agreed to.

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

Resolved, That this House welcomes the Government's record extra investment in the National Health Service; supports the Government's policy of linking investment to reform; notes that setting targets and monitoring performance against them are a vital part of the accountability process; welcomes the Government's determination to devolve power in the health service to the front line backed by three-year allocations of money to NHS organisations and clear delivery targets for the next three years; welcomes the positive effect of the right targets on staff morale, motivation and standards; welcomes the increases in capacity and workforce numbers, the greater availability of new and better drugs, the shorter waiting times and the greater choice available to all patients; notes that expenditure on NHS management as a proportion of the total NHS budget is falling; and supports the Government's commitment to a high quality NHS, responsive to the needs of patients, available to all free at the point of need.