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Mr. John Battle (Leeds, West) : Will the Secretary of State give way?

Mr. Clarke : I shall give way in a moment when I have given some more examples of what patients will find coming out of the reforms. Patients will probably choose the practices that offer high standards and new services, which we are encouraging by the new contract I intend to negotiate with the British Medical Association. I shall return to the subject of the contract negotiations in a moment. The hon. Member for Livingston said that nothing in our proposals dealt with the promotion of health and the prevention of disease which, as he rightly said, have to be part of the policy for the future of the Health Service. The new contract proposals, which we have been discussing with the BMA for so long, are founded heavily on just such principles. In four or five years' time, patients will expect to receive from their practices regular health checks, offered to all patients if they so wish, and especially better and more regular contact with older patients over the age of 75. There will also be regular surveillance by GPs of children under the age of five. Under our proposals, there should also be high levels of immunisation against disease for children and screening of female cancers. Those are some of the aims that we have set out. There will also be more personal visits by doctors from the practice that the patient joins instead of excessive use of a deputising service out of hours. As a result of our wider reforms, when a patient visits a GP he will be given better information than now about where the waiting times are longest in his locality and about the medical quality of the service being provided by the hospital.

Whether or not a GP has a practice budget, he will have more contact with and more influence over the developments of the hospital and community services in his area because he will be in contact with his district health authority. General practitioners are not in contact now with their DHAs about referral patterns. In future

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how the DHAs use their money to place contracts with hospitals will reflect the referral practices of the local GPs. We are bringing GPs and DHAs together to collaborate.

If a patient has a GP with his own practice budget, the patient will be attending the practice of a general practitioner who has access to taxpayers' money on a scale not known before to doctors, which will mean that the doctor can take into account the quality of care, waiting times, and the preference of the patient when determining how health authority money is used in that area. Those are big changes in general practice, and when patients evaluate those improvements we shall have a more considered view of our proposals--

Mr. Allen McKay (Barnsley, West and Penistone) rose

Mr. Clarke : I turn now to the hospital and community services. Patients will find that management of all hospitals will be delegated much more to the local people, to the doctors, the nurses and managers in the hospital itself--that is, to people who are closer to patient care than the people in the hierarchy of bureaucracy that we have now. Those people will decide on the use of resources, the management of the hospital and on the development of the service in their town.

Units will have resources coming in with the patient to match the work that they are doing. They will receive money in response to the demands made by the district health authorities and the GPs, who will refer patients and provide the necessary funds using their budgets. The system of encouraging hospitals to attract resources to their areas of strength will tend to bring the quality of all services up to the level of the best. Competition between them will bring down waiting times as well as raising the quality of the outturn from different specialists.

When we have finished our reforms, all hospitals will strive to please GPs and patients with the other things that they should all have now, such as reliable appointment systems, clear and sensitive explanations to patients of what is happening to them and of what is going to happen, and a whole range of optional extras and amenities available to patients who want to pay for them.

That is what the patient will appreciate. I do not believe that the Labour party will be wholly content, looking back, to realise that, because of what seemed a monetary political advantage, it has placed itself in a position whereby it opposes the development of general practice, the giving of more local autonomy to hospital and community services and the opportunity of making a better Health Service for patients.

Mr. Battle rose --

Mr. Kevin Barron (Rother Valley) rose --

Mr. Clarke : I give way to the hon. Member for Leeds, West (Mr. Battle).

Mr. Battle : How does the Secretary of State square all that he has just said with the push in the opposite direction from the Treasury, which is offering tax incentives to elderly people to move out of the National Health Service and in the direction of private practice? Is such a move the Secretary of State's real intention?

Mr. Clarke : Last year we obtained from the Treasury an extra £2, 000 million for the services and an extra £1,000 million or thereabouts for the nurses' grading. We ended

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the autumn settlement last year with spending plans 5 per cent. above inflation. Under this Government spending on the National Health Service is now second in the league of spending on public departments. We now spend more on the NHS than we do on the Ministry of Defence. It is obvious that spending on the Health Service will increase rapidly, but to say that spending more money is, in itself, a form of health care policy and that we should ignore inefficiences and the need to raise quality or to make the service more responsive is not an adequate policy, whether it be the policy of the Opposition or of any part of the medical profession. Anything that induces people who want to spend their own money in retirement to provide for some of their health care, such as for elective surgery, thereby reducing pressure on the Health Service, does no harm to the Health Service but enables us to make better use of the money that we obtain.

The Opposition's motion is about doctors. I have dealt with the benefits to patients, and there will be great benefit to doctors as well. It is all very well to say that there is no support from any organisation representing doctors. There are not all that many organisations representing doctors. What tends to happen is that there are endless sub- committees of the same organisation which keep doing the same thing.

I was at a BMA meeting at Tavistock house this morning. It was a meeting of the general manager branch, but all the participants were doctors, and the majority of those asking questions were in favour of these reforms.

Mr. Frank Dobson (Holborn and St. Pancras) : The right and learned Gentleman appointed them all.

Mr. Clarke : I did not appoint a solitary one. The hon. Gentleman was, in his time, an extremely effective spokesman on health matters but he has forgotten that the general managers of health authorities are appointed by district health authorities. The unit managers, who were about two thirds of those present this morning, are also appointed by the district health authority and I do not have the gift of a solitary general management post at my disposal.

As I say, they are in favour of benefits for patients above all, but there are benefits for doctors, too.

Mr. Dobson : Is it not true that all these apparently independent general managers/doctors to whom the right and learned Gentleman talked today are on three-year contracts and notes are taken by officials in that Box as to who does or does not collaborate?

Mr. Clarke : This Opposition motion talks about members of the Government traducing the motives of those who disagree with them. That is something, I strongly argue, that I have not done, and nor has my right hon. Friend. The hon. Gentleman referred to the opinion of the National Association of Health Authorities in England and Wales, which is in favour of our proposals, and immediately insisted that it is a collection of placemen. An awful lot of card-carrying members of the Labour party in that association will be very surprised to hear that. I cite to the hon. Member that I have attended a meeting this morning organised by the BMA to discuss with a number of doctors their reaction to the White Paper and

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that most of them were in favour, and many of them strongly in favour, of the broad principles of the White Paper and he says that they are all on three-year contracts.

The Opposition are deaf except to what they regard as the short-term political opportunity to join in a row which they do not wholly understand.

Mr. Andrew Rowe (Mid-Kent) : Is my right hon. and learned Friend aware that in the autumn of last year my local hospital closed a ward because the surgeons operating therein were working so effectively and quickly that, in their attempt to reduce their waiting list, they overstepped their budget within about three months? That is an absurdity and they are very much in favour of changing the system to make it impossible for it to happen again.

Mr. Clarke : I entirely agree with my hon. Friend. That is one of the principal benefits from what we are proposing that doctors immediately appreciated. At the moment, there is what is sometimes called the efficiency trap, where a hospital is so much in demand and organises itself so well that it increases its work load but, because we only distribute the money by formula, it is told to stop. Indeed, I think they are gilding the lily somewhat, but only recently some Birmingham consultants claimed that they were told to go and play golf rather than carry on doing their work.

I have not met for some weeks now a member of the medical profession who does not think that it is an improvement to provide that, when patients are attracted from district health authorities or general practitioners, the resources will go with them, and that that is a much more sensible way of proceeding.

Doctors also see other advantages. The point of the general practitioners' contract, which I trust we can settle, is that those who work hardest, introduce new services and reach good standards will be rewarded best. Many GPs think that aim is wholly desirable. Indeed, the BMA does not differ from me in my aims for the contract. Those GPs with practice budgets will, as I have already said, have much greater influence over where NHS funds can be used for the benefit of their patients. For doctors in hospital and community services there will be relief from the absurd situation that tends to hit the best--the situation which my hon. Friend the Member for Mid-Kent (Mr. Rowe) described.

They will also find that more responsibility has been delegated to their hospitals. As clinicians, they will be more involved, they will have more influence over management decisions and they will carry more responsibility for the decisions. I find everywhere that doctors welcome the introduction of what I would regard, as a layman, as quality control and what the doctors call medical audit, whereby they can systematically ensure that standards are properly set for the service and are monitored so that the medical standards remain extremely high.

Mr. Max Madden (Bradford, West) : Will the right hon. and learned Gentleman give way?

Mr. Clarke : I shall carry on giving way steadily, but, as this is a short debate, I apologise that I cannot give way to all. Given my description of the aim of the reforms and my belief in their benefits, it is surprising that the present bitter controversy has arisen between the Government and, on

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the one hand, the Labour party--and, to some extent the centre parties as well--and, on the other, the British Medical

opposition--British Medical Association-- [Interruption.] That is certainly my most Freudian slip of the tongue so far. Although they are both in opposition, there are a limited number of similarities between the Labour party and the BMA. One thing they have in common is that both of them denounced the proposals and began to campaign against them before they were even published. Returning to the letter from my hon. Friend the Member for Milton Keynes (Mr. Benyon) that was quoted by the hon. Member for Livingston, it appears that both the Labour party and the BMA can be described as conservative with a small "c". Their reaction to change of all kinds is remarkably similar. However, they are not natural allies. I have found in discussions with them that they come to such a person as myself with the precise nature of their complaints from opposite ends of the political and every other spectrum.

It is not surprising to find that the Labour party and the BMA do not always agree. They never have before. In response to an intervention from my hon. Friend the Member for Stockport (Mr. Favell), the hon. Member for Livingston implied that nowadays the BMA's views determined, Labour party policy. No doubt, the Bar Council will determine its policy on law reform, just as the Transport and General Workers Union will determine its policy on the dock labour scheme. It was never thus for the doctors. The BMA was nine to one against the foundation of the National Health Service. Aneurin Bevan did not follow the line of the hon. Member for Livingston.

In the mid-1970s, the disputes between the Labour Government and the BMA and the medical profession over private practice were described by a recent historian of the Health Service as being the most bitter in the entire history of the National Health Service. When Barbara Castle was opposed by all the medical organisations, I do not remember the Labour party saying that that settled the argument. It would not. Obviously, the Labour party's arguments do not now coincide with those of the doctors' organisations, and this unholy alliance will not hold together for too long.

So far the Labour party's campaign has been far less important to me and the public than that conducted by the BMA. The issue of so-called privatisation chosen by the hon. Member for Livingston has been a kind of barmy irrelevance to the actual issues to which the Labour party pledged itself. I believe that it is still pledging itself in by-elections to fight the privatisation of the National Health Service. That reminds me of an old story, which I will not relate at length, about the man in the railway compartment who had a device for keeping away elephants. He was sure it worked because no elephants got into his compartment. The Labour party is campaigning against the privatisation of the National Health Service. It will succeed. It is a noble campaign. It will sail on and meet no obstacles, because nobody has ever proposed privatising the Health Service. It is not threatened with privatisation. It is an irrelevant non-issue.

The campaign of the BMA--the doctors' campaign--to which the motion refers has been quite different. The hottest issue is obviously the question of the GPs' contract, coupled to some extent with the indicative drug budgets that we have described. The occasion of the debate is the present heat in relationships between the Government and parts of the BMA. It provoked the GPs' leaflet campaign

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and it was the subject of last week's conference of local medical committees, which I am glad to say finally brought to an end all talk of a resignation from the Health Service--which struck me as an odd way to show one's commitment to the service--but still talked of sanctions, and of using non-co-operation with our reforms to improve the Health Service unless they had the sort of contract of remuneration that they wanted. I do not believe that that is the view of every doctor.

It is important to sort out the GP contract. We have a debate on the White Paper coming up shortly, but the contract is the immediate issue. I believe that getting a better GP contract will have more effect on raising the quality of health care in this country than most of the other things we have attempted to do in the Health Service for a long time. That contract has been in the air for a long time, and it was clearly trailed in the primary health care Green Paper and subsequent White Paper. We have had long discussions about it.

I do not believe that anyone can be opposed to the idea of having a contract that is up to date and linked to hard work and good performance. We will pay more to the most hard-working GPs and we will set standards of service to patients for all our GPs. The policy of the contract is to build on the strength of British general practice and it is no threat to or attack on it.

Today, GPs, to whom I and the House are seeking to appeal, are better trained than their predecessors because general practice is now recognised as a specialty in its own right. There are more GPs than ever before--up from about 25,000 to about 30,000 during the lifetime of this Government. They have fewer patients each to look after than ever before, with average list sizes falling from 2,286 to 2,020 in England over the last 10 years, on average, a drop of 12 per cent. And they are better paid than ever before. This year's review body increase of 8 per cent. was the highest of any review body group and took their earnings increase 25 per cent. ahead of inflation since 1979.

I think that GPs should be paid well and my proposals are no threat to their average earnings--a suspicion to which I addressed myself forcefully only a few weeks ago. The total payment to GPs currently has been settled by the Government and I approve of it. The total payment out of the contract to the average GP is about £60,000 per annum, including all fees and allowances. The average salary element is set at £31,000, but that average includes part-timers, semi-retired and low-earning GPs. My published new contract proposals show how a GP with an average list could have his earnings potential raised from £43,000 to £47,000.

My proposals would increase the earning figures for the more hard-working GPs and those who hit the targets. I am in favour of paying good GPs very well and I am entitled to say that the incurable suspicion that, somehow, we shall try to reduce those earnings is wrong. What I say to the House and to the doctors--I am sure that the public would agree--is that such earnings are justified for professional men, but they mean that the Government are entitled to specify the work load of doctors, to encourage new services to patients and to set standards of health promotion and disease prevention for which to aim. The contract should pay good rewards and, in return, should set out the high professional standards at which the hard-working professional men and women should aim.

We are not aiming for all GPs to have bigger lists--that is a mathematical impossibility--as the contract is

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capitation-based now. We are aiming for new and better services for elderly patients. That is why one of our offers is to pay so much more to the doctor for each elderly patient that he takes on. The capitation for patients over 75 will go up sharply so long as the doctor maintains contact, at least once a year, with each old person. It is important to explain what we are discussing with the BMA. We aim for better medical supervision of our young people. That is why we are offering a new, generous payment to every doctor who introduces a surveillance system for the under-fives on his or her list.

I hope that we are all agreed that the NHS should keep up with the best international standards of immunisation, which represents disease prevention, and of female cancer screening, which also represents disease prevention. We pay all doctors for whatever immunisation and cervical cancer screening they do as they form part of the essential duties of any doctor nowadays. In my proposals I have suggested extra, new performance payments for those who attain the World Health Organisation target of vaccinating nine out of 10 children on their list. I do not believe that that is unrealistic as about 100 out of 190 district health authorities reached 90 per cent. target for diphtheria, tetanus and polio vaccinations in 1987-88. We are not talking about impossible targets, but we shall discuss the details to ensure that they are possible and reasonable for all subjects.

About 2,000 women are still dying needlessly every year of cervical cancer. That is why I have suggested that new rewards should be given to every GP who persuades eight out of 10 of the at-risk women on his list to have the smear test.

All these details can be discussed. Indeed, they have been discussed, and they can be further discussed. My negotiators and I have spent over 100 hours on matters such as rural practice allowances, basic practice allowances, payments for minor surgery and all the other details of the contract. Hon. Members on both sides of the House who have looked into the GPs' contract will, I hope, now study the Red Book and the mass of material which explains to the GP how to work the contract. I hope that they will also study the magazine Medeconomics which appears monthly and which serves no other purpose than to explain to GPs how to get the maximum return out of the contract.

I want to discuss the details yet again so that we can settle the terms of a contract that is up-to-date and rewards the best doctors, because the best doctors are doing this work. We all meet doctors who say, "We are delivering these services" and who will be content so long as the details are reasonable and reflect the realities of practice. We can reach agreement if there is good will, common sense and a commitment on both sides to a better Health Service.

Ms. Marjorie Mowlam (Redcar) : The Minister said in relation to cervical smears that women could choose quality clinical medical treatment. How does a woman, when faced with two doctors who are using different publicity, choose which one offers the best quality clinical treatment? There will be great advertising and excellent pictures, but the Minister must explain how a woman in

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that situation--indeed, the same difficulty will face

pensioners--will be in a position to choose the best quality clinical service.

Mr. Clarke : We are here talking about whether doctors carry out cervical smears and whether they carry out a positive drive to advise people of the benefits and so raise the level. If a woman is particularly interested in services for female patients, she might look at the literature to see, for example, whether what is usually called a well woman clinic is being offered by one practice rather than by another, because that is the type of health promotion session that the new contract would encourage.

Having dealt with the contract, I come to the hospital proposals. The concerns of the BMA are different. I by now have met many doctors. Indeed, I could not make up my mind when I last answered parliamentary questions whether I had met hundreds or thousands. Certainly the number must be well into four figures by now. Judging from the campaign that is being run, most hon. Members have met a lot of GPs. I trust that they have also met many consultants and junior doctors.

I believe--I defy anybody to challenge this--that it is clear from discussions with the hospitals that the great bulk of what we now propose is being accepted by hospital doctors, even though some of them still assert that they are against the White Paper as a whole. Most consultants, in my experience, approve of the whole idea of getting better financial management. That represents a transformation in opinion compared with my time as Minister for Health only four or five years ago.

Few consultants would now argue with the contention that it is ridiculous that the Health Service should be one of the last places to get up to date with modern information technology, to come to grips with the world of the computer, or to have any proper financial management system.

We recently extended what we call the resource management initiative to another 50 hospitals, and the 50 that we named had actually competed for the privilege of being put in the forefront of introducing financial management systems.

The profession is now almost wholly in favour of clinical audit. I have not met a doctor for some time who has been against it. That is almost a total reverse of the situation five or six years ago, when the Royal College of General Practitioners and the Royal College of Surgeons first tentatively began to go into this area. It was invented by the profession and I reassure the profession that it will continue to be professionally led because it is quality control by doctors, of doctors for the benefit of doctors and their patients. I know few consultants who do not welcome the idea of what is usually described as the concept of money following the patient. My hon. Friend the Member for Mid-Kent has given me a perfect example of how doctors are fed up with the present system which does not tie the resources with where the work is done best and to where the patients are being referred. So the question of money going over administrative boundaries and the ending of the efficiency trap are welcomed by all doctors.

Doctors have reservations and questions ; that is sensible. The White Paper is not a blueprint. My hon. and learned Friend the Minister of State says that it is not a tablet of stone. It is not intricately detailed. There is an enormous amount for discussion within it ; that is why we

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have eight working papers for discussion. The detail needs to be worked out with the service. People in the service want to know about planning. There are fears about a comprehensive service and about whether there will be fragmentation. When we debate the White Paper those fears can be answered. District health authorities will continue to have all the money they need. We are under a duty to provide a comprehensive service accessible to all patients. Health authorities will use their money to make sure that they plan where the service is best given to patients.

The profession wants to know about medical teaching and research, an extremely important and complex issue where the old arrangements needed improving anyway. We have to make sure that the training of our doctors and research are not adversely affected by the proposals. The same is true of nurse training. When I encounter consultants in the hospital service I find that they are suspicious to a certain extent of the new system of contracts. They are sometimes suspicious about the self-governing proposals and about the effect of GP practice budgets. They say that we are going too fast. They talk of the need for pilot schemes. They say that when new drugs are introduced they need to experiment.

All that has been picked up by the hon. Member for Livingston. I do not credit him with originality. In the press at the weekend he picked up a theme that has been put to me by the medical profession for the last month, but in a different way. He is interested in running pilots. I assume that he does not want to run pilots of things to which he is fundamentally opposed. Now he has come round to experimenting. As we need legislation before we can set up any of these things, he does not seem to want to rush to experiment because he does not want to legislate for a year or two. It might mean pilot schemes at two or three selected places and a multidisciplinary committee. We would spend years getting an agreed assessment. In the great tradition of that giant service, nothing would happen for a long time.

Consultants are interested in self-governing hospitals and GPs are interested in their own practice budgets. The hon. Member for Livingston is right to have his fears. Many doctors will react to our request for expressions of interest next month. Many of them will move forward with us. They are interested in how we will handle the changes and whether we are going too fast. I believe that we can meet the fears of plunging into the unknown. It is in the nature of our proposals on self-governing hospitals that we are asking who is interested. We shall work with willing volunteers where there is an adequate expression of interest.

There will be GP practice budgets only when GPs have said, "That is a good idea. You have satisfied me on the details. We have negotiated the basis of a contract that I am happy with." They they will go ahead. Before we have the first ones in place by April 1991 we shall have to work out the details. We shall discover much more about how to calculate a budget, about the structure of management needed in self-governing hospitals, and about care services, even after April 1991, depending on where we are. We shall run it on a fairly loose rein at first to get the system bedded in.

The question is, do Labour Members share the Government's aim for a better health service and improved management, and will they commit themselves to proceeding sensibly and purposefully in the right

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direction, testing things, working out the details, and making sure that it goes smoothly? Or does the Labour party, as some people did at first, just say that it is "agin" it, that the Government are commercialising the service and that it is fundamentally opposed to it?

I will be fair to the hon. Member for Livingston ; he has not done it today, but outside the debate has been reduced to a pathetically low level at various times. I have discussed keeping elephants out of the door by opposing privatisation. People have been told that the elderly will be turned away and that hospitals will concentrate on profitable lines, whatever that means. I went through a picket line in Glamorgan when I was late for a train. A chap ran after me and gave me a leaflet. I was told that I had gone past GPs. I do not know who most of them were. They were chanting, "People, not profits," whatever that meant.

The trouble with that level of campaigning is that, as will become clear when we reach the legislation and as we proceed, the BMA does not believe what is being said. It knows that the leaflets contain things that are not true. More importantly, the Labour party does not believe what is being said. It knows that it is not fighting a campaign for privatisation. The snag is that it has no proposals of its own to put forward. At the moment, it is trying to compound confusion for short-term political reasons.

I do not object to political exchanges, whether vigorous or less vigorous, but I strongly object when the Labour party, the hon. Member for Livingston and others doubt the sincere commitment of myself and the Conservative party to a better NHS. I and many of my hon. Friends have worked for years in stints at the Department of Health in order to secure the future of the NHS, which would decline if we adoped a do-nothing option and decided to let it stand still. The Government have spent more and done more for the NHS than any other Government in the previous two decades. We have presided over the growth of the service, the widespread introduction of new high- tech services and the particularly rapid spread of community-based care and better services for the elderly. We began the introduction of better modern management and we shall continue that.

The Labour party's claims for its commitment are based on the ancient history of two generations ago. Our claims are based on our recent achievements and, above all, on our vision of reforms which will make the NHS better still for future generations of patients and will give us a Health Service which, as a result of the Government's efforts, we shall be proud of in 40 years' time, just as we have been proud of it over the past 40 years.

4.46 pm

Mr. Michael Foot (Blaenau Gwent) : When the Secretary of State said at the end of his speech that what he resented was that anybody should question the allegiance of himself and his party to the National Health Service, I say to him right at the start that if he had been present in 1948, as I was, when the service was introduced, he would have known that the Opposition's suspicions were based on a great foundation.

The Conservative party made a great effort to stop the NHS, on its present comprehensive basis, from ever being introduced. That is why it put down reasoned amendments against Second and Third Readings. I know that the right hon. and learned Gentleman has said that his party was

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wrong on that occasion--I am happy that he should own up now--but he must not suspect our suspicions when we look back upon that record. The Secretary of State also referred today--he called it a Freudian slip, but it might be much more of a Freudian landslide--to the British Medical opposition. That is what he is up against, and he must not complain if on some matters the Opposition happen to agree with the British Medical opposition's opposition to his measures. I hope that this is not too parochial a reference to my constituency, but nothing is resented more in my constituency of Blaenau Gwent, or Ebbw Vale as it was, by the representatives of the medical profession than that the right hon. and learned Gentleman should in some way claim that his quarrels with the British Medical opposition, or the medical professions in their different forms, is in some way comparable to what Aneurin Bevan faced when the service was introduced.

One of the main reasons why doctors, or many sections of the doctors--not all of them by any means--opposed the introduction of the scheme was that they said that it would interfere with their clinical freedom. Large numbers of general practitioners and their leaders in the BMA genuinely believed that right up to the moment when the Health Service was brought into being, as I can confirm. At that moment, the transformation took place and the doctors discovered that they had far more genuine clinical freedom, particularly when dealing with poor people, than ever before. The vast majority of the medical profession welcomed the change as the greatest they had seen in the history of the country. Most of them hold to that same view now. Therefore, the Secretary of State cannot claim for a moment that his arguments are anything like the same as those that Aneurin Bevan had with the medical profession. At that time it was not easy to get the service comprehensively established, because it had been divided in such different ways. To achieve anything which could properly be termed a National Health Service necessitated detailed consultations with the British Medical Association and other sections.

A few moments ago the Secretary of State spoke as if the medical profession were contained in one body. However, there is a variety of bodies, and if the right hon. and learned Gentleman knew anything about this, he would know that the royal colleges have always taken different approaches. If it had not been for the detailed consultations between Aneurin Bevan and the royal colleges, particularly the leaders of the Royal College of Physicians, there would never have been a National Health Service.

The difference between Aneurin Bevan's Government and this Government is that his did not take orders from the medical profession. Aneurin Bevan always said that supremacy should lie with the House, but he consulted members of the profession. The shape of the National Health Service was powerfully affected by the discussions that he had with the heads of the royal colleges. The Government have done some terribly foolish things in relation to health. They have done nothing more foolish than slamming the door on the heads of the royal colleges

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not so many months ago. They did so over the contract but, even worse, they did not consult the colleges about their plans for the future. Why not?

The origin of the troubles that the Government and the country face over the National Health Service, which the Opposition want to protect and for which it has every right to fight, was the Prime Minister's decision to set up a review body--a Cabinet committee--under her chairmanship to investigate the Health Service. No one was stronger than Aneurin Bevan in saying that the service should be reviewed. Almost every Act introduced by the Government in which he served contained a clause stating that the service should be reviewed after five years, or some period, so that the people working in it and the patients dependent on it could take a fresh look at it. He was not dogmatic enough to say that it should stay the same for ever.

Aneurin Bevan would never have agreed to a Cabinet Committee that was presided over by a Prime Minister, even one that favoured the Health Service, which the present one does not. Even if the Prime Minister passionately supported it, it would not be satisfactory for an investigation to be carried out by a Cabinet committee with the Prime Minister able to carry through anything she wanted and to get rid of Cabinet Ministers who did not do as she wanted, almost as easily as if they were health managers.

The Secretary of State is a very clever fellow, although not quite as clever as he sometimes claims. However, I give him full credit for his quality compared to that of many of his comrades and companions in the Cabinet. When he accepted his job, his ambition exceeded his intelligence and he has to live with the consequences. Unfortunately, so do we. Unless we can cut it down, he will suffer to his dying day from the albatross round his neck, which is that he was prepared, in that Cabinet committee, to accept the formal investigation into the most precious of the country's national institutions, accept its terms and recommend them to the country. Even the right hon. and learned Gentleman can hardly stomach some of the terms, such as the special arrangements for BUPA patients, although he defends them. I suppose that most of the leakages on these subjects come direct from the right hon. and learned Gentleman. The story is that he opposed the proposals right up to the end, but then swallowed his pride. That is the price of keeping his job. He has made his biggest political mistake and, unfortunately, we have to suffer for it. I am sure that, when he has the chance, my hon. Friend the Member for Livingston (Mr. Cook) will carry out a proper overhaul and investigation of the National Health Service. That must take place, and the intelligent way to do so would be to have consultations before decisions are taken, not afterwards. If that had happened, even with these proposals, if they had not been handed down by the Prime Minister, there might have been some chance of decent consultations. However, nobody knows better than the Secretary of State how narrow the ground is for any possible negotiations. That is an affront to everyone who works in the Health Service, whether representatives of trade unions, about whom the right hon. and learned Gentleman is so rude, or representatives of the general practitioners. The right hon. and learned Gentleman is capable of offending GPs about their medical and monetary habits, when he is in a tight corner in negotiations. The presidents of the royal colleges, who

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represent some of the greatest traditions in this country, were never once consulted before decisions were made about these major questions on how the service which they did so much to build should operate in the future.

Doctors from my constituency, like many others throughout the country, have been to fake discussions and consultations held by the Secretary of State or by his Ministers, I was affronted by the one that took place on 20 April in Bristol, to which representatives from south Wales went to have discussions with the Secretary of State. After he had made his speech and after a few minutes of discussion, the media were turned out so that other discussions could be held. The Secretary of State did not allow the opportunity for other views to be put to him and many of those who went to the meeting went away affronted by the manner in which matters were discussed and debated, quite apart from their reactions to the proposals.

If the Secretary of State questions what I say, I can give him detailed evidence. I shall not go through every aspect of the objections, but I shall mention those relating to the major matters to which the right hon. and learned Gentleman referred. One of the leading doctors in my constituency went to the consultation meeting. It was the first chance that he and his representatives had had to speak about the proposal, which is now supposed to go through. I shall mention one of his objections from a list of almost equally valid objections : his criticism of the way in which the Government presented their proposals.

When the Secretary of State gets into such a ferocious rhetorical state about the propaganda spread by the BMA, he should be more careful, because he must be spending hundreds of millions of pounds of taxpayers' money on putting his case. The BMA, for probably the first time in history, is using an advertising agent to assist it in putting its case. I dare say the Government will soon introduce a law under which only Government Ministers will be allowed to use advertising agencies to present their case. I dare say that Lord Young, who often co-operated eagerly with the right hon. and learned Gentleman, would be happy to draw up a suitable piece of legislation that could be rushed through to ensure that only the Government have the chance to put their case, and if any other group tried to hit back it would be pilloried and attacked, as the right hon. and learned Gentleman has done so offensively on other occasions. Doctors in my constituency, and I am sure many others, are asking something that goes to the central principle of the Health Service. The right and learned Gentleman's arguments about the numbers involved in the work in the years ahead will not affect this argument. The doctor said :

"I think it is morally wrong to claim that the Service will be free at the point of first contact when some GPs will in effect be controlling waiting lists. It would have been more honest for Government to have encouraged these Practices to present private services altogether rather than continue the pretence of the scheme representing NHS principles."

Believe me, after the tuition of 30 or 40 years, doctors in my constituency --and, I would say, in most other parts of the country--understand the principles of the NHS very much better than the Prime Minister who presided over the committee that produced these proposals. The right hon. Lady has never understood those principles. Her idea is to kill Socialism, and I am sure that right up to 1979--or 1983, or perhaps 1987--she regarded the NHS as part of Socialism. It would be strange if she did not, because the

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NHS is the greatest and most obvious Socialist institution in the country and is based on Socialist principles. The Prime Minister cannot kill Socialism without killing off the National Health Service.

Of course, it would be very difficult to kill it off with a single blow or indeed a series of blows, even with such a skilful practitioner as the Secretary of State to do the Prime Minister's dirty work for her. The Government must go about it in a rather different way. I do not respect the good faith of the Secretary of State in these matters, but I know that some Conservative Members, and many doctors who are certainly not Labour party supporters, support the NHS and believe that its principles must be upheld over and above any competing principles about private profit, the market and so forth. That is what I mean by believing in the Health Service.

Many inroads have been made into the NHS as it was first introduced in 1948, and I acknowledge that they have been made by Labour as well as Conservative Governments ; but we are now witnessing a much more serious, dangerous and long-term attack on the NHS than we have ever seen before. In case anyone doubts what I say or thinks that I am overstating this aspect of our deep-seated suspicions about the Government's motives, let me quote what was said by the medical correspondent of The Independent a day or two after the publication of the Secretary of State's proposals :

"In the week since the NHS White Paper was published, the most revealing comment about it has been an aside from David Willetts, formerly the Prime Minister's health care adviser in the Downing Street policy unit and now director of the Centre for Policy Studies, the right-wing think-tank Mrs. Thatcher helped to found." No doubt the Secretary of State is familiar with those bodies : indeed, he may be familiar with David Willetts himself.

"Mr. Willetts, the closest of the outsiders' to the NHS review, said he had asked a senior civil servant what he would do to the NHS if he were the minister. The reply was, I'd either leave it entirely alone, because it is too politically dangerous. Or I'd destabilise it, and see what happened.'"

That is what the right hon. and learned Gentleman is doing with the backing of the Prime Minister, and that is why we believe that this attack will shape many other aspects of social policy in the years to come.

My hon. Friend the Member for Livingston has led the battle with such skill, knowledge, understanding and hard work that we will accept no insults that may be levelled at him by the Secretary of State. I am sure that the right hon. and learned Gentleman will wish to withdraw the few extra insults that he threw out today. My hon. Friend has led the battle to protect the service with constructive zeal, and we are still determined to protect it. We know that it needs much more money to be made better for the future ; but, although that is by far the most important aspect, there are many others.

The improvement of the NHS must be achieved by a Government who believe in the democratic Socialist principles of the service. The Prime Minister does not believe in them, and if the Secretary of State says that he does he will not stay in his job for long. We would find reasons to rejoice at that, and others not to do so. My hon. Friend has made a generous proposal to the Government. If it were merely a matter of political opportunism-- those are the Secretary of State's words, not mine--the best thing for the Labour party would be for the fight to go ahead until we could play it as one of our main cards in the next election. My hon. Friend, on behalf

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of the Labour party, has proposed that the issue be kicked out until after the next election : that we should have a vote about it. That is a fair offer, and if it is rejected that rejection will expose all the more the malice--the malignity--that the Prime Minister and her aides have brought to this great subject.

5.5 pm

Dame Elaine Kellett-Bowman (Lancaster) : I shall not detain the House for long. I wish to make three points.

I wish first to comment on the disreputable £7 million advertising campaign being run by the British Medical Association. Like many of my hon. Friends, I actually enjoy receiving letters from constituents, but I have been horrified by the number of letters that I have received from elderly patients, many of them in old people's homes, who have been worried stiff by the BMA's untruthful pamphlet. They have been led to believe that they will not obtain the treatment or--if it is near the end of the financial year--the drugs that they need. The BMA knows perfectly well that both those things are untrue.

Even worse, one 84-year-old was informed by his doctor that if the Government's proposals went through he would no longer be able to visit him at home in an isolated rural area. I should dearly like to know the name of his doctor. Despite all that, however, I continue to believe that locally we are very fortunate in our GPs, and that they have merely been misled by the BMA and are supporting what is, after all, their trade union.

I have responded meticulously, point by point, to every point that a doctor has made to me. I assured doctors that this was a consultative document and that I would forward all their letters and comments to the Secretary of State as part of the consultation process, which I have done. I said that I would seek answers to points which were unclear or which worried them, with a view to having them modified--as usually happens during a consultation period--or deleted altogether, as the case might be.

That was until Thursday. On Thursday I received a letter from a local GP. The final paragraph read as follows :

"Some doctors select the compliant patients by being so unpleasant that the others leave the list, and join the list of a softer doctor."

Those are not my words ; they are the words of a local GP. That letter came as a considerable shock to me, because I have always viewed our local doctors--delightful men--through rose-coloured spectacles, and have argued that what the Government were trying to do was bring other areas up to the standard of those in my part of the world.

No doubt the unpleasant doctors mentioned by their colleague are not typical, but even one such doctor is one too many, and shows that reform is necessary for the patients' sake. Fortunately for the excellent reputations of our local hospitals and the vast majority of our local GPs, on the very day that I received that disturbing letter the North-West regional health authority issued a report by its top medical experts showing that the expectation of life in Lancashire and Greater Manchester was two years below the national average--except in Lancaster, where it is above the national average. That rather proves the point that I was making all along to doctors and constituents alike--that the NHS is patchy and uneven. When the BMA and the Royal College of Nursing talk of destroying

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