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the comprehensive nature of the NHS, they are talking of a myth. The aim of the Government is to make sure that a comprehensive service, nationally funded, exists everywhere, and that people obtain decent treatment wherever they live.

It is said that things go in threes. On Thursday the BMA held its conference to decide its attitude to the proposals. As one GP representative put it, the BMA attitude is hardening. Really? When did the BMA not oppose change? It opposed it when Lloyd George tried to reform health care in 1911 ; it opposed the White Paper in 1943 ; it opposed the introduction of the NHS in 1946-48 until--as the predecessor of the right hon. Gentleman the Member for Blaenau Gwent (Mr. Foot), Aneurin Bevan, put it--its mouth was stuffed with gold ; and it opposed the changes in the contract in 1966, changes it is now defending tooth and nail.

I have news for the BMA delegate to whom I have referred : if the BMA attitude is hardening, so is the attitude of myself and my hon. Friends, with every letter that we receive from sick and elderly constituents, people who are frightened, misled and confused by the BMA pamphlets. We do not expect that sort of unprofessional conduct from the delightful and courteous men whom, until now, we have liked and respected. If there be any will to resume the protracted negotiations on conditions of service, all very well. If not, so be it. I advise the Secretary of State to press on with his reforms. The patients need them, and we shall support them.

5.14 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire) : I believe that the official Opposition's motion left the Labour party wide open to exactly the kind of counter attack launched by the Secretary of State. It is wrong headed at this stage to concentrate simply on the terms of the general practitioners' contract and doctors' oppo-sition. Such a move allows the Government to argue that the doctors are just another special interest group and that they are only concerned about their own wallets. Such an approach diminishes the importance of all the other professional and consumer groups, legion in number, who oppose the Government's proposals.

The range of dissent and the depth of feeling of opposition to the White Paper argue powerfully for the widespread mobilisation of public opinion against these proposals. The motion tabled by the Labour party has potentially minimised the opposition of Conservative Back Benchers and the possibility of getting a response from them to the position in which they find themselves. I get the impression that they are under a lot of pressure from their constituents. Therefore, I believe that an Adjournment motion would have produced a much more instructive and constructive debate.

The Secretary of State announced that a full debate will be held on the White Paper. It would be helpful to know when that might happen. It will be an important debate in Government time, and I look forward to it being held.

The Government's proposals relating to the NHS are ill thought out. No firm long-term commitment has been made to increase funding year by year. I understood the Secretary of State to say that he had won a 5 per cent. real increase at the battle with the Treasury last autumn. If that is correct and if the Secretary of State is saying that, over time, the Health Service can expect that sort of real terms

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increase in funding under his custodianship, many of the generally held fears will be assuaged. Of course, there is always the question whether Government statements can be trusted.

The very effective speech of the right hon. Member for Blaenau Gwent (Mr. Foot) underscored the fact that part of the problem has really arisen because of a lack of consultation. The Government engaged in an internal review. There was no consultation or empirical research. No evidence was submitted and studied. That situation weakens fundamentally the strength of the case that the Government are trying to argue.

The Secretary of State cannot so readily rubbish the idea of pilot projects. In the autumn, there will be a report on the resources management initiatives that have been in process. Why do we not wait at least until we have the preliminary findings, although even then it may take some further time to establish exactly what has been achieved in those projects? I am aware that another 50 or so are due to commence and they will also take further time to assess. There is no reason for this degree of haste ; the pilot projects should first of all be studied carefully, before decisions are made. The time allowed to introduce the plans is totally inadequate, and is a recipe for confusion and disaster. There is no guarantee of resources even to manage the introduction of the reforms--a substantial problem which the service will have to face. In the present situation there is considerable uncertainty and confusion. The response of the Secretary of State is simply to try to bully people into line. That is not a proper or responsible way to behave. The only major effect achieved is to lower morale of staff when they are trying their best to deliver the best service they can.

The proposals in the White Paper are undoubtedly fundamental and far reaching, irrespective of whether one thinks they are right or wrong. Given their importance, the changes should have been introduced much more carefully and thoughtfully. I believe that the debate should really be about the future of primary health care. The Government seem motivated by a desire to create a mechanism that will limit costs. I have a fear, and it is essentially the same fear as that which GPs raised when the NHS was first introduced. They fear now as they did then that limitations on cost will restrict clinical judgment. GPs are right to be afraid, because, given the lack of detail in front of us, that limitation is still a real prospect. An inevitable result of the present proposals would be doctors spending less time with patients. I cannot see how the Secretary of State can argue otherwise. Less time would be spent on meaningful preventive medicine. I listened carefuly to the Secretary of State's comments about Government targets, statistics and so on. However, meaningful preventive medicine depends on the general practitioner spending sufficient time with individual patients to deal with their requirements. As a result of the Government's proposals, there is certainly a prospect of a fundamental erosion of services provided in rural areas. The Secretary of State has not satisfied the profession that such services would not be eroded.

As a Scottish Member, I realise that some improvements have been made in the Scottish contract. I hope that, as far as possible, those improvements will be made in the English contract, built upon and taken forward. However, in general, doctors are still apprehensive that they are

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being asked to take a fundamental structural step in an unquantified way in an unknown direction, with the real prospect of damage to their patients as a direct result.

I want to ask some questions that I hope will clear up uncertainties that currently exist in the minds of medical professionals. If the Secretary of State has set up a new organisation known as the British medical opposition, I would certainly like to be a founder member ; I will join up this afternoon. Has the Secretary of State considered alternative models to deliver primary care? I refer him to an article published on 15 April in the British Medical Journal by Professor David Morrell, a professor of general practice. He outlines a detailed role for general practice and a contract that would make far more sense. He talks about the need for an increased basic practice allowance. His scheme would also involve annual reports by the GP practices to the family practitioner committee or the area health board, and regular visits by audit committees. I do not have time to go into his proposals in great detail, but general practitioners in my area have told me that it would be a sensible alternative, would lead to the attainment of many of the Government's objectives and would exclude all the objectionable features of the present plans.

It is important that we should hear what the Government have to say about care in the community for the elderly, the mentally handicapped and the mentally ill. What will be the administrative cost of setting up and maintaining the new system? Will the medical audit be adequately funded? The Government studiously avoided making a positive response to the exchanges on that subject in the other place. What will be the career structure for part-time doctors, particularly part-time women doctors? The Government have made no headway on that fundamental question. According to most informed commentators, the basic practice allowance and the group practice allowance are on the way out. That would have a fundemental effect on the career prospects of part-time doctors, particularly part-time women doctors.

The objective is to achieve greater choice for the patient. How will that be possible if a district health authority has a contract with a hospital to provide services and if a general practitioner has not opted to take control of his own budget, and therefore does not have money to send with the patient to that hospital? What will happen if that general practitioner wants to refer a patient to a hospital that has not entered into a contract with the district health authority? Frequently, there are valid reasons for referring the patient to a hospital outwith the district health authority for specialist treatment, or for other reasons. Can the Secretary of State guarantee that such a referral would still be permitted under the new proposals? That question is causing great concern and anxiety to general practitioners and patients in my area and others. If implemented, the White Paper proposals will change fundamentally the National Health Service. It will be changed almost beyond recognition. The old ideas of consensus and co-operation will be overtaken by competition and cost-cutting, with the result that the standards of care for the elderly and the chronically sick will fall and the administrative and treatment costs for everybody else will rise. The Government should think again.

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5.22 pm

Mr. Jonathan Aitken (Thanet, South) : I agree with the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) that the terms of the motion are tactically ill-judged. We have witnessed this afternoon a delightful irony of political history. The House was treated to the spectacle of the Labour party leaping uninhibitedly on the BMA's bandwagon.

The hon. Member for Livingston (Mr. Cook) said that it is not true that doctors always oppose change in the National Health Service. I thought I saw the right hon. Member for Blaenau Gwent (Mr. Foot) respond to that statement with a nervous twitch. It seemed to stir him into doing his best to paper over the cracks of Labour party history. He said that the doctors had responded quite favourably in the end to the Bevan reports and that we should not be surprised that the Labour party agrees with the BMA. However, that is not what the right hon. Gentleman said in his book.

By chance, to amuse myself on bank holiday Monday, I dipped into his majestic biography of Nye Bevan. On page 103, I discovered his description of exactly what was the mood of the doctors as the NHS reforms were introduced--reforms that the BMA opposed as implacably as it defends the status quo today. The right hon. Gentleman said : "Much the strongest bent in the medical mind was a non-political conservatism, a revulsion against all change, a habit of intellectual isolation which enabled them to magnify any proposals for reform into a totalitarian nightmare."

I find an echo or two of those words in today's BMA campaign and an echo or two in the speech of the hon. Member for Livingston. Conservative Members do not need to disparage the word "conservatism"--the fact that the medical profession is traditionally a conservative profession. That is natural. General practitioners have much to be proud of in the way that they carry out their duties. Our delicate task in the debate is to try to make a judgment on what parts of the general practitioner's world within the NHS should be preserved and what parts should be altered by the reforms. That is the judgment that we have to make on the White Paper and the supporting documents.

There are plenty of good ideas in the White Paper for both doctors and patients, which I strongly support. The medical audit proposals are excellent. The notion of a peer review is supported by many thoughtful doctors. I believe that the perhaps more controversial proposals on indicative or guideline drug budgets for doctors should be welcomed.

We have heard yet again the BMA's traditional trumpet call sounding the alarm that any such proposals will destroy doctors' clinical freedom to prescribe. Those arguments were shown to be ill-founded at the time of the limited list controversy in 1985. They are even more ill-founded today, in the light of that experience. I recall supporting my right hon. and learned Friend in his previous incarnation as Minister of State. He put up with all kinds of attacks when he introduced the limited list. What was the result when the dust settled? [Interruption.] The hon. Member for Peckham (Ms. Harman) says that he amended it. I hope that all political debates and consultation papers will lead to amendments. The accusations that were levelled against my right hon. and learned Friend were totally unjustified. When the dust had settled, £75 million had been saved from the nation's drug

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budget and diverted to better patient care. Moreover, the notion that clinical freedom was threatened or would be destroyed proved to be a complete nonsense. It has not been affected at all.

In a world where resources are finite and the demand for medicine is infinite, there can no longer be any absolute prescribing freedoms. We should welcome the guideline drug budgets for doctors as a non-compulsory yardstick of measurement, particularly since the yardstick can be moved after dialogue with the family practitioner committees and after peer review.

Having commended certain parts of the White Paper, may I also express a few misgivings about the sections that deal with the future management of general practice. My real concern is whether the proposals will actually work and whether they are based on the right principles. I must confess that I am a little worried that there may be some fundamental flaws at the heart of the management proposals for general practitioners. Above all, I fear that the White Paper's ideology of free market forces and the untried innovations that flow from that ideology may not satisfactorily be transplanted to the traditional and caring body politic of general practice --at least, not without some hideous practical difficulties.

The first flaw I detect in the White Paper is the impression it gives that all these sweeping management reforms are necessary because general practitioners go about their duties in a way that is inefficient and expensive. If that is Whitehall's view, it is not a view that is widely shared by patients at the grass roots ; nor does it seem to be justified by the available statistics. As far as I can discover, Britain's doctors--as gatekeepers of the NHS--operate one of the cheaper and more effective primary health care systems in the Western world. Medical salaries here are pinned down to less than half the levels that exist in some European countries and in the USA. NHS administrative costs are low, at 4.5 per cent. of the total, compared with administrative costs of 21 per cent. of the total in America's competitive, free market medical system.

One part of the Government's reforms that perplexes me concerning their call for greater business efficiency and consumer choice is the starting point of the grievance that doctors are inefficient. Of course there are some bad doctors ; there are a few bad apples in any profession. There are some 9 to 5 spirits who seem to have forgotten their vocation. However, on the whole the evidence suggests that there is widespread patient satisfaction with general practitioner services in this country, and I find it curious that a White Paper which is championing consumer demand in medicine should provide no evidence of consumer demand for reforms of general practice. As I see it, the whole key to the philosophy of this White Paper towards the doctors is summed up in a sentence on page 48 : "The practices which attract the most custom will attract the most money."

That sounds good as a fly-by-night economics textbook sentence published by the university of Chicago business school but, coming down to our own National Health Service, what it means is that the ultimate reward for improved efficiency and improved advertising is that market forces will send successful doctors a longer list of patients from which the doctors can earn higher and higher capitation fees and augment their incomes still

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further by the performance bonus rule which allows them to retain in their practices 50 per cent. of the savings they make from their budgets.

We should not try to pretend that such proposals are anything other than a very radical reform. After all, they go against the trend of general practitioners trying to keep small lists, as they have been for some years now. It seems to be a decisive shift away from dear old " Dr. Finlay's Casebook," as super-doc comes to the supermarket with these sorts of ideas. Will the reforms work, and if they do, will they damage, as some doctors fear, the fundamental basis of doctor-patient relationships or the established collegiate basis of doctor-to-doctor relationships?

These reforms may work in certain prosperous surburban or metropolitan areas such as parts of the home counties or the city of Westminster, where the residential community consists largely of youngish people of working age, who may well be content with the brusque "Wham bam, thank you, doctor, for getting me back on my feet as quickly as possible" approach, because on the whole that approach to medicine will be quite popular with the age and social group likely to suffer only from short bursts of illness.

However, consider for a moment a completely different kind of community. I take the town of Ramsgate from my own constituency, which is a seaside town with a population of whom 38 per cent. are pensioners and which has the biggest department of social security office in south-east England, with 16,000 people on benefit. It has a particularly high concentration of disabled, disadvantaged, geriatric, chronically sick and mentally handicapped people. In short, doctors there deal with a lot of patients who need time and care. I do not see, in the words of the White Paper, many pluses for elderly and deprived patients in that sort of community, for many of whom the language of consumer choice in general practice might just as well be Mandarin Chinese. They want guidance, not the ability to make yuppy-type consumer choice decisions.

Mr. Sydney Bidwell (Ealing, Southall) : What would the hon. Gentleman say to a constituent who came to see me on Friday to say that, after false diagnosis, his wife needed pretty urgent surgery to the nose after many months of distress? She went to Ealing hospital as a result and was told that she would still have to wait many weeks before the operation could take place, but if he could afford £1,000 it could be carried out next week. What does the White Paper do in this regard?

Mr. Aitken : The hon. Member tries to tempt me into completely different areas from those which are the subject of this debate, and I must resist that temptation other than to express sympathy with his constituent. Whether it is his constituent or my constituent with a problem, I want to emphasise that I am not talking about so-called bad doctors or inefficient practices.

I know a practice in Ramsgate which lives up to and exceeds many of the standards set by the Government in the working papers. Its child immunisation rates are in excess of the Government's target of 90 per cent. ; its drug bill is 23 per cent. below the average for the area ; it operates minor surgery sessions ; it holds preventive medicine clinics ; it is computerised, with modern capability and enjoys a good professional and popular reputation. It is just the sort of practice which should

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benefit from the White Paper proposals, and yet the doctors in that practice regard the Government's management and budgetary ideas and target payment schemes in particular with feelings close to horror. Why do they have those very strong feelings? The answer is that they believe--and I think they are right, with 12 per cent. of their patients over 75 and another 33 per cent. over 65--that they are serving the kind of community which can best be looked after by the gentler culture of traditional general practice, with all its occasional necessary time- wasting delays and pauses for counselling and sympathy which a caring service involves, rather than the harsher disciplines of competitive, doctor--versus--doc-tor consumer choice, free market medicine portrayed in the White Paper.

I do not want to fall into the trap which the Labour party has fallen into of knocking everything in the White Paper on the curious principle that any stigma will do to beat a dogma, but there should be more flexibility in some of the Government's proposals. I could not find much indication of that vital ingredient in the White Paper, but I was glad to hear in some of the things my right hon. and learned Friend was saying today, and indeed in the tone of some of the recent press statements and working papers, that a gentler and more flexible note may now be injected into some of these proposals as they affect doctors.

Can I follow the point made by the hon. Member for Ealing, Southall (Mr. Bidwell) in supporting his call to the Minister to pay some attention to that profound article by Professor David Morell in a recent edition of the British Medical Journal ? His point, as I understood it, was that the Government could get everything they wanted, but the foundation stone for the new contract should not be so much free market forces as the ideal that a medical practice serves the community in which it is based and that the standard of service by doctors to a community could be defined, graded and rewarded not by competitive forces within that community but by an annual audit carried out under the supervision of the area family practitioner committee. There was a great deal of merit in that proposal.

Finally, whether we are talking about Professor Morell's ideas or the Government's more radical proposals, when tackling this subject of reforming general practice a little humility and caution is essential. We are getting into deep and uncharted waters. I was sorry to hear the Secretary of State sound a little disparaging as he brushed aside any suggestion that pilot schemes might be workable. It is always bad news when the Labour party has a good idea, but the pilot scheme has something to commend it, because rural, coastal, inner city, suburban and metropolitan areas all have their different problems, and a different programme of pilot schemes in each one to see how some of these ideas work would be sensible.

The decent, diligent family doctor is part of the culture of Britain, part of the fabric of our society, and on the whole general practitioners have served their communities well. They rightly enjoy a far higher level of popularity and respect than a great many other professionals including, I might say, politicians. Maybe some general practitioners do need a bit of a shake-up and many of them would accept the best of the Government's new ideas and agree that the White Paper does give a useful nudge towards some welcome changes, but let us proceed by evolution rather than by revolution and let us have more time,

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collaboration and path-finding by pilot schemes, because that is the way of accomplishing what the Secretary of State and all his supporters wish to achieve.

5.38 pm

Mr. Ron Leighton (Newham, North-East) : The Secretary of State has had the unique distinction of uniting the whole of the medical world including all the royal colleges, against himself. I see today that he also has the opposition of the community health councils, who found the issuing of his White Paper

" objectionable', the proposals drastic' and the time scale unacceptably hasty'."

and are

"asking him to suspend implementation of these undesirable' and impractical' plans."

Today, we are discussing the views of the doctors. In preparation for the debate I conducted a survey of all the doctors in my constituency. They voted 47 against the Secretary of State's proposals and only three in favour. I asked them for any further comments and I received a huge sheaf of impassioned correspondence which I should be only too pleased to allow the Secretary of State to inspect.

I should like to read a small selection of the comments that I received, to which I hope the Secretary of State will pay attention. Dr. Spalding wrote :

"I am disturbed by the proposals of the Government's White Paper on the National Health Service. I see them as doing great harm to general practice. I have been in practice in Manor Park for 25 years and retire in one week and so I have no vested interest either way. The White Paper is pervaded by a materialistic attitude to medicine. Money matters but it should not be the only ruler. Interestingly, this attitude is revealed in the White Paper by the use of the word Consumer', where Patient is meant I am afraid that if its ideas are enacted, the patient will indeed become merely a consumer."

Dr. Patel said :

"No, the new proposals won't help the NHS, they will destroy it. Please ask the Government whether the advisers on the new proposals are full-time NHS doctors or economists? The new proposals will destroy the doctor and patient relationship. There would be a two tier fragmented Health Service."

Dr. Phillips said :

"Medicine is not a business and should never be run entirely on that basis. In general practice it would not improve patient care. Extra administration would be necessary--there is already too much. If the Government expects us to be capable of running the practice on a financial level, and negotiate with hospitals, etc. we should be considered capable of running the internal affairs of our practices without outside pressure and interference."

Dr. Kapur said :

"the opting out of hospitals, the buying of hospital facilities by Family Practitioner Committees, the restrictions on the GPs' budget and referral rights ; the increased (60 per cent.) payment on number of patients--all these factors plus many others will lead to a deterioration of morale, and to two levels of NHS care."

Dr. Graham wrote :

"In my opinion the new contract introduces increased bureaucracy causing a greater distance between doctors and patients and distrust. As a course organiser I am alarmed that the Government are demanding 20 hours in surgery per week as I spend two or more sessions a week in Newham General Hospital teaching post-graduates. When I see a patient who looks ill I cannot tell whether he has influenza needing rest, food poisoning or acute leukaemia where a bone marrow transplant costs £220,000. It is only detailed hospital tests that

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will eventually uncover the truth, by which time the patient is out of my control. He would not want a GP coming to Hospital behind his back to consult with the specialist and possibly saying, Our practice cannot afford this treatment in future this year'.". Dr. David Keable-Elliot said :

"The Government's proposed health service changes will seriously damage patient care and risk trust between doctor and patient. For the first time, general practitioner services are to be cash limited. This means a possible rationing of the care we provide each year. We are to be offered financial incentives to save on the cost of patient care We are to be offered rewards not to treat patients, or to delay their care whether this be arranging hospital tests, giving treatment or referring patients to a specialist for a possible operation. We are to be encouraged to arrange for patients to go to the cheapest hospital, perhaps not the best, the nearest or the one with the shortest waiting list. The Government want GPs to become rationers' of health care and thus take the blame for chronic underfunding of the NHS. Once that happens, our concern is that we will be blamed for the service's failures and that will then be used as an excuse to force further changes which will finally end the health service as we know it. We are not prepared to risk the trust and confidence our patients have in us. How long will that trust last when they know we have an incentive not to act in their best interest?"

Dr. Mahendran wrote :

"Budget or cost cutting on an open ended comprehensive service such as the NHS is unacceptable. An unlimited number of patients under a doctor will mean no time for patients who deserve more time and attention. Chronically ill, disabled and patients requiring multiple therapy will lose out from this White Paper. If Regional Hospitals opt out the patients will have to travel to distant hospitals to obtain basic specialist attention or hospitalised care. This cannot mean that patients have greater choice. Even if Doctors' surgeries remain prudent and minimise costs, what guarantee is there that the money allocated for the subsesquent years will match the needs and inflationary increases?"

He adds the postscript :

"In the entire discussion Kenneth Clarke sounds as if the NHS is a wasteful and inefficient service. Does he not realise that throughout the world there is no parallel to the effective, comprehensive health service provided by the NHS taking into account the total cost incurred?"

The hon. Member for Thanet, South (Mr. Aitken) also raised that point.

Dr. Dubal said :

"As budget holders we would be asked to offer our patients treatment influenced more by the cost than the needs of the patient. I have two patients with kidney transplants and a third on a waiting list for a kidney transplant. Each time I write medicine for these patients, as recommended by the hospital to stop transplant rejection it costs over £100. I also have several elderly patients with multiple diseases and disabilities which demand a lot of time, energy and social support. If I am to be a budget holder I would have to think seriously about keeping these patients on my list as I would not have the time or money to look after these patients--even if I tried hard. I would have to refer the patient to the cheapest hospital and look for the cheapest drug to treat them--the so- called shop around'. I do not believe that a patient who has paid his national Insurance and his dues' should be offered a second class treatment. If the Government cannot afford the National Health Service they should tell the people and patients, rather than hide behind the doctors and get their objectives done by forcing the doctors to do that for them."

He goes on to praise group practice and says that he had thought that the Government favoured it. He adds :

"By abolishing Group Practice allowance there will be a disincentive to form group practices with the resultant fall in the standard of patient care."

Dr. Bapna wanted me to tell the Government that

"Doctors are not running a shop, they are doing what is best for their patients."

Dr. Patel asked :

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"How can a doctor give more time and do all the preventative work by increasing the size of the list?"

I hope that the Secretary of State is paying close attention to the views of doctors in my constituency. Dr. Lazarus said :

"Having considered all aspects, I feel my time spent in budgetary and choosing cheap alternatives and unnecessary form filling would be better spent giving my patients a service I already provide." Dr. Desai said :

"The new contract is likely to cause deterioration in the service as doctors will not have time for promotive and preventative work if they have to look after more patients. In inner cities the situation is likely to worsen. The proposed payment structure for preventative work and immunisations etc., will make doctors despondent and lose interest in such work. The targets stated are not achievable as they depend on the patients."

Dr. Watt said :

"The immunisation and cervical smear targets are unreasonable. GPs cannot be a paternalistic police force forcing people to have what is good for them."

Dr. Christopher Derret said :

"Increased capitation fees are not an incentive to doctors to spend less time with each patient. Many patients say they already think their doctor gives too little time for each consultation. Quantity not quality is to be paid for. In the inner cities morbidity is higher and patient consultation rate can be almost double that in some prosperous areas."

The hon. Member for Thanet, South also mentioned that point. Dr. Derret went on :

"There is a widespread fear that the Government has a hidden agenda for the privatisation of Health Care."

Dr. Cramsie said--

Mr. Aitken : On a point of order, Madam Deputy Speaker. Is it in order for an hon. Member to read out verbatim quotes from doctors' letters with no break when many hon. Members on both sides of the House have speeches which they have thought about carefully and wish to deliver?

Madam Deputy Speaker (Miss Betty Boothroyd) : It is for hon. Members to deploy their arguments as they wish, but I remind the House that many hon. Members wish to take part in the debate and I appeal for very short speeches.

Mr. Leighton : I take your point, Madam Deputy Speaker, and I take the point made by the hon. Member for Thanet, South, but we are debating the views of the doctors. I am giving the views of rank and file doctors working in my constituency. Those are the views they have given me, which they have asked me to represent in Parliament. I shall compromise and read out two more letters. Perhaps the House will then have got the message from their remarks.

Dr. Rachman says :

"The plan to change the BPA to a per capita allowance will discourage existing practices from taking on new partners--there will be no incentive to. Instead I believe we will all be encouraged to employ assistants--these are often women and have no prospects of promotion or extension of their role. This is a retrograde move which seriously affects the position of all new young doctors seeking partnerships."

Dr. Haas says :

"I am very concerned that patients will find it hard to develop trust in their doctors as they will no longer see us as their advocates but as agents of cost control. Most of all, the health of those able to shout least loud, the old and physically handicapped will suffer."

That is an accurate reflection of doctors' views in my constituency. I would be delighted to give the Secretary of State the pile of correspondence so that he can read it. He

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should not laugh at the doctors' views or mock them. The doctors work in the depressed and deprived inner city. They have many problems. They considered the White Paper, then contacted me and asked me to put their views in the House.

How can the Secretary of State implement the proposals against what even he calls the "British medical opposition"? If the doctors do not become budget holders and if the hospitals do not opt out, what is left of the proposals? The Secretary of State should listen carefully and respectfully to the views of doctors. He should take his White Paper away and launch a genuine consultation. He should proceed by agreement to achieve a strong, free and adequately funded NHS. 5.51 pm

Mr. Jerry Hayes (Harlow) : It was fascinating to listen to the hon. Member for Newham, North-East (Mr. Leighton). Although it may destroy his political career, I must say that I rather like him. He held himself spellbound by some of the most awful codswallop. What have the doctors been reading? They must have been reading letters from the hon. Gentleman and the British Medical Association. If they want to hear what the Government are doing through the White Paper I would be only too delighted--and I am sure that many of my hon. Friends would be delighted--to speak to the doctors in Newham, North-East. I lay that down as a friendly challenge.

Mr. Leighton : The hon. Gentleman would have to be rather careful. If he spoke to the doctors like that, several of them in their white coats might think that it was a section 42 job and take him away.

Mr. Hayes : I concede that one on points.

It was fascinating to listen to the right hon. Member for Blaenau Gwent (Mr. Foot). It is always a joy to listen to such eloquence. Although I thought about what he said carefully, in the words of F. E. Smith, I was none the wiser or better informed. There was a lot of chat about destabilisation and under-resourcing. It suddenly dawned on me that this speech was coming from a member of a Labour Cabinet which cut capital expenditure on hospital building by 30 per cent., which for the first time in the history of the National Health Service agreed to cut the overall budget of the Health Service in real terms and which agreed to spend more on defence than on the Health Service--the opposite to what is happening now.

I want to draw to the attention of the House what was probably the most telling remark in the debate so far. It was made by the hon. Member for Livingston (Mr. Cook). He said that there would be a breach of the trust between doctor and patient and he asked how a patient would be able to look a doctor in the eye and trust him. The hon. Gentleman is right, especially when one considers the doctors who put skulls and crossbones up in their surgeries, the doctors who have been warning the most vulnerable members of society, such as the elderly, that they will not be welcome at their surgeries and the doctors who, at the instigation of the BMA, have put at the bottom of their prescriptions, "Voting Conservative will damage your health." That is where there has been a breach of trust. It has been a breach of trust by a small minority of general practitioners and by the overwhelming majority of the BMA.

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I raised a point with the hon. Member for Livingston earlier. He was giving a long litany of the opposition from the medical bodies, but he did not mention the National Association of Health Authorities in England and Wales. He stood there as if polyunsaturated margarine would not melt in his mouth and said that the association was the stooge of the Government. Yet the members of that association are the people who run the Health Service. I and many of my hon. Friends believe that their views are important. With the leave of the House, I shall quote the association's conclusions, warts and all, which is what consultation is all about. The association said :

"Overall, the Association welcomes many of the proposals in the White Paper. These include the more effective use of resources, greater responsiveness to the needs of the general public, clinical audit, greater delegation to the operational level, more involvement of clinicians in management and incentives for providing better services. The Association is also supportive of the separation of funding and provision of services.

It has to be recognised, however, that whilst many of these proposals are welcome, there are also a number of risks. The principal risk is that in the more diffuse NHS that is likely to emerge in the post White paper situation, it may be more difficult for the Service to guarantee comprehensive services to the population as a whole. It is therefore essential that RHAs, FPCs and DHAs are given the ability and authority to ensure that services are accessible, integrated, of a high quality and well funded. If these conditions are met, the NHS can look forward to the future with confidence."

That is constructive criticism such as my right hon. and learned Friend welcomes.

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