§ Order for Second Reading read.
§ [Relevant documents: Eighth Report from the Social Services Committee, Session 1988–89, Resourcing the National Health Service: the Government's plans for the future of the National Health Service, (House of Commons Paper No. 214-III, 1988–89), the Government's reply to that Report (Cm. 851), the Second Report from the Social Services Committee, Session 1984–85, "Community Care with special reference to adult mentally ill and mentally handicapped people" (House of Commons Paper No. 13-I 1984–85), the Government's reply to that Report (Cmnd. 9674), "Community Care: Agenda for Action" (1988 HMSO), and the White Paper "Caring for People: Community Care in the next decade and beyond" (Cm. 849 )]
§ Mr. Speaker
Before I call upon the Secretary of State, I must tell the House that the instruction in the name of the hon. Member for Birkenhead (Mr. Field) and other hon. Members is not in order. However, it will be in order to advocate the specific grants referred to in the instruction in the course of the debate.
There is great demand to speak in this debate and on Monday, so I propose to limit speeches to 10 minutes this evening between 7 o'clock and 9 o'clock.
§ Miss Ann Widdecombe (Maidstone)
On a point of order, Mr. Speaker. In addition to the instruction on the Order Paper to which you have referred, there is also a motion in the name of the hon. Member for Birkenhead (Mr. Field) and other hon. Members. My name appears as a signatory to that motion. I am not a signatory to that motion. I do not in any way approve of it, and I would ask you to rule it to be invalid because the House has been misled.
§ Mr. Speaker
Order. Let me deal with one thing at a time. I understand that the hon. Lady's name was included with a number of others when the motion was handed in to the Table Office. It was accepted in good faith, but if it was included by mistake, I shall have the matter looked into.
§ Mr. Gerry Hayes (Harlow)
Further to that point of order, Mr. Speaker. I am a member of the Select Committee on Social Services and I was present at the meeting when the decision was made. I support what my hon. Friend the Member for Maidstone (Miss Widdecombe) said. There was no malice or dishonesty on the part of the Select Committee, but it may be a matter for the Select Committee on Procedure to consider. It cannot be right for hon. Members to have their names included because a course of action has been decided upon. I was able to have my name removed yesterday because I could prove that it should not have been included, but because my hon. Friend could not be present, she was unable to do so. That cannot be a satisfactory practice.
§ Mr. Speaker
If the point of order refers to the same matter, I will take it, but it will delay matters.
§ Mr. Sumberg
Further to that point of order, Mr. Speaker. This is a serious matter for my hon. Friend the Member for Maidstone (Miss Widdecombe). She is an assiduous Member of the House and attends regularly, but if she had not seen today's Order Paper she would have been put in an embarrassing position. Will you look at this serious matter to prevent it happening again?
§ Mr. Speaker
This has been going on for many years. When the motion was submitted by the hon. Member for Birkenhead (Mr. Field) it included the names now on the Order Paper. The disagreement should be taken up with the hon. Gentleman, not with the Table Office, which accepted it in good faith.
§ Mr. Dennis Skinner (Bolsover)
Further to that point of order, Mr. Speaker. I think that I have got to the bottom of this. Select Committees tend to be consensus-minded and there is a tendency for whoever is in charge to say, "Well, I will stick all the names in because we agree on everything else." The nods and the winks took place, all the names went down and then the Tory Members, realising that they would embarrass the Government, tried to run away from their responsibilities. That is the top and bottom of it. One had the nous to get his name off in time and the other did not turn up to get it off.
§ The Secretary of State for Health (Mr. Kenneth Clarke)
I beg to move, That the Bill be now read a Second time.
This debate is an important stage in the bold reforms of the National Health Service on which the Government have embarked. Those reforms were inspired by a vision of what a good public service ought to be like in the 1990s, and I believe that when we pass the Bill we shall indeed have produced a better Health Service for the next generation.
There is, I think, a broad measure of agreement between us, and certainly among the public, about the kind of NHS that we want for the 1990s. Such a service should, in our view, be based on the fundamental principle—adhered to by all parties in the House—that free medical treatment should be provided regardless of means and financed largely by general taxation. The service should be well funded, which is why we have been putting such substantial additional resources into it: the two most recent public spending round settlements have increased the cash available to it by more than 20 per cent., or over £5 billion. At the same time, it is important for a modern public service to be efficient, and to avoid waste wherever that is practicable. No one can really be committed to a caring service without being committed also to raising efficiency levels whenever possible.
We believe that the service should be well led locally by people who are respected in their own communities—and led in a way that enables people to make clear decisions about priorities that reflect the wishes and choices of the local population. We want staff to be well motivated, knowing what their respective clinical units are expected to deliver to the NHS and what resources are available for the 490 purpose. Much of the low morale of recent years has arisen because many staff are frustrated by the muddle that often features in NHS decision-making and objectives.
Above all, we want a service that will be responsive to the patients that it serves, delivering high-quality, caring and friendly personal service.
I trust that we all hope and believe that we can create that kind of first-class public service by building on the foundations of our present National Health Service. Nevertheless, we believe that there is much room for improvement in the way in which the service is run, and in the quality of the care that it delivers. We all respect the NHS as one of the great British institutions—indeed, we probably all love it for being an old, traditional, national institution—but, if it is to remain a great public service in the forefront of the world's health care systems, we must raise standards everywhere to the highest level; and we must be prepared to contemplate change when that change is for the better. Certainly, when we are devoting ever more huge sums of public money to the service, we have a duty to ensure that that money is spent in the most effective way possible.
All hon. Members are constantly reminded by their constituents of the highest-quality care that is often—indeed, usually—received by patients seeking treatment of all kinds. We need not look far, however, to see wide variations in performance between different parts of the service, leading to equally wide variations in the quality of care that patients can expect. I sometimes think that patients do not complain enough about the chance factors that can determine whether the locality in which they live can provide a good standard of family practitioner service, for instance. Such services are much better in the prosperous rural and suburban parts of the country than in many of our poorer inner-city areas.
Patients also tolerate variations in the times for which they must wait for treatment, and in the standards of care or even facilities available in different areas. Most people are familiar with the variations in the effectiveness of prescribing practice, and in the extent to which it is prudent and careful, avoiding waste of money or even risk to patients. I have already mentioned in previous speeches the 2.5 tonnes of drugs that were handed in in Yorkshire during our three-week campaign, and 1 million tablets were handed in in the space of two weeks in the counties of Avon and Somerset. My private office was recently sent 22 vials of a drug costing £9.50 per vial, which had been returned to a pharmacist in Newton-le-Willows. They had been prescribed on a twice-monthly basis, but the patient had not got around to taking the drug or opening the vials.
Prescribing costs vary considerably. One practice with a list of 7,000 patients, only an average proportion of whom are elderly, is currently spending about £800,000 a year on drugs: that is 185 per cent. above the average for its family practitioner committee area. The phrase "above the average" is a little misleading. That practice is so out of line with all its neighbours that every other practice in the family practitioner committee is at least 5 per cent. below the average for the FPC because that practice is spending so much more than the others.
§ Mr. Gareth Wardell (Gower)
Is it not important that drugs that are prescribed for elderly people in particular should be taken? Drugs that are prescribed are often not taken because there is no adequate supervision at home.
§ Mr. Clarke
I accept that there is a wide variety of reasons for drugs not being taken. There are repeat prescriptions for many patients who have not seen their doctor for a long time. Drugs can be prescribed automatically and the doctor does not know whether the patient is taking them. No one should defend the wasteful prescription of drugs. The National Health Service needs to introduce effective methods to ensure that variations in the prescription of drugs do not occur.
§ Mr. Nicholas Winterton (Macclesfield)
Will my right hon. and learned Friend give way on that point?
§ Mr. Clarke
No. I shall return to prescribing costs when I deal with indicative drug budgets.
There are also wide variations in the performance of the hospital services. That is most apparent in the time that people have to wait for particular services. It is all too easy with waiting times, as with everything else, to put it all down to lack of money. For years and years the Opposition and far too many people in the National Health Service have said that whenever there is a variation in performance it is due to lack of resources. Variations in performance can never be attributable to resources. Variations reflect local efficiency and effectiveness in making the maximum use of all the resources, including cash, at their disposal.
There is a variation in performance when one considers theatre sessions cancelled in different district health authorities. The worst districts cancel one in six theatre sessions. The best districts cancel only 1.3 per cent. of their theatre sessions—in other words, one in 77 theatre sessions. Far more work is done in a district where only one in 77 of the theatre sessions is cancelled than in another district where the performance is so poor that one in six of the theatre sessions has to be cancelled.
To give similar statistics about the number of operations per scheduled session, in the worst 10 per cent. of districts, according to the best measure of performance that we have, the average is 3.29 cases per session. In the best 10 per cent. of districts, there are 5.19 cases per session. In the best districts, therefore, half as much again is done per session compared with the worst 10 per cent. In a statement that was issued in the summer, the previous Minister for Health said that, if all our districts could raise the efficiency of their management of theatre sessions and waiting lists to the level of the best, we should be very near to eliminating most of the waiting time.
§ Mr. Graham Allen (Nottingham, North)
The Secretary of State will be aware that quite recently the Public Accounts Committee closely examined operating theatre use. The Committee found that operating theatres are used as a financial regulator by local hospitals and that, were they to be run at full efficiency, they would come up against financial constraints that the Secretary of State has imposed.
§ Mr. Clarke
If the PAC said that—I think that was a bit of a paraphrase—I do not agree with all of it. I agree that one of the weaknesses of the present system is that if an efficient district increases its throughput of patients and raises its work load it finds, in the unreformed National Health Service, that it comes up against financial constraints. The districts that do not increase their 492 throughput do not get into such difficulties. It is no good saying that the only reason for variations is lack of resources.
To take the Sheffield district health authority as an example, great variations are to be found in different parts of the service. There are some examples of excellence, but there are others where a great deal could be done to improve the service.
Let us consider what is good about the Health Service in Sheffield. The authority has a new department to give stereotactic radio surgery at Weston Park hospital. It is an advanced form of radiotherapy, which makes the hospital a world leader. Heart transplantations are about to start at the Northern General hospital from 1 April next year. There is a lithotripter at the Royal Hallamshire hospital, which is at the forefront of treatment for gallstones, and clinical services for patients with diabetes there are amongst the best in the country. Pioneering work is being done. The spinal injuries unit in Sheffield is one of the two biggest centres in Britain. However, Sheffield combines those good points with the huge waiting list for trauma and orthopaedic surgery and one of the longest waiting lists for routine orthopaedic surgery in the country.
In the course of the waiting list initiative, we are subjecting such districts to studies. We have studied 22 with the longest waiting lists. The main cause for long waiting lists that emerged in Sheffield was the under-use of theatre sessions and the low level of work by surgeons in relation to a high level of surgical manpower—higher levels than those in 80 per cent. of other district health authorities.
Even though the Sheffield district has teaching responsibilities, there are few provincial teaching authorities with such consistently low output per surgeon and per theatre. It has low activity per surgeon and a lower number of cases per theatre session than one would expect, with huge variations between individual surgeons. Other districts had a better case for resources from the waiting lists initiative when we were deciding how to put the money to best effect to increase the number of cases treated.
In Sheffield we have had co-operation, and an agreement to tackle the management and work load problems, and given some extra money to set new work load targets, to increase the throughput and to improve waiting list management.
All that can be done when the cause of deficiencies is tackled and when the argument that they are all due to the Government's underfunding of the Health Service is not simply accepted, and when the co-operation of local doctors is forthcoming. As the hon. Member for Nottingham, North (Mr. Allen) pointed out, further reforms are needed because we have to ensure that money is distributed in the service so that, when the work load increases, patients can be dealt with more effectively, GPs will be attracted to refer more patients to a unit and the resources will be there to back up that improved performance.
At the moment, efficiency tends to be penalised due to the way in which the Health Service is run. In the future, we will ensure that those authorities that are efficient or that raise their efficiency thrive by attracting more work.
§ Dame Elaine Kellett-Bowman (Lancaster)
My right hon. and learned Friend must be aware that a very expensive lithotripter was installed at Withington hospital 493 to serve the whole of the north-west two years ago—it cost almost £1 million. In the first year it was allowed 400 cases fully funded, but unfortunately Withington hospital has now run out of its budget and has done 400. It is trying to persuade hospitals like mine to pay £500 to take people there to have their gallstones removed. The alternative is to have to spend between seven and 10 days in hospital for an operation. Can my right hon. and learned Friend persuade the regional health authority to fund more of those operations to remove gallstones?
§ Mr. Clarke
A lithotripter lends itself to doctors arranging to have a given quantity of work done for their patients, because they believe that that method of treating gallstones is preferable to intervention by surgery and they can give the resources to the particular unit that they want to deliver the service. At the moment, because we do not have the ability to enter into contracts that the Bill will give the Health Service, my hon. Friend is reduced to lobbying the regional health authority and, in Withington, great confusion occurs about where money is going, and how much it may be able to divert into the lithotripter.
When the Bill becomes law, we will have clearer, better ways to organise the distribution of money—for example, in this case to the Lancaster district health authority, if it wishes to use its resources to provide a particular system of care.
So far, I have described the objectives for the Health Service and the problems that need to be tackled. We seem to be a long way from the attitude in many of the debates in which I took part in the summer, and a long way away from the initial reaction from too many people in the National Health Service. I shall not go back over that old ground, because the atmosphere seems to be improving. Unfortunately, there have been attempts to frighten patients by inventing a series of claims that had nothing to do with the White Paper, the Bill or any of the reforms that someone like me, who is committed to the National Health Service, is likely to put forward. I have been accused of sending people 60 miles to hospitals that they do not want to go to. People have said that doctors are running out of money that they need for drugs. The other day, it was hinted that expectant mothers may lose local obstetric services because of our proposals. That is nonsense. No right hon. or hon. Member would suggest any of that rubbish.
Now that the proposals are being discussed on the Floor of the House, and we have left the posters and the postcards behind, we can move to a serious discussion of what the reforms are about. The hon. Member for Livingston (Mr. Cook) promised me hundreds of thousands of postcards but he could find only 50,000—obviously membership of the Labour party is falling to a greater degree than even I would have expected. Now the debate will have to move from fantasy to reality.
§ Mr. Rhodri Morgan (Cardiff, West)
The Secretary of State says that we have been spreading scare stories about the problem of patients going 60 miles to hospitals that they do not want to go to. If he confers with the right hon. Member for Worcester (Mr. Walker), he will find out that a hospital in my constituency has been working on a proposal since 1 December that will involve patients being sent 160 miles for surgery. Previously they would have had surgery at a local hospital. Will the Secretary of State tell his colleague that it is not a scare story, but reality? The 494 same thing could happen in several other hospitals in Wales, and instead of people being able to have surgery locally, they will be taken long distances.
§ Mr. Clarke
There will be Welsh wind-up speeches tonight, and hon. Members from both sides of the House will have an opportunity to comment on that, so I shall not intervene in the affairs of South Glamorgan. The Health Service in Wales has benefited from expansion and increased expenditure that at least matches that in England, for which I am responsible.
Of course, people may choose to travel some distance for better service. That possibility will be more available in the future. It is not true that the White Paper reforms will lead to people having to go miles down the road to have cheaper services.
§ Mr. Tony Marlow (Northampton, North)
On a point of order, Mr. Deputy Speaker. It could be argued that this is the most important Bill of the Session. So far, a series of hon. Members have got up and abused the procedures of the House, because it is stuffed full of television cameras, by raising constituency points. I wonder whether you could help the House to keep to issues of principle rather than allow pettifogging matters, aimed at gaining support from constituents, to be raised.
§ Mr. Clarke
The hon. Member for Alyn and Deeside (Mr. Jones) is winding up tonight on behalf of the Opposition. Some hon. Members wish to intervene about South Glamorgan. I am not responsible for that. My right hon. Friend the Secretary of State for Wales is responsible for South Glamorgan, which is an extremely successful district health authority.
§ Mr. Clarke
With the greatest respect, I would not normally refuse to give way to the hon. Gentleman but I cannot be expected to diverge into discussions about the work of a health authority for which I have no departmental responsibility. When my hon. Friend the Under-Secretary of State for Wales replies, I am sure that he will be delighted to talk about the arrangements for care there.
§ Mr. Robert Hughes (Aberdeen, North)
On a point of order, Mr. Deputy Speaker. Is it not intolerable that the Secretary of State should spend two thirds of his speech so far dealing with detailed matters in specific health authorities, but refuses to give way to Opposition Members who wish to raise issues relevant to other specific health authorities?
§ Mr. Clarke
I quoted the example of Sheffield, with which nobody quarrelled, so it was an excellent example of a national point. I cannot be expected to trot around the House dealing with district health authority after district 495 health authority. Many Adjournment debates are held in which such issues are dealt with by my hon. Friend the Minister.
§ Mr. Ray Powell (Ogmore)
On a point of order, Mr. Deputy Speaker. The Secretary of State said that he does not have a certain responsibility. I assume that the right hon. and learned Gentleman has responsibility for the whole of the Bill as he is presenting it, so he should answer questions about the whole country, including Wales.
§ Mr. Deputy Speaker
Order. I remind the House that, as Mr. Speaker said at the beginning, a very large number of right hon. and hon. Members wish to speak in the debate. I think that we should get on with it.
§ Mr. Clarke
I knew that it was a mistake to say that the debate was moving on to more sensible ground than it has been on for most of the summer, but I believe that to be the case. We should build on what is accepted by everyone in the service.
Hon. Members will have seen a press statement put out by the professions last week that still contained many criticisms of proposals in the Bill, which had then just been published. The press release included the following passage, which I commend to the House:We wish to work with the Government, not against it, because like the Government we are committed to the principle of a National Health Service financed out of public funds and free at the point of delivery. We welcome the Prime Minister's statement that her sole aim is to develop a better Health Service, and we share this aim. We wish to co-operate in the improvement of standards through professional audit, through proper resource management, through research into disease prevention and treatment, including the most cost effective methods of care, and through the introduction of better information technology to enable informed management decisions to be taken.The professions then made general criticisms which I have rebuffed. Some of the wilder ones that caught the headlines seem to have no sensible or factual basis. The Bill accepts that common ground, which is the widely accepted need to improve resource management and for quality control and the provision of a good basis for education and research, and enables us to put into effect the benefits of better resource management, which will be more effective patient care.
§ Mr. Michael Foot (Blaenau Gwent)
As the right hon. and learned Gentleman has thought it worth while to quote to the House the representations made by people in the service, why did the Prime Minister refuse to receive a delegation of them so that they could put their case directly?
§ Mr. Clarke
Because she referred the leaders concerned, as she would in any other similar case, to me and my colleagues as the Ministers responsible. Indeed, I had met all those people frequently during the previous few months. We recently answered a parliamentary question which showed that my ministerial colleagues and the chief medical officer could easily produce a list of well over 100 meetings with leaders of the medical and nursing professions during the past six months. I have no doubt that we shall have more. There have been constructive meetings designed to ensure that we implement the 496 changes and get the benefits of better information technology and quality control, which will be welcomed as we go along.
§ Mr. Nicholas Winterton
If my right hon. and learned Friend is so determined—rightly—to press ahead with resource management, which is so important for the efficient management of the Health Service, why was he not prepared to analyse and properly assess the resource management initiative in six hospitals, most of which the Social Services Select Committee visited during its recent inquiry, before rushing forward into the dark with unproven proposals which could do so much damage to the Health Service? I might add that those resource management initiatives were fully supported by everyone in the Health Service.
§ Mr. Clarke
We shall evaluate those six initiatives. Everybody accepts the need for better resource management in the Health Service. Change cannot be made conditional on a protracted academic appraisal of six particular experiments. Of course, we shall build on the experience of those experiments—
§ Mr. Clarke
And, of course, we set them up. We shall evaluate them. We did not set them up, however, on the basis that nothing would be done anywhere else in any other hospital until Brunel university had finished the evaluation. The crying need for resource management is obvious. The pace at which we proceed must, with respect, be somewhat more purposeful.
I always tell the business men whom I introduce to give advice on better management in the Health Service that, when they go into the public service, they must expect the clock to go rather more slowly than they have experienced in any other organisation. Sometimes, however, people in the Health Service want to make the clock crawl. They contemplate years of discussion before getting on with implementing such obvious improvements as a better system of financial management.
The Bill will enable us to build on the progress being made in resource management. It will enable money to be spent more sensibly and effectively. The key theme of the proposals is to have more real responsibility for decision making at the local level. We are putting it in the hands of the managers, doctors and nurses who are delivering care in hospitals and units. It has been the common experience for years that most people in the Health Service have, until I proposed the reforms, suffered from the feeling that there are far too many layers of authority above them and far too many constraints on running units better. The Bill will give much more automony within the Health Service to the people who are delivering care.
We need better decision making, which depends on better local leadership. Clauses 1 and 2 reconstitute district health authorities and the bodies who are responsible for decision making. The aim is to make them smaller and more effective. In my opinion, health authorities have never been able to make up their minds whether they are a kind of local government committee or a decision-making executive body for the health authority. We obviously want smaller, more effective decision-making bodies.
497 We are bringing executives in for the first time. We are building on all we have achieved with the introduction of general managers. It is absurd that there have been no executives on the boards. They have had to sit and watch. Others debate an agenda which, in the opinion of some executives, sometimes bears little relation to the real decisions and problems that face the authority. There will be a combination of chairman, non-executive members—local people appointed for the individual contribution and skills that they can bring—and executives. That will create a fuss because we are removing the arrangement by which local authority members are put on as of right.
I quite expect many non-executive members to combine their public service on a health body with service as local councillors, but the system under which local authority representatives go directly on to the health authority does not always produce desirable results. Recently, there has been a growing tendency, sometimes by supporters of my party and frequently by supporters of the Labour party, to put on local authority members who are mandated to pursue local political aims, and then to remove them when changes of political control or nuances in the local Labour group determine that a new political input must be made.
§ Mr. Harry Greenway (Ealing, North)
Will my right hon. and learned Friend make it clear whether family practitioner services authorities will employ medical advisers to examine the effectiveness of prescribing? If so, will they consider quality as well as expense?
§ Mr. Clarke
Yes, surely. FPSAs will certainly need professional advice when deciding on prescribing practices. The judgments that may in some cases have to be made about the prescribing practices of individual general practitioners or partnerships will be made by people who have professional qualifications and are therefore able to do so. Nobody will evaluate prescribing habits solely on the ground of cost. That is not my point. The quality of prescribing and the necessity for it in such quantity will also be considered in each case.
The Bill also introduces the possibility of a quite new method of distributing taxpayers' money. In future, it will be distributed according to a method which is loosely called contracts, but I should make it clear that it is certainly not my intention that any of the agreements about what service a unit should provide in exchange for a given level of resources should be made the subject of litigation between different parts of the Health Service, or be subject to over-legalistic interpretations.
The Bill allows NHS bodies to make administrative arrangements with each other for the provision of services as they have not been able to do previously. Those administrative arrangements will be a network of agreements whereby a district health authority or a general practitioner, using the funds he holds in his budget, will decide which unit they want to provide a given level of service and, when they have stipulated what they want and the quality that should be achieved in exchange, an agreed sum of resources will be accepted by the unit to deliver it.
It greatly alters the responsibility of people in the NHS. District health authorities will find their role considerably changed. They will have a vital responsibility to act on behalf of all the residents in their catchment area. They will need to assess the health needs of their districts and identify where the local service is not as good as it might be and could be improved. They will have to determine 498 what is required to provide a reasonably accessible comprehensive service in each locality. The money will be placed in their hands to finance the best pattern of service for patients.
District health authorities will enter into agreements with hospital units to specify what is required in terms of both quality and quantity. I expect that at first they will be broad-brush agreements. Nevertheless, authorities will stipulate a level of service in exchange for an agreed level of resources. As we develop the concept of resource management, both sides of the bargain will wish to include more sophisticated terms and details.
To go back to the jargon, we have stressed in the Bill and in the working papers that support it that district health authorities must respond to the wishes of general practitioners in placing contracts. In putting agreements in place, they will have to find out about GPs' referral patterns and reflect them wherever practicable and sensible. In their turn, GPs as well as the district health authorities will reflect the wishes of their patients both in terms of convenience of locality and expectations of service and allow for a reasonable degree of patient choice, which we on this side wish to reinforce in every case.
§ Mr. Clarke
I shall give way in a moment. The system will allow for individual referrals to be made and financed properly within the contractual system that we propose.
§ Mr. Campbell-Savours
Does the Secretary of State understand that many of us find it difficult to accept his reassurances because it was he who came to the House only just over a year ago to give us reassurances about the sale of Rover to British Aerospace? He was the Minister responsible for misleading the Commons on issues which are now being unravelled in the midst of a row. How can he expect Parliament and the British people to believe a word he says on the basis of his track record?
§ Mr. Clarke
If it were in order to do so, I should give way to the desire that I have had for the past few weeks to join in the exchanges on the sale of the Rover Group to British Aerospace. I have listened to a great deal of rubbish from the Opposition about the sale, under which a company was transferred into the hands of an extremely successful British engineering company and taxpayers were relieved of the risk of losing millions of pounds on the scale previously incurred under public ownership. I think that if I digressed further, you might call me to order, Mr. Deputy Speaker. I look forward to answering on that matter when I have the chance.
To return to contracts, I realise that it is difficult for those who work in the service to become familiar with the concept. It is a concept that is easy to attack. It is worth while bearing in mind the fact that the network of agreements will involve people making considerable choices about where best to place a service and how best to allow for patient referrals and make sure that the service provided is properly integrated and not broken up. The first key point that I would emphasise is that we intend and shall insist that all decisions about placing contracts will have as much regard to the quality of service that the district health authority and GPs seek as to cost.
Some critics have attacked the system on the basis that doctors will be made to obtain the service from wherever it is cheapest. That is nonsense. Every hon. Member in the 499 House makes the same judgment when he or she is ill as GPs and people outside the House make. The first thing that one wishes to know is where one will be best treated. Judgments about quality are as important as judgments about cost.
As I have already said, one great benefit of the system will be that where a unit is efficient, it will no longer have to cut back towards the end of the year, perhaps by closing wards, because it has outstripped its budget, however fast that budget has grown. In future, it will be possible to stimulate good performance in the Service. People are committed to their own units, hospitals and clinical units. In future, units will thrive and attract more patients to the extent that they succeed in cutting waiting times and demonstrating a high quality of care. By providing a friendly personal service they will be more likely to attract referrals and contracts from their district health authority and surrounding authorities and thereby increase their resources.
§ Mr. Clarke
That will be the opposite of the present position. I do not wish to attribute ill will to anyone in the Health Service, but no one has an incentive to reduce waiting lists. People strive to do so because they want to keep up with the work, but no reputable consultant would be without a waiting list, because it is a badge of status. District health authorities are not anxious to reduce waiting lists, because they are used by Members of Parliament to reinforce authorities, claims for more resources. We shall have to take care that our waiting list initiative does not reward units for having a long waiting list.
§ Mr. Clarke
It is no use the hon. Gentleman saying, "Cheek." No doubt if he were making his speech he would say that waiting lists were good for private practice. I would not allege that that plays too great a part in keeping waiting lists high.
In future, units which succeed in reducing waiting times will have more prospect of attracting patients, and NHS resources will flow in with the patients. That is one of the main ways in which the Bill will reduce waiting times, when it is fully implemented.
§ Mr. Simon Hughes
The precondition for what the Secretary of State says about the relationship between districts and hospitals is NHS trusts, for which the Bill provides. The Secretary of State will be aware that people have an honest fear that, because the contract will be placed by the district with the best hospital, it will not necessarily be given to the local hospital. If the Bill is all about choice, why does the Secretary of State not amend his plans in this respect, as some of his colleagues did in other legislation last year, to allow people who work in or use local NHS hospitals to choose by voting whether the hospital should become an NHS trust instead of a decision 500 being imposed on them by the Secretary of State? That happens in schools and in housing action trusts, so why not in hospitals?
§ Mr. Clarke
The hon. Gentleman is mistaken in one of his premises. It is not the case that the so-called contract system that I have just described will apply only where there is a self-governing NHS trust. What I described is a key element of our NHS reforms and will apply to the whole National Health Service, both to hospitals and community units. It will apply to hospitals run by the district and to those which are self-governing NHS trusts. The difference with a trust is that it will play its part within the system with a local board to manage it and make the day-to-day decisions. Hospitals run by the district will continue to be managed directly. I shall come to NHS trusts later—they are dealt with in the next part of the Bill.
§ Mr. Clarke
On the matter of who decides, we have always said that we shall consult on applications from hospitals to become self-governing trusts. I cannot receive such applications until the Bill has Royal Assent. People contemplate, "What if one has a self-governing trust?" Propositions will not even be worked out until next summer, and they will include plans for the development of services. We can have proper consultations then. I suspect that that is one of the many strange leaflets kicking around the Health Service on the subject of self-governing hospitals.
§ Mr. Clarke
I am happy to talk about the creation of NHSTs, if hon. Members wish to return to that point, but first I should like to stress the main point of the Bill.
These self-governing hospitals—that is what people want to call them—or NHSTs will be firmly anchored in the NHS. The clause provided for that. They set out the procedure for establishing the new bodies, their specific powers and freedoms, my reserve powers, which will ensure that they continue to meet their NHS obligations, and the basis of their funding. On establishment, the trusts will have boards of directors with substantial health, professional and outside expertise to provide the necessary range of skills and strong leadership on the ground. There will be special provision for medical school or university representation on boards should it be needed.
Schedules 2 and 6 set out the freedoms of the NHSTs which we have been expounding since we produced the White Paper. They include the freedom to employ their own staff, to conduct research and to provide facilities for medical education and other forms of training. NHSTs will have the same income-generation powers as other health authorities. The schedules also contain safeguards in the form of specific powers of direction which the Secretary of State will have over the trusts. These powers will allow me and my successors to direct all trusts on matters of safety or ethics where a common policy will be pursued throughout the Health Service and, in exceptional circumstances, to direct an individual trust where there is justified cause for concern.
My hon. Friend the Member for Leeds, North-West (Dr. Hampson), who told me that he had to leave to catch a train to his constituency, whispered to me about educational research. I referred him to the powers which cover the provision of education and research and the 501 powers of the Secretary of State to insist that proper arrangements are made in the unlikely event that any self-governing trust would wish to cease to play its part. The Government are certainly committed to high quality medical research and education in the Health Service and we propose to ensure that self-governing trusts play their part.
§ Mr. Derek Fatchett (Leeds, Central)
The Secretary of State mentioned his discussions with the hon. Member for Leeds, North-West (Dr. Hampson). Earlier he seemed to deny that health authorities had been spending taxpayers' money on working up proposals for hospital trusts. Where in the Leeds Western health authority does money come from to employ the consultant, Professor Bosanquet, and to produce and publish a report which advocates that Leeds general infirmary should become a hospital trust? Where is the legal power to spend that money, particularly bearing in mind that at a formal meeting the health authority voted against the proposal for the infirmary to become a hospital trust? Where is the power, or is taxpayers' money being used without legal authority?
§ Mr. Clarke
I know from my information that nobody is exceeding his legal powers in the Health Service or my Department. For as long as I can remember when a Government announce policy changes, a White Paper or an intention to legislate, it has been the obvious sensible practice for preparatory work to be done and for people to exchange ideas with the Government on how the concepts might work out in practice when they are introduced. The hon. Gentleman will know that that is the subject of litigation. Professor Harry Keen at Guys has been passing the hat round to employ lawyers to argue this for him. I would not dream of intruding on the litigation that will ensue. I am satisfied that we are acting within our legal powers and that what we have done is not out of line with previous practice. No doubt in due course that will be determined by the courts.
§ Mr. Clarke
With the greatest of respect, I am sure that the courts will be seized of this and I do not think that the House should spend more time on it. What we are doing is not out of line with usual practice. It is most certainly not an unlawful use of money. Professor Harry Keen and his colleagues think otherwise, so the whole matter is sub judice and will be determined by the courts.
§ Mr. Clarke
No; first, I should like to make a little more progress on NHSTs. I do not think that at the moment there is a proposal coming from Cornwall.
Throughout the country, partly as a result of this preparatory work, I detect mounting enthusiasm among many people in the service and among units and hospitals of all kinds about the possibilities that may arise from the establishment of NHSTs. It is not true, as some commentators have claimed, that interest is confined to the giant hospitals. Some small units have expressed interest. Indeed, interest has been expressed from outside the hospital service altogether. In some places, community services are being put forward and two ambulance services 502 are contemplating self-governing status inside the Health Service. They see the possibility for new freedoms for local people and new opportunities to develop their services.
Many doctors and nurses have for years been frustrated by the constraints which in the olds days the bureaucracy of the NHS, through my Department, RHAs and DHAs, undoubtedly used to impose on their ability to work as they wished. All those who work in the NHS have a great sense of pride and it is strongest when it is attached to a particular hospital or unit. That can be used for the benefit of all by developing the NHST concept.
Success will depend above all on the strength of local leadership that emerges and the quality of the plans for the future of the unit which are produced. Sensible local discussion and the eventual decision must wait for the production of those plans so that their quality can be evaluated.
For some reason, the Labour party has latched on to self-governing hospitals as a focus for opposition. The enthusiasm of the Labour party and trade union movement for bureaucracy and red tape knows no limit. The most amazing nonsense is being canvassed in support of votes. The hon. Member for Southwark and Bermondsey (Mr. Hughes) is the latest to impress that on me. People have been told that these units are opting out of the NHS, a point which I have dealt with; that this is a step towards privatisation, which nobody believes any longer; that it is the end of job security for the staff; and that vital local services will be closed in the interest of seeking profitable areas. I look forward to any hon. Member describing in Committee how that nonsense is to be put together. In places such as Redditch, the local council has spent a fortune of ratepayers' money to put out tendentious leaflets, with the result that people write back to say that they are against the curious nature of the proposals described.
Given that plans are beginning to develop in parts of the Service, next summer proper plans will be proposed by the Secretary of State in the normal way and consultations will take place. I am sure that in Committee we shall have many Divisions. Nobody has explained to me who on earth the electorate would be in those decisions, because hospitals do not belong to any particular section of the public. Even the Labour Government in their more foolish moments when they were responsible for these matters never held a referendum on local management structures for the Health Service, so far as I am aware. That is not a sensible way to run any service.
§ Mr. Tom Clarke (Monklands, West)
The Secretary of State will recall that he has been on his feet for almost exactly 50 minutes.
§ Mr. Tom Clarke
I accept that there were interventions. In that time the Secretary of State has not said one word about community care, which appears in the short title of the Bill. Is that consistent with the low profile of the Griffiths report, the publication of the White Paper the day after the House adjourned and the Government's low priority for the whole issue?
§ Mr. Kenneth Clarke
I apologise for the length of time that I am taking. I believe that the television cameras stopped transmitting at 5 o'clock and I thought that that might reduce the number of interventions that I would be 503 obliged to take during my speech. I am talking faster than usual, because I share the hon. Gentleman's concern for the community care part of the Bill, which is vital and must be subjected to debate over the next two days. I shall anticipate what I intended to say later, which is that my hon. Friend the Minister for Health will reply to the debate on Monday. She has particular responsibility for community care and will put heavier emphasis on it in her speech than it seems I am likely to have time for in mine. I agree with the hon. Gentleman that it is an equally important subject.
The Bill paves the way for GPs' fund holdings. As everybody, knows, I frequently state my enthusiasm for the family doctor service in the British NHS. It must play a key part in any service which is truly patient-oriented. The new contract will raise the quality and boost the service to the public. The system will also give GPs much more influence over what resources are spent on and much more contact with their DHAs than ever before.
The proposals for fund-holding general practitioners will give those who choose to develop it the opportunity to provide the patients in their practices with high-quality care. It will give GPs much greater control over the resources they deploy in any event in their referral patterns and much more influence that they have ever had over the development of the local services used by their patients.
The Bill provides the framework for the scheme to get under way, and I trust that it will be welcomed as it gets better understood. I never understood why the British Medical Association opposed the proposal, as I felt it was on the wrong side of the barricade. The BMA represents GPs in particular and it should have recommended to the Government a system that placed funds in the hands of GPs and gave them more influence over how resources are deployed.
If I said that doctors would abuse that power, refuse the treatment needed by their patients or seek to make a surreptitious profit out of it, the BBC—sorry, I mean the BMA,in fact—the BBC and the BMA—would get extremely excited about my disgraceful slur on the medical profession. The BMA has occasionally argued that it does not believe that all its members would use those powers properly. I hope that, eventually, the BMA is on the right side of the barricade as fund-holding for general practice is an exciting concept for family doctors of which many will want to take advantage.
During the discussion of the Bill, we shall issue the programme needed for GP practice budgets in the near future.
§ Mr. Clarke
When three of the noisiest Members of the House make a sedentary intervention, I feel obliged to respond to it, but I do not believe that two of them understand the matter. In reply to my hon. Friend the Member for Macclesfield (Mr. Winterton), in the first place the budget will be negotiated by the practice contemplating having that fund-holding budget with the regional health authority as the Bill provides. Eventually 504 we hope to devolve the negotiating responsibilities to the family practitioner service authorities, which will replace the FPCs.
I have dealt already in passing with prescribing budgets, but I shall do so again now. Clauses 17 and 31 contain the proposals for indicative prescribing budgets. "Indicative" is the key word. Those budgets will be targets that will be assessed as a reasonable expectation of what the prescribing costs should be for a practice. If a practice goes above that expectation it may well be obliged to answer to a professionally qualified group and to give an explanation as to why its prescribing costs are out of line.
The indicative prescribing budgets will be the machinery whereby the regional health authorities and the FPCs can manage prescribing costs more effectively than they have in the past. In that way, money will be targeted on effective patient care.
§ Sir Michael McNair-Wilson (Newbury)
If it is true that GPs will be able to prescribe whatever drugs they believe necessary and that that will not be a limiting factor on their drug budget, will the same be true of hospitals when a wonder drug is created? What will happen if a hospital wants to prescribe such a drug to its patients, but its existing budget is inadequate?
§ Mr. Clarke
Hospitals have always had to provide for their drug costs within the cash-limited provision. When a wonder drug is created, it has an inevitable impact on cash limits and, inevitably, it forms part of the claims that the Department of Health makes year in, year out, on the Treasury. In health care, when deciding what one must spend, one must pay regard to advances in the pharmaceutical industry. It is our intention that hospital and community service budgets and the GP indicative budget should reflect such expensive advances. Such advances are often counterbalanced by other medical advances that produce lower-cost alternatives to expensive hospital care for which GPs may opt. We must manage the budgets with common sense to ensure that essential needs are met and the best value obtained throughout the Health Service.
Clause 19 and schedule 4 allow the Audit Commission to take over the statutory audit of Health Service bodies from the Department of Health and the Welsh Office. My right hon. and learned Friend the Secretary of State for Scotland will introduce an amendment in Committee to permit a similar transfer of responsibility to the Commission for Local Authority Accounts in Scotland. My right hon. and learned Friend has taken no decision on whether to transfer his responsibilities, but he wishes to remove the statutory bar to the Scottish body taking on that role. He will make a final decision in the light of his review of the current arrangements for NHS statutory audit in Scotland.
The hon. Member for Monklands, West (Mr. Clarke) has already said that the Bill covers the legislation needed to implement the White Paper "Caring for People". Fortunately, we have a two-day Second Reading debate so that we can cover the NHS reforms and the future of care in the community. The policy aim of the Government is to give a better deal for people who need care in or near their own homes and a better deal for the relatives and friends who make considerable sacrifice to care for them. We announced our proposals first in the House and then in the 505 White Paper. The Bill builds on the existing powers of local authorities—they have many existing statutory powers—and gives them new supplementary powers.
The key policy changes mean that we shall move to a system where local authorities clearly have the overall role in community care. They will provide services based on a proper assessment of the needs of individuals. They will use that assessment to make a more suitable provision for services than has sometimes been made in the past when there was an undesirable bias towards social security support for patients in private nursing homes. That was done without first exploring the possibility of the provision of better services in or near the patient's home. We shall also require local authorities to produce community care plans and added powers will be given to my inspectorate to check on their performance.
I have largely concerned myself with the NHS. I believe that the Bill paves the way for fairly rapid progress towards big improvements to the NHS. Some critics say that the pace is too fast, and I do not know how long they will want to take debating the Bill in this House. The talk is always about the need for pilot schemes and experiments to test our proposals. So far, the critics who have advocated pilots to me do not appear to know what they mean. Some people have asked me why we do not try out part of the reforms in a certain area of the country, but, in my discussions with them, no sensible explanation has been produced as to exactly how such an experiment would be made. One cannot pilot any of the things we are proposing without the legislation to enable the health authorities to establish a network of agreements under the new arrangements that we contemplate.
There is plenty of experiment built into what we are doing. The ideas on the NHS trusts and GP fund holding will be developed by people inside the Health Service who have chosen to come forward to volunteer to work out the details with the Government. The whole process of reform will be based on working with people in the Health Service who want to see us make a success of our proposals. We shall learn from experience as we go along. I am sure that, at first, most parts of the country will use the contracts to put in place the existing pattern of care with which they are familiar. Once it is established what service is delivered with what resources, everyone will take advantage of the opportunity for choice offered by the new arrangements.
I trust that the debates in this House will enable us to reassure and appease the fears expressed by the professions. I hope that we explain to them that we shall learn from experience. Above all, we will be able to explain what we are doing for the patients. Patients are looking for shorter waiting times, a better appointments system and a much more personalised and friendly service. They want to know that everyone in the Health Service is striving for higher standards of care.
The critics of the reforms are trying to scare the life out of patients by suggesting that basic services will be lost. Those criticisms are not in the public interest. We are aiming for a better NHS for all, free for the patients regardless of need, financed out of taxation. We are looking for a great public service.
When we give the Bill a Second Reading, we shall give the NHS a new lease of life. We shall put it in good shape to provide an even better service in the next 40 years than it has provided for our people in the past 40 years.
§ Mr. Robin Cook (Livingston)
For the avoidance of doubt, it may be helpful to the House if I say at this stage that the Opposition do not propose to table a reasoned amendment before Monday. We are fundamentally opposed to the principle of the Bill and shall vote against it on Second Reading. We believe that it will destroy the public sector ethos of the National Health Service, and that it is designed to do so. Should the House be so illadvised as to pass this measure, it will prove in the future as unworkable as it has already proved unpopular in the present.
The Secretary of State and I have frequently jousted over the past 18 months since he returned to his office at the Department of Health. This is only the second time that he has appeared at the Dispatch Box with legislation since his return. The last time that he appeared before the House with legislation was a year ago, when he appeared in order to defend the abolition of the free eye test. I hope that the right hon. and learned Gentleman will forgive me if I begin by reminding him of the terms in which lie recommended that measure to the House. He told the House that he did not believe the optometrists when they warned that abolition would result in what he described as an eye charge of "anything up to £10". The right hon. and learned Gentleman went on to ask the House this question: even if there were a charge of anything up to £10 for an eye test, how many people would be deterred by it?
Earlier this week, fortunately, we had the latest return of the quarterly survey of the Association of Optometrists. It shows that the Secretary of State was right to advise the House that we should not believe that the charge for an eye test would be anything up to £10. In fact, the average has been between £11.50 and £12 per eye test.
We are able to see from that survey the answer to the question put by the Secretary of State when he recommended that legislation to the House and asked how many people would be deterred by it. On the present trends revealed by that survey for the first six months of this year, we are on course for 2.5 million fewer eye tests than in the year before. That is the result of the measure that the Secretary of State last recommended to the House. By commercialising the eye test, he has removed a public service and has seriously damaged a vital screening service. It is against that record that we must measure his promises on this Bill.
§ Mr. Kenneth Clarke
I promise that I will not intervene often, but the hon. Gentleman has specifically raised this point. He knows perfectly well that the figures which he uses reflect the inevitable fall in the number of eye tests. There was a terrific increase in the number of eye tests taken out before April last year. People have the test once every two years. Everyone in the profession will tell the hon. Gentleman that it is nonsense to suggest that the number will not return to normal in due course. If the hon. Gentleman wants to have a free eye test, I can refer him to an optician service on Walworth road which is only one of many offering such free eye tests.
§ Mr. Cook
I am glad that the Secretary of State gave me that opening. I have heard him make that point before. The facts, as confirmed by his Department in parliamentary answers to me, show that in 1988, in the period after the announcement that a charge would he introduced for eye tests, the number of eye tests increased 507 by 400,000. That is less than the increase in 1987, before the announcement, when the number increased by 600,000. In 1988, the increase was less than the year before.
§ Mr. Cook
The Secretary of State chose to intervene and I think that he can claim precedence even over the hon. Member for Tayside, North.
The increase last year was 400,000, less than the average for the previous two years. Because of the introduction of the charges, there has been a reduction not of 400,000 but of 2.5 million. That dramatic drop plainly shows that many people now find that the eye test is priced beyond their reach, although their sight may be fading and an eye test may well reveal much more serious medical problems than the mere failing of their eyesight.
§ Mr. Cook
I shall not give way at this point.
It is against that record of the promises of the Secretary of State—that there would not be charges of anything up to £10 and that they would not deter people—and the record of what happened when he put the eye test on a commercial footing that we must measure his proposals in the Bill to put the whole NHS on a commercial footing. Once again, the Secretary of State is doing this on the basis that he does not believe the warnings of the professions that care for the patients. Once again, the House is being presented with a measure on the now familiar basis that this Secretary of State knows better than any of the people who care for the patients.
The Secretary of State had the temerity to refer to a changing atmosphere among professionals and hospitals towards his Bill. It took brass neck to make that claim the day after the case for a judicial review was won on an application by over 3,000 consultants—10 times the number of doctors that the right hon. and learned Gentleman has been able to recruit for his own entryist front to support the White Paper.
The Secretary of State is fond of claiming that 80 per cent. agree with the objectives of the Bill. At the beginning of his speech, he claimed that the whole House agreed with the Bill's general objectives. That is hardly surprising, given the bland nature of those objectives as frequently stated by the right hon. and learned Gentleman. Those objectives are to increase patient choice, devolve more decisions to local level and improve value for money.
The argument turns not on whether we all agree with those platitudes but on whether the Bill is any more likely to achieve any of them than it is to promote warmer winters. The Secretary of State uses the language of contract. As a barrister, he will know that the sensible thing to do with a contract is to study the fine print. I therefore warmly commend to the House the idea that it examine the fine print of the Bill to see whether it matches the rhetoric that we are promised by the Secretary of State.
§ Mr. Hayes
I am grateful to the hon. Gentleman. I have listened closely to every speech that he has made on this subject. It is clearly time that he came clean and told the 508 House whether he is committing his party to reject money travelling with the patients. For the first time, this will mean giving hospitals the financial incentive to treat more people. Is the hon. Gentleman committing his party to rejecting the idea of doctors and consultants finding out their basic unit costs so that they can treat more people more effectively? Is he going to commit his party to rejecting medical audit resource management? The hon. Gentleman should tell us the answers. We have a right to know, and so do the electorate.
§ Mr. Cook
I am sorry to disappoint the hon. Gentleman. There is nothing in the Bill about a medical audit. If he is thinking of voting for the Bill because he supports the idea of a medical audit, I would strongly recommend that the hon. Gentleman—I would warmly welcome his joining me in the Division Lobby—think again about where he will cast his vote. Of course we do not oppose the idea of money following the patient. The question is whether the Bill does anything to provide for money following the patient, rather than providing for a situation in which the patient follows the money and the contract. I shall explain that point when I reach that passage in my speech.
Let us begin with the patient. The Secretary of State has frequently said—as he said again this afternoon—that his Bill will increase patient choice. The phrase which was in vogue in January when the White Paper was unveiled was that it would "put the patient in the driving seat". There is not much for the patient in the Bill. I have had the Bill read from cover to cover, and we could find only one reference to the word "patient" in the Bill. It is found in clause 14 where, characteristically, the word "patient" arises solely as a basis on which the money to be paid to the doctors is counted.
How little choice will be given to patients by the Bill is graphically revealed by the fact that there is to be no consultation with the patients. In February, the Secretary of State made a speech in which he said that his proposal would encouragelocal pride in our hospitalsand would give local peoplemore ability to take the big decisions in their own part of the service.What could be a bigger decision than whether one's local hospital goes into one of the NHS trusts and out of the local district health authority? Yet that big decision is to be taken without the by-your-leave of the patients of that hospital service. The person who takes it is the Secretary of State; clause 5 simply states:The Secretary of State may by order establish … NHS trusts.I must draw the attention of the House to the fact that, ironically, schedule 2 stipulates that there must be consultation before such a trust is wound up. In other words, there will be more consultation before such a trust can opt back into the NHS than before it can opt out in the first place.
Any doubt about whether there will be greater choice for local people in what happens to their local service is removed by the advice on self-governing trusts that the Secretary of State has sent to health authorities:It would not be sensible to organise ballots of staff or any other groups with an interest.This Bill does not extend choice to patients. The Secretary of State is terrified to offer them the choice, because he knows that they would give these plans the 509 thumbs down. I had not intended to refer to this, but since the Secretary of State mentioned it, I shall. The ballot in Redditch was held in a borough in which 57 per cent. of the electorate voted—a commendable turnout for a local vote. It is not a Labour stronghold; it is represented by one of the right hon. and learned Gentleman's colleagues in Government. In a large turnout in an area that is not in our Labour heartland, 81 per cent. of those responding declared themselves not in favour of the Alexander hospital opting out.
It will not do to dismiss this result by saying that the wrong type of leaflets were given out. This type of result is known as democracy. It would be flagrantly undemocratic if, as well as ignoring the views of those who work in hospitals, the Secretary of State were now to ignore the choice of the patients they serve.
There is another collision between all the promises of choice and local decision-making. That collision is to be found in the composition of the new district health authorities which exclude anyone who might choose to do something different from what the Secretary of State wanted. Out go the representatives of local authorities, who are the only people in the health authorities who are elected by patients. Out go the representatives of the professions that treat the patients. Instead, everyone on every district health authority will be appointed by the regional health authority, and everyone on every regional health authority will be appointed by the Secretary of State.
Just in case someone with an independent mind slips through this process, out goes the tradition of voluntary services on health authorities. All the non-executive directors are to draw a salary, at a total cost of £10.5 million, which is more than the entire budget for all the community health councils in England and Wales to represent the views of patients.
The Secretary of State has not come up with a system in which health authorities will be staffed by people who are respected in their local communities, as he put it. He has come up with health authorities that will have no pretence of representing local choices or interpreting local preferences. He has come up with a board of management that will exist to implement central policy—exactly the sort of machinery of the clapped-out centralised state which is being dismantled all over eastern Europe.
I know that the Secretary of State will say that this is not the sort of choice he meant, that he meant more choice for individual patients. So let us look at what will happen to them. This brings me also to the point made by the hon. Member for Harlow. There will be less choice for individual patients: less choice over which hospital to go to, for instance. The patient will go where the district health authority has placed a contract. It is curious to claim that that means money following the patient. I invite the hon. Member for Harlow or any of his constituents, once this Bill is law, to turn up at any hospital of their choice at which the district health authority does not have a contract and to tell that hospital, "It is all right—the money will follow me afterwards." Anyone who did that would be lucky to get past the reception desk.
§ Mr. Hayes
The hon. Gentleman is not quite accurate; indeed, he is wholly inaccurate. He should look at the Department's guidance to district health authorities which, at this very moment, are exercising their right to speak to doctors on their referral practices.
510 The hon. Gentleman should be honest enough to tell the House that the referral practices of general practitioners will remain the same.
§ Mr. Cook
That is not so. Under this Bill, the GP will not have the opportunity to send his patients to hospitals at which the district health authority does not have a contract. Nowhere in the Bill is that right of the GP defended.
If the hon. Member for Harlow turns up at a hospital in these circumstances, he will be asked where the money is coming from, and that is a question that the House should ask in a more general context. I have, as the Secretary of State knows, just completed a survey of the financial state of health authorities. It showed that three our of four—
§ Mr. Cook
I am delighted to tell the hon. Gentleman that two out of three general managers were content to reply to me, not to him. Three out of four of those responding reported that they were under-funded for present levels of service. All those three quarters are now taking emergency measures to avoid a deficit. Many of them are closing beds and freezing vacancies. Some of them are cancelling operating sessions and will no doubt feature in a future league table drawn up by the Secretary of State as people who are under-managing and under-performing.
In a rare passing moment, I shall seek some common ground with the Secretary of State. I agree that some of the variations in performance are not related to resources. Having looked at the figures, I agree that that is manifestly true, but as I have acknowledged that, I invite the right hon. and learned Gentleman to acknowledge that most of the frozen vacancies and cancelled operation sessions revealed in my survey are due to a shortage of resources. The financial pressures do not vary; the picture of financial pressure is the same in every region in Britain.
In the north, Newcastle district health authority reports under-funding by £2 million—a gap that it cannot fill without redundancies. In the midlands, Rugby reports that next year looks particularly grim. In the south, East Hertfordshire reports that the short-term outlook is extremely bleak. And Barnet district health authority, covering the constituency of the Prime Minister, reports that it is closing 10 paediatric beds and 14 gynaecological beds. That is the state of the Health Service after 10 years of her stewardship—[Interruption.] I am sure that the hon. Member for Harlow will return to the Chamber to intervene before I can finish.
There is a desperately worrying message for the hon. Member for Harlow, before he departs, and for all other Conservative Back Benchers in the results of my survey. I have been interrupted by enough Back Benchers in the past few months to know that every single one of them believes that it is his hospital that has a problem of success and a financial problem because it is treating more than its fair share of patients. They all believe that, when money follows the patient, the financial pressures will be magicked away.
I have never yet been interrupted by a Conservative Back Bencher anxious to tell me that the staff at his or her hospital are pretty useless and treat fewer than their fair share of patients, and that the sooner the Bill is passed the 511 better because then the money from the hospitals in their constituencies can be transferred to the over-performing hospitals in the constituencies of their neighbours. I can understand why they do not make that point. It is not that they do not relish the thought of the local paper holding its front page to capture their remarkable statements. It is because, as this survey shows, across Britain—
§ Dame Elaine Kellett-Bowman
Statistics prove that we take in 29 per cent. from outside our district.
§ Mr. Cook
All Conservative Members share the hon. Lady's view—that is precisely my point. Everyone's hospital has the same desperate problem of trying to make ends meet, and most hospitals cannot do that without a deficit. Conservative Members deceive no one but themselves by believing that the under-funding of the hospitals that they represent will disappear under this monumental and monumentally irrelevant upheaval in the administration of the NHS.
The Secretary of State assures us that, if this upheaval does not produce more choice, it will at least result in value for money. He will apply the magic potion of competition, as a result of which we will apparently achieve more output for the same input. The right hon. and learned Gentleman has certainly mastered the language of competition. I read with fascination last night the circular that his Department has issued to health authorities on the pricing of contracts. [Interruption.] My hon. Friends elected me to carry out these distasteful tasks on their behalf.
The circular contains a section headed, "Competition and the invisible hand". Someone from the Adam Smith Institute obviously slipped into Richmond terrace by the back door. I shall quote two sentences from the section. The circular says:it may be desirable, to have a 'spot' market as well as a long-term market. It may also be desirable to cater for peak and off-peak demand by differential pricing.Even more remarkable than reading through such circulars, I have waded through the submissions sent to the Secretary of State by hospitals that seek to be self-governing. I know that such language is also catching on with district general managers. Basildon and Thurrock say that they want to set up a self-governing hospital to prevent what they describe as "predatory hospitals" picking out their patients. The use of such language shows how quickly the new market discipline leads to the end of other hospitals being regarded as colleagues in the same service and the start of their being seen as competitors in the same market.
South Yorkshire set up a task force to advise on the change in management that was necessary to make self-governing hospitals work. One of the major injunctions that came back to the management of that hospital was the wonderful advice that, in order to maintain its market share, it should "keep changing the product lines."
§ Mr. Bill Walker
The hon. Gentleman declined to give way before. He is speaking about competition. [Interruption.] The hon. Gentleman is usually polite; the fact that he did not give way must mean that he was on a weak spot. He is aware that, competition in Scotland resulted in extensive advertising for free eye tests. That has been going on for some time in Scotland.
§ Mr. Cook
Plainly, the hon. Gentleman had only one matter to raise in an intervention, and when he was allowed to make it it was the only point that he could raise. I am aware of the company that is advertising free eye tests and have had some correspondence with it. The company is Duncan and Todd. Before it issued the advertisements for free eye tests, it got in touch with me to seek my assurance that the next Labour Government would abolish the charges for eye tests, because only on that basis could it carry the two-year loss of providing free eye tests. That is the reality of the advertisements to which the hon. Gentleman refers.
Conservative Members are so besotted with the market that it is an article of faith with them that haggling in the marketplace is the best way to achieve efficiency, even in health care. I view with profound distaste the allocation of health care discussed in the patter of a salesman. I do not want a health service of spot markets, predatory hospitals and product lines. I want it run as a public service to meet the need for health care and not the need to cater for market demand.
Thousands of consultants and sisters and even district general managers will take the deepest offence at the Secretary of State's remark that no one has any motive to cut waiting lists. That remark betrays the fact that the Secretary of State does not understand what motivates professional commitment to a service to patients. Of course he meant that no one has any financial incentive to get rid of waiting lists. That confirms that Ministers are incapable of recognising any motivation that is not financial. I shall be happy to be disabused of that view if the Secretary of State can do so.
§ Mr. Kenneth Clarke
I am used to the hon. Gentleman giving dark paraphrases of what he says I have said, and I am used to some of my critics outside leaping on to those paraphrases. I said that the present system gives no incentive to anybody to reduce waiting lists, and that is true. I described how the new system would give rewards and incentives in terms of resources for the unit if waiting lists were brought down. The hon. Gentleman is extracting curious phrases from the thousands of pages that he has read. As a would-be Secretary of State for Health, is he talking about the prospect of handling £28 billion of public money without any regard to elementary financial management and with a disdain for any system of matching resources to the work load?
§ Mr. Cook
The Secretary of State confirms exactly the interpretation that I put on his remarks. He sees only a financial incentive and does not recognise the clear motivation of the staff in the Health Service to tackle waiting lists. He is perfectly right to anticipate the next Labour Government; I am pleased to hear that from his own lips. He is concerned about what we will do. I assure him that I do not believe that spot markets are the best way to allocate £20 billion within the Health Service.
§ Mr. Cook
No. I have given way twice to the Secretary of State, who must take precedence over the Back Benchers. The more he intervenes, the more difficult it is to give way to Back Benchers, much as I should like to give way to the hon. Member for Taunton (Mr. Nicholson).
513 We are being offered an eccentric market, in which there will be no consumers. It is not the patients who will strike the bargain about where they go and what is to be done to them. Health authorities will bargain with one or other, and the vast majority of those health authorities are already in deficit. They will not bargain about quality, because, as a result of the financial pressures on them, they will be obliged to go where care is cheapest.
There are some missing commitments in the Bill. It contains no commitment to ensuring that quality is reflected in the contract; nor is there a commitment to the core services that are promised to self-governing trusts. In the absence of legal protection for those core services, we know what will happen. We can predict now which services the hospitals are most likely to shed. They will be chemotherapy, renal dialysis, geriatric care and community psychiatry—all the specialties which require a long-term commitment to high expenditure, with a low expectation that the patient can be finally cured and taken off the books. We can predict what will happen, because those are precisely the procedures that the private sector will not touch because they cannot be delivered at a mark-up. Whether the end result of all this is value for money is a matter of taste.
I noted the candid evidence of Dr. Ken Grant, who is the district general manager of City and Hackney. He has been one of the star turns at the conferences trying to make sense of the White Paper for the last nine months. My hon. Friends will know about Dr. Grant. Last week, he made the candid statement that at the moment, when St. Bartholomew's accepts an emergency admission from another district, it has an incentive to keep down the costs because it will be left with the bill. He said that, under the new scheme, St. Bartholomew's would have the incentive to do as much as possible to that patient in order to generate income from the health authority that will pick up the bill.
That is a perfectly rational response to the market opportunity with which Dr. Grant has been presented, and it would be wrong to criticise him for it. As a manager, he had a predictable solution to the problem that he had identified: his solution was more managers to comb through the bills to make sure that they were not being rooked.
There is one stark consequence of the Bill, and that is more administrative staff to try to make it work. The memorandum to the Bill states that we shall require 3,800 additional staff. I thought that it was a piece of unusual impertinence by the Secretary of State to accuse Opposition Members of being in favour of bureaucracy. The additional bureaucracy will cost him £200 million. Whether that is desirable expenditure is, I suppose, a matter of taste. I find it an odd priority in a Bill that is supposed to be about value for money, when health authorities throughout Britain are freezing vacancies because they cannot afford to pay the nurses and doctors to fill them.
I cannot see that the nation has received value for money from the White Paper entitled "Community Care". It was published on the Thursday of one week and the clauses of the Bill that is now before us fell fully formed on the Wednesday of the following week. I know of the Government's perfunctory commitment to consultation, but I believe that this time they have set an all-time record. 514 As the White Paper was published only as a collector's item, the Secretary of State might have been advised to spare the taxpayer the expense of footing the bill.
There is nothing in the Bill on community care to show that the Secretary of State has heard the criticism that broke out on the publication of the White Paper. I found it regrettable that, in a speech which lasted a full hour, the right hon. and learned Gentleman was able to find only one minute to discuss community care.
§ Mr. Cook
The Secretary of State said that the Minister for Health will refer to community care when she replies to the debate late on Monday night. This is a two-day Second Reading debate, and the Secretary of State might legitimately be expected to set out the priorities for debate and the ground to be covered, and at least one of the priorities is the future of community care.
We find that even the rhetoric of competition parts company with sections of the Bill. There is no perfect competition to be found. Roy Griffiths proposed that there should be a level playing field for fair competition between the public and private sectors, and the Opposition are prepared to go snap on that. We are happy to accept the challenge of competing with the private sector at level weight. I believe that, without a partnership between public and private provision, we have no hope of meeting the explosion of need of the very elderly in the next 10 years.
Instead, the Bill offers us a rigged market. Perversely, someone retains his right to public benefits, income support and housing benefit only if he goes into a private residential home. If he goes into public residential care, he will have no right to public benefits. It would be difficult to produce a more flagrant example of unfair competition.
What happened to choice? Why should those who go into residential care not have a free and fair choice whether they go into public or private care? The purpose of the rigged market is clear: it is intended to reduce available choice by obliging local authorities to privatise their homes so that they may qualify for subsidy from public benefits. It is not only local authorities that are worried. The Spastics Society stated:We are deeply concerned about any assumptions that the public provision of care for disabled people can be in the main shifted to the private and not for profit sector without devastating consequences for disabled people.What about the choice of those who live in residential care homes that are provided by local authorities? Should not they be able to choose whether their home stays in the public sector or is sold to the private sector? There is no such right in the Bill. The Government are fond of talking about individual choice, but they have produced a Bill that is curiously silent on the rights of the user of the service. Not once in the Bill is the user of community care services mentioned. Nor are carers mentioned.
The National Carers Association responded to the White Paper on care by saying:The White Paper contains all the right rhetoric about. helping carers, yet in spite of a 106 page document the practical reality of how this will happen is still unclear.It is even more unclear after the printing of the Bill. The Bill does not once mention carers, does not give them one new right, does not place on local authorities one new duty in respect of care, and does not place upon them an 515 obligation to assess the needs of carers, or even to consult carers about the community care services that they provide.
In the clauses on community care, we find the widest chasm between the promise of local decision making and the reality of central control. This is not a Bill that gives power to local authorities. Instead, the Bill gives all the powers to the Secretary of State. I have been through the Bill and I have counted the number of times that the Secretary of State is mentioned; the total is 127 times. That does not include the references to the Secretary of State for Scotland. The Secretary of State for Health is the one who will make the regulations. It is he who will lay orders and give directions.
I understand that it is fashionable to describe this arrangement as enabling legislation. That is a misuse of our language. This is not an enabling Bill. It is a Bill for arbitrary government by whomever happens to be Secretary of State at the time. We know who the present Secretary of State is. I have no doubt that in his own way he is lovable. We have certainly grown to know his face. He has been in his present post since July 1988, and the Bill will not become law until April 1991. That is a long time for anyone in this Government to hold office. We all know that by April 1991, the Secretary of State will want to be at Victoria street, Marsham street or the Paris embassy at rue du Faubourg St. Honoré. He wants to be anywhere but on the bed of nails at Richmond terrace.
What if, in April 1991, the Secretary of State for Health is the right hon. Member for Cirencester and Tewkesbury (Mr. Ridley)? What use would he make of the powers that he would then hold? What powers will he inherit? Clause 44 sets out the Secretary of State's duties in respect of community care:every local authority shall exercise their social service functions in accordance with such directions as may be given to them under this section by the Secretary of State.That is all we are told. We are not given any guidance on what the directions might be.
I must be fair and candid to the House and say that there is a limitation of the directions. There is one qualification of what the direction must be. Clause 44 (2)(a) states that the directionsshall be given in writing".That is the sole restriction on what direction the Secretary of State may give to local authorities in their use of community care powers. Even Erich Honecker would not have imagined that he could give directions that were not in writing. Clause 44 gives whomever is the Secretary of State the power to use directions without even the process of scrutiny of parliamentary approval, in so far as I can describe the rubber stamps on the Benches behind the Secretary of State as a process of scrutiny.
We are talking of directions to health authorities that have not been appointed by the Secretary of State. I ask my hon. Friends to mark this well: they are directions to local authorities elected by local people and accountable to local people. That brings us to the greatest reason of all for suspecting that rhetoric is running ahead of reality in the Bill.
The Government and the Bill are loading local authorities with responsibilities without disclosing what they will do to increase resources for local authorities. Here is another major departure from the Griffiths report. 516 There is no ring-fenced grant for community care for local authorities. Any money that is provided for community care will disappear in revenue support grant.
There are two critical problems, the first of which has been mentioned by the president of the Association of Directors of Social Services, John Rea Price. He asked, "What will happen to my authority?". His authority is Islington, which receives no revenue support grant. In other words, there is no grant for the money to disappear into. There are not many such authorities in Britain, but they are almost all inner-city areas with massive social problems. Their populations all need community care. It would be ludicrous if they were to have the liabilities under the Bill but, thanks to the funding arrangements, not a penny in grant to meet them.
The second problem is that already the revenue support grant bears no relation to the revenue that it is supposed to support. One Conservative Member referred to overspending authorities as Labour authorities. I must tell him that nine of the 11 authorities in England and Wales are overspending under the official definition, whether Labour or Conservative. In those circumstances, any additional money provided through the revenue support grant will be barely noticeable against the growing gap between the grant received and the services that authorities are supposed to maintain.
We know that the Secretary of State knows that. We know that he understands full well just how stretched on the rack those local authorities are. We know that he understands how difficult it will be for them to shape up to the new responsibilities without new resources. We know all that because the obligation in the Bill is limited to an obligation to assess people for the community care service; it is not an obligation to deliver that service once there has been an assessment. As the National Council for Voluntary Organisations observed:Assessment without action, or a place on a waiting list is of little value to someone in need of care and support.We also know what will happen when those waiting lists for community care services develop. From the Secretary of State's past performance, we can predict that the moment that those waiting lists of people who have been assessed but for whom there are no resources available appear, the Secretary of State will put the blame on poor management by directors of social services.
I shall conclude by trying to seek the common ground, desperate though that search is. On one point I will commend the Secretary of State; on one point I will pay tribute to him in recognition of what he has done this day. The Bill that he has presented to the House is, without question, the most fundamental change to the National Health Service in its 40 years. The Bill will change a public service into a business enterprise, in which the motivation will no longer be which treatment is most needed by the patient, but which treatment yields the highest mark-up for the hospital. It will change an integrated service of primary care, hospital care and community service into a fragmented service in which the new relationship between the divided units no longer will be co-operation with one another but competition against one another. It will change a service in which the objective is to give the patients the treatment they need at the hospitals of their choice into one in which they get the treatment for which their health authority has taken out a contract or which their general practitioners can afford at the hospitals that offer it most cheaply.
517 I do not deny that the Secretary of State has the power to do these things. I am confident that the Whips will deliver a majority on Monday evening and give him a Bill that gives him even more power. However, I deny that he has the mandate to use those powers for a Bill so unpopular that its passage through this House will be as much an affront to democracy as a threat to the NHS.
The Secretary of State tonight spoke for the Conservative party; he did not speak for a Government who represent the people of this country. In this debate, it is the Opposition who speak for the people outside. At the end of the debate, we will vote the way they would vote if they were admitted to this Chamber—we will vote to throw out this prescription for a commercialised Health Service.
§ Sir George Young (Ealing, Acton)
Listening to the phrases used by my right hon. and learned Friend the Secretary of State to describe the reforms in the Bill, I thought that they seemed familiar—promoting competition and choice; making the system more responsive to the consumer and less dominated by producer interests; pushing decision-making down the management tier; and promoting efficiency. In fact, those were the phrases used in the Education Reform Act.
The parallels between reforms in this Bill and those in the Education Reform Act are striking, and hon. Members on both sides of the House could learn much by considering them in tandem. For example, the proposals for grant-maintained schools are replicated by those for self-governing hospitals, giving a measure of independence and local autonomy within the state-funded sector. Those for local management of schools are replicated by those for general practitioners to become fund holders, allocating resources as closely as possible to the point of consumption. The proposals for open enrolment and funds following the pupil are paralleled by those that facilitate switching one's GP and greater reliance on capitation, so rewarding popular provision and making the system more responsive to the consumer. National curriculum and assessment are paralleled by the proposals for medical audit to try to measure output and value for money, to raise standards and to determine where improvements might be made.
The philosophy behind the Bill is not new; it is wholly consistent with a similar reform to another part of the welfare state, with high political stakes, that touches most of our lives. I draw much comfort from that parallel, and also the opportunity to learn some lessons. I remember when the education reforms were launched, before the last election. I do not doubt that, initially, they were a political minus. They were not popular on the doorstep. At that time we were told that it was wrong to apply the sort of concepts that I have described to state education. There was dismay at the violent reaction from the producer interests—principally the National Union of Teachers. There was a confused response from the Government to some fairly basic questions, giving the impression that the proposals had not been thought through.
Two years ago, Conservative Members spent a great deal of time explaining what was going on to school governors, parent-teacher associations and parents. Much of the time was spent fighting fiction and we also had to listen to the Opposition making the same sort of speeches 518 as the one that we have just heard from the hon. Member for Livingston (Mr. Cook). I do not expect Opposition Members to agree, but I believe that those educational reforms are now a political plus. There are still difficulties, to which I shall refer in a moment and from which we must learn, but the debate matured, the argument developed and it was won.
The new language, the new ideas, have taken root. Concepts that were derided three years ago are now quite popular. I speak not as a Conservative Member of Parliament but as a parent and school governor in saying that concepts such as national curriculum and assessment, local management of schools, open enrolment and grant-maintained schools are popular and accepted.
The conclusion that I draw from that parallel, which is relevant to today's debate, is that people do not rule out radical change to the welfare state, provided that the basic principles are left untouched—free at the point of use, available to all, funded out of progressive taxation. Indeed, there is much evidence that there is an appetite for change once it has been properly explained, and a warm welcome for it when it is implemented.
§ Sir George Young
I am prepared to give way only once, in an attempt to reduce the average length of speeches.
§ Mr. Taylor
I am grateful to the hon. Gentleman for making me his No. 1 choice. The hon. Gentleman has drawn a number of parallels between this Bill and the Education Reform Act. He suggested that, provided it was set out within the right framework, radical reform was acceptable. One of the differences between opting out of schools and the proposals for hospital trusts is that there is no intention to provide any process of consultation with the users in the way that there is with parents in schools. How does the hon. Gentleman feel about that?
§ Sir George Young
The users of a school are relatively easy to define, but the users of a hospital are not. That is an easy point with which to deal. I have now provided the one opportunity for Opposition Members to intervene.
There are lessons to be learned from the debate. First, changes must be adequately resourced. Secondly, the time scale needs to be realistic. Thirdly—and crucially—high staff morale is essential if the benefits are to be secured. In the same way that we cannot achieve our educational objectives without teachers, so we cannot achieve our health objectives without the enthusiastic commitment of NHS doctors and staff.
It is all very well Conservative Members of Parliament declaring themselves content with the philosophy of the Bill, but what will happen on the ground to convince the voters that we are right? I shall look briefly at the impact of our reforms at primary care level and assess the medical and public response. I choose primary care for a number of reasons. First, the units—basically, general practitioner practices—are far smaller than the other units in the NHS—basically, hospitals. Therefore, it is easier for them to respond than it is for an organisation that is, inevitably, more bureaucratic. Secondly, the units are run by independent contractors and are more likely to display an entrepreneurial flair. Thirdly, what happens in a GP practice is loosely defined. In my view, general practice is what is done by general practitioners. Therefore, it is easier 519 for them to respond pragmatically to changing consumer demand and raised expectations than it is for other parts of the NHS, where contracts may be more rigidly defined.
Politically, what happens at GP level is crucial, because for most of us this is the only experience of the NHS. Every year, two thirds of us visit a GP, and the average constituent goes to the GP four times a year. Nine tenths of consultations go no further than the GP practice, so it is here rather than at hospital level that we shall be judged. The hon. Member for Livingston was a little misguided in spending nearly all his time on the hospital service and saying almost nothing about the GP service.
The combination of advertising, leading to raised expectations the changed capitation arrangements and the facilitation of switching will have the most dramatic effect on primary care that the NHS has ever seen. I speak as someone who represents an urban seat, with many practices within the reach of most constituents. I recognise that the position will be different in the rural areas. In a nutshell, what will happen is that market forces will work. There will be competition and choice, and this will push up standards.
For example, it may become known at one medical centre there is a creche where parents can park their children while they have a consultation—if not every day then perhaps on some days. The word will get around that that practice offers that service. Another practice may be offering minor operations at the centre, dealing on the spot with cysts, verrucas and warts. Others may have negotiated special deals with local keep-fit centres and health clubs, perhaps with discounts for their patients. Others will have clinics for those with particular needs such as arthritis and diabetes, or slimming groups. We could see more chiropody and counselling at GP level. A variety of services will be developed, making it less necessary to visit hospitals.
§ Sir George Young
I shall give way to my hon. Friend when I have finished this point, but that will be the last time that I shall give way.
It is not unthinkable that, in some of the larger practices, they will take X-rays, saving patients the bother of going to hospital. After all, that has now become routine at the dentist. There may be other services that no one practice can provide on its own, but that collectively, a number of practices can provide to improve the quality of care. There will be enormous pressure to improve premises, to the benefit of the patient, and to improve what one might call customer relations, such as more helpful receptionists and less queueing.
§ Mr. Winterton
?: My hon. Friend is implying that these facilities and activities are not already provided by the large majority of practices. Will he comment on that, and also on the fact that the guru who advised the Government on the changes, Professor Alain Enthoven, has expressed deep concern that fund-holding practices cannot properly or even effectively operate on a practice of only 11,000 patients?
§ Sir George Young
The very next sentence in my notes says that some of this exists already. However, what does 520 not exist is the pressure to improve. There is little awareness of what is available in the more progressive practices. Expectations of what one should get from a GP are low. The Bill's provisions will result in more choice, more competition, more variety and an incentive to improve that does not exist at the moment. Some GPs will decide that this is not for them, but others will seize the opportunities available and dramatically improve services.
In two years' time, as we approach the election, people will be confronted by different rhetoric from the two sides of the House. We shall be talking in terms of billions of pounds spent—something that people seem reluctant to believe, and have difficulty in understanding. The Opposition will be full of their usual doom and gloom. I shall ask my constituents to judge for themselves, by their own experience of what has happened.
For that to be a successful test, we must learn from education. We need to examine resources, timing and morale. On resources, as we move over from a system where the producer is king to one where the consumer is king, there will be even more pressure for more resources. If the money is to follow the patient, the patient must have a full wallet. Otherwise, the patients will become impatient. The new system will quickly identify where supply is failing to meet demand. For our philosophy to succeed, there must be adequate funds.
What terrifies most of the GPs to whom I have spoken is timing. They are not all hostile to the concepts in the Bill, but the data that they need to give to the family practitioner committee and the district health authority are not data that they have at the moment. Nor do they have the information technology to identify, that data. I ask the Government to look again at some of the time scales to see whether we are not trying to do too much too quickly.
The third factor is morale. To achieve the higher standards of health care that we all want to see, we need an NHS in which the staff feel appreciated and are well motivated. We must do even more to win over their hearts and minds and show all of them that what they do commands our respect and appreciation. At the end of the day, they deliver health care, not us
In the time available, I have not touched on much of the Bill, and in particular have not mentioned community care. However, I hope that I have said enough to show that I have faith in the reforms and that I look forward with confidence to their introduction.
§ Mr. Michael Foot (Blaenau Gwent)
The hon. Member for Ealing, Acton (Sir G. Young) has already referred to the crucial aspect of the debate—the feeling of those who will have to operate the service. Before talking about that, I shall make two brief personal references. I am the only Member who was here in 1948, when the original Bill went through the House. Even more appositely, I have recent experience of the NHS. I had two operations done at once. When I went to another consultant in the same hospital, rather boasting about this achievement and thinking that I had got it purely on medical advice, the consultant who was dealing with a different part of my anatomy said, "At any rate, that will have saved the NHS some money." I am glad that I have done so, as I am interested in how much money the service gets.
521 I thought that the Secretary of State would have come here with a little humility after all these weeks and months of debate. I thought that he would have listened a little to what has been said by people outside this place. I was staggered when he quoted only one sentence from the document presented to the Government a week ago by the bodies representing all the people who work in the NHS. They include not only the unions, whom the right hon. and learned Gentleman is so eager to deride at every opportunity, but the nurses, all the royal colleges and the British Medical Association. They all joined to make representations to the Government at the last moment, to try to put their case. The Secretary of State merely picked out one sentence, trying to suggest to those Tory Members who might be innocent enough to believe it that there had been some change in the attitude of those who will have to put into operation the proposals that the Government are seeking to force on them. There has been no change in the attitude of all those bodies, and that is not just due to propaganda.
I hope that everyone working in the NHS will listen to, or read, the speech made by my hon. Friend the Member for Livingston (Mr. Cook). I am sure that they will have great respect for what he has done, and the way he has put his case, ever since these proposals were introduced. He was never better than he was today. To surpass even his own previous performances took some doing, but he did it and he tore the Government's case to tatters.
Why do the Government not stop for a few minutes—the hon. Member for Ealing, Acton (Sir G. Young) had enough diffidence to do so—to ask themselves why their policies are so unpopular, why their proposals do not command any real support among the vast majority of people who know about the service, be they the doctors, the nurses, the patients or anyone else involved in the service? Why have the Government been unable to persuade them? Do they not have the humility to wonder whether there might just be some defect in their proposals which has led to that extraordinary situation?
The Secretary of State was appointed to his job as the greatest of the communicators, but he must be the most misunderstood man of the century. Apparently, nobody knows what he has been saying. He has had plenty of opportunity and has spent huge sums of taxpayers' money to speak at the top of his voice, but still he is not believed.
When I was in hospital the other day I did my best to defend the right hon. and learned Gentleman; to see what his good qualities might be. I was asked whether I thought that he was all had. I stopped for a moment and I did my best to think, as I am thinking now, what I could say in his favour. The best thing that I could think of is the fact that he is a supporter of Nottingham Forest, but if my friend Brian Clough managed Nottingham Forest in the way the Secretary of State has managed the NHS he would be reapplying for readmission to the fourth division.
The right hon. and learned Gentleman should have learned from his follies and mistakes. Right at the beginning he made an appalling mess of the nurses' regrading, which was carried out so inefficiently and insensitively that there are still many scars. As the right hon. and learned Gentleman said, huge sums of money were spent on the regrading process, yet far from in any way improving the atmosphere in the service, it has done the exact opposite. I checked last week, and even today in Wales, and no doubt in many other parts of the country, great soreness remains among vast numbers of nurses 522 about the way in which the regrading was done and the way in which they were misused and misled. That is still creating grievance in the service.
One would have thought that the right hon. and learned Gentleman would think about that and consider some other way of going about his reforms, especially since the source of all the suspicion in Britain is the way in which the plans were originally devised.
When Aneurin Bevan set up the Health Service, he said that a way would be needed to inquire into the service every five or 10 years to see what improvements could be made and whether it could be enlarged, using the experiences that had gone before. He put forward such an argument on every Bill that he introduced. Of course he wanted to see such a process in the NHS. It was never dreamed then that the NHS would be kept on exactly the same lines as it was when it was first introduced.
The Labour party has never been against making changes in the NHS to make it greater, and I am sure that the next Labour Government will do exactly that. But the present Secretary of State and the Government began in the worst possible way, and that was the origin of the deep and justified suspicion about all their proposals—whether for general practice, for the NHS or for community care, on which the Government have consulted a bit more but not much more.
The Government did not consult at all. A committee presided over by the Prime Minister was charged to try to produce some proposals for the NHS which would satisfy the Prime Minister—the very worst way of going about it. The Secretary of State was not even on the committee. He chose to take on the job when the Prime Minister was showing greatest omniscience or omnipotence—whatever one likes to call it—when she thought that the Government had absolute power to do whatever they wanted. The Secretary of State is a clever fellow, but his ambition got the better of his political intelligence at that time. He took the job and now he is landed in it. Every time he gets up to speak he is even more unconvincing, and he has never been more unconvincing than he has been today.
§ Mr. David Nicholson
I am grateful to the right hon. Gentleman for giving way. It is always difficult to find a full stop in his remarks.
Will the right hon. Gentleman say whether it is still Labour policy to abolish competitive tendering in the NHS and whether the Labour party will continue the vendetta against private practice that the Government of which he was a member carried on? If so, how will that help the NHS?
§ Mr. Foot
There was no vendetta against private practice. The Labour Government carried out the measures that they said that they would carry out and introduced many measures for enlarging and protecting the NHS and some of its essential principles. I shall come in a moment to what should figure most prominently in a new Labour Government's plans for the NHS.
It is the origin of the Government's proposals that poisoned them right from the beginning. That is the reason for the strength of opinion throughout the country. The right hon. and learned Gentleman should have understood that. Do men gather grapes of thorns, or figs of thistles? No one could get good reform for the NHS out of a committee presided over by the Prime Minister, who was 523 eager to discover some means—she did not want to use the word "privatise"—to twist the Health Service into something different. The Prime Minister has no need to worry when such charges are made against her. She is supposed to be a great conviction politician. Presumably, one of her convictions is that Socialism is wrong.
Yet Socialism was embedded and entrenched in the NHS from the very first. The right hon. Lady says that she will kill Socialism in Britain, but she cannot do that without killing the NHS. To make a frontal attack would be too damaging, so the Government have carried their intentions through in a surreptitious way, which my hon. Friend the Member for Livingston (Mr. Cook) has exposed. But they will not succeed because they have not been able to carry any significant section of opinion with them. One of the principal reasons for the change in mood throughout the country, and one of the principal reasons for the Government's coming defeat, is what the Prime Minister has tried to do to the NHS. Most Conservative Members know the truth of that.
The question is how much damage the Government will be allowed to do in the meantime. Anyone who accuses the Labour party of using the arguments about the NHS for partisan purposes, should recall the offer made by my hon. Friend the Member for Livingston on behalf of the Labour party in May, before the Bill was introduced. From the point of view of political advantage, it was not an easy proposal, but from the point of view of protecting the Health Service, which we want to build up in a proper way when we get the chance, it was a good proposal.
My hon. Friend suggested that we should not go ahead with the Bill but should let the electorate decide what kind of Health Service they want. They did not have a chance to do that at the last general election because the Government's proposals were not before them. My hon. Friend suggested in May that the electorate should be allowed to decide at the next election. We shall indeed decide then, of course, but shall we be allowed to decide before all the changes and convulsions in the NHS are introduced, with all the damage that could be done? That would be much fairer. If the Government had any desire to protect the NHS they would have accepted that proposal. As I said, it would not necessarily be to the Labour party's political advantage, but it would have meant that the British people would have the fair choice of deciding whether they wanted the Labour party's proposals or the Government's proposals. If the Government had had any faith in their proposals, they would have accepted that proposition then.
It is quite improper for anyone to suggest that the Labour party has used the great argument about the National Health Service for its own partisan purposes. We have been eager to protect the NHS and its future, because we believe that the service is the greatest domestic achievement of any Labour Government in modern times and we want to ensure that we have a chance to build it up properly. I am sure that my hon. Friend will be there to do that.
We shall want—among other things—to carry forward some of the reforms that were initiated in 1948. No one claimed then that the NHS had been founded on a democratic basis—indeed, the co-operation of doctors and other staff would never have been secured if that had been 524 the case—and a national scheme had to be devised to take over many local government operations. Nevertheless, Aneurin Bevan and the others who introduced the scheme always argued that a much firmer democratic basis must be re-established in the NHS.
§ Mr. Foot
Certainly it was thought that the new democratic system should be partly union based, in that those who worked in the service should have their say; more important, however, it was felt that it should have a basis in local government. The Prime Minister and the Government hate local government almost as much as they seem to hate the trade unions, but they have been logically forced to return to it by the sheer need to do something about community care. Their scheme is still half-baked; it is time for them to discuss it much more openly with local authorities, and to give those authorities the chance to make a full contribution that they never gave to those who work in the Health Service.
The National Health Service is one of the main issues on which the next election will be fought. I have no doubt that the country will make up its mind that it needs the Opposition's proposals for the protection of the existing service, and for its future. I congratulate my hon. Friend and his colleagues on the steadfastness with which they have put the case for the whole country, and on their refusal to be led astray by any of the diversions prepared by Conservative Members. They have made a great contribution to the welfare of the whole country.
§ Sir Michael McNair-Wilson (Newbury)
I shall not follow the right hon. Member for Blaenau Gwent (Mr. Foot), except to say that it is clear from his speech that even an old Socialist will become inherently conservative as he grows older. The right hon. Gentleman's vision of 1945 is so perfect that, 40 years later, he believes that it cannot be improved upon; yet he knows that he was part of a Government who reduced expenditure on the same National Health Service that he is now lauding to the House. He also knows that it is Government's responsibility to manage the affairs of this country as they think best at any given moment, and to accept the economic circumstances in which such services can be provided.
I do not criticise my right hon. and learned Friend the Secretary of State or the Government in any way for taking on themselves the task of looking at the NHS 40 years after its inception, or for asking whether its structures are as perfect as the right hon. Gentleman would have us believe or whether they can be greatly improved—not only to make the service better for those who work in it, not only to maximise its assets, but, most important of all, to ensure that the patients who are its customers benefit from the best treatment available.
Having said that, I must also say with some regret that the Bill, in my view, has missed a golden opportunity. Both the hon. Member for Livingston (Mr. Cook) and my right hon. and learned Friend talked about patients, but the Bill makes no reference to their rights; I wish that it did.
The Health Service, as we all know, is available free at the point of use. It is about making people better—as many as we can, as often as we can and as effectively as we can, both economically and clinically. When, as sometimes 525 happens, it fails to offers the service that we can reasonably expect, we are right to ask for explanations and apologies—and, I believe, for compensation for medical accidents without recourse to law. We, the patients, have entrusted ourselves body and soul to the medical staff to be made well: they have a duty to tell us what went wrong, and to compensate us if they have made a mistake.
I know that that is contentious, but I do not believe that we can continue much longer with the present compensation scheme, in which negligence is the sole reason for an offer of compensation. I am sorry that the Bill has done nothing to redress what I believe to be wrong, or to establish patients' rights more firmly—as firmly as they were spelt out in the patients' charter, that I drew up with the Association of Community Health Councils for England and Wales and presented to the then Secretary of State at the beginning of 1987.
Because of my views on the need for the service to meet patients' requirements, I strongly support the concept of medical audit. That concept is inherent in the White Paper, whose intention was to raise standards generally. The Bill provides for the involvement of the Audit Commission, which will bring about a similar effect in a different way.
Audit can be clinical or managerial: it can be assessment of medical practice, or a check on how resources are being used. Either way, it measures performance, and that has been one of the shortcomings of the service hitherto. The structure that we intend to use for clinical audit, involving the royal colleges, will require many man hours of consultants' time if it is to be effective, and will thus be a costly exercise. Extra resources will be needed if it is to be done properly, and it must be done properly if it is to be of real value.
If we have audits, what sanctions will go with them? Will their findings receive a public airing, or will they be confidential? Will access to the findings of a clinical audit be restricted to the doctors involved? Can a health authority be censured for poor performance, and required to do something about it? That is what patients will want to know—or, at any rate, what their representatives on the community health councils will want to know.
Perhaps, at long last, medical audit will provide some yardsticks for clinical competence. If it achieves its aim in making a contemporary assessment of a doctor's ability, it may shed light on whether—as a result of the speed with which medicine is progressing—retraining should be part of the work experience of doctors.
Ever since the Secretary of State gave me an assurance earlier this year that no chronically sick person would ever go without the drugs that he or she required from a GP, I have found it difficult to be convinced by those who have spread scare stories suggesting that the effects of indicative drug budgets would be detrimental to patients.
The national drugs bill is huge, but I do not doubt that most of it is wisely spent. However, we all know of doctors who prescribe six months' supplies of drugs, such as sleeping tablets, without ever considering whether the drugs are really needed or whether another course of treatment might be better for the patient. We know that 27 million tranquillisers are given out anually and that some doctors prescribe without a thought as to the price of the drug, or whether there is a cheaper generic substitute.
We all know that antibiotics given to cure an illness are thrown away before they are fully used up, simply because we are feeling better and have no further need of them. Patients seldom stop to think that they are throwing away 526 public money. I do not think that it is unreasonable to ask the medical profession to have a care about what they prescribe; it is being paid for out of public money. That should not inhibit their clinical judgment, and from what my right hon. and learned Friend the Secretary of State has said, it clearly will not do so. However, it should make them more conscious of value for money. That point will not be lost on the drugs industry, efficient though it is.
I was grateful for the Secretary of State's answer to my question about hospital drug budgets. However, wonder drugs do not always receive the financing that they require. I personally am able to talk about a drug called erythropoetin, which is given to kidney patients who are receiving dialysis treatment. I am such a patient, and I can assure my right hon. and learned Friend that it is a wonder drug for kidney patients. It overcomes acute anaemia, it returns their haemoglobin to a normal level and it gives them back the energy that they lost when their kidneys failed. However, the hospital that is looking after me is funded for only half the number of kidney patients that could benefit from that drug.
I hope that the Department will examine again the possibility of finding sufficient money to fund a new drug when it comes on the market. It can, as in the case of erythropoetin, completely change someone's physical characteristics for the better. It is not good enough simply to say that the amount of money that can go into a hospital's drug budget is restricted and that the hospital must decide how to spend it. If we want to make progress with drugs research, we must provide the finance to make the wonder drugs available to the largest possible number of people.
I am concerned about an apparent overspend in West Berkshire health authority's drug budget during the first part of this year on acute cases. Taken together with other projected overspends, the authority will have to make reductions if it is to stay within its overall budget. Certain expenditure savings are possible without affecting patient care. However, in a letter to me, the chairman of the authority said:To a great extent the severity of the forthcoming winter will control the success of this exercise. Inevitably there will, in any event, be a reduction in elective surgery.That suggests to me that the two general hospitals in Reading are working within too narrow financial restraints. Some of the £33 million that, it was recently announced, will be used to help to reduce waiting lists may come our way. The abolition of the Resource Allocation Working Group formula, which has kept the Oxford region under-funded for so long, will improve our cash flow.
Perhaps we shall not have a severe winter, or an epidemic, but there are inescapable grounds for concern in the case of all of us who may need to use those hospitals this winter. I wonder why, year after year, we never seem to get the funding quite right. After April 1991, with the introduction of contracts between health authorities and hospitals, under which the health authority purchases health care from a hospital, that position will change. The audit may show up management shortcomings and even places where either savings can be made or resources generated.
We shall always want to use our district hospitals whenever possible because of the benefit of local access and family support, but the Bill will result in health authorities having a new discretionary power to buy 527 services that cannot be provided locally at an economical price and to use the hospital facilities of other district health authorities to meet the needs of patients living on their periphery, if that is more convenient for the patient. By the same token, district health authorities may well see the advantages in encouraging local hospitals to specialise and so attract external contracts.
To revert to kidney patients. I think that it is possible that, as a result of the Bill and of the fact that the money will go with the patient, district health authorities which are currently sending their kidney patients for dialysis to hospitals that are often a very long way away from where they live, will treat those patients in the local hospital. They will set up small dialysis units, because they will have more money with which to create them. That is a positive example of the benefits that the Bill will provide for a particular group of patients whose needs are not met under the existing structure.
That is an example of one group of patients about whom I know quite a lot. Perhaps I ought to have declared an interest and said that I am the president of the National Federation of Kidney Patients Associations. The money will go with the patient and the district health authority will have sufficient finance to set up dialysis units, of whatever size is needed, for its own patients.
The introduction of block contracts will result in new financial incentives for the Health Service. It should create healthy competition and an effective internal market, in which hospitals will consider what they can do best to maximise their assets. There will be performance audits to improve clinical care and quality of service. Practice budgets will give groups of doctors a new freedom to get the best for their patients. Some self-governing hospitals will be able to take responsibility for their budgets and for the way in which they manage their facilities and set out their stall.
The reforms will take time to shake down and to work effectively and efficiently. No doubt changes will be made as we learn from experience. That is how it is with all reforms. I end, however, as I started, by reminding the House that the changes brought about by the Bill will be a success only when patients say that they are successful. They are the customers of the health care provisions that we make. They will decide whether, after 40 years, we have crafted a National Health Service that, to quote the Prime Minister, is so good no one will want to go privately. I believe that the Bill is an important step in that direction. I wish it well.
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. It might be sensible if I were to remind the House that Mr. Speaker has decided that the 10-minute limit on the length of speeches should apply between 7 and 9 o'clock.
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
No hon. Member doubts what has been said by the hon. Member for Newbury (Sir M. McNair-Wilson) about his personal experiences, or the sincerity with which he speaks. It is always a pleasure to hear him speak in Health Service debates.
528 The hon. Gentleman legitimately criticised certain aspects of the Bill. I agree with him. Not the least of those criticisms is the fact that patient rights are given little prominence. The Secretary of State said little about those rights today. However, I do not share the hon. Gentleman's optimism about other aspects of the Bill. It can be understood only in the context of Conservative party thinking on the subject. During the last decade, the Government have come to believe that they know the price of everything. The Bill is the apotheosis of that process. However, they have revealed that they know the value of nothing. Nowhere is that more clearly demonstrated than in their proposals for the National Health Service.
Throughout the last decade, the Government have been singularly unsuccessful in persuading the British public, in the Prime Minister's famous phrase, that the Health Service is safe in the Government's hands. Opinion poll after opinion poll throughout that period has demonstrated that they have not persuaded the British public to that view. Personal experience at community level has underscored that point. People have seen the distance widen between the rhetoric of Ministers at the Dispatch Box and on national platforms and the reality of what is happening to the NHS. They have witnessed forced cuts, ward closures and a general decline in morale among so many of the professionals within the NHS.
Perhaps it reached its most farcical climax under the present Secretary of State during the difficulties and the controversy, referred to by the right hon. Member for Blaenau Gwent (Mr. Foot), which surrounded the nursing profession in the summer of 1988. The Secretary of State disappeared out of the country and the service appeared to be rudderless. More time and money seemed to be spent by the press trying to track down the Secretary of State abroad than the police devoted to trying to locate Lord Lucan. The difference between Lord Lucan and the Secretary of State is that Lord Lucan got away with murder before he left the country, whereas the Secretary of State has been trying to get away with ministerial murder since he returned from that summer sojourn.
The proposals were made by the Prime Minister and handed to the right hon. and learned Gentleman by his hapless predecessor. This is a fundamentally bad Bill for Britain.
It is worth taking the Government at face value and considering the thrust of their approach. Their White Papers are called "Working for Patients" and "Caring for People". I echo the words of the hon. Member for Newbury (Sir M. McNair-Wilson) and ask to what extent the Bill enhances, strengthens and extends patients' rights within the Health Service. The conclusion has to be, emphatically, that it does not.
Hospital trusts, budgets and contracts and the language used by the Secretary of State in his opening speech are all designed to enhance competition through the diversion of financial resources, rather than through the extension of consumer choice.
I shall give two examples. The first is hospital trusts. Several of my hon. Friends have challenged the Secretary of State during the debate to say why, if patients are to be of paramount importance, there is no inbuilt mechanism for them to be consulted about the future of a hospital, when it makes a fundamental decision about opting out of the Health Service—or, if the Government do not like that expression, deciding on hospital trust status.
529 Secondly, when we consider the new three-year contracts to be held by health authorities and GPs for care at a hospital which has put in a bid for a particular type of treatment, our main worry must be that the motivation for sending a patient in a particular direction will be financial rather than consultative or allowing the patient the right to choose the treatment and the most practicable hospital for it to be carried out.
The Government claim that patients will be all-important, but the truth is that, given the motivation behind the Bill and the mechanics involved in it, their position will be devalued.
On the principle of general practitioners' rights of referral, the Department of Health has said that theycannot be interpreted as a licence for GPs to disregard the contractual arrangements … a presumption of the right to make an extra-contractual referral cannot be a guarantee that the DHA would in all cases meet the cost".That is the proof of the pudding. Money is talking in all the decisions and the new mechanisms that are being set up. As many right hon. and hon. Members have already said, what is worse is that none of the available evidence shows that the Department has a clear conception of that.
Even more important is the fact that GPs, in order to make correct, informed decisions about a patient, will require a degree of information technology, recall facilities, and computer links within the National Health Service, which they simply do not have.
Today I heard evidence from a number of hospitals, some of which are potential bidders for trust status in two years' time. They said that they need time to bring information technology facilities up to scratch to meet the provisions of the Bill if they are to achieve independent hospital trust status. The Bill will be £6 million a time. I think that the Select Committee has examined that and come up with evidence for it.
Where is the money to be found for the necessary upgrading of information technology to make a success of the scheme, and to enable the necessary take-up of the innovations proposed by the Secretary of State? I do not base my arguments on the grounds used by the Opposition, because we are opposed to their scheme, but on those laid down by the Government. It has not been costed properly. A consultant surgeon, James Appleyard, perceptively wrote:No responsible and ethical business would undertake such an untried venture without the full costs and appropriate information technology to ensure these are valid and up to date.The best place to discover the possibilities of failure and abuse is in a letter to health authority chairmen and managers from the Department of Health, entitled "Pricing & openness on Contracts for health services" which states:Monopolists will have an incentive to restrict supply, to drive up price and either to inflate profits or costs. Buyers will be offered lower quantities at higher prices than would otherwise be the case … information about quality and price is generally poor … hence buyers are in a weak position to make meaningful price and quality comparisons and to shop around".I do not like the terminology, but let the Department speak for itself:All of this suggests that we will not always be able to rely on actual competition, potential competition or bilateral monopoly to ensure that the NHS internal and external markets work effectively".530 That is the advice sent out by the Department of Health, not an Opposition spokesman or a critic from within the Health Service.
Opposition Members should not feel so sad or frustrated about the Secretary of State. We know that he does not listen to nurses or to patients, he does not pay any attention to doctors and he rides roughshod over views expressed in Parliament. We can seek reassurance from the fact that he does not pay a blind bit of notice to what his own Department are saying about the centrepiece of the proposal—the flagship of self-governing hospitals. We will deal with that in detail in Committee, but I shall touch on three important issues.
First, the proposal turns the clock back. As the right hon. Member for Blaenau Gwent said, there has been a steady, if not always perfect, attempt to expand a truly planned National Health Service. Enshrined in that aim was the belief that, wherever one lived, one should have access, as far as possible, to the same level of treatment. The proposal can only erode that principle.
Secondly, the proposal will further entrench the importance of cash over care, with the result that the less profit-making services will have to be sacrificed to build an attractive and glamorous national image. The services that are most likely to go are basic services to the local community, such as geriatric and maternity services. I find it amazing that the Secretary of State could not say any more about that issue in his opening speech. We shall seek further clarification about what the Government and the Department think constitutes a core service that must be maintained by a district or regional general hospital.
§ Mr. Matthew Taylor
I have handed to the Secretary of State today a petition with 7,500 signatures from my constituents, who are concerned about the proposals. Are the problems of the scheme not best illustrated by hospital trusts? People feel that they are not being consulted about the future of a National Health Service that they are proud of and depend on. That problem is stirring up concern among ordinary people, not just among doctors and Front-Bench Labour or Conservative spokesmen.
§ Mr. Kennedy
I am grateful to my hon. Friend and pay tribute to the work that he has done in his constituency to alert people to the dangers. I know of one direct consultation exercise. It was conducted in the constituency of my right hon. Friend the Member for Yeovil (Mr. Ashdown). Some 96 per cent. of those who registered an opinion were unambiguous about their desire for the local hospital not to opt out of the National Health Service. That was a very good judgment.
Education and training is a deep worry to the Committee of Vice-Chancellors and Principals.
§ Mr. James Couchman (Gillingham)
It is flattering to have the whole Liberal doughnut to speak to. Perhaps Liberal Members will leave quitly.
I have taken a part in the management of the Health Service for much of the past 15 years, from membership of an area health authority and chairmanship of a social services committee in the middle 1970s to the chairmanship of a district health authority in 1982. My first year here was spent on the Social Services Select Committee, before I was invited to join the Department of Health and Social Security team as Parliamentary Private Secretary to my right hon. Friend the Member for Braintree (Mr. Newton).
From those diverse vantage points, I have become convinced of the urgent need for reform of the National Health Service. It has tottered from one crisis to the next for all of those 15 years. The symptom of the crisis has usually been a comparatively small apparent shortfall in the NHS budget. There appears to be a recurring £200 million shortage which suddenly manifests itself around Christmas time and causes panic among managers, who always try to resolve their imagined problem by closing beds, wards, or even hospitals, and by curtailing other sharp-end patient services. I deliberately used the terms "apparent shortfall" and "imagined problem", for £200 million represents less than 1 per cent. of the Health Service's enormous budget, and it requires much more sophisticated financial management to foretell an overspend of less than 1 per cent. four to five months before the end of the financial year.
Just two years ago, when my right hon. Friend the Member for Braintree was Minister for Health, there was a particularly severe dose of the pre-Christmas wobblies. As ever, 100 per cent. of the service was plunged into crisis for a 1 to 2 per cent. predicted cash shortfall. After some especially unsavoury examples of shroud-waving around the country, additional money was given to the Health Service, but the time had finally come to investigate the cause rather than the symptoms of the recurring crisis.
A committee to review the Health Serice chaired by my right hon. Friend the Prime Minister was convened. The result was "Working for Patients", which I welcome, for it challenges some of the most sacred cows of the service. The review recognises for the first time—the Bill tries to tackle it—the essential changing nature of health care, from the fairly simple public health service remedies of the 1940s to all the marvellous modern techniques which we increasingly regard as commonplace today. It recognises that the Health Service has become a victim of its own success, as each new therapy, whether surgical or medical, adds to everybody's life expectancy, but particularly that of the very elderly, and produces its own waiting list.
The Labour party uses waiting lists, or waiting times, as a stick to beat the Government because the last time Labour Members were in government, they allowed their union paymasters to force the devastating strike that we now remember as part of the winter of discontent. They remember the mismanagement of the economy, which led to the International Monetary Fund demanding major cuts in public spending, and the effect that that had on the NHS. The increase in waiting lists to an all-time record in 1979 was indeed a measure of failure. I believe that, today, the waiting list is largely a measure of the NHS's success.
532 There was no waiting list in 1959 for hip joint replacement or coronary bypass grafts. Those techniques were at an early stage of development. The lack of waiting lists for those and many other procedures was hardly a measure of success. Today, the waiting list is a good indication of people's vastly increased aspiration for life-saving and quality-of-life-improving treatments.
The review also recognised the rigidities in the present system which arise out of the NHS's very size, its massive work force, its inertia and the inefficiency with which its resources can be deployed. In short, the review recognises the near-impossibility of managing the Health Service in its present corporate or conglomerate form, and seeks to break it up into smaller, more manageable, and more reactive parts.
Waste is endemic in all very large organisations, and the Health Service is typical of that. Successive reorganisations have recognised, but not tackled, that problem of waste of resource, largely because they have not recognised the fundamental inefficiency of a vast monopoly purchaser of health care which is also a vast monopoly provider. The Bill tries to tackle that, but of course the Labour party, with its reverence for Aneurin Bevan's memorial, and its consciousness of its trade union masters, recognises the great danger of fragmentation to the trade unions. The Health Service is uniquely vulnerable to industrial dispute because of its national negotiating machinery and national wage agreements, which take almost no note of local circumstance. There is no doubt in my mind that it is this aspect of self-governing trusts which most frightens Opposition Members—that local pay and conditions will be negotiated without reference to the thrall of national union leaders.
The emphasis which the review and the Bill put on outcomes is to be welcomed. Medical accountability and clinical audit are long overdue. I believe that the vast majority of good clinicians will welcome the opportunity to have their dedicated efforts measured against sensible benchmarks. If the monitoring process highlights those few whose productivity is compromised either by idleness or by their assiduous promotion of their private practices, the Health Service will be the winner.
It is in regard to the outcomes that I should like to express one of my two reservations about the Bill. I refer to indicative drug budgets. I must declare that I have had many discussions with the pharmaceutical industry, and I have lately advised one company on matters pertaining to the Bill. It makes no sense to save a few pounds by denying a patient the most modern and efficacious medication if the outcome is that he or she lands up in hospital. That is a poor outcome for the patient, and a poor outcome for the service, but it is a risk if the only sanctioned or monitored measure of a doctor is his prescribing habits. Doctors who have practice budgets will have wider choices to make, but those without practice budgets may have care only for their indicative drug budget.
I should like to give an example of an extreme case. The new British drug eminase is a thrombolytic drug with the most exciting potential. It is given as a one-shot emergency injection to heart atttack victims. It dissolves the life-threatening clots and limits the amount of heart muscle that is destroyed by the atack. Moreover, its chemistry controls the rate of delivery over several hours. It is a very clever drug which markedly improves the 533 immediate prognosis for the patient, reduces the time likely to be spent in intensive care and reduces the likelihood of the victim being left a cardiac cripple.
Eminase offers excellent outcomes all round, but it is expensive. It costs about £500 for the single emergency shot. I should like to think that no doctor is mindful of his indicative drug budget when I fall victim to a heart attack and my condition indicates the need for an urgent shot of eminase.
While considering how to bring into line the minority of general practitioners who are bad prescribers—it is worth noting that under-prescription can be as detrimental as over-prescription—it behoves my right hon. and learned Friend the Secretary of State to remember his days at the Department of Trade and Industry, and the battle for a positive trade balance. The pharmaceutical industry is a rare star in that area, having an annual positive trade balance of some £850 million, but it is an industry in which decisions about investment are particularly susceptible to whether the market is perceived to be hostile or favourable. Investment decisions about where to put new research and development, manufacturing and distribution, especially by multinationals, but also by British companies, will determine whether that favourable trade balance is maintained.
The Henley centre has recently suggested that imprudent implementation of the White Paper proposals could be highly detrimental and cost far more than will he saved by the indicative drugs budget. That would be a poor outcome.
My second reservation is about the explanatory memorandum, which sets out in bland terms the costs of the Bill in financial terms and in manpower. That section sends shivers down my spine, for I have watched at first hand as a district health authority chairman the Health Service's infinite capacity for creating bureaucracy. The systems under which the purchaser, whether health authority or general practice, will contract with the provider for services offers scope hitherto undreamed of by bureaucreators. The method of tracing through and monitoring payment for service by the Health Service to the Health Service could make the reorganisations of 1974 and 1982 look positively transparent. Beware of the bureaucreator, who is already alive and well and flourishing among the regions, including my own region of South-East Thames.
As a former chairman of social services, I should have liked to speak about the community care proposals but I hope that I shall be allowed to contribute to the debate on them in Committee. I recognise that many other hon. Members wish to speak tonight. I believe that the Bill will take the NHS into the 21st century in a healthy and vigorous form. I wish it well and will support it enthusiastically.
§ Mrs. Gwyneth Dunwoody (Crewe and Nantwich)
For 10 years I have listened to Conservative Ministers say how strongly they are committed to the National Health Service and how simply it could be improved if only it had less money at its disposal. "Efficiency, efficiency, efficiency", we are told. More than one reorganisation of the Health Service has been masterminded by the great brains of the Conservative party resulting in chaos from which it usually takes the NHS a considerable time to 534 recover. But the present Bill is a real corker. One might call the ability to produce such a Bill a unique gift, even for the Conservative party. It is a Bill spawned in dislike, produced out of ignorance and apparently being pushed with malice.
The Secretary of State seems to have come to the House today, not to detail the changes that he genuinely believes will produce positive results for patients but to say that people in the Health Service who do not instantly agree with the mess of pottage that he is presenting to them are automatically ignorant, incompetent and malicious. That is the only explanation for his constant attacks on all sections of the NHS. He says that consultants keep up their waiting lists as part of their prestige, the nurses questioned their upgrading because they did not understand that it would put them on a better footing, and that the ambulance men must be starved into submission because they are just taxi drivers who do not understand patient care. I find that despicable. There are no words strong enough to condemn the performance of a Secretary of State who is not stupid and who knows that what he says is based irrevocably in deep contempt for the NHS.
The Conservative party has opposed every positive move since the Health Service was first suggested, and now it is coming forward with suggestions somehow to transform the NHS into a commercial organisation. I have received in my post an interesting glossy brochure emotively headed, "Not for Sale". One might think that that referred to some political party, but not on your life: it refers to the creation of hospital trusts among the mid-Cheshire hospitals. The brochure contains pictures of the district general hospital—in the centre of my constituency and the only one for a considerable distance—and the Victoria infirmary, telling us that they are not for sale.
Only towards the end of the brochure is one told that other hospitals will not be included in the opted-out independent NHS trusts. Those hospitals have one thing in common—all of them provide high-cost, important, long-term services for the mentally handicapped, for psychiatric and geriatric patients, and for others who require support services due to long-term chronic illness. The hospitals involved have one other thing in common—all have large acreages of land suitable for sale by an independent trust.
The Secretary of State says, "Don't worry, we shall have contracts," and that they will not really be contracts but agreements. If anything makes the hair on the back of my neck wave, it is a barrister who tells me, "Don't worry, it is not what it says but what I say it says." A contract is a contract. What will happen to services which are not provided to a standard that the people responsible for the bills regard as acceptable? Will there be constant litigation between sections of the NHS? When GPs find that they cannot obtain suitable services from hospitals, will they take some form of legal action against the hospitals concerned? It may seem absurd, but in my view it is all too possible.
What will happen under the Bill is quite different. It will be particularly damaging for rural general practices in my constituency. It is not true that the Bill will help women doctors. Many women doctors who have families like to provide single-session services, not just to keep up the standard of their medicine but to provide a useful service. General practices faced with a limited budget—we have been given no assurance that they will have sufficient 535 resources to run a proper service—will almost automatically cut down on use of single-session part-time doctors because, even if those doctors provide an essential service, the doctors in the practice will prefer to provide the service themselves even if it is less adequate. So long as they deal with sufficient numbers, that will be all that counts. They will say, "We can provide a sufficient level of care to ensure that we can put in the figures at the end of the quarter and get the cash back." That will be an increasingly frequent occurrence and those who wish to continue working on a single-session basis will have real problems.
There will also be problems of trust between patients and GPs. General practice is, after all, the best way of delivering health care to patients when they most need it. GPs are the best clinicians and they know when people need to talk and when they need medication. The GP should provide the services that have been paraded before us this evening as though they were revolutionary innovations. Twenty-four years ago I worked in a general practice where it would have been regarded as a disgrace not to be able to take out a verruca without being told by someone else that it was a brilliant idea.
We are talking not about the level of patient care but about money and the provision of more accountancy services. We are constantly being told of the huge sums put into the NHS in the past three years, but where has that money gone? It has gone to provide accountants and the modern equivalent of the cash register—the computer. Like all good computers, the NHS computers will no doubt lose as much detailed NHS work as they manage to lose political work.
There will be a fragmentation of the NHS. That was the word used by the Secretary of State. That is clear from the brochures that have been circulated to staff and it is clear to everyone who looks at the details of the Bill. The balkanisation of the NHS is what the Bill is all about. Increasingly, hospitals will compete with and not complement one another. They will not say, "Where are the services that are helpful?" They will not talk to GPs about the need to plan the integration of services so that practice nurses, physiotherapists and others can be provided. The Labour party has been asking for that for the past 10 years, ever since the massive investigation into NHS needs which was wholly ignored by the incoming Conservative Government.
I am still a softie at heart and I want to believe that the good, kind gentlemen in the Conservative party mean what they say when they talk about their commitment to patient care. Throughout the passage of the Bill, there will be repeated opportunities for them to prove that. They will be able to tell us how rural practices will carry on, and how inner-city practices, which already have difficulties with shifting populations, will be able to show that they have maintained the level of specialised care that they are told is essential. Conservative Members can also explain to us how the staff and, above all, the patients in my constituency are to discover what core services are.
The Bill does not make it clear what core services will be, but I can tell the House what the core of the Bill is—it is a deep contempt for the concept of the National Health Service, and the sooner the Government make that plain, the sooner patients will tell them where to go.
§ Mr. David Atkinson (Bournemouth, East)
This has been an exciting week in the Health Service for my constituents. On Monday, phase 1 of our new Bournemouth general hospital opened its doors to patients. It is a magnificent hospital, of which the East Dorset health authority has every reason to be proud. I congratulate all those responsible for it.
I take this opportunity to pay particular tribute to the people of Bournemouth and the surrounding districts for raising £2 million for the new Bournemouth hospital appeal. That enabled this already well equipped, new hospital to have the additional facility of a body scanner, which I had the pleasure to see in operation on Monday.
It would be well to remind the House, if it needs reminding after three Adjournment debates on this subject, why there were delays in starting the hospital. It was planned to be built more than 10 years ago, but together with many other hospitals it was a casualty of the cuts which the Labour Government imposed on their hospital building programmes. On behalf of my constituents and my hon. Friends the Members for Bournemouth, West (Mr. Butterfill), for Christchurch (Mr. Adley), for Poole (Mr. Ward), for Dorset, North (Mr. Baker) and for New Forest (Sir P. McNair-Wilson), I thank my right hon. and learned Friend the Secretary of State and the Government for making the money available for phase 1 to be completed and for the second phase now to commence.
Now I must be a little critical of my right hon. and learned Friend. I regret that he has combined in one Bill his White Paper proposals on the NHS with his White Paper proposals on community care. I know that the Bill is comparatively short, but these are two vital and distinct matters. One is primarily concerned with returning people to health, while the other is about keeping people in health at home. However, I welcome the Government's response to the Griffiths report, confirming his recommendation that it will be for local authorities to prepare plans for community care.
I wish to draw attention to several points which arise from the Bill and I look forward to hearing the response of my hon. Friend the Minister for Health on Monday. First, the need to ensure that schizophrenics are registered with a GP or are on a psychiatrist's out-patient list appears to have been overlooked. Clause 3 is not definite on that point. Secondly, mentally ill people are prone to moving around and to be of no fixed abode. How, then, will remuneration for health authorities on the basis of residence be made? Should the provisions in the Bill not be clearer on that? Thirdly, clause 41 does not make it clear that local authorities should agree their plans for community care with health authorities, as the White Paper suggested. I should be grateful for confirmation that the Bill provides for that. Fourthly, clause 46(3) provides for Scottish health boards to consult voluntary organisations in preparing their community care plan, but there appears to be no similar provision for England and Wales. I should be grateful for a response on that.
As one who helped to steer through the Schizophrenia After Care Bill [Lords] during the past Session, I was dismayed that clause 42 does not provide for community care packages for mentally ill patients to be specifically linked to their discharge from hospital. It is essential that this legislation is wholly meaningful for the mentally ill, 537 particularly for schizophrenia sufferers. The House will be aware of the widespread public awareness, support and concern for care of the mentally ill. Social workers will require new and specific training in the needs of the mentally ill to satisfy the complex community care needs which they will inevitably face. That will represent one of the major challenges of this legislation for local authorities.
I congratulate my right hon. and learned Friend on sticking so firmly to his original proposals, despite the unethical and highly misleading campaigns of the BMA and other unions. I welcome the opportunity for hospitals to free themselves from bureaucratic health authority control by applying to become self-governing trusts, if that is what they want. One of the essential points, which has not been accepted, is that that is voluntary and for local hospitals to decide.
All but one hospital in my health district have signalled to my right hon. and learned Friend their interest in becoming self-governing because of the opportunities that they foresee in developing the services and treatments which local patients and doctors want and which they can offer in services elsewhere. I expect that hospitals will return to being much more like the local community hospitals—which they were before nationalisation.
I welcome the opportunity for larger general practices to apply to manage their funds, if that is what they want. Again, it is entirely voluntary. In October I had a meeting with most of my GPs to discuss the contents of the White Paper, and, yes, I was disappointed that so few saw the advantages to develop their practice which would come with having their own budgets or the greater flexibility on treatment and waiting times for patients. Many of my doctors fear future underfunding, conflicts between partners, conflicts with the local family practitioner committee, conflicts of interests with patients and the need to employ accountants to control their budgets. I appreciate those fears, but I hope that practices that recognise the advantages and volunteer to have their own practice funds will prove that those fears are groundless.
I welcome the introduction of indicative drug budgets which build on the experience of the limited list, encouraging more cost-effective prescribing, which will release more resources to be spent elsewhere in the NHS. However, I must voice the concerns of some members of my local health authority who feel that the proposed smaller membership may mean too few members capable of adequately fulfilling the responsibilities and considerable commitments which membership entails. They also fear that there will be insufficient scope for a broad base of experience and representation.
A number of hon. Members have already said that my right hon. Friend the Prime Minister supports the reforms. She does so because she wants the NHS to be so good that no one will want to go private. The proposals are the last chance for the NHS to remove all the reasons why people are still prepared to sacrifice and to pay twice for an alternative service. If the reforms are not allowed to improve the service to patients so that waiting times are reduced a two-tier service will inevitably follow with the NHS as the safety net. My right hon. and learned Friend the Secretary of State has repeatedly said that he does not want such a service. It must be in the interests of all those in the NHS to make the proposals work.
§ Rev. Martin Smyth (Belfast, South)
I welcome the opportunity to follow the hon. Member for Bournemouth, East (Mr. Atkinson). I support his plea in aid of the mentally handicapped and schizophrenics. I also underscore what he said about local management. When the Secretary of State spoke about local management I began to wonder whether I was reading the Bill and the background to it in the same way as the right hon. and learned Gentleman. He talked about the need for smaller and more effective leadership and I can understand that. When he spoke of better local leadership, however, I could not understand him. He spoke about looking for respected people in the community to provide that leadership, but appears that locally elected representatives will be dropped. I find it strange that one should remove the local input and yet still expect the local leadership to be better than in the past.
I support the motion tabled by members of the Select Committee on Social Services which calls for a Special Standing Committee to be established after the Second Reading. Such a Committee would offer an opportunity to listen to and to cross-examine those involved in the NHS. That Committee hearing would last three days at the most and I believe that it would enhance the passage of the Bill.
I recognise that it is not always possible for Ministers t o listen to everybody. Last week some people were so keen to speak to the Under-Secretary for Northern Ireland with responsibility for health care that they pursued him over a roof. In the confines of the Committee Room I should like to think that the Committee, in the presence of the Minister, would be able to cross-examine NHS staff much more effectively.
Proper consideration should be given to special financing. When it was proposed that the finance specifically set aside for community care should be ring-fenced a Minister said that that meant that trust was not put in local authorities. The harsh reality is that the Government have rate-capped local authorities and come down on them in different ways. If the House budgets funds for community care, they should not be frittered away on other local authority services. If extra money is needed it should be raised in some other way and should not be taken from the funds for community care as that deprives people who require that care.
The National Consumer Council has pointed out that consumer input on the community care provisions in the Bill is inadequate. There is also no means by which local authorities can have a say and no provision for an appeal system to ensure that patients are treated where they want to be treated. In the Bill, no mention is made of community health councils. As far as I can tell, there is no requirement properly to consult those councils on community care plans. There is no provision for an appeal against a local authority social services department decision on community care, and there is no duty to assess that care. I know that that remark will be met with an immediate response that there is such a duty to assess. If one looks carefully at the Bill, however, it is clear that the duty to assess operates only when a need is identified. I believe that that leaves the door wide open.
When the Bill is in Committee I hope that careful examination will be made of its implications for the Disabled Persons (Services, Consultation and Representation) Act 1986. All over the nation the cries are 539 for the implementation of sections 1, 3, 2 and 7 of that Act. The White Paper promised that those sections would be implemented in the Bill, but there is no mention of that.
One of my medical friends in Northern Ireland who is generally sympathetic to the proposals wrote to me about one aspect which he felt limited the original emphasis of the Bill—patient choice. It appears that authorities and health boards will have the right to restrict the choice of the GP and the patient to be referred to a particular hospital if those bodies have no contact with that hospital. Perhaps that decision can be defended in terms of distance and finance, as suggested by the guidelines, but how does one equate finance with providing the right treatment for a patient? How does distance come into it when we have already heard about people being referred to a hospital 160 miles from their home? If the doctor and his patient believe that that is the place where he should receive treatment, why should an authority or a health board have the right to say no? That important consideration should be borne in mind.
As I represent a university constituency, I am especially concerned about research. The Bill provides little to require the NHS trusts to undertake and to commission such research. They are empowered so to do, but they are not required to do so. That will have an adverse influence on the proposed reforms.
I do not wish to prolong my contribution as I want other hon. Members to be able to participate. My specific request is for the appointment of a Special Standing Committee which can consider ring-fencing the necessary finance.
§ Mr. Nicholas Winterton (Macclesfield)
I am delighted to follow my hon. Friend the Member for Belfast, South (Rev. Martin Smyth). He and I have served on the Select Committee on Social Services for many years. The views that we express have been gained from the experience and knowledge derived from many years of service on that Committee.
I commend my hon. Friend the Member for Gillingham (Mr. Couchman) who sadly is no longer in his place, on the mention that he made of the indicative drug budget. The Government will neglect at their peril the pharmaceutical industries of the country. They make a major contribution to our balance of trade and they generate a surplus of more than £850 million. If we proceed with some of the proposals in the White Paper that seek, unjustifiably, to contain prescribing, we shall drive investment out of this country to the detriment of employment and the economy of our nation.
I speak with a constituency vested interest as ICI Pharmaceuticals, a massive employer in this country, employs some 5,000 people in my constituency. It puts about £50 million a year into new investment. We should bear such investment in mind. As my hon. Friend the Member for Gillingham has said, however, it is most important that the people who require treatment feel that they will get the best possible medication that they require.
When new drugs come on to the market and do dramatic things—such as the drugs to which my hon. Friend the Member for Gillingham referred—people should not be deprived of that beneficial medication 540 because of cost, especially as it often probably means that if they do not have it, they will spend much longer in hospital. That is far more costly to the health service, whether in the private sector or the NHS.
My hon. Friend the Member for Stockton, South (Mr. Devlin) should look at the American experiment. The Americans have tried formularies, which is the direction in which we are moving. That has imposed an extra cost on health service expenditure in that country. Medication can reduce the need to put a person in hospital.
I do not support the Bill and I will not vote for it on Monday evening. It is severely flawed and, in the limited time available, I intend to tell the House why. I do this not for reasons of prejudice or malice but from the immense knowledge which I have managed to glean from the more than 14 years that I have been on the Social Services Select Committee and its predecessor. The White Paper "Working for Patients" and the Bill, which implements its reforms, propose to improve cost and outcome information and tackle the problems arising from what many may describe as the lethargy of the medical profession in monitoring and evaluating its services.
The NHS could be improved considerably with the reforms contained in the Bill. Those reforms may enable the objective of the NHS—to provide health care on the basis of need, measured by the capacity of the patient to benefit from care—to be achieved much more cost effectively. I accept that view. I believe that the objectives behind the Bill and the White Paper are laudable in every way.
However, the other proposed reforms in the Bill—GP budget holders, or fund-holding practices, independent NHS hospitals and tax breaks to increase the purchase of private health care insurance by the elderly—may undermine the NHS as we know it. As a Tory, I am deeply committed to the NHS. There are many within the independent and private hospital sector who are deeply unhappy about what the Government are doing because they believe that it will prejudice them in acting complementary to, not in competition with, the NHS.
These other reforms—GP budget holders, independent NHS hospitals and tax breaks—may undermine the NHS, but of the three, the independent NHS hospitals may have the greatest adverse effects on access, quality and costs. With independent NHS hospital managers free to fix pay and prices and the removal of the NHS monopoly on purchasing power, which has held costs and expenditure in check, there is likely to be massive cost-inflation. If the Government hold cash limits, district general manager budget holders will face increasing pressures and the quality of care is likely to be eroded, as was shown in evidence to the Select Committee. If due to these pressures the NHS produces increased waiting lists and times and declining quality of care, the incentive to buy private health care insurance will be sharply increased.
The overall effect of these pressures may be increased expenditure on health care which is financed largely from private sources. Much of this increased expenditure may well represent increased rewards to providers rather than increases in the volume and quality of health care for United Kingdom citizens. This outcome—increased expenditure on health care from private sources—may be the Government's implicit objective. Their explicit objective is to defend the NHS, but that objective may not be achieved through the existing provisions of the White Paper, which are encapsulated in the Bill.
541 The likely outcome of these proposals is greater inequality in access to health care, provision of health care of inadequate quality and cost-inflation. [Interruption.] I hope that my hon. Friend the Under-Secretary of State is listening. Sadly, the Government appear from time to time not to listen to those who have some knowledge. I am delighted that my right hon. and learned Friend the Secretary of State said in responding to my intervention that I had some knowledge of this matter.
Having well and truly put my views on the Bill as it relates to the reforms to the Health Service, I should like to put my worries about community care. We are moving much too fast. The policy of community care is being introduced too rapidly, too soon and for the wrong reasons. It is returning patients to a community which is unwilling and unable to welcome them. We are losing centres of excellence and denying some patients the security and stability which they need and which they can find only in long-term residential care. Before disposing of all these centres of excellence, I hope that we will think again to ensure that we are genuinely improving the lot of the mentally ill, the mentally handicapped, those suffering from Alzheimer's disease and the elderly who need residential care.
My county of Cheshire, which is Labour-controlled with Liberal support, is being forced to dispose of its residential homes. This is disastrous. It is wrong that the private sector should have a monopoly of care for the elderly. I do not believe that the monitoring of the private sector is likely to be adequate.
We are perhaps debating one of the most important Bills of the past 10 years, not just of this Parliament. I therefore hope that, in Committee, the Government will listen closely and sensibly to the amendments that are proposed. I regret that I cannot support the Bill in the Lobby on Monday evening.
§ Mr. Jack Ashley (Stoke-on-Trent, South)
The views of the hon. Member for Macclesfield (Mr. Winterton) on community care are respected on both sides of the House and, as usual, they were vigorously expressed. The Government's proposal to end Crown immunity for all Health Service bodies is welcome, but suspect. If the Government are converted to my belief that Crown immunity is an unjust anachronism, all Crown immunity should be abolished, but that is not happening. Crown immunity cannot apply to private institutions. The Government are obviously paving the way for the future, privatising by this selective means. That is deplorable if health services are privatised.
Millions of people rely on community care for their wefare. The Bill is crucial to them, and I am glad that this matter has been raised in the debate. However, there should have been a separate Bill to ensure proper consideration of that aspect of the problems. I ask for a commitment from the Minister that discussion of the community care clauses will not be guillotined in Committee.
Disabled people demand very little, but they ask for some fundamental rights. Section 4 of the Disabled Persons (Services, Consultation and Representation) Act 1986 gives them the right to assessment of their needs, if they request it, but they also want the right to make 542 representations about that assessment. They want the ordinary right to appeal against decisions. Above all, they want the right to properly funded community care.
Assessment is the key to the new system, but unfortunately the way in which it will operate has been left entirely to the discretion or whim of local authorities. There are no requirements for local authorities, there is no guidance, and they are not committed to involving the disabled person in the way proposed in section 3 of the Act. There is also no right of appeal. Local authorities—the good and the bad—can do as they please, and there are some very bad ones. The Government are abdicating their responsibility.
Who would be assessed and reassessed under this provision? Reassessment can be as crucial as assessment. If this Bill had been in force, would deaf-blind Beverley Lewis, who died weighing four stone, have been reassessed? Would her life have been saved? Would disabled people and their carers be affected by the Bill? They are now at the end of their tether, trying desperately to cope. The answer is that Beverley Lewis would not have been saved; nor would severely disabled people be affected, because the Bill will do nothing to avert future tragedies in community care or to raise the present inadequate levels of care. The provisions of the Bill give local authorities the right to assess on whatever criteria they choose—it is a charter for evasion. It is essential that section 3 of the 1986 Act be implemented. It is also essential that centrally decided requirements be placed on all local authorities.
The Bill and the White Paper on which it is based view community care provision from the providers' perspective, not from that of the consumer. The truth is that the Government have been worried by the escalating costs of care in private residential homes and have decided to put a stop to them. They thought that they would ditch that commitment, and indeed they have done so. They are now talking in terms of administrative change, cost-effective provision and simplicity—fine-sounding words which permeate the White Paper and the Bill, but little attention is paid to the level and quality of care for the consumer.
The specific grant to local authorities for people with mental illness is welcome, but it has not been ring-fenced. That means that it will be vulnerable to the vultures. One of the main failures of the Bill is the refusal to allocate a specific grant for community care in general, as Griffiths recommended. The Government apparently intend to provide additional resources only for demographic change and for the new tasks related to the new procedures, but they have failed to recognise that today's unacceptable black spots of community care must be erased and that community care money must be used only for the people for whom it is intended. We do not want councils to spend the money on bypasses and other daft things. The Griffiths proposal will come to naught if his recommendation for a specific grant is disregarded. Nothing could be more crucial for the future of community care.
Devoted family carers are the kingpins of community care, but despite the bromides there are no specific proposals to help them—merely a mention in the White Paper that, when possible, their ability to continue to provide care should be considered and their participation included in the assessment. Who is to say whether that is possible? Again it will be the local authorities.
The Bill fails to recognise the army of carers who are being exploited and overstretched, many of whom are 543 themselves very frail. No one should be forced to care for a disabled relative if they feel that they cannot handle it, but local authorities are only too happy to turn the problem over to the family. Some local authorities are very negligent, and that is intolerable for the carers. There should be a commitment to seeking out carers, easing their burden and recognising that they should not be pushed to the point of total exhaustion.
I make this appeal to the House. The problems of carers and of disabled people will not be solved by the Bill, which fails to provide them with essential rights. It also fails to provide adequate cash and to provide comfort for carers. I hope that the Government will listen to the voices of disabled people, carers and voluntary organisations, and think again.
§ 8.6 pm
§ Mr. Bill Walker (Tayside, North)
The right hon. Member for Stoke-on-Trent, South (Mr. Ashley) has a distinguished record of defending the interests of the disabled, and I am sure that his words have been listened to with care throughout the House.
The proposals in this Bill are designed to increase choice in the National Health Service and make the service more responsive to patient needs. The Bill is also designed to raise standards of care in all health board areas and to bring them up to the level of the best. It is also designed to improve the efficiency and effectiveness of the services provided by the Health Service, and to ensure that the maximum possible resources go directly into patient care.
The Bill must be seen against the background of the continuing increase in Government support for the NHS—in the amount of taxpayers' money going to the service.
In Committee, I believe that we shall have ample opportunity to study the Bill's details in depth, and in the limited time that I have this evening no one would expect me to do that now.
It will come as no surprise that I want to concentrate on the Scottish aspects of the Bill. Reaction in my constituency to the Government's proposals can best be described as mixed. Some in the Health Service are wholly opposed and have made their views clearly known. I have met a number of those who are concerned, but they are unable to define precisely the causes of their worry. I know that because I have had a number of meetings with people in the Health Service—with GPs and others. I am pleased to inform the House that others have seen the proposals as a means of obtaining long-promised but never delivered new facilities.
I cite, for example, the county town of Forfar in Angus which, 25 years ago, was promised a new community hospital. Twenty-five years later it is still waiting.
Forfar GPs are trying to set up a budget. They are supported by many people in the area and are looking at the possibility of a self-governing hospital trust. That is no surprise to me, because I have always viewed health as I view education. In the House, a great deal of rot is talked about rural areas. My constituency covers 2,000 square miles of rural Scotland and I think that I can claim to know something about the problems of hospitals and Health Service facilities in rural Scotland.
There is a good Health Service in north Tayside and we are proud of it. However, it can and must be improved to 544 meet the demands of today. The Service is far better than it was 10, 20 or 30 years ago, but it must continue to improve because the demands upon it increase every year. Stracathrow hospital is not in my constituency but my constituents use its services and the GPs regularly use it. There have also been rumblings of interest about a self-governing trust for that hospital.
Anyone with any sense realises that the changes proposed in the Bill are fundamental and will cause concern. It is up to us to deal with that concern and we must get through to the people to make them understand. Our education reforms are beginning to be appreciated and understood and people are supporting them in my constituency and looking at self-governing schools. It was once suggested that no rural school would consider that. The school that I have in mind is very rural because it is in one of the remote parts of my constituency.
We must first deal with the misinformation that is being spread about the Bill. It is also important to recognise that there are problems within the British Medical Association. Its negotiators are not trusted and their recommendations have been rejected. That is hardly the way to move forward. I draw the attention of the House to early-day motion 63 about the leak of a BMA letter. The motion, in the name of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) who speaks for the Opposition on Scottish health matters, states:"That this House condemns the leak of a confidential letter from the BMA to the Scottish Office; and asks for an investigation to find out who was responsible for this letter coming into the possession of the Sunday Times (Scotland)."I tabled an amendment to the motion. It says:"Line 1 leave out from 'House' to end and add 'notes that a copy of the BMA letter, which is not confidential, has been placed in the Library where honourable Members can note that the British Medical Association Scottish Office is not interested in negotiating a special deal for Scottish general practitioners'."That comes out clearly in the third paragraph of the BMA letter, which says:The first point to make is that there is no question here nor has there ever been of making 'a special deal' for Scottish GPs.That is news to the GPs in Scotland and to most of us. We always thought that we negotiated things differently for our separate Health Service in Scotland, but now we are told that Scottish GPs cannot be treated differently as they have been for a long time. When the BMA is so divided and uncertain, one must be careful about what one takes from the kind of literature that the BMA has been putting out.
I repeat that there is a superb Health Service in north Tayside. That is because it is a lovely part of the world in which to live. We have no problems about recruiting teachers or doctors or anyone else from the professions because people go there for the quality of life.
Another reason for our good Health Service in that area is the spending by the Government. That needs to be mentioned. It has been said that the only thing that Conservative Members talk about is expenditure. I have news for everyone. If we had not spent that money, hon. Members would be talking about the lack of expenditure. The planned spending in Scotland for 1989–90 is £2,800 million. In 1990–91, that will be increased by £220 million. That will bring expenditure on the Health Service in Scotland to over £3,000 million. That is an interesting 545 figure because it is three times the size of the Health Service budget 10 years ago when we came to office. Spending on health in Scotland is now £550 per head.
§ Mr. Walker
It is not far too much. It is what is needed. The proposals in the Bill, which I support, require additional funding and the Government have pledged that. That is unlike the Labour party, which sets out what it will do but when it comes to office it cuts expenditure and hospital building programmes. This Government make a pledge and then deliver.
Since 1979 there have been 61 major new hospital developments in Scotland, providing 6,777 beds, and there are 40 major hospital developments in the pipeline. That is a 44 per cent. increase over the rate of inflation since 1978–79. If I had gone to the electorate in 1979 and said that we would increase expenditure by 44 per cent. on house and hospital building programmes people would have laughed at me, but that is what has happened. More people are being treated than ever before both in and out of hospital and we have more doctors, dentists and nurses.
§ Madam Deputy Speaker (Miss Betty Boothroyd)
Order. I regret that I have to call the hon. Gentleman to order. His time is up.
§ Mr. Jim Cousins (Newcastle upon Tyne, Central)
As the Secretary of State suggested, clause 4 of the Bill, which introduces the concept of universal contracts, is at the heart of the proposed legislation. Section 8 of the White Paper on community care, which makes the disastrous distinction between the cost of care and the cost of keep and attempts to stitch plans together for people on the basis of that distinction, is at the heart of the White Paper. That is where the difficulty lies. For many years the Government have tried to operate a network of clumsy cash limits. The Bill does not lead us away from those limits but clones and reproduces them on a massive scale. Through the network of care plans, keep plans and universal contracts, it extends those cash limits into every region of the service, thus controlling the experience of every patient.
Eminase has already been cited as a drug treatment which is difficult to fit into a contract, format. Another example is hormone replacement therapy. How do we put speech therapy into a contract, when 80 per cent. of referrals come not from doctors but from schools, health visitors, self-referrals and concerned parents? The Government will have to face those difficulties.
My city of Newcastle upon Tyne has one of the six centres of the resource management initiative. The products of that initiative are interesting. They clearly show that, given time and money—far more time and far more money than the Bill allows—one can formulate the cost of individual patient treatment plans. That can be done by eliminating the costs associated with long-term support which is hard to fit into the format. The result will be a system which cannot survive in a system of block contracts which are looked upon as rationing cards, whereby every patient is treated as a unit with absolutely identical needs. That is the deficiency of the contract system, and that is where it will fail. In the same hospital at Newcastle, which is a world centre for transplant surgery, no food is served from 5 pm until 8 am the next 546 day. Only a few weeks ago, patients were asked to bring pillows because they were in short supply. That situation will be reproduced on a massive scale if the Bill is implemented.
There are further examples of the same sort in the same city. The regional health authority is privatising some of its staff and handing them over to a company which includes BUPA membership in its employment contract. There could be no greater testimony to the direction in which such a system will lead us. In the same city we have one of the finest networks in Britain of community residential care provision for the mentally handicapped. As a cost-saving measure, and to meet the needs of community care within the administrators' understanding of the Bill, those facilities will be disposed of to the private sector. That will be a calamity and a disgrace.
In the same city, the regional blood transfusion service—responding to the terms of the Bill—is proposing to convert itself into a trading agency which will sell blood to hospitals. Blood that is freely given will be converted into a commodity that is traded. It will be sold to hospitals.Is that the sort of spot market in blood to which my hon. Friend the Member for Livingston (Mr. Cook) referred in his compelling and brilliant speech? That, too, is a disgrace.
As my hon. Friend the Member for Livingston said, the lines of power in the Bill all radiate from the Secretary of State. That is its central defect. But the lines of responsibility also lead back to the Secretary of State, and it is for that reason that Conservative Members will regret the confetti of controls and cash limits that they are creating.
§ Mr. Quentin Davies (Stamford and Spalding)
The essence of the debate is that the Opposition seem determined to present themselves as the defenders of the National Health Service in its present form and to be blind to its shortcomings and deficiencies. The Government have recognised those shortcomings and deficiencies and—in my view with considerable courage—are trying to remedy them.
What are the key deficiencies? First, there are the excessively long average waiting times for a range of non-emergency hospital treatments, including some key areas of elective and orthopaedic surgery. Ours is the only country in the European Community to suffer from that problem on such a scale. No Member of Parliament should remain content with that. I refer advisedly to average waiting times and not to waiting lists. It might be satisfactory to have 2 million people waiting a month, on average, for non-emergency operations, but to have 100,000 people waiting 20 months would be entirely unsatisfactory. I hope that the Opposition will recognise that important distinction.
Secondly, there is a lack of patient choice in the NHS, which means that, against a background of generally dedicated and devoted care, for which many of my constituents and members of my family are deeply grateful, there are too many instances of perfunctory or arrogant care. There are take-it-or-leave-it attitudes—for instance, or "Strip off and wait for three hours"—and I fear that such attitudes are inseparable from monopoly provision in any area of human activity.
547 Thirdly, and most seriously of all, is the slow rate at which new life-saving therapeutic and diagnostic techniques, even those invented in Britain, have been incorporated in the NHS. I have in mind the number of kidney dialysers per 1,000 people in this country compared with the number elsewhere in the western world. I think, too, of the insufficient use in Britain of colorectal scanning, computerised tomography, magnetic resonance imaging, ultrasound scanning and other diagnostic techniques. I have the figures on MRI and CT, thanks to a recent answer from my right hon. and learned Friend the Secretary of State. There are 198 CT scanners in this country, compared with 450 in West Germany, 3,000 in Japan and 3,600 in the United States. In the United States there are 1,300 MRI machines, compared with 275 in Japan, 85 in West Germany and 15 in the United Kingdom.
We pay a heavy price for that. The figures reinforce the conclusion that the NHS has had a tendency over the past 40 years to be not so much the National Health Service as a national illness service. We neglect modern diagnostic techniques at our peril. In the past half century, as in the first half of the century, the general health of the population has improved markedly, but in the second half it has improved at a much slower rate than the average rate of improvement in the rest of the western world. In 1948, we were in the first quartile among western countries for life expectancy and the last for infant mortality. I fear that we are now in the third quartile in both respects. We should not be satisfied with that.
The Opposition have a simple answer to such problems. It is a mindlessly simple answer—the five-word answer "Throw more money at it". If one thing has been proved by the Government's experience, it is that throwing more and more money at the NHS is not a sufficient response. Of course we must spend more money on the nation's health, and we have thrown enormous amounts of new money at it, yet by all available measures patient satisfaction has continued to decline. I fear that that demonstrates incontrovertibly that the money has too often been spent by the wrong people in an inefficient way or on the wrong things.
I shall give four important examples of how spending has gone badly wrong. First, until now there has been no effective cost information in the NHS. Managers have not known whether it was cheaper to perform operations, or to deliver other treatments in their own units or to farm them out to the private sector. They have not known their own costs. My right hon. and learned Friend the Secretary of State and his predecessor, for the first time since 1948, have now addressed that problem.
Secondly, until now there has been no notion of depreciation in the NHS. That is extraordinary. The idea of taking rational management or investment decisions without any idea of the cost of capital is ludicrous. Yet until my right hon. and learned Friend came along, that was exactly the position in the NHS.
Thirdly, there are perverse incentives, some of which my right hon. and learned Friend mentioned briefly today. Time and again performance is penalised and failure or mediocrity rewarded. The hospital manager who increases his throughput runs through his budget and is penalised. The manager who wishes to stay within his budget by 548 cutting his variable costs and leaving wards empty at the end of the year is patted on the head. Under the Resource Allocation Working Group system, a health authority which has been successful in improving the morbidity rate in its area to a greater extent than the national average will be penalised. For the first time, my right hon and learned Friend has faced these problems head on, and these at least of the bad practices of the past are coming to an end. I thank the Lord for that.
Fourthly, I come to the heart of the great devotion which Opposition Members have to the present structure of the NHS, including the right hon. Member for Blaenau Gwent (Mr. Foot), for whom I have the greatest personal regard. Opposition Members display this great devotion precisely because the NHS enshrines to the supreme degree the model of paternalistic, bureaucratic provision which lies at the heart of Socialism.
The great and the good in Westminster and Whitehall decide what proportion of national income should be spent on health. That money is handed down through the RAWG system to the regions. They arbitrarily and unaccountably distribute it to district health authorities, which equally arbitrarily and unaccountably allocate it to whatever purpose they choose—more intensive care beds, another orthopaedic unit, more chronic care for psychiatric and geriatric patients or just doing the garden or painting the staff canteen. There is no assurance that the actual distribution of resources and the pattern of outputs under this system will in any way correspond to what would be the aggregate choice of patients if they could express such a choice. There is every reason to suppose that, as the volume of outputs and services under such a system increases, the correlation between that selection and potential patient choice declines.
This is a historic moment in the NHS because the Government have had the courage to face those problems head on. In all the years that I have taken an interest in politics—long before I came to this House—I have never known as man so subject to such sustained, ill-informed and hysterical vituperation as my right hon. and learned Friend the Secretary of State. I have also never known a man who would be less affected by it than he appears to be. I salute his courage and greatly support his Bill. I look forward to supporting both him and it during its passage through the House.
§ Mr. Jeremy Corbyn (Islington, North)
For the greater part of the past two hours, there has been no Minister in the Chamber. We are now graced with the presence of the Adam Smith look-alike, who has just returned to the Chamber but who is not even replying to the debate. It is disgraceful. The Government claim that the Bill is important and they have spent £5 million telling people how good it is, yet Ministers cannot be bothered to be here to listen to hon. Members responding to the Government's consultation and the Government's publicity.
There is a fundamental difference between the two sides of the House. We believe that health care should be a right, free at the point of use for everybody irrespective of background, social standing or ability to pay. The hon. Member for Stamford and Spalding (Mr. Davies) is a good, true Tory who understands only pounds and pence. He understands only the cost of something—he does not have any idea of the value of anything.
§ Mr. Corbyn
Hon. Members are limited to 10 minutes. The hon. Gentleman had plenty of opportunity to tell us about the value of the market economy in health care. I think that I should take this opportunity to tell him about the value of socialism in health care.
Does the hon. Gentleman honestly believe that everything should be bought and sold? Must every operation be judged against its cost? At no time did the hon. Gentleman mention the convenience of the patient, his safety or his comfort. He knows that the Bill's aim is for every hospital to become a company. Every doctor must look to his accountant before doing anything—
§ Mr. Quentin Davies
On a point of order, Madam Deputy Speaker. Would it not be in accordance with the best traditions of this House for an hon. Member who attributes to me opinions that I did not express, and who is giving a summary of my speech that I seriously dispute, at least to give way to allow me to correct the position?
§ Madam Deputy Speaker
The hon. Gentleman has made his point, but it is for the hon. Member who has the floor to decide whether to give way.
§ Mr. Corbyn
The House can judge for itself which side of the argument it wished to support. The problem for my constituents is that for many years there has been persistent underfunding of our health authority, which each autumn leads to the spending crisis faced by most inner-city health authorities. My authority has met that crisis by taking more than 100 beds out of use. That is happening throughout the country and is a measure of the crisis in health care.
Conservative Members lecture us and claim 10 years of success under successive Secretaries of State, yet hospitals and wards have been closed. I accept that new hospitals have been built, but there are fewer beds available, there is a worse service and there are longer waiting lists than there were 10 years ago. Conservative Members should recognise those facts. They should study a few of the international comparisons. By every index on health spending in industrialised countries, this country comes very low if not bottom. The solution is not to bring in the accountants, the market economy, the sales people and the idea that every hospital must have a commercial manager to decide what can be sold to make some money; the solution is to begin thinking about the health needs of our people.
Why is the life expectancy of working-class people shorter than that of middle-class people? Why do people living in overcrowded accommodation have a shorter life 550 expectancy than those living in salubrious suburbs? Why do children living in high-rise council flats or the slums in every one of our major cities suffer more bronchial problems than children living in suburban areas? Why are all those inequalities in health ignored by the Government in favour of the market economy? They know that the market economy means that those who can afford to pay can buy their way past the queues. The Bill is a massive attempt to privatise the entire National Health Service by stealth.
The other matter that I wish to raise, and which predict will be guillotined off the agenda in Committee, is that of community care. Conservative Members have lectured us for a long time about the needs of community care. Those who honestly believe that community care is working should, when they leave the House tonight, walk across the river, go along the south bank and talk to those: living in cardboard city. They should talk to the people at Charing Cross station. There are 10,000 people sleeping on the streets of this city; some, although not all, have been in long-stay institutions. There is not much community care for them in living in a cardboard box outside a tube station on a cold winter's night in London. That is the sort of issue that should be dealt with in the Bill. It is the reality of the inequality of health care, the inequality of life expectancy, the inequality of community care—inequalities that are exacerbated, not lessened, by the Bill.
I make no apology for being sponsored by the National Union of Public Employees. The question of very low pay for Health Service workers is not dealt with by the Bill and neither is the question of their conditions if a hospital decides to opt out. They are not protected—they are given away, along with the hospital, to any trust that it chooses. There is an attempt to break up the national negotiating machinery that has been some protection for some of the lowest paid and most dedicated people in the NHS.
The Government often lecture us on the freedom of choice—the freedom to lead one's life as one wishes. It is true that there is freedom of choice. We are all free to go out and buy a Rolls-Royce—the only problem is that 98 per cent. of the population cannot afford it. We are all free to buy a house—the only problem is that as thousands cannot afford to do so they go homeless. We are all free to pay high rents—the problem is that most people are too poor to pay them. The Government now say that we are free to choose the health care that we want. The Prime Minister said that she wants her health care when she wants it, how she wants it and from whom she wants it. For her there is freedom of choice, but for the majority of the population there is not.
The Government talk about protecting and defending democracy in this country. Every health authority that has, in the past 10 years, attempted to stand up against the Government's attempts to cut resources and, when, RAWP was in operation, to take money away from inner-city areas, found itself in receipt of a letter either from the chair of the regional health authority or from the Secretary of State, announcing that its services were no longer required because it had attempted to represent its community. Now, what vestiges of democracy remain in local health authorities will be taken away by the Bill because health authorities will be stuffed full of placepersons put there by the Secretary of State, and representing the local business community. The idea that local authorities have no part to play in health matters is both insulting and disgusting.
551 The centralisation of powers that the Secretary of State is taking unto himself through the Bill would do credit to the most authoritarian of states. He should remember that what comes out from Richmond terrace to the health authorities also goes back to Richmond terrace and when an election finally comes, people will have one person and one person alone to blame for the inadequacies of their Health Service, and that is the Secretary of State.
Many of those who work in the NHS, as nurses, ancillary workers such as porters or gardeners, doctors or consultants and all those who work in community care, attendance or long-stay institutions, are frightened and fearful of the Bill. There is little protection for them. There is no ring fencing to protect the salaries of those who are transferred. There is no protection for the money transferred into local authorities from the long-stay institutions. The treatment that the Government mete out to the ambulance workers, in their attempt to destroy the dispute when those workers are providing the only real emergency service, shows the Government's contempt for people who are genuinely trying to run a Health Service. The Bill may not be defeated in the House, but it will be defeated eventually, because the principles on which it is based are wholly and odiously wrong.
§ Mr. Andrew Rowe (Mid-Kent)
This autumn, our youngest child, an extrovert and articulate girl, went away to university. Soon after she arrived there, she telephoned home. It was, in family terms, an epoch-making call. It lasted for three minutes and ended when she said, "Must stop, can't afford any more." It was her first telephone call as a budget holder. How many parents recognise the changes in behaviour that come when their children have to start paying for the services that they use? Even when the budget is £28 billion, the same principles are at work.
The hon. Member for Livingston (Mr. Cook), like a Savonarola of the social services, is roaming the country urging citizens to burn the Bill on a bonfire of Socialist sentimentality, just as his Florentine predecessor forced Botticelli to burn his easel and paintbrushes in front of the Duomo. I am not suggested that my right hon. and learned Friend the Secretary of State is the Botticelli of the Front Bench, but I am clear that subsequent generations would be impoverished if the Bill were to be destroyed.
The hon. Member for Livingston excoriated the Bill for leaning on incentives, where he would trust that enormous sum solely to the staff's good will. I share his admiration for the generosity and altruism of NHS staff at all levels, but under the present system, the disincentives are acute. For example, what about the departmental head who, in my district health authority, on his own initiative saved the hospital thousands of pounds, but saw it all disappear into the district funding and found his enthusiasm for making further savings sorely blunted?
We are talking not about personal gain, but about the salutary effect of letting staff see gains for their own unit as a result of their better use of their resources. What about the supplier to a great hospital, who, week in and week out, sees over-ordering of perishable goods, but sees no evidence of management concern about it?
"Cost-effectiveness" is not a dirty phrase. It is not, as the hon. Member for Livingston and his friends suggest, a 552 device for making cuts. Rather, it is a necessary discipline for ensuring that money is spent on patient care and not on wasted food or dependence-generating tranquillisers. The Government will always find it hard to win the rhetorical argument on the NHS, but they have to find the money. They do that very well, as is shown by the 25 per cent. increase in cash terms in the past two years.
The hon. Member for Livingston and his colleagues have no such need. They can, as they have done again today, leave the nation with the implied suggestion that, if they were in power, the resources for the NHS and for community care would somehow be limitless. That works because all of us would love it to be true and because the public, after 10 years of Conservative increases in NHS funding, have forgotten just how deep and savage were the cuts made in NHS funding by the Labour party when in power.
I do not wish to follow my right hon. and learned Friend the Secretary of State down his path of leaving community care to another occasion. I have already told him and my right hon. Friend the Leader of the House that it would be a disaster if the partisan dispute over the NHS proposals cut out a full and proper debate on the Bill's proposals on community care. Those proposals are both important and overdue. The level of service depends on the level of resources available, but the Bill sets out to do what Griffiths saw it was vital to do—make the best use of whatever level of resources is achievable at any particular time, and remove the perverse incentives that waste money by making it hugely profitable for a local authority to send clients into expensive residential care at the expense of the Department of Social Security, when it would be both cheaper and better care to keep them in their own homes at local authority expense. That is an important advance, and it has met with widespread approval.
The Bill requires local authorities to create a care plan for every client, and that, too, is an advance. However, in Committee, we shall need to look in detail at how that should be done. First, we must make sure that the client is properly heard. The Bill must have no more to do with paternalist prescription; we must listen to the client's preferences. Where a client cannot state them for himself, he should be afforded a friend or volunteer to speak for him.
We must make sure that the assessment is well founded. It will be no service to anyone if the natural suspicion and ignorance that social services staff have of NHS staff and vice versa leads to lopsided and partial assessments. For example, the contribution that can be made by occupational therapists, speech therapists, voluntary alcohol abuse counsellors and so on has to be understood and incorporated in the assessment. That will mean a large exercise in co-operative working, and to the extent that it can be addressed by training, that joint training should be started now.
I welcome the recognition of voluntary organisations, which have done so much to pioneer new patterns of caring and carried so much of the load that the aging of our population, and their rising expectations, lay upon them. I share their unease lest their initiatives and priorities should be distorted by having too many public priorities pushed upon them. A huge amount of work must be done in the development of community care, and my time is too short to go through it all. The truth is that we shall always have a crisis, both in health and in community care, because the expectations of the public rise, quite 553 properly, every year and there is no possibility whatever of any Government ever being able to provide enough resources to meet the growing needs that our own success in solving many problems has called into being.
Ring fencing is not the answer. Everybody who has a special interest in politics, whatever it may be, clamours to have that part of Government expenditure which is devoted to their interests ring-fenced. Somehow that seems to be a way of keeping the thieving hands of more powerful committee chairmen off their precious budget. Ring fencing is a recipe for conservative structural developments. The moment someone is inside a ring fence, he is reluctant to pioneer services which spread outside it; most of the advances in community care, and many of the advances in health care, will come from that kind of lateral pioneering co-operation between services which, if they were ring-fenced, would never extend a hand across the boundary to one another.
§ Mr. Ieuan Wyn Jones (Ynys Môn)
I listened with great care to the Secretary of State. He was at great pains to explain once again to the House that the Government's plans for the NHS will not lead to privatisation. But it is not so much the right hon. and learned Gentleman's speech that worries many hon. Members, as the Bill, because in many respects privatisation is clearly behind it.
When one looks at the new-style management of the district health authorities, as they are to be called, and the family practitioner services authorities, as the family practitioner committees are to be called, it is clear that they are to be run along the lines of private companies. In other words, there will be no room on the new-style boards for local authority representatives. As other hon. Members have said, that is a retrograde step.
Paragraph 8.5 of the White Paper says:The Government believes that authorities based on this confusion of roles would not be equipped to handle the complex managerial and contractual issues that the new system of matching resources to performance will demand.That is the official reason why local authorities are not to be included on the new management-style boards. But the real reason is that the Government believe that local authorities will not do what they are told—that they will not he party to cuts in health provision.
Another vital point is the way in which the Government seem to want to set up NHS trusts. In particular, the management boards of those trusts will have no provision to ensure that patients' needs are taken into account. In the White Paper, the Prime Minister says that the needs of the patient are to be paramount. But when one considers the way in which the new trusts are to be set up, one sees that there is no way in which patients are to be consulted. In Committee, we shall need to look at ways in which patients are represented on those boards at area or district health authority level and in the trusts.
We shall also need to consider the way in which the NHS contract principle is included in the Bill. Traditionally, the Health Service has been based on the statutory responsibility of hospitals to provide care. In the private sector, there is a contractual relationship. It is that contractual relationship that is now being brought into the Health Service between health boards and those services which provide health care. We are moving away from the 554 traditional statutory responsibility to provide health care that we have known in the Health Service and into a contractual conception.
A general practice which is large enough will be given a budget, which will clearly be cash-limited because budgets cannot mean anything else. If a practice is not big enough to acquire a budget, the district health authority will force doctors to choose health care for their patients, not according to their needs but according to the cost of that provision. In other words, as the cash limits bite, they will be shunted from hospital to hospital.
All the provision for a privatised Health Service—the NHS trust hospitals, the new board managements and GP budgets—are now in place. We may not have a Secretary of State today who believes in a privatised Health Service, but if a future Secretary of State does, the structures are there. It is only a small step between the Bill and a fully privatised service.
Hon. Members on both sides of the House have said that the great danger is that that will lead to a two-tier Health Service. Moreover, it will mean that the Health Service provision in rural areas will be drastically affected. There is no question about that.
The Bill's central provisions are completely irrevelant to Wales. I asked the Secretary of State for Wales two questions, which were answered yesterday. First, I asked how many hospitals in Wales want to opt out under the new system. The answer was none. That is because no GP in Wales wants a budget, and so cannot buy in services. There is no private provision in Wales. As the White Paper makes clear, that is underdeveloped. Therefore, the hospitals cannot buy in from the private sector. That is completely irrelevant. Secondly, I asked how many general practices in Wales want their own budgets. The Secretary of State made it clear that none of them wants that.
Those provisions are irrelevant to Wales, and in Committee we shall be seeking to exempt Wales from the Bill. If the Committee will not agree to that, the only sensible course will be for each area health authority to have a referendum of all the electors in that authority to decide whether a hospital should opt out. Consultation is not sufficient, because all the patients who may be affected by such a decision should be consulted in a referendum.
I welcome the news that local authorities are to be given responsibility for assessing the needs of individuals: that seems sensible. However, as Opposition Members have pointed out, there is no obligation on local authority social services departments to carry out such assessments, and I feel that we should do something about that.
I disagree with the hon. Member for Mid-Kent (Mr. Rowe), who said that funding for community care should not be ring-fenced. He should look at the submission sent to all hon. Members by the voluntary agencies and local authorities that will have to operate the scheme. They all say that, unless a community care budget is specified, money will simply go into the local authority pot without being earmarked for community care. Such specification is necessary to ensure that both current and future needs are met. If there is to be a partnership between the social service departments and the voluntary agencies, they must know how much they can spend on community care from year to year.
We in Wales have a passion for the Health Service, and we speak of it with passion. We know that its guiding principles were based not in City boardrooms but in the mining communities of Wales, Scotland and northern 555 England. Those principles were born not in the rich pastures of the south-east but in communities that have had to fight for everything they have ever owned. If the Government will not pay attention to the need to retain the Health Service as it is—free at the point of delivery for every patient who needs it—the people will vote them out in the next election.
§ 9 pm
§ Mr. Tim Devlin (Stockton, South)
As the hon. Member for Ynys Mon (Mr. Jones) has just said, the National Health Service is every bit as valued in the north of England as it is in Wales and Scotland. It is valued, indeed, throughout the length and breadth of the country, for it is a national Health Service—and it is in pretty good shape, considering that it is 41 years old this year.
Despite soaring costs and increasing demand, coupled with the pressures of an aging population and expensive leading-edge technology, the service is still free to all, and funded mainly from taxation. It is still equally available to all types of patients from all parts of the country. It still provides a system of primary health care, giving each person his or her own GP, and a referral system for specialist consultations of every kind. It is still highly regarded internationally, and it provides good-quality training for doctors who come here from all over the world. Each and every one of us, whether we are for or against the reforms suggested by my right hon. and learned Friend, should begin our speeches by paying tribute to an excellent service in which many people give of their best to provide help for us all.
The Government, however, have played an essential part. It is their fine record in running the nation's economy soundly that has enabled total spending to rise from £166 per head in 1979–80 to £444 per head in 1989–90. My hon. Friend the Member for Macclesfield (Mr. Winterton) suggested that we should fund any treatment that came on the market regardless of cost, but I cannot stand idly by and listen to such a suggestion. I have seen at first hand— because all my family were in the NHS—the effect of diverting resources to expensive procedures with indifferent or uncertain outcomes, at the cost of many thousands of "bread-and-butter" operations which could otherwise be carried out. Under the last Labour Government, a Royal Commission found that, even if the country spent its entire gross domestic product on the NHS, there would still be unsatisfied demand for services.
The hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) asked us to look at our own communities, and when my hon. Friend the Member for Tayside, North (Mr. Walker) was looking at his, I happened to remark jovially —and jokingly, I must add—that spending in his region was too high. Spending per head on the NHS is indeed far higher in Scotland than in England, but after tabling some parliamentary questions I have been able to obtain the figures for my part of the country. Hon. Members may think that I am going to recite the usual cash figures—revealing that in 1982 the figure for the northern region was £520 million, compared with £802 million this year —but I have had all the figures recalculated at constant 1989–90 prices. In 1982, the figure was £741.8 million, while in 1989—at constant prices—it had reached £846.8 million. That is a significant improvement.
556 Services have also improved. In 1983, 409,000 in-patients were treated in the north; by 1988, the figure has risen to 462,000. The number of new out-patients rose from 550,000 to 590,000. None of that is possible unless the money can first be made available by running the economy correctly. There are 22 major capital schemes worth over £1 million under way in the Northern Region health authority. That has to be compared with the cut of over one third in the region's funding that was imposed by the last Labour Government.
My own hospital, North Tees, has only just been given the new roof that it should have had in 1977, but for the cuts that were imposed by the last Labour Government. The figures for the Darlington, North Tees and South Tees health authorities show that there has been a significant improvement in their funding under a Conservative Government.
Amid all the good news, however, a major case for change can still be made. It is not quite a mid-life crisis; I shall be 40 in 10 years, and I should not like to have to regard myself then as being old. A structural change is needed. Woman's Realm asked 10,000 of its readers what they expected from their GP services. Less than half of those who responded thought that their GPs were sympathetic and took their problems seriously; 60 per cent. considered that most GPs were helpful, whereas 43 per cent. were only "satisfied" with the treatment that they had received.
A recently undertaken "Which?" survey commented that theConsumers' Association welcomes the stated objectives of the Bill. In particular we applaud the Government's commitment to putting 'the needs of the patient first.' Consumers' Association wants consumers to have a greater choice of better quality health care, wherever they live. In pursuit of these objectives we support the major principles behind the Bill—of promoting efficiency and value for money; bringing all parts of the NHS up to the standards of the best; and developing a system which rewards those who work hardest.The standard of care in and the performance of different hospitals varies greatly. The average stay in hospital for the same treatment varies from three and a half days to nine and a half days. The average cost of treatment can range from £450 to £1,300. How can that possibly be justified? It must be right in a compassionate society to seek to maximise the performance of a service that has to rely on limited resources. However great those resources may be, that will always ultimately be limited.
The hon. Member for Livingston (Mr. Cook) said that there should have been consultation before the reforms were implemented. However, the right hon. Member for Blaenau Gwent (Mr. Foot) said that, when the National Health Service was established, there was no consultation —for the very good reason that the Labour Government knew that a National Health Service was not what the providers of health in the country wanted. It is interesting to note the different arguments on just that one point.
Payment should be linked to performance. The Bill will ensure that additional payments are made to general practitioners for health screening, the elderly and patients with persistent health problems. Additional money will be provided for those who work in the inner cities, under the Jarman index. Additional money will also be provided for those who work in distant rural areas. All the various factors that ought to be taken into account will be taken into account.
557 GP practices will be provided with much greater powers as a result of the budget-holding provisions in the Bill. It is right to make the point that many practices do not yet possess the information technology that they will need if they are to carry out their responsibilities. Many forward-looking practices have, however, already installed the technology. Many of the GP practices in my constituency and in other areas have already bought computers and are considering how they can best improve the range and quality of the services that they offer to their patients. The real power of this reform is that it is patient-led and patient-driven. It is up to the patient to obtain more information about health services in his area. He has to make the comparisons and find the doctor who suits him best.
As for hospitals, the funding will, quite rightly, follow the patient. However, a contracting system, which is regarded as the central provision of the Bill, already exists in many parts of the country. The waiting list initiative has already been introduced on a contractual basis. It is only right that we should cease rewarding the bad performers in the Health Service.
There are two adjacent health authorities in my constituency. One has a waiting list in one specialty and the other does not. The Government came along with their waiting list initiative and paid money to the poor performer—the authority with the waiting list. The authority without a waiting list came to me and said that they had never had a waiting list for that particular discipline but, for the first time, they thought that it might be a good idea if they did, because otherwise the money would go to the authority across the river. I have never understood why that kind of resource allocation took place. Managers who save money by making sensible economies within their local unit find that the money is taken away and reallocated to a less efficient manager. That cannot be right.
Surgeons within the Health Service know which are the bad surgeons and which are the good—my father is a surgeon. They know which surgeons turn out a large number of good quality operations, and which turn out either a low quantity or low quality. Good surgeons are happy to bid for work from other areas. We must get rid of the boundary problem that prevents patients from going across the river, or across the line. Then improvements will follow and that will be the reward for popular and successful units.
§ Mr. Devlin
I am trying to get on as quickly as possible, and I am sure that the hon. Lady will have many more opportunities to speak about health than I shall have.
Let us consider the information that is available at the moment. For example, only recently have figures for post-operative complication rates become available. The confidential inquiry into peri-operative deaths showed that some 1,000 unnecessary deaths each year result from inappropriate surgical procedures. That information has only recently become known because the Government, during the past 10 years, have progressively increased information requirements and the information technology to bring them to light.
558 The internal market will result in patients being referred to more specialised units, and that will mean that costly, post-operative complications must decrease.
I welcome the fact that audit is part of the Bill, as it is critical to its success. Unless clinicians can get to grips with their costs, we will never get to grips with the overall funding problems of the NHS. People must know what they are expected to do. Clinicians must realise that they have a responsibility to manage expensive resources well.
In an article in the Daily Mail on 27 November 1989, Dr. Colin Leon said:It's about time the medical profession accepted the need for some kind of accountability. We spend public money so should be called upon to explain what we do with it.He continued:I have always voted Labour and have always believed socialism to be more attractive than capitalism, but I do not share Labour's belief that the Health Service is under threat from these reforms.Consultants have a closed shop and they must regulate themselves. The royal colleges do not deny the need for change in the NHS. There are several pleas for improvements of the NHS, resourcing must be made available for information technology, and more imaginative powers are needed for patients.
I say to Ministers that if we are to gain the hearts and minds of the British people, we have to explain, in a patients' charter, exactly what rights and abilities they will have after legislation has been passed. That is the one thing that is not in the Bill, and it should be in it. That would solve all the arguments for us. If we were able to present a shopping list of rights and abilities for patients vis-a-vis their own doctor, or hospital and other NHS, services, they would be a lot happier.
At the top of the shopping list, they would see the one thing that we should have made clear time and time again —that there is no proposal in the Bill for any hospital to be privatised. No one can opt out of the NHS, and it will be disciplined—business not oriented. The service will be better organised and better disciplined. I commend the Bill to the House.
§ Mr. David Hinchliffe (Wakefield)
I shall concentrate on community care and express some regret that the Secretary of State for Health had to be reminded by Opposition Members that it is affected by the Bill. It is quite clear that there is an urgent need for change in the Government's policies on community care, and the reasons are precisely the legacy of the policies they have pursued since 1979.
One of my worries is the indecent haste with which large psychiatric hospitals are being run down because of financial pressure on the Health Service. That process is also influenced by performance-related pay for general managers, who have had incentives to get people out into cardboard boxes, rather than proper community care, and have discharged patients in questionable circumstances.
The huge explosion in private institutional care is the direct result of the publicly funded experiment in free-market provision. People are being forced into institutional care because of the contraction of an alternative to it in their communities.
A letter from Pat and Michael Frobisher, who live in Walton in Wakefield, arrived on my desk here last week. With their permission, I should like to quote it, as it illustrates my argument. Pat Frobisher writes: 559Michael was diagnosed with MS in 1970. I have nursed him since he gave up work in 1975. I had help from a nurse to bath him once a week after 1981 and respite care one week in 6 in the YDU at Pinderfields since then. Last year, in 1988, I begged for more help from the Health Authority. No dice. No money. No staff—consequence, I collapsed in July 1989 and Michael had to go into care, the one thing we had hoped would never happen.He was moved 15 miles away from Wakefield to a private home near Goole.
Pat Frobisher then mentioned costs, saying that they are covered by the Department of Social Security and a small occupational pension, which gives them an income of £245.05 a week. The letter continues:The fees at Greenacres are £245 pw, leaving Mike 5p per week spending money.As a result, the family are having to sell their house in Wakefield to raise money to pay for the man's care, simply because domiciliary support is not available. I telephoned Mike Frobisher today to ask his permission to use the letter. He reminded me that we had met—when I spoke at a meeting to try to keep open the younger disabled unit at Pinderfields hospital at Wakefield because it was threatened with cuts by the Government whose performance we have heard praised by Conservative Members throughout the debate. What I have described is the reality of Government policy. People are being forced into institutional care because domiciliary provision has disappeared in many areas as a direct result of Government cuts.
The Bill's parentage is highly questionable. The motivation behind it is financial and ideological. It is a clear attempt to reduce Government spending. There is deep anxiety about the financial mess that has arisen because of the open-ended income support of private care. The Bill is a deliberate attempt to shift the burden of funding residential care away from the Department of Social Security to the backs of local authorities. The Government continue to regard community care as a cheap option. It is a disgrace that the Bill fails to finance the resource requirements that have been identified by many, including the Association of County Councils. Professional training and resourcing requirements are not being funded in the Bill.
The Bill is ideological because it attacks local authority provision and discriminates in favour of the voluntary and private sectors. That discrimination against local authority is indefensible. They will no longer be able to provide part III accommodation and residential care, which, as everyone knows, is a safety net for people whom the private sector reject.
I support the voluntary sector—I am aware of the many initiatives taken by voluntary groups—but it is patchy and uneven. The many representations that hon. Members receive from such organisations show that they do not want to play the role envisaged for them in the Bill.
There is deep anxiety about the implications of the market forces approach. Experiments in such an approach to private institutional care provide clear evidence that market forces do not lead to improved quality. Problems after problem in the private sector has forced the Government to bring forward the Registered Homes Act 1984 to tidy up the problems faced by people in private homes and the scandals that continue to occur in the private sector.
560 I find the issue of choice interesting. Genuine choice in residential care would mean leaving vacancies. How many owners of private homes will say, "We believe in choice, so we will leave three or four vacancies"? The idea that choice can be provided in community care is a myth.
In the debate on the Queen's Speech, I said that competitive tendering for care was offensive, and irrelevant to the care that our welfare state should continue to provide.
My time is virtually up. Once again I am at the dog-end of the debate. I seem to manage to have this slot every time that I speak in the Chamber. In Committee, the Opposition will put forward radical alternatives to institutional provision. Let us get away from the legacy of the workhouse. Our alternatives will be to bring about an intensive domiciliary support service, to keep people out of institutional care rather than force them into private homes as the Government have done.
I am proud to boast that I have been personally involved in community care. The community care provisions in the Bill are clearly an afterthought, as was the Secretary of State's reference to it towards the end of his speech. The Bill is a dog's breakfast. It is inappropriate to say that it makes sensible provision for community care. It will compound, rather than correct, the appalling consequences of 10 years of Conservative policy in that area.
§ Mr. Barry Jones (Alyn and Deeside)
I am glad to follow my hon. Friend the Member for Wakefield (Mr. Hinchliffe), who always speaks with insight and conviction.
My right hon. Friend the Member for Blaenau Gwent (Mr. Foot) said that he was here in 1948, when the original NHS Bill was introduced. We know from his speech that he has just had an operation, so he has sampled the NHS many years later. He congratulated my hon. Friend the Member for Livingston (Mr. Cook)—rightly, in the view of all hon. Members on this side—on his superb speech. He made many points, but he will agree with my right hon. Friend the Member for Blaenau Gwent that the Prime Minister wishes to twist the NHS into something else.
As my right hon. Friend knows, the Bill is greatly disliked throughout the length and breadth of Wales. In an intervention, the hon. Member for Lancaster (Dame E. Kellett-Bowman) asked about lithotripters for the treatment of kidney stones. Why do the Government consider that it is permissible for Wales to be without those machines? Why should the people of Wales, who fall prey to kidney stones as much as any other people, not have that treatment? These machines are in Leeds, Sheffield, Bristol, Manchester and Scotland and there are two in London, but none in Wales. Will the Under-Secretary of State tell us whether the Bill will guarantee these long overdue machines for Wales?
The Secretary of State for Wales will not take part in our debates on the Bill, yet this is the most important Second Reading debate in this Parliament. Why has he resolved not to speak? Perhaps he is ashamed of the Bill. Perhaps he dislikes the tinge of commerce that runs through it. Perhaps in Cabinet Committee he lost the fight against hospital trusts in Wales, but his name had to go on the Bill, or he could not stay in the Cabinet. That was the price of high office. This wretched Bill appears to be the 561 price that he had to pay to remain in office. It is regrettable that he is not even in the Chamber for this greatly important debate.
Wales comes at the bottom of too many tables of social indicators. We are the land of low wages. We tend to be at or near the top of any assessment of poverty, ill health and poor housing. Our anxiety is that the Bill overlooks the interests of the average family on low wages. Until now, that family has had the guarantee of a comprehensive Health Service, free at the point of use—a compensation, a buttress and an insurance for families who find it hard to make ends meet. In this Bill we see the first disturbing signs of the erosion of the concept of a comprehensive Health Service. The Bill raises doubts for the retired miner in Tymbl or Blaenavon, the quarryman's widow in a terraced house in Blaenau Ffestiniog and the unemployed steelman in Shotton.
The great Aneurin Bevan in Mr. Atlee's Administration bequeathed the NHS to our people. The NHS was conceived and nurtured in Wales, where in the different communities miners and quarrymen initially banded together to provide basic health care. Many will agree that the NHS has bound us together as a society. It represents the pursuit of a humane and social objective: that the sick should receive treatment of the highest possible quality because they are sick, not because they are rich.
The Bill is irrelevant for Wales. There are barely 13 general practices of the required size. So far, there is not one application for a hospital trust. The plans are deeply unpopular throughout the length and breadth of Wales. That partly explains our magnificent parliamentary election successes throughout 1989. We can say without a shadow of doubt that there is no mandate for the Bill in Wales—none whatever.
The Conservatives are a minority party in Wales. This Bill is a home counties solution to the Health Services problems. It is the socially divisive Cabinet politics of the south-east of Britain. Without a shred of support for it in Wales, it is yet another example of the north-south divide.
The Bill fails to address the problems of health inequalities. The Bill sees the model patient as a person in a health supermarket or in Marks and Spencer, with time and money to spend choosing health care from among the many goods on sale. That is not true of most people who use our health services. The Bill's proposals will make the Health Service less accessible to those most in need, especially the elderly, the disabled and those with mental health problems. The poor already have difficulty in getting the best out of the Health Service. All those people may need to see a doctor more often and receive more treatment in hospital than others.
In Wales we have areas of social and economic disadvantage that are among the worst in Britain. This decade, unemployment, poverty and industrial decay have increased enormously. Those social and economic disadvantages are shown in major health indicators—41 per cent. of Welsh people report long-standing illness, compared with 33 per cent. in England and 31 per cent. in Scotland. In Wales, child health is poorer than in the rest of Britain and there are 5.2 stillbirths per 1,000 live births. The mortality rate among children under one is much higher than in England or Scotland. Such health disadvantages are often a function of the Welsh industrial history. The death rate among men in Wales from bronchitis, emphysema and asthma are much higher than in Britain.
562 It is also true that Wales is a black spot for heart disease. The Welsh heart health survey, the most comprehensive survey of its kind, found that deaths from heart disease among women increased by 25 per cent. between the years 1970 and 1980. Heart disease accounted for half of all deaths in Wales in the survey year—something like 10,000 men and women. In the Rhondda valley, the mortality rate is 20 per cent. higher than the British average.
Comprehensive health services, within easy reach of all, are absolutely vital to the Welsh people. The proposals in the Bill will not provide those services. Local accountability of the Health Service will also be reduced by the Bill. The number of community health councils in Wales will be reduced from 22 to nine, but the changes to the Health Service will make those councils more not less important. The proposals mean, however, that patients will be more remote from health care. If there are fewer community health officers, there will be less local representation and less local accessibility to the Health Service.
The chairman of the Society of Community Health Council Secretaries in Wales, Mr. Ivor Roberts, has told me that the proposals are incompatible with the supposedly "consumer-orientated" aims of the Bill.
The changes are unwelcome. We know that the aim of community health councils in Wales is to enable people to participate in the planning and running of the Health Service. The proposal to reduce the number of such councils from 22 to nine is a retrograde one. It will mean that the Health Service is less accessible—more distant from, and less responsive to the needs of, the communities that it seeks to serve.
A number of hon. Members have already expressed great concern about community care. The provision of the highest quality community care to our elderly and mentally and physically handicapped is of the utmost importance. Wales has the second highest proportion of elderly people of any part of Britain. Wales has a higher proportion of elderly people in local authority residential homes than the United Kingdom average. The number of severely handicapped adults in Wales is more than double that for Britain as a whole. The Bill's proposals are just not good enough to meet the challenge.
If the Bill is enacted, there will be a problem with travel and access. People may be expected to travel to hospitals in other areas to avoid waiting. However, for those with mobility problems—the elderly, the disabled and the poor —this may be impossible. For everyone, it will be harder for families and friends throughout Wales to visit. The problem will be particularly great in rural areas, where patients already experience longer travelling times than people in other areas. Bus and train services are not as good as they were 10 years ago.
For women, the great users of health services, travel can be a particular hardship in Wales. Difficult and expensive journeys may deter some women from attending clinics for antenatal and post-natal care. Increased travelling costs to more distant maternity units could create financial pressures for those with incomes just above the level of eligibility for financial help for travel. The problems are even greater for parents with sick or handicapped children who need to remain in hospital or return there regularly.
It is no exaggeration to tell the House on behalf of the people of Wales that this measure is of great concern to people with children in hospital, to people who are in great pain who are in hospital for a long time, and to the 563 terminally ill. Modern hospitals' care of children relies heavily on the participation of parents. How will that be possible if the hospital is distant from home?
I want to pose some questions which I hope will be answered by the Under-Secretary of State. Has the Bill been costed? What do the changes mean in real terms? Will there be the manpower with sufficient skills to implement the proposed changes? If these supposedly massive amounts of money are available, the nurses in Wales ask this question: why cannot the money be given now for patients' care?
There are no proposals for ballots. The changes will occur over very short time scales. It looks as though there will be greater centralisation of the control of the Health Service in Wales. It is a cheek to push the Bill in Wales. Waiting lists are already a disgrace. We have seen hospitals and wards close and the loss of many beds. The Government have imposed eye test charges. They are increasing the cost of dental examinations. The Government have given well-off older citizens tax relief, should they go for private treatment. Many hon. Members have said what must be the truth—the morale of those who work in the service is very low.
It is no exaggeration to say that in Wales the Health Service is the people's health service. Now, it is free and accessible to all, but the Bill has no support in Wales. No Conservative Back Bencher from Wales will say that it has support. I challenge any of them to say that they will support it. There are no such Back Benchers here tonight. The Secretary of State for Wales is not here. They have run away. They are afraid, and know that there is no support for the Bill. In the Vale of Glamorgan parliamentary by-election, the proposals on the Health Service constituted one reason why the seat was gained by Labour from the Conservatives. We had a great deal of help from the Secretary of State for Health, too. His proposals helped us to win the seat.
The people of Wales are not behind this Bill; those who work in the Health Service will have none of it; the community health councils are critical; patients and voluntary groups are almost universally opposed. Opinion in our country of Wales is that the humane and magnificent aims of the Health Service are under threat and that the Government are up to no good. We all believe in Wales that we shall lose if Government Whips push this measure through against the interests of our people.
The Government have a clear choice: they can abandon dogma or face the loss of parliamentary seats throughout Wales. Even if they will not listen to public opinion, perhaps they will at last listen to their own voters. This Bill should be dropped and Wales should be exempted. I am sure that we shall vote against it next week.
§ The Parliamentary Under-Secretary of State for Wales (Mr. Ian Grist)
That was a miserable speech, but it was in line with what one usually hears from the hon. Member for Alyn and Deeside (Mr. Jones). I shall be going to his county tomorrow to see the great new hospitals that have been built there under this Government—Maelor Wrecsam and Ysbyty Glan Clwyd. I hope to learn there of the support that we have gained for building the hospitals 564 that the hon. Gentleman so signally failed to build when serving in my position for five years under the Labour Government.
When the Labour Government were in power, expenditure on the Health Service rose by only 6.6 per cent. in real terms, whereas I am delighted to say that, in the district health authority serving Alyn and Deeside, it has risen under this Government by no less than 46 per cent. in real terms. That is the measure of the difference between the Conservative record and Labour promises.
It is remarkable to hear the hon. Member for Alyn and Deeside talking about waiting lists, doctors and nurses and the need for greater resources. When he was in power, nurses' pay fell by 20 per cent. in real terms. Hon. Members who were in Parliament then will remember nurses complaining to them. The same applies to the right hon. Member for Blaenau Gwent (Mr. Foot), who made a heartrending speech about the Health Service, claiming that it was Socialism in action. We do not accept that; nor do the people who worked in the service and suffered under the Labour Government.
Of course we are sorry about the disputes in the service, but they are as nothing compared with the industrial action in the Health Service in the last months of the Labour Government. It is no wonder that the hon. Member for Alyn and Deeside and the right hon. Member for Blaenau Gwent feel guilty when they reflect that, if we had continued nurses' pay at the level at which it stood when we came to office, it would be worth £68 per week less, than it now is. Consultants would be paid £63 per week less and the average remuneration of GPs in Wales would have to fall by £94 per week to bring it to a level comparable with that in the last year of the Labour Government. When the hon. Gentleman had the power to act, he paid nurses, doctors and consultants miserable sums. There was no capital expenditure, there were 7,000 fewer front-line staff in Wales—including nurses and doctors—and the hospital service was treating 400,000 fewer patients every year.
Practice funds have been discussed in today's debate. They will give GPs much greater freedom to be masters and mistresses in their own houses and to deploy their resources in such a way as to enable them to provide patients with the high quality care that they want and need. Hospitals will become more responsive to the needs of GPs and their patients, as GPs will obviously choose those which offer the best quality services with the shortest waiting lists. Practice fund holders will also be able to transfer funds between different elements of their budget. That will provide them with greater flexibility in meeting the needs of their patients. Greater freedom in managing budgets will also enhance their clinical freedom and they will be able to make savings from the fund which can be used to provide improved patient care.
As with National Health Service trusts, we want GPs to be attracted and not compelled towards becoming fund holders. If GPs consider that funds are not in the best interests of their patients, no pressure whatever will be placed on them to accept funds against their better judgment. In addition, before any practice is allowed to hold funds, the Secretary of State will have to be satisfied that the practice has the capacity to manage them efficiently and in the best interests of patient care.
Full discussions will be held with a practice which applies to hold funds so as to take account of its particular circumstances and the composition of its practice lists.
565 There will be safeguards to ensure that any unforeseen circumstances leading to a need for additional expenditure on patient care can be accommodated. In short, funds will be set up and run in such a way that patients will receive all the care that they need within a structure which provides much more directly for the GP taking into account the wishes of the patient to ensure the best quality care.
The Bill also provides a framework for more effective prescribing by GPs through our proposals for indicative drug budgets, to which several hon. Members have referred. Doctors will be given an indication of what their expenditure on medicines should be, based on the age and range of patients treated. If they spend more, as they may, they will be expected to show that there were good medical reasons for so doing. If they can show such reasons, that will be the end of the matter. Any necessary follow-up on GPs who appear to be prescribing irresponsibly—and irresponsible prescribing damages patients—will be undertaken by senior and experienced doctors whose aim will be to help GPs maximise patient care.
The proposals for indicative drug budgets have been the subject of dreadful misrepresentation. I emphasise that they will be indicative, exactly as they are described. They will not in any way infringe the right of medical practitioners to prescribe all the drugs that their patients need. The scheme will provide GPs with an incentive to examine critically their prescribing patterns and costs. Every patient being cared for by a general practitioner will, of course, always be able to get the drugs that he or she needs, including high-cost medicines, for as long as they are needed. I hope that that meets the fears of my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) who spoke so feelingly.
§ Mr. Grist
I am sorry, but I will not give way at this stage.
Indicative budgets are not cash-limited and the Bill exactly replicates existing provision about cash-limiting expenditure in the family practitioner services.
I come next to the part of the Bill which provides the necessary framework to carry forward our proposals for community care, about which many hon. Members were extremely interested. Details were set out in the White Paper "Caring for People". The broad thrust of the proposals has been welcomed by many people, including those whom I met on Monday at a meeting with the social services chairmen and directors in Wales. The proposals place a clear responsibility on local social service authorities in co-operation with medical, nursing and other interests, to assess the social care needs of their population and to design and make arrangements for the delivery of appropriate packages of care that will meet the needs of individuals.
§ Mr. Grist
No, I am sorry, but I will not give way.
Many people have benefited from the expansion of the independent sector, about which the hon. Member for Wakefield (Mr. Hinchliffe) spoke, and nursing home care which has been made possible by massive new expenditure through the social security system. In Wales alone, the numbers have quadrupled, to about 12,000 during the 566 Government's period of office. As the hon. Member for Wakefield said, that care has not always been the most appropriate for individuals.
The present funding arrangements that have created the incentive to place people in private residential or nursing homes, irrespective of whether that was the type of care that they wanted or needed, will end. From April 1991, there will be a phased transfer from central Government to local authorities of resources to enable them to carry out their new role. The details of the resources involved will be determined in next year's public expenditure deliberations. It was extraordinary to hear the champions of local authorities sound off so suspiciously about their colleagues in local government who they suspect will misuse those funds. I include in that my hon. Friend the Member for Macclesfield (Mr. Winterton), who was not too friendly last night either.
In Wales, the new arrangements will build upon strategies and initiatives that we have embarked upon already in respect of services for those with mental handicap and mental illness, as well as services for the elderly, which have been widely praised by many, including Opposition Members. For example, I think that the hon. Member for Ynys Môn (Mr. Jones) has praised the efforts that have been made under our mental illness and handicap strategy. I do not think that I would be going too far if I suggested that the Government's approach to future arrangements for community care for the whole of Great Britain may owe something to our pioneering initiatives in Wales. I sincerely believe that they provide the opportunity to develop quality services that will sustain local communities and maximise the independence of individuals. It is the framework that we need to meet the demographic and social changes that we face over the next decade.
I had hoped that the contributions of Opposition Members would have been rather more constructive than they have proved to be. There are objectives underpinning our proposals which I hoped we could all share. The Opposition are making a serious error of judgment in the way that they express total opposition to our proposals. As the debate unfolds during the passage of the Bill, more and more people will understand that the increased pressures to improve services that will be placed on the NHS in the next decade and beyond as a result of increasing numbers of elderly people and other social changes, as well as from the continuing advance of medical science and the growl :h of available treatments, can be met only by the programme of reform which the Government propose.
§ Mr. Morgan
On a point of order, Mr. Speaker. Is it in order for the Minister to fail to give an explanation of how 567 it is that, in advance of the Bill becoming law, he and his boss have decided already to implement part of it in my constituency since December—
§ Mr. Speaker
Order. Hon. Members from the Back Benches and from the Front Benches make their own speeches. The debate will continue for 10 minutes more.
§ Mr. Grist
The hon. Member for Cardiff, West (Mr. Morgan) has shown that he has not read the Bill and that does not understand what it is about.
Opposition Members have gone on about expenditure. If that alone were the answer, we should not have a problem today. Since 1978, spending on the Health Service in the United Kingdom has increased massively from £8 billion to £26 billion in 1989. I have no doubt that the hon. Member for Alyn and Deeside will remember with satisfaction that when he was a member of the Labour Government and a Minister with responsibilities for health, he cut expenditure on the NHS by no less than 23 per cent. in one year. That must be compared with the growth of over 25 per cent. that we have provided in Wales alone this year. As my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) said, his spanking new hospital was delayed for 10 years.
§ Mr. Grist
Indeed, many of us can say the same thing. It is the reversal of the position which prevailed under the previous Labour Government, which explains why the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) finds it so difficult to understand where all the money has gone. It has gone on new hospitals, new units, new drugs and a vastly increased work force in the Health Service.
I suppose that it is just possible for the Opposition to fool some people about their intentions and their earnestness, but I doubt whether they will ever be able to convince the public that they could manage the economy well enough to create the resources that are needed for the NHS. Even if they were able to do so, would they convince anyone that they would not fritter the money away on the pay of those employees in the NHS who threaten the loudest?
In another sense, resources lie at the heart of the matter. I hope that we can all share the objective or overriding aim of ensuring that we derive maximum benefit from the massive resources that we are investing in the NHS so that we can be sure that every pound purchases the greatest possible amount of direct patient care. We have been accused of pursuing market ideology, but Opposition Members are the ideologues. They are hidebound in the way in which the cling to a structure and an organisation which is monolithic, over-bureaucratic and corporatist. It is too distant from those whom it is meant to serve.
The fundamental aim of our proposals is to make the Health Service more responsive to the needs of patients and to provide a widening choice. We shall do that be delegating responsibility to local level, by developing more patient-centred treatment and care and by increasing the accountability of those in the front line who deliver the patient care and the managers in the authorities providing the conditions in which front-line staff work.
568 Opponents of our proposals have consistently failed to recognise the crucial and strengthened role of the district health authorities. For the first time, the authorities will be funded on the basis of their resident population. They will have a clear duty to ensure that the health needs of that local population are properly met.
Each health authority will need to carry out a systematic assessment of the health status and needs of its local population. The director of public health medicine in each district will be responsible for carrying out that assessment, in consultation with clinicians in hospitals, with general practitioners and with other interests. Their task will be to identify local needs and priorities and to ensure that people have access to a comprehensive range of high quality, value-for-money services from the hospitals and units judged best able to deliver them.
Complementary to that will be the duty that we intend to place on social service authorities to produce social service plans in collaboration with health authorities, voluntary bodies and the users of services and their representatives. They must set out how they intend to ensure the provision of quality social care for people in their homes and their communities. Taken together, our proposals will lead to a systematic assessment of people's health and social needs and the planning of comprehensive services to meet those needs.
Central to our approach is the need to devolve responsibility for the day-to-day provision of services to local unit level, thereby freeing district health authorities to concentrate on their principal task of assessing the needs of those for whom they are responsible and ensuring that those needs are met by service providers—[Interruption.]
§ Mr. Grist
That does not matter—I have plenty of brief.
Our approach builds on the acknowledged success of the progressive introduction of general management at all levels of the NHS—which, of course, Opposition Members resisted so bitterly. Our proposals for new, streamlined health authorities will make them far better equipped to perform those functions. Listening to our opponents' views, I fail to understand what can be so terribly wrong with a system of which the overall objective is to achieve better value for money so that more resources can be released for direct patient care. Our opponents do not like that approach—
§ Mr. Powell
The hon. Gentleman should withdraw. I would not call him a cheat. If it were anyone else, Mr. Speaker, you would ask him to withdraw. He referred to me as a cheat. I ask you to use your authority to ask him to withdraw his remark. Otherwise, I shall have to take the matter further.
§ Mr. Speaker
Order. Let us calm down. Did the hon. Member for Watford (Mr. Garel-Jones) mention that word?
§ Mr. Garel-Jones
At your request, Mr. Speaker, I apologise to the hon. Member for Ogmore (Mr. Powell).
§ Mr. Grist
I hope that the hon. Member for Alyn and Deeside is pleased with that. I am staggered by the opposition of Labour Members, who have so misunderstood and misrepresented the aims and purposes of our proposals. I have twice been in hospital this year, and my wife and younger son have also been in hospital, all of us as patients of the NHS. I cannot speak highly enough of the care, skill and dedication of our health staff. It is to give them more fulfilling careers, as my hon. Friend the Member for Mid-Kent (Mr. Rowe) pointed out, and to give even better treatment to their customers—us, as patients—that I commend these proposals to the House. I look forward to the Committee debates, in which they will be examined in detail and when the public will learn precisely what is in the legislation instead of listening to the rubbish that they have heard from Labour Members, their trade union friends, the British Medical Association and many others.
§ [It being Ten o'clock, the debate stood adjourned.]
§ Debate to be resumed upon Monday 11 December.