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Dame Jill Knight (Birmingham, Edgbaston) : A fool has infinite capacity for self-deception and a knave has infinite capacity for deceiving others. Far be it for me to accuse the British Medical Association of being either of those things, but I cannot understand why it has chosen to misinform, to mislead and to misquote the Government's review to its own members and to the country. The BMA's version of "Working for Patients"--I have read it carefully several times--is a travesty both of the Government's report and of the true situation. I shall not say what I think, but I shall say what is in the BMA's review and point out where it contrasts clearly with what is in the Government's plan. In several places the BMA's review speak as though underfunding is normal. If the facts are repeated often enough everyone will believe them. The BMA speaks of the underfunding of the Health Service--we have heard
Column 225that again today--when we are pouring money into the Health Service like Croesus, Midas and the IMF all rolled into one.
We heard again from the hon. Member for Peckham (Ms. Harman) that tired old fable that more money is being spent on the continent than is being spent here. If we do not add the amount of money that people are spending on their own health and are not receiving from the taxpayer at all, one can happily come up with an answer like that, but it is not an accurate answer.
In fact, our expenditure and our plans for putting more money into the Health Service are following a far steeper graph than anywhere else on the continent. We are doing much more for health care. I am proud to mention that, and even to boast about it. I know that Opposition Members hate hearing this, but when we came into office expenditure was £7,000 million per annum and it is now more than £26, 000 million per annum. That is a large sum in anyone's
language--except the BMA, which does not even notice it. Despite that immense increase, all that the BMA talks about is underfunding. I sometimes wonder whether the BMA would consider any sum worth mentioning as even adequate.
In paragraph 2.4 of the document the BMA goes even further. It keeps up its reputation for frightening old ladies by saying that the Government's main proposals in the White Paper are to
"reduce the level of public expenditure"
for health care. I was horrified to read such an accusation. I searched the Government White Paper from cover to cover, from back to front, upside down and inside out, and there is not one word to indicate any such thing. It is a lie. Does it even make sense? Mr. Alex Salmond (Banff and Buchan) rose --
Dame Jill Knight : No, I shall not give way. I am trying not to be too long and I give notice that I shall not give way to anyone. The BMA's version of "Working for Patients" says that doctors will run out of money to treat patients. That is utter nonsense. The BMA says that doctors will have to take on more patients than they can possibly cope with. That is absolute rubbish.
Dame Jill Knight : The hon. Gentleman might do the Government the courtesy of reading the White Paper, which says what the plans are. It is no use Opposition Members talking about what they would like it to say. They will have to read what it says. Conservative Members are not fools. Could anyone in his right mind imagine us doing anything to harm the National Health Service? [ Hon. Members :-- "Yes."] I am glad to have had that extraordinary reaction from Opposition Members--it shows that they do not know anything.
Column 226great deal about it and, as our efforts have shown, we have repeatedly given more and more money to it. That is how we shall continue.
The paper published by the BMA speaks of the
"present uniform distribution of specialist services throughout the UK".
What "uniform distribution"? Where has the BMA been all this time? There is ample evidence of a wide variety of services up and down the country. Why does the BMA pretend otherwise? Why does it give us this rubbish about
"present uniform distribution of specialist services"?
The Government are anxious to achieve such a uniform distribution of specialist services, which will be available to everyone. The Government are working towards that goal, not jettisoning it. In paragraph 2.7 the BMA states :
"Extreme pressure is being put on health service managers, consultants and other hospital staff to seek self governing status for hospitals"
That is another lie. No pressure is being exerted on hospital managers or consultants. If the Government were exerting pressure, extreme or otherwise, why on earth would they include conditions? One cannot exert extreme pressure and then say, "but the conditions are this, that and the other." The White Paper makes it absolutely plain that there is no question of pressure being exerted. Hospitals will be able to choose what they want to do. If the Government intended to exert pressure, why does the White Paper say that hospitals must be interested in achieving self-government? One cannot have it both ways. The Government have made it plain that before any decision is made about self-government the option must be wanted by the particular hospital. That is not equivalent to forcing hospitals to adopt self-governing status.
There is no more pressure on hospitals to go independent than there is on general practitioners to become budget holders, as the BMA suggests. Recently a banner headline in a west midlands newspaper said proudly :
"Birmingham family doctors will refuse to carry out the Government's plans"
All along, the Government have made it perfectly clear that doctors are entirely free to decide whether they wish to become budget holders. The hon. Member for Peckham was wrong--there is no hidden pressure on doctors. That is not to say that their expenditure will not be monitored, and so it should be.
Some doctors prescribe 50 per cent. more drugs than others with exactly the same case load. Some doctors send 20 times more patients to hospital than others, again with the same case load. What is wrong with monitoring doctors and asking why a particular doctor sends so many more patients to hospital? I know of a young woman who was put on valium by her doctor and stayed on it for seven years without any medical examination at any time. She was simply given repeat prescriptions. [Interruption.] Opposition Members may not like what I am saying, but that is a ludicrous situation and it must be stopped. The Opposition clearly do not want to do anything about it. It is right to monitor the amounts of money spent by different doctors and the reasons for that expenditure. It would be thoroughly irresponsible of the Government not to try to get all practices to run as efficiently as the best ones. The best ones are extremely good, but I am appalled at what some of the bad ones do.
In this connection, I draw the attention of the House to a leaflet which has been distributed in Poole. A copy of it
Column 227was brought to the House by my hon. Friend the Member for Poole (Mr. Ward). Hon. Members should know that there is a skull and cross-bones at the top of the leaflet. I thought it had something to do with pirates, but dear me no--it is a health warning. It says : "The Government is about to force dangerous changes on the National Health Service. They are going to put strong financial pressure on family doctors to give you fewer medicines, give you cheaper medicines, cut down on your hospital tests, cut down on your hospital treatment"--
[Hon. Members :-- "That is true."] If the Opposition believe there is a scintilla of truth in that, they are out of their tiny minds. It continues :
"Dangerous illnesses will be discovered and treated too late. People will die."
That has been published by a profession which has already said that it will not agree to advertising. Yet it apparently agrees with handbills which contain lies being directed at sick, old and frightened people. That is monstrous, and it is all of a piece with the deplorable BMA document.
In one respect, my right hon. and learned Friend the Secretary of State has brought trouble on his own head and contributed to the misunderstandings. I was astonished by accusations in the BMA paper that the Government are "rushing through" far-reaching and complicated reforms. The reforms are far -reaching and complicated, but they are not being rushed through. We all know that we shall not see a Bill until November or December at the earliest.
I have tracked down the source of some doctors' concern about this. In the first of the working papers the Government say that they intend to complete discussions by May. The whole thrust of the BMA's Luddite paper is to put the worst possible interpretation on the proposals and to suggest that the Government are rushing them through. That is not true, of course, but I wish that those words had not been used in the working paper as they suggest a lack of consultation.
Consultations are taking place. I know of no hon. Friend who is not having meetings every week with doctors or consultants in his constituency. We want to hear everything and we want to listen--that is what I call consultation. There is no question of rushing anyone as we have plenty of time. The BMA's interpretation of the proposals suggests to its members that the BMA's interpretations are fact. The words "might", "maybe", "possible" and "perhaps" are used right through the document--in one paragraph there were four "coulds" and a "might". It is infinitely better to have statements of fact than interpretations of the worst possible kind.
Another part of the BMA paper expresses concern that family practitioner committees
"might be filled by individuals with no experience of the primary health care services".
Why on earth would we be likely to appoint such people, especially as the paragraph directly opposite complains that the Government intend to appoint health authority members who
"reflect the strength of skills and experience' that the member could bring to the work of the health authority".
The BMA cannot have it both ways, but by golly it certainly tries. I will take on a fair and honest political battle any day of the week. What I deplore about the BMA's misleading attitude and actions is that it knows perfectly well what the Government are driving at. It even acknowledges in some parts of the document that those objectives are absolutely right. The BMA forgets itself several times in the
Column 228document and it says that the Government's objectives are right-- [Interruption.] Opposition Members should be careful. They have obviously not noticed how much of the White Paper the BMA considers is a good idea. That is made plain in its document. That is in there, too.
The worst part of all this is that members of the BMA are obviously being encouraged to mislead and frighten their patients. Our reforms have nothing to do with privatising, starving or ending the Health Service ; they are about strengthening, extending and financing--
Dame Jill Knight : I do not give a damn about private practice. What I do give a damn about is that people outside this place should have the freedom to spend their money in the way that they wish. If they want to spend their money on health care, what has that to do with the hon. Gentleman? Why should he poke his nose into the way they choose to spend their money? What we are interested in is that there should be the best possible Health Service for sick people who need it, whether they can afford to pay for it or not--and it is because those are the aims of the Government that they will succeed, come what may from the Opposition.
Mrs. Alice Mahon (Halifax) : I am happy to follow the hon. Member for Birmingham, Edgbaston (Dame Jill Knight), and I hope I can put her right on one or two things which are certainly not the case. Her interpretation of what the BMA says is not the same as mine. This White Paper is not working in the interests of patients. Indeed, organisations working for the National Health Service have all told me that they are quite insulted by the title of the White Paper, in that it implies that they are not working for patients now. Nothing could be further from the truth, and many of these organisations have worked under a great deal of stress, thanks to Government policies over the last 10 years on the National Health Service.
This White Paper is not just another reorganisation ; it is something quite different. My hon. Friend the Member for Peckham (Ms. Harman) said it has turned out to be a monster, and that is absolutely true. She has been to America and studied in detail the system there, so she knows what the effect of the White Paper will be on the future of the National Health Service. It is about ending the National Health Service as we know it. [ Hon. Members :-- "Rubbish."] Oh, yes it is. It does not address the real problems of the National Health Service : under-funding, waiting lists, and the disgraceful segregation of the elderly which has gone on over the last 10 years. We have seen wholesale privatisation of the care of the elderly, something that hon. Members opposite should be deeply ashamed of. The White Paper does not address the lack of care for the mentally ill and mentally handicapped. In fact, the disgusting emphasis of the White Paper is on competition, markets, buying, selling, incentives and assets-- dehumanising terms when talking about care, but certainly reflecting the Government's values.
What is missing from the White Paper is any notion of the National Health Service as we would like to see it, as it once was, and as it was envisaged by its founders : care and compassion, the alleviation of pain, and an end to
Column 229suffering, regardless of the ability to pay. Most of it is focused on ending the basic character of the National Health Service. It is an extremely obvious prelude to full privatisation after 1992, and we on the Opposition Benches are not fooled at all ; should a Conservative Government be elected then, that is what we will get. Looking at the detail of the White Paper, I am shocked by the absence of local control and planning, because the district health authorities will essentially disappear. Paragraph 3.20 of the White Paper virtually announces the end of district health authorities. As the acute hospitals become self-governing, we are told that it will be the responsibility of those placing contracts to monitor their performance in providing agreed services. That is absolute nonsense, because the reality is that most district health authorities will possibly go, and where one remains in existence, it will be seriously weakened, and no monitoring of any authority is built into the White Paper.
I have read all the discussion documents, and it is only the training of junior doctors which will be monitored by the royal colleges. There is talk of questionnaires and follow-up surveys, but it is misleading to talk about monitoring by health authorities, because they will be either extinct or seriously weakened. As my hon. Friend the Member for Peckham said, the capital arrangements are quite dangerous for some hospitals which might be tempted to opt out. The claim in the Prime Minister's introduction that the National Health Service will be financed mainly by general taxation looks like a very flexible and unreliable commitment. The delegation of operational money and increasingly large capital schemes to trust hospitals will encourage opting out, despite the Minister saying it is not true. There really is an arm-twisting operation going on, with lots of carrots being dangled ; offers of a great share of the new market in hips and hernias and the like are being made.
I put it to the Minister that these trusts may be called the National Health Service but that that will soon become meaningless ; despite what the hon. Member for Edgbaston said in her passionate address, hospital services will be subject to jungle law, because the hospitals which compete less successfully will slowly but surely lose patients, funds, reputations and staff, and communities will lose their hospitals.
One cannot have a free-standing accident and emergency department. I asked the Prime Minister and the Minister of Health for an assurance that Calderdale area health authority will not lose its accident and emergency service, and I received wriggling and sleight-of-hand answers, which is the technique this Government use when they do not want to be frank. But, reading those answers, it is clear that there is no guarantee that Calderdale will retain its accident and emergency service and the health authority or hospital trust may have to buy that service from Bradford or Burnley, thus putting life and limb at risk.
We may have thought that the arrangements under which schools and housing might be permitted to opt out were bizarre and undemocratic, but if we consider paragraph 3.15 in the original document, which mentions that a group of staff or people from the local community might initiate the process or respond to any initiative taken by the Secretary of State to form a hospital trust, we realise
Column 230what a sham any democratic consultation about these hospitals is. Paragraph 3.19, which talks about adequate publicity for trust formation, really does not comply with any notion of consultation as we all understood it.
My district health authority is under the direction of a politically appointed chairman, a Government lackey, who does the bidding of the Government on every instruction to cut and has done for years, and a district manager, a redundant manager from British Steel, who was thrust upon us and has proved an unmitigated disaster for our local health services. Any of these people can say to the Secretary of State, "We want to opt out," and the Secretary of State himself, as I understand it, can say, "I believe you should opt out." There is absolutely no sense of fairness or democracy in that at all.
This is not their Health Service. What right has a redundant steel manager, who now manages our local health service--very badly, in my opinion--to say that he will move us on the road to privatisation? He has no right. I worked for the Health Service for 13 years and I have more right than he to take decisions about our local services. I at least put my blood, sweat and toil into the Health Service. I cared very much for it. The bizarre and quite undemocratic notion of opting out will meet great opposition. The public will perceive it as so unfair that it will be a non-starter.
The hon. Member for Edgbaston referred to the BMA and what she thought were its unfair objections to the White Paper. As a member of the National Union of Public Employees, I worked actively for the benefit of staff in the National Health Service for many years. I was also an auxiliary nurse in the NHS. I did not often find myself on the same side as the BMA. Mostly the BMA is on the Government's side, not on the side of the rest of us in political terms. However, there is nothing iffy about the objections voiced by the BMA in Halifax to the White Paper :
"A large proportion of patients will not be able to travel to hospitals outside their locality. Many patients and their relatives cannot afford to pay for fares involved ; they will certainly find it highly inconvenient.
For hospitals to provide a competitive quote' for any service, corners will be cut, for example, skimping on investigations or reducing in-patient times increasing the likelihood of problems for the patient."
If a patient has been investigated at one hospital, but the treatment is cheaper at another hospital, will the patient need to be transferred?
Many questions are raised about patient care. With regard to general practitioner services the Halifax division of the BMA states :
"Concern was expressed that no pilot-study had been carried out, or is proposed, to see if the GP budget-holding is feasible." It continues :
"Reduction of the basic practice allowance is likely to cause fewer vacancies for women doctors, who commonly work less than full-time while they have a young family.
The proposed budget-holding GPs will have no incentive to screen patients as any pathology found might cost some of his/her budget. Patients on expensive treatments might find doctors reluctant to accept them because of the financial implications.
GP budget-holders will have difficulty controlling their budget because of the open-ended nature of GP services. GPs cannot refuse service to patients on financial grounds."
There are many more specific objections from the BMA.
Column 231The idea that GPs require a different structure to provide them with incentives to practise better medicine is abhorrent and insulting. The emphasis of the White Paper is clearly on finance instead of patient care.
Cash-limiting primary health care will be hugely disadvantageous to the people who really need help--the old and the chronically sick. Far from criticising the BMA, GPs, nurses, hospital workers, consultants and all the other decent organisations which have put patient care first and objected to the proposals, the Opposition applaud those people roundly and soundly.
The National Health Service is suffering from starvation caused by under- funding. If Conservative Members were not blind, they would see the headlines in the press about this. On 13 April, I read a headline which stated :
"Patients are dying because Calderdale does not have its own specialist heart unit."
The report continued :
"the inevitable delays mean that many die, according to a report by Bradford Cardiologists."
The report states that roughly 11 per cent. of people waiting for an operation die.
If the Government were really serious about doing something about the Health Service, they should address that obscenity. They should not be trying to restructure something which does not require restructuring. The White Paper has little if anything to do with organisation or restructuring. The Health Service has been kept going, while the Government have been bleeding it to death, by the motivation of individuals and the dedication of those who work for it.
The Guardian said that the White Paper has met
"a wall of professional opposition"
"to look more impregnable day by day."
I believe that the opposition will grow. This is just the start. I welcome the debate and I believe that the White Paper will be defeated because it is about ending the National Health Service. The public have rumbled that.
Mr. Ray Whitney (Wycombe) : This is a very sad day for what remains of the Social Democratic party. In its very short history it has had many sad days, but I believe that the contribution from the right hon. Member for Plymouth, Devonport (Dr. Owen) who sadly cannot be with us any longer, marked the nadir of that party's troubled life. Possibly that has something to do with the right hon. Gentleman's personal history. However, it is particuarly sad because when that party was formed many Conservative Members, without any temptation to join it, welcomed it because it might offer an alternative to the tired Socialism and faded Marxism of today's Labour party. We hoped that it would offer open minds and new ideas. However, today we heard a speech from one of the most closed minds on this issue. The speech was totally lacking in new ideas.
The right hon. Member for Devonport suffers from what across the Channel might be called a professional deformation. That is to say, as a professional medical man, he shares the short-sightedness which sadly seems to afflict so many professional medical people in this country. They seem to be wilfully ignorant of the standards and what is being achieved in other parts of the world. They are totally cocooned and complacent about what the National Health Service can or should offer. When they look overseas, they
Column 232choose only the worst of the American experience, and ignore the very impressive best. They also ignore the enormous gaps growing in many areas between the standards on the continent and the standards which we can offer here now, with the great impact of the resources which the Government have invested in health care over the past 10 years.
The hon. Member for Devonport also suffers from a personal sense of guilt. He attacked fiercely the fact that we now spend--I believe he said "only"-- 6 per cent. of our national GDP on health. He seemed very anxious to forget the fact that when he was a Minister with responsibility for health, we spent 4.8 per cent. of a very much smaller GDP. That takes a lot of living down for someone who had any responsibility for the Health Service.
The right hon. Member for Devonport also made great play about the present flurry from the medical profession, including the royal colleges. Although he admitted that such flurries had happened before, he suggested that they were happening now at absolutely unprecedented level. A short time ago, the presidents of the royal colleges and the deans of the medical faculties issued a statement which said :
"The ills within the NHS are serious and by threatening standards threaten the health and well-being of the community. There is a real danger of standards deteriorating to a point from which recovery will be impossible within a foreseeable term."
That statement was issued by the presidents of the royal colleges and the deans of the faculties in October 1974, when the right hon. Member for Devonport was a Minister responsible for health. Therefore, he should understand that this is not a new problem. It is a problem that has been developing. Indeed, it has been developing during the past 10 years, despite the resources that we have provided. I will not rehearse our record yet again, but it is a proud record--a record of commitment to a comprehensive, universal Health Service. But, clearly, more and more funding is not enough. On the Jimmy Young show about 12 months ago, the hon. Lady said :
"We need perhaps another £200 million, and then the problems of the health service will all be over."
Since the hon. Lady said that, we have produced billion after billion after billion, and, of course, we still have the problems. We know why. My hon. Friend the Minister of State, Deparment of Health enumerated the problems : the aging of the population, technical innovations and their resource implications, and rising expectations and aspirations.
These are serious problems that have to be dealt with seriously, but they are not being dealt with at all by members of the Opposition parties. Those Members are applying closed minds, totally ignoring what we have done and the fact that, in addition to more funds, which are coming forward thanks to the strength of the economy, we need structural and organisational changes. It is monstrous that, after 40 years, including the period when the right hon. Member for Devonport had some say in these matters, the sensitivity for resource management in the National Health Service should be virtually non-existent.
Happily, in recent years, we have had the resource management initiatives, the Korner report, and one or two other things, but we have a long way to go. But we cannot go that way unless mechanisms are put in place, and that is precisely what the reforms now proposed are intended to
Column 233do. The suggestion that this involves the break-up of the National Health Service is nonsense. What it involves is doctors, nurses and others concerned taking a much more concrete interest themselves in the disposal of the available resources.
The right hon. Gentleman did at least have the grace to recognise that resources are finite. I will not say that demand is infinite, but certainly it can never seriously be contained. It is much more sensible that judgments about the allocation of resources should be made not at the level of the Chief Secretary to the Treasury or the Secretary of State for Health, but, to the best possible extent, in the surgery by the general practitioner, by the professional who knows. It is the professional who has the greatest insight, the best judgment and the most experience. Likewise, he must be much better equipped to judge which hospital his patient should go to. This is the essence of the proposals, which will bring great benefits to the consumer--and I do insist that we are consumers and customers, not just patients.
One of the unfortunate features of the Health Service, great though it is in many respects, is that in too many areas patients are pushed around. They have to wait here and wait there. This is the wrong atmosphere. Consumerism is growing and developing in so many other areas of life. Indeed, the Social Democratic party would consider that it is in the van of consumerism--but not in respect of the sacred cow of health, because it lacks the political courage to tackle the problems, as, of course, do all the other parties opposite. I urge my right hon. and hon. Friends on the Front Bench not to be discouraged by the extraordinary performance of the British Medical Association. They should take comfort from the fact that there are many historical precedents. Every time a Government in this country have sought to improve the National Health care system, they have been opposed by the medical professions and their organised bodies. Those people opposed Lloyd George's National Insurance Act 1911, until they discovered two years later that it benefited them. They were the only people who opposed the coalition White Paper put forward by Henry Willink, the Conservative Minister of Health in 1944. We all know that their opposition to the Aneurin Bevan proposals were silenced only when, as we have been reminded, their mouths were stuffed with gold. Most of us in this House remember their ferocious opposition to the 1984 selected list, which we all now know is a great success. In all those cases, after fierce opposition for a year or two, the medical profession came round. I hope that it will not take so long this time.
Mr. Simon Hughes (Southwark and Bermondsey) : I welcome this debate, and I welcome the opportunity to speak specifically to one aspect of it, in my role as the Member of Parliament representing Guy's hospital, which is thought to be the hospital with the strongest desire to become a self- governing hospital trust. It may interest the House to know that, when it comes to a vote tonight, there is not one thing in the motion as tabled by the right hon. Member for Plymouth, Devonport (Dr. Owen) with which
Column 234my hon. and right hon. Friends and I do not agree. We shall therefore vote with the SDP and, as I understand it, the Labour party, at the end of this debate.
We shall be voting with the other Opposition parties because the people represented in those parties are the successors to those who supported the idea of the Health Service both in concept and in legislation, in the 1940s, when the Tories opposed it. We believe that the Tories' commitment then, which was noticeable by its absence, to the provision of a free Health Service--free at the point of delivery for all, without distinction- -is matched by their lack of commitment now.
I would point out to the hon. Member for Birmingham, Edgbaston (Dame J. Knight) that the evidence for that is that there is not equal choice for all. This year, her Government have introduced tax incentives for people, if they are of pensionable age, to go to the private sector. Her Government have always allowed the private sector to benefit from training that is paid for out of the public purse. The reality is that, over and over again, it is the Tory Government who push towards the private sector people who would--given a fair choice--far rather remain in the public sector.
Many of the people who may be contemplating going into self-governing hospitals as consultants are doing so not because they support the idea, but only, as the hon. Member for Peckham (Ms. Harman) said, because they believe that if they jump quickly, if they jump first, the Government will make sure that they are protected, whatever happens to the rest. They are doing so not out of conviction but out of concern for their self- preservation. That is a cynical--understandable, but cynical--way of justifying any argument that they support the Government's proposals.
It is not right to say, as the hon. Lady argued, that the Government are not encouraging people to move in the direction of being independent within the Health Service. The working paper on self-governing hospitals says :
"The Government believes that self-governing hospitals will have a major role to play in improving services to patients. It will therefore encourage as many hospitals as are willing and able to do so to seek self-governing status as NHS hospital trusts. The Government aims to establish a substantial number of trusts with effect from April 1991."
There is no doubt that the Government will encourage, push and contrive to make sure that, if possible, there are at least some flagships sailing into the new sea of the private Health Service after the next election. Whether they succeed is yet to be determined.
I accept the argument of the hon. Member for Wycombe (Mr. Whitney) that in this sort of debate it is not necessarily best to pray in aid those who traditionally have been difficult to please when reform has been mooted for them and their profession. The BMA has argued against reforms in the past. Inevitably, it sees things from its professional point of view. I do not think that its members are necessarily the best people to cite as advocates for a case that one seeks to argue here. One has to argue from principle and from the point of view of the public at large.
I must tell those hon. Members who believe that the users of the Health Service will not represent the greatest patient difficulty that the enormous majority of them are strongly opposed to the Government's plans. They believe