House of Commons Hansard Debates for 2 May 1989

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Point of Order

3.31 pm

Mr. Max Madden (Bradford, West) : On a point of order, Mr. Speaker. You will no doubt have heard, during Prime Minister's Question Time, the hon. Member for Edmonton (Dr. Twinn) ask a question about more street lighting. I did not have an opportunity to give notice to the hon. Gentleman that I would raise the matter, but it is a classic illustration of the urgent need to reform the rules on Members' interests to require Members to declare an interest if it is relevant at the time. It is important that we should all know that the hon. Member for Edmonton is a consultant to Thorn Lighting Ltd. It is a classic illustration of the need to reform the rules regarding the Register of Members' Interests so that in such circumstances the Member would be required to declare an interest.

Mr. Speaker : The hon. Gentleman could draw that to the attention of the Select Committee, which has already discussed the matter and reported upon it. The Select Committee said that, during Question Time, interests that were declared in the Register did not have to be mentioned on the Floor of the House.

Mr. Nicholas Bennett (Pembroke) : Further to that point of order, Mr. Speaker. Four members of the Labour party who are serving on the Dock Work Bill are sponsored by the Transport and General Workers Union, and none of them has declared that in Committee.

Dr. Ian Twinn (Edmonton) : Further to that point of order, Mr. Speaker. I just wish to confirm that if the rules of the House required it and if it was thought necessary in the interests of the House, I would be only too pleased to declare the interest.

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Aircraft (Freedom from Smoking)

3.33 pm

Mr. David Martin (Portsmouth, South) : I beg to move.

That leave be given to bring in a Bill to permit all passengers on certain aircraft to travel in an atmosphere free from tobacco smoke. I accept immediately that anyone proposing a measure of this kind must face frankly the question of principle whether the law ought to have a part to play in conferring freedom on some people at the expense of the removal of the freedom of others.

I do not intend to sermonise against smoking. That is a free choice for adults to make for themselves. I would not support a Bill which prevented people from smoking on grounds of harm to themselves, any more than I would support a Bill making illegal the eating of food considered hostile to good health. What I maintain, however, is that people should, in certain circumstances and in certain places, have the freedom to enjoy a smoke-free atmosphere and that that freedom, like the freedom to walk the streets without being assaulted, inevitably rests on lawful restraint being imposed on the freedom of others.

That principle is not novel. It has been conceded over and over again in the House, particularly in the past century and a half, to all Governments of every political complexion in the area of public health and safety. Examples are both commonplace and common sense. It is upon that ground that I base my Bill, including enforcement of its provisions.

My Bill is not about whether someone should smoke, but where. It is not concerned with the effects of smoking on the smoker, but with the effects of smoke on the non-smoker. It is specifically limited to aircraft flights of up to three hours' duration, which effectively means domestic and European destinations. Many other countries have acted already, and I shall refer to that in due course.

All but diehards now accept that there is a serious risk of smoking damaging the smoker's health. It is also generally accepted that, while the risk is small by comparison, there is a risk of damage being done to the health of non-smokers from breathing in tobacco smoke--known as passive smoking. Should any doubts remain on that score, the 1988 fourth report of the independent scientific committee on smoking and health, chaired by Sir Peter Froggatt, should dispel them.

Such reports were predated some 400 years by the famous one-man royal commission of that scourge of tobacco lovers, James VI of Scotland and I of England ; a man of whom it has been said that he was never drunk, but he was never quite sober. His conclusion was that smoking was a custom

"loathsome to the eye, hateful to the nose, harmful to the brain, dangerous to the lungs and in the black, stinking fumes thereof nearest resembling the horrible Stygian smoke of the pit that is bottomless."

With that language he would make rather a good modern press officer for the British Medical Association.

King James later clashed with Sir Walter Raleigh, widely credited with having introduced tobacco into Britain. I do not condone the somewhat extreme retribution exacted from Raleigh by King James who had him executed in 1618, ostensibly for treachery and to please the Spanish. But who knows- -perhaps he was the first tobacco martyr.

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On the subject of executions, it is interesting to note that the only example of a statutory right to smoke is to be found in the Executions of Sentences of Death (Army) Regulations 1956 and 1959 under which, besides the right to be visited by relatives and a priest, the prisoner under sentence of death

"shall be permitted to smoke".

I presume that that official connivance can be justified on the ground that for a person in such a position considerations about the long-term injurious effects of smoking are somewhat superfluous. In the confined spaces of modern aircraft, the impossibility of escape from fumes, despite attempts at segregation of smokers from non-smokers, increases the health risks, as well as causing irritation, coughing and so on.

My own recent experience of that involved my 10-year-old daughter being forced to sit next to a smoker on a British Airways scheduled flight to Portugal this Easter. I had paid in full nearly five months in advance for all six family seats together. I had rung the airport two days before to emphasise our non-smoking requirements. We arrived at the Gatwick check-in desk in good time only to be told that my wife and I could not sit together with our four young children aged three to 10 years except in the smoking area. My 10-year-old daughter was coughing for half the journey and plaintively asked me, on a fully booked flight, "Can't I sit somewhere else, Daddy?" The answer was no, she could not.

I took the matter up afterwards with British Airways only to be told--in the age of computers, remember--in a letter from its customer relations executive :

"It is impracticable to reserve seats for passengers at the time of booking".

British Airways should try running a theatre and tell people that. It is practicable to take customers' money months in advance, but apparently it is not practicable to guarantee anything in return, except the gamble of having a seat next to one's children with the added chance of sitting next to a chain smoker thrown in. That shows a dreadful lack of consideration for the customer, wholly at variance with the attitude of airline staff, who could not be more pleasant and helpful.

However, credit must be given for BA's advances with regard to smoking on flights. Generally, the smoking of cigars and pipes is not permitted, so the freedom question

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has been resolved there. Also, it does not permit the smoking of cigarettes on domestic flights, as is the policy of Air UK on its flights, including those to the Channel Islands. Research indicates that, even among smokers, such policies are welcome, They help them to control the habit and mean that one less activity or pastime is associated with smoking.

For safety reasons, no smoking is permitted in the toilet facilities of aircraft. I fail to see why it should be considered safe to permit it in confined cabin spaces, particularly on tiring night flights, when there is a risk of someone nodding off. Other countries have already acted to protect not only paying passengers but cabin crews, at a time when it is increasingly recognised that protection for non-smoking employees in workplaces is both reasonable and necessary, particularly where air conditioning and heating arrangements restrict access to direct fresh air. In the United States, flights of up to two hours became no-smoking, by law, from April last year. In that country, an airline must guarantee that a person can book a non-smoking seat, which is a sensible provision and one that I hope we shall adopt.

Air Canada has a no-smoking law on flights that last up to two hours. Scandinavia also imposes such restrictions. The Australian Government banned smoking on all domestic flights from December 1987. Noel Coward said in his play "Private Lives" that China was a big country. The same applies to Australia.

In summary, my Bill is a modest attempt to carry matters a stage further in this country. The time is ripe now, as it was in the 1950s with the belching chimneys of London, to put the health and safety considerations of the non-smoker before the considerations of freedom of the smoker, and to call in aid the law in the limited respects that I have outlined. I commend my Bill to the House.

Question put and agreed to.

Bill ordered to be brought in by Mr. David Martin, Mr. Timothy Kirkhope, Mr. Graham Bright, Mrs. Marion Roe, Miss Ann Widdecombe, Mr. David Evans and Mr. Matthew Carrington.

Aircraft (Freedom from Smoking)

Mr. David Martin accordingly presented a Bill to permit all passengers on certain aircraft to travel in an atmosphere free from tobacco smoke. And the same was read the First time ; and ordered to be read a Second time upon Friday 7 July and to be printed. [Bill 131.]

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Opposition Day

[ 9th Allotted Day

]

Mr. Speaker : I regret that the order of the two motions on the Order Paper for today's Opposition business does not accord with that announced by the Leader of the House last Thursday. I propose to revert to our original intention, that the National Health Service debate should come first and the teacher shortages debate should come second.

NHS White Paper (Doctors' Response)

3.43 pm

Mr. Robin Cook (Livingston) : I beg to move,

That this House, noting that every independent organisation representing medical opinion has recorded the deep concern of doctors at the White Paper Working for Patients', and recognising that the concern of doctors arises from the serious threat to their patients reflected in Her Majesty's Government's determination to introduce market forces into health care, regrets that Ministers have failed to respond to informed criticism other than by impugning the motives of their critics ; affirms its support for the basic principles of the National Health Service that patients should receive the treatment they need, not the treatment they or their doctor can afford ; and calls upon Her Majesty's Government to prove its proposals by pilot projects before imposing them on the profession, and to postpone any legislation for a structural change in the National Health Service until it can be first submitted to the electorate in a General Election.

Mr. Speaker : I have to tell the House that I have selected the amendment in the name of the Prime Minister.

Mr. Cook : When the former Secretary of State for Health, the right hon. Member for Croydon, Central (Mr. Moore) announced the review to a rather startled nation, he said that the impact on the nation's health could be as dramatic as the discovery of penicillin. The outcome of the review had a dramatic and electrifying effect on the medical profession. It was so dramatic and electrifying that it has been rejected by every organisation representing medical opinion, not just by the British Medical Association.

I noted at last week's Health Question Time that the BMA held a special place in the affections of Conservative Members. That place is somewhere between the National Union of Mineworkers and members of the national dock labour scheme. The review has also been rejected by the joint consultants committee, representing ten royal colleges. It was also rejected by the Royal College of Nursing. Almost exactly a year ago, that college gave the Secretary of State's predecessor a standing ovation.

Some of the opposition from organisations representing medical opinion does not seem to have been anticipated. A fortnight ago, in reply to a question, the Prime Minister quoted, approvingly, a doctor who said that the White Paper

"embodies so much of what the Royal College has been working for over the years."--[ Official Report ; 11 April 1989 ; Vol. 150 c. 736.]

Six days later, the Royal College of General Practitioners voted, by 49 votes to one, to reject the White Paper.

In a statement explaining why it could not support the White Paper, the college said :

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"As an academic body, it must state that, just as it opposes medical treatment based on guess, so it must regret the treatment of a whole health service on hunch."

Even those who have tried desperately to like the White Paper have found it a forbidding task. The Institute of Health Services Management, which represents overwhelmingly members on short-term fee contracts to the Government, did the best that it could, but even it could not avoid coming out with the statement that the White Paper was likely to produce in the Health Service "confusion and fragmentation."

Nor is it only the institutions that have come out against the White Paper. The notion that a few activists in those bodies are manipulating the membership is pure fantasy. Dozens--scores--of doctors' meetings have been held around the country, but not one has found a majority in favour of the White Paper. I shall mention only one of those meetings : in Barnet, 170 doctors, including doctors from the Prime Minister's constituency, assented unanimously to the proposition that the White Paper could not work.

I know that Conservative Members are well aware of the strength of feeling among doctors : I know that because I keep being sent the letters that they have sent back to doctors who write to them. I treasure particularly a letter from the hon. Member for Milton Keynes (Mr. Benyon), who wrote to a general practitioner in his constituency, replying to his comments on the White Paper :

"I must tell you that I have never read such unhelpful, negative and totally conservative comment."

I like the hon. Gentleman's equation of "negative" and "unhelpful" with "conservative". I have always suspected the hon. Gentleman of being something of a dissident on the Conservative Benches. I assure him that his general practitioner is happy to agree with his phraseology--that the White Paper is negative, unhelpful and conservative.

I notice that the amendment tabled by the Prime Minister and her right hon. Friends

"welcomes the widespread medical support for the objectives of the White Paper".

We must handle that phrase with care. The objectives of the White Paper, as stated in it, are unexceptionable : broadly speaking, it is in favour of patients living longer and against their dying. However, I challenge the Secretary of State--it is the first of a few challenges that I shall issue to him in my speech--to produce the name of a single medical organisation that has welcomed the proposals in the White Paper.

In case the Secretary of State rises to the challenge by responding that the Conservative Medical Society has welcomed the proposals, let me tell him that that particular case is rather suspect, as there is some doubt about whether it carried out the ballot of its members before announcing its decision.

Mr. Jerry Hayes (Harlow) : The hon. Gentleman has specifically mentioned medical organisations. Is that so that he can leave out the National Association of Health Authorities in England and Wales, which welcomed the report, or does he consider it rather inconsequential to take into account the views of those who actually run the Health Service?

Mr. Cook : If the hon. Gentleman reads the comments of the National Association of Health Authorities, he will find that they are much more carefully balanced than he has suggested. It is, however, hardly surprising that members of health authorities have welcomed the

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Government's proposals, as the Government have spent the past 10 years stuffing those health authorities with their placemen and placewomen.

The Secretary of State's response to this overwhelming opposition is to insist that none of it will stop him. As he said in a lecture to the Royal College of Nursing, these changes will happen whether we like them or not, and whatever we say. It may surprise hon. Members, given the defiant ring of that statement, to learn that we are at present in a consultative period. The extent to which the right hon. and learned Gentleman is willing to enter into a dialogue with doctors during that consultative period was discovered by doctors in the Vale of Glamorgan last week, when he pushed his way through them, leaving behind the sole intelligible question on which he had consulted them : "Where is my car?"

In this alleged consultation, the Secretary of State is displaying an arrogance which sits uncomfortably with his supposed role as an accountable Minister in a democratic country. In a week in which we ruefully reflect on what 10 years of the present Prime Minister have meant for the nation, I warn the Secretary of State that the nation is heartily sick of this style of hectoring, opinionated government.

Mr. Tony Favell (Stockport) : Does it really come as any surprise to the hon. Gentleman that the general practitioners oppose the White Paper? After all, has he found many barristers in favour of the Lord Chancellor's proposals, or many scheme dockers who favour the abolition of the dock labour scheme?

Mr. Cook : The odd thing is that I remember that, on 31 January, the Secretary of State, when unveiling the £1 million package to communicate to doctors and to medical opinion how useful and wonderful his proposals were, said nothing about doctors being against the proposals or that he expected general practitioners to be against them. On the contrary, everything said at the time to defend the £1 million expenditure was about how important it was to communicate these ideas so that people employed in the Health Service could understand and agree with them. The people involved certainly understood, but whether or not they agreed with the proposals is an entirely different matter.

Since this point has been raised, I can say to the Secretary of State that, as a result of one of his six consultations with the West Middlesex hospital, on the night of his presentation of 31 January we were able to recruit seven people to the Labour party who applied on the spot for membership.

Dame Jill Knight (Birmingham, Edgbaston) : Is the hon. Gentleman able to cite a single instance of any reform suggested by any Government to the National Health Service, from its inception 40 years ago, to which the doctors have had no objection?

Mr. Cook : It is perfectly true that a number of concerned doctors in 1948 opposed the setting up of the NHS, as did the Conservative party at that time. However, it is certainly not the case that doctors are opposed to all changes in the Health Service.

Mr. Robert McCrindle (Brentwood and Ongar) rose

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Mr. Cook : I have given way generously to hon. Gentlemen and the hon. Lady, but, as I am conscious that this is a three-hour debate and that other hon. Members will wish to speak, I must decline to give way on this occasion.

To comprehend the bitterness of general practitioners, it is necessary to understand how they have been deceived by this Government. For a year, the representatives of general practitioners have been negotiating on the practitioners' contract. In the course of that year, the representatives were repeatedly assured that nothing in the White Paper would affect general practitioners and their contract. That assurance was repeated at a meeting on 21 December last year.

General practitioners first heard that the assurance was inoperative on 18 January, when the Department of Health cancelled the February meeting of the negotiators in order to give general practitioners time to consider how the White Paper would affect the practitioners' contract. A fortnight later they received the White Paper, which contained two major departures. First, it has thrown into reverse the drive by successive Governments to encourage general practitioners to take fewer patients on their list. Instead, the new contract proposes to increase the per capita element by a third, rewarding those general practitioners who hoard patients and penalising those who want to keep the list to a number to whom they can give individual attention.

That departure will have an impact on general practitioners and an even bigger impact on their patients. More patients on every list means less time for each patient. It is purely double-speak for the Secretary of State to describe this measure as encouraging general practitioners to take on more patients in order to improve the quality of service to each patient.

The second major change that general practitioners discovered on reading the White Paper was that the Secretary of State proposes to entice GPs in larger practices into practice budgets. The essential problem with practice budgets is that they will result in a conflict of interest. When GPs see a patient now, they have to ask themselves only what treatment the patient needs. In future, with a practice budget, they will have to ask themselves a second question : what treatment can the practice afford? It is because of that conflict of interest that there will be a suspicion in the mind of the patient that he or she is not being recommended for the best treatment. It will destroy the trust of the patient in his or her doctor. As one doctor expressed it graphically, when a patient looks into the eyes of his or her GP, the patient wants to see reflected in those eyes his own anguish, not the calculations of an accountant.

Another major proposal in the White Paper which has also caused concern to doctors is that hospitals should opt out of--

The Secretary of State for Health (Mr. Kenneth Clarke) : The hon. Gentleman implies that the White Paper was an act of bad faith over the negotiations on the contract, because we introduced two changes. Will he pause in his reading of his Tavistock house brief to explain that an increase in the capitation element of the contract was floated in the White Paper on primary health care 18 months earlier? That was nothing new. Furthermore, GP practice budgets have nothing to do with the negotiation of the GP contract. On what grounds does the hon.

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Gentleman support the BMA's assertion, which it appears to have given him, that the White Paper interrupted the 12 months of negotiations on the GP contract?

Mr. Cook : The right hon. and learned Gentleman is being characteristically offensive by suggesting that I have come to the House armed with a brief from Tavistock house or anywhere else. I do not claim for myself much credit, but I claim for myself the credit of preparing my own speeches ; they are not prepared for me. I take issue with the tone of the right hon. and learned Gentleman's question and the abuse with which it was accompanied. If he wishes to make more rapid progress, the House should be treated as a place for open debate, not as a place for abuse.

The right hon. and learned Gentleman asked two questions. I shall respond first to his second question. He cannot claim that the practice budget proposal does not have a bearing on the GP contract. Such an argument is Jesuitical. His claim that it was foreshadowed 18 months ago in the White Paper will not stand up to examination. The Government said in that White Paper that they intended to increase the capitation proportion from 47 per cent. to 50 per cent. The January White Paper said that the Government intended to increase the proportion from 47 per cent. to 60 per cent. There is a big difference between the two figures.

The other major proposal in the White Paper that is causing concern to doctors is that hospitals should opt out of local authority control, that they should be free standing, that they should not be accountable to the local health authority, that no local council members should be able to serve on the governing body and ask difficult questions and that their only obligation should be to make ends meet by marketing their services. As the joint consultants committee observed :

"These proposals inevitably change the prime aim of the management of these hospitals from the provision of adequate care to the community as a whole to the financial success of the hospital." What will it mean when hospitals have to change their prime management aim from the provision of care to the community to the financial success of the hospital? The long-term consequences of that financial pressure have been obligingly spelt out by the director of the private Lister hospital. He has asked what lessons can be learned from his experience of running a private hospital by those hospitals that choose to opt out. Helpfully having asked that question, he then provides the answers. In his article he writes :

"The opt-out hospital will need to make firm decisions as to which services to promote and which are uncompetitive. Some specialties may have to go. The problem of unsuccessful specialties will be a real one. For how long could one carry a loss-making specialty including its medical team?"

I invite the House to note the revealing way in which the director of the Lister hospital defines an unsuccessful specialty. An unsuccessful specialty is not one which offers poor quality of care or care that patients do not need in the community ; an unsuccessful specialty is a loss -making specialty. That is the reality of what will happen with the opt-out hospitals. Care will be defined according to which specialty can provide the most generous mark-up on the treatment, not the care that is most needed by the community. What happens to hospitals if they fail to move with the times and persist in offering loss-making specialties? The disaster of the Lister hospital has a neat phrase : they will

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be "shaken out of the market". Not closed, mark you, but shaken out of the market. It is a pity that the director of the Lister hospital has not been working for the Department of Health for the last 10 years ; otherwise, we could have learnt that the 300 hospitals closed under this Government were not closed but shaken out of the market and the 20,000 beds we have lost in the last 10 years were not cut, but shaken out of the market. Also shaken out of the market, of course, is any commitment to the National Heath Service as a public service to every community in which there is a district general hospital providing ready access to a comprehensive range of medical services.

The right hon. Gentleman is not just nurturing a threat to the Health Service : what he is proposing is an affront to our democracy. He has sent an instruction to every regional health authority to provide by next Monday a list of volunteer hospitals for opt-out. They in turn are instructing unit general managers to volunteer for opt-out. I do not doubt that by Monday the right hon. Gentleman will have his list of volunteers. What I find thoroughly offensive is what he proposes will happen next, which is that he, and he alone, will then decide whether they opt out. The decision on opt-out will be taken in a smoke-filled room, and most of the smoke will come from the Secretary of State's cigar.

What happened to all the talk of greater local decision-making? What happened to the promises of patient choice? If the Secretary of State is serious about choice in local decision-making, why not give local people the choice of whether their hospital opts out? I issue my second challenge. If the right hon. and learned Gentleman seriously believes opt-out is so good, let him put it to the vote of the local community. Let it be decided by the local community which that hospital serves and which in many cases was the community which once upon a time paid for the buildings that the Secretary of State proposes to give away.

There is an obvious comparison with the speed with which the Secretary of State is proceeding in his White Paper. His proposals were conceived in haste and are now being imposed with premature haste. Just over a year ago, the right hon. Gentleman's predecessor received the Griffiths report on community care. There has been no progress there, no timetable for consultation, no urgent circulars to regional managers and no promise of legislation in the next Parliament.

I give the Secretary of State my third challenge. His Government owe us a debate on the White Paper in Government time. Having taken so long to find that time, before he comes back to the House to debate this White Paper, let us have his Government's response to the Griffiths report on community care, so we can put it side by side with the White Paper and see what sense they make together. It is almost three years since the National Audit Office observed that, in community care, doing nothing is not an option. That is precisely what the right hon. Gentleman has chosen to do, and we all know why. It is because Sir Roy Griffiths had the bad taste to point out that, if we are serious about developing the health and social services which will enable the elderly and the handicapped to live full and rewarding lives in the community, we must provide extra resources and responsibilities to the local authority which delivers those services to the community.

Labour councils have a clearer understanding than the right hon. and learned Gentleman of what elderly people

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need to keep them in the community and to keep them healthy. Yesterday, I released a league table that ranked local authorities by the number of home helps per thousand elderly people. Only one solitary Conservative council made it into the top 20 councils in that league table. Conversely, not one majority Labour council was to be found in the bottom 20. That is the difference between our parties' understanding of community care.

If Conservative Members consider that observation too partisan, I can offer them an observation with which they will agree. The record of the Democrats is even worse than theirs. Out of seven councils under Democratic administration, a clear majority are in the bottom 20 of that league table. That record shows that the Labour party understands the changing direction which health and social services need to meet the challenge of the rapid growth in very elderly people. Instead, the White Paper offers us the fatuous irrelevance of tax relief on private medical cover for the elderly.

We need to integrate the hospital and primary care services to get into the communities the diagnostic skills we keep locked up in our hospitals. Instead, the White Paper proposes that those hospitals will opt out and that consultants will meet GPs mainly to price a contract. We need to change the Health Service from a rescue service into a service that promotes health and prevents ill health. The White Paper contains not a single proposal for health promotion. It is full of measures that will cost treating illness but puts no price on health. I have outlined the basis of Labour's programme for health, which we shall be publishing this month at a launch cost rather less than the £1.5 million that the right hon. and learned Gentleman spent on the White Paper.

The fundamental difference between our proposals and the Secretary of State's White Paper is that our proposals will rest on our commitment to a Health Service in which resources are allocated by medical and social need and are not marketed by commercial demand. I conclude with my final challenge to the Secretary of State. I noted that the Minister of State observed that the Government have been elected to govern and will not shirk the task of government. No one can deny that the Government have been elected to govern, but no one, not even the Government, can claim that they were elected to carry out such changes to the NHS. Where in the last Conservative manifesto were those proposals spelt out to the electorate? Where in the last manifesto were the electorate warned that hospitals would be encouraged to opt out and GPs encouraged to volunteer for cash limits? My final challenge to the Secretary of State is this : if he is so convinced that his proposals are right for the nation, that they will produce a better Health Service and more choice for patients, let us put it to the test of electoral opinion and find out whether Conservative Members are elected to govern while chained to those policies. If he puts it to the electorate, I assure the Secretary of State of our full co-operation in spelling it out to the electorate so that they thoroughly understand what the right hon. and learned Gentleman is proposing. In the meantime, I ask the right hon. and learned Gentleman, as it is our right to ask in this democratic Chamber, to put off legislation on these drastic changes until we have put them to an electoral contest.

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I do not doubt that the Secretary of State will win the vote tonight. He has already lost the public debate. He came to office with no mandate for such changes. Since taking office, he has been unable to win any support for them. If he persists in abusing his majority in Parliament to push them through, he will not only destroy the trust between patients and doctors ; he will undermine the faith of those patients in this place as a democratic institution. 4.8 pm

The Secretary of State for Health (Mr. Kenneth Clarke) : I beg to move, to leave out from "House" to the end of the Question and to add instead thereof :

"welcomes the widespread medical support for the objectives of the White Paper "Working for Patients" and believes that the proposals in that White Paper will enable the health service and individual doctors to respond better to the needs and wishes of patients, extend patient choice, delegate responsibility to where the services are provided and secure the best value for money ; affirms its support for the basic principles of the National Health Service which will be strengthened by the early implementation of the White Paper proposals ; and looks forward to the constructive contributions from medical organisations to achieve that."

By a curious turn of events, this is the first debate on the National Health Service in which the hon. Member for Livingston (Mr. Cook) and I have taken part since I came to my present office last July, with the exception of some exchanges on the dental and optical charges, which he will recall. We are shortly to have a debate in Government time on the White Paper reforms, so we are about to make up for that and to discuss Health Service matters at considerable length.

The Opposition have chosen to found their motion on the subject of the doctors' opposition to the National Health Service reforms. I shall concentrate on that and save many of my remarks for the debate on the White Paper. I want to talk about the points raised by doctors, some against and some in favour of the White Paper. I shall explain the present position to the House and examine the sudden, new relationship between the Labour party and the doctors. I do not believe that the opposition of the two groups to the reforms is based on the same premises. The Labour party's sudden discovery of the doctors' position is nothing other than political opportunism, because it sees a dispute apparently breaking out.

The House should begin the debate on the basis that the best members of the medical profession are interested in the Health Service above all from the point of view of their own patients. One of the tests that the best members of the medical profession will apply, just as the public outside will, is what the overall impact of the reforms will be on the way in which the Health Service delivers care to patients. When one examines the highly complex proposals which I and the Government have put forward, one has to try to form a picture of the effect on the Health Service in four or five years' time--or more--and how patients will appreciate what the reforms have done to improve the service for them. The one simple aim of the Government is that the National Health Service should be made a better Health Service from the point of view of patients and their families. That is the yardstick that should be applied to each proposal that the Government are putting forward.

We have a long way to go before the reforms come fully into effect, but in a few years' time, when patients look back on the battles over the review, they will see that the

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principles of the Health Service remain intact, that the service remains free and financed by the taxpayer and that it is delivered according to medical priority and need. But they will find that many other changes have taken place in a Health Service run in a more business-like and efficient way, because it will be run in a more consumer- conscious way as well. The Health Service will be keeping up to date.

Patients tend to approach the Health Service firstly through the agency of general practice and most of us look, for ourselves and our families, to our GP as our continual health adviser and as our guide to the rest of the system. From now on, patients will be freer to decide which practice they wish to join and they will be able to make that choice on the basis of much better information. At present, people choose their GP--with whom, I accept, they are usually fully satisfied--on the basis of word of mouth recommendations from neighbours. Many of us do not have much experience of what general practice is like outside the practices that we have experienced ourselves. In future, practices will produce information leaflets. Thanks to the Monopolies and Mergers Commission, practices will be able to advertise if they wish and will put before patients and would-be patients the services offered to families, the opening times of the surgery and any other particular features.

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