National Health Service

Mr. Chris Smith (Islington, South and Finsbury)

I beg to move, That this House expresses its deep concern at the grave situation now evident in the National Health Service in England, Scotland, Wales and Northern Ireland; believes that anxiety about Her Majesty's Government's policy for this situation now transcends party lines; notes with alarm that throughout the United Kingdom beds have been cut, operations are being cancelled, intensive care beds are unavailable, and emergency services are under intolerable pressure; believes that the spiralling costs of the internal market—now totalling an extra £1.5 billion a year—and its diversion of resources away from front-line patient care have created these problems; salutes staff of all kinds and at all levels in the NHS who have worked hard to keep the service going; believes that government policy has left many people in urban and rural communities without the access to health care they need, especially in relation to services for the elderly and for those being discharged from hospital after surgery at an increasingly early stage; deplores the way in which many NHS decisions, especially on the future of hospitals and casualty services, are being taken in a manner that does not give due weight to the views of local people; and calls upon Her Majesty's Government to set about restoring the NHS as a public service that puts patients first. The starting point for the debate must be that the national health service is in a serious crisis. It is not just the Labour party which is saying that, but the British Medical Association, the Royal College of Nursing and the report of the King's Fund on mental health services in London. The figures that we published this morning, to which I shall refer later and which were the subject of discussion in relation to the question on paediatric intensive care at Prime Minister's Question Time, also show it.

Mr. Michael Fabricant (Mid-Staffordshire)

I am grateful to the hon. Gentleman for giving way to me so early in the debate. On the subject of crisis, did he see the ITN news last night, when a member of Unison—a hospital worker—having heard the speech of the right hon. Member for Dunfermline, East (Mr. Brown), said that if Labour were elected there would be another winter of discontent and the national health service would be in crisis?

Mr. Smith

I like to think that we should be discussing, not one individual's views of what might happen in a year's time, but what is happening here and now. In wanting to address those issues, we share the Secretary of State's views.

A rather plaintive letter from the NHS executive of the South and West region, dated 28 November and sent out to all health authority chief executives, begins as follows: The Secretary of State has asked for regular fortnightly briefing on winter pressures. We understand that he wishes to have a full understanding of the pressures the acute services are under during the winter. 747 The Secretary of State wants information, so let us give him some. Let us tell him, for example, about the waits being experienced in casualty units up and down the country. Let us tell him about Geoffrey Coppin, a stroke victim who spent two and a half days on a trolley in St. Helier hospital. His daughter had to go out and buy pillows at Woolworths to make him comfortable. Let us tell the Secretary of State about Stanley Coombs, a 69-year-old man from Mitcham with chronic lung disease who had a 20-hour wait in casualty at St. George's hospital in Tooting. Those are not isolated examples: they occur time after time around the country.

Let us tell the Secretary of State about those people who, owing to long casualty waits, eventually feel forced to opt for private medical treatment to shorten their wait. Let us tell him about Mary Vaughan, an elderly pneumonia sufferer. After she had spent 21 hours on a trolley in St. Helier hospital, her son paid for a private bed for her at St. Anthony's hospital, Cheam. Mildred Brown, a 77-year-old with a broken ankle, had an eight-hour wait at Wythenshawe hospital and finally went to the private Alexandra hospital in Cheadle. Why should people who have paid into the national service all their working life now have to use their last pennies to pay for private care?

Let us tell the Secretary of State about the new experience of people who are waiting not just on hospital trolleys in casualty departments, but on ambulance trolleys. At the end of December, patients at Llandough hospital near Penarth in south Wales had to wait 45 minutes on ambulance trolleys before being admitted because accident and emergency staff were swamped. As a result, ambulance crews had calls backing up because they were tied up at the hospital waiting for trolleys to become free.

Let us tell the Secretary of State about the patients being discharged too early—the patients being sent out from Bristol royal infirmary in the middle of the night to make way for emergencies that the hospital could not accommodate. Let us tell him about the search for intensive care beds around the country. A child was taken to Sunderland general hospital with breathing difficulties, but because no intensive care beds were available in Tyne and Wear he had to be driven 120 miles to Scotland to find a place to be treated. Edna Harrison was treated at St. James's hospital Leeds after suffering a heart attack. She was unable to be admitted because all 13 intensive care beds were taken. She was then taken 60 miles by ambulance to Hull after two hospitals were unable to find her a bed. Those are examples of the search around the country for beds in accident and emergency or intensive care units.

Let us tell the right hon. Gentleman about cancelled operations—about Queenie Harrild, the 69-year-old heart operation patient from Lewisham who died after her operation was cancelled four times in 11 days, or about the 3,000 non-urgent operations cancelled or postponed at the Royal Devon and Exeter hospital, including in some cases patients in severe pain. Four major hospitals in Wales are now closed to non-emergency cases. In Nottingham, the Queen's medical centre has said that only emergency and life-threatening cases will be admitted until further notice. The North Staffordshire Hospital NHS trust has said that all elective surgery has been cancelled until further notice.

748 That is the reality of what is happening up and down the country, affecting patients and hospitals. For the Secretary of State and the Government to claim that everything is hunky-dory is to fly in the face of the real experience of real people and real patients.

Mr. Charles Hendry (High Peak)

Perhaps I may give the hon. Gentleman another example—that of my father, who was dying of cancer when the last Labour Government were in power. It was not a doctor who decided what he could be fed when in hospital, but a trade union official who decided that he could not be given soup, which he could swallow, but that he would have to be given hard-boiled eggs, which he could not swallow. He died. That is one of the reasons why people like me will never believe that the health service can be safe in Labour's hands.

Mr. Smith

Any such imposition by anyone on any patient is completely unacceptable and no one would argue to the contrary. We argue that the current state of the health service shows that it is not in good hands. The evidence of what is happening to patients clearly demonstrates that. The Secretary of State says that people have long memories, and that is true: they know what the Government have done to the national health service and they will remember it when they come to the ballot box.

My hon. Friend the Member for Dulwich (Ms Jowell) painstakingly carried out a survey on the state of paediatric intensive care. We talked to hospital after hospital and established the precise figures in each case. The Government have said that the figures are complete nonsense and the Prime Minister airily dismissed them at Prime Minister's Question Time, but they are not complete nonsense: we have a recording of every telephone conversation with every one of the 19 hospitals that provided information and we know precisely how many children each of those hospitals has had to turn away.

The Secretary of State for Health (Mr. Stephen Dorrell)

The hon. Gentleman does not accept the words of my right hon. Friend the Prime Minister, but does he disagree with the chairman of the British Paediatric Intensive Care Society, Dr. David Hallworth? My right hon. Friend quoted Dr. Hallworth, who said: Figures in isolation are pretty meaningless.

Mr. Smith

I disagree with the application of that point to Labour's figures.

Mr. Dorrell

Will the hon. Gentleman give way?

Mr. Smith

In an act of unusual generosity, I will give way to the Secretary of State again.

Mr. Dorrell

The hon. Gentleman has made it clear that he rejects the advice of the chairman of the British Paediatric Intensive Care Society—a man who devotes his life to providing the sort of care that the hon. Gentleman is talking about. Will the hon. Gentleman tell the House whose advice he does take?

Mr. Smith

The advice I certainly do not take is that of the Secretary of State, who obviously did not hear what 749 I said. I said that I did not agree with the application of that remark to the figures that Labour has produced. The figures were accurate and painstakingly collected—

Mr. Dorrell

They tell us nothing.

Mr. Smith

They actually tell us an awful lot. They tell us that children referred to paediatric intensive care units near where they live and where they can get immediate treatment are being told, by hospital after hospital, that they cannot be seen there. Quite possibly they get a bed somewhere else eventually—100 or 200 miles away—but that is not an adequate response to the needs of very sick children.

Mr. Dorrell

Will the hon. Gentleman confirm that no child who needed intensive care and was referred to the emergency bed service was denied intensive care? Will he also tell the House, if that is not the right standard, what standard he would apply to the service?

Mr. Smith

The Secretary of State has quoted one paediatric intensive care consultant to me. I will quote another to him. Dr. Mark Darowski, paediatric intensive care consultant at Leeds general infirmary, says: Mr. Dowell has not learnt the lessons of last winter". He told the Yorkshire Evening Post on 4 January: It is just luck that we have not had another Nicholas Geldard. On New Year's eve there was one paediatric intensive care bed available in the whole of the North of England. We've been operating at 100 per cent. and only luck has prevented the system crashing. It is all very well the Secretary of State claiming that there have been only 40 referrals to the intensive bed central monitoring unit over this period—nothing like the figures that the Labour party has produced. He ignores the fact that many referrals are made outside the centralised system—

Mr. Dorrell

Successfully.

Mr. Smith

I do not call it success when children have to be carted from one end of the country to the other to find intensive care beds.

Mr. Hugh Bayley (York)

I remind the House that Dr. Mark Darowski was the doctor who admitted Nicholas Geldard to Leeds general infirmary and who had the unpleasant task of telling the child's parents that he had died on his way over the Pennines through a snowstorm. A year ago Dr. Darowski wrote to me drawing my attention to the fact that the regional health authority, just before it was abolished, recommended that the Northern and Yorkshire region needed seven additional paediatric intensive care beds to meet patient demand. Since then, just one has been provided. Surely the Secretary of State must explain how the promise that he gave the House in the spring of last year is to be kept.

Mr. Smith

I have the Secretary of State's words of 6 March 1996 in front of me. He said: There is no doubt about the need now to deliver a proper level of paediatric intensive bed space. It will be done".—[Official Report, 6 March 1996; Vol. 273, c. 360.] 750 Certainly, the Secretary of State organised a report which was published and put in the Library of the House a couple of months after his statement. About 20 more beds were provided around the country—

Mr. Dorrell

Thirty, actually.

Mr. Smith

The latest Library figure was 20. In any event, it is welcome news that more beds have been provided, but it is clear from what happened this winter that we still do not have a proper service. It would behove the Government rather more, instead of trying to bluster their way out of the problem, to admit that the service is not yet adequate and tell us how they intend to make it so.

One of the problems is that the Government do not know what is happening in relation to many aspects of health care. It is interesting that they can now give us precise figures for paediatric intensive care beds. When my hon. Friend the Member for Dulwich asked, in a parliamentary question on 12 December last year, how many paediatric intensive care beds there were in this country, the Secretary of State replied that the information was not held centrally. He can tell us how many extra beds the Government have created since his statement of 6 March last year, so perhaps he can now say that the information is held centrally. It is important that it should be held centrally for the proper planning of serious emergency services. I shall return to that point in a moment because it is not the only area in which the Government do not know what is happening.

It may be because the Government do not know what is happening within the health service that they blithely claim that everything is going wonderfully well. I was struck at Prime Minister's Question Time when, in response to an Opposition question about the Government's handling of the national health service, the Prime Minister's final remark was that this was a success story. How can it be a success story when patients have to wait on hospital trolleys or ambulance trolleys, operations are cancelled, beds are closed, accident and emergency services are in crisis and children are being sent halfway across the country for paediatric intensive care? I do not call that a success story.

The Secretary of State told the "Today" programme this morning that the NHS is improving year by year. I do not call it improvement. In the real world, people who work in the health service are struggling in the face of ferocious odds to preserve a decent service, provision for ordinary people is collapsing, operations are being cancelled in hospital after hospital and in many parts of the country it is now impossible to get elective general surgery before the next financial year.

Mrs. Alice Mahon (Halifax)

This morning I contacted hospitals in Leeds to find out why a constituent of mine who has been waiting 14 months for heart bypass surgery had been sent a letter saying that he could not have the surgery in the foreseeable future, but that if he went to Leicester he could have it in two or three months' time. I understand that all Calderdale patients waiting for heart bypass surgery are in exactly the same position. That is the reality of Conservative health care.

Mr. Smith

That is, indeed, the reality of what is now happening. It is even worse because not only are 751 distinctions made between people in different areas, depending on their hospital or health authority, but distinctions are also made between availability of and access to treatment, depending on the general practitioner. GP fundholders' patients who happen to come under the aegis of Lincoln county hospital can have their out-patient appointments within the following month, but patients of a non-fundholding GP cannot have an out-patient appointment until the next financial year. Not only are people told that they must wait months for operations or out-patient appointments, but they are treated differently even though they have the same medical condition. The health service was supposed to treat people according to need, not according to where they happen to live or the type of GP that they happen to have.

Mr. Stuart Randall (Kingston upon Hull, West)

Is my hon. Friend aware that at Hull royal infirmary the unit which deals with coronary cases is no longer making forward appointments? I am advised that that is because the beds are being used for orthopaedic and medical cases.

Mr. Smith

My hon. Friend gives me information of which I was not aware, but it adds to the overall picture of the condition of the NHS.

Perhaps the Secretary of State does not realise what is going on, as he has had other things on his mind. One day during the Christmas and new year recess, he popped up on our television screens as the Conservative spokesman on the family. A couple of days later, he popped up on the radio as the Conservative spokesman on the constitution. A few days after that, he decided to give us his considered views on Europe, which do not appear to have done him much good with either wing of his party. While all that frenetic activity was going on, it is small wonder that the NHS was falling to pieces without the Secretary of State noticing.

Mr. Simon Hughes (Southwark and Bermondsey)

The hon. Gentleman knows that I share his view that much in the health service is not going right. It is difficult to take an objective view of the aspects that have or have not improved; many aspects have improved. Does he object to the idea that I proposed to him—that we should try to separate the argument from the facts, and that we take out of the political arena an assessment of what the NHS has by way of beds and hospital capacity and what it needs? We should get independent people to examine that, so that we can argue on the basis of objective, agreed facts, and not on the basis of the hon. Gentleman's political views, mine or those of the Secretary of State.

Mr. Smith

I hesitate to point out to the hon. Gentleman that the last time that a supposedly objective examination was conducted, it was carried out by a character called Professor Tomlinson in relation to London's hospital provision. I am not sure that a repetition of that exercise would be helpful. However, I sympathise with the hon. Gentleman's suggestion. A proper assessment of provision across the country, conducted as far outside the political football arena as possible, would be a sensible approach. I am not sure that I would go along with him in saying that everything 752 should freeze while that was under way, but I welcome his approach and look forward to further discussions with him.

Mr. Nigel Waterson (Eastbourne)

Can the hon. Gentleman confirm that in the dying days of the last Labour Government, which seems a long time ago, as indeed it is, the foundations were laid for the collection and collation of NHS statistics—for example, for finished consultant episodes? How can he therefore take issue with the basis on which the facts are produced?

Mr. Smith

I do take issue with the basis upon which many facts are produced. I have no particular quarrel with using a finished consultant episodes accounting mechanism, provided that it is made clear that it does not refer to the number of patients treated. That is the fatal conflation that the Government always make: they take the finished consultant episodes figures and, because they have increased, claim that the number of patients treated has also increased—ignoring the fact that they do not know how many patient readmissions form part of the finished consultant episode figures.

We have insufficient information about the level of NHS readmissions at present. We should have those figures, as they are good indicators of how well or how poorly patient treatments are working. However, that information is not held. The Government should be more accurate in their language, instead of talking breezily about patient numbers when they are really talking about the number of treatment episodes.

Mr. D. N. Campbell-Savours (Workington)

I can speak from personal experience as I have been a patient in many hospitals over the years. In some hospitals, the readmissions figure can be as high as 20 per cent. on surgery wards. That is a substantial figure which totally destroys the credibility of any statistics produced in that area.

Mr. Smith

Absolutely. A major problem is that the internal market—to which I shall refer in a moment—places intense pressure on hospitals to get patients through as quickly as possible. Inevitably, that means that patients who enter hospital for a course of treatment are often sent home too early—particularly elderly patients who are unable to recuperate as quickly as younger patients. Such patients often receive no proper support at home and are unable to recover properly. As a result, they end up back in hospital four or five weeks later. That is wonderful for the Government's statistics, because they count that readmission as another patient, but the quality of care provided is not good and the overall cost to the health service is increased. That is one way in which the operation of the internal market acts as a distorting pressure on the system at present.

I said earlier that the Secretary of State does not seem to know what is happening in the health service. His lack of knowledge about the NHS is extremely revealing. My hon. Friend the Member for Dulwich tabled a series of parliamentary questions and received a bonanza of answers on 12 December 1996. They showed that the Secretary of State does not have a lot of basic information about the current nature and form of the health service.

For example, my hon. Friend asked about the number of acute hospitals in each health authority area. That is a fairly simple question. My hon. Friend the Member for 753 Bolsover (Mr. Skinner) asked earlier about the number of hospitals that have closed since 1979. Ministers did not know the answer to that question, but perhaps they know how many hospitals the national health service comprises—after all, they are supposed be in charge of the NHS. However, we were told that the information "is not held centrally." When we asked how many community hospitals are in the national health service, the answer was the same. We asked how many ambulances are owned by ambulance services across the country—that is fairly basic information—but we were told that the information is not held centrally. We asked how many acute hospitals have been closed in the past five years—a matter of intense interest to many local communities throughout the country—but again the Government replied that the information is not held centrally.

Given the promises that the Secretary of State made last March on intensive care and on accident and emergency care, we asked how many intensive care units there are in each health authority area. We were told that the information is not held centrally. The Government do not know how many intensive care beds there are in each health authority area, or how many paediatric intensive care units or beds there are. They do not know the number of nurses who have ceased to practise in each of the past six years or the number of trusts that have cancelled elective surgery until the end of the current financial year.

The Government have placed every possible emphasis on the cost of operations in the health service and on how the internal market will sort it out, but they do not know the average cost of a hip replacement operation in England. Given all that the Secretary of State does not know about the health service, it is no surprise that he presides over a health service that is in such a disastrous condition.

The principal problem, of course, lies in the operation of the internal market, which has led to the fragmentation of decision making and directly to the problems in intensive care and accident and emergency services that we have seen in the past few weeks. It means that there cannot be the overall look that we need and which the hon. Member for Southwark and Bermondsey (Mr. Hughes) advocates. It has also led to a loss of beds—a fall of 24 per cent. overall in England since the changes were introduced. The chairman of the British Medical Association council laid the blame for that squarely on the internal market. Hospitals are downsizing their capacity to the minimum, rather like airlines double-booking many of their seats.

The internal market has also led to a distortion of clinical priorities. I will cite just one example—Glenfield Hospital NHS trust, in Leicester, which issued a letter on 7 January to local general practitioners. It is interesting to note that the letter was issued to GPs who are covered by health authority contracting. It was sent only to non-fundholding GPs. Fundholding GPs are exempt from the letter, which begins: After several weeks of negotiation, this Trust has reluctantly reached agreement with Leicestershire Health, Southern Derbyshire Health Authority and North Nottinghamshire Health Authority, to restrict services. With immediate effect, for Cardiology and Cardiac Surgery"— we are talking about serious surgery— 754 only emergency patients and those potentially breaching the 12 month Patient's Charter guarantee, will be admitted. This restriction will apply until 31st March 1997. This action is not being taken because of any wish to do so on the hospital's part. The letter continues, and this is the real sting in the tail: It does not reflect this hospital's capacity to treat patients. We have the capacity to perform all the work which GPs could refer to us". Do we not live in a crazy world? We have a hospital which says that it has the capacity to carry out all the work that GPs in cardiology could refer to it. We know that there are patients who need treatment. Yet because of the procedures and rules of the internal market the hospital must close its doors to those patients. The internal market distorts priorities within the health service.

Mrs. Mahon

I spoke earlier about patients from Calderdale who cannot have their operations performed in Leeds. The letter from Leeds General infirmary reads: Your local health authority has found a suitable alternative hospital which is … the Glenfield Cardiac Unit in Leicester. It would seem that patients from Calderdale who cannot get into the Leeds infirmary until after July will be taken to Leicester, where local patients cannot be operated upon because a restriction has been placed on their local hospital. That is mad.

Mr. Smith

My hon. Friend, whose information I did not know, redoubles the force of my argument about the absurdity of the way in which the market system that the Government have imposed on the NHS is distorting the manner in which the NHS operates.

The market system has led also to spiralling bureaucratic costs amounting to £1.5 billion a year. That is the British Medical Association's estimate, not one produced by the Opposition. That is the cost of the bureaucratic procedures of the internal market. That is why our proposals for the replacement of single-practice GP fundholding by locality commissioning, a move from annual contracts to three to five-year agreements, with agreements based on the process of co-operation rather than competition, an end to the system of individual invoicing and reducing to one tenth the number of contracts swimming around in the system, will all help to reduce the bureaucratic costs. The money saved can be diverted into patient care.

Mr. Nigel Forman (Carshalton and Wallington)

rose—

Mrs. Margaret Ewing (Moray)

rose—

Mr. Smith

I want to make progress because I have given way on many occasions. I shall, however, give way briefly to the hon. Lady.

Mrs. Ewing

Exactly how much money does the hon. Gentleman expect will come from the savings that he has outlined and how quickly will it move into the system? We have heard a clear statement from an Opposition Treasury spokesperson that there will be no additional funding. It is important that we know what is being promised by the Labour party and the time scale involved.

Mr. Smith

As the hon. Lady knows, we have identified an immediate £100 million which, as a start, 755 we shall take from the system's bureaucratic costs. I believe that more money will be available by reducing bureaucracy after that start has been made. The early target is £100 million. I believe that that money can be better spent on patient care.

The answer to many of the problems that we are seeing lies, first, in recognising that there is a crisis. It would help if the Government would admit that they are facing some problems. It would help also if they would stop being quite so complacent and smug as the Secretary of State can sometimes be. Secondly, they need to end internal market procedures, with the distortions that they bring to patient care.

Thirdly, we need to bring back strategic thinking and preparation into the health service. Fourthly, we need to end the inequity between patients that we all too often see. Fifthly, we need to divert money from wasteful bureaucracy and transfer it into patient care. That is the way forward.

The chairman of the BMA council put it rather well on 11 October. This is the leading voice of the medical profession, not the Labour party's voice. He said: We are facing the most difficult winter in the NHS since the internal market was introduced. It is not as though the Government were not warned. He continued: We need to reform the market, eliminate the perverse effects of competition, restore co-operation and stability to hospital and community health services and begin the task of rebuilding a comprehensive national service where patients' clinical needs come first". I do not disagree with any of his sentiments.

What Sandy Macara could not say, but the British people can, is that there is a sixth requirement in order to restore and rescue the NHS, and that is a Labour Government. Labour created the national health service—even the Prime Minister had to accept that this afternoon—in the teeth of opposition from the Conservative party, and a Labour Government will rescue and renew it. The Labour party will fulfil its fundamental aim of restoring the NHS so that it is run not as a commercial business flooded with paperwork—as it has become under the present Government—but as a public service that puts patients first.

The Secretary of State for Health (Mr. Stephen Dorrell)

I beg to move, To leave out from "House" to the end of the Question, and to add instead thereof: notes that the National Health Service is providing high quality care to more patients than ever before; congratulates the dedication and professionalism of the National Health Service's staff during the recent cold weather which has placed exceptional demands upon them; believes that the National Health Service requires a growing budget for patient care and therefore welcomes the Health Service Guarantee given by the Prime Minister to increase spending on the National Health Service in real terms in each of the next five years, including an extra £1.6 billion for patient care in 1997–98; and believes that this guarantee reinforces the Government's consistent record of investment in the National Health Service and its professional staff. The speech by the hon. Member for Islington, South and Finsbury (Mr. Smith) shows why Labour is about to lose the fifth general election in a row. The hon. Gentleman seems to believe that all that is required of him on these occasions is to parade a few individual cases 756 that are supported by incomplete facts, make a half-researched charge about the Government's record, wave a shroud, repeat the mantra that Labour will abolish the internal market and base metal will be transformed into gold. He thinks that Labour's claims will be vindicated by that process. His predecessor, the hon. Member for Peckham (Ms Harman), never carried conviction when she had the job. We expected more and better of the hon. Gentleman, but we have been disappointed every time he has come to the Dispatch Box, and we were disappointed again this afternoon.

Labour's approach is best summarised by referring to the war of Jennifer's ear, which was the technique that discredited Labour in the run-up to the last election. It did not work: Labour Members were found out then, and they will be found out again. If they want to be taken seriously on health, they should say what they would do about it. So far, they have shown a taste for the politics of the gutter. They play on public emotions and fear, run down the efforts of the dedicated professional staff of the health service and cover the whole concoction with a thin veneer of synthetic concern. They believe that that will suffice in place of a health policy. It is the politics of perpetual opposition, which is clearly what the hon. Gentleman is preparing for.

I shall consider the issues raised by Labour from the Dispatch Box, and I shall begin with paediatric intensive care. In its press release, Labour says: Over 400 children turned away". That is a grotesque misrepresentation of the facts, and it is specifically designed to cause maximum concern and alarm among parents of young children.

The facts about what has actually happened in paediatric intensive care are clear. Last spring, I assured the House that we would increase the total number of places available for paediatric intensive care, and that is what we have done. There were then 249 beds in paediatric intensive care and high-dependency care, and there are now 279 beds—as I said in May there would be by this time this year. I apologise to the hon. Member for Islington, South and Finsbury if he was not provided with those figures. He has my assurance that he will be provided with them if he asks a further parliamentary question. I gave the House an assurance in May that those beds would be provided, and provided they have been. The Government have nothing to conceal on paediatric intensive care.

Mr. John Gunnell (Morley and Leeds, South)

Are those beds going to the regions in which they were promised? I do not think so. I do not think that the Leeds paediatric intensive care unit, about which we have had correspondence, has had the increase that was anticipated. When I visited that unit a year ago it had five beds, but it could have accommodated six at a squeeze. The Secretary of State says that it now has six beds, but it had that capacity before; has it the resources to take care of six beds?

Madam Deputy Speaker (Dame Janet Fookes)

Order. The hon. Gentleman's question is becoming far too long for an intervention.

Mr. Dorrell

I published the commitments that the Government had given in May last year. There is a 757 published document on the record. If the hon. Gentleman tables a question about the availability of paediatric intensive care and high-dependency care by region, we will provide the information and he can test it against the undertakings that were given at that time. If he again studies the document that I published in May, he should also note the emphasis that I placed on the availability of both bed space and proper retrieval systems, providing ambulances to take children needing intensive care who are in hospitals that cannot provide beds to meet their needs to the hospitals that are best able to meet those needs.

This afternoon, the Leader of the Opposition said from the Dispatch Box that I had given an assurance that every child who needed intensive care would be provided with it in the hospital to which that child reported. I never gave that assurance, and the fact is that no responsible Health Secretary could ever give it. Such an assurance would not be supported by the paediatric intensivists who know how to deliver high-quality care to children in that condition. The service that they want to deliver is based on specialist paediatric intensive care units with proper ambulance services to take children to the units best placed to meet their needs. That is the assurance that I gave the House in May, and it is the assurance that the Government are in the process of delivering.

The doctor whom the Prime Minister quoted at Prime Minister's Question Time is the chairman of the Paediatric Intensive Care Society—the leader of the group of doctors responsible for delivering this service. Let me repeat his words: I don't think this should be subject to party political point scoring. To look at something in isolation as they"— the Labour party— are apparently attempting to do is wrong, because it doesn't give the whole picture. The Opposition motion seeks an all-party approach to some of the key health issues. I accept that, because what I have set out to do in paediatric intensive care is deliver the pledge that I gave the House last spring. I believe that the best measure of the delivery of that pledge is that no child—

Mr. Bayley

Will the Secretary of State give way?

Mr. Dorrell

I will finish this point before I give way to the hon. Gentleman. His Front Benchers allege that his party is interested in paediatric intensive care, and I am replying to their concerns.

Last May, I gave the House an assurance that we would establish a proper basis for the provision of paediatric intensive care. Since 1 December, when we established the computer bed clearance system that I undertook to deliver then, not one child has had a need for intensive care confirmed by a clinician and then not been offered bed space. Indeed, since that date 40 cases have been referred to the emergency bed service, and on each occasion we were able to offer at least two paediatric intensive care units to accept the transfer—not just one, but two. I believe that such a paediatric intensive care service, delivered through the national health service, can be seen to be addressing the real needs of children who require intensive care.

758 I might have hoped that, if the Labour party was seriously interested in the issue, it would—rather than seeking to make cheap party points—welcome the improvement in the quality of the delivery of the service for which the Government have been responsible over the past 12 months.

Mr. Bayley

This afternoon, the Prime Minister told the House that we should not be unduly concerned about 400 children being turned away from paediatric intensive care, because they were all found intensive care beds elsewhere. I am told by the head of a paediatric intensive care unit that, although of course all those seriously ill children were found intensive care beds elsewhere, they were not all found paediatric intensive care beds. Some were placed in ordinary intensive care beds, which are not at all the same thing and which are not designed to meet the intensive care needs of children. Will the Secretary of State clarify the position, and tell the House whether a paediatric intensive care bed was provided for each of those 400 children?

Mr. Dorrell

I remember, when this issue was the subject of intense debate last spring, being engaged in a studio discussion with Professor Sir Roy Calne, who made the clear point that, in his view, the best way of treating a child who did not have access to paediatric intensive care was to provide that child with a place in an adult intensive care unit.

If what the hon. Gentleman says is true, I still rest my case on the proposition that we have put in place an expansion of paediatric intensive care provision—as we said that we would—and the monitoring system for which the Labour party press release calls. In fact, the gentleman whom Labour spokesmen have been so keen to brush aside in their comments this afternoon is the chairman of precisely the monitoring system called for in the press release. We have put all that in place in order to deliver the commitment to parents of young children that children who need intensive care will be provided with such care by the national health service.

Mr. Chris Mullin (Sunderland, South)

Will the Secretary of State give way?

Mr. Dorrell

I will give way once more on this subject; then I will move on.

Mr. Mullin

I think everyone accepts that it is not always possible for a particular intensive care unit to accommodate a patient, but does the right hon. Gentleman agree that the 120 miles that a 20-month-old child in Sunderland was taken by ambulance was too far? It was a hazardous journey, as the child was having difficulty breathing. On the way back, the ambulance broke down; had that happened when the child was on its way to the hospital, the outcome might have been different.

Mr. Dorrell

The hon. Gentleman says that 120 miles was too far, but I am pleased to say that I am told that the child is now at home, out of danger and making a full recovery. It is rather difficult to argue that the distance travelled was too far if the case has a successful outcome. The hon. Gentleman's argument is undermined by what actually happened.

Mr. Chris Smith

Let me pursue the point a little further. Is the Secretary of State saying that every single 759 one of the 400 paediatric intensive care applicants whom we identified as having been turned away from various units ended up—to his certain knowledge—in a paediatric intensive care bed?

Mr. Dorrell

No, I am certainly not saying that. There are numerous examples of clinicians ringing a paediatric intensive care unit to discuss a case, and then agreeing that intensive care is not needed in that particular case. There are a number of reasons why children are refused admission following telephone conversations of the kind that the Labour party has been counting.

If the Labour party would stop making cheap points and listen to the chairman of the Paediatric Intensive Care Society, the hon. Gentleman would find that the statement on the Press Association wires answers his point very directly. As I have said, there are a number of reasons why cases are not admitted to paediatric intensive care following discussion between clinicians. What I am saying is that if, in the opinion of the clinician caring for a child, that child needs intensive care, I imagine that—failing to find any other bed—the clinician would use the emergency bed service which was established precisely to meet the need he feels he has on behalf of his patient. If we use that test—earlier, I invited the hon. Member for Islington, South and Finsbury to define any other test—40 cases were referred, every one of which was offered at least two options.

Mr. Richard Burden (Birmingham, Northfield)

Will the Secretary of State give way?

Mr. Dorrell

I want to deal with other emergency services.

It is true that, since Christmas, the national health service has been under pressure. I do not seek to deny that; it regularly happens during the first few weeks of the year, and it is not difficult to see why the emergency services are affected in that way. There were two weeks of extremely cold weather at the beginning of the year and there has been a high incidence of 'flu. As a result of those developments, some hospitals have admitted emergency cases at roughly double, and in some cases more than double, their normal admission rate for this time of year. The emergency services have been working under considerable pressure and I pay tribute to the doctors, nurses, therapists and managers who kept the service working through that period to ensure that the emergency need was met.

It is not right to seek to create the impression that nothing has been done to meet the peaks of emergency demand that have been experienced over the past few weeks. Plans have been made and acted on to ensure that the health service meets the peaks of emergency demand. This winter, as it does every winter, the NHS has taken the steps that are necessary to meet those emergency peaks. One such step is to delay less urgent cases. If there is a doubling of the emergency admission need at a hospital, the rational response is to delay some less urgent admissions for a week or two. That has certainly been done.

We have also provided short-term extra bed capacity. In Dartford, we provided an extra 33 beds; in Ashford, an extra 40; in St. Helier, an extra 35; in Poole, an extra 18; in Derriford, an extra 11; in Plymouth, an extra 35; in 760 Rotherham, an extra 33; in Doncaster, an extra 38; in Mansfield, an extra 28; in Burton, an extra 16; and in the north-west region we provided a total of 200 extra beds.

Faced with emergency pressures, the health service has acted rationally by deferring less urgent cases and opening short-term ward capacity, as it planned to do when it thought during the summer and autumn about winter pressures and about how to meet the peaks of demand that are experienced at this time of year. Some other responses have been set out by the National Association of Health Authorities and Trusts in the press release issued this morning which deals with the winter emergency in the health service.

I had hoped that, as that was the subject of the Opposition debate, they might refer to what health authorities and trusts have done to meet the winter peak of emergency pressure. There is a page and a half of specific changes that have been made by health authority and trust managers to meet those peaks. The Opposition have not referred to that report by NAHAT, because, although the health authorities have been under pressure, the report concludes: Undoubtedly, despite the problems, the service generally has been maintained". Faced with emergency peaks, the NHS has taken action to respond and, overwhelmingly, the story is of the service meeting the emergency need that has been placed upon it.

Mr. Burden

The Secretary of State says that all the right preparations were made. If that is so, why did his Department get into such a pickle over 'flu vaccine? Apparently it did not order enough vaccine and issued instructions to hospitals to be careful about which members of staff it was given to, to ensure that enough was available for patients and old people. Is not the result that when 'flu increased—as it is likely to do in winter—more staff than necessary went down with it and there was more pressure on staff numbers and patient care suffered? Why were there no preparations for that? It should have been easy for anybody to predict what would happen during the winter months.

Mr. Dorrell

The 'flu vaccination programme has been running for many years and, rationally, focuses on those who are at risk. Of course, we all run the risk of experiencing a bout of 'flu, but for most of us there is no serious health risk associated with it. For the elderly and others for whom a serious health risk is associated, 'flu vaccination is available. The health service has pursued that policy for many years.

Mr. Simon Hughes

I welcome the steps that have been taken since March to improve paediatric and general intensive care. On the best current information, what is the Secretary of State's assessment of whether there are enough paediatric intensive care beds to ensure that no parent runs the risk of his child not being admitted, which is what we all wish? Are there enough intensive care beds throughout the country? If the answer to the second question is yes, something is wrong when people die in hospitals such as Guy's in my constituency after being told that there is no intensive care bed there. The right hon. Gentleman's answer would enable us to judge whether we have arrived or whether we are still on the way to providing the service that the NHS should supply.

Mr. Dorrell

The problem with the hon. Gentleman's question is that it implies that there is a final answer to 761 these problems, and that is not the case. He asked whether we have arrived. Last spring, I took the best advice available on the extra intensive care places that were needed to deliver the service that I wanted. I also set up a process for continual assessment. The gentleman who has been quoted so much in the debate is responsible for the special committee that is analysing the current situation and for producing a report that will allow us to project the question further and see what, if anything, needs to happen next.

Our analysis last spring led to the conclusions that I announced at that time. They were widely welcomed in the field and they have been delivered. The Government have made clear their commitment to an expansion of the adult intensive care service. That is why I made two announcements following the Budget. First, I announced a targeted fund to support the growth of intensive care facilities, and especially such facilities for adults, in the next financial year. Secondly, just after Christmas I announced a £4 million fund to bring forward that expansion of intensive care into the current financial year. I announced the distribution of the money and said that it would be used to deliver almost 100 extra adult intensive and high-dependency beds in the last quarter of this financial year. The process is one of growth and assessment of need, but we can never reach the final destination, which is what the hon. Member for Southwark and Bermondsey (Mr. Hughes) implies in his question.

Mental health is a key part of the national health service. The hon. Member for Stockport (Ms Coffey), who is no longer in her place, said that for too long, under Governments of every political complexion, mental health has been the Cinderella service of the NHS. But the Government have raised the priority of mental health and we have made clear our determination to improve the quality of the mental health care that is delivered by the NHS. We have not merely accepted the central recommendation of today's King's Fund report, but have announced our intention to implement it as soon as that is possible, on 1 April.

From that date, the NHS cash distribution formula will reflect the differing needs of different parts of the country for community health services. That central recommendation of the report has been implemented and will lead to increased resources being targeted at mental health problems, especially in inner London. That is the latest of a series of initiatives over the past few years, the effect of which has been to strengthen the commitment and raise the priority that the health service attaches to mental health.

The mental illness specific grant, introduced six years ago, is now supporting about £100 million of extra expenditure by social service departments on mental illness provision. The national health service challenge fund, which I introduced for the first time in the current financial year, has been extended into next year and will then be supporting £25 million of new expenditure by the NHS.

In this year's Budget, I introduced a special fund to improve the provision for mentally disordered offenders, which is a particular problem in inner London, particularly east London and south-east London. That is a targeted fund addressing one of the specific needs 762 identified by the King's Fund report. As is now widely known, within the next few weeks the Government will introduce a Green Paper canvassing options for the strengthening of the management of the mental health service.

I have never made any secret of my recognition of the fact that, under Governments of all political complexions, mental health services have not been accorded the priority that we should have seen over the past few years. That is a weakness that the Government have acted to remedy, and I had hoped that the hon. Member for Islington, South and Finsbury would welcome that.

The Labour party's charges on the health service do not add up, but there is something more serious than that about the speech of the hon. Member for Islington, South and Finsbury: as everybody knows, this Parliament does not have much longer to run and, when the election comes, the electorate will ask both major parties and the Liberal Democrats about their policies. Behind all the bluster and cases such as Jennifer's ear and the updated version of that, they will want to know the health policy that the Labour party is offering to the people of this country. When that is the question asked, we are faced with a gaping void.

The first question must be about money. Let me remind the House of the Government's record on financial support for the health service. Since 1979, there has been an increase of roughly three quarters in the real budget available to the NHS. That represents 3 per cent. real-terms growth on average every year over the past 18 years. That is the Conservative's record of commitment to the NHS. I remind the House again of the Prime Minister's pledge to our party conference to continue real-terms growth year on year on year through the five years of the next Parliament.

We then come to what the Labour party offers in reply. The editorial of The Guardian said that the Labour party needs to match the Tory spending promise. Honouring next year's settlement is meaningless—Labour can hardly take away money already promised. What it must do is match the Tory five-year promise: real increases, year on year on year. That is the challenge that comes from a newspaper that Labour must be hoping will support it in the general election campaign. The same challenge is posed by Conservative Members and Liberal Democrats and all around the community. They want to know whether the Labour party will set out clearly its commitment to a real, growing national health service. The Labour party never answers that question. It dodges and fudges and finds a formula to get around it, but will it answer it? Will it hell. That is the question that will be asked by every elector in every public meeting attended by the hon. Member for Islington, South and Finsbury. They will be asking him why he will not match the Tory party pledge for a real growth in the national health service.

Mr. Chris Smith

It would help if the right hon. Gentleman and his Government had not already broken that pledge. The Red Book shows that they have.

Mr. Dorrell

The hon. Gentleman keeps saying that, but it is absolute nonsense. The Red Book sets out clearly—I can give the hon. Gentleman the correct reference—a budget that represents real growth year by year, throughout the three years of that spending 763 programme. Furthermore, I can give a commitment that there will be real growth of the health service budget through not only the three years of that spending programme but the remaining years of the next Parliament. That is the commitment that we have given and delivered through 18 years. We give the same commitment for the five years of the next Parliament and the Labour party will not match it.

Ms Jean Corston (Bristol, East)

rose—

Mr. Dorrell

I will give way when I have finished dealing with the hon. Member for Islington, South and Finsbury on funding.

When Colin Brown was writing in one of the health service magazines recently, he said that the Labour party should fight again to keep the Tory promise alive for future years so that he"— the hon. Member for Islington, South and Finsbury— can promise that every year, year on year, Labour will increase spending on the national health service in real terms. I bet he can't. Well Colin, no bets, because that is a pledge that the right hon. Member for Dunfermline, East (Mr. Brown) will not allow the Labour party to make.

Ms Corston

Does the Secretary of State accept that the people of Bristol will judge the Government on their record, not just on the rhetoric of Front-Bench spokesmen? On the night of 5 January, 10 patients at Bristol royal infirmary were asked to get out of their beds after 10 o'clock at night because their beds were needed for other patients who were waiting on trolleys. One of them was a man in his 80s. The patients were sent home in taxis or relatives were asked to collect them, sometimes as late as 2 am when the temperature was minus 2 deg. That has received widespread publicity in Bristol and has caused a great deal of anger. Is the right hon. Gentleman surprised that people do not believe him when he denies that the health service is in crisis?

Mr. Dorrell

It is not me they will not believe; it is the Labour party. The hon. Lady is trying to make me return to discussing individual cases. I will not do that. The challenge for the Labour party is to demonstrate how it will deliver a health service that matches the Government's pledge.

It is not only a matter of total spending levels. There is worse to come when one thinks about the implications for the health service of the commitments that Labour has given. As I said at Question Time, the Labour party is committed to abolishing compulsory competitive tendering in the NHS. Such tendering is currently estimated to save £90 million on the health budget. Within the budget, which will not be growing because the right hon. Member for Dunfermline, East will not allow it, the Labour party has to earmark £90 million to pay off its trade union paymasters through the abolition of compulsory competitive tendering.

The Labour party is also committed to the introduction of a minimum wage. When the right hon. Member for Livingston (Mr. Cook) held the health brief, he was honest enough to admit that that had a cost attached to it. He put that cost at about £500 million. I look forward to hearing the up-to-date estimate from the hon. Member for Islington, South and Finsbury. The hon. Gentleman was 764 chiding me about not knowing every detail of what goes on in the health service. If he can break off his private conversation with his hon. Friend the Member for Dulwich (Ms Jowell), he might be able to offer the House an estimate of what he believes the minimum wage will cost the health service. Can the hon. Gentleman improve on £500 million? Can he offer any analysis? He must have made an analysis. I can offer him the full resources of my Department and any information that he needs to provide an accurate assessment of the cost of that commitment to the NHS.

The cost of that commitment is an important element in the choice that the electorate have to make. If the hon. Gentleman has not thought of that, I look forward to the correspondence that will enable us to develop a figure that we can then debate. We can then know whether that commitment will be a sensible use of health service money and whether it reflects a sensible priority in the frozen budget that the hon. Gentleman will have to put up with.

An issue that will be of considerable concern to many of my hon. Friends and their constituents is what is to happen to the private finance initiative. The Government have made it clear within their spending plans that they are determined to deliver a major investment programme for the national health service through the PFI. We have already signed up 43 schemes with a total spend of £317 million. A further 28 schemes have been approved with a total value of £309 million. There are 150 schemes being worked up by individual trusts under the PFI. The health service investment programme for the period ahead is £2.1 billion, to be provided by private sector partners through the private finance initiative.

Mr. Toby Jessel (Twickenham)

Is my right hon. Friend willing to comment on the private finance initiative in relation to West Middlesex University hospital, which, as he and the Under-Secretary are well aware, is a matter of eager and enthusiastic interest to my hon. Friend the Member for Brentford and Isleworth (Mr. Deva) and to me? We very much hope that the scheme can go ahead lickety-spit without delay. Can he give us any encouragement on that matter, which is important for our constituents, so that the existing, old hospital can be replaced?

Mr. Dorrell

My hon. Friend is right to raise his constituents' concerns about that hospital. He will know that it is one of the many schemes that local managers are preparing to meet real local need with health authority support and that the Government are determined to see carried through to projects that modernise the capital stock of the health service. I can give him every encouragement that the Government are determined to carry that through.

The question whose answer my hon. Friend and his constituents will want to hear from the hon. Member for Islington, South and Finsbury is: what would be the implications of a Labour Government for that investment programme, which is valued at a lot more than £2 billion to the future of the national health service? Will the hon. Gentleman carry on with the private finance initiative, in which case he will have to eat mountains of words—both his own and those of his hon. Friends—or will he honour those words and scrap the schemes, so that they too have to be financed out of the frozen budget that the right hon. Member for Dunfermline, East will not let him increase?

765 I know what is being said to the electorate in my home town of Worcester on that subject—once again, by the right hon. Member for Livingston. The hon. Member for Islington, South and Finsbury ought to have a word with the right hon. Member for Livingston, as when the latter travels around the country he appears to be rather too honest for his hon. Friend's good.

When the right hon. Member for Livingston recently visited Worcester, he made it crystal clear that, if the Worcester scheme went ahead before election day, as I know the citizens of Worcester hope, Labour would honour it; but if the contract was not signed by election day, it would go out the window. Bad luck to the citizens of Worcester. For them, the slogans are, "Vote Labour. Ditch your local hospital scheme" and "Vote Labour. Cancel your hospital project". Those are the slogans on which the hon. Member for Islington, South and Finsbury will go to the country, because he has no public capital—the right hon. Member for Dunfermline, East will not provide it—and he is not committed to the future of the private finance initiative, so he will not get it from that source either.

Every scheme that is not signed up before election day will be out the window, because the right hon. Member for Dunfermline, East can offer no hope that the schemes will go ahead. It is a good vote-winning message for the Tory party: "Vote Labour. Ditch your local hospital".

Mr. Gunnell

The Secretary of State has told us about the 43 schemes totalling £317 million. Can he tell me in how many of those schemes work has started, which scheme is most advanced and how much money has been spent on it?

Mr. Dorrell

Thirty-two have been finished.

The final question is one that Labour has invented for itself. It goes to the heart of the structure of the modern national health service. When we introduced local management, the Opposition fought us every inch of the way. The present Opposition Chief Whip said that Labour was implacably opposed to the provisions for hospital trusts outlined in the White Paper."—[Official Report, 11 December 1989; Vol. 163, c. 696.] The present Labour spokesman on education said, "We will abolish trusts."

Mr. Chris Smith

Before we move too rapidly away from the private finance initiative, will the Secretary of State confirm one or two things? First, he told the House more than a year ago that every month from then on he would announce a major new hospital scheme under the PFI. Will he admit that no such hospital has been confirmed in that intervening period? Secondly, will he confirm that in the case of the Norfolk and Norwich hospital, which was announced by the Chancellor of the Exchequer in the Budget and was the only major hospital scheme supposedly signed up under the PFI, although the contract with the contractors has been signed, the finance has not yet been finalised? Will the right hon. Gentleman also draw a conclusion from that about how much trust the people of Worcester or anywhere else can put in this 766 Government to come up with actual bricks and mortar, rather than windy rhetoric about the hospitals that they are going to get?

Mr. Dorrell

As a citizen of Worcester, I was eager to give the hon. Gentleman the opportunity to clarify Labour's policy about the projects that rely on the continued commitment of the Government to the PFI. The citizens of Worcester need have no doubt about this Government's commitment. We are determined to deliver hospital projects through the PFI. What the citizens of Worcester—myself among them—want to hear from the hon. Gentleman is whether he is committed to those projects or whether all the £2 billion plus of projects being carried forward under the PFI would be ditched if there were a Labour Government. If that is the Labour party position, the hon. Gentleman owes it to the electorate to make it clear. Will the schemes go ahead under the PFI? Will the hon. Gentleman produce the money from the right hon. Member for Dunfermline, East, or are we talking about taking £2 billion out of patient care to allow those hospitals to go ahead? Or—by far the most likely option—are we talking about schemes that will go out the window if the country is misguided enough to elect a Labour Government?

Sir Raymond Whitney (Wycombe)

In pursuance of that question, to which my right hon. Friend has conspicuously had no answer from the Opposition, will he remind the House that, over five years, the last Labour Government cut capital spending on the health service by 28 per cent? Does that not give us a clue to the answer to the important questions that my right hon. Friend poses?

Mr. Dorrell

My hon. Friend is right. It was not merely the capital budget that the last Labour Government cut, however. When nurses are considering the prospects under a Labour Government, they might remind themselves that nurses' pay fell in real terms by 3 per cent. and doctors' pay by roughly a quarter under the last Labour Government. That is what the right hon. Member for Dunfermline, East has got lined up for the hon. Member for Islington, South and Finsbury. The right hon. Gentleman is refusing to provide him with any money for the national health service.

Mr. Gerry Steinberg (City of Durham)

rose—

Mr. Dorrell

I have given way a great deal and I think that the House will want me to get through my final point.

The final question is one that Labour has invented for itself. Labour fought local management and trust management in the health service. Now the Opposition say that they are in favour. At the same time that they fought the introduction of local management of hospitals, they were also fighting the introduction of the purchaser-provider arrangement. The present shadow education spokesman said in 1993, which is not that long ago: I am vehemently against the notion, currently in vogue, of splitting administrative responsibility for health from delivery of care—divorcing regulation from provision. That was the position of the Labour Front-Bench spokesman a little more than three years ago. The hon. Member for Islington, South and Finsbury has changed that and I give him credit for it. He is now in favour of 767 the purchaser-provider split—the fundamental change that was introduced in health service administration in 1991. He cannot persuade his party that he is in favour of it, however, so he has invented a new distinction: he distinguishes the purchaser-provider split from the internal market. We have the ridiculous spectacle of the hon. Gentleman saying that he is in favour of the purchaser-provider split, but against the internal market. Until the hon. Gentleman discovered that distinction, the rest of the world thought that those two phrases meant exactly the same thing. The hon. Gentleman has not begun to explain how he has discovered a difference between those two phrases which have precisely the same meaning. It is a distinction without a difference that makes the hon. Gentleman look totally ridiculous.

Labour is in a state of total confusion. Every time the hon. Member for Islington, South and Finsbury speaks about health, he reveals new depths of his own ignorance. With every passing day, it is becoming clearer that the hon. Gentleman is determined to continue to act like the Opposition spokesman he is destined to remain.

The day of reckoning for the Opposition is drawing near. When the claims that they enjoy making are put under the spotlight, they melt like morning dew, and all that is left is a squalid determination to make political capital out of human misery. It is a sad commentary on the depths to which a once great party has sunk, and when polling day comes, the electorate will treat it with the contempt that it richly deserves.

Mr. Richard Burden (Birmingham, Northfield)

I am pleased that the Secretary of State finished by talking about the private finance initiative. Such matters are part of the debate and I want to discuss them.

The title of the White Paper launched shortly before the Christmas recess, "Choice and Opportunity", was rather interesting. My constituents, and people throughout the country, would appreciate a little more choice and opportunity in the national health service than the Government have given them over the past 17 or 18 years.

On the previous two occasions on which I spoke on national health service issues in the Chamber, I mentioned the proposed primary health care centre in my constituency. It was promised on several occasions many years ago by the then regional health authority—now swept away by the Government—and every time that I speak on health service issues, I ask the Government when it will be built.

The delays have arisen because of precisely those matters on which my hon. Friend the Member for Islington, South and Finsbury (Mr. Smith) was questioning the Secretary of State: the operation of the internal market, organisational structures in the health service that simply do not work and, most recently, the private finance initiative of which the Secretary of State has been singing the praises today.

The latest but one phase was when the plan to build the centre was forced to go through the private finance initiative. Some time ago, I asked the Secretary of State and the Minister what were the administrative costs associated with processing that health centre, which had not yet been built, through the private finance initiative. The answer was £50,000.

768 When I asked the Minister what the administrative costs—supposedly associated with a value-for-money exercise—consisted of, I received the usual answer about the information not being held centrally, or something to the same effect. I was therefore referred to the trust, which told me that the £50,000 was spent on consultants' fees. Was the £50,000 well spent? Clearly not, because now we have been told that the project will go ahead with public money, because the private finance initiative did not work.

As a result of that merry-go-round, not only has something that was promised to local people years ago been delayed time and again, but public money that could have been spent on patient care has been put into the pockets of consultants, even though the project was never appropriate for the much vaunted private finance initiative.

That is the reality of the scheme by which the Secretary of State sets so much store. He challenges us on whether we intend to go ahead with the PFI projects, but I would like to know whether they would go ahead in the very unlikely event of the Government being re-elected. The plain fact is that projects promised under PFI do not get confirmed: not one has started in bricks and mortar.

I want to give the Secretary of State another example of how bureaucracy has gone mad in the health service under the Conservatives and of how the PFI is operating. In Birmingham, there used to be several health authorities. Later, we had the North Birmingham and the South Birmingham health authorities, which recently merged, with the family health services authority, into a single authority for Birmingham.

There was a problem with premises, because each of the former authorities had its own headquarters. It clearly made sense, in the interests of patient care and of ensuring that NHS resources were spent appropriately, to rationalise the buildings and save money. The health authority considered the most cost-effective and economical way of providing a single headquarters, and found an appropriate set of offices that was competitively priced and would enable it to get rid of the expensive former premises. In one of its buildings, owned by someone else, it had been given notice to quit, and in another it had installed some tenants to bring in some revenue; and it proposed that the third building could be sold. It was a rounded plan that made economic sense.

The authority sent a costed business case to the Department of Health for moving into the new rented offices. After several weeks, or even months, it received an incredible letter saying that its plan to save money had to be processed through the private finance initiative.

The contents of the letter sound like something straight out of a "Yes, Minister" script. It says:

1. "1. Thank you for the opportunity to review the above business case. I apologise for the length of time taken in its completion.
2. 2. It is not clear whether the case is an OBC or an FBC. This makes it difficult to decide on the criteria against which it should be assessed. In summary, a number of issues have been raised about the failure to develop the case along the lines set out in PFI in Government Accommodation, economic appraisal issues and more general business case issues (such as failure to consider project risks and project management arrangements). These points are developed below.
3. 3. The status of the document needs to be clarified. Is it an Outline Business Case or is it a Full Business Case? The purpose and requirements of both documents are different.
769
4. 4. The former establishes the need for the investment and identifies a preferred option (assumed at this stage to be a publicly funded option), whilst the latter evaluates methods for funding the preferred option (based on the results of the PFI procurement process). I presume this is submitted as an OBC. Apart from this difference, an FBC would also address issues centred on the management of the project (ie Benefit Realisation Plan, In-Project and Post-Project Evaluation Plan, Risk Management Plan and Contract Management Plan)."

The letter goes on and on in that vein. It is comical to read, but it is the outcome of that bureaucratic madness. The letter was dated 27 November 1996.

The end result is that the problem of the Birmingham health authority's accommodation is still unresolved. The only reason why it will not be sorted out is the crazy, bureaucratic rules laid down by the Department of Health. If the problem is not sorted out, the health authority will have to move out of the building that it occupies because it has been given notice to quit and does not own the building. It will have to move back to the place that it has sub-let and get rid of the tenants, thereby losing income for the NHS. It will have to pay more in rent than the cost that would have had to be paid had the Department accepted its original suggestion. That is the reality of the bureaucratic nightmare of the Government's way of running the NHS.

One health authority, admittedly a big one, and one set of buildings—how did we get to this stage? Because the health authority was unable to pursue a simple transaction, the health service will have to pay more—money that should be going into patient care. The PFI is not a miraculous way of finding new investment for hospitals, as Ministers and Conservative Members claim. It is an incredibly expensive bureaucratic morass with unclear rules that has not yet produced one hospital, health centre or health service establishment. I am all in favour of attracting private finance to public projects and of proper partnerships, but they must work, they must be clear and they must be designed to do the job. They must not delay things and cost more money.

Earlier, I mentioned primary care. I shall give credit to the Secretary of State for making some attempt to address that in his White Paper, some points of which are worthy of support. It was interesting that he made little reference to the matter in his speech. I am still waiting for an answer to a question that has been put to the Government several times. How do they think that the provisions in the White Paper will work?

The White Paper suggests that general practitioners need not necessarily retain their traditional role of independent contractors in the NHS. They could become employees of other bodies, which would be the contractors to the NHS rather than individual GPs or groups of GPs. It has been acknowledged that GPs could therefore become employees of trusts. There is no problem with that if the trust concerned is a community trust involved in the provision of primary care. However, the Secretary of State has not satisfactorily dealt with the case of acute trusts that wished to employ GPs. A body whose main operation is the provision of secondary care would employ family doctors, whose job is to provide primary care.

The Minister for Health (Mr. Gerald Malone)

Let me set the hon. Gentleman's mind at rest. General practitioners are not in the NHS; they are independent 770 contractors. We foresee that they may be able to organise themselves in a different way, either through another body or by coming together to provide services or most likely, as he said, through a community health trust. He asked about acute trusts. The answer, in respect not only of acute trusts but of any other organisation where a conflict of interest might arise in the proposals made, is that the conflict of interest would be recognised and we would not expect such an application to be honoured. Clearly, if there were such conflicts, they would not be desirable.

Mr. Burden

I am grateful for that answer. I shall give way again if the Minister can clarify the matter further. Groups of GPs getting together to provide expanded primary care services is potentially a good development. Labour has been pioneering such developments in talking about local commissioning teams, and local pilot teams have been working. In Birmingham, there are proposals to develop such services. Such a pattern of service would fit more easily with the locality commissioning suggested by the Opposition than grafting it on to the internal market that Conservative Members have imposed on the NHS.

I must press the Minister further on conflicts of interest. I am pleased that he says that if there is a conflict of interest, he would not expect the application to be honoured. Is he saying that acute trusts would not be allowed to employ GPs?

Mr. Malone

indicated dissent.

Mr. Burden

If he is not saying that, the Minister is heading down the road of conflicts of interest.

Mr. Malone

I shall say what I said again, because it was perfectly clear. There could be applications where conflicts of interest might arise. If they did, they would be addressed at the time in the light of the individual application. I am not going to rule out an acute trust making proposals. I cannot predict whether there would be conflicts of interest. If there were, they would prevent the proposal from reaching fruition.

Mr. Burden

I am afraid that that is not good enough. It might be just about tolerable if an acute trust employed GPs in its own area, because the pattern of referrals in a given area tends to be static and predictable. Where they can, GPs like to refer patients locally. What if an acute trust tried to contract out of area? That is where conflicts of interest would develop. Such a system could already be in place through the mechanism to which the Minister referred.

What if private health care organisations such as PPP and BUPA wanted to set up a nice little local health centre to employ GPs? GPs would tell the Minister, if he asked them, that there can be pressure on them to refer patients to places that they do not necessarily believe will provide the best clinical services but which are often euphemistically described as the preferred providers. Private patients, perhaps those in insurance schemes, are already affected by such pressure. Currently, GPs can insist that referrals go to the place that they consider to be the most appropriate clinically.

If we move down the road that the Government want to go down, what barrier will there be against a private health insurance firm buying up a local health centre and 771 employing GPs and against the employer putting pressure on its employees—the GPs—to refer patients to places that are not the most clinically appropriate in the judgment of GPs but that are the preferred providers in the interests of the employer? Those issues need to be addressed. I raise the matter today because when the Secretary of State talks of ensuring that there is a primary care-led NHS, I believe that that is what he wants.

The Secretary of State needs to square a circle in order to achieve his goal, but he cannot do that unless he fundamentally challenges the assumptions according to which the Government have operated the NHS. In answer to my hon. Friend the Member for Islington, South and Finsbury, he said that no one had ever recognised the difference between the internal market and the separation of the commissioning of health care from the provision of it. I must tell him that most other people have always recognised that difference.

Let me tell the right hon. Gentleman precisely what is the difference—I find it sad that he does not know. If he merely believes that the split between those who plan health services and those who provide them is equivalent to an individual contracting relationship, governed by a financial transaction, he has a problem in ensuring that the NHS keeps to the principles on which it was founded. Those principles are meant to guarantee the provision of health care, free at the point at which it is needed and to ensure equity in i