HC Deb 26 January 1993 vol 217 cc887-973 4.17 pm
Mr. David Blunkett (Sheffield, Brightside)

I beg to move, That this House regrets the growing crisis within the National Health Service; condemns the commercialisation of the health service and the development of two-tier health care; expresses concern at the total fragmentation of health care due to underfunding and the impact of the internal market, Trusts and GP fundholding; regrets the destruction of NHS dentistry and the uncertainty over the future of London's health care; deplores the lack of accountability now at the heart of the NHS; and calls on Her Majesty's Government to act immediately to tackle this crisis before the end of this current financial year and to begin a review of their so-called health reforms for 1993/94.

Madam Speaker

I have had to limit speeches to 10 minutes between 6 pm and 8 pm because of the demand by Members to participate in this debate. I have selected the amendment in the name of the Prime Minister.

Mr. Blunkett

There is a crisis at the heart of the national health service. That is why I and my right hon. and hon. Friends are moving this motion. The NHS is under-funded. It is being undermined. Unfortunately, it is under the direction of a weak and indecisive Secretary of State. A sophisticated sophistry of statistics is invented by the PR Department who present her, albeit wonderfully, in the guise of mother superior of the NHS.

We have before us an amendment by Her Majesty's Government which has the cheek to welcome the NHS changes and to talk about the record numbers of patients being treated", when waiting lists are increasing, operations are being cancelled and, as we all know, across the country there is a real crisis in our hospitals.

The amendment also mentions elimination of two-tier waiting lists in the regions". Well, instead of two-tier waiting lists in the regions, the Government have created a two-tier health service across Britain. The amendment goes on to claim a substantial reduction in long waiting times generally". We all know that the time taken to undertake serious elective surgery is rising in proportion to the number of minor ailments being treated in this two-tier service.

The NHS, far from being safe in the Government's hands, is gradually and regrettably beginning to fall apart. Instead of policies for caring, we have competition. Instead of service, we have commercialisation. The internal market and the two-tier service are undermining equal access, which is now being denied to patients throughout the country. Information sought by the Opposition and by Back Benchers of all parties is being denied increasingly by a Government frightened to tell the truth. In the words of the Parliamentary Under-Secretary of State for Health, statistics—what was the phrase?—if you can believe them, or for what they might mean.

Hospitals are no longer called that; they are called provider units. Patients are now described as episodes. Instead of a health service of which all of us can be proud, we have something that has turned into a commercial enterprise. Promises have been broken, and broken again, from small promises about drug and alcohol units being safeguarded and ring-fenced, to the promise that was made leading up to the general election that the Government would be spending billions of pounds more each year on our NHS. Instead, on 12 November, the Chancellor of the Exchequer announced that that promise, built into the public expenditure predictions on which the Conservatives fought a general election, has now been set aside, with a cut in England alone of £700 million in the projected budget for next year.

A promise is not worth a thing when it is in the hands of Conservative Ministers, and that promise has been substantially broken for one very clear reason: because of the total incompetence of Government Ministers in handling our economy. We have had the fiasco of black Wednesday; the £2 billion plus gold and currency reserves that were squandered; the inability to manage the health service, with £300,000 per bed being spent on the Chelsea and Westminster hospital; and an audit service that is not allowed to publish its results, not allowed to tell the truth to the people of the west midlands, Wessex and elsewhere about the mismanagement of the service that is supposed to be operated in their name.

Mr. Jerry Hayes (Harlow)

The hon. Gentleman spoke eloquently a moment ago about broken promises. Does he remember the promise that he made to the Blackpool Labour party conference on 30 September 1992, when he spoke about the Tories' own Frankenstein monster, meaning national health service trusts? He went on to say —I paraphrase—that the people of Britain had a right to know when, if ever, the Government would admit that their great trust experiment was not working and was in urgent need of reassessment. He has just broken that promise, has he not, because he has reversed his policy; he is not going to abolish trusts at all.

Mr. Blunkett

I am sorry to disillusion the hon. Gentleman. I presume that he must read The Daily Telegraph, which misreported me. Having not sent a journalist to the briefing meeting and therefore not being aware of the facts, The Daily Telegraph then declined to publish my letter setting out the truth. The Secretary of State said on "Question Time" about 10 days ago that she supports the Bill of my hon. Friend the Member for Hammersmith (Mr. Soley), which is coming forward next Friday, but unfortunately will not be voting for it. She should have a word with the editor of The Daily Telegraph, because the right of reply is important if we are to have an honest and sensible debate.

As we are dealing with trusts, let us get something straight. Even the Secretary of State admits that trusts are non-accountable, that they are not working and that she will have to bring them to heel. There is the well-funded federation that represents their views, not forgetting the £60,000 spent on the salary of the new chief executive, recruited from Tory party central office. It will all be wasted because the Secretary of State knows that she will have to make trusts accountable.

Several hon. Members


Mr. Blunkett

I willingly give way.

Madam Speaker

Order. To whom is the hon. Member giving way? Several hon. Members wish to intervene.

Mr. Blunkett

I give way first to the hon. Member for Amber Valley (Mr. Oppenheim), on the ground that at least he knows in which direction he is going.

Mr. Phillip Oppenheim (Amber Valley)

I am not sure what to read into that, but I thank the hon. Gentleman for his courtesy in giving way.

In relation to NHS trusts, if the hon. Gentleman denies the report in The Daily Telegraph to which reference has been made, may I ask him to comment on the report in The Times on 14 January of this year, which quoted him as saying that he would not be in favour of abolishing NHS trusts, just integrating them into some future coherent NHS strategy"? What did he mean by that?

Mr. Blunkett

I do not have any difficulty in saying that non-accountable, completely undemocratic, self-governing trusts will not exist under a Labour Government, because we believe in democracy and accountability, with the involvement of local people, by which I mean not just business people and Conservative party friends. I am not talking about the sort of nepotism that is now being practised in a remarkable way throughout the country.

The latter part of the Government amendment, which refers to the Opposition politicising the health service, takes the biscuit, considering what has been going on in Britain. South Glamorgan is only the tip of the iceberg —not so much a two-fingered handshake as the ability to shake hands with one's next door neighbour and promise that neighbour a job the following week. All have their snouts in the trough. That is happening in the health service in Britain.

In that context, let us consider the health service and the integration of community services with hospitals that made such a difference to planning the service. Let us then question community care, which the Government have ill planned and under-funded.

The Secretary of State for Health (Mrs. Virginia Bottomley)

The hon. Gentleman talks about snouts in the trough. Is he referring to people such as Helen Hayman and Rabbi Julia Neuberger, who have agreed to become chairmen of NHS trusts?

Mr. Blunkett

The Minister need only talk to her hon. Friend the Member for Macclesfield (Mr. Winterton) to get a picture of snouts in the trough and the facts about the transfer of the chairman of the Merseyside region, Sir Donald Wilson, to the west midlands, presumably to peddle the same nepotistic attitudes and policies. The fact that the Secretary of State can quote the names of Labour and Liberal Democrat members is indicative of how many people are being appointed—[Interruption.]—with Tory party cards in their pockets.

Accountability is non-existent for trusts and general practitioner fund holders. To whom are they accountable? Is it to the region? Is the region accountable to the Secretary of State? Is the Secretary of State accountable to this House, remembering that every time we raise questions about detailed matters we are given the platitude that the statistics for which we ask are not collected or held centrally? The politicised management executive is not accountable; nor are health authorities and family health services authorities.

It was the European Policy Forum, and not a left-wing think tank, which talked about the new, undemocratic, paternalistic way in which Government agencies and the Department of Health are now being operated. It said that we have a new magisterial epoch in which people get jobs not because they are elected or accountable but because they have friends in high places.

Mr. Patrick Nicholls (Teignbridge)

I am grateful to the hon. Gentleman for giving way yet again on the question of accountability. He complains that trusts are not accountable, yet his hon. Friend the Member for Livingston (Mr. Cook) said in the House less than two years ago that the simple test for judging the trusts was whether they did more or less work for NHS patients. Does the hon. Member for Sheffield, Brightside (Mr. Blunkett) confirm that test or does he repudiate it?

Mr. Blunkett

I do not confirm the test, the results or that trusts are working. Doctors, consultants and patients across the country, reading their local newspapers, watching their regional television programmes and listening to regional radio, will know what is happening to their health service.

Professor John Ward, director of medicine at the Royal Hallamshire hospital, said in the local paper last week: The service has reached breaking point. Speaking about his meeting with Sir Duncan Nichol, the head of the management executive, two days later, he said:

I shall be putting the boot in. I do not think that we should blame the messenger; we should blame the Secretary of State and the Government who provide the message. The boot will go in from us and from the electorate up and down the country.

In that one hospital alone, six emergency admissions in one afternoon were sitting in the corridor waiting for a bed, not in a general ward but in the admissions ward. In the words of Professor Ward, 850 emergency admissions were dumped in the hospital between September and the end of December. All three emergency hospitals in the city of Sheffield have been on red alert for virtually all of 1993. That situation is repeated up and down the country, from Cambridge to Birmingham, across the length and breadth of the land. If it is not a red alert, it is a yellow alert.

Mr. Eric Pickles (Brentwood and Ongar)

Will the hon. Gentleman give way?

Mr. Blunkett

No, I want to make a little progress. In the same report, Sister Milne said:

Waiting times on trolleys can be five, six or seven hours. The Secretary of State knows all about waiting times of five, six or seven hours, because that very reliable organ of Conservative party propaganda, edited by a minor public schoolboy, The Sun, reported that her mother had waited for seven hours in St. Mary's hospital before being seen to.

I did not know whether to believe the Secretary of State's family or The Sun. My instincts told me to believe the family. I believe that the Secretary of State's brother and family are honourable people, but if she does not stand up and contradict them, I shall have to believe that the minor public schoolboy who has frightened Conservative Members so much in the past few days was telling the truth after all.

Instead of taking action on behalf of patients, the Secretary of State bows to publicity stunts. We had one this morning; a new British Telecom health line. I do not know whether the health line will be available for people seeking emergency ambulance cover when they cannot get through on 999 or whether, BT style, the new health line will simply say, "You are being held in a queue, this is normal for the NHS.". Whatever it is, I do not think that it is a particularly good gimmick.

I do not think that the doctors thought it a particularly good gimmick when on new year's eve the Secretary of State took herself off to plague them at her local hospital. I should be careful about quoting correctly because I think it was The Daily Telegraph that reported her striding down a corridor at the stroke of midnight having talked to doctors and nurses who were too busy dealing with casualties on new year's eve to take seriously her eulogies about the new NHS reforrns.—[Interruption] The Secretary of State seems to be saying that no one was with her. It must have been a phantom reporter who put out the news that Virginia Nightingale was ministering to the sick and the wounded on new year's eve. I hope that the right hon. Lady has a very happy new year. I hope that next year she will be able to drink a toast to a health service that has improved rather than deteriorated.

Perhaps the right hon. Lady will take notice of Dr. Ian Bogel, chairman of the general medical services committee of the British Medical Association. When describing the guidelines on access to the NHS, he said: Equal access to secondary care has been flouted by hospitals which cancel operations but continue to treat GP fund holders' patients. That is repeated throughout the country.

A letter from the Plymouth health authority states: It is increasingly clear that GP fund-holding practices have the capability and are intent on encouraging the development of mini clinics in dermatology outside the hospital service. This has the effect of taking NHS money away from the acute unit to the detriment of that unit. We propose to set up a clinic with sessions at Greenbank hospital every Wednesday evening between 5 and 7 o'clock with the specific intention of seeking patients from GP fund-holding practices. The letter then lists seven reasons why GP fund-holding practices should take up the work. It continues: While it is clear that this will create a two-tier system within the service, it will have no greater effect than that already commenced by several general practices employing their own dermatologists outside the hospital service.

Dr. Liam Fox (Woodspring)

For the sake of clarity, will the hon. gentleman tell us whether it is Labour party policy to abolish both NHS trusts and GP fund-holding practices?

Mr. Blunkett

I think that I have comprehensively dealt with trusts, so I shall comprehensively deal with GP fund holdings. I have made it unequivocally clear—it is on the record of every occasion on which I have spoken—that the Labour party and I, as its spokesman, are against GP fund-holding practices and a two-tier service.

The reason for our opposition is that given by Dr. Michael Jenner of Tonbridge. In a letter to me last week, he said: I know of a case in my practice where a patient had been on the waiting list for two years for a minor complaint and had to be admitted before a patient with a potentially malignant diagnosis because of the patients charter saying no one should wait more than two years … The NHS is rapidly becoming split in two and morale is at the lowest I have experienced in the 25 years I have worked in the service. My only advice to patients now is for them not to vote for the present Government.

Mr. Ken Eastham (Manchester, Blackley)

Only this week I received a letter from a doctor in north Manchester about the Booth Hall children's hospital and a child aged six who had been referred to it for an operation in January 1992. That child is still waiting and the earliest date for the operation is now May this year. He referred to the child's suffering and to the education that he had missed. It is a disgrace. If we were a third-world country, with a shortage of theatres and wards, we could understand the reason for long waiting lists—but that children's hospital has actually closed a theatre and a ward.

Mr. Blunkett

My hon. Friend is quite right. In 1987, when we last had a crisis in the health service—not the worst for 30 years, as the British Medical Association described this one, but so serious that the last Prime Minister had to decide to demolish the whole NHS so that it could be dealt with—there were 100,000 fewer people on waiting lists, and children such as the one to whom my hon. Friend has referred were being admitted and dealt with before minor cases.

The Government have simply devised a new, bizarre and irrational way of running out of money. The doctors are there, the nurses are there and the hospital wards are there, but the contracts have run out. Whatever increase there has been in productivity has been dissipated by the system that is currently being operated. A person with a serious but non-life-threatening ailment cannot get in to hospital, but when a person from a GP fund-holding practice has a minor illness, care can be bought.

Mrs. Virginia Bottomley

Can the hon. Gentleman name any Labour Government who left office with waiting lists lower than when they came to power? In fact, every Labour Government left office with waiting lists higher than when they came to power, whereas all Conservative Governments have seen waiting lists fall.

Mr. Blunkett

Had we managed to get rid of the Conservative Government on 9 April we should have had a startling and outstanding example of a Government leaving office with waiting lists much higher than those they had inherited. The Government have to hark back to 1978 for the lowest interest rates, and to 1968 for the lowest level of inflation. People ought to be reminded that many of the great records are held by Labour Governments. And we shall hold them again.

The NHS reforms are making matters worse. Waiting lists have increased since 9 April, and they are continuing to increase. The money does not follow the patients; the patients follow the money—if they are lucky. That is the truth of the matter. But what do the Government do about it? They talk to doctors about slowing down, about pacing themselves, about spreading the money over 12 months instead of nine months, about preventing embarrassment for the Government when the NHS has run out of money after nine months of the financial year.

The Government seek not to help hospitals to treat more people or to treat more serious cases, but to hide the truth from the British people—slow down, put down, perhaps lay off. That is the logic. If there are consultants who cannot work to full capacity, who cannot take on serious cases, are they to be laid off'? Are nurses to be laid off? Are more contract works simply to be taken on so that they can be laid off at the drop of a hat? Hospitals still have to be heated, the beds are still there, even if they are not made up, and the on-costs still have to be met. But the cosmetic surgery of the so-called waiting list initiative takes priority over the real needs of patients and of care in the health service.

Let us not have the fiddled figures paraded as though the Government were doing better. Waiting lists have lengthened, but there is a new technique—people are not put on waiting lists at all. People are now being told that they cannot be given a definite date for a hospital bed. Therefore, they do not appear in the statistics. This is gross distortion worthy of George Orwell, and the Government are getting away with it.

What is more, as the patients charter and the waiting list initiative take effect, the Government deliberately skew the figures so that one can no longer find out nationally how long it takes to get a first appointment with a consultant. The first appointment is the most important of all, as it is at that point that an illness is diagnosed as being serious or minor. And that is critical to the saving of life. Yet, having tabled a parliamentary question a few weeks ago, I was told that the Department saw no need for national collection of statistics on waiting list times.

Mr. Eddie Loyden (Liverpool, Garston)

Is my hon. Friend aware that in the very recent past an epileptic young woman of 19 in my constituency was taken into hospital and discharged, was taken into hospital again, and discharged, and was taken in a third time and died? Surely that indicates the nature of the problem in the national health service.

Mr. Blunkett

My hon. Friend, as ever, speaks from the heart about the truth that emerges from our postbags day in and day out, week in and week out. Consultants, other doctors and patients write to us about the stark reality that Conservative Members are unable to face.

What about activity levels, about which the Secretary of State spoke at Question Time today? As John Chawner, the chairman of the committee of consultants and specialists, pointed out to the Secretary of State in a letter of 22 December, more day cases—minor cases—are being dealt with, while more serious cases are being made to wait. In addition, research shows that 28 per cent. of so-called episodes of activity levels turned out to be fraudulent. A patient was moved from one ward to another—and was counted as a new episode. The whole thing is a farce and a fiddle. One can no longer believe anything.

What are these changes costing us? Longer waiting lists, more suffering, greater worry and £1,180 million. This is a scandalous waste of money that could have been spent on patient care, on improved quality and on equal access. And all this is happening during a winter when there has been no major epidemic. There has been no major outbreak of flu, except in my own case.

Mr. Pickles

Given that 90 per cent. of doctors have now reached the immunisation target, why does the hon. Gentleman object to fund holders? Is not this an example of success?

Mr. Blunkett

I have never criticised immunisation. The hon. Gentleman needs an injection of common sense, decency and care to stop his blithering—the blithering in which he used to engage when he was leader of Bradford city council.

Instead of care and action, we have public relations offensives. In newspaper and television interviews the Secretary of State tells us how wonderful things are. Journalists become star-struck the minute she smiles beguilingly and gives her enchanging, "mother superior" view of the world. But the record speaks for itself. In July we had her announcement about dentistry, which created such chaos that, since then, 250,000 people have been removed from the NHS dental lists. Of these, 13,000 live in Surrey, the county of the Secretary of State. And in the Prime Minister's constituency 99 per cent. of dentists are refusing to register adult patients.

Mrs. Virginia Bottomley

I urge the hon. Gentleman to look again at his information. There are 1 million more people registered with dentists than there were last July, and there are 7 million more courses of adult treatment than there were in 1979. Finally, Bloomfield has said that dentists' earnings are now at a record high. The hon. Gentleman might like to consult the record to see what happened to dentists' earnings in real terms when his party was in power. They fell by more than £3,000.

Mr. Blunkett

The Secretary of State, as I suggested at the beginning of my speech, is a sophistry of statistics, but the reality is different. The deregistration of patients, the refusal of dentists to take on patients, the increase in private dental practice encouraged by the Government, the steer given to the Bloomfield inquiry, which has all sorts of suggestions about a new, privatised service, cannot disguise the truth. The registrations were encouraged by the Government on the grounds that unless dentists found their records and registered those who had not been to visit them in the past two years, they would not "benefit" from the new system. When the Secretary of State eventually comes to the House, as she is so often reluctant to do, to make a statement on what she will do about dentistry in the national health service, we will deal with this matter comprehensively.

In September the London ambulance service staggered, as it had done for months, from crisis to crisis. What action was there from the Secretary of State? None. There was a resistance to action, a resistance to getting rid of the people running the service, a resistance to doing anything to safeguard life and limb—until she was forced to come to the House when the whole system collapsed in October.

Right through the summer and autumn, the West Midlands regional health authority was nothing less than a fiasco—millions of pounds wasted on privatisation and consultancies, audit reports, National Audit Office reports, but no action, a refusal to take any steps to deal with the chairman or with the authority's incompetence until the Secretary of State was forced to take action when Sir Roy Griffiths said that it could not carry on any longer. When the chairman went, whom did she appoint? Sir Donald Wilson, the 70–year-old chairman of the Merseyside region. She really has a sense of humour. The only thing I can say for her is that she is not ageist. If the Secretary of State listens to her hon. Friend the Member for Macclesfield, she will know just what the west midlands is in for in the months ahead.

What else in October? The Secretary of State announced with a fanfare of trumpets that she would consult on the Tomlinson report. There was to he a major review of London's health care.

Mr. James Clappison (Hertsmere)


Mr. Blunkett

I am not giving way, Mr. Deputy Speaker. I have given way more than most hon. Members on the Front Bench.

The Tomlinson report, and the consultation on it, was to be the great step forward for London's health care. A major announcement was to be made after the Minister of State had toddled around the hospitals, not consulting the people of London or the local communities, the patients, the people who mattered. Then a message came round from Downing street to the Secretary of State. It said that she must forget about the frontal attack, about the comprehensive approach, because the Government were running scared. She was to announce that Bart's would be saved. We are all grateful for that; the campaign run by the Daily Mirror and the Evening Standard and by my right hon. and hon. Friends in London has done a superb job, and I am pleased about it.

But what sort of a Secretary of State announces one week, at the beginning of January, that it is full steam ahead and no change, and the next week is called into No. 10, and it is all overturned? Or perhaps it is not quite all overturned, as we will hear if we can get the Secretary of State to make a statement to the House about what she intends to do—because what they were not prepared to do in a full frontal attack they are determined to do by stealth. That is the truth of the matter on Tomlinson.

What about January? What about Ben Silcock being mauled by a lion at London zoo? I pay tribute to the Secretary of State's commitment to mental health issues. I even accept her sincerity in the media blitz that she launched in the aftermath of that accident. But what happened to her promise that action would be taken? The Daily Mail splashed it across the front page. She appeared on television, metaphorically with her arm around a number of her friends, telling everybody how much she cared and that steps would be taken immediately. What has happened? Precisely nothing. Once again, it is all wind and no action, and the same will be true for future announcements on what is to happen to the regions.

The Secretary of State has not even made an announcement about what is happening to health authorities. Their number is being reduced from 190 to 85 without an announcement to the House and without giving us the opportunity to debate such issues sensibly on the Floor of the House. We have the withdrawal of information that I have spoken about, and the Touche Ross report which the Secretary of State will presumably leak out on Friday afternoon, telling us again that nothing will be done.

We had tobacco and the Smee report: no action. The Secretary of State eventually chaired the first meeting on 13 November in that ill-fated six months when the Government had the presidency of the European Community. There was no action by way of banning tobacco advertising or joining forces with our colleagues in Europe to take decisive steps.

What about prescription charges? We expect increases in them to be announced in the next few weeks. Will the new cost be £4 or £4.25?

What about the Bloomfield report on dental services which the Secretary of State referred to? Will nursing mothers and pregnant women be denied free treatment, which is what the Bloomfield report threatens? Or will the Secretary of State take the advice of someone who once wrote about families cutting down on visits to the doctor because they could not afford the prescription charges, who wrote about mothers who could not afford the then small prescription charge not visiting the doctor for a cure for minor ailments?

The author wrote that people looked around for other cures. When they could not afford a cure for their toothache, some of them, said the author, used to bite on a clove. Adult members of these families would not go to the dentist because of the charges and consequent problems. They could not afford it with children to look after, or, as one family said, they would not go unless they were in absolute agony.

Who was the caring, decent person who talked about frightful housing, who talked about being unable to afford prescription charges, who talked about the problem of access to the dentist? It was the Secretary of State for Health, in an earlier, caring period when she worked with the Child Poverty Action Group and wrote pamphlet No. 8.

Is the right hon. Lady now the caring young woman who got down to the realities of what was happening in family life or is she the Secretary of State beholden to a Cabinet, to colleagues such as the right hon. and learned Member for Rushcliffe (Mr. Clarke) who appears still to run health policy from the back seat?

Our health service is in a mess, and this expensive mess has been created by the Government. I pay tribute to those in the health service who have fought to keep it going over the years. I pay tribute to those who have been telling the truth about our health service despite the risks and problems that they face. I pay tribute to those who are working to improve the quality of patient care, and I pledge that we will continue to fight for a comprehensive health service, tackling prevention, investing in primary and community care, intent on early intervention and, above all, linking health with housing, unemployment, poverty and inequity, a health service that provides equal access for all, a health service that is accountable and a health service of which all of us can be proud.

4.58 pm
The Secretary of State for Health (Mrs. Virginia Bottomley)

I beg to move, to leave out from "House" to the end of the Question and to add instead thereof:

congratulates Her Majesty's Government on its reforms to the National Health Service which have led to record numbers of patients being treated, the elimination of two year waiting lists in the regions, a substantial reduction in long waiting times generally and significant improvements in the quality of care; looks forward to more general practitioner fundholders and National Health Service trusts and the further improvements they will bring; and believes that in the modern health service the focus should be on patients and prevention and not on politicisation, which remains the dominant concern of Her Majesty's Opposition.". The Opposition motion refers to a crisis in the health service, but in reality the debate is more about a crisis in the Labour party and the particular crisis facing the hon. Member for Sheffield, Brightside (Mr. Blunkett). The dilemma for Labour health spokesmen is that they are condemned to pass as an unread chapter unless they cart generate a crisis. The hon. Gentleman has deepened his troubles today. His speech was wanting in substance, it was wide of the mark and none of my hon. Friends is any the wiser about Labour party policy on health than he was at the start. Labour party policy on health is a policy-free zone. Hundreds of thousands of staff and millions of patients and their families and friends will have found it difficult to recognise their national health service from the hon. Gentleman's speech.

Throughout the country, millions each year rely on the care that they receive from the health service. Time and again, the Opposition take individual cases, exploit them out of all recognition and paw upon personal detail to try to create a crisis in the service.

I will tell the hon. Gentleman about one of the individuals that he mentioned in his speech. I do not want to intrude on the privacy of all the many other individual cases in which his party trades. I will tell him about my mother who, like many others, could not speak more highly of the care that she received not only at Queen Mary's but also at Guy's, where she had been extremely ill beforehand. My mother spoke, as so many others do, with respect, affection and admiration for all that is achieved by NHS staff, and she was not best pleased by the way in which her privacy was intruded upon at a moment of considerable illness.

Ms. Jean Corston (Bristol, East)

Will the Secretary of State tell the House when any Labour Member has criticised an individual member of staff working in our NHS hospitals? They are the people who are coping with the mess that she has created.

Mrs. Bottomley

Those with memories which go back as far as the general election will know that the Opposition trade in individual cases taken out of context.[Interruption.] One of my hon. Friends mentions the case of Jennifer's ear; I need say no more.

This is the first time for nearly two years that the Labour party has chosen to debate health in its own time. For a party which is so arrogant about its supposed special claim to the NHS, it is remarkably reluctant to debate the matter in this place—and from the hon. Gentleman's speech, it is all too clear why.

During the general election Labour turned our children's wards into a political battlefield. The voters rightly punished it for its repugnant tactics, but it is clear that it has learnt nothing from that. Scaremongering and shroud waving are still the base elements of its approach.

We hoped for fresh thinking on health from the hon. Gentleman, but there was precious little sign of that in his speech today. He has dashed any hopes that a Labour Government would play a constructive role in improving people's health. Where was his admission that the health reforms are here to stay? When will the Labour party apologise for getting it so completely wrong? The hon. Gentleman's speech boiled down to the same old whine: more money for the NHS. His preoccupation, as always, is with inputs and not outputs. Yet in a recent press comment the hon. Gentleman said that the NHS had had a massive cash boost in the year of the election. It is hard to know which message he is trying to give. He cannot have it both ways. His mode of communication is not just waffle, but multi-directional waffle.

Mr. Blunkett

As there was a cash boost for the general election and the Secretary of State has been parading it, and as I am not denying that, why is there such a crisis? Why is the money running out within three months of the financial year ending in a year in which she says that the Government have an all-time record on spending on the NHS?

Mrs. Bottomley

I shall be addressing the House on the situation in which we find ourselves, where hospital after hospital has exceeded all expectations in the amount of work that they have done. But NHS trusts and other hospitals also have to live within their budgets. If, two thirds of the way through the year, I were to break other parts of the NHS budget, I would be doing exactly the very thing for which I would expect the hon. Gentleman most to criticise me. The way in which I would do it would be to raid the community budget, or help myself to the budget for the mentally ill, community nurses, or all the other unfashionable areas of the health service.

If we are to have a principled health service which delivers services according to a strategy which is right for the health of the nation, it is not right for a Secretary of State for Health three quarters of the way through the year suddenly to say, "No, you have all been providing more care of a higher quality: we will change all the priorities now and take money from the budgets of those least able to defend themselves."

I am proud of our achievements. Hospitals have done well to achieve their high figures—some have treated 4,000, 3,000 or 2,000 more patients than they did a year ago—but they have to live within their budgets and manage the resource for the year.

Mr. Richard Burden (Birmingham, Northfield)

If the Secretary of State feels that it is inappropriate to provide extra cash for hard-pressed hospitals, how does she explain the fact that the West Midlands regional health authority was prepared to make cash handouts to a privatised firm that it had set up?

Mrs. Bottomley

That is far from the discussion about how hospitals can manage their budget through the year. There are serious questions about the West Midlands regional health authority. That is why I have appointed such a distinguished and eminent chairman as Sir Donald Wilson to take over in the short term. I deplore the ageist comments of the hon. Member for Brightside. This is the European year for older people and solidarity between the generations. Yesterday I launched the year with Sally Greengross. She talked of the problems of ageism; yet today the shadow health spokesman has shown the most shamelessly ageist approach to a most distinguished and eminent chairman. If the west midlands can achieve the results that Mersey has achieved, the hon. Gentleman's constituents will wonder what on earth he is talking about. They want similar reductions in waiting lists and waiting times and the delivery of health care in an effective, practical and sensitive manner.

We now spend £100 million every day on the NHS, but the challenge—as always—will be to live within a budget. A budget has to be maintained for 12 months, not eight or nine months. Of course I share people's concern when they hear that hospitals are unexpectedly slowing down elective admissions or going on yellow or red alert in the face of exceptional seasonal pressures, but we must learn those lessons and ensure that in placing the contracts for next year we benefit from the experience of this year, pacing activity more effectively through the year and, above all, ensuring that there are proper discussions with the district and the general practitioners and, within the hospitals, between the managers and the clinicians.

Mr. Robert Ainsworth (Coventry, North-East)

On the issue of budgets and slowing things down, the Secretary of State talked about principles, but she now accepts that some people are waiting for serious operations while others, brought into local hospitals from fund-holding practices outside the area, are treated ahead of them. Where on earth are the principles in that? I shall not quote an individual case because the right hon. Lady goes on about shroud waving, but she knows that that is happening throughout the country.

Mrs. Bottomley

I shall say a little more in a moment about general practitioners' fund holding. The Opposition still seem to have failed to appreciate that it is GP fund holding that offers the real lever for change if we want a service which is sensitive to patients' interests, because the advocate for the patients in the health service is the general practitioner.

Only last week, the hon. Member for Brightside said that in the long term there would be a shift of resources from traditional hospital care. Yet today he argues the reverse—that money can only come from other services to go into the hospitals. He cannot have it both ways. The majority of services are not affected by the present end-of-term pressure on budgets.

The British Medical Journal survey, which has been much quoted, also hides a number of other issues. In Calderdale, for example—

Mrs. Alice Mahon (Halifax)


Mrs. Bottomley

Is the hon. Lady going to tell us that in Calderdale only 14 patients now wait for more than a year? That is a dramatic achievement. In Manchester., the number of patients waiting for one to two years has been halved. In Brighton, by March no one will wait longer than 18 months, and an extra 1,500 patients will have been treated. In Norwich and Norfolk, 4,000 more patients will have been treated, and 3,000 more will have been treated at Stoke Mandeville.

Mrs. Mahon

The Secretary of State mentioned Calderdale. A close relative of mine has suffered under that practice. Will the right hon. Lady tell us how many people are waiting to see a consultant before going on to a waiting list? I have absolute proof of what is going on: it is going on in my family.

Mrs. Bottomley

I shall say more later about waiting times, and about what we have achieved. I should very much like to move to a stage at which benchmarks operate for first out-patient appointments. I am sure that that is the next step—having brought down in-patient waiting times, to start setting benchmarks for out-patient waiting times. That is the way forward—to deliver change throughout the service, and to make clear, steady progress.

I should make it clear that the amount of money currently involved is less than three quarters of 1 per cent. of total hospital and community budgets. The problem must be seen in perspective but, relatively small though it is, I do not think that we should ignore it. Doctors and managers do not always get together to work out how to plan activity through the year. General practitioners and district health authorities still have more to do in discussing priorities for the year ahead. I want to encourage closer co-operation between managers and consultants, GPs and other professionals, in the drawing up of contracts for health care between purchasers and providers. That is where discussion should rightly take place. We also need careful co-operation in the monitoring of performance against contract through the year.

I am pleased that the chief executive of the NHS and the chief medical officer have established a working party to examine those questions in detail with the professions, and to spread advice and assistance. The chief executive, Sir Duncan Nichol, will shortly issue further helpful guidance to the NHS. It is important for the lessons that we have learnt from this year to be acted on, and used further to improve the contract process for next year.

Mrs. Barbara Roche (Hornsey and Wood Green)

Will the Secretary of State give way?

Mrs. Bottomley

I will, but only because the hon. Lady stood against me in my first by-election.

Mrs. Roche

I am grateful to the Secretary of State. I remember that by-election with relish; I also remember that we discussed health on that occasion.

The Secretary of State mentioned the yellow bed alert. She will recall that my region, North East Thames, had such an alert. How does she reconcile her policy with the damaging effect that it will have on the more than 130,000 people on the London waiting list? Does she not agree that it will cause them tremendous harm?

Mrs. Bottomley

The hon. Lady will be aware that pressures in the winter are a traditional part of health care management. Yellow alerts, and other pressures caused by a variety of unforeseen circumstances, must be managed' better: we must be better prepared. I should make it clear, however, that all urgent and emergency cases are seen. Our emergency service is unrivalled anywhere in the world.

Overall decisions about priorities must be made by the district authority, which acts as the champion of local GPs. It must form a strategy for health, deciding priorities between different areas of interest and concern. That coherent approach must be followed to deliver ever-rising standards of health care, which will achieve health gains for local communities.

Dr. Lynne Jones (Birmingham, Selly Oak)

Will the Secretary of State give way?

Mrs. Bottomley

I want to make a little more headway. I have already given way a huge amount. I want to talk about the achievements of the NHS reforms—[HON. MEMBERS: "Give way."] I have been enormously generous in giving way. I have given way almost entirely to Opposition Members; I fear that I have neglected my hon. Friends. I now wish to proceed with my speech.

The NHS reforms have been a tremendous success. We see that success in the record number of patients being treated this year. The number of acute in-patients treated is up again—more than 4 per cent. higher than last year, and even higher than that in the trusts. The health service is on course to treat 7.6 million patients this year; an extra 600,000 a year are being treated only two years into the new health service.

Those record increases have been accompanied by reductions in waiting times. We have now eliminated waits of more than two years in the regions; what for many years was a dark feature of the NHS has gone. Since our reforms were introduced, there has been a fall of more than 50 per cent. in the number of patients waiting for more than a year. In line with our manifesto and patients charter commitments, we are on course to eliminate waits of more than 18 months for hip, knee, and cataract operations. A number of regions and areas are heading for an 18-month maximum wait across the board: Mersey, South Western, Northern—

Mr. Andrew Rowe (Mid Kent)

My right hon. Friend has mentioned hips, knees—[HON. MEMBERS: "And boomps-a-daisy."] And, no doubt, boomps-a-daisy. The trouble is that the nature of what can be done in the health service is changing very fast, which creates an entirely different kind of debate about priorities. But for the Government's reforms, it would be impossible to have a sensible debate about priorities, because until now we have not had the faintest idea what any of the procedures in the health service cost.

Mrs. Bottomley

My hon. Friend's welcome intervention has precisely identified one of the profound changes brought about by the NHS reforms. I hope that he will elaborate on his arguments if he catches your eye, Mr. Deputy Speaker.

Reducing long waiting times is central to the patients charter. We have spent more than £200 million on the waiting time fund in the past six years, and today I am announcing an allocation of a further £2 million from the £39 million fund this year to pump-prime 30 innovative pacesetter projects to reduce waiting times further. Each project will harness innovation, spread good practice and set quality benchmarks in the service which others can aim to meet.

We are determined—and we shall continue—to take the waiting time battle further.

Mr. Rhodri Morgan (Cardiff, West)

Waiting for what?

Mrs. Bottomley

As the hon. Gentleman rightly implies—and as I have already said in the House—we want to set waiting time targets for out-patient as well as in-patient appointments. This is yet another example of the way in which the Government have won the argument. Labour Members want us to go further, faster, and I am the first to agree.

NHS trusts are good for patients and staff, and they are here for good. It is far from clear whether the hon. Member for Brightside has yet been able to make up his mind about trusts, but I can tell him that patients have. They will have noticed, for example, the developments in the hon. Gentleman's own area. They will have noticed the £22 million Firth wing at the Northern General trust in Sheffield which opened last May, the two new children's and six new adults' surgery wards, and the state-of-the-art theatre suites and recovery rooms.

The hon. Member for Brightside referred to accountability. I despair at the fact that, even at this stage, he is so unclear about the way in which accountability works. The trusts are accountable financially to their management executive, but they are accountable through their contracts to the district—to the purchaser, who acts on behalf of local people, securing quality improvements, having detailed discussions and championing the interests of local people. That opportunity simply did not exist in the past. The district could not tell a hospital, "We like this aspect of your work, but are not happy with other areas; our GPs are unhappy about one development, but are pleased about your progress in another department." Under the contracts, which are open to the public, accountability is exercised more effectively than ever before.

There has been a revolution in information—in the plans, the accounts, the annual meetings. As my hon. Friend the Member for Mid-Kent (Mr. Rowe) said, when the Labour party was in power no one had the faintest idea what anything cost in the health service, what a hospital's budget was, or how resources were used. That suited Labour Members—sponsored, to a man, by the National Union of Public Employees—because they did not want the public to know what they were doing and how they were spending money.

Several hon. Members


Mrs. Bottomley

Many hon. Members will want to catch your eye later, Mr. Deputy Speaker, to make their own contributions, but my hon. Friends want me to put on record the tremendous achievements of the health service. I feel duty bound to do so, because my hon. Friends want to know what I am about to say. I am about to announce a record capital allocation to the national health service —nearly £2 billion. Taking internally generated capital into account, total NHS capital spending for next year is expected to break the £2 billion barrier for the first time. This £2 billion programme will allow trusts and health authorities to take the initiative in developing their services to meet the needs of the future. As my hon. Friends will be only too well aware, it will support the construction industry and support jobs at the same time. It is scarcely surprising that the Labour party is so embarrassed by my announcement of this £2 billion programme, because, as my hon. Friends are aching to say—

Mr. Andrew Miller (Ellesmere Port and Neston)


Mr. Rhodri Morgan

Give way.

Mr. Deputy Speaker (Mr. Michael Morris)

Order. The Secretary of State will indicate when she is giving way to hon. Members, but it is clear that there are occasions when she is not. It is no good the hon. Member for Cardiff, West (Mr. Morgan) saying, "Give way".

Mrs. Bottomley

As I feared, my hon. Friend the Member for Harlow (Mr. Hayes) took my punch line. As soon as I sat down, he rightly said this is why the Labour party was making so much noise—that the Labour party cut the capital programme by 28 per cent. That makes the £2 billion that I have announced really look quite something. The punch line is that when the Labour party was in power the capital programme was not a record £2 billion but was cut by 28 per cent.

I very much want to deal with the question of GP fund holding—a voluntary scheme that we hope to extend more widely. We hope that the benefits of fund holding, even for GPs who do not become fund holders, will be taken for granted by all GPs. GP fund holders have helped to raise standards across the board and to integrate primary and secondary care. They have reduced waiting times and brought more health care into the community. The Labour party, wallowing in the politics of envy—as ever—derides this as the success of a two-tier service. As ever, its policy is equal misery for all. We can never have levelling up; we must always have levelling down from the Labour party.

Let me make it clear that we are going forward with fund holders and we shall make it easier for them to extend services for their patients. The regulations will be changed to ensure that budget holders can cover the cost of providing a wider range of services, covering a range of diagnostic testing and minor surgical procedures which are outside the scope of their existing contract. This will make it easier for them to provide extra services where they are qualified to do so and to bring specialists into their practices. As a result, fund holders will be able to provide those services for patients without having to go to the trouble of setting up limited companies.

We are the party of change and of progress. We have set in place, with our health reforms, a health service fit for the next century. For more than 40 years, the NHS was driven by institutions and illness, not by patients and prevention. We are changing the focus to concentrate on the needs of patients today and tomorrow and on work for better health. We can look forward to achieving the aims of the National Health Service Act 1946:

a comprehensive health service designed to secure improvement in the physical and mental health of the people … and the prevention, diagnosis and treatment of illness. We have established the mechanisms to decide priorities on a national and local basis, and we are not prepared to leave the service to stumble from problem to problem with only the knee-jerk excuse of underfunding to fall back on like the Labour party. We are determined to use the potential of our greatest resource—our skilled and committed work force. In the face of the most negative opposition and the most scurrilous and distorted tactics that the Labour party could muster, the Government have accepted the challenge of reform and carried it through.

Dr. Lynne Jones

The Secretary of State rightly referred to our skilled and dedicated work force. I received a letter this week from a consultant who says: junior medical staff, nurses and therapists are on their last legs and morale is lower than ever before. When will the right hon. Lady get off the clouds, put her feet firmly on the ground and listen to the people who know what is really going on in the health service: the 29 consultants who say that she had said that she will only interfere in the west midlands—

Mr. Deputy Speaker

Order. The purpose of an intervention is to raise a single poignant point, which the hon. Lady did.

Mrs. Bottomley

I can tell the hon. Lady when morale was lower: when the Labour party was in power and it cut nurses' and doctors' pay and spending on the health service. Of course there is more for us to do, but we are reducing junior doctors' hours and giving people hope and confidence in the way forward.

Let me speak about the great achievements of the new strategy for health, putting prevention right at the heart of the delivery of health care. I hope that I shall receive co-operation from the Labour party as we take forward that strategy, which is chaired at the highest level by the Lord President to ensure that all members of the Government play their part in achieving and taking forward health gain.

We are determined to see further shifts of power in the NHS—away from institutions and providers to patients. The patients charter has been very important in spelling out the rights and standards that patients should expect.

It is interesting to see the sneering approach of the hon. Member for Brightside to the new telephone information line. Many members of the public, many of our constituents and many patients are not clear about what services or health advice is available and do not know where to go for help. Today I launched the national helpline, which was a commitment in the patients charter and in our manifesto. The number is 0800 66 55 44. That single freephone number, which is available to all, will better empower patients to make the best possible use of the health service. The sneering, patronising attitude of the Labour party shows that it fails to understand that the number will enable our constituents to make better use of the service.

Mr. Den Dover (Chorley)

I applaud my right hon. Friend's superb speech, which accurately represents the situation in my constituency of Chorley. More in-patients and out-patients are now being treated in the community, and below budget. There is one major cause for concern, indeed, I will call it crisis: more than 6,000 of my constituents have been put out of the national health service dental system. I know that my right hon. Friend has already received a report of the dentists' pay review, and I hope that in the closing minutes of her speech she will be able to deal with that problem.

Mrs. Bottomley

I am happy to deal with the matter for my hon. Friend the Member for Chorley (Mr. Dover). One million more adults are now registered for dental care than in July. Dentists' earnings are also at an historic high. Sir Kenneth Bloomfield's report, which I hope that my hon. Friend will refer to his dentists and patients, and also consider himself, offers a number of options for change.

Opposition Members seem surprised that the Government do not have a knee-jerk response to every publication that we produce for consultation. We wish to talk to dentists, the health service and others about whether there are ways in which we can change the system of remuneration. My hon. Friend should be sure, however, that his constituents have access to an NHS dentist. The family health services authority should employ a salaried dentist. If there are any difficulties, I shall personally be more than happy to look into them.

The hon. Member for Brightside spoke about information. Sometimes he tried to lambast the Government for not making available the information that he wants for his own purposes, and which we do not collect because it is not needed to help to run the service. In the next breath, he claimed that there were too many managers and accountants and too much bureaucracy, which is precisely what would be needed if we were to collect a huge amount of unnecessary data.

The role of management in the health service is of great importance: something like two NHS staff out of every 100 are managers.

Mr. Blunkett

I am grateful to the Secretary of State for giving way to me twice. Can she tell me why the Yorkshire regional health authority yesterday refused to provide me with figures on waiting lists which it has available at its headquarters in Yorkshire? Other regions have been prepared to do so, so why was Yorkshire regional health authority not prepared to release those figures, even though it had had to collect them for its own internal purposes? Is the Secretary of State prepared to take action to stop the secret society taking hold of the NHS?

Mrs. Bottomley

I do not know the content of the hon. Gentleman's discussion yesterday with the Yorkshire regional health authority, but I feel strongly about information being available, which is why I have today launched the national helpline. It is not only the hon. Gentleman who should have information—I believe that members of the public should also have it, and I shall certainly consider the matter for him.

Mr. Jimmy Boyce (Rotherham)

As the Secretary of State is so ready to go to Chorley to talk to dentists there, will she speak to the dentists who are complaining in Rotherham? We assure her of a riotous welcome.

Mrs. Bottomley

I thank the hon. Gentleman for that warm invitation, but he should listen to what I am saying. I said that dentists' earnings were at an all-time high and that we now provide 7 million more adult treatments per year than in 1979. I was comparing that with what happened when the Opposition were in power—when dentists' real earnings fell by some £3,000 per year.

The health service has an annual budget of £37 billion, it employs nearly 1 million people, and the money must be managed. I do not think that the Opposition understand that. They continue to promote a state of apartheid between managers and doctors. The Opposition also talk about accountability. My hon. Friends are deeply suspicious of what the hon. Member for Brightside means by accountability. We fear that he means that those who manage—

Mr. Bernie Grant (Tottenham)

On a point of order, Mr. Deputy Speaker. Is it in order for the Secretary of State to—

Mr. Deputy Speaker

Order. I shall let the hon. Gentleman continue in a moment, but he must be clear that a point of order is a matter on which the Chair can rule, not a matter of the political content of speeches.

Mr. Grant

I am surprised that you will not let me finish before you rule, Mr. Deputy Speaker.

Mr. Deputy Speaker

Order. I shall let the hon. Gentleman finish, but I want to be sure that he is clear that it is something on which I can rule.

Mr. Grant

I am sorry but, like other hon. Members, I raise a point of order and then you tell me whether it is true. Is it in order for the Secretary of State to make a promise to one of her hon. Friends but not to other hon. Members?

Mr. Deputy Speaker

The hon. Gentleman knows that that has nothing to do with the Chair.

Mrs. Bottomley

I do not think that I should make a promise to another hon. Friend that I would not also make to the hon. Member for Tottenham (Mr. Grant).

My hon. Friends are deeply suspicious about what is in the mind of the hon. Member for Brightside when he talks of accountability. We know that he is really an old-fashioned municipal socialist. I wonder whether he remembers telling the Association of Direct Labour Organisations last year that municipal services were started because there was so much price-fixing and corruption when services were not in council control. That comment will cause a bitter laugh among the people of Lambeth today. I do not think that the people of Merseyside, with all their experience of Labour's chaos and the incompetence of the town hall, would swap the management of the health service for the form of accountability established by local government. I think that the hon. Gentleman's prescription for the health service would be Lambeth-style militancy, Lambeth-style madness and, I fear, Lambeth-style fraud.

I now speak about a subject of great concern, I hope, to all hon. Members—the situation in London. There are inequalities of provision in the health service and they must be tackled. The issues that Sir Bernard Tomlinson has put on the agenda have long been recognised. Many hon. Members have long been worried about the extent to which they subsidised services in London. London spends 20 per cent. of the money on 15 per cent. of the people. Far more serious, however, is the fact that the health service for Londoners is not of the standard that I am determined that it should be. That is because of the great provision of institutions, many dating back hundreds of years, which are not appropriate to the health needs of today and tomorrow. In the past 100 years there have been 20 reports all urging change. At the end of the last century Florence Nightingale argued that St. Thomas's should move out to Blackheath.

We must grasp this opportunity to ensure that there is change. It will not be easy. It means tough decisions, but we shall take them. I pay tribute to the work of the Minister of State, who has held thorough meetings with about 50 institutions and organisations so that we have the opportunity to listen to the views of the people most directly involved. We recognise the need to bring an end to uncertainty—nobody recognises that more than us—but we also have to make sensible, practical, clear decisions to make cost-effective improvements in health care which lead to improvements in treatment, research and teaching.

We shall not transform the health service in London overnight, nor shall we impose change by central diktat. It will take time to correct the imbalances and distortions which have grown up over many decades. There will be different forces in play, not least the shifting pattern of referrals as health authorities inside and outside the capital exercise greater choice on behalf of their patients. The operation of the internal market must continue to play a part in determining the future pattern of services in London.

Mr. Jeremy Corbyn (Islington, North)

The Secretary of State says that she is aware of serious problems with the administration of the health service in London. If that is so, why does she still support a report which proposes the closure of seven hospitals while 130,000 people are on the hospital waiting list in London?

Mrs. Bottomley

I regret having given way. The hon. Member for Brightside has a more enlightened view of these matters than the hon. Member for Islington, North (Mr. Corbyn) has. The hon. Member for Brightside has made it clear that the status quo cannot continue. I know that the hon. Member for Brightside got into trouble with his hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) for daring to have such an enlightened view. The hon. Member for Hackney, South and Shoreditch, who normally saves his wrath for castigating Conservative Members, took his hon. Friend to task for having an enlightened view on the question of London. All reasonable and thoughtful hon. Members know that the change must happen—and it must happen on the basis of improved health services for London. All agree that the enhancement of primary care is a basic building block in that change.

I was surprised that the hon. Member for Brightside spent so little time talking about care in the community. Care in the community is an enormously important policy which we are making a reality, not only in the policy, in the guidance and in the legislation, but in the resources. I am sorry that the hon. Gentleman misunderstood the issue of ring fencing for drug and alcohol support. When we debated the matter, we did not expect to have a ring-fenced sum for the whole of the transfer money. We have secured £565 million which will be ring-fenced for community care. That is 35 per cent. more than would have been spent through social security.

There is an important opportunity here for local authorities. They are rightly proud that the Government have asked them to provide the lead in community care. That leadership means grasping challenges, establishing priorities, making decisions and shouldering responsibilities. It does not mean running back to the Government for more cash at every turn. Through the funds that we have made available, and through the consistent, practical support and guidance that we have given, we have honoured our commitments in full.

Our community care reforms provide choice for individuals, choice for users and choice for carers. We are determined to protect the independent sector. We fear that Labour councils, left to their own devices, would distort the system as ever—in favour of their own services at the behest of their trade union masters. There would be the old temptation to ride roughshod over the interests of users in the interests of producers—[Interruption.] Before Opposition Members cry too loud, I should tell them that I worked in Southwark at the time of Nye Bevan house. I know many of the scandals with which the Parliamentary Under-Secretary of State for Health, my hon. Friend the hon. Member for Suffolk, South (Mr. Yeo), has to cope when local authority providers fail to serve those who are entrusted to their care. The Government want first-class —not Lambeth-class—services for the elderly and needy. That is why we have insisted that a high proportion of community care money must be spent in the independent sector, and that is why we have backed up the reforms with statutory direction which enshrines the right of individual choice.

I leave the last word on community care to Mr. David Townsend, once a special adviser to Baroness Castle and now director of social services in the London borough of Croydon. Mr. Townsend works at the sharp end of social services and he disagrees with the hon. Member for Brightside. In a recent letter, Mr. Townsend said: Having failed to alter the national political map, Blunkett … goes home and kicks the cat; in this case local councillors and directors of social services. Mature reflection on Blunkett's part would have led to the correct conclusion that he is the one who loses general elections, not us. Most of us directors … get on with the job—"[Interruption.]

Mr. Martin Redmond (Don Valley)


Mr. Deputy Speaker

I call Mr. Redmond.

Mrs. Bottomley

I sat down because I could not get any quiet, Mr. Deputy Speaker. We are all aware that Opposition Members make a great deal of noise because they do not want my hon. Friends to hear what I am saying. I was hoping for your assistance to ensure that. I could complete the words of Mr. David Townsend. It would be discourteous to interrupt his remarks and I should like to get to the end of them. Mr. Townsend says:

Most of us directors … get on with the job, increasing the range of services year on year … and leave the more self-exciting 'grand political claims' to those like Blunkett who recline on the green leather benches for a living. While the hon. Member for Brightside is reclining on the leather Benches, he should reflect on the fact that spending on the NHS is at record levels. It has grown by 57 per cent. in real terms since 1979. We are treating more patients than ever before. Nurses and doctors are better paid than ever. They have seen a substantial real increase in their incomes since 1979. We have cut junior doctors' hours substantially and there are more reductions to come. The range and quality of services the NHS now offers has never been greater. Waiting times are tumbling and long waits are set to fall further.

The hon. Member for Brightside referred to my work many years ago for the Child Poverty Action Group. Memories of that work have stayed with me over the years. The hon. Member for Brightside mentioned prescription charges. It is a source of pride to the Government that, whereas a charge was claimed on one item in three when Labour were in government, a charge is now claimed on only one item in five.

It is an achievement for the Conservative party that more babies now survive the earliest months of their lives than at any time since records began. We have seen life expectancy grow by two to three years over the past decade. In the past decade, perinatal mortality has fallen across all regions and in all social classes. It has fallen substantially in London. The figures in London—[Interruption.] As I made clear earlier, many of the changes have been brought about because of the introduction of the GP contract, which the Labour party rejected and voted against. It is as a result of that change that we have seen the dramatic increases—which are still not high enough—in many of our inner-city areas in terms of immunisation and cancer screening figures. For the past two years—for the first time ever—no child has died from measles or from whooping cough.

In "The Health of the Nation" we have established a health strategy that the World Health Organisation has described as a model for others to follow. Those are achievements of which we are proud. It is only those whose sole concern is politicising the health service who wish to deny those achievements. It is only those who are interested in politicising the health service who whine about underfunding rather than trying to get to grips with the complex issues. It is only those who are interested in politicising the health service who exploit individuals' misfortunes rather than examining the arguments. I am afraid that the hon. Member for Brightside and his hon. Friends have shown how out of touch their party is with the modern NHS.

The health reforms were not designed to produce a quick fix or to gain temporary political advantage: they have equipped the NHS to serve the people of this country for the next half century even better than it has done in the present half century. The NHS is going through a time of change and a time of great opportunity. It may be easier for hon. Members to duck change, as the hon. Member for Brightside has done, and to indulge in sloganising, but that would betray the people of this country. We have begun the work and we shall finish it.

5.49 pm
Mr. Martin Redmond (Don Valley)

The Secretary of State has been speaking a load of drivel for more than an hour. Will she not go out into the world of reality where the facts speak for themselves? The facts are at variance with what she has said from the Dispatch Box today. There is a hidden agenda and a two-tier health service. The evidence for saying that exists, and my hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) has given it.

The chairmen of the trusts—[Interruption.] If the Secretary of State would listen instead of opening her big gob, she might learn something. That is the trouble with Conservative Members. They are for ever opening their gobs. If they would listen—

Mrs. Virginia Bottomley

Will the hon. Gentleman give way?

Mr. Redmond

I will not give way. Shut up: the Minister has had well over an hour.

We have had correspondence with the Department about the appointment of chairmen of trusts. Mr. Peter Horsburg was appointed as a chairman but was refused to be acknowledged by the Secretary of State. There was a misunderstanding about the facts surrounding that event. However, there are rewards for political obedience among officers in the health service. When trusts are created, the directors receive wage increases of 100 or 150 per cent. It galls me that the Secretary of State and Trent regional health authority, in my area, appoint political stooges—as the chairman of the health care trust in Doncaster has said. They are paid salaries approaching £20,000. Non-executive directors receive £5,000 each as well as free lunches, subsistence and travel.

Few, if any, of the chairmen and non-executive directors even approach the time commitment that they should make in return for the political gift which they have been given. I challenge the Secretary of State to order the Audit Commission to investigate the time that directors put in for the monetary reward that they receive from the health service. The Tories have always attacked local councillors for working seven days a week for the pittance that they receive. The Government should examine the position of trust directors.

Regretfully, the Government have proposed effectively to reduce the pay of those who keep the NHS alive. They have limited their pay increases to between 1 and 1.5 per cent. Perhaps the Government will reduce the ill-gotten gains of trust directors to the pay of nurses since 1989.

The Secretary of State talks about the health service. She should go into a hospital for 24 hours, seven days a week for a few weeks. Then she would see whether the health service was growing as a result of all the money that the Government are putting into trusts. I do not believe that the NHS is growing. Millions of pounds have been put into the NHS to create the trusts.

The Secretary of State is now telling trusts to slow down. Does she not realise, as she laughs, that to tell trusts to slow down treatment could at worst result in patients dying? She is not interested in the deaths among NHS patients caused by her policies. At the least, the quality of life of patients is affected.

It is no good saying that patients can obtain treatment if their case is an emergency. That depends on the clinical judgment of the GP. The Secretary of State referred to patients' rights. They are nothing but a con trick. Patients have no right to a first out-patients appointment. That fact, together with the placing of patients on review, falsifies the in-patient waiting lists. I wish that the Secretary of State would get the figures right. Millions of patients who are not on any list are waiting to see a consultant. The lists have been reduced simply by removing patients from them.

The Conservative Government shout from the roofs about value for money. I am pleased that the Secretary of State does not live in my household. The reforms have cost money in increased administration costs. Far from reducing the bureaucracy, the reforms have added to it. Doncaster health authority had administration costs of approximately 4 per cent. Celia Wilson, the former chairman, was a Conservative, but she was committed to the health service and to the people of this country. That is a commitment which the Government do not have. [Interruption.] I will not give way to the hon. Member for Harlow (Mr. Hayes). If he will shut up and listen, he may learn something from Opposition Members.

Celia Wilson, the chairman, Tony Dale, who was in charge of administration, and David Eves, the treasurer, did a marvellous job of ensuring that the health authority produced value for money. Doncaster now has four chairmen whereas previously it had one. It has 24 non-executive directors at an annual cost of more than £200,000. It has three chief executives, three directors of nursing, three directors of finance and four directors of medicine, all at vastly increased salaries. There is massive duplication of management. The bureaucracy of Conservatives in government is crazy. If the Secretary of State wants to make improvements, she should reduce the bureaucracy.

I admire the working doctors, nurses and support staff for their complete commitment in return for little reward. They have to live with the greed of the people who seek to exploit them. I am extremely grateful to the doctors, surgeons and nurses of Doncaster Royal infirmary without whose skills I would not be here today. I am also grateful for the research done at Weston Park hospital in Sheffield. Marvellous work is going on there under Professor Hancock and his team. I am also grateful to my GP, who used his clinical judgment to put me into the accident and emergency department. It was his decision, not that of a consultant. That onus should not be placed on GPs.

When one is on a ward for 24 hours, one can see the nurses and junior doctors working under pressure. The Secretary of State should spend a little time on a ward at 2 or 3 o'clock in the morning and see what the nurses have to do.

Mrs. Virginia Bottomley

The hon. Gentleman asked me to spend a little time at 2 or 3 o'clock in the morning on a ward. That is exactly what I have been doing.

Mr. Redmond

I am not sure whether it was as a patient or as a visitor. If she spent time on a ward day and night, she would know. If she opened her eyes, she would perhaps learn a little. Regretfully she does not appear to have done so.

An early-day motion has been tabled requesting a public inquiry into the maternity wing at Doncaster Royal infirmary. It is important that a public inquiry should take place. The internal inquiry was purely and simply a statistical game. It compares Doncaster with Sweden and western Australia. Instead of looking at figures, it should investigate practices because that would be to the benefit of nurses and the people of Doncaster. I hope that the Secretary of State or the Minister will say whether a public inquiry is to take place. The policy of GP fund holders does not appear to be welcome, but apparently it is the only policy under which money can be obtained from the Department. I hope that even at this late stage the Government will abolish the trusts and let us get back to a true national health service.

5.59 pm
Dame Jill Knight (Birmingham, Edgbaston)

It is a mystery to me why the Labour party constantly contrives to turn a success into a failure, an achievement into a disaster and a cure into a calamity. About £100 million a day is spent on the health service, more patients are being treated with better operations and better drugs—

Mr. Bob Cryer (Bradford, South)

It says here, "Issued by Conservative central office".

Dame Jill Knight

I wrote my own speech, as I always do.

There is also better equipment, and, even more important than all that, there are now cures for diseases which would have killed patients only a short time ago. Waiting lists are down and the pay of doctors and nurses is up. I could go on listing the improvements, but to listen to Labour Members one would think that all was doom, gloom and despondency. We fundamentally disagree with Labour's carping and belly-aching and we are proud of the record of the health service under this Government.

In my well-known way of spreading light, sweetness and agreement, let me turn to a matter on which all hon. Members can agree. All the experts in the health service deserve our admiration and every help which we can give to them and they should not have to face dangers which we have the power to remove. Consider the scenario of a patient needing a transplant of some vital organ—perhaps a lung, heart or liver—being prepared for the operation. All sorts of tests are carried out. Blood cells are measured, haemoglobin and blood gases are checked and the functioning of his organs is carefully assessed by electro-cardiogram. Every test that doctors deem necessary for the safety of the patient is meticulously embarked upon.

However, the one test that is essential for the safey and peace of mind of the medical team is left out—the test as to whether the patient has AIDS. Doctors can check for hepatitis and syphilis, but they cannot check for AIDS unless two conditions are fulfilled. The first is that the patient must agree to the test, and the second is that counselling has to be available for the patient.

I am told that in a recent case a young surgeon's razor-sharp scalpel slipped and cut his hand in the middle of an operation. No one knew whether the patient had AIDS, but when he came round and was fit to talk he was asked whether the doctors could conduct tests to make sure that he was all right. He said that they could not. That young surgeon will not know for many long and agonising months whether he has contracted AIDS. He will not be able to get on with his professional or private life because he can neither operate nor sleep with his wife. We should not put doctors in that position.

Let us look at the case of a person who is brought unconscious into an operating theatre following an accident, an attack or seizure or perhaps an overdose. I am assured that, although he is unconscious, he may vomit blood and that instant care has to be made available to him. However, no AIDS tests can be carried out because he cannot be asked whether he agrees. I do not want to harass AIDS victims or hurt their feelings or multiply their agony, but I certainly want to protect nurses, doctors, surgeons and laboratory staff and all others who may put their own lives at risk by caring for someone who has AIDS.

As I have said, doctors are allowed to test for venereal diseases such as syphilis and the patient does not usually know that the test has been carried out. I am told that if the patient does not have the disease there is no problem, but if he has he is advised about the best medical care that he can be given. Surely we should follow that rule for AIDS. Why not extend the practice? It is not right to sacrifice the life, health and peace of mind of medical staff and their ability to continue to operate, nurse or test because of fear of hurting the feelings of people who, although tragic, undoubtedly pose a serious threat to the lives of others.

I have a second request on another matter to make in my short speech. I am trying to be constructive in asking my right hon. Friend the Secretary of State to take two actions that could be of immense help in two different fields. The second concerns a thoroughly responsible and respectable couple in my constituency who were asked by a social worker in March 1988 to take in a six-day-old Sikh girl who had been abandoned by her mother. They did so. They came to love the child and, although they had a boy and a girl of their own, they eventually asked Birmingham social services department whether they could adopt the little girl. Incredibly, the council not only flatly refused but spent a large sum of ratepayers' or poll tax payers' money, or whatever we want to call it—I am told that it amounted to tens of thousands of pounds—on court action to try to get the child away from her loving home, the only home that she knew and the one in which she wanted to stay. A social worker told those caring and excellent parents that white people were not good enough to bring up black children.

Can we imagine the fuss, the headlines and the furore that would result if a black couple were told that they were not good enough to look after white children? And quite right too; I would similarly decry such an appalling statement. No one except the couple and a friend who tried to help them knew about that because for three years Birmingham city council gagged the couple with art injunction. They were not allowed to speak to anyone. I am their MP, but they did not dare to write to me or anyone else about what had happened. They were afraid that, if they broke the injunction, they would not be allowed to adopt the little girl.

It seems that not only the Race Relations Act 1976 but freedom of speech was flouted. At one stage the couple were told that a black adoptive family had been found for the little girl, but they discovered that it was not a Sikh but a Muslim family and the mother could speak no English, although the little girl had been brought up in a home in which English was the natural language. The proposal to send the child to the Muslim family was called off after the parents protested. A social worker visiting the family forbade the little child to call her parents—the only parents she knew—dad and mum.

The child was then secretly introduced to another Asian family who agreed to take her as a foster child. All this when Joanne had lived for years with the family and loved them dearly, as they loved her. Then, when the couple were given 48 hours' notice that Joanne would be taken from them, they took court action. It was three years before the High Court, in November last year, ruled in their favour and they can adopt the child. There is no excuse for all this, especially for telling a loving couple that they are not good enough to adopt a child because of the colour of their skin.

I make the direct appeal to my right hon. Friend the Secretary of State to look into both these totally different sets of circumstances and stop social workers from behaving in that way in one set of circumstances and to help surgeons and medical staff in the other circumstances.

Mr. Deputy Speaker

Before I call the next hon. Member, may I remind hon. Members that Madam Speaker has ruled that we should now start on 10–minute speeches.

6.10 pm
Ms. Liz Lynne (Rochdale)

We, too, regret the growing crisis in the NHS. The national health service, which is approaching its 50th anniversary, has served several generations very well. Whenever possible, it has cured us. At other times, it has at least healed us. Few would disagree that it has almost always cared for us. Against this background, it is tempting wholeheartedly to follow the Labour party argument. There can be little dispute that the system is underfunded and that the internal market is creating two tiers of care.

However, if we are to alleviate the crisis in the NHS, we cannot just go back to the status quo before the reforms. Before the general election, I was opposed to GP fund holding and to hospital trusts and still am, but we have to accept that they are there and that there will be even more before the next election. We have to face that reality and try to find a solution. The Government are not going to change their minds.

Although I do not embrace this Government's philosophy of change for change's sake, I do at least accept that some change is needed, but that change should have taken into account the needs of the patients and the fact that there was not enough money to meet everyone's needs and that more money should have been found for the health service. I know that some more money has been put in, but that is not enough to meet those needs.

The internal market has not been a great success in most instances. The market can be very cruel when applied to the vulnerable: the sick child who cannot be admitted to hospital until after 1 April will not understand that his GP is not a fund holder; nor do the caring health service staff appreciate having to close hospital wards when they know that there are people who need treatment. The Secretary of State responds by telling hospital staff to pace themselves; in other words, "don't cure people too fast". This is at a time when the Government's own target, a maximum of two years on the waiting list, has not yet been achieved in all areas. They have to acknowledge that fact.

The internal market is also creating problems in a number of trusts. My local Rochdale trust has increased its patient activity, reduced its waiting lists and cut costs considerably, but having done that, it will not be awarded any further contracts by the health authority because of lack of funds. This is not because the health authority does not want to spend the money. It simply does not have enough.

Dr. Liam Fox

Perhaps the Liberal spokesman will tell us how much extra money the Liberal party believes we have to put in to achieve the situation that she wants? Exactly how much?

Ms. Lynne

I am grateful to the hon. Member: as we said before the general election, another £2 billion over the course of a Government. That was stated very clearly in our manifesto commitments.

The hospital at Rochdale is now forced to close wards. Many hospitals may in future, because of this trend, have to throw people out on the dole. GP fund holding has also served only to promote a two-tier system.

It is naive in the extreme for the Government to expect an even result when it has installed two budgetary structures, a more generous one for fund holders and a rather more stringent one for health authorities. At least they cannot say we did not warn them about the problems they were creating. All our calls for wider consultation on the internal market generally were ignored. That will be cold comfort for the thousands turned away from hospitals and told to come back after 1 April. It will be cold comfort to, for instance, the two children in Rochdale who have been in traction for some time and were just settling into their ward but will now be forced to move to another hospital.

The question is how we can reverse the crisis in the health service. A two-tier system with care for some is not quite the way to celebrate the 50th anniversary of Beveridge's proposals. The way forward would have been through pilot projects, consultation, listening to both the users of the service and to those who make the very difficult decisions in it every day. But the Government did not do that. Even though they did not do it to start with, the least they can do is to conduct a full survey of the reforms, and, more important, to make the results public. We have a right to know the extent of the problem and why they did not consult fully to start with. We have a right to know how they propose to get out of this mess.

I believe that a new idea of locality fund holding represents a positive way out of the present mess. I am not going to dictate the solution, but I want to talk to health professionals and see whether it is the appropriate solution. As I have already said, hospitals up and down the country are running out of money and closing wards while some GP fund holders have excess cash. Locality fund holding could be a way round the problem. I hope that the Government will take this on board. Under locality fund holding, GPs in a particular area would band together and become fund holders, between themselves, thus avoiding the two-tier system that is being created at present. Community care services could also come under the locality fund-holding umbrella in order to stop people falling through the net between health authority and social services provision.

I have deliberately not spelt out a definitive policy on locality fund holding, because, unlike the other two parties, I believe in genuine consultation before policies are fully formed and I do not want to limit the responses I receive.

Another area on which the Government appear to have failed is Tomlinson. That also is due to lack of consultation. Why did they not ask the people who know, the professionals and users of the service? If they had, they would have been told that they could not think about closing hospitals before the primary and community health service was up and running. They would have been told that we need a single London health authority. They would have been told that the figures used by Tomlinson simply do not add up. Why did they not ask? Why did they not listen even though they did not ask?

The Minister for Health (Dr. Brian Mawhinney)

I was wondering whether the hon. Lady thought that when she and her colleagues came to see me to give me the benefit of their views, as part of the London consultation, I was not listening or taking account of what they were saying.

Ms. Lynne

Yes. My colleagues and I were grateful for that. I feel that the Minister was listening, but he should have consulted more widely previously and should have consulted the health professionals earlier. I am talking about consultation, not with us, but with the people within the health service and with its users. I know that the hon. Gentleman has been round to all the hospitals, but I do not think that he has really been listening. I do not think the Government are going to consult this time. I do not think that they have learnt the lessons, because I do not think that they are listening properly.

Are they going to listen to the dentists and their patients? They have already forced many dentists out of the NHS. Dental health is already at risk. Now the Government want to take away free dental treatment from pregnant women. How much further do they want to go?

Dr. Mawhinney


Ms. Lynne

If the hon. Gentleman wants to intervene again, I will gladly give way.

Dr. Mawhinney

Which Minister said that?

Ms. Lynne

It was in all the reports, including the report that came out recently. Neither the hon. Gentleman nor the Secretary of State has come to the House to make a statement on that report. Perhaps the right hon. Lady would like to do so; then we can debate the report. I know that the Opposition spokesmen have asked for this, so perhaps the hon. Gentleman can give a commitment to it today.

Dr. Mawhinney

But the hon. Lady wants us to consult.

Ms. Lynne

I should like the Secretary of State to come to the House and make a statement on dentists. Now, if the hon. Gentleman will allow me to continue—

Mr. Deputy Speaker

Order. Sadly, not this afternoon; the 10 minutes are up.

6.20 pm
Mrs. Marion Roe (Broxbourne)

Once again I have listened to my right hon. Friend the Secretary of State with admiration. It is not just the grasp of her subject that is impressive, but the clarity of her vision and her determination to do what is right. Conservatives should not let the mantle of compassion be taken from them. We need to put paid to the myth that management is outside the welfare arena. To manage well is to ensure fairness and the best possible service.

The debate on the health service has certainly come a very long way in the last 15 years. Up to the early 1980s, the service's success tended to be measured by how big a budget could be wangled from the centre and how quickly it could be spent. Huge blanket sums were consumed without guidelines, and seemingly with few controls. The game was to spend, to look good and not to worry about the consequences for others either within the service or outside it. Peter was robbed to pay Paul and shroud waving—a new expression, I think, in the Chamber—was the main feature of the yearly expenditure round.

Less than 20 years ago, the health service did not even know how many doctors it employed, let alone how much a certain course of treatment would cost. Morale was low, and the service was to suffer under the last Labour administration its biggest capital cut ever. The situation was critical, and those of us who believe in the principles enshrined in the NHS knew that there had to be a radical change if a comprehensive free service was to survive into the 1980s and 1990s.

The first step was to restore confidence and to reverse those cuts. There is no disputing that the health service has benefited from massively increased funds under the Conservatives. The health service now has the second largest budget in Government expenditure. At £37 billion, it is second only to social security—and I believe that few here doubt that that is as it should be.

The provision of money alone was not enough to reverse the games that were played before, and the Government deserve credit for moving the debate on. They are only too aware now that it is not how much is spent that matters, but how it is spent. By insisting on and providing the tools for better management, by improving the management structure and by introducing financial disciplines, the Government have given the NHS its own lifeline.

It is less than two years since the biggest ever reforms of the national health service were introduced. The second year has not yet been completed. GPs—only those who could and wanted to—were given the ability to handle their own budgets in certain areas, and some hospitals became self-governing trusts. There is, and has been, no duress to become a trust. Application for trust status is entirely voluntary and open to any unit which satisfies the criteria. Less than two years on, 95 per cent. of hospitals and community health service provision have either moved to trust status or expressed an interest in doing so. Moreover, nearly 550 GPs have become fund holders, and there is a likelihood that a further 700 will join them. That will mean that one quarter of the population will be served by fund holders.

By any standards, that is an enthusiastic response to the reforms in the service—encouraged, no doubt, by the early signs of success. In a recent survey, more than 70 per cent. of GP fund-holding practices reported falling waiting times and improving efficiency. In their first year of operation, trusts treated 8 per cent. more patients than in their last year as directly managed hospitals.

In my own constituency, the East Hertfordshire NHS trust has boosted out-patient attendances by 3 per cent. from last year, and in-patient cases have risen by 4.2 per cent. Also, waiting times are dropping. The East and North Hertfordshire district health authority is on target to achieve by 1993 the region's standard of no one waiting more than 18 months. The expectation is that waiting times will be dropped to 15 months in the coming year.

I maintain that contracting has improved service delivery and will continue to do so. GPs handling their own affairs can understand the cost implications more easily and arrange their priorities according to their needs. Trusts can plan ahead freely without interference from the regional health authorities and the Peter robbing Paul mentality. Services can be delivered as promised and strategic plans made for the future with confidence. They know at the beginning of each financial year how much elective—that is, non-urgent—work they will be required to do, so they can plan staffing and other facilities accordingly. Better information also enables trusts to make accurate estimates of the amount of emergency and urgent work that they are likely to do and to plan their budgets accordingly.

Inevitably, some of the shroud-waving mentality has survived and is finding its voice on the Opposition Benches today.

Mr. Ian McCartney (Makerfield)

Will the hon. Lady give way?

Mrs. Roe

We have a 10-minute time limit, Mr. Deputy Speaker, and there is a great deal that I want to say. I shall give way when I have finished my speech.

No reasonable person would expect radical change to be introduced without some teething problems. Equally, no reasonable person could expect to return to the old mentality which was so ruinous to the provision of services. It is unfair to other parts of the health service to raid their budgets to get some hospitals out of financial difficulties. It is also unfair to take a snapshot view of what is happening in the health service before the year is out. Doing so distorts the picture. The fact that there has apparently been over-performance on elective surgical contracts reflects the situation that more elective work is done in the first six months of the financial year—that is, in the summer—because more beds are required for emergency medical admissions in the winter months. Surely it could also be claimed that this is sensible planning —to plan the elective work when it can be done and leave the hospitals free to cope with the demands that winter brings.

To counter some of the very negative stories that we have heard from the hon. Members for Sheffield, Brightside (Mr. Blunkett), for Don Valley (Mr. Redmond) and for Rochdale (Ms. Lynne), I should inform the House that the East Hertfordshire NHS trust is working to contract and has no plans for bed closures. The elective and emergency services will be maintained to year end, and financially the trust will be broadly in balance. Its strategic plans have been published and over the next five years its programme of development includes completion of a 30-bed day care unit at the Queen Elizabeth II hospital in Welwyn Garden City, construction of a purpose-built orthopaedic unit in the grounds of that hospital, and construction of a 60-bed unit for continuing care of the elderly on a site in Hoddesdon in my constituency. There are also a further six projects. The result of such developments will be that services will be more convenient and supplied more quickly and efficiently and to a higher standard.

I urge the Government to continue with their reforms. Recently, the Health Select Committee published its interim report on NHS trusts. One of its concerns was that there should be a strategic overview of the management of trusts. Within this question lies the future role of the regional health authorities. I believe that as the reforms take a firmer hold on the future provision of the services the present role of the regions will change. Their role will therefore have to be redefined as we continue to improve the standards and provision of patient care.

Mr. McCartney

Perhaps the hon. Lady would like to comment on the statement of one of her local GPs, Dr. Laurence Buckman, that patients in his area have already died because of serious bed shortages—and one of his patients died in an ambulance because of a row as to who should pay for his treatment. That is not the Labour party but one of the hon. Lady's local GPs.

Mrs. Roe

That local GP has certainly not written to me on the matter. He has not drawn it to my attention for me to bring it to the attention of the local authorities.

6.30 pm
Mrs. Alice Mahon (Halifax)

I shall not be congratulating the Secretary of State on her speech. Indeed, when she resumed her seat I thought, "Thank goodness we have got to the end of that self-righteous rant."

This month's edition of GP News, referred to by my hon. Friend the Member for Makerfield (Mr. McCartney), contains a report under the headline: Human toll mounts as reforms fail. It goes on to say: Patients have already died waiting for beds. In that article Dr. Buckman, a member of the General Medical Services Committee, whom the hon. Member for Broxbourne (Mrs. Roe) claims has not written to her, reveals in tragic detail the case of a severely asthmatic girl who nearly died when Barnet general hospital sent her away because no beds were available.

What I say may be dismissed as shroud waving by some Conservative Members. They would not dismiss things so lightly if members of their own families were affected. What would the Secretary of State say if her mother experienced the suffering of a patient cited by Dr. Buckman—an elderly person with a leaking aortic aneurism who died in the ambulance while a row ensued as to who would pay for the treatment? Conservative Members would not want tragedies of that sort to affect their families. Labour Members do not want them to affect anybody at all—that is why we demanded today's debate.

It is time the Conservatives admitted, before more tragedies occur, that the internal market has been an unmitigated disaster for health services in Britain. Dr. Buckman's examples highlight the human cost of the greatest crisis in the hospital service since the NHS was formed.

I do not want to talk simply about headline tragedies. I am anxious to bring attention to bear in the debate on what is happening to the NHS throughout the country. The Secretary of State referred to Calderdale. Halifax is one of the two towns comprising that district. There has been a massive bed closure programme in Halifax. It has been going on for the past 13 years and it has led to many serious problems. Management there will hasten to deny it, but I know from talking to members of staff and patients, and from visits to hospitals, that serious problems exist in Calderdale. The Royal Halifax infirmary recently had no beds available for a two-week period. I understand that panic sets in regularly among managers and consultants who are desperate for beds. I also understand that they regularly discharge patients early.

That brings one to the dreadful business of bedding out, which has not been referred to in the debate so far. Bedding out is the norm in most hospitals nowadays. Does the Secretary of State know what bedding out is all about? A woman who had been pregnant recently wrote to me saying that although she was in danger of losing her baby —she finally lost it—placed in the next bed to her was a psycho-geriatric patient. That happened on the gynaecological ward as she was going through the trauma of losing her baby, and it was distressing for both patients and for staff and relatives.

The Secretary of State might feel differently if she had been moved from an acute medical ward to a surgical ward to make way for new admissions. Such transfers happen on a regular basis. Had she experienced it, she might understand just what a rotten practice bedding out is. Elderly people are regularly suffering dreadfully as they are admitted to casualty and have two or three moves as they are bedded out on to different wards to make way for other patients.

It is widely known in Halifax that psycho-geriatric patients are often admitted to ordinary wards for the elderly because there are not enough specialist beds to cope with patients of that type. That, too, puts great stress on staff. Noisy, disturbed and perhaps doubly incontinent patients require special care. Would the Secretary of State describe such a situation as levelling up or levelling down? I assure her that that sort of thing did not happen when I worked in the service in the 1970s.

For years, we in Halifax have not had any coronary care beds for males. Four beds are coming on stream and should have opened on 1 January. I believe that their opening has been delayed due to lack of cash, though the Tory-appointed administrators will no doubt say that the delay has occurred for other reasons. It is high time that those beds came on stream.

Because of the shortage of beds, a practice known as mixing is taking place. I was recently visiting a friend in a ward for elderly females and noticed that there was one elderly male on the ward. I believe that he died during the following 24 hours. I did not regard it as respectable, dignified or comfortable for people of that age to have to be on a mixed ward. I have spoken to many patients in that position and it is clear that they are not happy in that situation. I ask Conservative Members to ask themselves whether, if they were feeling low, they would like to be on a mixed ward. I would not. That is happening as a result of the Government's bed closure programme, and the Tories are proud of it.

The response of the Secretary of State to the types of situation that I have described has been frankly insulting. She tells my hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) that he is scaremongering. The criticisms of the British Medical Association are dismissed, the BMA being told that it has said nothing apart from complaining about the NHS being underfunded. The right hon. Lady may say that my hon. Friends and I do not know how the system works, but I accuse her of not understanding what is happening in the NHS. Her highly paid political friends who are now running the service are issuing harsh penalties against anybody who dares to blow the whistle.

We have been made aware of how serious a threat that is to the freedom of staff to speak out. Doctors and nurses are under great pressure not to express their views, as their evidence when trusts were looked into made clear. The Government have devised a special plan for dealing with what one might call the deviant doctor. It is called a rolling contract or a fixed term contract. Tory business managers are casualising the work of doctors. Indeed, they have the ultimate weapon over doctors. As Mr. Chawner of the joint consultative committee with the BMA said: A doctor is bound to think … his job is coming to an end … unless he complies with some set objective which may not have been set by him or his peers. In fact, at times I have to say I think it may be set for political reasons in that it would be useful to cut a waiting list. That a doctor should be subject to that sort of influence is quite undesirable from the patient's point of view. Doctors should always decide on the basis of an individual patient, in front of him, and not according to whether he is going to please the manager or anyone else. I would go further than Mr. Chawner. I would call them not rolling or fixed contracts but blackmailing or gagging contracts. Clearly, the present contracts have been well thought out.

Labour Members have time and again said that underfunding is the problem with the NHS. We warned that the Government's guidelines on equal access would be openly flouted. Fast-track patients from GP fund holdings are being canvassed openly and placed at the head of the queue for purely financial reasons. The Secretary of State's excuses on that have been disgraceful.

Because of the 10–minute limit, I do not have time to quote from a letter dated 24 December from the managers of the Bradford trust. They were clearly canvassing GP fund holders in respect of consultants holding waiting lists. That must represent a two-tier system and it should be exposed, as should the waiting list cheating that goes on. Cheating is taking place on a massive scale. The report of the Select Committee and the evidence about trusts makes the position clear. Doctors said that the two-year waiting list was fatally flawed, that people with acute clinical conditions were sometimes unable to get treatment and that they often faced a life and death situation. The Royal College of Nursing says that nurse redundancies are occurring throughout the country, including 300 at Horton psychiatric hospital.

That is happening at a time when political nepotism is the norm. What qualifications does Alan Titterington have to make him a suitable chair for the West Yorkshire ambulance trust? His businesss background is fibre-optics in the music industry—his political background is the chair of a local Conservative association. Nor should we overlook Lord Hayhoe, who yesterday deliberately canvassed for the chair of St. Thomas's and Guy's.

There is only one place for the Tomlinson report, and that is the dustbin. It is disgraceful. I hope that Londoners can get back the feeling of the blitz, recognise who the enemy is, defeat the Government and damn the report.

6.39 pm
Mr. Jerry Hayes (Harlow)

First, may I make a declaration of an interest? I advise the Western Providence Association, which is a non-profit-making organisation.

I listened most carefully to the speech of the hon. Member for Halifax (Mrs. Mahon) whom I have known for years. We served together on the Select Committee. It was interesting to hear that she totally disagrees with her Front Bench on the Tomlinson report.

We have heard on many occasions from the hon. Member for Sheffield, Brightside (Mr. Blunkett) that he believes that the status quo is no longer an option. I wish that the hon. Gentleman were in his place. Bring back the hon. Member for Livingstone (Mr. Cook); all is forgiven. I may not have agreed with him, but at least he understood and mastered his brief. Here we have a shadow Secretary of State who has hands on, but absolutely no grip whatsoever.

I understand why Opposition Members feel rather twitchy about the motion. It is not so much a motion as a stream of consciousness in the image of Dave Spart. They talk about the growing crisis in the health service, the commercialisation of the health service, concern at the total fragmentation of care due to underfunding, the impact of internal market trusts and GP fund holders. It goes on and on. Worst of all, it contradicts Opposition Front-Bench policy—[Interruption.] Hon. Members should listen and then they would learn.

Not so long ago we heard the hon. Member for Brightside at the Blackpool conference going on about the Tories' own Frankenstein's monster and saying that he was committed to getting rid of the trusts. The hon. Member for Bristol, South (Ms. Primarolo) said pretty well the same thing. On 21 August 1992 she told The Independent that trusts enjoyed "no public support". She told BBC television that she was committed to getting rid of them.

Ms. Dawn Primarolo (Bristol, South)


Mr. Hayes

Let that be on the record.

When I picked up my copy of Hospital Doctor which I recommend to the hon. Lady, I turned to the back page. This is not The Daily Telegraph or the Tory press, it is Hospital Doctor. It says: Labour abandons vow to end trusts". It goes on: Labour has officially reversed its general election pledge to abolish trust hospitals. Announcing the decision, Labour health spokesman David Blunkett said, 'you can't turn the clock back'. I hope that the hon. Lady totally agrees with the new policy.

Ms. Primarolo

I am happy to say now, to avoid speculation until the end of the debate, that Labour party policy was confirmed by my hon. Friend the Member for Sheffield, Brightside (Mr. Blunkett) this afternoon. We do not accept trusts, GP fund holders or the internal market. The hon. Gentleman has heard that twice now and I hope that he is now clear.

Mr. Hayes

I hope that the hon. Lady and the hon. Member for Brightside will be calling for an immediate apology from Hospital Doctor for publishing such a terrible travesty, accusing them of making a U-turn.

Opposition Members attack GP fund holders. In The Times on 14 January 1993 the hon. Lady and the hon. Gentleman said that the system would be scrapped. But another medical publication, not the Tory press but BMA News Review in January 1993, published an interview with the hon. Member for Brightside saying:

he is aware, however, that all GPs have benefited from increased flexibility and influence in purchasing decisions".We watch this space for another dramatic U-turn.

The wonderful Dave Spart motion also attacks underfunding. On 26 September 1992 The Times reported: On funding, Mr. Blunkett made it clear that Labour was no longer tied to the general election commitment to restore underfunding within the NHS since 1979. Perhaps there should be another apology. I imagine that the hon. Lady would totally refute that as well.

The Dave Spart motion goes even further, condemning the internal market. The hon. Member for Brightside was reported in The Times on 14 January 1993 as saying that Labour should not have any hang-ups about the market. I am delighted to hear that the hon. Gentleman has no hang-ups, which is more than many hon. Members, but perhaps he will demand an apology from The Times as in his motion he has condemned the internal market, as have his hon. Friends.

The hon. Member for Halifax made a wonderful attack on Tomlinson. We know full well what the hon. Member for Brightside said about Tomlinson. The Guardian, which is not exactly the Tory press, said on 24 October 1992: If Labour was in office it would be proceeding in exactly the same way. But what did the hon. Gentleman say about Tomlinson? The status quo is no longer an option. He went even further in a Labour party press release on 15 October: The evidence is now overwhelming that there is a need for the reorganisation and relocation of resources in London. That was another dramatic U-turn; it is absolutely remarkable.

We have heard something about the BMA backing rationing and saying that we have the worst crisis for 30 years. It is written on the front page of Hospital Doctor. However, in the same column the National Association of Health Authorities dismissed the BMA's criticism and allegations. Its director, Phillip Hunt, said: I am not disputing that there are problems, but we have to set them against the impressive results that we are achieving on waiting lists. Hon. Members on both sides of the House should appreciate that.

I have no interest in Hospital Doctor, but the first two pages cover eight little stories. One is headed, "Praise for Combined Drug Cash"; another reports neo-natal services in Wales being given an extra £4.5 million boost; another reports nearly £2 million being made available to treat babies with severe combined immuno deficiency-related disorders and another deals with the United Kingdom's first small intestinal transplant at Addenbrooke. That is all good news.

I am not trying to say that everything is rosy in the national health service; of course it is not. I now refer again to The Times and I think that the Opposition may agree with this: Imminent demise has been the prognosis on the Health Service almost since its inception, but in recent years complaints that it is falling apart from lack of money have become louder … Doctors complain that the service is chronically under-financed, that their incomes have not kept pace with inflation and that the 1974 reorganisation led to chaos in hospital services. That article was in The Times in 1978. Nothing whatsoever is new.

Ms. Primarolo

Except that the money was spent.

Mr. Hayes

The hon. Lady said that the money was spent and I expect that she is about to make an incredibly crass point about bureaucracy. Let me give her some help. For every £1 spent on bureaucracy, £47 is spent on doctors and nurses—

Ms. Primarolo


Mr. Hayes

The hon. Lady says "So?" but it is incredibly important. We have increased financing of the health service in real terms by 57 per cent. and £100 million a day is being spent on the national health service.

The hon. Member for Rochdale (Ms. Lynne) made an interesting speech. Although she did not tell us what the Liberal Democrats would do, she said that they would make a commitment to an extra £2 billion. She made that commitment at the general election, but that was the precise amount that my right hon. Friend the Secretary of State got for the health service in the last financial round.

6.49 pm
Ms. Jean Corston (Bristol, East)

This debate is well named. There is a crisis in the health service and it is necessary to go back to the founding principles to identify it. One of my most treasured possessions is a leaflet sent out to the population in 1948 by the Central Office of Information entitled "The New National Health Service." It said: Your new National Health Service begins on 5th July. What is it? How do you get it? It will provide you with all medical, dental, and nursing care. Everyone—rich or poor, man, woman or child—can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a 'charity'. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in time of illness. Those were the founding principles of the NHS, but the Government's policy is a retreat from them. They spent £1.7 billion to change the service—and I emphasise the word "service"—into a market.

Like the hon. Member for Birmingham, Edgbaston (Dame J. Knight), I make no apology for using anecdotes. Unlike the Secretary of State, I understand that health care is about personal experience rather than statistics, and anecdotes are all that can relate personal experience. I shall explain the consequences of the Government's policy on Bristol by using letters written to me by constituents. I consider that to be a reasonable way of dealing with the matter.

There is now a 19–month wait for an orthopaedic out-patient appointment at Frenchay hospital. I discussed that with trust officers, who confirmed that it was true and said that it was the norm. They said that it was due to underfunding. Are they whingers? Are they shroud wavers?

A woman constituent wrote to me saying that her condition caused her such pain and distress that she is afraid that she will have to give up work. She cannot even get an out-patient appointment at a clinic in the directorate of surgery at the Bristol Royal infirmary. She cannot get on to the waiting lists that we are told are being reduced. Another example is of a frantic woman waiting half a Saturday afternoon for her collapsed husband to be taken to hospital by ambulance because the bed bureau could not find a bed.

At the ambulance service, which is now a trust, the aim of the management is to cover 95 per cent. of shifts. Ambulance crews say that the cover should be 100 per cent.; that is their commitment. However, to provide that cover they have to work through their meal breaks and rest periods. Meanwhile, to make money the trust has produced a corporate brochure advertising servicing and maintenance of vehicles; sales of pagers, portable radios and telephones; and first aid and driver training courses. The logical conclusion for patients of all that is that money talks.

Another constituent who needed a physiotherapy assessment after a serious accident telephoned the Bristol Royal infirmary to ask when he would get that appointment. He was told—he says somewhat irritably —that it would be at least a month. When he mentioned that membership of BUPA was a condition of his employment and asked whether that made any difference, he was told to come at 2.30 pm that day. That is what is happening. If the Secretary of State were to wander around our hospitals incognito and talk to staff and patients, she would see that for herself, rather than being shielded by officials and protected by a massive departmental public relations machine.

The United States private health care system has admirers in the Conservative party, but one third of the population has no cover, one third has inadequate cover and one third has some overprovision. It is no accident that President Clinton won the election when he promised a proper health care system; the market has been shown to be wasteful and inefficient. One 200–bed hospital in Massachusetts employs 220 staff to send out bills to various insurance companies. I have spoken to consultants working in our hospitals who are overwhelmed by the paperwork in the new market system. Is the American experience to be our inheritance? The price of each General Motors car in the USA includes $1,050 for the cost of its employees' private health care. The company is now thinking of relocating to Canada where there is a health care system.

The Government are always telling us that we cannot have the social chapter, wages councils or a decent minimum wage because of what they claim to be the burden on employers. Will they tell us what is the current cost to commerce and industry of providing health care insurance for employees? To cap it all, I understand that BUPA is in contact with the Dental Practice Board to consider the feasibility of a national private dental insurance scheme.

I met members of the Avon dental committee yesterday. They described a system that is fast breaking down. The Department of Health concept of the "average" dentist bears no reality to the true position in Avon; neither does the assumption that a dentist's pre-tax income after expenses is £35,805. Dentists in Bristol would need to increase their gross income by at least £20,000 a year to guarantee that level of income.

Many of my constituents in Hengrove are being told that their dentist can no longer continue to provide NHS treatment and they are being invited to join a scheme called Denplan at a cost of £9.75 per month. To add the insult of bureaucratic red tape to the injury of a withering service, patients are now subject to automatic monthly deregistration from a dentist's register. Adults who have not contacted their dentists for two years—for children it is one year—are taken off the list by the Dental Practice Board. They then have to shop around for NHS treatment.

Dr. Mawhinney

indicated dissent.

Ms. Corston

It is no use the Minister shaking his head —that is the experience of dentists who spoke to me yesterday. The Minister should try telling them that that is not the case.

To safeguard their patients' position, dentists now send out reminders telling patients to make an appointment so that they do not risk deregistration. However, the dentists have to bear the added costs of the administration, printing and postage. Most dentists in Avon are keeping open their current lists, but they are not adding patients. The Medical Sickness Society will no longer cover dental practitioners beyond the age of 55 because of its experience of claims resulting from the stress of trying to work harder to keep up. I was told of a dental technician who worked from 2 am to 6 pm to make a living.

The Bloomfield report will not lead to initiatives until 1993–94. Avon dentists told me yesterday that that would be too late. They asked me to draw the attention of the Secretary of State to paragraph 2.6 on page 3 of the report, which states: I have been asked to identify options"— and the word "options" is emphasised— for change rather than a single recommended course. I welcomed this opportunity to examine alternative possibilities. The sums made available for the remuneration of General Dental Practitioners are not simply for the purpose of paying dentists but for the wider purpose of securing dental health. Much will depend upon the direction in which Government—no doubt after full discussion with the relevant interests—wishes NHS dentistry to go. The dentists ask, "Which way do the Government want NHS dentistry to go?" They say that it is fast going down the drain.

6.58 pm
Mr. Roger Sims (Chislehurst)

I have some sympathy with the Opposition today because when I was first elected to the House in 1974 I spent my first few years on the Opposition Benches. From time to time, Opposition Supply days are available and the Opposition have to find a subject for debate. It has to be one on which they can try to prove that the Government are not doing a good job and they could do better. That is the Opposition's position today. After an interval of two years, they have settled upon the NHS. I suppose the feeling was that the health service is always a good subject for the purposes of finding something somewhere that has gone wrong. But the Opposition may well be having second thoughts about their wisdom in choosing this topic for debate, having been so effectively dealt with by my right hon. Friend the Secretary of State in a very robust speech. In my view, she won game, set and match, as she did at Question Time today.

Inevitably the cry is for more money—hardly a new or original slogan. But we all know that more money than ever is being spent on the national health service, and we heard from my right hon. Friend today of a further £2 billion. The argument is not simply about how much money is spent but also about how it is spent. That is the important issue that we are discussing today.

The other theme that has been coming through revolves around the in-word "crisis". How very original. When has the national health service not been in crisis? I made a point of looking up the definition of "crisis". Presumably the Opposition are using it in the sense of an emergency or a time of distress—as they allege. But a crisis, by definition, is also a crucial or decisive moment or a turning-point. That is where the national health service is. We all remember the 1980s, when although more and more resources were being devoted to the health service, there were still lengthening waiting lists and variations in the quality and efficiency of service up and down the country. This led to the Prime Minister's instigation of the review that resulted in the White Paper from which flowed the National Health Service and Community Care Act 1990. I have vivid memories of serving on the Standing Committee that dealt with that Bill.

A review of health services is hardly unique to this country. Such exercises are taking place in countries all over the world. It is well that, following the general election, there was a change in the health affairs personnel on the Opposition Front Bench. If the dire predictions of the hon. Members for Livingstone (Mr. Cook) and for Peckham (Ms. Harman) were quoted to their faces, they would at least blush, if not hang their heads in shame.

The truth is that the reforms are working and that the beneficiaries are the patients. I am not saying that the reforms are working smoothly. There are bound to be problems in a new climate and with a new way of working. Hospitals must learn that when they know the contracted work for elective activity the work load must be phased. They must involve the clinicians in the management process, and the clinicians must be willing to he so involved. The situation is not easy. There are bound to be teething problems, but what is intended can be done and, indeed, is being done up and down the country. Only here and there have problems arisen. Everybody can learn from the experience of the early days of these reforms, just as we are learning from the experience of the role of the GP fund holders, who can themselves negotiate contracts. There are bound to be circumstances in which health authorities have exhausted their budgets and where hospitals have capacity that the fund holders can use. Why not, if priorities and emergencies are not overridden? Consultants are now going to surgeries to do work on the spot for fund holders—a new concept for surgeons, but surely a good one. This too is working for the benefit of patients.

Some problems have certainly arisen with regard to extra-contractual referrals. Perhaps that too was inevitable, as this was unknown territory. Again we are learning from experience, and health authorities may need to earmark a larger proportion of their budgets for extra contractual referrals. But the fact is that the reforms are working.

As soon as the White Paper proposals came out, it was obvious that they would have a particular effect on London. I recall discussing this matter with a previous Secretary of State—not the last one but the one before that, I think. Up to now general practitioners in outer London and the home counties have tended to refer cases to their friends in the inner London hospitals. Now, because of costs, they refer far more on a local basis. It would have been easy to let matters take their course, to have a gradual falling-off of activity in the London hospitals, some of which would eventually have withered on the vine. But this would have been messy, it would not have been in the interests of patients, and it would have been costly.

I congratulate my right hon. Friend on the fact that she grasped this nettle by asking Professor Tomlinson to look at the matter and make recommendations. Clearly there must be managed change. I admire the way in which the Tomlinson report is now being considered in detail, and I admire especially the diligent manner in which my hon. Friend the Minister for Health is visiting every hospital and—contrary to the impression given by the hon. Member for Rochdale (Ms. Lynne)—listening to representations about the proposals in the report.

It is interesting to note the similarities between the Tomlinson report and the King's Fund report and to note the number of hospitals—such as Guy's and St. Thomas's, Brompton and Marsden—which, by discussing possible ways forward, were anticipating Tomlinson before he even started his work. I eagerly await my right hon. Friend's decision, but should like to make two comments.

First, we must not lose sight of the fact that Tomlinson is not only about the number of hospital beds—at present there are four acute beds per 1,000 people in London, as against 2.5 nationally—but also about primary and community care in inner London, which is well below the national average and, clearly, under-resourced. Secondly, Tomlinson looked at medical need but, on his own admission, did not quantify costs, on the rather curious ground that it would be too difficult to do so. I do not need to tell my right hon. Friend or the House that costs cannot be ignored, that they are an essential element of any political decision. We have to consider not only the loss of capital investment that the closure of hospitals entails but also the cost of effecting some of the moves that are proposed.

It is obviously important that some of the centres of excellence in London be retained. But, whereas some are simply teams of highly qualified people—and it is immaterial where they work from—others involve specially constructed units and complex equipment. For example, one needs only to visit the cardiac unit at Brompton hospital to see that its removal to purpose-built premises at Charing Cross hospital might be possible but would be enormously expensive. Then there is the unique asthma/allergy centre that is under construction at Guy's. Incidentally, that centre was financed largely by funds raised voluntarily.

There are two other matters that I wish to raise briefly. First, I pay tribute to the work of the voluntary hospices, which perform such a valuable role in relieving the national health service by providing high-quality care to people nearing the end of their days. From modest beginnings—pioneered by Dame Cicely Saunders—they have become a national movement. I welcome the fact that the Department gives them some support, but more would certainly be welcome.

Secondly, my right hon. Friend will not be surprised if I mention the question of nurse prescribing. In view of my personal involvement, I was naturally deeply disappointed at the decision—one of the autumn statement measures —to defer implementation. But, more to the point, it was a very deep disappointment to the thousands of nurses who were looking forward to such a step—

Madam Deputy Speaker (Dame Janet Fookes)


7.9 pm

Mr. Brian Sedgemore (Hackney, South and Shoreditch)

I wish to speak about the future of St. Bartholomew's hospital. Last Wednesday a candlelit procession moved from Bart's to St. Paul's cathedral. This was followed by a service as part of the campaign to save Bart's. Sixteen hundred people prayed to God that Bart's would survive. Afterwards the Dean of St. Paul's said to me, "If Bart's does survive, perhaps we should have a thanksgiving service." I pointed out to him that, because of the personal determination of the Secretary of State to close it, Bart's might not survive. We may have to rely on the Prime Minister's political antennae which tell him that there will be an enormous eruption if the hospital is closed.

People are puzzled at the attitude of the Secretary of State. They ask why she seems determined to do what the Black Death, Henry VIII and Hitler's bombers could not do. They ask why she desires to destroy St. Bartholomew's hospital. The answer is simple. It lies in the fact that she wants to get rid of the impediment which has blocked her political career—the fact that she has less political clout than the proverbial feather falling on a blancmange. She wants to be able to say that she took on the finest doctors in Britain and beat them. She wants to be able to say that she closed down the best hospital in the world, and it shows how strong she it. Closing down the best hospital in the world, however, is a sign not of strength but of weakness.

The House will be interested to know that shortly before Christmas, St. Bartholomew's hospital received a telephone call from one of the best-known journalists in the country who said that he had dined with the Secretary of State and that she had told him she was going to close Bart's. We have recorded a number of occasions, mainly Conservative functions, when she has told people that she will close Bart's. Bearing in kind that one is not supposed to prejudge a consultation, this is a contempt of Parliament and an insult to democracy.

To show that I am even-handed, I should like to say of the Minister for Health, with whom I have had many talks since the consultation began, that I have found him to be courteous, charming and propriety itself. When the decision to keep Bart's open is finally made, I imagine that the Secretary of State will resign and that he will take her job. Congratulations, doctor.

There is something special about a hospital that can persuade one of our greatest cathedrals to hold a service for it. There is something special about a hospital that has persuaded no fewer than 750,000 Londoners, an enormous number, to sign petitions in its favour. Looking back over the past 50 years, I cannot remember an occasion when one single, small institution facing political survival has had such support. I dare say that no institution this century facing political survival on its own has had the same amount of political support.

There is something special about a hospital that has support from every part of the globe. I have here a publication which contains 53 letters from all parts of the world to the Prime Minister. We also know that the Prime Minister has received a large number of letters of which St. Bartholomew's hospital does not have a copy. In addition to that, Professor Leslie Rees, the dean of the medical school, has received 406 letters from 46 countries round the world. They are from doctors and specialists, all of whom are pre-eminent in their field. So, in total, 500 top doctors and medical scientists around the globe have pleaded for St. Bartholomew's hospital to stay open.

I will give a few brief quotations. Herbert Pardes, dean of the faculty of medicine of the College of Physicians and Surgeons of Columbia University, writes to the Prime Minister: The adverse effects of closing St. Bartholomew's Hospital will be felt not only in the United Kingdom, but the medical community throughout the world. What's more, it may raise justifiable doubts about the future viability of the British biomedical research establishment which is already under attack by recent extensive budget cuts. Joe Leigh Simpson, faculty professor at the University of Tennessee, Memphis, writes about the proposed closure of Bart's: I hope this is mere rumor as I personally have ongoing experience with two groups of valued collaborators—Professor Nicholas Wald (Epidemiology) and Professors Gedis Grudzinskas and Timothy Chard (Reproductive Endocrinology/Biology). I can personally attest that both these groups are not merely national (U.K. treasures) but rather worldwide resources. Professor Jorn Nerup from the Steno Diabetes Center in Denmark writes to our Prime Minister: Seen from abroad, closing this excellent institution and dispersing its facilities and specialists to other locations will be a major loss for British as well as for international medical science. Lastly, Professor Jenkin from the Toronto-Bayview Regional Cancer Centre writes to our Prime Minister: I have recently heard, to my distress, that there is an official proposal to close and disperse St. Bartholomew's Hospital. I cannot understand the thinking that must have gone into such a decision … [it] is quite unbelievable and surely unprecedented. The Secretary of State, in attempting to take on the whole of the world's medical establishment, is surely behaving like some female version of Doctor Strangelove.

I have spoken in an Adjournment debate, but I want to make two further brief points. Tomlinson measures bed efficiency by the number of beds that a hospital uses to treat 1,000 patients. He uses this analysis to say that there is a great deal of scope for efficiency improvements in London as a whole, and that this factor, rather than changes in patient flows, will be crucial in determining loss of beds. Yet, amazingly, in his analysis of individual hospitals' vulnerability, Tomlinson includes potential loss of patient flows, but makes absolutely no reference to performance on efficiency.

The North East Thames regional health authority submitted figures to the Tomlinson inquiry in July. The figures were not published, but I have them here. On bed efficiency, they show that Bart's is more efficient than the Royal London, the Royal Free, University College Hospital/Middlesex and the Whittington/Royal Northern. Further figures show that, taking the combined effect of efficiency improvements and loss of distant patient referrals, Bart's is less vulnerable to bed loss than any other inner London provider in the North East Thames region—that is, less vulnerable than the Royal London, which it is proposed to keep open, the Royal Free, UCH/Middlesex and the Whittington/Royal Northern.

The region also submitted to Tomlinson an analysis of day cases as a measure of efficiency and progressive clinical practice. It shows that Bart's fared better than the Royal London, the Royal Free, UCH/Middlesex and the Whittington/Royal Northern.

There is, therefore, a gigantic inconsistency in the Tomlinson report. Tomlinson says that efficiency is the key to bed loss in London. He says that the survival of many hospitals will depend on it. Yet he recommends the closure of the hospital in north-east London with the best record of efficiency.

My last point concerns the financial deficit of Bart's. Tomlinson wrote that the unit was in severe recurrent financial difficulties. The Minister of Health, quite rightly, has bullied and cajoled Bart's into bringing its deficit down. In June this year, its total projected deficit was £11.45 million, made up of £6.74 million recurring deficit and £4.71 million non-recurring deficit. As a result of the extraordinary efforts of the new chief executive, Professor Besser, two days ago the total deficit had come down from £11.45 million to £5.5 million, made up of £2.45 million recurring deficit and OA million non-recurring deficit. That is an extraordinary example of bringing finances under control. The news that I have for the House, however, will excite the Minister and make him ecstatic, because early this morning I was lying—

Madam Deputy Speaker (Dame Janet Fookes)

Order. I am sorry to cut the hon. Member's peroration short. Mr. James Cran.

7.19 pm
Mr. James Cran (Beverley)

This is one of those occasions that generates a great deal more heat than light. I am bound to say that, on the basis of the evidence before me, most of the light in today's debate has been shed by my right hon. Friend the Secretary of State in what was a superb speech.

I say that against the background of the Opposition's motion which is peppered with exaggerations—"growing crisis", "total fragmentation", "destruction of NHS dentistry". That is simply not reflected in my constituency in east Yorkshire. From correspondence with my constituents, I know that they take the view that the internal market is beneficial to their interests and is delivering, as the Americans would say, the bacon to the people of east Yorkshire.

I freely admit—it is only prudent to do so—that general practitioners were unhappy in the run-up to becoming fund holders. They distributed leaflets to my constituents describing the dire consequences of fund holding. I would not say all of them, but many are now beginning to see the benefits to which they have signed up.

The same applies to the staff in the trusts in my constituency. Before the event, staff could not relate to this thing called the national health service because it was too big. They had few means of communicating with anyone. Now the NHS has been broken down into units to which they can relate.

I was surprised to hear the hon. Member for Sheffield, Brightside (Mr. Blunkett) say in an intervention in the speech of my right hon. Friend the Secretary of State that he had unsuccessfully requested statistics relating to the health service in Yorkshire. I have found it exceedingly easy to obtain statistics on health provision in Yorkshire. All I had to do was to ask for them, and I got them.

I could spend much time outlining those beneficial statistics, but I shall not do so because I do not have the time. Suffice it to say that statistics resulting from a survey of health users in the Yorkshire region, which was published in November last year by the National Association of Health Authorities, show a satisfaction rate of 89 to 90 per cent. Such a level of satisfaction would not be achieved if the Opposition's motion, to which I am having to address myself, was the case. It simply would not be so.

The Opposition could and perhaps should say that the level of satisfaction should be higher. If so, I would agree. That would be a reasonable statement to make. But, on the basis of a 90 per cent. satisfaction rate, it is not reasonable to say that the NHS in my neck of the woods is in crisis.

My constituency has a first-class general hospital, the Castle Hill hospital, built mainly out of own resources. I receive few complaints from my constituents about health care and health delivery at that hospital. Out-patient cover there has increased by about 54 per cent.

Opposition Members have spent much time talking about long waiting lists, but open heart surgery in my constituency has one of the shortest waiting lists in the country. The same is true of cardiology. Patients are attracted from all around the country to my constituency and the Castle Hill hospital.

There is clear evidence that people prefer day care and Castle Hill hospital and my authority are responding to that. I repeat that my constituents are not complaining in the way that Opposition Members are. In addition, the radiological unit at Castle Hill hospital is acquiring a new digital X-ray machine and a whole body scanner.

I could go on and on outlining—[Interruption.] I know that Opposition Members would really like me to go on, and if I had the time I would. I shall simply say that the evidence does not seem to show a service in retreat.

However, naturally, all is not completely well. It would be silly for me to say that everything is well. Of course, it is not. My constituents' access to orthopaedic surgery is not as it should be. One of my constituents had to wait 96 weeks for an appointment with the relevant consultant. That is simply not good enough, as we all know. However, I can report that my health authority and the hospital trusts are moving like greased lightning to reduce that waiting list. If it does not reduce to the level to which I think that it should, I shall make vigorous representations to my hon. Friend the Minister for Health and my health authority. But I am confident that improvement is on the way.

I have no worries that my right hon. Friend the Secretary of State will not respond in the way that I would wish to the Bloomfield report on dentistry in the NHS. I simply want to register the fact that my constituents wish to be able to obtain dental care within the NHS. They do not want, as is reported to me to be the case in other parts of the country, only private dental care to be available.

That is not acceptable to my constituents. It is in that light that I would expect my right hon. Friend to respond to the Bloomfield report.

The Department of Health has looked in some detail at no fault compensation. In one case at the Beverley Westwood hospital, not involving one of my constituents, a child was starved of oxygen at birth with the result that she sustained severe mental injury. Eight years later the health authority has decided upon a settlement of £l million. The delay is just not good enough. All hon. Members will appreciate that the family in question has gone through eight years of sheer hell. I hope that it is not beyond the wit of man to devise a compensation system whereby such families would not have such an agonising wait and I await the comments of the Secretary of State.

In summary, the NHS in my constituency is in good order. We deeply resent people, particularly politicians, running down the NHS. Thus, Opposition Members who would like to see how the NHS should be run should come to my constituency. I should be delighted to welcome them and show them around.

7.27 pm
Ms. Mildred Gordon (Bow and Poplar)

I listened carefully to the Secretary of State and some of what she said surprised me greatly. She expressed great respect and admiration for workers in the NHS, but went on to denounce members of the National Union of Public Employees and other trade unions. Apparently, she respects only those NHS workers who are not members of a trade union.

The right hon. Lady talked about the hot line, or the information line, that she is opening today. That will not be much use to the gentleman in my constituency who wrote to me recently to say that his urological operation had been cancelled three times and to ask whether I could find out when he was likely to have it. In reply to my inquiry, the Royal London hospital trust said that the district health authority was low on funds and could afford only emergency and urgent operations and my constituent would be considered in April in the new financial year.

The Secretary of State said that people often do not know to what services they are entitled. In the old days, my constituents knew very well how to get their services. They used to go to their GP, wait a few weeeks and get an appointment with a consultant who would then put them on his list and they would have an operation within a fairly short time. Now they do not know how to obtain the services that they need, because those services are not there. Such services are not free; people have paid national insurance contributions throughout their working lives to receive them. Some of those people have hardly used the national health service in the past, but, when they are older and need an operation, they find that the service is no longer there for them.

I am sure that the Royal London hospital has not given up all elective surgery; but for whom is it performing that surgery? Is it performing surgery for people who live outside London and whose GPs are budget holders? That is very likely.

An old friend of mine, whom I have not seen for years, telephoned me today: he said that he had had four heart attacks, and was waiting for a bypass operation. He went to Kings College hospital in south London, and was told that he would have to wait for at least 15 months. He said to me, rather naively, "Strangely enough, the only three people who were admitted came from quite far away: one of them lived in Ramsgate. I could not understand it. All of us local people were sent home. Perhaps they were emergency cases." I thought, "Perhaps their GPs were budget holders, or their district health authorities had not run out of funds."

The system is becoming totally unfair. As many hon. Members have pointed out, it is turning into a two-tier system. This callous, inefficient, doctrinaire, bungling Government are destroying the benefits of a service that people have enjoyed for four decades.

The Royal London hospital trust—the very organisation that wrote to tell me how sorry it was that my constituent's operation had been cancelled three times; that the trust understood how awful that must be, but he still could not have the operation—is in favour of the Tomlinson report. It is closing one of its two accident and emergency departments in February, but says that it can deal with some of the specialty work currently handled by Bart's, along with paediatric work currently handled by the Queen Elizabeth children's hospital: a merger is proposed between that hospital and the Homerton hospital. The trust also says that it can take on the work of the London chest hospital and sell its site. It can do all that—it is into empire building—but it cannot operate on a man whose operation has already been cancelled three times.

I recently visited the Queen Elizabeth children's hospital and the London chest hospital, and met the general managers of both hospitals. The London chest hospital is in a rather salubrious, unusually green part of the borough of Tower Hamlets, near Victoria park. It has a wonderful reputation: many people have written to me saying how awful it would be if it closed and how it saved their lives, or their mothers' lives. If it becomes part of the Royal London hospital—separated from the Brompton chest hospital—the building will be sold in the medium term: that is the plan. Patients with severe respiratory problems will be treated in the Whitechapel area, in the midst of filth and dust, rather than in the green area that contains the London chest hospital, with all its marvellous facilities. That will not benefit the people of London, no matter how the Secretary of State twists the truth and tries to pull the wool over our eyes. It will damage their chances of good treatment, and will prevent lives from being saved and improved.

Although Tomlinson treats it as a general hospital, the Queen Elizabeth children's hospital is more than that. It is a specialist hospital. If it is merged with Homerton, Great Ormond Street hospital will be affected very badly. I was told by officials at Queens that, without the Queen Elizabeth children's hospital, Great Ormond Street would be unable to provide the full range of paediatric care for which it is universally renowned. The research in pathology, radiology and anaesthetics which, for babies and children, represents a very special sphere of practice is done at the Queen Elizabeth children's hospital. If the Tomlinson proposals are implemented, the Great Ormond Street hospital will have to compete in the market, and is unlikely to be able to do so successfully: a comparatively small volume of the population uses its services, and the highly specialised procedures for small children are expensive.

The Carshalton and Westminster children's hospitals are closing, so that London will be the only capital city without a specialist children's hospital. Hospitals in Toronto, Boston and Melbourne, for instance, all work on the system used by the Queen Elizabeth and Great Ormond Street hospitals. We should view the matter in context: 30 per cent. of babies in London attend an accident and emergency department in the first six months of their lives, and 15 per cent. are kept in—mostly with respiratory and gastroenterinal problems. The child population in Tower Hamlets, on the borders of which the Queen Elizabeth hospital is situated, will grow by up to 19 per cent. in the next few years, and the area has twice the average number of premature births. These recommendations can only lead to the death of babies and children through lack of facilities. In these circumstances, do hon. Members think it is worthwhile to implement a doctrinaire policy about market forces in order to save money? I certainly do not; nor do my constituents, and nor would any right-minded person.

The Tomlinson proposals will affect Londoners severely. We want better primary health care in Tower Hamlets; there are many single-person practices there, and, although the position has improved, it could improve further. We want better care in the community—and we want the funding for it: in the past, care in the community has meant increased burdens on carers of both sexes, but especially women, and, often, on the whole family. "Care in the Community" has meant no real care, but the imposition of more burdens on people who are already doing more than their fair share—picking up the pieces of the welfare state that the Government are destroying. As my hon. Friends have pointed out, 13,000 Londoners are on waiting lists. The Americans are currently demanding, and moving towards, better health care provision; meanwhile, our Government are moving us towards the bad arrangements that have existed in that country hitherto.

A number of hon. Members on both sides of the House have mentioned dentistry. The Government have offered early retirement to all dentists over the age of 55. My dentist has taken it; he would have been stupid not to. But it is a way of encouraging large numbers of dentists to leave the health service. The other day, my husband had a small filling and his teeth cleaned: it cost £12.60. He was told, "This is the last time; at the end of January, the dentist will retire and do only private practice. He will not work in the health service any more." That dentist had spent 20 years in the health service. I said, "What will the same cost privately?" I was told, "Between £45 and £50."

I remember the days before the health service. I remember when many people in my constituency—not necessarily old people; some were not much more than 20 —had no teeth. Their teeth had been pulled out, they could not afford false teeth, their gums had hardened and they had had to eat sops. I recall clearly their gummy faces. Do we want a repetition of that? I fear that, with prices such as this, many people will be unable to afford dental treatment. Meanwhile, competition to get on to the list of a national health service dentist is becoming increasingly fierce.

Opposition Members are proud of the health service. Labour created it, and is justly proud of its creation. Londoners are proud of their hospitals, and do not want them to close. I have had an enormous postbag about Bart's, although it is in an adjacent constituency. We want to modernise and improve the health service, but on the basis of the fundamental principles—

Madam Deputy Speaker


Ms. Gordon

May I finish my sentence?

Madam Deputy Speaker

No; I am sorry.

7.37 pm
Mr. Gerald Malone (Winchester)

I am sorry to have to disagree with one of the points made by my hon. Friend the Member for Harlow (Mr. Hayes), but I feel safe in doing so because he is not in the Chamber. He suggested that the hon. Member for Sheffield, Brightside (Mr. Blunkett) was not nearly so welcome as his predecessor. I profoundly disagree: I believe that in this debate we can put in context some of the remarks made by Opposition Members before the general election, and some of their predictions about the health service which would result from the re-election of a Conservative Government. One of my hon. Friends mentioned that earlier, but chose not to return to the assertions made then. It may be worth detaining the House for long enough to quote some of those predictions, so that we can see whether they would be endorsed yet again by Opposition Members.

We were told by the hon. Member for Livingston (Mr. Cook) that we were moving quickly towards a system in which patients would die in casualty rooms while the accountant was finding out who would pay for them. My hon. Friend the Member for Broxbourne (Mrs. Roe) said that she had never heard of waving the shroud before: I commend that totally unsupported assertion as just one example of what was happening on the Opposition Benches during the last Parliament. We also heard from the Labour party that the Government were planning to embark on the final stage of selling off those hospitals that they had prepared for privatisation, that we were proposing to return health care to the free market of the 1930s and that we were creating trusts which would not be part of the NHS. That was one of the five great scare stories, which ran for some months without any foundation, none of which came to pass and none of which will come to pass.

I welcome the transition of the hon. Member for Livingston to another post and the arrival of the hon. Member for Brightside, from whom we heard not scare stories but nothing at all. We certainly heard little to support the contention in the Opposition motion that the health service is in crisis, and we heard nothing about the second part of the motion, which calls for reform. What reform? I doubt that we shall hear more detail from the hon. Member for Bristol, South (Ms. Primarolo) because the truth of the matter, whether she or other Opposition Members like it or not, is that Labour has conceded that our reforms will remain broadly in place—and quite right, too.

I wish to deal with the free market in health, which has not been mentioned so far. It is not a free market at all. Opposition Members suggest that the unseen, hidden hand of the market is directing reforms in patient care. That is sheer balderdash. There is a seen hand in the internal marketplace which has been created by national health service trusts—the seen hand of primary care. We must not forget that what underpins the reforms is the fact that, for the first time in the health service, provision will be dictated by primary carers. It is not the unseen hand of accountants that will dictate what happens, but the seen hand of need as determined by general practitioners who will be able to place contracts and have them fulfilled.

Many eloquent speeches have been made on the Tomlinson report by Opposition Members who have constituency interests, I too, have a constituency interest, but it is somewhat different. It lies at the heart of what Tomlinson is trying to do—to reallocate resources within the health service to areas of population expansion and away from areas of population decline. That is what drives the report. Wessex region has, historically, received one of the lowest allocations of resources in the country, principally because a tremendous amount of resources have been siphoned off to nearby London. I am delighted to tell my hon. Friend the Minister that Wessex's 1.5 per cent. increase in real terms for 1993–94 is extremely welcome, taking Wessex's budget to over £1 billion for the first time, but still leaving it as one of the lowest areas of expenditure per head of population. However, Wessex has experienced the highest growth in population of any area in the south in the past 10 or 15 years. I welcome the Tomlinson report because it will mean that resources follow population in a more sensible pattern than hitherto, which will be to the long-term good of health care not only in the Wessex region but throughout the country.

My right hon. Friend the Secretary of State made a tremendous speech in opening the debate. She and other health Ministers have made remarkable efforts to visit all the hospitals affected by and mentioned in the Tomlinson report and to listen to what is said. I hope that she will decide that some of the decisions about hospitals will be determined by those in the primary care sector, who by the contracts that they provide will show what the health service pattern should be in London. I hope that that will determine the process.

An application made last year for the Winchester integrated health care trust was rejected because it was deemed not to be in the interests of the Government's policy for it to be an integrated trust. The application has been resubmitted with some changes, and I commend it to my right hon. Friend the Secretary of State. It is important that Winchester should be carried along in the fourth tranche of health care trusts. Some changes have been made since the previous application was submitted. Some fear was expressed that the extent of current clinical and management integration in the health service in Winchester would not enable a self-standing trust to operate. I have taken considerable care to speak to all those who provide the service. Management changes have been effected and are being implemented. I believe that it will be well worth while giving the application close consideration again. I do not want to go through all the details in this short debate, but I shall write to my hon. Friend the Minister soon to back up the arguments advanced by those who provide health care in my constituency.

I join other hon. Members in paying tribute to those who provide health care in our constituencies. We owe them a tremendous debt. They do a tremendous job, but they do a better job under the reforms that the Government have put in place than they were able to do before. A record number of patients have been treated in Winchester this year. Like many other hospitals, we are now experiencing problems with pressure, but they do not disguise the fact that 28,000 patients have been treated. That was the target, but it has been exceeded by 400 already and there is still some time to go. It is a bit rich to suggest that such success, where budgets are being used by enthusiastic medical personnel and where more patients are being treated than before, is not an improvement on the previous situation.

The debate has exposed clearly the paucity of Labour policies for the health service. They criticised the health service in the run-up to the last election and exaggerated its position, saying things which were not going to happen and, what is worse, which they knew were not going to happen and formed no part of the Government's policy. We have now seen a collapse into inactivity. Labour Members do not know what their policy is. They have fumbled and mumbled about what they would do, but they will not come out—I shall be interested to see whether we hear more about this in the winding up speeches—with a detailed policy about why we are wrong and what they would do about it.

7.47 pm
Dr. Joe Hendron (Belfast, West)

The World Health Organisation has defined health as a state of complete physical and mental well-being and not merely the absence of disease. Health economists inevitably place themselves in an uneasy position if the economy being promoted by them undermines that well-being, which should be central to their endeavour. In short, what has gone wrong with the national health service?

Rationalisation really means centralisation, whereby the central, powerful and big are allowed to colonise the weak, small and peripheral. In other words, central institutions are dictating people's need, rather than responding to needs of the people. We have the technology to put men on the moon, yet there is much debate about whether women can have their babies in the local hospital.

Since the Westminster election of 1987, the Conservative Government have embarked on a reorganisation of the health service that owes more to the ideology of the marketplace than to real concern for the health and well-being of people. Northern Ireland has adopted a copy of those proposals, regardless of the different circumstances of small size, high levels of deprivation and the fact that regional specialist services are provided in a single location.

The Government's changes are not intended to reform the national health service as a public service but to deform it into a commercial business. Hospitals are being forced to compete against each other for business rather than to co-operate with each other for the benefit of the patient. The national health service is not and should not be treated as a marketplace. There is no proper democratic accountability.

The Royal group of hospitals in Belfast, which includes the Royal Victoria, the Royal Maternity and the Royal Belfast Hospital for Sick Children, and which is in the heart of my constituency, is among the finest in Western Europe. It is not only in the front line of medicine but has been in the front line of civil unrest and conflict in Northern Ireland for more than 20 years. It serves the people of Belfast and, through its regional services, the people of Northern Ireland. I pay tribute to the nurses, doctors and other professionals who, with the nonprofessional staff, have given so much to the health and welfare of the people.

It takes much more than manpower to run a health service. Under the so-called rationalisation of services, many peripheral hospitals in Northern Ireland have been closed and there has been a serious reduction in the number of beds in the larger ones, including the Royal group of which I spoke.

The incidence of coronary artery disease in Northern Ireland is one of the highest in the world. Through its research, the Northern Ireland Chest, Heart and Stroke Association has shown that 1,200 bypass operations are needed each year, but only half that number was being carried out because of a lack of staff and resources. However, I accept that the chief medical officer in Northern Ireland is doing something about that at present.

The Royal group of hospitals has applied for trust status and will become self-governing on 1 April. While I wish the chief executive and his staff well, I believe that the road ahead is fraught with great difficulties. Only in the past few days we have been informed that the Eastern health board had a secret meeting last week. It is to hold a public meeting on, I think, Thursday and will put forward proposals that will decimate those great hospitals. Even those seeking trust status have been taken by surprise.

Like other hon. Members who have spoken in the debate, I read last week's British Medical Journal which said that many hospitals around Britain are working at less than full capacity because health authorities do not have enough money to buy their services. Apparently, some of those hospitals will have to scale down admissions and operations unless they can obtain more funds from the health authorities and fund-holding general practices that buy their services.

The Government have ignored the wishes and needs of the people. Perhaps they will listen to the British Medical Association which said that the breakdown of many hospital services, which will lead to a two-tier provision to patients in many parts of the country, is wholly unacceptable. The current cash-limited funding is inadequate to deliver fully comprehensive patient care. Also like other hon. Members, I read the letter that the Consultants Specialist Committee recently published which speaks of the difficulties of most of the hospitals in Great Britain.

In the Government's strategy for community care, it is right to place great emphasis on keeping the elderly, the mentally and physically handicapped and the chronically sick in the community if at all possible. However, proper resources and care for the carers are extremely important. There are an estimated 210,000 carers in Northern Ireland according to the Carers National Association and without them current Government policy would be a nonsense. They are unpaid and largely uncomplaining. Much greater emphasis must be put on respite care which can be of such tremendous benefit to the carer.

Earlier, reference was made to the young man who went into the lion's den. One of the greatest problems in primary health care is with the young psychotic or schizophrenic who refuses treatment. I know that the Secretary of State for Health expressed her concern at the time and I shall certainly wait with great interest for any realistic proposals to resolve that burning issue.

Insufficient attention has been paid to the implications for health of social inequalities, including unemployment and poor housing, which were identified in the 1980 Black report, "Inequalities in Health", and in "The Health Divide" published in 1987.

Rev. Martin Smyth (Belfast, South)

I share the burden that the hon. Gentleman is bringing before the House. Does he agree that where there is a need for cardiac surgery in Northern Ireland, there could also be room for co-operation? The City hospital had the theatre space and nursing staff, if only surgeons had been prepared to use them instead of saying that there was not sufficient surgery space in the Royal Victoria, as a result of which many people are still waiting for surgery.

Dr. Hendron

The hon. Member for Belfast, South (Rev. Martin Smyth) makes a point, but I understand that it would be difficult to have the extremely expensive technology for cardiac surgery in two hospitals that are literally only a mile apart. However, I understand that there are plans to increase the number of operations in the Royal Victoria.

The health service in Northern Ireland is in a state of chaos. Senior executives are attempting to defend the indefensible while people in need of urgent care are being neglected or ignored. The Government have unashamedly helped to secure the acquiescence of a significant number of senior staff by enhancing their terms of employment.

The national health service is in a state of crisis, and I seriously believe that the Government should take heed of that message which is ringing out across the land.

7.56 pm
Mr. Michael Trend (Windsor and Maidenhead)

From listening to the Opposition, one would think that a £37 billion national health service was the end of the world, instead of the envy of the world which indeed it is. We have witnessed the political football marked "underfunding" being kicked about wildly and heard the national health service being talked down. Overall, I believe that the national health service is in good shape and improving all the time, but there are aspects still to be considered. That is the work of the Select Committee on Health, of which I have the honour to be a member.

One particular issue which recently came before the Select Committee was tobacco advertising, which I shall deal with in the context of the prevention policies mentioned in the Government's amendment and of the unjustified criticism of the Government by the Opposition spokesman. The Select Committee considered tobacco advertising and took evidence from a number of witnesses. There was general agreement on most of the analysis which resulted from our inquiry—that it was a laudable aim that smoking should be reduced, and that the means to achieve that should be considered. There was a great deal of agreement, but there was also an important dissenting voice on the final recommendations in our report last week which, in a magnificent week for Select Committee reports, was slightly overlooked by the press.

Of the eight members voting, three did not agree with a total ban. As background to what I shall say later, I should like to explain the two main reasons why I and two others did not agree with such a ban. First, in the context of the European dimension, we were being asked to subscribe to a European directive which we did not think was an appropriate vehicle. We did not think that it was necessary for the completion of the single market. It was not a matter of competence for trade but a matter of health —and health is not and should not be a matter for majority voting.

There was also much bogus talk about what happens in the rest of Europe. Is it not odd that all countries with nationalised tobacco industries support a ban? Some may say that that is to discourage imports. Is it not odd that the vast majority of those countries which grow tobacco and support a ban receive more than £1 billion in European Community subsidies? Is not our record on curbing smoking second only to that of the Netherlands where, as here, there is no statutory ban? Yet there are countries in Europe where tobacco consumption is still rising, and the highest rises in consumption coincide with the lowest prices.

The second reason why we objected to the final recommendations of the Select Committee report was the important matter of commercial freedom of speech. Tobacco is a legal product. A ban on its advertisement would be a serious step in a free country. Commercial freedom of speech is part of freedom of speech itself. I can think of no other example of the makers and vendors of a legal product not being allowed to advertise that product, but I can think of many areas to which some people might want to extend an advertising ban if the proposed tobacco advertising ban set a precedent. There could be a knock-on effect in many areas, such as alcohol, some fatty foods, fast cars, fireworks, gambling and guns.

There may be an argument for banning tobacco, but I should like to see someone brave enough to put that argument forward in this context. Unless tobacco is made illegal, commercial freedom of speech should not be sacrificed in terms of banning tobacco advertising. A statutory ban on the advertisement would turn a hard case into bad law. If we need to consider the whole idea of restricting commercial freedom of speech, we should do so openly and honestly. We should not do it in this way. We should start with the basics and establish new ground rules from which to judge particular cases. One generation's unique evil will soon be overtaken by another's. If we changed the general rule on commercial freedom of speech, bans would be extended.

I support the Government's present position —a basket of measures which have been notably successful. Effective prevention, as mentioned in our amendment, has been the heart of our policy. The Government have done much in terms of price. The price of cigarettes has gone up by 43 per cent. in real terms in the past 12 years. It is calculated that each 10 per cent. increase in price leads to a 3 per cent. to 6 per cent. fall in consumption. It is a serious mechanism.

The Government have insisted that warnings are put on tobacco packets. The tobacco industry is often accused of being a friend of our party, yet it has taken the Government to court over what it regards as the over-zealous size of the warnings that it is required to put on packets. Some people have said that the only way to spot a cigarette advertisement nowadays is by the large Government health warning on it.

The Government have made much progress in education, through the health education authority and through the inclusion of aspects of smoking in the national curriculum. The GP contracts include a remit for health promotion clinics which deal with smoking. There is also the general determination of the Government and especially of the present Secretary of State as shown in the White Paper, "The Health of the Nation". There is no doubt that the Government intend to bear down strongly on smoking.

Social pressure is even stronger. In the past 10 or 15 years, people have made their own decision in companies, in factories and elsewhere. In restaurants and in trains, smoking has become socially more unacceptable as the years have gone by. The climate of opinion has been a strong mechanism. Against that background, I support the Government's package of measures. I should like to see the continuation of the voluntary agreement— indeed, I should like to see it strengthened, especially for children and young people.

1 am suspicious of conceding a false point to the European Community over the directive, especially when I consider the bogus practices which I have described. I have said that I am suspicious of making new case law for commercial freedom of speech without first looking long and hard at the deeper implications of such a move. I am also suspicious of the idea that there is a quick fix to be had by banning tobacco advertising. Although I do not deny the obvious link in general terms between the advertising and consumption of all products, I did not find any convincing evidence in the recent Smee report that a ban now would lead to a major drop in the smoking of cigarettes in the United Kingdom. His own evidence was decidedly ambiguous on that point.

I am against the quick-fix school of politics in general. Those who advocate quick-fix policies seem to be permanently fixed on the Opposition Benches. They use the NHS as a political football, but, as the past four general elections have shown, all that they have done by kicking the ball around in their characteristically volatile and hare-brained manner is to score an impressive series of own goals. To continue the football metaphor, that is why Labour Members are sitting on the Opposition terraces looking as sick as parrots.

8.4 pm

Mr. Malcolm Chisholm (Edinburgh, Leith)

The one benefit of the recent economic chaos from the Conservative party's point of view is that it has masked the health chaos developing in the wake of the NHS reforms. The two problems are connected because, just as an ideological obsession with the market has damaged the economy, so an ideological obsession with the market will destroy the national health service unless action is taken to check it.

We in Scotland are protected at the moment from the worst excesses of the market. There are only two GP fund holders and no trusts yet in Edinburgh, but it is with alarm and dismay that we have looked on as events have unfolded in England. We hear from the British Medical Association that we face the worst crisis for 30 years. We see hospitals under red and yellow alerts, patients turned away and admitted only when they become emergencies and an all-round preference being given to GP fund holders as a two-tier system develops.

We also read about plans to axe hospitals in London when waiting lists there clearly show that the problem is not that there are too many beds for the patients, but that there is simply not enough money to cover the necessary treatments.

The Government know that the market system, with its purchaser-provider split, is the most effective method by which to cash-limit hospital services. While cynically claiming that choice has been increased, as the Secretary of State said today, the Government know full well that the reverse is true.

The most extreme manifestation of the market system on the provider side is the trusts, which are now about to be imposed on Lothian region and on Scotland as a whole. The phoney consultation for the West Lothian trust has just been completed, and the phoney consultations for all the hospitals in Edinburgh are about to begin.

The dates for all the opt-outs were pencilled in in a document in the Scottish Office at the time of the general election and no serious consideration has been given to the alternative, which is directly managed units. Even the Select Committee on Health, with its Conservative majority, suggested that the Government should proceed with caution with trusts. The Committee referred to problems of accountability, of strategic planning and of conditions for staff, yet within two years Scotland will be covered with trusts in the way that England is at present. That is undemocratic from several points of view, not least because the vast majority of people in Scotland are totally opposed to the imposition of opt-out hospitals. It is also irrelevant to the real problems of the health service in Scotland and will make them far worse.

The real problems in Scotland, as in England, are to do with underfunding, with lack of health service democracy and with the social conditions in which people live. The Government may ignore the connection between poor health and poverty, but Dr. Helen Zealley, the director of public health for Lothian health board, recently asked the health board to take seriously the greater rates of death and of illness among people living in deprived areas of Lothian. The figure for such people was 29 per cent., and many of them live in my constituency. It is scandalous that that link was not highlighted in the recent White Paper "The Health of the Nation".

The effects of underfunding in Lothian can be seen in waiting lists, accident and emergency services, continuing care of the elderly and community care. More than 25 per cent. of people wait more than one year for general surgery in Lothian. There is no way of reducing that list without spending more money.

Accident and emergency services in Edinburgh were centralised in the Royal infirmary following the cash crisis in 1990. I and three of my hon. Friends visited that hospital on Friday and saw the consequences of that centralisation of services. We were told that 80 per cent. of beds were tied up in emergency admissions. Of course, that is one reason why it is difficult to reduce the waiting lists. We were told that there were not enough beds in the coronary care unit but that every 999 heart attack call had to go to that hospital because it was the only one in Edinburgh with an accident and emergency department. We were also told, as I knew full well, that people from all over Edinburgh had to go to that hospital with even the most minor injuries. That has been the result of the centralisation.

Care of the elderly is another issue which is being hotly debated in Edinburgh. Following the English example, Lothian health board proposes to cut the number of NHS continuing care beds from 1,800 to 500. That means that 1,300 beds will be privatised. The reason is simply that the hoard does not have a sufficiently large capital allocation to build the necessary new buildings. That means that we cannot have the continuing care hospital in my constituency of Leith for which many people have been planning in the past few years.

Another cause of anxiety to which my attention was drawn at a recent surgery is the drugs which the Government will allow on prescription. A newspaper article was brought to me which said that many drugs would no longer be available on prescription. When I sent it to the Secretary of State, she did not deny that that was the case. Examples of such drugs were the contraceptives Femodene and Minulet. They are more expensive than others and may be taken out of the list for that reason, even though they have no side effects and may help to protect against breast cancer.

The Government claim that they are putting a great deal of money into the health service in Scotland. However, detailed analysis of the figures shows that the outturn health expenditure this year for Scotland is £3.64 billion. The planned health expenditure for next year is £3.75 billion. That is an increase of slightly more than 3 per cent.

Mr. George Kynoch (Kincardine and Deeside)

Does the hon. Gentleman recognise that health expenditure in Scotland is some 50 per cent. higher in real terms than when his party was in office? Does he accept that a record number of patients are being treated in Scotland and that there has been a great deal of major hospital development in Scotland since his party was last in office? We now have more hospital beds and more doctors and nurses. Far from being in crisis, the health service in Scotland is faring well under the Conservative Government.

Mr. Chisholm

I cannot reply to all of those points, but the number of nurses has declined recently. I ask the hon. Gentleman to use all his influence to ensure that his Government approve a new hospital for Edinburgh. The proposal has been with the Treasury for a long time and many people in Edinburgh want an answer soon.

The 3 per cent. increase in health expenditure in Scotland covers normal inflation, but everyone knows that health service inflation runs at 2 per cent. beyond that. That is not covered. Everyone knows that an extra 1 per cent. is needed to cover the needs of the increasing elderly population. That is not covered. Everyone knows that at least an extra 0.5 per cent. is needed to cover developments in medical technology. That is not covered either. So the much-trumpeted deal on health expenditure for Scotland is not acceptable and is not enough.

The example of the accident and emergency services which I gave a moment ago also raises the important issue of health service democracy. When the Public Accounts Committee recently investigated accident and emergency services in Scotland, my right hon. Friend the Member for Swansea, West (Mr. Williams) asked the chief executive of the national health service in Scotland whether local people had been consulted about removing the accident and emergency service from the Western General hospital. The chief executive was reluctant to answer for the simple reason that no consultation had been carried out.

In my constituency people from Granton, Pilton and Muirhouse opposed vigorously and vociferously the closure of the accident and emergency department. Yet their views were ignored.

The rhetoric on trusts is all about taking account of local needs and paying attention to local people. But the reality is the opposite. Reference has been made in the debate today to new appointees to the health boards. There is no democracy about that. The political affiliations of new appointees have been referred to by several hon. Members. I would point out that few women and few representatives of the ethnic minorities sit on the new trust boards. The proportion is even lower than in the House. That shows how bad the position is.

The new agenda for the national health service must involve emphasising the connection between poverty and poor health. It must involve developing health service democracy and replacing the market. That is not going back but going forward. The Conservative party lives in the past with its market obsessions. It has taken 14 years for many people to see the Conservative party's failures in economic policy, but its health policies are imploding after only two years. It is time for another U-turn. Let the Government start by saving all the hospitals in London and not proceeding with any more trusts in either Scotland or England.

8.16 pm
Dr. Liam Fox (Woodspring)

It is a shame that the debate, which could have been an opportunity for rational and mature discussion about the future of the national health service, has been turned into something of a circus by the Opposition. The hon. Member for Sheffield, Brightside (Mr. Blunkett) made a supposedly keynote but ultimately sournote opening speech. He made personal attacks on the Secretary of State. I am sure that she is flattered that the Opposition feel that they have to attack her personally on so many occasions.

The hon. Member for Brightside failed to grasp the main issues. Startlingly enough, he did not come up with a single suggestion about how to move ahead in the national health service. Instead, he carped on about this and that problem and threw up individual cases, as we have heard Opposition Members do in every debate in the House since the election. Not one constructive idea has been given. For a party that believed that it would form a Government last April, it is amazing that, after all this time, it cannot come up with one constructive idea about the way forward.

However, Conservative Members like to listen. I am sorry that the hon. Member for Rochdale (Ms. Lynne), the Liberal spokesman, is not in her place. Conservative Members like to consult. We do not take lightly the views of any who work in the NHS, not least the British Medical Association. Therefore, we must take the BMA chairman seriously when he says: The low morale in all areas of the service is largely due to the poor state of so many of our hospitals, lack of equipment to improve and, in some cases, save the lives of patients, shortage of staff, and the proper rewards to which all health workers are entitled. I am sure that Opposition Members support those words. Unfortunately, that was the BMA chairman in 1978, when the Labour party was in government.

That was the year when I went to medical school. My first experience of the national health service was of a service falling round our ears—that was when we could get into the hospitals, when they were not being blockaded by the unions and when the health workers were not on some sort of strike.

My first experience of the national health service was of staff having to push patients into the wards because porters were on strike, supported, needless to say, by the National Union of Public Employees and the Confederation of Health Service Employees, which have gone all white and caring in recent years.

Of course, 1978 was one of Labour's years of record. The hon. Member for Brightside talked about Labour records. One of the records of which I am sure that the Labour party does not want to be reminded is that it is the only party to have cut spending on the NHS; 1978 was the only year in the history of the NHS in which spending was cut. The Opposition cannot get away from that, but I do not intend to dwell on their record in office compared with ours, as it is becoming statistically insignificant.

We must look at the health service in 1993 and its problems and compare it with my early experience. In the first six months of this financial year we treated 200,000 more patients than last year. National health spending has reached £100 million per day and capital spending has gone up by 76 per cent. from when I entered the medical profession. Those are all achievements.

We are looking at ways to make the service more efficient and to bring doctors and others with medical expertise into management. That is one of the great benefits of trust hospitals.

We have heard much from the Opposition about how encumbered we are by management, but those in management at all levels in the NHS constitute only 2 per cent. of its work force. Total spending on management in the NHS is only 3 per cent. of total health service spending, and that makes the NHS one of the most efficient health services—if not the most efficient—in the world. Compare that with the United States where current management expenditure is 19.5 per cent. of total health care funding. That shows the efficiency of our NHS.

There are 17,000 more doctors in the NHS than there were when I went to medical school in 1978. General practitioners' lists are 18 per cent. lower than when we came to office in 1979. Preventive medicine is now at the heart of medical policy making and that was unheard of, even unthinkable, in 1978–79. Those are all major achievements and the House would be held in higher esteem if, from time to time, the Opposition accepted such achievements. Problems may still exist and may always be there for us to tackle, but for the Opposition to pretend that everything in the health service is rotten makes a mockery of rational debate.

The hon. Member for Bow and Poplar (Ms. Gordon), who is not in her place, said that the Labour party created the NHS and that it was proud of its creation. When were the Opposition last proud of the NHS? Was it when they left office, which they occupied from 1974 to 1979, when the NHS was falling apart? At no time that I can remember since 1979 have the Opposition said that they are proud of the NHS. When advances are made, why can they not say that they agree with the Government, congratulate them and then move on to rational debate? The answer is that they simply cannot bear Conservative success. Even when it is staring them in the face, they refuse to accept that what we have done has benefited the health service.

Over the past few years, we have been subjected to all sorts of predictions about what would happen under the Conservative reforms. Listening to some Opposition Members, one would think that the health service was absolutely perfect before we instituted our reforms. We introduced those reforms simply because the NHS was such an inefficient system and was failing to deliver what we regarded as modern standards of health care. Standards have improved as a result of the reforms, not least of which is the GP contract.

The hon. Member for Bristol, South (Ms. Primarolo) shakes her head. The Opposition told us that we would never reach our targets for immunisation or cervical smears. We surpassed them, and that is another major achievement. In view of those rising levels of immunisation it beats me why for once the Opposition cannot say, "You have done well."

The hon. Member for Peckham (Ms. Harman) said that there was no support among GPs for the concept of fund holding. How is it that already we have 3,000 GP fund holders and by April there will be 5,000. When the Secretary of State relaxes some of the conditions governing GP fund holders, as she told us she will, there will be even more. I welcome the fact that GP fund holders will be able to come in with a list of 7,000. Many Opposition Members and Liberal Democrat Members—when they decide to come to the House—are keen to speak about consultation and pilot schemes. We said that we would limit GP fund holding to those with a practice size of 9,000 and later said that we might extend it. Did we get credit for that pilot scheme? No, we did not, but it has been an undoubted success and now we shall extend it because that is the prudent way to go forward and it has always been the Government's policy.

The magazine Doctor, hardly a mouthpiece of the right, this month conducted a survey of GP fund holders. The survey showed that over 70 per cent. reported cuts in waiting times and improved efficiency for their patients. Over 60 per cent. reported improved services for follow-up appointments, over 50 per cent. reported improved dealings with consultants and were providing extra services such as chiropody. Over 40 per cent. reported better pathology services and improvements in the prescribing service and almost 40 per cent. of practices now have consultants visiting their practices. Those are all good for patients. We must get away from the idea that the health service is for those who provide it. We run it for those who use it, and that is one of the biggest differences between the Conservative party and the Labour party. It is one of the reasons why we are in government. [Interruption.] I shall give way to any Opposition Member who wishes to intervene.

We are concerned philosophically to move in the health service in a direction that allows decisions to be made closer to the patient. That is why it is correct to concentrate more power in the hands of general practitioners. There has always been rationing of one form or another in the provision of health services. There was hidden rationing for a long time and it worked in the following way. If I wanted to refer a patient for consultation I ticked one of four boxes at the top of the letter. The boxes are labelled "emergency", "urgent", "soon" or "routine". That was how GPs always rationed care in the health service, but in many cases it was not explicit. However, GP fund holders can decide which groups of their patients can be seen more quickly than others, and surely GPs are better placed than bureaucrats in health boards to decide whether a group of patients in a specialty should take precedence over another group. That is why we must continue to extend the fund-holding practices.

Not all services are covered by GP fund holders. The Opposition seem to think that GP fund holders are keen to involve themselves in coronary care and every other acute service. They cover "cold" services for which GPs can make a rational decision—one that does not involve acute patients. The Opposition say that a two-tier system is being created. If they believe that GP fund holders can offer a better service to patients than GPs who are not fund holders, surely the logic of the argument is to extend the fund-holding scheme to more and more GPs. However, the Opposition are intent on destroying our improvements and returning to the lowest common denominator, which is the base line for all their policies.

Of course, there will be problems during the transition. We are some way from knowing how GP fund holders use their contracts and how they will pan out. It is not entirely unexpected to encounter problems nine months into the financial year. No matter how we decide to use the funding, problems will remain throughout the decade. Medical science is advancing at a far greater pace than we can ever fund by public money. The gap between what can be provided by medicine and what we can afford to purchase will increase. Within whatever finite budget is in place there will have to be choices between acute and chronic care, between centralised hospitals and community hospitals, an issue raised by the hon. Member for Edinburgh, Leith (Mr. Chisholm).

There is a conflict of interest in my constituency about whether funding should go to Bath or to one of my local hospitals in Paulton. It is a matter of trying to decide at the lowest possible level to respond to what local people want. We must take a fresh look at the advantages of community hospitals as opposed to centralised care. There will be a limit to the level of increase in funding that can be internally generated by efficiency. Sooner or later, we shall have to make explicit judgments about the rationing of health care.

I asked in a previous debate whether it was acceptable, when there is a shortage of money in certain sectors, to pay for tattoo removal and so on. We shall have to look explicitly at whether we make these things freely available on the NHS. We have to use the personnel who work in the NHS in the most efficient way, and that is especially true of general practitioners. They are at the forefront of all the advances that we are making. As GP fund holding is extended, they will be asked to make more and more specific rational decisions, but their time must be used appropriately and, while many benefits have come from fund holding, not least the ones I have mentioned about cancer screening and immunisation, we must make sure that GPs are not overburdened with regulation.

It is prudent now, a couple of years into GP fund holding, for the Government to look at which areas are being productive and which may be unnecessarily overregulated. As we have asked for unnecessary regulation to be swept away in other areas of government, the Department of Health should also look at whether it is using GPs' time most efficiently.

We also have to look at whether we must have the regional tier because, while we are waiting for the internal market and its working to become clearer, as it will over time, there is still some need to keep the regional tier but there will come a point in the not-too-distant future when the regional tier will become over-bureaucratic and interfering and we may no longer require it. I hope that the Government will seriously look ahead to that time.

I want to make a final point, about the mental health changes, following the comments made by the hon. Member for Belfast, West (Dr. Hendron). I also feel strongly about this subject. It is dangerous to try to oblige any one fashionable medical idea across an entire spectrum and that is what has happened with mental health.

I do not believe that it makes any more sense to say that all the mentally ill should be institutionalised than it does to say that they should all be in the community. There has to be a balance, and I very much welcome the commitment by the Secretary of State a few weeks ago when she said that the Government would be reviewing all those guidelines. Surely we must have a balance in that system so that those who can integrate will be integrated and those who require institutional care can get that institutional care.

I hope that we shall turn back a little of the medical fashion which is putting everybody into the community which, as one can see on the streets of any city, is proving to be something of a mistake, especially for patients suffering from schizophrenia.

The Government have been brave in recent years in carrying forward their proposals. They have always done so against the wishes of the Opposition, who cannot tolerate anything that smacks of change and movement away from bureaucracy, and often in the face of criticism from the medical profession.

It has taken seven years for the Labour party to change their mind about council housing policy; five years for them to change their mind about British Telecom. I wonder how long it will take them to change their mind about NHS trusts and fund-holding practices.

I am sure that the real world will catch up with them in this, as in all the other policies which they have foolishly turned their faces against. I hope that it will be sooner rather than later, but for the electorate it will not make any difference because the Opposition will not get the chance to put their policies into practice.

8.34 pm
Mr. Alan Milburn (Darlington)

The hon. Gentleman's belief that everything in the NHS garden is lovely is not a view shared by NHS professionals or NHS patients. He will know that the BMA recently condemned the breakdown of many hospital services leading to a two-tier provision of service. The BMA has also condemned underfunding and flaws in the reforms and has called for radical reforms of the Government's changes immediately.

They know, and we in the Opposition know, that two years into the market all the impact that we predicted would occur with the introduction of the market into the NHS is now coming to fruition. The chickens are coming home to roost. Hon. Members on both sides know in their heart of hearts that the Government have created a system in which hospital services in many parts of the country lie idle for three months of the year because there is not sufficient money. It is unfortunate that NHS patients refuse to become ill for just nine months of the year. They become ill for 12 months and many are having to wait longer and longer for treatment.

The lack of resources for clinical care contrasts markedly with the booming resources that seem to be made available for bureaucracy within the NHS. The hon. Member for Woodspring (Dr. Fox) and some of his colleagues have spoken of the relatively small ratio of bureaucrats to clinical staff in our national health service. That was something to be proud of. I speak in the past tense because the figures from the Department of Health, as the Minister knows full well, point in a startling new direction.

Mr. Malone

So that we can get something positive from the Opposition, with what structure would the hon. Gentleman replace the management structure?

Mr. Milburn

I will deal first with the point that I was attempting to highlight and come to that later. We have more and more red tape in the NHS. Arguably, it is strangling the service. We have had a boom in bureaucracy in the past few years. The figures that I have received from Ministers indicate that during the period when the market was introduced into the NHS, between 1989 and 1991, the number of managers tripled while the number of nurses and midwives available on our hospital wards and in our communities fell by some 8,500. That has to be coupled with the enormous growth in administration generally. We now have 9 per cent. more clerical staff and more administrative staff as a result of the Frankenstein that the Government have created. Once one has the market, one has the purchasers and providers, opted-out units, more accountants, more financial directors and more of the institutions of the market.

In my region in the north, during that three-year period we saw a 500 per cent. increase in the number of managers. I would happily have lived with that, and many of my hon. Friends would happily have lived with that, if it had been complemented by a 500 per cent. increase in the number of nurses and midwives, but it was not—it was accompanied by a real decline in their number. There are fewer nurses on our wards. Many nurses are losing their jobs altogether and almost 5,000 health workers were made redundant between 1989 and 1992 because of the closure of their hospital units. Those are not my figures. They are not NUPE's figures. They are not the BMA's figures. They are the figures of Ministers from the Department of Health. They know in their heart of hearts exactly what is happening. Job losses were up by 50 per cent. in the first year of the market. It will not surprise my hon. Friends to learn that the biggest wave of redundancies took place in NHS trusts because there the ethics of the market are running amok. We are seeing more redundancies and sackings and fewer nurses and midwives at the sharp end of health care.

I go back to the introduction of the market and the Government's White Paper promising all these changes. I vividly remember as a humble parliamentary candidate that we were promised a leaner and fitter national health service. We were promised that it would be more efficient and less bureaucratised and that there would be a freeing of resources to enable the health service to treat patients at the sharp end. But it is not leaner: it is fatter—fatter with bureaucracy. It is bureaucracy gone mad. I understand that the Secretary of State enjoys being well briefed and therefore might want extra staff to monitor the effects of her policies, but do we need thousands of extra bureaucrats, accountants and administrators at the expense of qualified nurses? That is what we have got. That is a national scandal because it has done precisely nothing to improve patient care in this country.

I will allude briefly to some of the problems in my own area. Darlington's NHS is suffering a three-fold crisis because of underfunding, continuous administrative upheaval and the emergence of a two-tier health service. Darlington health authority is being denied any growth funding until 1995, despite having a greater than average elderly population. The local hospital is in dire financial crisis. In the current financial year, it is rumoured to be facing a £2 million deficit, and that is having a real impact on patient services. Hon. Members have spoken about looking after, listening to and ensuring that the concerns of NHS staff are taken fully on board, but in Darlington there is a vacancy freeze on new NHS staff.

In the past six years the hospital's cost improvement programme has taken £3.25 million away from hospital services. As a result, we have seen acute medical and surgery wards closed, children's wards being merged and, finally, desperate underfunding of our accident and emergency provision. The accident and emergency department treats some 10,000 patients every year. In the event of a major crisis on the east coast mainline railway, at Teesside airport, just two miles from Darlington, or on the AIM, just one mile from Darlington, that accident and emergency department would have to deal with a catastrophe without having any specialist accident and emergency consultant because the hospital cannot afford to appont one in this financial year. That is courting disaster and gambling with local people's lives.

Mrs. Audrey Wise (Preston)

Before my hon. Friend leaves the point about the lack of jobs for nurses, he may be interested to know that a student nurse recently described to me graphically how, as an official part of the course in the final year, students are being lectured on how to find opportunities to work overseas when they qualify.

Mr. Milburn

I am grateful to my hon. Friend. I believe that we face a major brain drain from the health service precisely because opportunities are lacking for qualified nursing staff.

Money can always be found for managers, of course. I understand that Darlington health authority is about to appoint a new project manager to lead the opt-out of acute services, on a salary of up to £53,000 per annum. That appointment is quite unnecessary. It is a direct product of the interference from Whitehall in local decision making about the future make-up of local health services in Darlington.

Dr. Liam Fox


Mr. Milburn

I have given way on a number of occasions and I should like to begin to wind up my remarks.

One of the final issues that I want to address is the decision which has just been taken today about the future make-up of health services in my constituency. We are sick and tired of governmental interference with our local health service. Just today, the regional health authority agreed a merger between Darlington and South West Durham health authorities, in the teeth of opposition from patients, staff, the two community health councils, the four Members of Parliament, the local authorities and local people. It is claimed that the Government are prepared to listen, but where is the listening there? They have not listened; they have ridden roughshod over the wishes of local people in my town. There will be no choice for patients as a result of that merger, because increasingly patients will have to travel for treatment to Bishop Auckland and out of the town altogether.

Some patients, of course, will not need to travel at all. They can take advantage, if they are lucky, of the top tier of health care in a two-tier service. Fund-holding GPs in my constituency have the benefit of referring patients directly to fast-track treatment. They do not do so through the NHS; they refer patients directly to the local private hospital. Hon. Members have attempted to mock some of the statements made by my hon. Friend the Member for Livingston (Mr. Cook) prior to the general election. He warned about creeping privatisation. That is not creeping privatisation; it is full steam ahead privatisation. Hon. Members should be ashamed that we have seen the development of a two-tier health service in this country.

I do not blame the GPs or the patients; they are playing by market rules, but the market means winners as well as losers and I am afraid that the NHS has become a national lottery. Lucky patients hit the jackpot, but this is not the sort of NHS that the British people want. They want an NHS which is free at the point of use, guaranteeing equal access to expert medical help when it is needed. That is the sort of NHS that we had in 1948 and the sort of NHS that we had in 1979. Unfortunately, it is not the sort of NHS that we have today.

8.45 pm
Mr. David Willetts (Havant)

I am grateful to you, Mr. Deputy Speaker, for calling me to speak in this debate because the motion put forward by the Labour party reveals that it fails to understand the basic objective of the Government's health reforms and how they work for the benefit of patients. Hon. Members talk about commercialisation of the health service and fragmentation of health care, but what the Labour party calls commercialisation and fragmentation is freedom for the providers of health care to serve the best interests of patients for whom they have responsibility.

A piece of doggerel that was circulating in the NHS many years ago summarises the purpose of the Government's health service reforms. It was said of doctors:

Masters of their patients when servants of the state, Servants of their patients when masters of their fate. It is the purpose of the Government's health reforms to make GPs and self-governing hospitals masters of their fate, no longer tied up in elaborate bureaucracy, and in doing so to ensure that they can properly serve the interests of their patients.

I will look first at primary care and the role of GPs now that they have the opportunity to be budget holders. Here I draw on my experience of serving for several years as a member of a family practitioner committee. Although many advocates of the old-style NHS have said that one of its strengths was the so-called gatekeeper function carried out by GPs, in practice the division of responsibility between primary and secondary care was one of the great weaknesses of the old NHS. It was a weakness that went back to Bevan's original design. On the one hand, GPs had the freedom to refer wherever they wished; on the other hand, they had no power to send resources to the places to which they were referring patients. The allocation of resources was determined by the Department of Health —determined, as Nye Bevan famously observed, by a department where, if a bedpan was dropped in any hospital in the NHS, the sound could be heard in Whitehall. That was no way to run the NHS.

If GPs are to be given proper freedom to refer, that freedom must be backed by the power to send the money to the places to which they are referring. That, of course, is the crucial significance of the option for GPs to become budget holders. It is an innovation which resolves one of the contradictions in the old-style Nye Bevan NHS. It not only solves the problem of that tension with which the NHS had wrestled for a long time, but also goes with the grain of technological development. The old-style view of the NHS as a service which required larger and larger hospitals, with more and more functions centralised in enormous hospitals, is not what the patients want, it is not what communities want, and it is no longer what medical technology requires. The power of miniaturisation and medical advance makes it possible for many treatments to be carried out in the GP's surgery or in the local clinic. Only 10 years ago, such procedures would have been thought to require hospital treatment. GPs are now properly reimbursed for minor ops—lumps and bumps. In future they will be able to carry out in their surgeries pathology tests with the use of small sensors, enabling patients to have immediate results. In the past, patients would have had to go to hospital, lie on a bed, have a blood test, return home, and be called to see the GP or hospital a week later for the result. Many enormous simplifications will be made possible by technology.

The old style NHS stood in the way of such advance. It had no interest in services becoming available at the primary care level because there was no financial system by which the pattern of funding the NHS could keep up with the pattern of technological change. Freedom to spend the money that they are allocated in the way they know to be in the best interest of their patients will result in GPs saying, "I need not send my patients to the big district general hospital 10 miles away for some tests; I can invest in the technology which will enable me to do those tests in my surgery."

The strengthening of the GP has been one of the great success stories of recent reforms, going beyond the wildest hopes of Ministers when they originally planned those reforms. In the old days, the contempt with which many hospitals and district health authorities treated GPs had to be seen to be believed. I recall the way in which the local district health authorities, as they saw the review of the NHS coming into effect, for the first time realised that if they really wanted to make sure that money was properly allocated, they had to conduct research into what GPs thought about the current pattern and quality of hospital services. They were horrified when, for example, they came across GPs who could say, "We are not satisfied with the quality of treatment from this or that hospital or department."

When writing contracts and deciding the services that they wanted to buy on behalf of patients, DHAs for the first time seriously consulted GPs to find out what they wanted. They now know that if they ignore GPs' views, many more GPs will become budget holders. The threat of becoming a budget holder has improved the quality of care for GPs who are not budget holders as much as it has improved the quality of care for those who are. That is why the reference in the Opposition motion to a two-tier health service goes against the reality of developments in recent years.

Dr. Liam Fox

Does my hon. Friend agree that what is important in cases of referral is not where patients go—whether to a private sector or a NHS hospital—but how quickly they are treated? The Labour party is tied to dogma, whatever Opposition Members say about Conservatives being dogmatic on the issue.

Mr. Willetts

I agree with my hon. Friend. He reveals the cynicism with which Labour Members speak of privatisation. They use it in the sense of people having to pay for their health care. That is not, and never has been, Conservative party policy and what we are discussing is not in any way privatisation in that sense.

Completely different is the concept of a patient enjoying health care free at the point of use—that care perhaps being delivered most expeditiously by a private hospital with which a DHA has a contract so as to reduce its waiting list. That is not privatisation, but delivering publicly financed health care free at the point of use in the most cost-effective and efficient manner. Only blinkered ideology could lead anyone to oppose such an approach to health care. The patient gains by getting the best possible health care without having to pay for that care at the point of use.

I move from primary to secondary care—the hospital service. An irony of the hostility of Labour Members to self-governing hospitals is that they oppose a measure which was modelled in many ways on a feature of Nye Bevan's health service which deserved approbation. When he was establishing his health boards, he deliberately decided, after consulting the leading representatives of the hospitals, that the leading teaching hospitals, with their medical schools, should not be brought under the direct control of medical boards. The old teaching hospitals were to remain self-governing.

Bevan envisaged that they would be self-governing, and so they remained until—the irony of what occurred will not escape my hon. Friends—Lord Joseph's reforms of the health service in 1970 to 1974, which brought those teaching hospitals under the direct control of health authorities. It was not a fundamental feature of the post-war NHS, but a relatively recent development. Indeed, in Guy's hospital there is a notice on the wall with a rather melancholy inscription saying that the board of governors met there for their final meeting, in the 250th year of their existence, in February 1974.

An idea behind the reforms which has proved enormously popular is now to give every NHS hospital the opportunity to enjoy self-governing status, the sort of freedom which Nye Bevan envisaged should be enjoyed by our great teaching hospitals. It is in no sense a dismantling of the NHS, but an attempt to ensure that all hospitals can enjoy the freedom which teaching hospitals had up to 1974. It is ironic that Labour Members should be committed to a stout defence of an over-bureaucratic, over-managed structure of the NHS introduced in the 1970 to 1974 period. There is no reason why that should be regarded as a fundamental feature of the NHS. As we see with several waves of applications for trust status, doctors, nurses and managers at those hospitals greatly relish the opportunity to employ staff more flexibly so as to serve patients in the ways that they know best.

Much has been said by Labour Members about the management of the NHS. If one wanted an indication of the inability of the Labour party to take seriously concepts such as efficiency, effectiveness and high quality care, it is their manifest opposition to anything regarded as management in the NHS. They do not like the idea of managers or accountancy or the efficient use of money. The NHS is one of the largest organisations in western Europe. The idea that it can survive simply by the endeavours of doctors and nurses, crucial though they are, without a professional cadre of people committed to the efficient use of resources, the proper control of money and the proper management of large and expensive hospitals is at best naive and at worst shows an extraordinary disregard for what is in the real interests of patients. I hope that we shall hear no more attacks on the essential work that managers do in the NHS. We do not say that the only staff doing a real job in ICI are chemists or that the only people doing a worthwhile job in Shell are those who work on oil rigs. We accept that large, complicated organisations have management functions which need to be carried out by experts.

Mr. John Gunnell (Morley and Leeds, South)

The hon. Gentleman has philosophically explained his case for fund holders and has made a similar case for trust hospitals. Now he is moving on to management. He has left out the purchasing authority. He obviously envisages an increase in the number of fund holders and presumably he wishes all GPs to become fund holders. What role does that leave for the purchasing authority? Or is the purchasing function to be entirely in the hands of individuals?

Mr. Willetts

The hon. Gentleman has raised an important question. The reply is twofold. First, the Government have always made it clear that becoming a GP fund holder is a voluntary option. Nobody is being dragooned into becoming a fund holder. I welcome the enormous number of GPs who have already exercised that option and I expect that many more will do so in future, but it is not compulsory.

Secondly, as my hon. Friend the Member for Woodspring (Dr. Fox) has already pointed out, the GP budget does not cover all services that the NHS provides. It covers the services which are frequently used at relatively low cost, but it was not thought feasible or sensible to include expensive and relatively rare treatments because they are randomly distributed. A relatively small number of cases would risk overturning a GP's ability properly to plan his budget, so such treatments remain financed through DHAs as purchasers. We may hope that some of the services currently bought by district health authorities will in future be bought by GP budget holders, but I expect that there will always be a wide range of services to be purchased by DHAs and not by GP budget holders.

I return to the point about management with which I was concluding, and to the record and the figures that we heard from my right hon. Friend the Secretary of State for Health today in a speech that I thought was so effective and persuasive.

Mr. Trend

It was brilliant.

Mr. Willetts

My hon. Friend describes it as a brilliant speech—[Interruption.] Opposition Front—Bench Members say that they were deeply impressed. I am pleased to have such confirmation of its quality. That speech included figures on the record number of patients treated and the record activity in the new style NHS which have been achieved by a combination of high-grade management and the freedom at last for people working in hospitals and for GP budget holders to act without the crippling control of the state. I therefore strongly oppose the Opposition motion.

9.2 pm

Mr. Richard Burden (Birmingham, Northfield)

The Opposition, and indeed the country, are getting quite used to the bland assurances of Conservative Members that there is no crisis in the NHS.

The picture of fund-holding GPs, hospitals and health authorities all competing in perfect harmony and patients armed with their own personal copies of the patients charter waiting only a short time for treatment is about as believeable as the adverts for private health care which show healthy people sitting up in hospital and smiling, being treated by nurses who never look tired while the patients never look sick. I cannot comment on whether that is an accurate picture of a private hospital because, unlike some Conservative Members, I do not use them. However, I do know that that is not a picture of care in the national health service in my region, the west midlands. In that region, the Government's health reforms are creating a kind of Trotter's Independent Traders, without the same social conscience but with the same financial acumen.

Qa Business Services, the computer division of the regional health authority, was sold off and went bust within 18 months. Millions of pounds have been spent on a value-for-money exercise that saves no money. We see HealthTrac, a new all-singing, all-dancing supply system that has to be investigated by the Audit Commission. That is what is happening under the new-look national health service.

It would not be so bad if the effects were simply financial. But it is not simply money; it affects real people such as those who worked for Qa Business Services—pensioners who stand to lose two thirds of their pension entitlement because of that mismanagement.

In my area of south Birmingham a merger was forced through against the wishes of local people and community health councils. It resulted in a deficit of about £25 million. That is leading to the closure of hospitals. It has already led to the loss of beds, and it means that the Royal Orthopaedic hospital in my constituency is to close, as is the accident hospital which has one of the best burns unit in the country. Services are also to be transferred from the general hospital in the city centre. Consultants opposed it and the local community opposed it. Consultants have warned of the danger of cross-infection—but because the market dictates, the policy must be pushed through.

Even before that happens, the Royal Orthopaedic hospital has to offer bargain basement prices to get contracts from other health authorities, but it cannot get them because those authorities do not have the money. A constituent of mine has been told that he must wait 92 weeks even to see a consultant. He needs the services of that hospital. The services exist, but he cannot use them because the market dictates that he cannot do so.

Another constituent of mine, a young boy aged nine called Thomas Leavy, has cerebral palsy. The health authority has told him that, because it does not have the resources as a result of the financial crisis caused by the health reforms, he cannot get adequate physiotherapy treatment and he must wait six months just to see somebody about the possibility of occupational therapy.

That is the reality of the Government's health reforms. It has been summed up much more eloquently than I could put it by a Birmingham consultant, who wrote to general practitioners in the north Birmingham and Bromsgrove areas—copying the letter to the Secretary of State, among others saying that it was not possible to place patients from their authority in his hospital. He said: My medical colleagues and I believe that this is a totally unsatisfactory state of affairs. The NHS reforms are not working. Money is not following the patients. The choice of patients and General Practitioners is being restricted not preserved as promised. We are into the realms of a two-tier health service depending on who has got the money and where patients live. Those are not my words, nor the words of the Labour party, nor even the words of NUPE—which Conservative Members like to quote—but the words of a consultant. That is the reality of the health service as it operates today.

Everything happens behind closed doors; secrecy surrounds the health authority. I and other Birmingham Members have tried to get answers time and again. We have asked the Secretary of State, Ministers and the regional health authority to provide us with the reports of the investigations into the financial crisis facing the South Birmingham authority. We have asked for copies of audit reports on the financial scandals in the West Midlandls authority.

Time and again, the Government insist that they listen and consult, but they have fobbed us off. Time and again, the Secretary of State has refused to meet Members of Parliament from the south Birmingham area to discuss the plans to close hospitals such as the Royal Orthopaedic. Of course, they say that it is a matter for management. We know what management means in the west midlands—financial scandals. It has meant Sir James Ackers running the flagship of the authority's internal reforms. We called for his resignation for months and months. Finally, after ignoring those requests, the Secretary of State was forced to accept his resignation a month or so ago, under circumstances not yet revealed.

There is now new management in the authority—Sir Donald Wilson, formerly of the Merseyside authority, which is itself the subject of calls for a public inquiry. He has been foisted on us. We are told that there is a new regime with a new open-door policy. That sounds great, but still all the hon. Members who have been asking for those reports have not been given them. That new management has not said that it will save one hospital or one hospital bed.

The new management is not much change on the old. When we discovered that, we asked the Secretary of State to direct the new management to ensure that the reports were made available to us, the local democratically elected representatives. Although she said in the debate today that she was in favour of all information being made available, her hon. Friend the Minister for Health replied to our requests, "No, it is a matter for management whether those reports are released."

A stop must be put to the situation in which the health service is run as if it were some kind of glorified supermarket. When we say that privatisation is creeping into the NHS, we are not exaggerating. We shall have in the health service what has happened in a number of other industries. First, the financial structure is changed and financial shackles are applied. Then there is the pretence that there is some kind of decentralised decision-making, whereas the only thing that is being decentralised is responsibility. When that system breaks down, Ministers say, "Wouldn't it be much easier if you went independent, if you freed yourselves from the shackles of Government control?"—the Government that put the shackles on in the first place. That is what Conservative Members intend for the national health service, although they do not have the guts to say so, and it is what Opposition Members will oppose and oppose and continue to oppose because we support and defend the health service that we created.

Conservative Members have asked us what our alternative is. Let me make three points for a start. First, the market mechanism, which is alien to the concept of health care and proper health planning, should be abandoned. Secondly, the health service should be given the funding that it needs. No amount of jiggery-pokery, with purchasers, providers and contracts, can make good the underfunding. Thirdly—and equally important—people who believe in the national health service, who use it and who live locally should be put in to run the service in a way that does not suggest that it is some kind of glorified supermarket.

9.10 pm
Mr. Jeremy Corbyn (Islington, North)

I should like to put on the record my thanks to my hon. Friend the Member for Bristol, South (Ms. Primarolo) for giving me five minutes of her time.

I want to put on the record too—so that it will not be possible for anyone to claim otherwise—the fact that, as a Member of Parliament, I am sponsored by NUPE. I am not ashamed of that connection; indeed, I am rather proud of it. Members of my union and, indeed, of the unions with which we are about to merge do very valuable work in the health service and are dedicated to the principle of a health service free at the point of use. They will remain dedicated to that principle, as has been demonstrated by their many years of service.

I wonder how those people are expected to continue their dedication when they are told that their pay rise in April will be limited to 1.5 per cent. despite the fact that the rate of inflation is far higher than that. Conservative Members may find this extremely amusing, but they are quite concerned about the future of their own jobs—especially the London Members, to whom I wish to address my comments tonight.

The Government's treatment of the health service in London is nothing short of appalling. We have seen 5,100 beds lost since 1982; during the same period there has been an increase of 18 per cent. in demand for hospital places; and regional health authority decisions have been imposed on London health districts, with no democracy whatsoever in the decision-making process. With the growth and merging of health authorities, we now have bigger, more impersonal and less accountable bodies in London and a continual drift of resources out of London and into the home counties.

I do not intend to be dragged into a false argument about the needs of inner London as opposed to those of Essex, Hertfordshire, Surrey and Kent. What we require is recognition by the Government of the needs in inner city areas. In London there are 60,000 people living in temporary housing accommodation, a considerable number sleeping on the streets, 1 million people living in poverty, above-average levels of deprivation and a high incidence of suicide, AIDS and many related diseases and illnesses. If the Secretary of State were to look at statistics produced by any family health service authority in inner London, she would recognise the degree of deprivation.

But what did the Government offer? The Tomlinson inquiry. It is proposed that a considerable number of hospitals, including Bart's, about which my hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) spoke so eloquently, should be closed, with the loss of a very large number of beds. It is claimed that, somehow, this will solve the problem of a London waiting list of 130,000 people. The implication is that the problem will be solved by transferring resources from the hospital sector to the primary care sector. That is not the alternative for which we are looking. What we want is recognition of the fact that the people of London need and deserve a proper health service. That means increased resources for the primary sector, increased resources for general practitioners, and better general practitioner services. But that will not be achieved if much of the general practitioners' time is taken up as a result of premature discharges from hospitals and inadequate hospital services in the first place. The Secretary of State and the Government must recognise that Tomlinson has got it fundamentally wrong. What Tomlinson is talking about is mass closures, with loss of beds, in order to solve the problem of underfunding of primary care in the first place when what we require is a recognition of those needs.

There is at last an inquiry into the activities of the London ambulance service, after years of providing an inadequate service because of an incompetent management and a particularly incompetent board. What we need at the same time is the recognition that the health needs of London will be met not by things like the Tomlinson inquiry but only by an increase of resources as a whole to the people of London. It is not right that people living in inner London suffer a higher level of infant mortality, a shorter life expectancy and a higher level of notifiable diseases than those living in the rest of the country. These problems must be addressed by an adequate provision of resources by Government to meet the need.

9.15 pm
Ms. Dawn Primarolo (Bristol, South)


Hon. Members

Hear, hear.

Ms. Primarolo

Perhaps I should sit down now and quit while I am ahead, with the support from my hon. Friends.

The debate has been about the realities of the national health service and the experience of people using and working in the service. My hon. Friends who have taken part in the debate have adequately described that experience. My hon. Friend the Member for Don Valley (Mr. Redmond) pointed out the political nature of the appointments, the placemen who are put on to trusts and rewarded generously while poor pay continues in the national health service and there is a pay freeze of 1.5 per cent.

My hon. Friend the Member for Halifax (Mrs. Mahon) spoke about the human cost of the national health service reforms, the bed closure programme and the desperate situation in her constituency because of bed shortages.

My hon. Friend the Member for Bristol, East (Ms. Corston), speaking about her constituency in particular, concentrated on what the national health service was created to do and what it does now in our communities. She spoke particularly from the personal experience of her constituents waiting 19 months not to be treated but merely to receive an appointment to see a consultant. She also mentioned the problems with dental services in Bristol, the ambulance cover, which is only 90 per cent., and the two-tier system whereby the patients of general practitioner fund holders are treated in advance of those on the waiting list.

My hon. Friend the Member for Hackney, South and Shoreditch (Mr. Sedgemore) was cut off in his prime. He had enthusiastically defended Bart's hospital, and I am sure that the Minister on his frequent visits to Bart's will likewise defend that excellent institution, but my hon. Friend was cut off before he could tell us that Bart's has now eradicated its deficit. It is, I hope, about to tell the rest of the London hospitals how it managed it, and then the closure programme proposed by Tomlinson can be abandoned as irrelevant.

My hon. Friend the Member for Bow and Poplar (Ms. Gordon) spoke about the importance of access to care on the basis of need, the cornerstone of the national health service, and went on to describe why the basic facts and data used in the Tomlinson report were incorrect.

My hon. Friend the Member for Edinburgh, Leith (Mr. Chisholm) spoke about the experience in Scotland and drew comparisons with England; he rightly said that the British Medical Association describes the crisis now being experienced in the national health service as the worst for 30 years. That is nothing for hon. Members on either side of the House to be proud of, and it is something which we should address.

My hon. Friend the Member for Darlington (Mr. Milburn) spoke with great authority and accuracy, cutting through the assertions made by Conservative Members about our now having a leaner, more efficient national health service in which the bureaucracy has been reduced. Using Department of Health figures, he put paid accurately to that misrepresentation. As he pointed out, there has been no freeing of resources for patient care.

My hon. Friend the Member for Birmingham, Northfield (Mr. Burden) talked eloquently about Trotter's independent trading company, as he called it, in the west midlands, and the secrecy that persists about the misuse of money in the NHS. He pointed out that one of his constituents had a 92–week wait to see a consultant. That is disgraceful.

My hon. Friend the Member for Islington, North (Mr. Corbyn) pointed out further shortfalls in the Tomlinson proposals. Most important, he showed that at no point had there been any assessment of London's health needs or any assessment of the tremendous problems that London faces, as do many of our other inner cities.

The Secretary of State told us that she had launched a new health help line to which she had made the first phone call—presumably to try to find out what is going on in the service. However, she failed to tell us that the help line closes at 5 o'clock. We have tried several times to get through, in the hope of obtaining some of the information that we cannot obtain from the Government, only to be held in a queue or requested to leave a recorded message which would be dealt with in due course. I hope that we do not have to wait until April when the new contracts start.

The Secretary of State said that a health service should be based on principles, but she went on to qualify that, saying as long as those principles stick to the budget. That is the politics of the balance sheet, not clinical priority.

The Secretary of State announced that £2 million would be given to pump prime pacesetter projects. I wondered whether that had anything to do with heart surgery; then I realised that it did not. She said that the object was to reduce waiting list times by setting new benchmarks. Perhaps she will explain to the House how pacing treatment, spreading it over a longer time, will lead to a reduction in the waiting lists. Presumably people will have to wait longer before they are reached.

The Secretary of State then announced something that she has already told us about.

Mrs. Virginia Bottomley

The sort of schemes to be funded are those at Walsall and Horsham which ensure that people can have their cataracts treated more swiftly and that people coming forward for breast cancer checks will be seen within 48 hours—innovative schemes, different ways of doing things, which others across the health service can emulate.

Ms. Primarolo

It is a shame that the Secretary of State could not have told us that in her speech and that she did not make it clear that the scheme was not about pacing treatment but about access.

The Secretary of State also announced for the second time the £2 billion to be used for capital projects within the NHS. She went on to say that that was to be provided by the sale of land and property. First, that is not new money, because it was in the autumn statement and, secondly, it is money which is funded by closure programmes, and the right hon. Lady cannot be sure that it will be available.

The Secretary of State referred to the huge investment that has been undertaken by the Government, and derided Opposition Members for the performance of past Labour Governments. She went on to talk about primary care. In 1981, the Acheson report identified the fact that 15 per cent. of GP premises in London were below the national average in that respect. Extensive and good proposals were made for the expansion of primary care. Hardly any of those were implemented, but linked to that was a bed closure programme. That, no doubt, sounds familiar to my hon. Friends.

A total of 5,000 beds were closed to pay for the increased primary care, but, by 1992, when we received the Tomlinson report, we found that the situation in London had deteriorated rather than improving: now 46 per cent. of GP premises are below the national standard. That decline in primary care has been presided over by a Government who claimed that they were providing more money.

Mr. Willetts

Will the hon. Lady give way?

Ms. Primarolo

I hope that the hon. Gentleman will appreciate that Conservative Members have spoken at length, and that I have given up some of my time to ensure that my hon. Friends could speak and to allow time for the Minister. Every time hon. Members interrupt me, thus reducing my time, I shorten the Minister's time. Does the hon. Gentleman want to incur the Minister's wrath?

I hope that the Minister will take the opportunity to repudiate paragraph 12.25 of the Bloomfield report on dentistry, which states: In considering priorities for exemption from payment, there must be doubts about the category of pregnant women/nursing mothers. Will the Minister state categorically that there will be no reduction in that exemption? Will he also refer to the new blacklist that is to be introduced, and give the House a categorical undertaking that no contraceptives will be removed from the list?

The Government told us that the national health service stumbled from crisis to crisis, and that we needed to accept the implementation of their reforms; the crises would then disappear.

Mr. Miller

We have heard a good deal about choice from Conservative Members. Would my hon. Friend like to comment on the board of the Countess of Chester hospital, in the Mersey region? There are four Conservative activists on the board—including Lord Wade of Chorlton—a failed Tory party treasurer and cheese maker. Would my hon. Friend care to contrast them with my constituent, a YTS trainee who suffers from a life-threatening disease and who—because of the "choice" offered by the Government—cannot get free prescriptions on the national health service?

Ms. Primarolo

My hon. Friend has summed up what is happening in the national health service. There are jobs for the boys; jobs in return for past work; jobs as a reward. But there are no prescriptions for those who need them.

The market, we were told, would eradicate the crisis. We would have a lean, finely tuned, responsive national health service. Let me give the House an example by describing a day in Bristol's health service. Bristol has three large teaching hospitals and a number of other hospitals.

This is what happened on 7 January. All through the night, Manor Park hospital had no female beds available. Before 8 am, the Bristol Royal infirmary and the Frenchay hospital had no coronary care beds available. The Southmead had one. The Frenchay refused to take patients from outside its catchment area. The BRI started at 9 am with no medical beds, and, by 2 pm, was completely closed; it had no beds. By 12 o'clock, the Southmead had no available beds, and Western General was closed to all admissions. Shortly after lunch, the Bristol general hospital had no beds. By 8 pm, the Frenchay, the BRI and the Southmead all had no medical beds available. Some time after 9 pm, the Southmead decided to accept medical admissions, but only from within the Southmead area.

The crisis in the NHS has been documented by everyone except the Government and their Department of Health. It has been demonstrated that patients wait in casualty for hours on end, and hospitals go on and off red and yellow alert.

Job losses among health workers rose by more than 50 per cent. in the first year of the Government's market-style changes to the NHS. Junior doctors are reportedly working more than the legal number of hours, despite the Government's pledge that the NHS would meet its first major deadline. Hospitals run out of beds and emergency admissions are not allowed as the money dries up. The BMA says that hospitals are facing financial collapse because of the ravages of the internal market. The mechanism that the Government told us would save the health service is destroying it.

We are seeing queue jumping; patients are refused treatment; people's working conditions deteriorate further; yet the Government do nothing except peer at the world through the rose-tinted glasses of Richmond house. An editorial in the Doctor, in absolute desperation, advised doctors to Bend Virginia's ear with proof of the crisis. The Secretary of State's underlings do not tell her the extent of the bad news. What can doctors do to persuade her that the present crisis is the most catastrophic but can be avoided?

One day the Secretary of State is full of praise for those who work in the national health service and is proud of their professionalism and commitment—rightly so—but the next she shifts the blame for the chaos on inept managers, greedy consultants or whingeing GPs. She should make up her mind about who is to blame, what is going wrong and how it should be put right. It is her fault and her Government's fault. Her reforms have demonstrated the persistent underfunding of the national health service: the very thing that the Government wished to disguise has been exposed by their own reforms.

The Secretary of State tells us that pacing work in hospitals is important. Hospital resources stay underused for three or four months of the year. How do doctors pace themselves when they are faced with seriously ill patients? I shall give an example of how they pace themselves from the intensive care unit admission policy of Gloucester health authority. This is what the reforms mean: Any surgical patients who are expected to require post operative intensive care will be deferred or transferred to another hospital pre operatively … In addition the following … patients will not be admitted. Patients with acute … chronic lung disease … Patients with chronic poor quality of life"— goodness knows what that means— Patients 70 years or over with: Acute Renal failure … Respiratory failure due to pneumonia". That is what pacing is. Those are the priorities of the budget sheet.

Waiting lists, perversely, allow people to be treated not according to clinical need but on the period of time and political priorities of the Government. People are called finished consultative episodes instead of people. Refurbishment means closure: in the Secretary of State's national health service, any word can be used. Prevention is distorted. Breast cancer services are a clear example. There are 1,400 victims in the United Kingdom every year —the highest number of deaths in Europe. We have the fewest cancer specialists in Europe, yet the Secretary of State tells us that prevention is better than addressing the need for such facilities. Prevention is a good strategy, but 4 million women in this country, 2 million of whom live in London, have not had a cervical smear in the past five and a half years. It is about time that that was addressed. Patients' choice has been eradicated; patients cannot choose their hospitals. Money does not follow them—they follow the money.

In Bristol we are about to have catchment areas for hospitals—if one does not live in the catchment area, one cannot go to the hospital. It is interesting that we are not allowed to have catchment areas in education, but we are allowed them in health. Frenchay health authority is already proposing to administer such a scheme. We are in the ridiculous position where the hospital in TruroTreliske—faces financial difficulty because tourism has dropped in the west country as a result of the Government's failure with the economy. That shows the state of the national health service under the Government's reforms.

We have tried today to show the perverse incentives that the Government have introduced into the national health service. The reforms have not worked, but are making the situation worse. It is about time that the crises were dealt with. I urge my hon. Friends to support our motion, as I know they will. If the Government continue to preside over this crisis, they will carry the shame in years to come.

9.35 pm
The Minister for Health (Dr. Brian Mawhinney)

In view of the self-proclaimed importance that the Opposition attach to the health service, some of us have wondered why they have not called such a debate for so long into this Parliament. Now we understand: they have not had such a debate because they had nothing to say. Indeed, some of us are driven to conclude that today's debate has more to do with the standing of the hon. Member for Sheffield, Brightside (Mr. Blunkett) in the shadow Cabinet than with the health service. I am sorry that the hon. Gentleman had the flu, and I hope that he will soon be feeling better. I shall not go into his speech in great detail. However, he talked about records of which Labour and Labour Governments were proud.

I need to remind the hon. Gentleman, as did my hon. Friend the Member for Woodspring (Dr. Fox), that he forgot to mention the record of a real cut in NHS spending under the previous Labour Government. He also forgot another record which will have great relevance against his hon. Friends' rhetoric during the debate: in four of the five years of the previous Labour Government, nurses' pay was cut in real terms. I hope that the hon. Member for Darlington (Mr. Milburn) will take careful note of that point.

Another of the hon. Gentleman's points that interested me involved accountability. My right hon. Friend the Secretary of State dealt with that in political terms, but I am genuinely surprised that the hon. Gentleman and the hon. Member for Bristol, South (Ms. Primarolo) have taken such a jaundiced view of the Government's attempts to empower patients by giving them as much information as they possibly can to enable them, in turn, to have informed conversations with their general practitioners, the better to get the type of care in the location and in the time frame most suitable for them.

Not only is the help line being launched today but regional health authorities have had a number of similar schemes available for some time. Indeed, some have been publishing waiting list times in local newspapers. I believe that The Citizen in Peterborough was the first in the country to do so, and I applaud it. We believe that patients should have as much information as possible because, after all, the service is designed to benefit them and to deal with their needs.

The hon. Member for Bristol, South invited me to comment on the Bloomfield report and on selective lists. When the Government said that they would listen to the views of people in the NHS, of dentists and patients before reaching a conclusion on the report, they meant what they said. On the whole, the hon. Lady is encouraging us to consult and listen and to try to find common ground, so she will not take it amiss if I do not accept her generous invitation but stick to the consistency which, as she is learning to appreciate, is shown by the Government.

I sum up the speeches of Opposition Front-Bench Members as follows: nothing should change in our thinking in a world that is changing. To paraphrase more neatly, they seemed to say, "Stop the world, I want to get off."

My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) raised two important points. First, she asked about AIDS testing. I can confirm that the arrangements that she set out are those contained in the General Medical Council guidance. I listened carefully to her speech, and I and my right hon. Friend the Secretary of State will reflect on it.

Secondly, my hon. Friend the Member for Edgbaston spoke about an adoption story. I am sure that I am not alone in the House in being shocked by the details she gave. We have a strong commitment to and a strong appreciation of the work of social workers, but we draw definite lines beyond which they should not go. From what my hon. Friend has said, it seems that she knows of a case in which those lines were transgressed. If she would be kind enough to let me have the details of the case, I will ask my hon. Friend the Parliamentary Under-Secretary, the hon. Member for Suffolk, South (Mr. Yeo), who has responsibility for these matters, to investigate the case in depth.

Mr. John Marshall (Hendon, South)

Will my hon. Friend give way?

Dr. Mawhinney

No, because I should like to make a little progress.

The hon. Member for Rochdale (Ms. Lynne) encouraged us to consult. She was, if she will forgive me for saying so, rather churlish about the efforts that the Government are making legitimately, sensibly and sensitively to do exactly what she wants us to do. I am pleased that she was gracious enough to recognise that, when she and her colleagues came to see me, I was genuinely consulting and genuinely listening. I assure her that I took note of the points they made.

My hon. Friend the Member for Broxbourne (Mrs. Roe) made an important point. She said that management cannot be taken out of the context of care, and she was right. Some peddle the false argument that we have to choose between care, and the efficient and effective use of resources. That is a spurious dichotomy. As we use resources efficiently and effectively, we enable more patients to be treated. There is nothing from which to resile in wanting to see the £100 million a day we spend on the health service used to best effect.

My hon. Friend the Member for Chislehurst (Mr. Sims) raised a number of questions about London to which I shall return in a few moments. He also expressed his concern and regret about our decision on nurse prescribing. I pay tribute to my hon. Friend, who has been one of the strongest advocates in the House of nurse prescribing. The genesis of the policy, to which we are still committed and about which we are still enthusiastic, owes much to his advocacy.

We are concerned to ensure that nurse prescribing is launched in an environment that is as conducive as possible to its success. We are not at all certain that the present climate, in which there is to be an extended discussion about the drugs bill and about prescribing generally, is the best in which to move forward that policy.

My hon. Friend the Member for Chislehurst paid an appropriate tribute to the hospice movement and to its work. I am sure that that is a matter for appreciation across the House. There is nothing partisan in our appreciation of the work done by hospices. I am pleased to announce to the House a £43 million extra payment to charitable hospices through health authorities in the coming year to help them to provide support for voluntary hospices. The Department will provide £32.3 million for voluntary hospices. A further £5 million is to be given to health authorities to help them to pay for hospice care for terminally ill people as part of the community care changes, and £5.6 million is to give voluntary hospices access to drugs supplied by health authorities. That means that the total Government funding to voluntary hospices since 1991 is £l05.3 million.

Mr. Blunkett

As we are not having an evening of churlishness, I should like to put it on record that the Opposition welcome that statement and wholeheartedly give their backing to the allocation of those resources to hospices, which do such good work.

Dr. Mawhinney

I am grateful to the hon. Gentleman. I appreciate the generosity of his statement and of his gesture in making it.

I pay tribute to the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) for the assiduous way in which he has represented his constituents' views on the future of St. Bartholomew's hospital. Indeed, outside my family, I have probably written more letters to him than to anyone else in the whole world in the whole of my life.

The hon. Gentleman is in danger of going down in this debate as a tease because he raised my expectations to fever pitch and was cut off in his prime. So exceptionally —I hope that you will not feel that I am transgressing your 10–minute rule, Madam Deputy Speaker—I am happy to give way to the hon. Gentleman to let him have his expectation.

Mr. Sedgemore

I am grateful to the Minister for allowing me to intervene. I received a telephone call from Professor Besser, the chief executive of Bart's, this morning. He said that Bart's should be making an announcement in the next few days that it can finance the whole of its non-recurring deficit and that its recurring deficit should so be slashed that it will be close to having a balanced budget.

Dr. Mawhinney

The hon. Gentleman will understand, given the discussions that we have had in the past few months, if I hang on to my ecstasy for a little longer until I see the small print.

While the hon. Gentleman was personally generous, I deplored the attack that he launched on my right hon. Friend the Secretary of State. It was without justification or foundation. I hope that he will find it possible to withdraw it on a suitable occasion.

My hon. Friend the Member for Beverley (Mr. Cran) was entirely right to draw attention to the importance of day care surgery and the effect that it is having on the ability of the NHS to treat patients.

I intended to dissect the Opposition motion this evening, but my hon. Friend the Member for Harlow (Mr. Hayes) did it for me and probably did it better than I could. He pointed out that for every claim in a newspaper there was a counter-claim in another newspaper and that mutually exclusive statements were made elsewhere. He said that, while the Opposition Front-Bench team had been busy, it did not have an idea what it had been busy about.

Only a fraction of hospitals are affected by the crisis that Opposition Members have unsuccessfully tried to sell to the House this evening. We spend £100 million a day on the NHS. It has treated 600,000 more patients on average every year since the reforms were introduced. The number of people who wait between one and two years is down by more than 50 per cent. since the reforms were introduced. According to a recent survey in Doctor magazine, 70 per cent. of GP fund holders recorded reduced waits and improvements in efficiency.

The NHS trusts treated 8.2 per cent. more patients in the first year of operation, compared with 7.2 per cent. for the directly managed units. In other words, no matter how we approach the reforms—whether it is trusts, GP fund holders, quality, waiting lists or convenience to patients —they are delivering better services for patients.

Mr. David Trimble (Upper Bann)

Not only the Opposition Front-Bench team is in two minds. As the Minister knows, in Northern Ireland the boards of both the local health authorities and the hospital trusts are composed of Government appointees. He may also be aware that a trust will come into operation in my constituency in a couple of months. However, the health board is rushing through a review which threatens to close two hospitals, thus pre-empting what the trust might do. We have good reason to believe that the trust will keep at least one and perhaps both hospitals open. Is not that an example of bad co-ordination and management?

Dr. Mawhinney

The hon. Gentleman's constituents are fortunate if they are to have a trust in a couple of months because they can look forward to better patient care and more treatments. I was in the Province for six and a quarter years and it may have appeared to the hon. Gentleman that I was a permanent fixture. However I was not, and he will have to raise those issues with my right hon. and learned Friend the Secretary of State for Northern Ireland.

Mr. John Marshall

My hon. Friend will be aware that the London gender clinic is in my constituency and that its activity has caused great concern. Will he ensure that it operates within the law and look at any lacuna by which it may have breached the law?

Dr. Mawhinney

As my hon. Friend may be aware, the British Medical Association has expressed some views about the clinic and the HEFEA committee has published a paper on the issue. We are looking carefully at the matter.

The characteristic feature of the debate is that, while we have been speaking about patient treatment and care and numbers of patients, the Opposition have spoken about beds and buildings. I suppose that that represents the division on thinking between us. For more than 40 years the health service was provider driven. As a result of the reforms, it should become purchaser driven, with the needs of the patient at the centre.

I accept without embarrassment or difficulty that a service that has been running for more than 40 years on provider lines and has to start running on purchaser lines will find that that line is not unlikely to be as strong as the previous one. There are obvious reasons for that and it takes time to build expertise. It would be absurd to suggest that there is not a single case among the 45 million people whose lives are touched by the NHS in any one year in which the system has not worked to maximum advantage. We are debating 1 million employees, 45 million patients and an organisation with a budget in England of £30 billion.

However, I am perfectly prepared to defend the reforms, to laud the advantages that they are bringing to patients, to confirm the strengthening of the purchasing line year by year and to recognise that the contracting process needs to be properly managed. It is more likely to be properly managed if hospitals, doctors and consultants are included at an early stage in management discussions. It is likely to be even better managed if GPs who are not fund holders enter into early discussions with purchasers, with the district health authorities, so that when those authorities are putting contracts to providers they will do so in a way that satisfies the GPs in the area.

We have heard much about GPs. It is quite wrong to assume that GPs who are not fund holders are unable to influence the standard of care that is available to their patients. I should like to see more influence exercised by GPs on the district health authorities as they prepare contracts for hospitals. I hope that those with management responsibilities in the trusts will recognise that their ability to deliver consistent health care throughout the year will be improved if doctors are involved in the process from the beginning.

My hon. Friend the Member for Havant (Mr. Willetts) made an excellent speech, as one would expect because he clearly understands the importance of the freedoms—[interruption.]

Madam Speaker

Order. I should be obliged if hon. Members on both front Benches below the Gangway ceased their conversations so that I might hear the Minister.

Dr. Mawhinney

My hon. Friend clearly understands the importance of the freedoms that we have given to GPs and the importance that we attach to their fundamental role. If the service is to be as sensitive as possible to the needs of the patient, the GP must be involved in the system as much as possible.

My hon. Friend was right. The proof of the pudding is in the eating. We are not coercing, forcing or cajoling GPs to become fund holders. The debate on trusts is over. By April 1994, something like 95 per cent. of all the provider units in the country will be trusts, and if the Opposition ever come up with a policy they will not be able to put it into effect if that policy in any way involves dismantling trusts. Of course they will not get into office, so it is a bit of a hypothetical point.

At the heart of the reforms is the role of the GP and of the GP fund holder, and GP fund holders are increasing in number precisely because they recognise that they can provide more, better and more sensitive services to their patients.

It is worth reminding Opposition Members that we have made it easier for patients to move from their GPs if they are dissatisfied. What is happening to GP fund holders? Their lists are not going down but up. To talk about a two-tier system is totally to misunderstand the heart of the Government's reforms. It is not a two-tier system but a shared purchasing system. I am very clear, particularly given the record of Opposition Members in this debate, that we shall have to keep on saying that to them regularly month by month for a long time until finally the penny drops. The penny will need to drop because GP fund holders are at the heart of the reforms and will drive forward the improvements we are all committed to making.

Turning to the question of London, I wish to pay tribute to Sir Bernard Tomlinson, a distinguished academic and public servant who has produced an excellent report. He does not deserve some of the personal abuse which has been heaped on him over the past three months. It is important to understand that the Tomlinson report, which remains, until my right hon. Friend makes her decisions, advice to Government, is not about whether one closes a hospital here or merges a couple of hospitals there but rather about the re-configuring of health care in London. The fact is that change is taking place and even the hon. Member for Brightside once recognised that London's status quo could not be maintained. He has wobbled a bit and waffled a bit since, but he did at least recognise that.

Part of the change is reflected in increased standards of health care provision in hospitals outside London so that those who used to send their patients to London no longer have to do so, because the patients do not want to travel if they do not have to and they can get treatment at home.

We have been consulting. I have been listening to representatives of the users, of the providers and of the purchasers as well as to the politicians, and I recognise the importance of primary care. Tomlinson does and so do we. In addressing primary and community care, we recognise that we have to address the problems of bed blocking in hospitals. All of my conversations have been confidential. but I will give the House one piece of information from a medium sized teaching hospital in London, which told me that on every day of the year between 60 and 100 of its beds are blocked by people who are clinically discharged but cannot go home because of inadequacies in primary care. We recognise the importance of addressing that issue.

It is easy to sum up this debate. There is a crisis. It is a crisis in the Labour party; and those who do not believe it should have been watching the face of the Leader of the Opposition when the hon. Member for Brightside was speaking. The Labour party policy on the NHS was rejected by the public in April. Now there is not even a policy, not a whiff of a policy. The Opposition have elevated the whinge to an art form.

Labour Members have a concern for individuals, as do all of us. The difference between us is that we are developing systems that ensure that more patients are treated to higher standards and with more regard to their wishes than ever before. GP fund holding is at the heart of those reforms.

The public's appreciation of the NHS is far greater than the Opposition's. Its appreciation of what we have done to improve the NHS is far greater than the Opposition's. Our commitment to the NHS is clearly far greater than the Opposition's. For those reasons, our vote tonight will be far greater than the Opposition's.

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

The House divided: Ayes 281, Noes 316.

Division No. 125] [9.59 pm
Abbott, Ms Diane Corston, Ms Jean
Adams, Mrs Irene Cousins, Jim
Ainger, Nick Cox, Tom
Ainsworth, Robert (Cov'try NE) Cryer, Bob
Allen, Graham Cummings, John
Alton, David Cunliffe, Lawrence
Anderson, Donald (Swansea E) Cunningham, Dr John (C'p'l'nd)
Anderson, Ms Janet (Ros'dale) Dafis, Cynog
Armstrong, Hilary Dalyell, Tam
Ashton, Joe Darling, Alistair
Austin-Walker, John Davidson, Ian
Banks, Tony (Newham NW) Davies, Bryan (Oldham C'tral)
Barnes, Harry Davies, Rt Hon Denzil (Llanelli)
Battle, John Davies, Ron (Caerphilly)
Bayley, Hugh Davis, Terry (B'ham, H'dge H'l)
Beckett, Margaret Denham, John
Beggs, Roy Dewar, Donald
Beith, Rt Hon A. J. Dixon, Don
Bell, Stuart Dobson, Frank
Benn, Rt Hon Tony Donohoe, Brian H.
Bennett, Andrew F. Dowd, Jim
Benton, Joe Dunnachie, Jimmy
Bermingham, Gerald Dunwoody, Mrs Gwyneth
Berry, Dr. Roger Eagle, Ms Angela
Betts, Clive Eastham, Ken
Blair, Tony Enright, Derek
Blunkett, David Etherington, Bill
Boateng, Paul Evans, John (St Helens N)
Boyce, Jimmy Ewing, Mrs Margaret
Boyes, Roland Fatchett, Derek
Bradley, Keith Faulds, Andrew
Bray, Dr Jeremy Field, Frank (Birkenhead)
Brown, Gordon (Dunfermline E) Fisher, Mark
Brown, N. (N'c'tle upon Tyne E) Flynn, Paul
Bruce, Malcolm (Gordon) Foster, Derek (B'p Auckland)
Burden, Richard Foster, Don (Bath)
Byers, Stephen Foulkes, George
Caborn, Richard Fraser, John
Callaghan, Jim Fyfe, Maria
Campbell, Mrs Anne (C'bridge) Galbraith, Sam
Campbell, Menzies (Fife NE) Galloway, George
Campbell, Ronnie (Blyth V) Gapes, Mike
Campbell-Savours, D. N. Garrett, John
Canavan, Dennis George, Bruce
Cann, Jamie Gerrard, Neil
Carlile, Alexander (Montgomry) Gilbert, Rt Hon Dr John
Chisholm, Malcolm Godman, Dr Norman A.
Clapham, Michael Godsiff, Roger
Clarke, Eric (Midlothian) Golding, Mrs Llin
Clarke, Tom (Monklands W) Gordon, Mildred
Clelland, David Gould, Bryan
Clwyd, Mrs Ann Graham, Thomas
Coffey, Ann Grant, Bernie (Tottenham)
Cohen, Harry Griffiths, Win (Bridgend)
Connarty, Michael Grocott, Bruce
Cook, Robin (Livingston) Gunnell, John
Corbett, Robin Hain, Peter
Corbyn, Jeremy Hall, Mike
Hanson, David Morris, Estelle (B'ham Yardley)
Hardy, Peter Morris, Rt Hon J. (Aberavon)
Harman, Ms Harriet Mudie, George
Harvey, Nick Mullin, Chris
Hattersley, Rt Hon Roy Murphy, Paul
Hendron, Dr Joe Oakes, Rt Hon Gordon
Heppell, John O'Brien, Michael (N W'kshire)
Hill, Keith (Streatham) O'Brien, William (Normanton)
Hinchliffe, David O'Hara, Edward
Hoey, Kate Olner, William
Home Robertson, John O'Neill, Martin
Hood, Jimmy Orme, Rt Hon Stanley
Hoon, Geoffrey Parry, Robert
Howarth, George (Knowsley N) Patchett, Terry
Hoyle, Doug Pendry, Tom
Hughes, Kevin (Doncaster N) Pickthall, Colin
Hughes, Robert (Aberdeen N) Pike, Peter L.
Hughes, Roy (Newport E) Pope, Greg
Hughes, Simon (Southwark) Powell, Ray (Ogmore)
Hutton, John Prentice, Ms Bridget (Lew'm E)
Ingram, Adam Prentice, Gordon (Pendle)
Jackson, Glenda (H'stead) Prescott, John
Jackson, Helen (Shef'ld, H) Primarolo, Dawn
Jamieson, David Purchase, Ken
Janner, Greville Quin, Ms Joyce
Jones, Barry (Alyn and D'side) Radice, Giles
Jones, Ieuan Wyn (Ynys Môn) Randall, Stuart
Jones, Jon Owen (Cardiff C) Raynsford, Nick
Jones, Lynne (B'ham S O) Redmond, Martin
Jones, Martyn (Clwyd, SW) Reid, Dr John
Jones, Nigel (Cheltenham) Robertson, George (Hamilton)
Kaufman, Rt Hon Gerald Robinson, Geoffrey (Co'try NW)
Keen, Alan Roche, Mrs. Barbara
Kennedy, Charles (Ross,C&S) Rogers, Allan
Kennedy, Jane (Lpool Brdgn) Rooker, Jeff
Khabra, Piara S. Rooney, Terry
Kilfoyle, Peter Ross, Ernie (Dundee W)
Kirkwood, Archy Rowlands, Ted
Leighton, Ron Ruddock, Joan
Lestor, Joan (Eccles) Salmond, Alex
Lewis, Terry Sedgemore, Brian
Litherland, Robert Sheerman, Barry
Livingstone, Ken Sheldon, Rt Hon Robert
Lloyd, Tony (Stretford) Shore, Rt Hon Peter
Llwyd, Elfyn Short, Clare
Loyden, Eddie Simpson, Alan
Lynne, Ms Liz Skinner, Dennis
McAllion, John Smith, C. (Isl'ton S & F'sbury)
McAvoy, Thomas Smith, Rt Hon John (M'kl'ds E)
McCartney, Ian Smith, Llew (Blaenau Gwent)
McCrea, Rev William Soley, Clive
Macdonald, Calum Spearing, Nigel
McFall, John Spellar, John
McKelvey, William Squire, Rachel (Dunfermline W)
McLeish, Henry Steel, Rt Hon Sir David
Maclennan, Robert Steinberg, Gerry
McMaster, Gordon Stevenson, George
McNamara, Kevin Stott, Roger
McWilliam, John Strang, Dr. Gavin
Madden, Max Straw, Jack
Mahon, Alice Taylor, Mrs Ann (Dewsbury)
Mandelson, Peter Taylor, Matthew (Truro)
Marek, Dr John Thompson, Jack (Wansbeck)
Marshall, David (Shettleston) Tipping, Paddy
Marshall, Jim (Leicester, S) Trimble, David
Martin, Michael J. (Springburn) Turner, Dennis
Martlew, Eric Tyler, Paul
Maxton, John Vaz, Keith
Meacher, Michael Walker, Rt Hon Sir Harold
Meale, Alan Wallace, James
Michael, Alun Walley, Joan
Michie, Bill (Sheffield Heeley) Wardell, Gareth (Gower)
Michie, Mrs Ray (Argyll Bute) Wareing, Robert N
Milburn, Alan Watson, Mike
Miller, Andrew Welsh, Andrew
Mitchell, Austin (Gt Grimsby) Wicks, Malcolm
Moonie, Dr Lewis Wigley, Dafydd
Morgan, Rhodri Williams, Rt Hon Alan (Sw'n W)
Morley, Elliot Williams, Alan W (Carmarthen)
Morris, Rt Hon A. (Wy'nshawe) Wilson, Brian
Winnick, David
Wise, Audrey Tellers for the Ayes:
Worthington, Tony Mr. Andrew Mackinlay and
Wright, Dr Tony Mr. Eric Illsley.
Young, David (Bolton SE)
Adley, Robert Davis, David (Boothferry)
Ainsworth, Peter (East Surrey) Day, Stephen
Aitken, Jonathan Deva, Nirj Joseph
Alexander, Richard Devlin, Tim
Alison, Rt Hon Michael (Selby) Dickens, Geoffrey
Allason, Rupert (Torbay) Dicks, Terry
Amess, David Dorrell, Stephen
Ancram, Michael Douglas-Hamilton, Lord James
Arbuthnot, James Dover, Den
Arnold, Jacques (Gravesham) Duncan, Alan
Arnold, Sir Thomas (Hazel Grv) Duncan-Smith, Iain
Ashby, David Dunn, Bob
Aspinwall, Jack Durant, Sir Anthony
Atkinson, David (Bour'mouth E) Dykes, Hugh
Atkinson, Peter (Hexham) Eggar, Tim
Baker, Rt Hon K. (Mole Valley) Elletson, Harold
Baker, Nicholas (Dorset North) Emery, Rt Hon Sir Peter
Baldry, Tony Evans, David (Welwyn Hatfield)
Banks, Matthew (Southport) Evans, Jonathan (Brecon)
Banks, Robert (Harrogate) Evans, Nigel (Ribble Valley)
Bates, Michael Evans, Roger (Monmouth)
Batiste, Spencer Evennett, David
Bellingham, Henry Faber, David
Bendall, Vivian Fabricant, Michael
Beresford, Sir Paul Fairbairn, Sir Nicholas
Biffen, Rt Hon John Fenner, Dame Peggy
Blackburn, Dr John G. Field, Barry (Isle of Wight)
Body, Sir Richard Fishburn, Dudley
Bonsor, Sir Nicholas Forman, Nigel
Booth, Hartley Forsyth, Michael (Stirling)
Boswell, Tim Forth, Eric
Bottomley, Peter (Eltham) Fowler, Rt Hon Sir Norman
Bottomley, Rt Hon Virginia Fox, Dr Liam (Woodspring)
Bowden, Andrew Fox, Sir Marcus (Shipley)
Bowis, John Freeman, Roger
Boyson, Rt Hon Sir Rhodes French, Douglas
Brandreth, Gyles Fry, Peter
Brazier, Julian Gale, Roger
Brooke, Rt Hon Peter Gallie, Phil
Brown, M. (Brigg & Cl'thorpes) Gardiner, Sir George
Browning, Mrs. Angela Garel-Jones, Rt Hon Tristan
Bruce, Ian (S Dorset) Garnier, Edward
Budgen, Nicholas Gill, Christopher
Burns, Simon Gillan, Cheryl
Burt, Alistair Goodlad, Rt Hon Alastair
Butcher, John Goodson-Wickes, Dr Charles
Butler, Peter Gorman, Mrs Teresa
Butterfill, John Gorst, John
Carlisle, John (Luton North) Grant, Sir Anthony (Cambs SW)
Carlisle, Kenneth (Lincoln) Greenway, Harry (Ealing N)
Carrington, Matthew Greenway, John (Ryedale)
Carttiss, Michael Griffiths, Peter (Portsmouth, N)
Cash, William Grylls, Sir Michael
Channon, Rt Hon Paul Hague, William
Chaplin, Mrs Judith Hamilton, Rt Hon Archie (Epsom)
Churchill, Mr Hamilton, Neil (Tatton)
Clappison, James Hampson, Dr Keith
Clark, Dr Michael (Rochford) Hannam, Sir John
Clarke, Rt Hon Kenneth (Ruclif) Hargreaves, Andrew
Clifton-Brown, Geoffrey Harris, David
Coe, Sebastian Haselhurst, Alan
Colvin, Michael Hawkins, Nick
Congdon, David Hawksley, Warren
Conway, Derek Hayes, Jerry
Coombs, Anthony (Wyre For'st) Heald, Oliver
Coombs, Simon (Swindon) Heath, Rt Hon Sir Edward
Cope, Rt Hon Sir John Heathcoat-Amory, David
Cormack, Patrick Hendry, Charles
Couchman, James Heseltine, Rt Hon Michael
Cran, James Hicks, Robert
Currie, Mrs Edwina (S D'by'ire) Higgins, Rt Hon Sir Terence L.
Curry, David (Skipton & Ripon) Hill, James (Southampton Test)
Davies, Quentin (Stamford) Hogg, Rt Hon Douglas (G'tham)
Horam, John Pickles, Eric
Hordern, Rt Hon Sir Peter Porter, Barry (Wirral S)
Howard, Rt Hon Michael Porter, David (Waveney)
Howarth, Alan (Strat'rd-on-A) Portillo, Rt Hon Michael
Howell, Rt Hon David (G'dford) Powell, William (Corby)
Hughes Robert G. (Harrow W) Rathbone, Tim
Hunt, Rt Hon David (Wirral W) Redwood, John
Hunt, Sir John (Ravensbourne) Renton, Rt Hon Tim
Hunter, Andrew Richards, Rod
Hurd, Rt Hon Douglas Riddick, Graham
Jack, Michael Rifkind, Rt Hon. Malcolm
Jackson, Robert (Wantage) Robathan, Andrew
Jenkin, Bernard Roberts, Rt Hon Sir Wyn
Jessel, Toby Robertson, Raymond (Ab'd'n S)
Jones, Gwilym (Cardiff N) Robinson, Mark (Somerton)
Jones, Robert B. (W Hertfdshr) Roe, Mrs Marion (Broxbourne)
Kellett-Bowman, Dame Elaine Rowe, Andrew (Mid Kent)
Key, Robert Rumbold, Rt Hon Dame Angela
Kilfedder, Sir James Ryder, Rt Hon Richard
Kirkhope, Timothy Sackville, Tom
Knapman, Roger Sainsbury, Rt Hon Tim
Knight, Mrs Angela (Erewash) Scott, Rt Hon Nicholas
Knight, Greg (Derby N) Shaw, David (Dover)
Knight, Dame Jill (Bir'm E'st'n) Shaw, Sir Giles (Pudsey)
Knox, David Shephard, Rt Hon Gillian
Kynoch, George (Kincardine) Shepherd, Colin (Hereford)
Lait, Mrs Jacqui Shersby, Michael
Lamont, Rt Hon Norman Sims, Roger
Lang, Rt Hon Ian Skeet, Sir Trevor
Lawrence, Sir Ivan Smith, Sir Dudley (Warwick)
Legg, Barry Smith, Tim (Beaconsfield)
Leigh, Edward Soames, Nicholas
Lester, Jim (Broxtowe) Speed, Sir Keith
Lidington, David Spencer, Sir Derek
Lilley, Rt Hon Peter Spicer, Sir James (W Dorset)
Lloyd, Peter (Fareham) Spicer, Michael (S Worcs)
Lord, Michael Spink, Dr Robert
Luff, Peter Spring, Richard
Lyell, Rt Hon Sir Nicholas Sproat, Iain
MacGregor, Rt Hon John Squire, Robin (Hornchurch)
MacKay, Andrew Stanley, Rt Hon Sir John
Maclean, David Steen, Anthony
McLoughlin, Patrick Stephen, Michael
McNair-Wilson, Sir Patrick Stern, Michael
Madel, David Streeter, Gary
Maitland, Lady Olga Sumberg, David
Malone, Gerald Sweeney, Walter
Mans, Keith Sykes, John
Marlow, Tony Tapsell, Sir Peter
Marshall, John (Hendon S) Taylor, Ian (Esher)
Marshall, Sir Michael (Arundel) Taylor, John M. (Solihull)
Martin, David (Portsmouth S) Taylor, Sir Teddy (Southend, E)
Mawhinney, Dr Brian Temple-Morris, Peter
Mayhew, Rt Hon Sir Patrick Thomason, Roy
Mellor, Rt Hon David Thompson, Sir Donald (C'er V)
Merchant, Piers Thompson, Patrick (Norwich N)
Milligan, Stephen Thornton, Sir Malcolm
Mills, Iain Thurnham, Peter
Mitchell, Andrew (Gedling) Townend, John (Bridlington)
Mitchell, Sir David (Hants NW) Townsend, Cyril D. (Bexl'yh'th)
Moate, Sir Roger Tracey, Richard
Monro, Sir Hector Tredinnick, David
Montgomery, Sir Fergus Trend, Michael
Moss, Malcolm Trotter, Neville
Nelson, Anthony Twinn, Dr Ian
Neubert, Sir Michael Vaughan, Sir Gerard
Nicholls, Patrick Viggers, Peter
Nicholson, David (Taunton) Waldegrave, Rt Hon William
Nicholson, Emma (Devon West) Walden, George
Norris, Steve Walker, Bill (N Tayside)
Onslow, Rt Hon Sir Cranley Waller, Gary
Oppenheim, Phillip Ward, John
Ottaway, Richard Wardle, Charles (Bexhill)
Page, Richard Waterson, Nigel
Paice, James Watts, John
Patnick, Irvine Wells, Bowen
Patten, Rt Hon John Wheeler, Rt Hon Sir John
Pattie, Rt Hon Sir Geoffrey Whitney, Ray
Pawsey, James Whittingdale, John
Peacock, Mrs Elizabeth Widdecombe, Ann
Wiggin, Sir Jerry Wood, Timothy
Wilkinson, John Yeo, Tim
Willetts, David Young, Sir George (Acton)
Wilshire, David
Winterton, Mrs Ann (Congleton) Tellers for the Noes:
Winterton, Nicholas (Macc'f'ld) Mr. Sydney Chapman and
Wolfson, Mark Mr. David Lightbown.

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments), and agreed to.

Madam Speaker

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

Resolved, That this House congratulates Her Majesty's Government on its reforms to the National Health Service which have led to record numbers of patients being treated, the elimination of two year waiting lists in the regions, a substantial reduction in long waiting times generally and significant improvements in the quality of care; looks forward to more general practitioner fundholders and National Health Service trusts and the futher improvements they will bring; and believes that in the modern health service the focus should be on patients and prevention and not on politicisation, which remains the dominant concern of Her Majesty's Opposition.