NHS Recruitment and Retention

HC Deb 22 June 2004 vol 422 cc1265-96

Mr. Deputy Speaker (Sir Michael Lord)

I must tell the House that Mr. Speaker has selected the amendment in the name of the Prime Minister.

5.15 pm

Mr. Andrew Lansley (South Cambridgeshire) (Con)

I beg to move, That this House recognises the central role of NHS professionals in delivering high quality healthcare through the NHS; notes the need for substantial increases in NHS staffing to meet future demand for healthcare; further notes that the levels of bureaucracy, red tape and imposed targets within the NHS demoralise NHS staff; regrets the problems in the implementation of the consultant and GP contracts; further regrets the delay in progress on 'Agenda for Change'; expresses its concern over staff shortages in general practice, hospital specialties, nursing, especially community nursing, midwifery, radiography and biomedical sciences; is alarmed at the extent of recruitment of health professionals from developing countries which are unable to sustain the loss of such staff; and urges the Government to give the NHS the freedoms and incentives needed to support a growing workforce.

This week we will have a series of debates—some in this Chamber and some outside—on the national health service and health care in this country. I hope that we can start with a shared perspective, which is that no serious progress would be possible, however much we might wish it, however much we might invest in the national health service, however much we might introduce choice in the national health service, and however much we might introduce competition in the provision of the national health service, without the skill, hard work and commitment of NHS professionals and health care professionals generally.

Today is our chance to show that we value the work of NHS doctors, nurses and health care professionals generally. That matter is not something to which I have turned as part of my current Front-Bench responsibilities. I hope that the House will be aware, and I know that the Minister of State, the right hon. Member for Barrow and Furness (Mr. Hutton), is aware, that as a Back Bencher, I secured a debate in Westminster Hall in November 2002 on nursing and nurses' pay and conditions. That was the only debate on those subjects in this Parliament so far—the previous one was in 1999.

As a preface to our discussions, it is a pity that we do not debate more regularly pay and conditions, the prospects for recruitment and retention and the contribution made by NHS professionals to the NHS. One of the things that the Audit Commission's survey of NHS professionals made clear was the importance of the extent to which those professionals feel that they are valued by the Government and the public, and the fact that the lack of understanding that they are valued is one of the reasons why people leave the NHS. It is therefore right that we demonstrate that they are valued, that we do that together, and, although it may not be easy to achieve this afternoon, that we do it in a spirit of consensus.

There are 1.3 million staff in the NHS—they represent one in seven of all public sector employees and about one in 20 of the whole UK work force. It is vital that we discuss that work force. It is not a subject to which the Government have given time, so I hope that it will be recognised that it is right for the Opposition to give some of our time to understanding and reflecting on that work force.

We will need to discuss a number of issues, and I want to start, as I did previously, with nurses. The congress of the Royal College of Nursing met in early May—just over a month ago—and some information was presented on how nurses feel about the NHS. It was interesting to note, for example, that only 30 per cent. of nurses believed that the number of permanent nursing staff had increased over the past four years at their hospital. Clearly, something is not happening to make nurses perceive that the front-line resources are getting through. When we asked doctors the same question, two thirds said that they did not perceive that the resources that they heard were going into the NHS were getting to the front line. It is vital that they do see that happening.

Jonathan Shaw (Chatham and Aylesford) (Lab)

The hon. Gentleman said that "we" asked doctors? Is that "we" the Conservative party?

Mr. Lansley

It was we, the Conservative party, who asked doctors. We did it through a reputable research company and published the results, so that seems perfectly reasonable to me.

On the issues relating to nursing, we know that during the past 10 years the average age of nurses has increased from 37 to 41. We know that half the rise in the number of nurses registered in the UK is the result of overseas recruitment, and there are issues about the sustainability—[Interruption] If the Secretary of State has something that he wishes to tell us, no doubt he will intervene.

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

Yes, the hon. Gentleman mentioned the increase in age. A large number of nurses came back to work in the health service when they got a new Government who were putting in the investment, giving the support needed and increasing the number of nurses.

Mr. Lansley

I welcome the increase in the number of nurses. It is absolutely right that we should attract nurses back into the national health service. If the Secretary of State has read my speech from November 2002, he will know the precise reasons that I presented for that. I made it clear that Addenbrooke's, a major employer of nurses in my constituency, would need "Agenda for Change", that a reflection of the valuation of nurses should be considered by the pay review bodies—which the Government's evidence to the pay review bodies had not sufficiently reflected—and that Addenbrooke's would need to make changes such as improving working lives. Addenbrooke's is a model employer in the ways in which it has addressed the issues in improving working lives, such as non-discrimination, supporting staff, opposing harassment and putting together family-friendly policies and child-care arrangements for nurses. I do not dispute any of that. That is exactly where we want to go, but the Government should not believe that the overseas recruitment of nurses is a sustainable basis on which to undertake the expansion of the nursing work force in the NHS in years to come.

Mr. Peter Pike (Burnley) (Lab)

Will the hon. Gentleman recognise that prior to 1997—in my first 14 years in this House—I continually fought here and in my constituency against hospital closures, the reduction in the number of beds and massive cuts in the national health service, year after year? I cannot believe that the hon. Gentleman, in what he is now saying, fails to remember what his party did when in office.

Mr. Lansley

What the hon. Gentleman says is interesting. We are today talking about the work force, and also about what can be achieved in the NHS. We have had an increase in the number of nurses and in the number of doctors. It is interesting to note that under the previous Conservative Government, in the seven years leading up to 1997, the number of consultants in the NHS increased by 30 per cent In the seven years since 1997, it has increased by 34 per cent., so to a large extent the trends in numbers of doctors have been very similar during those periods.

I will accept that matters in relation to nurses are different, but one of the problems with which the Secretary of State and his colleagues have wrestled—The Sunday Times illustrated this by its reporting of leaked documents from inside the Government—is what appears to be a substantial reduction in the productivity of the NHS. The Secretary of State knows that changes in working hours and in NHS structures have meant that although there has been a 14 per cent. increase in the number of nurses, on a whole-time equivalent basis, in recent years, we have had only a 5 per cent. increase in activity in the NHS.

On increase in activity, let us look at finished consultant episodes. The Minister of State has been good enough to respond to a question that I put on finished consultant episodes, which are a measure of inpatient activity in hospitals, and include day cases. Between 1990–91 and 1995–96, a five-year period before the 1997 election, there was an increase in finished consultant episodes from 8.8 million to 11.07 million— about 2.25 million additional finished consultant episodes. In the five years from 1997–98 to 2002–03, the number rose from 11.5 million to 12.76 million, an increase of 1.25 million episodes. So, over a five-year period, whereas there was an increase of 2.25 million under a Conservative Government during the period of the internal market reforms, there was an increase of 1.25 million under the present Government. That has resulted not from a reduction in the number of nurses—the numbers of nurses, consultants and doctors was increasing—but because, simply in order to stand still in the NHS in the light of all the additional impositions, changes in working hours and contractual arrangements, about 10 per cent. of the increase went into adjustment. The level of increased activity was, in fact, very small.

David Taylor (North-West Leicestershire) (Lab/Coop)

The hon. Gentleman seems to be tip-toeing around the most important figures, which are performance indicators in respect of nursing. At the moment, the number of nurses employed within the NHS is heading rapidly towards 400,000—an increase of almost a quarter since 1 May 1997. Is it not the case that, when the hon. Gentleman was wringing his hands in Westminster Hall at the plight of nursing, the Government were ringing the advertising agencies to recruit even more of that valuable resource to our prized national health service?

Mr. Lansley

The hon. Gentleman is trying to make a partisan point—[Interruption.] These are the Houses of Parliament and it is our responsibility to promote the interests of the NHS. What I am doing now is promoting the national health service's interest in recruiting and retaining more nurses. It will be good if we can reach 400,000 nurses. Why not? It will be one of the benefits of introducing the changes that I sought to encourage in "Agenda for Change", but we cannot do so simply on the basis of overseas recruitment. The Royal College of Nursing made it clear that 10,000 people from third-world nations registered to work as nurses in the UK over the two years leading up to 2002–03 and that many of them came from the Philippines, South Africa and India, but argued that it was unsustainable for us to deprive developing countries of that number of nurses when they were trying to meet their own health care needs.

Mr. Henry Bellingham (North-West Norfolk) (Con)

My hon. Friend will be aware that the Queen Elizabeth hospital in my constituency, which also serves the constituents of my right hon. Friend the Member for South-West Norfolk (Mrs. Shephard), has embarked on a policy of recruiting a large number of Philippino nurses. They make excellent nurses, but, as my hon. Friend rightly says, that policy is not sustainable, which is why we need much more focus on retention and far more imagination on the part of the Government in their attempts to retain hard-working nurses who are leaving the NHS.

Mr. Lansley

My hon. Friend makes a very good point. He is absolutely right. He and I know—as do Government Members—that when recruitment from the Philippines was first taking place, it was done in conjunction with the Philippines Government on the basis that their nurses were so good. That has been my own experience in hospitals in my constituency. They make extremely good nurses. I was talking the other day to the chief executive of another hospital, who endorsed that view. However, there comes a point at which our recruitment from such countries simply cannot go on.

I want to make some progress and we have only a couple of hours. I want to continue and finish my speech, but I also want other hon. Members to have the opportunity to contribute.

I should say more about "Agenda for Change". I recall talking to hospital nurses who were engaged in the process of preparing for that agenda, and I know the enormous effort that was required. It was a valuable effort, but they were working to a definite timetable. When I spoke to them—in late April, if I remember correctly—they believed that they were aiming for October. I can only endorse what amounts to deep irritation on the part of the RCN, which is putting in so much effort to implement "Agenda for Change" for the nursing profession, that the Secretary of State told its conference that the Government were aiming for October but put the date back to December only a few days later. I hope that we will hear why that was necessary and what can be done to offset the very demoralising effect on nurses.

On consultant contracts, every consultant that I have spoken to believes that the Government operated on the basis that consultants were skiving off in order to go out on to the golf course. I do not believe that that is so. I do not suppose that Ministers believe that it is, but that is what consultants think. They also think that the proposal is being implemented in a way that is completely mad.

Consultants' job plans show that, on average, each does about 12.5 programmed activities a week. Hospitals are supposed to get 10.8 programmed activities, but the primary care trusts are not necessarily passing them through. Perhaps the Minister will tell the House how many PCTs pass through the money that the Department says it has given them for the contract. In any case, consultants are as a result being constrained to 11 programmed activities a week, or even only 10. The contract will mean that consultants will be paid more to do less.

Alternatively, consultants will not sign the contract. Their attitude will be, "If the Government are going to treat me as though I were a production-line worker, that is how I will behave." If consultants have to clock on and clock off, they will behave accordingly. That is not good enough.

In an Opposition day debate a short while ago, I asked the Minister about implementing contracts for staff and associated specialists. Happily, he has made it clear that contracts should now begin to be negotiated, but how soon will that happen? The conclusion reached by the pay review body has demoralised staff and associated specialists. They were linked to the consultants who are not signing up to the new contract, and they are therefore not due to get any substantial increase.

GPs believe that the contract has been designed to reduce their work load. I do not quite see it that way, and it would be interesting to know whether the Minister does. It seemed to me that the aim was to enable GPs to manage their work more effectively and to use a range of specialists to do so, in a framework that delivered better care to people with chronic diseases. I hope that GPs will see the contract in those terms, but communication with them has been too ineffective for that to be the case.

I am seriously worried about the extent to which NHS Direct seems to be gearing up to take over responsibility for out-of-hours services. The result will be that those services will no longer be GP-led, but will be delivered by NHS Direct. The Secretary of State is supposed to be reviewing NHS Direct, among other bodies. However, the advertisements that are now appearing show that it is looking for a chief operating officer and a medical director, as well as directors of finance, service development, nursing, corporate affairs and communications, human resources and of information and communications technology. It is all expansion in NHS Direct at the moment. A reading of the Estates Gazette shows that, across the country, NHS Direct is buying twice the amount of space that it has already in order to accommodate its new size. That shows where growth is taking place in the NHS, although it may be happening nowhere else.

I turn now to some specific specialities. People in the NHS understand that we must know where the constraints are before we can deliver a better service. For example, we need twice as many neurologists as we have at present. Relative to population size, we have a quarter as many neurologists as France has. We need to double the number available here if we are to meet National Institute for Clinical Excellence guidelines on multiple sclerosis, or on the standard of care required for Parkinson's disease.

On radiology, 80 per cent. of hospitals covered by the recent National Audit Office report cited lack of skilled staff as a constraint Vacancy rates for diagnostic and therapeutic radiographers have risen.

Since 1996, the number of midwives has risen by only 186, which severely constrains our ability to provide the necessary choice to people seeking maternity care. For example, some hospitals—one of them is in my constituency—cannot provide a midwife-led unit simply because they cannot recruit the number of midwives needed.

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

The hon. Gentleman just said that we needed twice as many neurologists in the NHS. I understand from The Independent and other newspapers that the proposals that he is about to announce mean that there would be no national targets for the NHS—including work force targets. Will the hon. Gentleman explain that contradiction?

Mr. Lansley

Yes I will, and I am grateful for the question. Our proposals for the care of people with multiple sclerosis or Parkinson's disease, for instance, are based on NICE guidelines. The NICE guidelines for multiple sclerosis were published last November. At the moment, NICE produces guidelines, but no one is under a requirement to implement them. We need at the same time to see where the capacity constraints will be. That includes things like diagnosis. But then it will be the responsibility of primary care trusts to commission that care. This is not elective surgery; this is chronic disease management.

Dr. John Reid

So there will be no targets?

Mr. Lansley

No, there will be a responsibility to commission care. If hospitals know that they have commissioners seeking the delivery of a service to a standard, they can put in place the necessary consultant posts.

Dr. Reid

Will the hon. Gentleman give way?

Mr. Lansley

Just a moment. Under the next Conservative Government, it will be the responsibility of the Department of Health to expand the NHS work force.

I have not read the story in The Independent, but if it has reported our intentions accurately, the story will be that we do not believe in imposing targets on NHS hospitals and general practices. We are in the business of imposing targets on ourselves, not on the NHS—

Mr. Hutton

What targets?

Mr. Lansley

Public health targets, for example. The Minister was not here for yesterday's debate. Pretty much every kind of target that ought to be imposed on the Government for public health and the work force is a target for the Department of Health, and the Department must take responsibility for meeting it. Changing the culture of the NHS means doing away with targets and performance management. Such a system is an attempt to run the NHS from the Secretary of State's desk instead of making responsibility lie where it ought—in hospitals that respond to the needs of patients. That is where performance management should be.

Dr. Reid

Presumably, that includes the targets that have reduced the scandalous two-year waiting times to nine months, and will reduce them to six months next year. That target will go as well, and we shall have unlimited waiting times.

I wish to understand the recruitment figures. Will the hon. Gentleman confirm that what he is saying is that if there is a shortage of midwives and radiographers nowadays, it is the fault of this Government but it would not be the fault of a future Conservative Government because they would have no targets for the number of midwives or radiographers in the first place?

Mr. Lansley

No, the Secretary of State is wrong about that.

Dr. Reid

rose—

Mr. Lansley

I will answer the question. The Secretary of State cannot intervene before I have answered his point.

Dr. Reid

Will there be any targets is or not?

Mr. Lansley

I shall tell the Secretary of State. I have said it once, and I say it again: we will not impose targets on the NHS, but there are responsibilities for the Department of Health, and they include stimulating the—[Interruption.] I do not know what Labour Members find so difficult to comprehend. The point is that it will be for the Department of Health and the Conservative Government to manage their own responsibilities, and one of our responsibilities will be to create the circumstances in which there is a volume increase in the work force—doctors, dentists and nurses—available to the NHS. That does not mean that we need to impose performance targets on hospitals. The star rating system sets down 44 targets. None of them is a work force expansion target. If we abolish the star rating system, it does not mean that we have abolished the responsibility of the Department of Health to increase the work force of the NHS.

Dr. Reid

The hon. Gentleman has just spent the past 10 minutes criticising the Government for not reaching the target for the number of nurses, midwives and radiographers. Is he telling us that he will not have such a target for the number of radiographers and midwives? Or will he have such an objective for the NHS? Is he saying, in other words, that while we are in power, to have such an objective number is to have a target, but when he is in power, it will be left entirely to the local hospital to decide how many midwives and radiographers it employs?

Mr. Lansley

The Secretary of State has demonstrated three times that he does not understand. It is perfectly clear that—[Interruption.] I shall try once more and then I shall move on. We will have a responsibility as the next Conservative Government to expand the work force available to the NHS.

Dr. Reid

To what level?

Mr. Lansley

As I have just said, in order to supply the diagnostic resources and personnel that NICE guidelines require, we would need substantially to increase the number of neurologists.

Dr. Reid

Will the hon. Gentleman give way?

Mr. Lansley

The Secretary of State cannot keep intervening.

In order for that to happen, we will have a Department of Health with responsibility to make available additional medical manpower to the NHS. It will then be up to hospitals to decide the extent to which they appoint additional consultants in order to provide that service, but the service will be set up.

Dr. Reid

Will the hon. Gentleman give way?

Mr. Lansley

No, I have finished now and the Secretary of State can sit down.

Dr. Reid

This is absolutely—

Mr. Lansley

The Secretary of State can sit down because only one person can speak at a time, and I am not giving way.

Dr. Reid

rose—

Mr. Deputy Speaker

Order. The Secretary of State must resume—

Dr. Reid

He is running from—

Mr. Deputy Speaker

Order. The Secretary of State must realise the position. He takes a vigorous part in debates and that is in order, but it is not in order to interrupt if the hon. Gentleman who has the Floor does not wish to give way.

Mr. Lansley

Thank you, Mr. Deputy Speaker. This is a short debate and the Secretary of State is trying to prevent other people from contributing to it. I shall not now have time to talk about the lack of dentists or the further issues relating to overseas recruitment. I hope that my hon. Friend the Member for Billericay (Mr. Baron) will be able to expand on those subjects when he winds up.

The Government have considered several ways to try to increase the NHS work force in the future. They have considered trying to increase overseas recruitment; stimulating the return to work of previous staff by improving working lives; and increasing the supply of training places. Those are important, but one needs also to consider why people leave the NHS and why they change jobs—staff turnover is high. The Audit Commission considered that and the reasons include bureaucracy, poor resources, a lack of autonomy, a sense of being undervalued by the Government and the public, and unfair pay. We need to address all those issues, and the Government need to understand that bureaucracy and the lack of autonomy are seen as part of the reasons why people do not stay in their jobs in the NHS, why we do not see the return to work that we should among nurses and doctors and why we cannot recruit and retain as we would wish. We can attack those issues. We can cut the levels of bureaucracy and we propose to do so. We can give greater autonomy and freedom to the NHS to provide services and to respond to patients.

NHS professionals are valued by this House, and they should be valued, for the clinical care they give, for the choices they make and for the responsibility they take on—nurses, for example, are taking on greater responsibilities across the NHS—and they should be trusted and given the autonomy they want. We should set the NHS free. It will be our job to do so, and to give people the right to choose.

5.42 pm

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

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 which has resulted in increases of 19,400 more doctors and 67,500 more nurses since 1997; supports the extra investment in training which has increased the intake of medical school students by 61 per cent. and nurse training students by 53 per cent. since 1997; notes that over one million NHS staff will benefit from improved terms and conditions; recognises that the international recruitment of healthcare professionals has already made a significant impact on the delivery of NHS services; notes the Government's commitment to ethical international recruitment, with its robust Code of Practice, the first of its kind in the world, ensuring that NHS organisations do not recruit staff from developing countries without the agreement of their government; and welcomes the sharing and transfer of experience and ideas that international recruitment brings to the health service.

I congratulate the hon. Member for South Cambridgeshire (Mr. Lansley) on his elevation to the shadow Cabinet. I hope that he will not mind if I say how sorry I am that the hon. Member for South Suffolk (Mr. Yeo) will no longer be joining our debates on health, for the simple reason that he spent most of his time in his job as a shadow public services spokesman dumping the health policies that he inherited from the hon. Member for Woodspring (Dr. Fox). We all hoped that the hon. Member for South Suffolk would carry on a little longer. To give him credit, he eventually scrapped the top-up schools voucher, but he had not got round to scrapping the Tories' top-up hospital voucher—the NHS passport—under which a patient's access to treatment would depend not on their clinical need but on the amount of money in their pocket.

Jonathan Shaw

My right hon. Friend will recall that the hon. Member for South Cambridgeshire (Mr. Lansley) mentioned several issues that arose from the conference of the Royal College of Nursing. Does my right hon. Friend recall that more than 90 per cent. of nurses at that conference voted against the passport to pain proposed by the Opposition?

Mr. Hutton

Yes, I intended to mention that shortly. I suspect that the hon. Member for South Suffolk remembers that even more clearly than I do.

The Leader of the Opposition has now confirmed that they intend to keep the policy of top-up patient vouchers, under which people have 50 per cent. of costs met by the NHS and make up the difference from their own resources.

Mr. Lansley

When something wrong is put on the record, it stays there, so to put the Minister right, under our proposals, which we shall announce shortly, no NHS patient will have to pay anything to receive NHS treatment.

Mr. Hutton

I know that, but that policy will provide patients with an exit visa from the national health service. I shall come on to that point in a second. We need to be clear about those vouchers, because they affect the issues that we are discussing. The policy will put ability to pay ahead of clinical need, and it will cost the national health service more than £1 billion to finance.

It should come as a surprise to no one that the only aspiration that lot have—the only objective the Tory top-up voucher is designed to serve—is to persuade people that the only way to get faster treatment is to leave the national health service, to leave the public sector altogether and to go private. It will not provide the same level of choice and opportunity to all NHS patients but will offer more choice to those who can afford it. It concedes that the fastest treatment will be available only to those who can afford it, and only in the private sector.

Under the Tories, it will be money that talks; it will be money that guarantees access to the fastest treatment, not the degree of pain and suffering that a patient might be enduring. What a contemptible policy: fundamentally flawed, fundamentally unfair—a typical Tory policy.

Mr. Bellingham

Will the right hon. Gentleman consider two points? First, if one of my constituents who is waiting for a hip operation decides to use the voucher scheme—to go to the BUPA hospital in Norwich, for example—she will free up an NHS place. It is as simple as that. Secondly, will he comment on the fact that a record number of people are having to go private to get their operations done in time?

Mr. Hutton

No, I very much doubt whether that would be the case. On costs, typically, the hon. Gentleman's constituent would have to find several thousand pounds from their own resources to fund that treatment, taking money directly from the NHS. Furthermore, it is very likely that the surgeon who treated the patient would also be an NHS surgeon.

David Taylor

Under Conservative policies, if people switched from the NHS to a private hospital, would it not be almost certain that NHS doctors and nurses would have to be sacked? Has my right hon. Friend made any estimate of the numbers that might be involved?

Mr. Hutton

We have estimated the cost of the patients passport as £1 billion. The hon. Member for South Cambridgeshire, who is keen to match our spending on the NHS, would clearly have to find that money from somewhere else. The truth about the patients passport is that the policy has not been thought through; it is fundamentally unfair and it will discriminate against ordinary NHS patients.

Helen Jones (Warrington, North) (Lab)

Does my right hon. Friend find it as odd as I do that in a debate in which the official Opposition have said how much they value NHS staff they are still promoting a policy that states that those NHS staff cannot deliver the kind of service they want? In fact, NHS staff have delivered, and are delivering, improvements because we have put in the resources. What would my right hon. Friend say to the students I met recently at the school of nursing and midwifery in Warrington, all of whom are enthusiastically waiting to go into jobs in the NHS, about the value that the Opposition put on them now?

Mr. Hutton

I think those student midwives have already made up their minds about the policy of the hon. Member for South Cambridgeshire and about what a Conservative Government would do to the national health service; they simply have to remember what the Conservatives did to the NHS when they were in office.

Mr. Andrew Turner (Isle of Wight) (Con)

The right hon. Gentleman did not answer—or rather he answered wrongly—my hon. Friend the Member for North-West Norfolk (Mr. Bellingham)—[Interruption.] The Minister answered my hon. Friend wrongly because he said that he did not believe that someone who goes private, and thereby ceases to be on the waiting list, was freeing up a space in the national health service. Can he explain how someone who has already had their hip operation privately could use the space?

Mr. Hutton

I want to return to the patients passport in a moment, and I am sure that the hon. Gentleman will be able to follow the logic of the case that I make.

The main thrust of the attack on the Government made by the hon. Member for South Cambridgeshire relates to recruitment and retention of NHS staff. I should like to tell him and his hon. Friends some of the facts that he failed to cover. When we came to office six years ago, investment in the NHS was being cut in real terms—it was falling. The NHS did not have enough front-line staff. As a result, waiting times were rising. The number of nurses in training, about which the hon. Gentleman has spoken eloquently, had been falling and was less than it had been in 1992. As a direct result, the NHS was short on both investment and capacity. It had failed to invest properly not only in the buildings, equipment and drugs that it needed, but in its staff as well. In the NHS, our staff are our most precious asset.

In 1997, the starting salary for a newly qualified nurse was £12,000, and NHS porters earned £7,000 a year—pitiful salaries, given the responsibilities of those staff. Training budgets were falling. There was no coherent or visible strategy for recruiting and retaining front-line NHS staff. Terms and conditions of employment, which the hon. Gentleman has also spoken about today, were antiquated and fragmented. There was only a handful of NHS staff nurseries. Pay awards from the pay review bodies—again, he referred to them—were implemented in stages, further diminishing the value of those pay rises to NHS staff. That was the legacy of the Conservative Administration.

Mr. Pike

My right hon. Friend may not know that, when I asked a question before the Conservatives lost office in 1997, they did not know how many GPs were due to retire in each area of the country, so they could not recruit and train enough GPs because they did not have the records in the system.

Mr. Hutton

I am not surprised; and we need to remember the Conservatives' legacy. The hon. Member for South Cambridgeshire has not presented any coherent case today. People are entitled to judge an Opposition not just on what they claim that their policies will do, but on their record in office as well. Undermined by his record in office, as he was today, he made his case with no conviction and no credibility. He has no serious alternative to the policies that we are pursuing.

Mrs. Gillian Shephard (South-West Norfolk) (Con)

The Minister has now begun to talk about recruitment and retention. My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) has said that he welcomes the increased number of nurses in the NHS, as indeed we all do. The Minister will accept, of course, that early intervention and public health are among the Government's priorities. Will he explain therefore what policy priority he and the Government put on the recruitment and retention of school nurses? Will also explain why one team in my constituency is working at 42 per cent. of its capacity? The reason cannot be the number of nurses, or recruitment or retention, because both are fine, according to the Minister, so what is it?

Mr. Hutton

I do not dispute for a second that it would be a good idea if more school nurses were working in the NHS and our schools. That is an excellent idea. My only difficulty with the right hon. Lady's suggestion—I have a lot of respect for her views—is that she has not fully understood the policies that the hon. Member for South Cambridgeshire has been outlining today.

Mrs. Shephard

Will the Minister give way?

Mr. Hutton

I will give way if the right hon. Lady will give me a second. In essence, she is asking to set a target or to quantify the extra number of school nurses that she wants. I am trying to say that we should like to see more school nurses working in the NHS, and the extra investment that we are putting into the NHS will help us to do so.

Mr. Lansley

Perhaps the Minister would care to explain something. If he turns to page 98 of the Department's annual report—I do not have it with me, but I remember it—he will see the number of episodes of care provided by a range of community services. He will see that the number of health visitor episodes of care was 3.6 million in 1997–98, and that that figure has gone down to 2.9 million in the latest year. The number of district nurse episodes of care has gone down from 2.2 million to 1.9 million. That is a 1 million reduction in the number of episodes of care provided in the community by health visitors and district nurses. The Minister talks about community nursing services, such as school nursing services, but they have declined over the past seven years.

Mr. Hutton

As I keep saying to the hon. Gentleman and the right hon. Member for South-West Norfolk (Mrs. Shephard), we are investing significantly more in primary care, and I shall come on to what that means. There has been a slight fall in the number of community district nurses, which is regrettable, but that has to be set alongside a significant increase in the total number of nurses working in primary care. Something like 750,000 more activities have been undertaken in primary care than was the case a few years ago, so we are seeing a shift from secondary to primary.

Mrs. Shephard

The Minister has explained that more nurses are in the work force. My question to him was this, and I hope that he can now answer it: are the falling numbers in the school nursing service a result of a lack of a policy priority placed on their services by his Government?

Mr. Hutton

That is not a reasonable conclusion to reach from the figures suggested by the right hon. Lady. If she is patient, some of the Government's policies and proposals will become clearer.

During the Conservative party's period in office, it is inescapable—this is the only conclusion that the vast majority of the people of this country would recognise—that the NHS was run down and neglected. It had been allowed to fall seriously behind compared with health care systems in Europe and around the world. The idea that the period between 1979 and 1997 somehow represented a high watermark in the history of the national health service is totally risible. That is not how people remember things. It is not how anyone who worked in the national health service during that time would recall those years. People have not forgotten what the Tories did to the NHS. That is why we need to keep the facts clearly in mind when we consider the criticisms that have been made of this Government's record on the NHS.

In short, the NHS had neither the investment it needed nor the political support it required from the previous, Conservative Government to have had any chance whatsoever of meeting the health care needs of the British people. It is for those reasons that this Labour Government have followed a different policy on the NHS. They cut investment in real terms; we are increasing it. They subsidised private health insurance; we put that money back into the NHS. They let waiting times rise; we are ensuring that they come down. They cut the number of nurses in training; we are increasing them at a faster rate than at any time in the history of the NHS. We are investing in new and improved terms and conditions for NHS staff; they did precisely the opposite.

In the past five years, 16 major new hospitals have been built and a further 10 are in the process of being built. In the last five years of the Conservative Government, they only managed to get two major new hospitals completed. At the same time, we have substantially improved more than 2,000 GP premises, and nearly 300 new primary care centres have been completed. That is because of the investment in the NHS, now rising at its fastest ever rate.

Spending will rise from £33 billion in 1997 to more than £58 billion this year. It will continue rising until 2008, when we will be spending £90 billion on our national health service. Real-terms spending in the NHS is increasing at very nearly three times the rate achieved under the previous Conservative Government. This extra investment has led to a 22 per cent. increase in the number of hospital operations and an 18 per cent. rise in the number of out-patient appointments. New drugs are becoming available more quickly. We have new services in primary care, such as NHS Direct and walk-in centres, treating and advising millions of people every year. The number of MRI scanners has doubled. CT scanners have increased by 60 per cent. We are doing hundreds of thousands more diagnostic tests every year. Most importantly of all, waiting times for an operation have halved. Twice as many people can now see their GP within two days as could in 1997.

Mr. John Baron (Billericay) (Con)

The Minister paints a rosy picture, and there is no denying that there have been some good improvements in the NHS, but he mentioned waiting times. Does he accept that despite the massive increase in expenditure, average waiting times during the past four years have risen from something like 90 days to 99 days, and those are the Department of Health's own figures?

Mr. Hutton

That is not the case. I shall write to the hon. Gentleman and set him straight on that.

Mr. Baron

I am afraid that it is the case, because those were the Department's own figures. Will the Minister address the issue and explain why average waiting times have risen—a fact admitted by Sir Nigel Crisp?

Mr. Hutton

Let me write to the hon. Gentleman and sort that out.

There is no doubt that waiting times are falling, not rising, as they did under the Conservatives. Death rates from cancer and coronary heart disease are falling more quickly here than in any other country in Europe. The new investment going into the NHS is making a huge difference, which the Opposition refuse to acknowledge for political reasons, as that simply would not happen under a Conservative Government. We are investing for the future as well. The NHS training budget has doubled since 1997, and it is money well spent. It has allowed us to increase the numbers of doctors in training by over 8,000. The hon. Member for South Cambridgeshire made a claim about the number of NHS consultants, and compared the increase in their numbers in the past five years with that in the last five years of the Conservative Government. We need to look at the totality of NHS doctors. In the last five years of the Tory Government there was a 12 per cent. increase in the number of NHS doctors. Since 1997, the number of NHS doctors has increased by 23 per cent.—double the rate under the previous Government.

Dr. Andrew Murrison (Westbury) (Con)

I would be grateful to know how the Minister defines a consultant, because the British Orthopaedic Trainees Association, which came to see me this morning, was concerned that his figures included nurse consultants and consultant podiatric surgeons, who are not medically qualified. To what extent do his figures include such practitioners?

Mr. Hutton

We do not include nurse consultants or podiatric surgeons in our definition of consultants because they are not medically qualified doctors.

We have increased the number of doctors in training by over 8,000. Places at medical school have increased by 60 per cent.—the largest increase since the NHS was established. Four new medical schools have opened since 1997. No new medical schools were opened in the entire period of the Conservative Administration. Since the extra places at medical school came on line in 1999, nearly 5,500 more students have entered medical school in England. The extra investment has allowed us to increase the numbers of GPs in training by two thirds. The number of nurses entering training has increased by more than 50 per cent. Training places for therapists have increased by nearly 70 per cent. The numbers entering training as radiographers have doubled since 1997.

David Taylor

Does the Minister share my dismay and astonishment at the attitude of the hon. Member for South Cambridgeshire (Mr. Lansley) towards the difficulty of filling vacancies for midwives and radiographers, as he did not offer any new commitments? Will midwives throughout the land not be disappointed by the delayed delivery of commitment to the NHS, and will not radiographers see right through him?

Mr. Hutton

I do not want to labour the point about midwives, but my hon. Friend has highlighted a fundamental conundrum at the heart of the policies set out by the hon. Member for South Cambridgeshire. I shall return to his policy of no new targets for the NHS when I conclude. The record that I have described on recruitment and retention is one that the Opposition simply cannot match.

Helen Jones

Does my right hon. Friend agree that when talking about NHS staff, in addition to doctors, nurses and associated therapists we should include the vast numbers of support staff, such as cleaners, health care assistants and porters, who offer the NHS a valuable service, whose chances at work have been vastly improved under this Government and whom the hon. Member for South Cambridgeshire (Mr. Lansley) failed even to mention?

Mr. Hutton

That is a telling point, as 0.25 million more people work for the NHS today than in 1997, and many of those jobs are in the support roles to which my hon. Friend referred. Not only are there more jobs, but a better training infrastructure is in place to support skills development, with individual learning accounts being properly invested in and supported by central Government for the first time.

We will know one thing for sure after today's debate. The Tories have no plans whatsoever for recruiting more doctors or nurses. We have set out our plans for recruiting more doctors and nurses up to 2008. What are their plans? They either do not have any—I suspect that that is the case—or they will not tell us. Why not? Do they plan to recruit more or fewer than we have set out? If they cannot answer any of these questions today, their attack on the Government's record can only be described as a mixture of pure opportunism and naked hypocrisy. The Opposition complain about staff shortages, but they have no plans whatever to address them. How utterly pathetic.

Despite the record increases in staff numbers and in staff training, it is still true that there are many skills shortages in parts of the NHS. There are several reasons for that. Some of the shortage is due to long-term historic under-investment, some of it is down to the fact that we are trying to expand our services and therefore our capacity as quickly as possible, and there is always a time lag between the investment that is made in training and staff development and that capacity becoming available to the NHS.

That is why we have recruited extra staff, particularly nursing staff, from other countries, but we have done so with a clear view of the importance of protecting the health care systems in developing countries. No other developed country has taken the steps that we have taken to ensure that international recruitment is conducted fairly and ethically. The code of conduct that we introduced in 2001 set out clear principles and priorities.

Only recruitment agencies that sign up to the code can be used by the NHS for international recruitment. More than 170 agencies have so far done so. When there is evidence that the code is not being complied with, we have taken action to remove those agencies from the approved list. The Department monitors compliance through data supplied by the international recruitment co-ordinators based in each strategic health authority. Two agencies have so far been removed from the list for non-compliance. I have arranged for a copy of the code to be placed in the Library.

We have sought Government-to-Government agreements on international recruitment with Indonesia, the Philippines, Spain and India. A separate agreement with South Africa was signed last year. That focused on creating opportunities for health care staff in both countries to undertake limited placements in each other's health care systems. I hope the first staff will begin their placements later this year.

We will recruit internationally only with the agreement of the host country, and we will always respect and act on its wishes. We have a clear view of which countries we will not recruit from. The list is based upon the Organisation for Economic Co-operation and Development development assistant committee's list of aid recipients and includes the vast majority of sub-Saharan countries.

The World Health Assembly recognised the importance of this issue at its recent meeting in Geneva. There is an increasingly global aspect to the issue. The challenge for us is to manage international recruitment sensibly and in a way that affords health care staff the opportunity to improve their own skills. That is precisely what we want to see. That is why I was particularly pleased that the World Health Organisation expressed its support for the agreement that we reached with South Africa as a model for other countries to follow.

The code of practice has been in place for nearly three years. This is a good time to review its operation. My right hon. Friend the Secretary of State announced recently that we were looking at every aspect of the code to see how we could improve its effectiveness. I will keep the House informed of the progress of that review.

Laura Moffatt (Crawley) (Lab)

Does my right hon. Friend accept that there have been even more benefits as a result of recruiting people to the NHS from other countries? It is right and proper to protect the health care systems of those nations, but the NHS has benefited from new experiences, new technologies and sharing those experiences. In my local group of hospitals, it has been a massively beneficial event, which we very much welcome.

Mr. Hutton

There is no doubt at all that overseas staff have made an immense contribution to the national health service for many years. I have seen many hospitals throughout the country, as I am sure other hon. Members have, where nurses from the Philippines, India and other countries continue to make a huge contribution. It is right and proper that we pay tribute to the work that they are doing.

Mr. Andrew Turner

rose—

Mr. Hutton

I have been generous in giving way and I am conscious that others want to speak. I want to make progress now.

I was speaking about international recruitment. My question to the hon. Member for South Cambridgeshire is: what would he have done instead? What did his party do in office to deal with the same issues? The answer is nothing at all. Here again, his attack on our actions has all the hallmarks of expediency, not principle.

The hon. Member for Billericay (Mr. Baron) says that we should direct NHS trusts to comply with the NHS code of practice. That was his view in a letter to The Times. How does that square with the policy of the hon. Member for South Cambridgeshire—that Ministers should stop telling NHS trusts what to do all the time?

Clive Efford (Eltham) (Lab)

Does my right hon. Friend agree that targets are a means by which the Government can set out where they intend to take the national health service? If the Opposition are not prepared to set targets, is that not an indication that they do not intend to deliver anything for the NHS except what we have seen in the past?

Mr. Hutton

My hon. Friend is absolutely right. I shall deal in my concluding remarks, which I hope are not too far away, with the place and role of targets in any sensibly managed public health care system.

I believe that there are some fundamental inconsistencies in what the Opposition have been saying which serve only to highlight once again just how threadbare their arguments are. We are enforcing the code sensibly and with the least possible bureaucracy. I think that that is the right way of proceeding.

Of course, it is one thing to recruit staff—and we have an excellent record to be proud of—but another to retain them. If we are going to succeed, we need to offer attractive terms and conditions for all our staff. We intend to do that. That is what the new contracts for GPs and consultants and "Agenda for Change" are all designed to do. It is what our investment in extra child care and nursery places for NHS staff will help secure, and what new part-time, school-time and flexible working arrangements are designed to support.

The new arrangements for primary care that have been agreed as part of the national negotiations are now being successfully implemented. These new arrangements recognise that delivering primary medical care to patients is not the sole responsibility of a general practitioner, but the responsibility of a group of clinicians working together to cater for what can be the somewhat complex and individual needs of patients. That is why this is a new practice-based contract covering all primary medical care contractors—GPs, nurses, other health professionals and practice managers.

Let me remind the House of the benefits that the new contractual arrangements will bring to our constituents. This is a something-for-something deal in which primary care professionals are rewarded for the outcomes that they achieve, and not just for how many patients they treat, as has been the case in the past, and there are extra rewards for providing a quality service. The new contract provides an unprecedented level of investment in primary care to improve services to patients and revitalise general practice. As a direct result, UK expenditure on primary care will rise from just £6 billion in 2002–03 to £8 billion by next year—an increase of more than 33 per cent.

Some 99.9 per cent. of existing GP contractors signed the new general medical services contracts offered to them by their local primary care trusts in April. All practices have been paid on time, too; again, that is in direct contrast with what happened when the Opposition introduced their changes to the old GP contract in 1990, when GP practices experienced serious delays in receiving accurate payments. Primary care trusts are currently in the process of agreeing new locally enhanced contracts with practices, to deliver additional new services for patients in their area. That is all underpinned by a new minimum guaranteed spending level.

On the consultant contract, we have invested substantial extra resources—some £250 million more by 2005–06—to reward the NHS consultants who do most for the NHS and to secure real changes in the way in which patient care is delivered. The new contract is designed to provide over time a 15 per cent. increase in consultants' lifetime career earnings while improving basic starting salaries and ultimately having a corresponding impact on the value of their pensions. The new contract also provides a stronger, unambiguous framework of new obligations, with more consistent and equitable recognition for on-call duties and more effective job planning, based on a partnership approach, enabling consultants and employers to prioritise work better and to address excessive workloads.

Following the outcome of the British Medical Association's ballot last year, NHS trusts have been reviewing the job plans of more than 20,000 consultants. That was always going to take time, but by the beginning of this month, four out of every five consultants who expressed an interest in the contract had received their final job plan offers. More than a third have now accepted work under the new contract. Progress to date has been slower than I would have preferred, but I expect the figures to improve significantly over the next few weeks.

We are also making good progress on "Agenda for Change". As of 11 June, more than 70 per cent. of staff in "early implementer" sites have been matched to their new pay bands and, on average, just under half of all staff in those sites have moved on to the new pay system. In some trusts, that figure is as high as 98 per cent. National roll-out will begin on 1 December 2004 with the collective agreement of the NHS trade unions. It was originally envisaged that that would start in October. The delay was made primarily to allow some unions extra time for their second ballots to take place.

We remain fully committed to implementation of "Agenda for Change". We are clear about one thing: all the union members who have already voted for "Agenda for Change" will receive the improved terms and conditions that will go with it from 1 October. That has never been an issue, and those members of staff will be unaffected by implementation, beginning in December.

The Government are investing £1 billion in the first year of the implementation of the new pay system. Under "Agenda for Change", a newly qualified nurse will earn a minimum of £18,114, putting nurses' salaries on a par with teachers' starting salaries for the first time, and a porter will earn at least £10,762—both figures have increased by just less than 50 per cent. compared with 1997. None of that would have happened under a Conservative Government, and we know that the potential service and staff benefits fully justify the investment.

For the first time, "Agenda for Change" will bring fair pay based on the important principle of equal pay for work of equal value, with appropriate rewards for those staff who take on additional duties and responsibilities. We are also working on measures to enable staff to work more flexibly. The NHS childcare strategy has provided central funding of more than £70 million to develop 140 new on-site nursery facilities, which will provide an extra 6,000 new nursery places for NHS staff.

The Health Care Commission will inspect all NHS trusts against progress in those areas, which is something that the hon. Member for South Cambridgeshire would stop. The hon. Member for South Cambridgeshire wills the ends, but never the means, and in the process, he panders to the interests of producers rather than championing the interests of patients, which is exactly the same place occupied by the Liberal Democrats—no change there, either.

The hon. Member for South Cambridgeshire said today that a Conservative Government would scrap all NHS targets. Maximum waiting times for NHS patients, which the Tories introduced, would be abolished under a new Conservative Government, who would also provide no guarantees on how long people wait in accident and emergency departments. A new Conservative Government would have no ambition to reduce death rates from cancer and coronary heart disease; they would not provide the right to see a GP within 48 hours; they would not specify minimum numbers of extra nurses and doctors; and they would not require new drugs to comply with National Institute for Clinical Excellence guidelines. What a total betrayal of the public interest! Conservative plans would provide not only no targets, but no accountability either. It would be the postcode lottery all over again, and the public will not wear it.

We are not claiming today that every problem in the NHS has been solved—it has not—nor do we say that the NHS cannot improve still further, because we know that it can. Our argument today is that the NHS needs a clear strategy of investment and reform. Investment will allow NHS capacity to grow, and reform will allow us to deliver our services more efficiently, with greater responsiveness to the needs of patients, and greater and equal choices for patients over when, where, and how they are treated. Those choices are based on need, and not on ability to pay.

The hon. Member for South Cambridgeshire cannot deliver either of those objectives, because he fundamentally misunderstands the nature of the challenges facing the NHS and the changes that are needed in order to respond to them. I invite all my hon. Friends to follow our course, and to treat the Opposition motion with the contempt that it deserves in the Lobby tonight.

6.18 pm

Mr. Paul Burstow (Sutton and Cheam) (LD)

This is a useful debate in which to explore staff recruitment and retention. The NHS certainly achieves successes every minute of every day—it saves lives every day, and it changes lives every day. We should place on record our appreciation of the dedication and deep knowledge of the staff, doctors, nurses and other health care professionals and managers, and treat them as one of the greatest, if not the greatest, asset that the NHS possesses. It is therefore right that we are debating the recruitment and retention of staff and the challenges that confront the NHS.

The debate is based on a motion tabled by the Conservative party. I have no particular problems with the motion, which is a statement of the blindingly obvious. It simply lists a series of concerns, many of which have been well rehearsed and are not subject to real debate. Understandably, the Government amendment sets out those aspects of the Government's record that they want to put in the shop window. However, it does not deal with the concerns about recruitment and retention, and I want to consider a few of those.

One of the ways in which we can gauge the state of play in recruitment and retention is by considering the amount that the NHS spends every year on agency staff. According to the latest figures, the NHS spends £4 million every day on agency staff; that is £1.46 billion a year. Every year since the Government came to power, the cost of agency staff has increased. My criticism of spending on agency staff is, therefore, that it is out of control. That is not only my view, but that of the Audit Commission in its report "Brief Encounters", which was produced a couple of years ago. The Audit Commission found that not only was it rare for trusts to take a strategic overview of their use of temporary staff, but there was significant under-reporting of expenditure on agency staff in the NHS.

Spending is poorly targeted and controlled and lacks strategic direction on questions such as the reason for the use of agency staff. Too often, they are recruited to fill gaps on a firefighting basis rather than as part of a sensible human resources strategy that is designed to provide greater flexibility for permanent staff as an aid to their retention and recruitment.

Sarah Teather (Brent, East) (LD)

rose—

Sandra Gidley (Romsey) (LD)

rose—

Mr. Burstow

I shall give way to my hon. Friend the Member for Brent, East (Sarah Teather) first.

Sarah Teather

Great minds think alike. Does my hon. Friend share my anxiety about the all-doctor three-month vacancy rate for the North West London strategic health authority, which is currently 4.6 per cent.—higher than the London average—and about the consequent cost implications for temporary staff cover?

Mr. Burstow

My hon. Friend makes an important point, which I want to develop. There are questions to be asked about the age profile of the work force, which will mean a further increase in the number of people who retire and thus in vacancies that need filling. I want to deal with that point later.

The Government's answer to the question about the way in which the NHS deals with the costs of agency nursing has been the introduction of NHS Professionals.

Sandra Gidley

My hon. Friend rightly raised the problem of agency staff, but I assume that he also knows that, although the Government trumpet the fact that they do not use staff from overseas in parts of the NHS, that does not apply to agency staff. High numbers are recruited from overseas and the purchasing agency appears to have no plans to deal with that. Would my hon. Friend like to comment on that?

Mr. Burstow

It is interesting that NHS Professionals, which currently provides a service in approximately one in every four NHS hospitals, can currently cover only 65 per cent. of requests for agency staff. Private agencies provide 25 per cent. of agency staff. It would be useful if the Minister could confirm in her winding-up speech whether the ethical recruitment codes apply to private agencies through NHS Direct. Clearly, that is a cause for concern.

It is surprising that, even with only one in four hospitals buying in to NHS Professionals, the body can meet only 65 per cent. of the demand for agency staff. The specialist press, especially for nursing staff, is regularly filled with concerns and complaints about the time it takes for people to get their payments. I understand that a report was commissioned to consider the establishing of NHS Professionals and the lessons to be learned from that. Will the Minister tell us today whether the report will see the light of day? Written parliamentary questions show that the Government have not been willing to publish their conclusions and findings from the experience of NHS Professionals.

Another measure of staffing pressures in the NHS is the increase in the use of overseas staff, which has already been mentioned. The number of overseas staff has increased from 2,281 in 1996 to 44,442 last year. Nurses constitute the lion's share of the overseas recruits. Currently, 8 per cent. of nurses in England, 28 per cent. of nurses in London and more than half the new entrants to the Nursing and Midwifery Council register are from overseas.

As Ministers know, I have raised concerns about overseas recruitment in Adjournment debates and through written questions for many years. I have expressed anxieties about both the ethics of overseas recruitment and the way in which some of those who come here to work in good faith, especially in the independent sector, are mercilessly exploited by their employers. Those concerns remain, and the Government's code of practice on overseas recruitment, although welcome, offers very little practical protection, particularly for staff outwith the NHS.

My concern is not just this country's reliance on the recruitment of overseas staff for the NHS; it is also the increasing number of home-grown staff who are opting to work overseas. The fact is that the health care work force is becoming increasingly globalised, and competition among industrialised countries for scarce resources is intensifying. We have already seen more than 8,000 nurses leave the UK to work abroad in a single year, and the number opting to work in the United States has more than doubled. Indeed, it has been estimated that the US has a shortfall of more than 1 million nursing staff, and it is coming to the UK and other industrialised countries to recruit nurses to take back to the United States.

My plea to the Government is that they should not rest on their laurels in regard to international recruitment. This matter requires concerted international action, partly of the kind that the Minister described earlier. Surely the Government should take the opportunity provided by their chairmanship of the G8 to propose an international code of good practice for health recruitment, so that we can not only set a good example but ensure that others follow it, especially those industrialised nations with the spending power to recruit not only from each other but from those countries that can least afford to let staff go.

Mr. Andrew Turner

I am interested to hear the hon. Gentleman's argument, in which he seems to equate the United Kingdom with a third-world country.

Mr. Burstow

That is pathetic.

Mr. Turner

Well, I thank the hon. Gentleman for that intervention. What is wrong with nursing staff from this country choosing to work in the United States?

Mr. Burstow

I fear that the hon. Gentleman was not really following my argument, which was that we are in a globalised, competitive environment, and we have to take due heed of that when we negotiate with our partners. We need to have arrangements in place to ensure that we are not withdrawing from recruiting overseas while others are still doing it. There needs to be internationalisation of the arrangements, rather than the UK simply doing this on its own. I certainly do not have a problem with people choosing to work elsewhere; that was not my point. However, if we do not address this issue beyond the domestic level, we shall have serious problems.

Mr. Lindsay Hoyle (Chorley) (Lab)

Does the hon. Gentleman have comparative salary figures for nurses and doctors in the United States, the UK and Europe?

Mr. Burstow

No, I do not have those figures immediately to hand, but if the hon. Gentleman would like them, I shall try to find out what they are. However, I am sure that a written question would be able to elicit the information from the Department of Health.

This increasing reliance on agency and overseas staff is likely to increase because of the demographics of much of the UK's health work force. Whether we are talking about nurses, doctors or other key health professional, there is—dare I say it—a demographic time bomb ticking away under the NHS. The fuse for that time bomb was set during the Conservatives' time in government, because they failed to provide the necessary training places and investment in staffing. However, the time bomb is still ticking away today. For example, one in five nurses is over t he age of 50—indeed, the Royal College of Nursing goes so far as to say that it is one in four—and a huge number of nurses are due to be lost through retirement over the next few years. The same applies to general practitioners. According to the Department of Health, at the last count there were 3,435 GP vacancies—an increase of 31 per cent. over the year before.

More telling than that is the fact that the number of applicants applying for each post has fallen in each of the last three years. In 2001, there were 6.9 applicants per vacancy, but that figure had more than halved to 3.3 by 2003. Things appear to be getting worse rather than better in terms of recruiting extra GPs, not least because of lifestyle choices resulting in more of them choosing to work part-time rather than full-time, although the Government record these figures only by head count, rather than by full-time equivalence

Mr. Hutton

The hon. Gentleman must know that he is wrong about that. We publish figures on both head counts and whole-time equivalence, and I am sure that he will want to correct that statement. My question to him on international recruitment is perhaps historical, but I think that it is important. When we had the election in 2001, his party was promising to recruit something like 4,000 more doctors a year than we were planning to. He has just lectured the House, in very polite terms, about the dangers of international recruitment, but can he tell us where those extra doctors would have come from, if not from international recruitment?

Mr. Burstow

I think that the Minister has misconstrued what I was saying about international recruitment, perhaps to make a political point. The point is surely that, when it comes to recruiting from overseas, there needs to be an ethical framework that is not only pursued by this country in making individual agreements with individual countries. It must be an arrangement that involves other countries as well. That is the context. I do not have a problem with a globalised market in terms of health care. But given that in the last year for which there are figures, 44,000 staff have come from overseas, that demonstrates the extent to which the NHS is reliant on those staff to provide health care in this country.

Several hon. Members

rose—

Mr. Burstow

I am spoilt for choice. I give way to my hon. Friend the Member for Somerton and Frome (Mr. Heath).

Mr. David Heath (Somerton and Frome) (LD)

My hon. Friend is being generous with his time. May I return to the point about general practitioners? I am a little alarmed to be told by long-established practices in my constituency that for the first time for many years, they are not having the opportunity to train new GPs in their practices this year, not because of any deficiencies in the training that they are providing, but because of funding at a higher level. Does he share my concern that at a time when we need new, young GPs, apparently, practices in Somerset that are willing to provide that sort of training in a perfect setting are not allowed to do so?

Mr. Burstow

Certainly, I share my hon. Friend's concern, and I am sure that the Minister will address it.

I want to address the issue of the demographics of the GP work force, because it causes concern to many Members on both sides of the House, and particularly to my hon. Friend the Member for Brent, East (Sarah Teather). The number of GPs who will meet the mandatory retirement age of 70 in the next few years is set to rise rapidly, particularly in London and the west midlands. Looking forward, two thirds of the 4,000 GPs who qualified in south Asian medical schools are due to retire by 2007. A lot of today's work force difficulties, however, must be seen as a legacy of the last Conservative Government. Poor work force planning, a reduction in training places, and cuts in staff left the NHS with chronic staff shortages. In 1983, the Conservatives recruited 37,000 nurses, but by 1995, that had dropped to 6,000. By the time that the Conservatives had left office, the figures that I have seen suggest that at least 51,000 fewer nurses were working in the NHS.

The legacy of staff shortages, however, was made worse by this Government's decision to stick to the Conservative spending plans for the first two years after coming into office in 1997. It was not until the NHS plan that a concerted effort was begun to tackle work force issues. Clearly, there is a long way to go to tackle the shortages that have been outlined so far in today's debate.

That brings me on to the issue of contracts, in relation to GPs, consultants and "Agenda for Change". Clearly, there is concern about slippage in the implementation of "Agenda for Change" among the work force, but the Minister's comments today are undoubtedly welcome. The implementation of the consultants contract, however, has stretched the capacity of personnel staff in the NHS to the limit. As has been mentioned, the British Medical Association survey earlier this month found that eight months after doctors had voted yes to the new contract, around a quarter of NHS hospital trusts had still not implemented the contract in full. The Minister has told us today that only a third of consultants currently work to the new contract. He has at least indicated some regret that progress has not been as rapid as it should have been. Clearly, it needs to be more rapid if we are to see the improvements that we all want in that respect. But we also need to raise concerns about capacity. One of the consequences of the new consultants contract is often that consultants work fewer sessions, which means less capacity in the NHS.

Taken together those contracts are welcome developments, and over time they should deliver significant improvement to the working lives of the staff and to the quality of care for patients. However, implementing all those changes during the same year, against a background of continuing staff shortages, runs the risk of reducing NHS capacity. When all those changes are combined with the impact of the working time directive, some serious risks are posed to the NHS in terms of its ability to deliver the Government's wider agenda on issues such as choice.

The Minister of State, the hon. Member for Doncaster, Central (Ms Winterton), who will respond to this debate, has responsibility for dentistry. I want to pose one quick question to her. When does she expect the work force review in relation to dentistry, which has been long awaited, to be published? It was commissioned back in July 2001, and given to the Government in the autumn last year. We are told that it will be coming shortly. How long is shortly? It would be useful to clarify that, not least because when the Commission for Health Improvement examined dentistry, it found that 26 per cent. of people have not seen an NHS dentist for more than two years, and 8 per cent. have never seen one. Half the population are not registered with a dentist. Staggeringly, there was a 70 per cent. increase in the number of people having to contact NHS Direct on dentistry matters between November 2001 and February 2002. When will that survey be published?

Public health is a very live issue today, and we expect a White Paper in the autumn. In March this year, the Faculty of Public Health Medicine published a report on the specialist public health work force, which made sorry reading. It warned: There is strong evidence to suggest that the current numbers of consultants and specialists in public health, health protection and academic public health in the UK are insufficient for the work that is required. It went on to point out that deficiencies in staff numbers had been known since the national survey of communicable disease function undertaken by the NHS executive in 1997, but that important deficiencies have not generally been rectified despite the addition of significant new responsibilities to these consultants. Just when will the Government come forward with a work force plan to ensure that that part of the work force is increased? Do they agree with the faculty's figure of a need for a 40 per cent. increase in the consultant work force in that field?

Just recruiting more staff to meet ever-increasing demands on the NHS is not a sustainable policy. As Derek Wanless found in his first report on health funding, if the NHS continues much as it is at present, it will cost an extra £30 billion a year to provide health care by 2020. There is a need to tackle the causes of ill health, both through preventing and postponing the onset of disease and through better controlling the spread of infection.

I shall not rehearse the need to tackle health-care acquired infections, an issue that we debated yesterday in some detail under the Health Protection Agency Bill.

Jonathan Shaw

Will the hon. Gentleman tell the House what his policies are? He is just giving us a commentary on the issues that the NHS faces. What are his solutions to the problems that he has set out?

Mr. Burstow

I am speaking to the terms of the motion. The hon. Gentleman should read the motion, tabled in the name of the Leader of the official Opposition, which is simply a list of the problems. I am not going to give the hon. Gentleman what he wants today, but I am more than happy to debate Liberal Democrat health policies in Government time.

On infections, the National Audit Office has said that 100,000 people every year pick up infections while in hospital. Research by the Public Health Laboratory Service has found that patients with health-care acquired infections stay in hospital on average 2.9 times longer—about 14 days extra—than those who do not pick up infections. That implies that about 1.4 million bed days are lost every year as a direct consequence of infections picked up in the NHS, which is the equivalent of seven and a half average-sized district hospitals. The potential capacity gain for the NHS from tackling issues of infection, and really bearing down on that problem, would be huge.

Work force issues are and will remain a critical factor in the NHS's ability to deliver. There are many issues still to be tackled in developing a work force strategy in this country, but what is clear, if not perhaps to every Member present today, is that we as a House must continue to applaud, reward, recognise and value the staff of the national health service as its greatest asset. Today's debate is not about Liberal Democrat policy but about the Government's record. That record is not as good as the Minister and the Government would like us to believe, and we have outlined why that is. When the elections come, we will demonstrate why this Government's record does not justify their being returned to office.

6.39 pm

Mr. David Hinchliffe (Wakefield) (Lab)

The hon. Member for South Cambridgeshire (Mr. Lansley) has had to leave the Chamber for a moment, for which he has apologised. I want to wish him well, in his absence, in his new role. He has a good command of health policy, and I am sure that our debates will be assisted by his contributions. Having said that, I think that his contribution today was somewhat thin, to put it mildly—about as thin as the Tory Benches have been during a Tory debate. There are just two Tory Back Benchers in their places at the moment, which raises serious questions about the Conservatives' commitment to health policy. They cannot drum up more support than that, yet it is their own Opposition debate.

I have always believed that effective opposition, whether at the national or local level, will bring about better government. However, this Parliament has lacked an effective Opposition. What worries me particularly about the Opposition's focus is that their attention on policy issues has tended to skew us away from what I believe are the real issues on health policy. A good example was the first Opposition debate this year, which was on care of the elderly. The Conservatives skewed the entire debate by concentrating on the number of people in care homes, failing to debate prevention, how to assist people or measures to help people to retain their independence in the community. It was basically the Tory party being led a dance by nursing home and care home owners—and the Conservatives danced well to their tune.

Today's debate, following the Tory motion, portrays health as an essentially curative process. We are talking about the response to illness and about cures. We are bogged down with the institution of the hospital, just as we were bogged down in the earlier debate with the institution of the care home. I really think that we need to question the focus of the Opposition's concerns about health care.

We are not talking today about the fundamentally important health issues, although they were touched on by the hon. Member for Sutton and Cheam (Mr. Burstow)—by that I mean the preventive agenda, which is about helping people to avoid being in hospital in the first place. The NHS Confederation said this week that one in 10 people who are in hospital do not need to be in hospital—and I believe that that is a gross underestimate. A consultant I spoke to recently told me that one in three people did not need to be in hospital, so let us examine why that is the case. It is sad that our debate has not touched on that crucial issue. The Opposition's frame of debate distracts us from addressing the crucial issues of health policy at the present time.

Turning specifically to the motion, the Opposition are, frankly, daft in trying to censure the Government over staff shortages. For anyone seriously looking into health policy, that really does not wear. The present Government have probably done more than any other in the history of the NHS to try to deal with staff shortages and they should be commended rather than criticised for their efforts during their seven years in power. The Government deserve praise for their initiatives on recruitment, which have been set out by the Minister of State, Department of Health, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton). The efforts of the Government have also brought about investment in training and they are attempting to establish a family-friendly NHS environment. My right hon. Friend spoke about 6,000 nursery places. That is important for getting people, particularly nursing staff, back into the health service when they have left to have children.

David Taylor

My hon. Friend is focusing on family-friendly policies and the attitudes of hospitals as employers towards human resource issues. Does he agree that, as these policies start to bed in and become more widely known, many returning nurses will return direct to the NHS work force rather than, as some do now, choosing to work for agencies on account of their more flexible employment policies? That will be good for continuity and good for economics.

Mr. Hinchliffe

Yes, I believe that that is the case. It will be a long, slow process, but we are heading in the right direction.

We should do more to care for our NHS staff and seek to improve the environment in which they work. About six months ago, I spent one night—a Saturday night and Sunday morning—with my daughter in a casualty unit in my constituency, and I saw the pressures placed on nursing and medical staff. It really opened my eyes to the pressures that they are under and I think that we need to address those pressures. I saw how members of the public who ought to know better could abuse our health service staff.

The motion talks about the role of staff in high-quality health care. The Government are guilty of failing to emphasise the progress that has been made on quality of care. The hon. Member for South Cambridgeshire talked about numbers of finished consultant episodes, the normal measurement that is used, and he said that the number of FCEs did not reflect the amount of investment that had been made.

However, the Opposition very rarely mention one factor—the improvements that have been made in the quality of care offered by the NHS. The Government deserve great credit for the measures that they have taken to address in detail some of the problems that used to exist. For instance, the introduction of clinical governance has made a big difference to the operation of the NHS. The Commission for Healthcare Audit and Inspection, which replaced the Commission for Health Improvement, has done a lot of work on quality at local level, and that has made a big difference nationwide. Again, professional validation seems like common sense, but the Government deserve credit for ensuring that people's skills are checked and updated.

The Opposition's motion talks about bureaucracy and red tape. One assumes that that very easy criticism is aimed at organisations such as the Commission for Healthcare Audit and Inspection, or at the measures and mechanisms introduced to cover the important question of quality.

I disagree fundamentally with the Tory motion, but I have a few personal anxieties that I want to express about the direction of certain Government health policies. I begin with the question of central directives to the NHS. I said earlier that the debate had a curative approach and, all too often, central directives reflect a curative, hospital-based approach to health. That needs to be examined when the direction and targets set for the NHS by the Government are reviewed.

Occasionally, the central directives can also be seen to constitute a market-style approach to health. I am genuinely concerned about the consensus in respect of choice that has developed among the three main parties in this Chamber. Where will that concept take us? We are all for choice—of course we are—but we need to discuss in detail what the word really means.

Who is pushing for choice in the NHS? I get hundreds of letters about the service from all over the country, but I do not recall one that asked about choice. People write to ask about all sorts of things, and to tell me that they want their local service to give them what they need, near where they live. However, they do not go on about choice. Where does the concept of choice come from? I should be interested to get to the bottom of that.

Also, are we prepared for the consequences of choice? We know about the impact of choice on education, and about what is commonly called middle-class flight from schools. People with inner-city schools in their constituency will know that choice has meant that middle-class people move out and shift their children to schools in the leafy suburbs. Are we prepared for the same thing happening in the NHS? There is no doubt that it will happen, and the consequence that it will have for the NHS needs to be thought through.

What is the consequence for the wider health care agenda of concentrating on choice? I must tell my hon. Friends on the Front Bench that, if we are not careful, we are in danger of making again the mistake that the Tories made—that is, we will create a public perception of health that is all hospitals, treatments and cures but which has nothing to say about prevention.

Mrs. Patsy Calton (Cheadle) (LD)

Is not real choice a matter of getting timely diagnosis and treatment for people near where they live, and not about chasing all over the country after the best surgeon? Not everyone can go to the best surgeon, although some would like to be able to buy their way into doing so. We need good, local treatment that is available when needed.

Mr. Hinchliffe

I agree with the hon. Lady. I think that the Government probably agree with the point that she has made. On the choice issue, when we discuss Tory policy we often get down to the idea that somehow a person choosing to go private assists the NHS. The Tories do not seem to understand that the doctors treating people in the private sector are the same ones treating people in the NHS. They are not some magic, additional number of consultants. People say, "We are helping the health service by going private." What a load of tripe. What a load of nonsense. Of course they are not. They are damaging the health service by giving consultants the continuing incentive to treat people privately. We have to get those consultants back working in the health service. It is the big issue that has not been addressed by successive Governments since 1948. This Government have tried, and I wish them success in it. It is the key to solving so many of the problems.

David Taylor

Will my hon. Friend give way?

Mr. Hinchliffe

I will not give way because I know that colleagues want to contribute.

One of the things that I have learned from looking at some of the central directives is that they can be crude and simplistic and can have unintended consequences. I shall give just one example in the time that I have—waiting list targets. We come back to the activities of certain consultants. I know for a fact that some consultants wait until their waiting list levels reach a stage at which the trust will be penalised and then say to the trust managers, "Look, with certain patients you are going to be penalised. You might have your star rating affected." The patients on the waiting list end up being put into the consultant's session on a Saturday morning at a hugely increased cost to the NHS. That has happened in many parts of the country, and the Government should look into the way in which targets are skewing our approach and being exploited.

The concordat with the private sector was a fundamental error. We know that each item costs 43 per cent. more than we would have paid within the NHS. Okay, some people have gained from that. They have obtained earlier access to treatment. Some of my constituents have done so, but we have not addressed the reason why they had to wait all that time. The reason is frequently because the consultants were not on the golf course but doing private work instead of meeting clinical priorities within the NHS.

Mr. Hoyle

Will my hon. Friend give way?

Mr. Hinchliffe

I will not give way. I apologise to my hon. Friend.

The Tory motion exposes a worrying narrow view of health care, which the Government should not follow. It is a curative approach. It does not address the real issues in health.

I have spent the past year on the Health Committee investigating sexual health—some of those problems really do need to be addressed—and obesity. The message that one gets big style when one looks into public health issues is that the Tories made a fundamental error way back in the 1970s by castrating public health. In 1974 they got rid of the medical officers of health. Between 1979 and 1997 they cast aside public health. That is the real agenda.

In his conclusion the hon. Member for South Cambridgeshire talked about setting the NHS free. We have set it free from the legacy of 1979. The consequences are still having to be addressed by this Government, who have been in power for seven years. God forbid that we ever get the Conservatives back in power, setting free the NHS and letting the market rip, as happened in the 1980s and early 1990s.

6.54 pm

Mr. Andrew Turner (Isle of Wight) (Con)

It is a great pleasure to follow the hon. Member for Wakefield—yes, Wakefield.

Mr. Hinchliffe

Somewhere in Yorkshire.

Mr. Turner

Yes, somewhere in Yorkshire. It is a great pleasure to follow the hon. Member for Wakefield (Mr. Hinchliffe). I do not intend to go far down the road that he explored, but I was interested in his suggestion that family-friendly policies were a priority in the NHS when it is only since the introduction of the new GP contract that none of my GP practices is open on a Saturday morning.

I wish to pursue a number of issues briefly, and the first is the question of shortages. My hon. Friends have spoken of the shortages of doctors, consultants and nurses and the need to recruit from overseas to provide an adequate supply. I refer the Minister, the hon. Member for Doncaster, Central (Ms Winterton), to the shortage of dentists in my constituency. She is familiar with that situation, having kindly visited the Denbigh House practice in my constituency on 3 March this year. I remember that she said at the time that a review would take place of the provision of dentists, because the number of NHS dentists on the island had declined significantly. I congratulate her on being the first Minister to say that access to NHS dental provision should be available on the island and that my constituents should not have to travel to the mainland for that purpose.

Sandra Gidley

The hon. Gentleman mentions travelling to the mainland to find an NHS dentist, but they are similarly rare in Hampshire. When found, they often provide care for children only on condition that the parents register privately with them.

Mr. Turner

I am indeed aware of that, because I read in the Southern Daily Echo recently that my hon. Friend the Member for New Forest, West (Mr. Swayne) was concerned about the shortage of dentists. I also know that constituents have been referred to a dentist in Southsea by NHS Direct and have travelled there to be told that their children will only be treated if the parents sign up for private dental treatment. The issue of dental provision is a serious weakness in the Government's strategy.

The chief executive of the local primary care trust wrote to me on 14 June to say that he had expected the recommendations of the Government's review to be available to the PCT by mid-May so that we could begin to make progress. [Interruption.] I know that the Minister finds her colleague more interesting than me, but the chief executive also says that we have been advised by the Department of Health that the report is taking longer than was originally anticipated … We have not, as yet, been informed of the date this will be to hand. I accept that the Minister has good intentions, but the number of NHS dentists in my constituents and in Hampshire has rapidly declined, and my constituents are suffering. I hope that in her reply she will bring up to date the remarks that she so kindly made on 3 March.

Clive Efford

The hon. Gentleman seems to want a target for the number of NHS dentists. Would he care to comment on the remarks earlier by the hon. Member for South Cambridgeshire (Mr. Lansley)? Does he expect that at the next election the Conservative party will publish a target by which their success in improving access to NHS dentistry would be measured?

Mr. Turner

The answer is simple. The Minister is charged with delivering a promise that the Prime Minister made in 2001 that within two years everyone should have access to an NHS dentist. It was the Prime Minister's target, but the Government have failed to deliver. My hon. Friend the Member for South Cambridgeshire (Mr. Lansley) explained our position on targets amply and adequately, and I do not intend to go further down that road.

Clive Efford

Will the hon. Gentleman give way?

Mr. Turner

I am sorry, but I do not have time to give way again.

The second point to which I would like the Minister to respond is that raised by my hon. Friend the Member for Westbury (Dr. Murrison) in European Standing Committee C on 24 March. My hon. Friend referred to the effect of the European working time directive on the number of consultants required in small hospitals—

It being Seven o'clock, the debate stood adjourned.