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House of Commons

Tuesday 25 April 1989

The House met at half-past Two o'clock

PRAYERS

[Mr. Speaker-- in the Chair ]

PRIVATE BUSINESS

Hythe Marina Village (Southampton) Wavescreen Bill

Penzance Albert Pier Extension Bill

Wesleyan Assurance Society Bill

As amended, considered ; to be read the Third time.

Buckinghamshire County Council Bill [Lords]

Kingston upon Hull City Council Bill [Lords]

Orders for Second Reading read.

Read a Second time, and committed.

Oral Answers to Questions

HEALTH

GPs (Contracts)

11. Mr. Jack : To ask the Secretary of State for Health what subjects have been raised with him by doctors making representations on the proposals for their new contracts.

7. Mr. Anthony Coombs : To ask the Secretary of State for Health if he will make a statement on the current situation in the negotiations on general practitioners' contracts.

12. Mr. Hunter : To ask the Secretary of State for Health what progress has been made in negotiations on general practitioners' contracts.

The Secretary of State for Health (Mr. Kenneth Clarke) : Discussions on the new contract have now lasted for more than 12 months. I last met the General Medical Services Committee negotiators on 20 March. In the light of the discussions my officials are now preparing amendments to the relevant NHS regulations and to the statement of fees and allowances, on which they will be consulting the General Medical Services Committee negotiators. A conference of local medical committees is being held this week and the negotiators will no doubt consider whether to seek any further meetings with me in the light of the outcome of that conference.

Mr. Jack : Will my right hon. and learned Friend confirm that in his future negotiations and deliberations on this subject he will take fully into account the representations made by many Conservative Members following meetings with their doctors, who have expressed


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concern about the contract? Will he also take this opportunity to put at rest the minds of the many patients who have written to me and my hon. Friends about the effects of the contract and assure them that the principles of the National Health Service will be maintained as a service free at the point of consumption with medicine supplied without let or hindrance because of budgets?

Mr. Clarke : I am grateful to my hon. Friend and to other hon. Members who have informed me of the views of the practitioners in their constituencies. We have taken on board many of the present representations which have already been made in the course of the discussions and we will certainly take on board all constructive representations now. I agree with my hon. Friend that it is most unfortunate that, in the course of negotiating the contract, some doctors have gone out of their way to cause needless alarm to patients, because no threats to patients will arise from this.

Mr. Coombs : Does my right hon. and learned Friend agree that there are 5,000 more doctors than in 1979, they are far better paid than ever before and the number of ancillary workers working for them has doubled, and therefore the disgraceful statements made in a pamphlet by the British Medical Association are often untruthful, alarmist and verging on the paranoid? Will he confirm once again that, under the proposed Health Service reforms, no patient will go without a comprehensive local health service, adequate drugs or appropriate treatment?

Mr. Clarke : I agree with my hon. Friend. We now have more doctors than before. They are better paid and their average list sizes have gone down. That is why it is right to concentrate on a contract which rewards fairly those who carry the largest work loads and one which also encourages new services for patients, which we offer in the contract. In contrast, the leaflet produced by the BMA to which my hon. Friend referred, contains scurrilous nonsense. It is a long time since I have encountered a trade union which is prepared to spend millions of pounds of its members' money on spreading untruths among its consumers in that way.

Mr. Hunter : In the light of a general practitioner telling an elderly constituent of mine that, under the new contract, he may not be able to treat her, will my right hon. and learned Friend emphasise the fact that the elderly will be well looked after under the provisions of the new contract?

Mr. Clarke : Yes. If such an allegation has been made--and of course, I accept what my hon. Friend has said--it is totally untrue. The contract is so designed to give extra payments to those doctors who take on elderly patients. The contents of the new contract that we are discussing include new services which are expressly aimed at elderly people to ensure that they--particularly those over the age of 75--have more regular contact with their GPs. The contract is designed to improve services to the elderly. It is scandalous nonsense to claim that any elderly patient is threatened by it.

Mr. Fearn : What representation has the Secretary of State received from women doctors? Does he not agree that the new contract could harm women doctors' practices, which tend to be smaller?


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Mr. Clarke : The contract proposals recognise explicitly the prospect for job-sharing. We also acknowledge the right for someone to have the full status of a principal when taking on part-time obligations. The contract is designed to encourage women doctors in general practice. An ever higher proportion of GPs will be women. The difficulties arise from the changes in basic practice allowance, not from the contract. They stem from the fear of some women that partners will not take on female partners unless the BPA is so constructed as to give all partners a financial benefit when a part-time partner is taken on. Women have no reason to be fearful of their colleagues' prejudice. Nothing in the contract would encourage that.

Mr. Dalyell : Are GPs to be cash-limited?

Mr. Clarke : No they are not.

Mr. Loyden : Does the Secretary of State accept that the only reassurance that he could give to National Health Service users would be to cease the stupidity of trying to transform doctors into accountants? The public's clear answer is that they want no part of this crazy scheme.

Mr. Clarke : Doctors are independent contractors. It is my duty, on behalf of the patient, to negotiate a contract which rewards heavy work load and encourages good performance. The rest of the population are paid according to the work that they do and the standards that they attain. Many doctors can see no reason in principle why the same criteria should not apply to general practice. The result of the new contract will be an improved service for the patients, because the best and most go-ahead practices will be rewarded. We shall also introduce into the contract up-to -date services in disease prevention, health promotion, and closer surveillance of young children and elderly people.

Dame Elaine Kellett-Bowman : Will my right hon. and learned Friend accept my thanks for putting at rest the fears of my 84-year-old constituent, who had been informed by his doctor that if this contract went through his doctor would no longer be able to visit him at home in a rural area?

Mr. Clarke : The new contract will place the doctor under an express duty to keep in touch with the elderly patient and keep himself well informed of his home circumstances. By its capitation payments, the new contract will pay the doctor extra to enable him to carry out that new duty. I can only assume that if the doctor in question has put out such information, he has been totally misled by the information from Tavistock square.

Ms. Harman : Is it not the case that a patient receives better care if a GP has more time to spend with each patient? Is it not going in completely the wrong direction to give financial incentives to doctors to have as many patients as possible on their lists?

Mr. Clarke : I quite agree that patients will wish to join practices that give them adequate time and care and, I hope, offer the new services, for which the new contract is an encouragement. With respect, the arguments about list sizes constitute a complete red herring, which has been put in the forefront of many of the discussions. Under this contract, there is no reason why anyone with an average size list should wish to acquire new patients. A doctor


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seeking to enhance his income would go for the new services and seek to hit the new performance targets. The hon. Lady and hon. Members on both sides of the House should not be misled by the simplistic argument that this is all about increasing list sizes. The new contract is aimed at raising the standards of general practice to the general public, and the best GPs will respond to that.

Working for Patients"

2. Mr. Pawsey : To ask the Secretary of State for Health how many representations he has received from members of the public about his White Paper "Working for Patients."

Mr. Kenneth Clarke : I have received well over 2,000

representations from members of the public, expressing a wide range of views. I shall take these into account as part of the process of implementing the proposals.

Mr. Pawsey : Can my right hon. and learned Friend estimate how many of those representations are based on complete inaccuracies? Will he join me in deploring the black propaganda circulating among so many of our constituents, and causing such fear and distress to the elderly? What further action can he take to reassure the British people that the White Paper will improve the Health service?

Mr. Clarke : I regret to say that a proportion of the representations that I have received are indeed based on inaccuracies. They come from two main sources. One is the campaigning literature about the contract, which suggests that somehow the elderly will be turned away and that other damage will follow ; the other is the Labour party, which is carrying on a private and eccentric campaign of its own, claiming that it is rescuing the Health Service from privatisation. I have never proposed its privatisation, and nor has any other member of the Government.

Mr. Wigley : Surely the Secretary of State accepts that all the GPs who are responding negatively to his proposals--as the overwhelming majority are--are neither paranoid, to quote the hon. Member for Wyre Forest (Mr. Coombs), nor scurrilous, to quote the Secretary of State. They are genuinely concerned about the future of a service to which they have given their lives, and it is time for the right hon. and learned Gentleman to respond more sensitively to their

representations.

Mr. Clarke : Very few GPs, I think, would challenge my aims of improving general practice. Very few do not accept, for instance, that we should seek to attain World Health Organisation standards of vaccination for children and should not get cervical screening to a level of 80 per cent., which will help to tackle the biggest single avoidable cause of death among women in this country.

I think that those aims have the support of the great body of responsible GPs, and it is a pity that their representatives believed recently that they were supporting their interests by putting around scurrilous leaflets. I hope that those representatives will now come back to discuss the serious aims of general practice with me and with my colleagues.

Dame Jill Knight : Are not so many GPs behaving as they are because they have been totally misled, misinformed and disinformed by their own leaders in the


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British Medical Association? Will my right hon. and learned Friend constantly try to fight off those lying attacks, particularly the claim that the aim of the review is to cut back expenditure in the National Health Service?

Mr. Clarke : The Government have increased expenditure on the NHS more than any Government. I assure my hon. Friend--if she needs reassurance --that all our plans for the future are based on the expectation that expenditure on the NHS will need to increase in line with rising demands and changes in demography.

Similarly, my proposals are not aimed at any cutting of costs in general practice, and are certainly not aimed at cutting the average remuneration of doctors. What we are seeking to do is use resources to the best effect for patients, and to use rewards for doctors in a way that encourages higher standards of service.

Mr. Leighton : Is the Secretary of State aware that I have conducted a poll among all the doctors in my constituency, in which 47 voted against his proposals and three in favour? Is he aware that their letters were accompanied by impassioned criticism of his proposals? What notice is he prepared to take of their

representations?

Mr. Clarke : I am meeting thousands of doctors, and so are my ministerial colleagues. We are taking serious account of all constructive representations put to us. It is pointless to consider accounts of straightforward votes of the kind to which the hon. Gentleman has referred unless we know whether they concern the contract or the White Paper ; if the White Paper, what part of it ; and what proposals they are putting forward.

I find that discussions with doctors who are seriously committed to the Health Service--as the great body of doctors are in this country--lead to much more productive results than votes, leaflets or the campaigns to which we have been subjected in the past week or two.

Patients (Treatment)

3. Mr. Knox : To ask the Secretary of State for Health how many patients were treated in National Health Service hospitals in the most recent year for which figures are available ; and what were the comparable figures for 1978.

The Parliamentary Under-Secretary of State for Health (Mr. Freeman) : Between calendar year 1978 and fiscal year 1987-88 total annual in- patient cases for England increased by 23 per cent. from 5.4 million to 6.6 million. Over the same period, day cases rose by almost million and out- patient attendances by over 2 million.

Mr. Knox : Does my hon. Friend agree that these figures provide the best evidence of the improvement and expansion of the National Health Service since this Government came into office because they show a substantial increase in the number of patients being treated?

Mr. Freeman : The figures underline the success this Government have had, with a 40 per cent. increase in real terms in expenditure on the National Health Service. For the year just commenced, there is a £2 billion increase in resources.


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Dr. Moonie : Can the Minister comment on the waiting lists in the corresponding period and say what he will do about them?

Mr. Freeman : Over the last 10 years, waiting lists have gone down by 8 per cent.-- [Interruption.] True. Regarding the west midlands, waiting lists in my hon. Friend's constituency and the surrounding region have gone down by 19 per cent.

Mr. Hayes : Is my hon. Friend aware that the South Glamorgan health authority has contracted out all its open-heart surgery to a private hospital in Southampton? This means that patients are getting speedy care absolutely free to the patients and at a lower cost to the National Health Service. Is that not precisely what we are trying to do in the White Paper?

Mr. Freeman : There are many examples--and doubtless there will be more--of good co-operation between the private and public sectors.

Working for Patients"

4. Mrs. Ray Michie : To ask the Secretary of State for Health what further representations he has received from doctors in rural areas about his National Health Service reform proposals in the "Working for Patients" document.

The Minister of State, Department of Health (Mr. David Mellor) : We have received a number of representations and will take them carefully into account in implementing our proposals.

Mrs. Michie : Will the Minister give details of the people and institutions that he consulted before he produced his White Paper document and proposals, particularly those in relation to rural general practices?

Mr. Mellor : I do not know whether the hon. Lady is referring to the White Paper or the contract. There were considerable discussions of the contract prior to its publication by the Secretary of State after no less than 12 months' negotiations with the doctors' representatives. That document includes most of the material about rural practices. The process of consultation has not yet ended. The Secretary of State has already made it clear that he and his fellow Ministers are meeting regularly with general practitioners, and we shall certainly bear in mind the points that they make on those issues.

Sir Michael McNair-Wilson : General practitioners' income is to rely to a greater extent on capitation. Will this not mean that doctors in rural areas will be rather worse off as a result of the change and, in those circumstances, should not the rural allowance be left in place?

Mr. Mellor : I do not believe that doctors will be worse off, because we intend to pay a rural supplement to recognise the particular problems of doctors in rural areas. There has been some concern because of the aged definition of "rural" used in some cases. Areas that are actually no longer rural have been benefiting from some of the rural payments. We believe that our policy will enhance the position of rural practitioners. All points to the contrary are being borne carefully in mind before we make our final decision.

Rev. Martin Smyth : I welcome that assurance, but is the Minister aware that there is great concern that the small


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rural practices which have been giving good service believe that they will be penalised under the new system? Will the Minister accept that the consultation time of 20 hours face to face in surgery may not really be a useful basis on which to work, especially when one allows for home calls?

Mr. Mellor : In making that determination, we have borne home calls in mind but, as I have said, all points are being considered. In a number of cases rural practitioners have smaller lists, and to make allowance for that we intend to pay an enhanced capitation fee for practices between 500 to 1,500. In the exceptional circumstances of highly rural communities, where it is justifiable that the practitioner has under 500 patients, it might be possible to pay such a person under the inducement payment scheme, which recognises the exceptional problems of highly scattered areas. I hope that in that respect we shall ensure that rural practice is enhanced and not diminished by our proposals.

Mr. Bill Walker : Will my hon. and learned Friend accept that in the rural areas the quality of medicine, and particularly the motivation of the general practitioners, has been very high, because the quality of life has encouraged good GPs to take up practice? There is nothing to the contrary in the Government's White Paper. Certainly the proposals we have for Scotland show clearly that all this is taken on board and we shall continue to enjoy this quality of service.

Mr. Mellor : I warmly endorse my hon. Friend's remarks.

NHS (Leicestershire)

5. Mr. Vaz : To ask the Secretary of State for Health if he will make a statement on the state of the National Health Service in Leicestershire.

Mr. Mellor : Leicestershire has benefited substantially from the extra money that the Government have made available--almost £200 million this year to Leicestershire health authority compared with £177 million last year, which is a real terms increase of some 2.4 per cent. There has been a substantial investment in new and improved facilities, including a new community hospital at Coalville opened in 1988 at a cost of £3.3 million, and further phases of Glenfield general hospital and Leicester royal infirmary, which are due to open in August 1990 and July 1991 respectively.

Mr. Vaz : Is the Minister aware that, despite those mythical millions, currently 16,000 Leicestershire people are on the waiting list, more than 1,000 of whom have been waiting for longer than one year? Is he aware also that in Leicestershire, it takes 12 months to have a hearing aid fitted after referral from a GP? The Leicester royal infirmary has overspent its budget by £750,000 to protect local hospital services. Is the Minister further aware that last Friday I met general practitioners in my constituency, many of whom were lifelong supporters of the Conservative party, and many of whom said that their patients will suffer and in some cases die if the Government's doctor-capping proposals are brought into effect? When will the Government defend the National Health Service rather than destroy it?


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Mr. Mellor : There can be nothing mythical about the work being done at Glenfield and at Leicester royal infirmary, which will result in 700 new beds at a cost of more than £30 million. There can be nothing mythical about the fact that in the years 1982-86, some £47 million was spent on capital works in that district. However, there was something mythical about capital spend in the late 1970s under the Labour Government, when only £1 million was spent in 1978-79. We have increased that figure tenfold every year.

Mr. Latham : Is my hon. and learned Friend aware that Rutland people warmly welcome the offer of my hon. Friend the Under-Secretary of State for Health to visit Oakham and--in view of Leicestershire health authority's regrettable decision to close Oakham maternity unit--to talk to people there about rural services? Can an early date be set for that visit?

Mr. Mellor : My hon. Friend the Under-Secretary of State is for ever using his Away Day ticket to travel to such meetings. It is a regrettable fact that when there is massive capital expenditure on major facilities in a district such as Leicestershire, it is necessary also to close smaller facilities. That is particularly so with maternity units, where the necessity to continue reducing perinatal mortality means that larger maternity units are needed. I understand the stress and difficulty that such decisions sometimes cause local communities, which is why we have a system in which community health councils can object and in which, ultimately, Ministers can make a separate determination as to whether a closure is justified.

NHS (Performance-related Pay)

6. Mr. Hinchliffe : To ask the Secretary of State for Health if he will now make public details of performance-related payments made to managers in the National Health Service and state in each case why such payments have been made.

Mr. Mellor : No, Sir.

Mr. Hinchliffe : Does the Minister accept that the 100,000 Wakefield people who petitioned against the proposed closure of Snapethorpe hospital in my constituency have a right to know whether a district health authority general manager having a salary of £35, 000 per year will receive a cash bonus for achieving the closure of that hospital?

Mr. Mellor : Snapethorpe hospital has not had a patient in it since 1984. I know that the hon. Gentleman has been pursuing a vendetta against the district general manager concerned but he cannot blame that manager for obeying the instructions of the health authority rather than those of the hon. Gentleman.

Consultants

8. Mr. Bellingham : To ask the Secretary of State for Health what progress is being made with the plans to create 100 new posts for consultants.

Mr. Mellor : On 13 April we wrote to all regional health authorities setting out the criteria and inviting them to "bid" for those posts. The posts will be targeted on the six specialties that account for 80 per cent. of patients who have waited more than one year for treatment, but bids


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can be made for any specialty. We expect to inform regions by October which of their bids have been successful. The first new consultants under the scheme could be in post by the end of the year.

Mr. Bellingham : I am grateful to the Minister for that helpful reply, which will be particularly welcomed by junior doctors. However, when it comes to considering the bids from the regions, may I ask him to look very carefully at west Norfolk, where expenditure on the Health Service has risen very sharply in real terms, but where the growth of population is among the fastest in the country?

Mr. Mellor : My hon. Friend makes two good points. I certainly agree with what he says about his region. It is important to bear in mind not only the 100 new consultants proposed in the White Paper, but the massive expansion in the number of consultants proposed under "Achieving a Balance". The number of consultants in this country, which was 14,500 in 1987, will increase to 19,500 by 1998. That will increase the ability of junior hospital doctors to become consultants--which, of course, is a legitimate ambition of all of them--and will mean that consultants can play a fuller part in covering some of those duties which at present lead to junior hospital doctors being on call for unacceptable periods.

Mr. Janner : Will the Minister's proposals have any impact whatever on the vast number of people waiting for consultant or other services in physiotherapy? Will they help the children in special schools--such as the Emily Forty school, the Greenacres school, the Long Close school and the Western Park school in my constituency--who cannot walk, and many of whom can scarcely move? There are not enough consultants, doctors or physiotherapists to look after them.

Mr. Mellor : I have already pointed out to the hon. and learned Gentleman, but I think it is worth repeating, that the number of consultants in the country is scheduled to go up by 5,000, or over 30 per cent., over the period. There has never been so much expansion, and, of course, it will take place across the board. [ Hon. Members : -- "Answer the question."] I have answered the hon. and learned Gentleman's question.

British Medical Association

9. Mr. Adley : To as the Secretary of State for Health when he next intends to meet the British Medical Association ; and what he intends to discuss.

Mr. Kenneth Clarke : I have no plans to meet the BMA, but I have arranged to meet representatives of the medical profession through the joint consultants' committee tomorrow to discuss the implementation of the NHS White Paper "Working for Patients".

Mr. Adley : While thanking my right hon. and learned Friend for that reply, may I ask him please to obtain from the BMA an apology for the distortions with which it is frightening patients? Does he agree with me that if the purpose of its campaign is to persuade Ministers and Conservative Members of Parliament by the mindless barrage of propaganda that it is putting out, it is singularly unsuccessful? The main beneficiary of this propaganda appears to be the advertising agency handling the account. Will my right hon. and learned Friend accept from me


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that, he and I having been in the House together for more than 19 years, I am more than happy to recommend his advice rather than that of the BMA to my constituents?

Mr. Clarke : I have written to all GPs under contract in England, setting out why we disagree strongly with the five principal assertions made in that leaflet, and why we say that they are all untrue. I have invited GPs to consider whether they want to carry on putting the leaflet in their surgeries, and I am glad to say that I think that many of them do not. I look forward to having sensible negotiations with the BMA, if it will return to constructive proposals, about how to improve general practice in this country. Some of the campaigning on which it is spending such money is not really helping to improve the atmosphere, or the prospects for patient services either.

Mr. James Lamond : When the Secretary of State meets the consultants, as he has said he will, will he ask them if the people appointed to the new consultant posts that he intends to agree to--the 100 posts that have just been mentioned--will accept that they must devote 100 per cent. of their time to the National Health Service, and not, as at present, be permitted to devote as much time as they like to private medicine, using National Health Service facilities, and charging old people, who cannot wait in the queue any longer, exorbitant prices for operations that should be performed free?

Mr. Clarke : Consultants are able to enter into contracts on the present basis with the National Health Service. They can be full-time, and maximum part-time, and so on. What we have ensured in the White Paper is that district health authorities will agree a job description with each consultant each year and will act as the agents of the regional health authorities in ensuring that that job description is, indeed, fulfilled by the consultant. So the consultant will be paid according to the extent of his commitment to the National Health Service, and the district health authorities will be able to ensure that that commitment is carried out.

Mr. John Greenway : Does my right hon. and learned Friend agree that much of the confusion in the minds of the public in relation to the proposed reforms of the Health Service stems from a mixing of aspects of the general practitioner contract with proposals set out in the White Paper, and that this misinformation is largely perpetrated by some GPs who do not understand the differences themselves? Will my right hon. and learned Friend take the opportunity for further negotiations to get the GP contract settled, so that discussions about the White Paper reforms may continue, and the beneficial ideas in the White Paper may be discussed and put into practice?

Mr. Clarke : I agree entirely with my hon. Friend's analysis. My experience in discussions has been the same as his. I sent to all general practitioners a copy of the White Paper on the National Health Service review and the relevant working papers that related to the White Paper. I sent out separately the proposals for a new contract, in which I described the stage that we had reached in our discussions and negotiations. I asked all general practitioners to read whichever parts that interest them but to keep them apart and made it quite clear that discussions on the contract-- where we hope to reach a reasonable conclusion, if people will accept the aims of the new


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contract--are one thing and that the evolution of the Health Service review is quite another. A great deal of discussion still has to take place on that while we are getting the details in place. The sooner that we can settle the contract and stop this protracted negotiations battle, the sooner we shall get on with implementing the NHS review.

Mr. Galbraith : When the Minister next discusses the general practitioners' contract with the British Medical Association and the general medical services committee will he deal with the concessions that have been made in the tartan contract--the concessions on basic practice allowance, the retention of the rural practice allowance and the lowering of screening targets? Will those concessions be offered throughout the United Kingdom so that they become the basis for a United Kingdom contract?

Mr. Clarke : I discussed the details of the tartan contract, as the hon. Gentleman described it, with my right hon. and learned Friend the Secretary of State for Scotland before he issued it. That contract reflects in part our reactions to the submissions that we had received on the contract and expresses Scottish conditions. Average list sizes in Scotland are smaller so doctors have, on average, fewer patients. The average level of vaccination is lower and targets are adjusted accordingly. Moreover, doctors serve many scattered rural areas. I shall be interested in the reactions of the general medical services committee and of anybody else to the provisions in the Scottish contract. The Government sought to react to the representations made to us. We have tried to meet local conditions in order to ensure that good practice is encouraged.

NHS (Privatisation)

10. Mr. David Nicholson : To ask the Secretary of State for Health whether he has any plans to privatise the National Health Service.

Mr. Kenneth Clarke : No, Sir, and I never have had any such plans.

Mr. Nicholson : Will my right hon. and learned Friend sanction a modest amount of public expenditure to enable a special courier to take, by motorcycle, a copy of this exchange to BMA house, Tavistock square, because the BMA may not be aware of that fact? Is it not highly regrettable that those who are in a position to know the truth should seek so fundamentally to mislead their patients and our constituents?

Mr. Clarke : I agree with that, but I do not think that the BMA believes that we have any intention of privatising the NHS, or that we ever had any such intention. I think that the courier should be diverted to Walworth road. As we have seen this afternoon, the Labour party has no particular contribution to make at this stage to the evolution of the review or the doctors' contract. It is continuing to fight a totally bogus battle against a proposition that only the Labour party believes was ever made.

Mr. Campbell-Savours : Has the Secretary of State seen a copy of the report that I am holding in my hand from the General Audit Office in America--the American National


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Accounting Office--to the House of Representatives? It deals with private health care in America, roundly condemns the principle of fixed budgets and says that they lead to a reduction in health care. Will he send a copy of the report to every Member of the House before the next debate on these matters so that we can learn the truth from the experience of general practitioners in the United States of America?

Mr. Clarke : I believe that the British health care system is superior to that in the USA. There are centres of excellence in the United States where extremely high standards of medical care are achieved. There are also centres of excellence where extremely high standards of management and use of resources exist. We could learn from that experience. However, my White Paper proposals have nothing whatever to do with taking the National Health Service in the American direction. We remain firmly committed to the principles upon which the National Health Service is based.


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