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not that there is just a scintilla of truth in leaflets such as that which the hon. Member for Birmingham, Edgbaston (Dame J. Knight) cited as coming from Poole, but that there is a flotilla of truth in the allegations and assertions made in such documents. They believe that the Health Service is not safe in the Government's hands. Mr. Day rose --

Mr. Hughes : I shall give way in a moment if I have time. Those who usually look to Guy's hospital as their local district hospital have specific reasons for concern. Many aspects of the White Paper are worrying, but those which worry people in south-east London most are those which are likely to change the nature of Guy's hospital and its quality of care. Guy's is at the forefront of those reported to be interested in becoming a self-governing hospital trust. However, many at Guy's, from the most senior to the most junior, are resolutely opposed to opting out. Many have written expressing their views. Even those who have said that they support the idea, among whom are some on the management board, have many crucial questions about self-governing yet to be answered by the Government. The Government have not yet convinced Guy's--far from it. Just like the other five hospitals which are part of the resource management initiative, all of which have opposed the ideas in the White Paper, Guy's hospital has also not come out in support because it is not yet satisfied that its specific questions and concerns have been answered, some of which have even been put forward by advocates of the White Paper, one of whom was an adviser to the Prime Minister on these matters.

There is no guarantee that the introduction of market forces as proposed will in anyway improve care. On the contrary, there is evidence that unprofitable patients will become unpopular patients. In my area, where more than 25 per cent. of the community are pensioners, the probability is that in the long term Guy's will not be able to look after them and they will have to go much further away.

An increasing number of constituents in an inner city are likely to be elderly. On my last visit to Guy's I asked what would happen when they are admitted and could not be returned to their homes after an operation or treatment because they could not cope on their own. I was shown a graph of the profits to be made from the hospitalisation of an old person. After the initial operation or intensive care, profits begin to tail away to little or nothing. In order to prevent an old person blocking a bed, the hospital might, after about 10 days, have to impose a surcharge on the district for keeping the district's elderly, non-earning patients in hospital. The district would not have catered for that surcharge because it would have gone to Guy's because it offered the cheapest contract available. Therefore, the district will not be able to keep in hospital an elderly patient who has had an operation, but will have to move the patient out or look for somewhere else for that patient to go. It is right that hospital beds intended for acute purposes should not necessarily be used for long- term convalescence, but in a place such as north Southwark there is nowhere else to go for long-term convalescence. We do not have nursing homes or long-term geriatric care facilities. If the last refuge, a bed in the local district general hospital, which also happens to be a regional national specialty,

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disappears, the Government will be saying to the elderly in a community such as that in south London and Southwark, "You must leave your community because we cannot pay for you here."

There is no profitable solution to the care of old people ; there are only caring solutions or uncaring solutions. With the district health authority forced to enter contracts on the basis of what will be the most economical, there is no hope of the less profitable services being expanded. The only answer will be out-of-town homes where residents will be far away from friends and families, inaccessible to visitors, isolated and alone. Commercialisation always has losers and the losers are always the weakest and most vulunerable in our community.

But care of the elderly will not be the only area to suffer. Centralisation will be inevitable as one hospital becomes known for a certain specialty. District health authorities will be powerless to prevent the services that they want to purchase being discontinued at one hospital and will be forced to go elsewhere. It is a twisted sort of logic to think that choice can be widened simply by a provider becoming a purchaser.

Anyone who has visited their corner shop knows that it does not work by providing everything because market forces do not allow it to do so. The convenience of the consumer does not mean that every shop has every product for sale. It will be the patient who has to travel away from his or her home and who will not receive continuity of care from the same general practitioner and consultant who will suffer yet again. Patients may have to go to Walsall for eyes, Maidstone for hearts and Southampton for backs because of the contract that the district has entered into. Many doubts still centre on whether it will be profitable for a local hospital to give a comprehensive service. The reality is that it will not be, and comprehensive local care in one's local hospital will be a thing of the past. What effects will the White Paper have on teaching? For Guy's to survive as a teaching hospital there needs to be a wide range of medical activity. What will happen if Guy's loses its core contract with the local health authority of Lewisham and north Southwark? In any year, market forces may determine that the contract goes somewhere else--to St. Thomas's, King's, Bart's, the London or elsewhere. Commercialisation will not provide the stable basis that is needed to give students a five or six- year medical degree course. What will happen to the future provision of skilled doctors if medical schools are struggling to provide adequate training in an uncertain environment? And will they spend a lot of money on training--an expensive commitment--which they will not easily be able to recoup?

Commercialisation means the end of a balanced service in other ways too. The good consultants will be bought by the hospitals that can afford them and other hospitals will become second class with second class staff. The test in the White Paper is what is cost-efficient, not what is best for care.

The White Paper speaks of consultants becoming more efficient managers. Nowhere does it speak of managers becoming more caring health providers. Everywhere profit will be the governing factor. The providers, the general practitioners and the health authorities, will not be able to rely on a consistently secure provision of services. The hospitals will not be able to rely on a consistently secure flow of patients. The patients will not be able to rely on

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consistently secure provision of care. The Opposition are right to be deeply cynical in their belief that the Government are intent on replacing care with profit as the motivating factor in the Health Service. I hope that Conservative Members will join us in voting for the motion tonight.

6.48 pm

Mrs. Gillian Shephard (Norfolk, South-West) : It is noticeable that the debate has been distinguished yet again by the continued inability of Opposition Members to give the Government credit for the record amounts now being spent on the Health Service. The nurses had an enormous pay award of almost £1 billion during the year, with an extra £2 billion being spent in the current financial year and an extra £2.5 billion planned for next year. The Government should give themselves credit for that extra spending and for the fact that our attention is now directed at the way in which those enormous sums of money are to be spent. I am sorry to note that Opposition Members apparently have no notion of the inequalities in the levels of provision across the country which the White Paper seeks to put right.

I mention in particular the new arrangement for the resource allocation working party. The abolition of RAWP will be welcomed in many rural areas with a high population growth, and especially in East Anglia, where the chairman of the regional health authority has said that that single measure will help East Anglian patients more than anything else in the shorter term. We hope that that wil be implemented rapidly.

The White Paper also seeks to remedy the poor quality of information about costings and quality of care within the Health Service, a matter frequently highlighted by the Select Committee. That too will be greatly welcomed by all the professionals working in the Health Service as a way of measuring the quality and evenness of care across the country.

In rural areas, patients are not always satisfied with the standard of service that they get from their general practitioners. Financial incentives will be given to general practitioners on a new basis for rural populations, for caring for elderly people amd for caring for children under five. Those and a great number of other incentives will do a great deal to bring the standard of service enjoyed by rural patients up to the best standard provided by GPs for their urban counterparts.

It may be of interest to Opposition Members to note that rural patients can perceive advantages in some of the provisions of the White Paper. If the new contract and the provisions of the White Paper can do anything to improve the attitude towards patients of a general practitioner who says that he does not need an appointments system because village people like talking to one another all morning, it will certainly have been worth while.

6.51 pm

Mrs. Rosie Barnes (Greenwich) : The debate has been set against a necessary Government review of the Health Service. The SDP has always welcomed the review. We were looking for a radical and imaginative overhaul of a system that has served us well for the last 40 years and that we want to serve us well for the next 40 years. We share

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many of the Government's objectives--at least the ones to which they pay lip service. We welcome an increase in patient choice, better rights for patients and a more consumer-related service. The SDP has long been committed to the internal market, but not necessarily the internal market that we see in the White Paper. We also welcome a better quality of service across the board, and structural and organisational changes.

The White Paper sets the wrong agenda. There is nothing on funding. In spite of the many protestations from the Government Benches, without proper funding for the Health Service, no amount of juggling or reorganisation will make it work. The Health Service is under-funded compared with our comparable European competitors. It has to receive a substantial influx of funds to make any subsequent reorganisation and restructuring work.

Also incorporated in the White Paper and in some of the Government's recent thinking is an erosion of the basic principles of free service at the point of use, funded entirely out of direct taxation. There are major gaps in what we have seen so far. There is no acknowledgment of the growing need of the elderly and no proposal to take account of how a Health Service that is already straining under pressure can cope with the increasing number of elderly in our midst.

One of the things that troubles me most about the review is the speed with which it is being implemented. Again, we have heard from the Government Benches that it is a leisurely process. I could not disagree more. We are looking at a radical review which is demanding new skills, new structures and new procedures. There are dangers in what will happen. We have heard the words "might", "may" and "possibly"--the changes might or may possibly have disastrous effects on the Health Service. One way to make sure that they do not is to pilot schemes and see how they work. The Government should proceed slowly, cautiously and carefully on the basis of proper information. I have a document from a leading city management consultant which addresses some of the problems. It deals with what regional health authorities, district health authorities and general practitioners will have to do. It is an extensive list. Due to lack of time, I shall read only a few of the items that it lists in relation to district health authorities :

"establishing the likelihood of hospitals becoming self-governing ;

specifying the volume and standards of service which will be required to meet local health needs ;

setting up and evaluating contracts for both core' and other services ;

establishing tight contractual arrangements within minimum and maximum service levels for the full range of services required by the DHA's population ;

establishing financial management systems which monitor contract expenditure and activity ;

establishing mechanisms by which quality of contract performance is monitored, and ensuring all providers have comprehensive quality assurance and medical audit programmes".

The list goes on and on. It is a complex list of serious things that need to be done properly in order to get the service right. We have before us not only an impossible time scale but a programme that is being implemented without proper consultation and without the good will and support of the

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innumerable tiers of staff who have to carry out the procedure. The White Paper has provoked at best quiet resentment and at worst open hostility.

Severe and major strategic changes, which should be implemented sequentiously, are proposed. We should ensure that the cost and quality information is available well in advance of the procedure starting. There is no point in saying that we will go ahead on the basis of incomplete or incompetent information and, if we get it wrong, so be it. We are dealing with people's lives and with a Health Service that has been built up over the years. I agree with some Government Back Benchers that the current debate is taking place against a background of many successes that have often been overlooked while we focused on the failures.

The time scale for the review should be five to 10 years. We should move slowly and surely to get it right. There is a need to develop business plans and to acquire and use marketing and contractual skills. There is also a need for capital accounting. The whole procedure will need new skills. For all that to be done within two and half years is nothing more than a joke.

I support the resource management initiative, clinical audit and the use of information technology, but the way it is all being picked out of a hat and offered to the Health Service as a panacea for all evils makes the whole process unrealistic when the people, the resources and the structures are not there. Information technologists are an expensive breed. Many hon. Members will have spoken to hospital technicians who can all double or even treble their salaries overnight outside the Health Service. This scheme will rely on those self-same experts being in the Health Service, with no extra resources to pay for them. It just cannot work.

I prefer to speak in terms of patients' rights when considering the internal market. The SDP's version of the internal market was triggered by patients. It was based on offering patients a choice of a faster service in another hospital or in another health authority. But it would be up to them to make the choice. Because it was a choice, it was a carrot rather than a stick. It was not a cheap option, it was not punitive and it was not a cost -cutting exercise. The review will have disastrous consequences for the NHS.

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

The House divided : Ayes 77, Noes 230.

Division No. 161] [6.59 pm


Archer, Rt Hon Peter

Barnes, Harry (Derbyshire NE)

Beckett, Margaret

Beith, A. J.

Boateng, Paul

Boyes, Roland

Campbell, Menzies (Fife NE)

Campbell-Savours, D. N.

Carlile, Alex (Mont'g)

Clark, Dr David (S Shields)

Clay, Bob

Clwyd, Mrs Ann

Corbett, Robin

Cryer, Bob

Dalyell, Tam

Davies, Rt Hon Denzil (Llanelli)

Davis, Terry (B'ham Hodge H'l)

Dixon, Don

Duffy, A. E. P.

Ewing, Mrs Margaret (Moray)

Fearn, Ronald

Fields, Terry (L'pool B G'n)

Fisher, Mark

Flannery, Martin

Godman, Dr Norman A.

Golding, Mrs Llin

Gordon, Mildred

Harman, Ms Harriet

Haynes, Frank

Heffer, Eric S.

Howarth, George (Knowsley N)

Howell, Rt Hon D. (S'heath)

Howells, Geraint

Hughes, John (Coventry NE)

Hughes, Simon (Southwark)

Johnston, Sir Russell

Jones, Martyn (Clwyd S W)

Kilfedder, James

Kirkwood, Archy

Livsey, Richard

Lofthouse, Geoffrey

Loyden, Eddie

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McFall, John

McKay, Allen (Barnsley West)

Madden, Max

Mahon, Mrs Alice

Meale, Alan

Michie, Bill (Sheffield Heeley)

Michie, Mrs Ray (Arg'l & Bute)

Morris, Rt Hon A. (W'shawe)

Mullin, Chris

Owen, Rt Hon Dr David

Parry, Robert

Patchett, Terry

Pike, Peter L.

Powell, Ray (Ogmore)

Quin, Ms Joyce

Rees, Rt Hon Merlyn

Richardson, Jo

Rogers, Allan

Rooker, Jeff

Ruddock, Joan

Salmond, Alex

Sheerman, Barry

Short, Clare

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