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Sir Peter Emery (Honiton) : Will my right hon. and learned Friend bear in mind the fact that, in answering any attack on this scheme, he must emphasise the caring nature of any Government who will spend an extra £3,300 million on the Health Service in this period? Will my right hon. and learned Friend answer two questions for me? Will the amount of money that will be available to the large practices, allow them to use funds for the support of cottage hospitals in the country, to build up some of them in areas where they provide a major service for people?

Secondly, will my right hon. and learned Friend perhaps think again to overcome the appointment of consultants by means of a contract for life? The concept that any person today can from the moment he gets his first appointment believe that he holds the appointment for ever seems inequitable and wrong. For a consultant, surely, a four-year contract to begin with, then to be renewed, is something everyone would support.

Mr. Clarke : If a well-run general practice makes savings on its practice budget, for example, by making use of a new formulary and tightening up prescribing costs, it will be able to plough back those savings into local services. We will not claw savings back from successful practices. That would permit them, for example, to put the funds into cottage hospitals supported by local GPs as part of local general practice.

On consultants' contracts, we are not changing the basic nature of the contract, which is not quite as my hon. Friend described : a consultant is in theory open to dismissal at three months' notice. At the moment, that is subject to a right of appeal to the Secretary of State. As I told my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), we are reconsidering the position because of the ineffectiveness of that right of appeal and the length of time it has taken in the past. We think that we have reached agreement with the profession about it.

Rev. Martin Smyth (Belfast, South) : I welcome the Secretary of State's statement, which has clarified some points which did not come across in the official leaks. For example, until today I was not aware that Northern Ireland was included in the review. Will there be a discussion with people in Northern Ireland akin to what is planned for England and Wales and, to a lesser extent, Scotland? The Secretary of State for Northern Ireland paid a fleeting visit to the Chamber earlier, but there is no one from Northern Ireland here now to answer such questions.

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Will the National Health Service management executive and the National Health Service policy board include representatives from Northern Ireland, or are they technically for England and Wales? The Minister said that efficient hospitals would not have to close wards because there was not enough money. Is that an open-ended commitment to general practitioners throughout the land to provide them with sufficient funds to treat their patients properly?

Mr. Clarke : I understand the hon. Member not fully appreciating the scope of the review before today, because he had to rely on the hon. Member for Livingston (Mr. Cook) to be the interpreter of most of the documents which were available. My right hon. Friend the Secretary of State for Northern Ireland has been closely involved in all this. The review will apply to Northern Ireland, but in a way which reflects the local service. One whole chapter, chapter 12, is about Northern Ireland and explains exactly what will happen. I am sure that my right hon. Friend will have discussions within Northern Ireland with all interested parties.

The policy board and the management executive relate to my responsibilities, which are for the English Health Service and for England only. The position in Wales, Scotland and Northern Ireland is different in a number of important ways. My respective right hon. Friends will be responsible entirely for the way in which the principles of the policy are put into practice in their countries.

Mr. Roger Sims (Chislehurst) : Is my right hon. Friend aware that his imaginative proposals, which are centred not on the clinicians or on the administrators but on the patients, are warmly welcomed on this side of the House, as they will be throughout the country? It must make sense that patients, GPs and administrators can choose where treatment is to take place on the basis of quality and cost. That can be done only if it is possible to compare costing in the Health Service with that in the private sector. At present, that is not practicable in many areas, because the information is not there. What steps is my right hon. and learned Friend taking to enable comparisons to be made?

Mr. Clarke : I agree with all the points which my hon. Friend has made. It is important that, when people are making a choice based on a combination of quality and cost, they should have the best information. The information should be properly comparable between one hospital and another within the Health Service and between the NHS hospital and the private sector provision. That would make it possible for a district health authority or a general practitioner to look to the private sector for part of the service and equally possible for the private sector to look to the NHS. The artificial divisions, and the daft political argument that has gone on about the respective merits of the public and private sectors, should be put behind us, and we should all work to the best effect for patient care.

We will have to develop systems for costing. That will include examining methods of reflecting various capital costs between one and the other, as well as the revenue costs incurred in particular services. This will involve a major management effort over the next couple of years before the system can get running.

Mr. Jack Ashley (Stoke-on-Trent, South) : If the National Health Service is to be as good as the Minister

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says, why is he encouraging older people to take out private medical insurance? Surely they are wasting their money. If the NHS is not to be as good as he says, what will happen to the millions of people who cannot afford private medical insurance? Can he tell us also why he has misled the House of Commons about the future of the Health Service? Does he recognise that great institutions in Britain are driven by their objectives and that the noble objective of the National Health Service is the best possible treatment, which is to be replaced by the cheapest possible treatment? That is an act of political vandalism for which he will never be forgiven.

Mr. Clarke : As the right hon. Gentleman puts it, we may be encouraging elderly people to go for private care, but they do not need encouragement from the Government. It is an inevitable consequence of rising living standards that an ever-increasing proportion of the population want to consider making insurance provision for their own health care. I cannot for the life of me see why we should stand in their way. If we encourage it for those over the age of 60 it will benefit millions of other elderly people by reducing the pressure on elective surgery in the Health Service, thus reducing waiting lists and waiting times. That is the basis on which we are proceeding.

I accept entirely what the right hon. Gentleman described as the noble objective of the National Health Service. The growing silence and absence of people on the Opposition Benches is because they realise that they have been misled by their official spokesman into believing that that objective was under attack. No doubt most of the right hon. Gentleman's hon. Friends have gone to the Library to look through the document to try to discover how the hon. Member for Livingston (Mr. Cook) felt able to base his attack on the document by raising all over again his ridiculous hare that we were trying to privatise the service.

Sir Fergus Montgomery (Altrincham and Sale) : Does my right hon. Friend agree that the provision of 100 new consultants must have an effect on waiting lists? Will he also confirm that these consultants will be given the necessary back-up staff they require?

Mr. Clarke : I am grateful to my hon. Friend. Over three years, there will be 100 extra consultants, with the necessary support care they require. The problem is not with the people. There are a little over 100 who will be qualified for appointment in that time. We need the actual men and women to be consultants. Then we need the operating theatre time, the beds, the nursing staff and so on. Finance will be available to provide the back-up which will enable the extra work to be done. The consultants will be appointed in key specialties such as general surgery and general medicine where waiting times are worst. The extra consultants will also have some impact on the problem of junior doctors' hours. It is not every junior doctor who works the long hours which we all know to be excessive. Junior doctors' hours tend to be worse in general surgery, general medicine and obstetrics.

Mr. Dafydd Wigley (Caernarfon) : The statement is nonsense in Wales, where we do not have regional health authorities. We should have had our own statement. Can the Secretary of State clarify the position in large, scattered areas, where virtually no medical practice comes up to the

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11,000 threshold? They will miss out on the opportunities. Likewise, in valley communities, will this not lead to an amalgamation of practices and a lessening of choice for patients? As there are virtually no private beds in Wales, is it not appalling that paragraph 11.9 of the White Paper should give priority to an increase in private provision, which is deeply detestable to the thousands of doctors, nurses, paramedicals and auxiliaries who work in Wales and who have given a lifetime of service to the NHS? Can the Secretary of State give an assurance that any hospitals currently under threat of closure will have the threat removed until the full implications of the statement have worked through?

Mr. Clarke : My right hon. Friend the Secretary of State for Wales was also closely involved. There is a chapter on Wales, which the hon. Gentleman will have seen. Wales is of a size similar to an English region. That gives my right hon. Friend and the Welsh the advantage of having the centre of the service much closer to practical provision on the ground. The Welsh have been spared some of the remoteness which I hope we shall now overcome in England by devolving so much responsibility to lower levels of management nearer to the patient. I am delighted to hear that the hon. Gentleman wants to be sure that GP budgets are introduced in Wales. Any question of reducing the threshold for Welsh general practice will have to be addressed to my right hon. Friend the Secretary of State for Wales.

Mr. Jerry Hayes (Harlow) : I warmly welcome my right hon. and learned Friend's revolutionary proposals for patients, within an evolutionary framework. But will he confirm that, when the GPs' budgeting scheme comes into force--including the scheme for prescriptions--no surgeries will close and no patients will be deterred from treatment or turned away because of a lack of resources?

Mr. Clarke : I can give an absolute assurance to that effect. As will be clear to my hon. Friend, now that he has the documents, the system will be very flexible. Those who start overspending can indeed be called to account, but there is no question of stopping the service.

For the past few days, my hon. Friend and I have had to put up with critics projecting the absurd vision of practices closing down in the middle of February until the next financial year, people being turned away from medical treatment and so forth. Anyone who wants to know what will happen should study our proposals with care. Those who have tried to find criticisms of them have been on a wild goose chase.

Mr. Peter Shore (Bethnal Green and Stepney) : The Secretary of State has already told us about the massive extension of medical auditing, accountancy and financial costs that his proposals will entail. Has he costed the proposals? If so, will he tell us what the cost will be, and whether he will make additional finance available to the Health Service or intends to meet the cost of his reforms from existing expenditure?

Mr. Clarke : "Medical audit" is a phrase that I do not like when it is applied to a system of quality control devised by the medical profession. Clinicians will consult each other about the outcome or success of procedures, comparing notes and advising each other on how to raise

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the standard. That is separate from financial auditing. We have always had financial auditing in the Health Service, and we are now strengthening that by giving it to the Audit Commission and making it independent from the Health Departments. I am sure that the whole House wants good financial auditing and value-for-money studies in the Health Service, in the interests of taxpayers and patients. We made provision for some of the implementation costs in this year's public spending round. Provision has already been made in regional budgets for the introduction of financial management systems and so on, which, despite the attacks on them by Opposition Members, are desirable in themselves. If we were not reviewing the Health Service, we should still want Health Service management to take advantage of the best modern management techniques and to improve management information. It is shell- backed in the extreme for the Opposition to oppose advances in a great public service.

I can give the right hon. Gentleman an assurance that the cost of the proposals will not be met at the expense of plans for patient provision. There will be some cost up front, although eventually the savings made by cutting out waste will outweigh that and will benefit the service generally.

Dr. Alan Glyn (Windsor and Maidenhead) : Having removed the difficulty of doctors using different areas, can my right hon. and learned Friend envisage a system in which the number of vacant beds is made available to doctors, so that, instead of having to ring round and ask hospital after hospital whether there is a vacancy, they will know immediately?

When will the self-governing hospitals come in? Is it possible to advance the date if a hospital wants to become independent before then?

Mr. Clarke : I agree entirely with my hon. Friend's first point. It is an excellent idea. I envisage that, as soon as possible, the microcomputer that every GP will have on his desk will provide, among other things, instant access to information about waiting lists within a wide area of his practice, so that he can advise patients about the shortest waiting times. In future, when he refers his patients, the hospital will pay for the extra patients, whereas in the past he would rather pay the hospital to keep it quiet, because it might receive patients for which no financial provision had been made.

We shall put the first self-governing hospitals into operation as quickly as we can, but for all the reasons that have been enumerated, including those mentioned by my hon. Friend the Member for Eastleigh (Sir D. Price), it will take a year or two before the first hospitals are capable of managing the process of self-government and making a success of it.

Mr. Jim Sillars (Glasgow, Govan) : Will there be separate Scottish legislation to give effect to the document? Secondly, is the Secretary of State aware that he has now put the final nail into the lid of the coffin of the Tory party north of the border? It is transparently clear that the intention of the lady in Downing street is to fracture the national character of our Health Service and commercialise it, as a prelude to privatising it. We have never believed her claim that the National Health Service was safe in her private-patient hands. Is the Secretary of State aware that the fundamental gulf between the Scottish people and the English Tory party that governs us at

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present is that we do not consider the concept of market forces compatible with the medical ethic of providing care at the point of human need?

Mr. Clarke : We will probably not begin drafting legislation for any country until the summer, when the process of discussion will have advanced considerably. I am certainly not contemplating legislation in the present session of Parliament. When we draft the legislation we shall no doubt decide whether to have separate Bills for England, Scotland and the other countries or to have a single Bill for all of them.

I am rather vague about Scottish questions, because although the document contains a chapter dealing with them, the system of governing the Health Service in Scotland is completely devolved. My right hon. and learned Friend the Secretary of State for Scotland is clearly best placed to answer questions about Scotland, and has already offered a debate in the Scottish Grand Committee. I am astonished that the hon. Gentleman should think that opinion in Scotland will be so different from that in England. It would be absurd if we had a modern, more patient-conscious and efficient Health Service in England while the Scots preserved the Health Service as it was 40 years ago, with some modest changes. I know that my right hon. and learned Friend does not intend that, and that he will ensure that the Scottish Health Service, in a Scottish fashion, is made stronger, better and more responsive to patient needs.

Mr. Steve Norris (Epping Forest) : I warmly welcome my right hon. and learned Friend's statement. May I remind him, however, of his comment that the better the management, the better would be the care? Many of us may be disappointed if he limits the management of consultants' contracts to giving district health authorities some sort of vague agency rights. Those of us with experience of managing the service at district level will look to him to ensure that consultants' contracts are held at that level by those who have to manage the consultants. Will he assure us that his effective management of consultants will include that provision?

Mr. Clarke : My hon. Friend has considerable experience of a district health authority himself, and I know that his views are shared by many people in such authorities. I ask him, however, to look closely at our proposals. Although the contract will be held with the region--it would be disruptive to change that for the sake of change--management of the contract will be devolved to the district, as the region's agent. In particular, the new provision for an up-to-date job description, to be reviewed each year, will close the gulf that sometimes now exists between local management and consultant.

Mrs. Audrey Wise (Preston) : The Secretary of State failed to answer the point about lack of consultation. Will he now tell us plainly why the review had to take place behind closed doors? Could the reason have been a fear that evidence given publicly by those in the profession would get in the way of imposing this kind of change? Will the Secretary of State admit his determination to impose cash limits on general practice? Can he not imagine the shudder that will go through people when they realise that their treatment will be subject to the state of the practice budget?

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Mr. Clarke : I hear what the hon. Lady says about consultation, but it seems to me that it is the duty of Government--and of a political party, come to that--to have a policy on how they propose to improve a great public service. Of course, having produced our policy, we are also producing a large amount of back-up material on which we will have the widest possible discussion with everyone interested, and we are starting discussions with our own staff straight away. We are engaging in much closer discussion with those who really work in the Service than I think has been tried by anyone before. The Labour Party's idea of consultation is to take a blank sheet of paper with no policy on it and to hold a series of silly meetings at which it asks whether anyone has a good idea. That is no way to form a policy.

I have already tried to explain--successfully to most people--that there is no prospect of patients' access to care being determined by the state of GPs' budgets. In the extreme case of a practice that has consistently overspent by more than 5 per cent. for two years in succession, its budget will be taken away and it will be brought back into the general service. That will be a matter between the practice and the regional health authority. The patient will not notice any difference, except that, if the budget is operated properly, he will find that his GP can offer better choice and service, and hospitals will have an added incentive to provide better service.

Mr. John Greenway (Ryedale) : Does not the clear and unambiguous support for the principle of a free Health Service available to all, outlined in my right hon. Friend the Prime Minister's foreword to the White Paper, constitute the most significant commitment to the National Health Service since it was formed 40 years ago? Is it not also right that the success of any service should be measured by the satisfaction of its customers and that, in putting patients first and creating a more coherent, responsive and effective National Health Service, the Government are right to say that we are working for the patient?

Mr. Clarke : The Labour party has been acting in this way for years. I am sure we all remember the 1983 election, which was largely fought by the right hon. Member for Birmingham, Sparkbrook (Mr. Hattersley) claiming that he had a secret document that said that the Government were about to privatise the Health Service. All that the hon. Member for Livingston (Mr. Cook) has done is to take that old gimmick out of its box, give it a whirl again and claim that it was possible to rerun the story on the strength of the leaked information he had received. We have not only repeatedly committed ourselves to the National Health Service--as we do today--but we have demonstrated that commitment by putting in more resources to enable the Service to treat 1.5 million more patients now than when the Government came to office. We have made it a better and more effective service for patients, and we propose to continue doing so.

Mrs. Rosie Barnes (Greenwich) : Will the Secretary of State accept that, for the first time since the formation of the National Health Service, general practitioners will have financial incentives to limit how they treat their patients? There will be a restriction on prescribing and an incentive to refer fewer patients to hospital. Most importantly, there will be a strong disincentive for doctors to take on to their lists high- risk, high-cost patients such as

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the elderly, the chronically sick and the mentally ill. There is already evidence that, in the United States, where there are budget restrictions, such patients find it hard to persuade a GP to take them on. What would be acceptable grounds for budget practice GPs refusing patients? What right of appeal would the patients have, and to whom would those GPs be accountable if they refused?

Mr. Clarke : I do not understand why we should not offer incentives to GPs to make cost savings in their practices. At present there are wide discrepancies in costs between similar practices. Prescribing costs vary between different practices by as much as four times ; the number of patients referred to hospital can vary by 20 times. If savings are made by GPs, they will not be clawed back by the Treasury but will be ploughed back into the practice to develop patient care in any way that the GP wants--for instance, in the form of new chairs for the waiting room or the support for a community hospital that my hon. Friend the Member for Honiton (Sir P. Emery) mentioned. I thought that I had dealt several times with the argument that there will be incentives to take low-risk patients. That might be so if we paid the same rate for every patient, but we do not. By paying more for high-risk patients we have eliminated the risk--which I understand the hon. Member for Greenwich (Mrs. Barnes) fears--that there might be a disincentive to take high-risk patients. We always do our best to ensure that no such perverse incentives are built into health care systems.

When the hon. Member for Greenwich studies the report, she will find that much of what it recommends is astonishingly near to what the leader of her party, the right hon. Member for Plymouth, Devonport (Dr. Owen), advocated two or three years ago as an internal market in the Service. We have refined that idea to a much greater extent than anybody else and produced a good system, whereby cash follows patients. Immediately, the Social Democrats disown their interest in the internal market, saying that it is a commercial system and dreaming up all sorts of fanciful risks that they say will lie behind it.

Mr. Derek Conway (Shrewsbury and Atcham) : The fact that the NHS is treating more patients with more doctors and resources proves the Government's commitment to the NHS, not the Opposition's stolen lies. What will the proposals mean for rural areas such as Shropshire, which has a population of less than half a million but covers a land mass in excess of 25 per cent. of the west midlands? We should also like to opt out of the dead hand of regional control.

Mr. Clarke : I am familiar with the problems of Shropshire, not least because they are often pressed upon me by my hon. Friend the Member for Shrewsbury and Atcham (Mr. Conway)-- [Interruption.] I think that my hon. Friend will acknowledge--even if the hon. Member for Holborn and St. Pancras is not instantly familiar with Shropshire--that the background to the problems in Shropshire is that we are opening, at considerable expense, a new district general hospital in Telford. Shropshire will have two district general hospitals, and would have had 20 small ones as well, had the service not been rationalised.

I know that my hon. Friend disapproves of how the region, and to some extent the district, have gone about rationalisation. Therefore, I am sure that he will welcome

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any proposals that give more local responsibility for such matters. Shropshire will want to take advantage of them as quickly as possible.

Dr. Lewis Moonie (Kirkcaldy) : The Secretary of State's own GP will undoubtedly receive a large premium for looking after him after these these reforms are introduced, because he clearly has only a tenuous grasp of reality. The proposal is born of the eccentric mind of someone in the Adam Smith Institute who has no concept of what it is like to run a health service, as opposed to talking and thinking about one.

I wish to put three specific points to the Secretary of State.

Mr. Speaker : Order. One question, please.

Dr. Moonie : The three points are all part of the same question about how the service will be administered.

The Secretary of State mentioned the patients' dependency as a factor for calculating costs. Is he aware that there is no way of measuring costs on an individual basis? He mentioned patient administration systems in hospitals. Is he aware that, as yet, no such system is fully effective? How long will it be until such a system is fully effective and capable of general introduction? Where shall we find computer staff to run it? The Health Service is already short of such staff.

Mr. Clarke : The hon. Gentleman talks about the need for clarity about how to measure different aspects and needs of patient care. As he knows, our English system of RAWP and the similar system in Scotland, SHARE, depend on a complicated formula that attempts to distribute resources on the basis of population, numbers, age and morbidity. It is easier--

Dr. Moonie : Reliable data do not exist--ask your officials.

Mr. Clarke : That is how it works. We shall discuss details afterwards. I am more familiar with RAWP than the hon. Member for Kirkcaldy (Dr. Moonie). Any distribution of funds involves such calculations. We must make the best calculations using modern methods. We have been developing patient administration systems and resource management information systems as rapidly as possible. They are required in the Health Service and I am sure that the hon. Gentleman will welcome their introduction. We have an ambitious timetable to introduce the necessary systems to implement the reforms. We shall need computer staff to do so, and I welcome the hon. Gentleman's recognition that the modern administration of a good large system is a good step--even if, at present, that is not remotely comprehended by his right hon. Friend the leader of the Labour party.

Mr. Robert McCrindle (Brentwood and Ongar) : If greater efficiency and better value for money are the watchwords of the White Paper, as they seem to be from my initial reading of it, is it not true that the health authorities appear to have escaped leniently? Does not my right hon. Friend agree that there is a case for the abolition of regional health authorities and for the absorption of some of their residual activities into the Department of Health? That would strengthen and exercise greater control over district health authorities. Is it not a fact that, rather than approaching it in that way, the White Paper appears to be strengthening the power of the regions?

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Mr. Clarke : I would not take the powers of the regions back into the centre on any account. If we had to deal directly with 190 districts and 90 family practitioner committees--without any regional authorities--it would be impossible to have any effective contact. We shall get the regional health authorities to concentrate on their real job, which is distributing funds locally, monitoring performance and laying out policy objectives. We shall stop the amount of detailed decision and supervision at regional level, which is no longer suitable for the Service.

Mr. Terry Davis (Birmingham, Hodge Hill) : As some general practitioners refuse to give reasons for removing people from their list, how will the Secretary of State prevent a general practitioner from removing a patient from his list when the high risk has become high cost? If family doctors are trying to work within a budget, and even make savings, how can patients be sure that the doctors will do their best to arrange for the treatment needed by a patient, even if it means that the budget will be exceeded? Does not this development strike at the very heart of the relationship between doctors and patients?

Mr. Clarke : The doctor will be paid for a high-risk patient. Therefore, the financial incentive which the hon. Gentleman believes to exist simply will not exist. With regard to the patient's satisfaction with his or her treatment and service, we propose to make it easier for the patient to choose for him or herself. If patients become dissatisfied with the service they are receiving from one doctor, we shall ensure that it will be easy to transfer from one doctor to another. That will give a greater incentive to general practitioners to ensure that the quality of the service and the way in which it is provided are the best possible for the patients in their care.

Mr. Henry Bellingham (Norfolk, North-West) : Further to the question put by my hon. Friend the Member for Honiton (Sir P. Emery), I welcome the confirmation that cottage hospitals, which in Norfolk do so much for the care of the elderly, will still have a role to play. Does my right hon. and learned Friend agree that, increasingly, their future will be in the private sector, but with beds set aside for NHS patients?

Mr. Clarke : I believe that many cottage hospitals have an extremely important future. The last one I visited was Bealeys. It is an extremely small, well-run, GP hospital, which has a secure future in Bury. I know that there are many cottage hospitals in Norfolk, too.

The cottage hospitals will, of course, be able to continue as they are now. They will be given, anyway, greater responsibility for their affairs, because of the general devolving of responsibility about which we are talking. It is conceivable that some will find that self-governing status is suitable for them. Some hospitals are run by the GPs as independent hospitals. It is that variety of provision which is best. People in Norfolk know best how to provide for Norfolk. The combination of NHS and private care provided in Norfolk in their small hospitals will make it much easier for people in Norfolk to decide on their care.

Mr. Nigel Spearing (Newham, South) : Does the Minister agree, from his constituency and family experience, that people, especially the elderly, value district general hospitals and expect to go there--not further afield--when they are ill? Will not the right hon. and learned Gentleman's scheme encourage wider

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movement? Why should people from Newham have to go to Newmarket, people from Grantham to Gainsborough, or people from Finchley to Fulham? Is not such criss-cross market movement, even perhaps by motorway, completely incompatible with the wishes and the deep desires of the patients? How does he square that with the signed statement by the Prime Minister that the patient's needs will always be paramount? Does not that incongruity suggest that neither patients nor the Health Service are safe in her hands?

Mr. Clarke : I agree that patients look increasingly to local provision, which is why we have had such a massive system of capital expenditure to improve local hospital provision throughout the country, and it is much less concentrated than it was. When confronted with the choice of either speedy treatment 30 miles down the road or a long wait for treatment in their local hospital, it will be for the patient and his or her GP to decide whether the inconvenience of travel is worth the speedier treatment. It would be perverse to deny patients that opportunity to choose. We are proposing that the patient should make the choice.

Mr. Robin Maxwell-Hyslop (Tiverton) : Can my right hon. and learned Friend tell us about extra resources for patients who have come out of hospital--for instance, stroke patients--and need physiotherapy if they are to recover the faculties and functions they lost? My right hon. Friend will recall that Devon Members discussed this matter with him a couple of weeks ago. As there is less provision to keep patients in hospital long term-- that seems to be a medical trend--the need for follow-up medical services and services ancillary to medicine simply are not being met at the moment. How does the very imaginative scheme that he has announced today compete with that admitted problem?

Mr. Clarke : Certainly, the services of the kind mentioned by my hon. Friend are every bit as important for the local community as services in the acute sectors of the hospital. I should make it clear that, when we talk about self-governing hospitals, what we are talking about in practice is the hospital together with the associated community health services, which we are used to seeing provided alongside hospital services, such as district midwifery and health visitor services, physiotherapists and other people providing service. We shall have to deal with the problem of stroke patients and others in Devon in our response to the Griffiths report on care in the community. We shall have to ensure that we are able to make the best and most sensible use of the resources available to carry on strengthening our community services.

Several Hon. Members rose --

Mr. Speaker : Order. I have an obligation to protect the subsequent business. I appreciate the importance of this statement. I will allow it to continue for a further five minutes. We shall then have had an hour and a half, which is a long time for a statement, but then we must move on.

Mr. Robert N. Wareing (Liverpool, West Derby) : The Secretary of State began his speech by bemoaning the increasing cost of drugs to the National Health Service. Why does he not insist upon generic substitution for drugs

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in the Health Service, or even--better still --tackle the problem at source by taking the private monopoly drug companies into public ownership?

Mr. Clarke : I believe that general practioners should prescribe generic drugs when the remedy is as effective as a more expensive and branded alternative. We have been encouraging that. The last time that I was involved in an attempt to move in that direction, with a selected list, the Labour party made the foolish mistake of opposing it bitterly as a wicked attack on a doctor's freedom of choice. Having seen some of the hon. Gentleman's documents, I believe that his party is at least moving in the right direction on that subject. We shall not force generic substitution. We are constructing a system which will give every encouragement to general practitioners to make a sensible clinical judgment and go for the less expensive remedy when it is every bit as effective medically as the expensive alternative. We are tackling that all over again, and I look forward to the support of the hon. Gentleman and his right hon. and hon. Friends.

Mr. Tim Yeo (Suffolk, South) : Does my right hon. and learned Friend agree that his proposals will be welcomed by everyone who has the future of the NHS at heart? Does my right hon. and learned Friend agree, too, that the fact that patients will be given more choice and power will provide the best possible spur to greater efficiency, effectiveness and consumer acceptability? Does he agree that the only person to whom his proposals must have come as a bitter disappointment is the hon. Member for Livingston (Mr. Cook) whose statements over the past few days have been shown to be so absurd that he no longer possesses any shred of credibility?

Mr. Clarke : I agree with my hon. Friend. I entirely endorse what he said. These proposals are for the benefit of the patient and every management or financial change of whatever complexity has underlying it the desire to ensure that the resources go to where they can best be used for patient care. The Labour party has no answer or equivalent to that. As my hon. Friend has said, I hope that the silly games that the Labour party has been playing in the past few days will be exposed for what they are.

Mrs. Alice Mahon (Halifax) : Will the Minister confirm that his proposals will mean the end of national pay bargaining, and that one of the reasons for him meeting in secret was that he did not want to alert the staff to that fact? Is he aware of the disgust at the decision to kick out the only elected members of district health authorities, which is just one more example of the authoritarianism of this Government?

Mr. Clarke : I have long been advocating a much more flexible pay system for the National Health Service.

Mrs. Mahon : We know that.

Mr. Clarke : We have introduced more flexibility for some staff. We have asked the review body to consider

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allowing us to experiment with more local variations in the remuneration of nurses where there are local difficulties in recruiting them.

Of course, we keep our present structure of pay bargaining, but I make no apology for saying that I think our proposals will encourage more flexibility, and the self-governing hospitals in particular will take full advantage of it.

We are altering the nature of the district health authorities. It is nonsense that, at the moment, local government has the right to directly nominate representatives on the Health Service. Many of them do very valuable work but, at the other extreme, there are some who are merely there to bring local politics into the decision-making process of the Health Service. In some cases they have been exceedingly disruptive and people working in the Health Service--doctors and others--have to sit and listen to discussions of subjects which are only dimly related to the day- to-day problems with which they are dealing with in the hospitals.

Mr. Anthony Nelson (Chichester) : In giving a strong welcome to these proposals, but questioning whether they go far enough, can I ask my right hon. and learned Friend to acknowledge that restructuring the system, replacing one allocation system by another or introducing budgetary independence does not in itself create net additional resources with which to satisfy the increasing demand for medical services of all kinds? Will he therefore keep an open mind about extending the tax relief that has been introduced for elderly people--which I very much welcome--not ruling out the possibility in the course of time of basic charges for hospital services?

Mr. Clarke : Plainly, we are injecting resources into the health system at the moment because we are reflecting rising demands for health care. Our proposals are not a substitute for more resources but are accompanying the extra resources which the Government are putting in from the taxpayer in order to make better use of the service. That is the way forward.

I do not agree with my hon. Friend on the general case for tax relief, largely for reasons which lie outside my direct province. I do not believe that the tax policy of the Government is to give tax relief for desirable forms of expenditure compared with others. We prefer a level of taxation which is low and gives the maximum individual choice to the taxpayer. However, the position of the retired, who often have contributed during their lifetime to health care, is different and it is defensible to say that to encourage, in the public interest, those people to continue in, or come into, private insurance is beneficial in effect for the general public. Several Hon. Members rose --

Mr. Speaker : Order. May I say to those hon. Gentlemen and hon. Ladies who have not been called that I shall do my best to ensure that they are given some precedence when we subsequently debate this matter.

Column 191

Points of Order

5.2 pm

Mr. Frank Dobson (Holborn and St. Pancras) : On a point of order, Mr. Speaker. Earlier, in response to queries from a number of my hon. Friends the Secretary of State said that hon. Members on the Government Benches had in their possession certain documents which could be obtained from the Vote Office. I am not suggesting that the right hon. and learned Gentleman was attempting to mislead the House, but what he said was not true. The White Paper was available in the Vote Office, but the abbreviated version distributed on the Government Benches--the idiot's guide to the White Paper--was not available either in the Vote Office or in the Library. Even the DHSS press office was unable to say when it would become available, although it believed that it was intended to be made available at the Secretary of State's press conference.

I should be grateful, therefore, Mr. Speaker, if you would inquire into how the custom and practice of the House came to be breached in this way, so that pamphlets printed at public expense were distributed on the Tory Benches but not on the Opposition Benches, and make sure that this does not happen again.

Mr. Speaker : It is not my responsibility, but the Secretary of State will have heard what has been said. I hope that it will always be the practice for the same documents to be equally available to hon. Members on both sides of the House.

Mr. Tim Yeo (Suffolk, South) : On a point of order, Mr. Speaker. Will you also, if you are going to undertake such an inquiry, inquire why the document that was available to the hon. Member for Livingston (Mr. Cook) was not also made available to the House?

Mr. Speaker : That is equally a matter for others, not for me.

Mr. Joseph Ashton (Bassetlaw) : On a point of order, Mr. Speaker. Could I draw to your attention the fact that every Privy Councillor you called this afternoon and every spokesman for the minority parties immediately walked out once they had asked their questions? This showed their concern about this matter. The rest of us stayed for an hour and a half. Can you bear this in mind when you give them some sort of preference in the future?

Mr. Speaker : I also have to bear in mind those hon. Members who seek to make interventions from a sedentary position during a statement.

Mr. D. N. Campbell-Savours (Workington) : On a point of order, Mr. Speaker. Are you suggesting in that statement to the House that those of us who may have intervened from a sedentary position will be penalised when you select on the next occasion on which these matters are debated? If so, a very important precedent is being set today. I have sat for two and a half hours in this

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