House of Commons Hansard Debates for 2 May 1989

Mrs. Alice Mahon (Halifax) : Can the hon. Gentleman tell us how many letters he has received from GPs and consultants supporting the Government's proposals? Like my hon. Friend the Member for Newham, North- East (Mr. Leighton), who was criticised for doing so, I could read out a file of letters from doctors who oppose the Government. How many letters has the hon. Gentleman received in support?

Mr. Hayes : The hon. Lady has raised a valid point. I have received many letters from general practitioners who are wholly opposed to the White Paper. But when I go to see them and talk to them about it, they realise that the proposals are working for their patients. The overwhelming majority of general practitioners care deeply about their patients and do not like to be conned by people making cynical political capital out of other people's misfortune, as is happening now. The time must come when, in the words of my hon. Friend the Member for Thanet, South (Mr. Aitken), the dust must be allowed to settle, the megaphone diplomacy must stop and we must get round the table with those who care about the Health Service--the GPs, the consultants, the administrators and the nurses. There is much in the proposals for all of them, as they will appreciate soon. In the past-- and I see my right hon. and learned Friend the Chief Whip sitting here--I have been highly critical of Government policy on the Health Service--[ Hon. Members :-- "No."] Yes. That may come as a shock to some of my hon. Friends. Some of us have voted against the Government, but when they get it right, we should darn well support them.

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Dame Jill Knight : My hon. Friend spoke about letters he had received from doctors. Will he take the point that those doctors have been grossly misled and misinformed by their own leaders about the true contents of the review?

Mr. Hayes : Of course, many of us on the Select Committee raised that issue with the people who run the BMA, and they have said, "This is what we feel is in the White Paper," or, "This is what we think might be in the White Paper." However, when confronted with the facts and the reality, they are speechless-- [Interruption.] Let us be constructive. This is a time when there should be sensible negotiations.

Going back to something else that my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) said, this is not the first time such things have happened because all of us can remember notices going up in local surgeries in 1985 about the limited list. We all received letters from doctors, consultants and even from elderly patients who said, "My health will deteriorate if this wicked proposal goes through." That proposal was put forward by the then Minister of State, my right hon. and learned Friend who is now the Secretary of State for Health. There was sensible negotiation on that, the NHS saved £75 million and patients are receiving a good standard of health care. If one speaks to a GP now and says, "Hang on, a few years ago I saw a poster in your surgery about limited lists," that GP will probably say, "Oh well, we agreed with it really." I suspect that when GPs hear the truth now, the same thing will happen. However, there are a few things that I should like my right hon. and learned Friend to take into account--[ Hon. Members :-- "Ah."] This is not a criticism. It is about negotiation and consultation. I want to put to my right hon. and learned Friend some of the points that many doctors have put to me and to some of my hon. Friends. I know that my right hon. and learned Friend has said on television and on radio that there will be compromise and negotiation. I ask him to look carefully at the rural practice allowance, which is concerning many doctors. I ask him to look also at the 20-hours provision because it is absolutely right that there should be a division between part-timers and full-timers and many doctors are concerned that the Secretary of State means 20 hours in the surgery, which might cause problems. I am sure that my right hon. and learned Friend will look again at such things and at the targets for immunisation which in many areas, especially in highly ethnically populated areas, might cause some difficulty. Perhaps it will be worth considering some form of exemption for doctors who have done their very best to get people in for cervical smears and immunisation but whose patients do not turn up. I do not see why the doctors should be penalised. The Health Service is really about people getting their operations. One can wax lyrical about more money and about more doctors and nurses, but what people really care about is getting into hospital for their operation. Once they are in hospital, they like the nurses and the doctors--they do not much like the food--and they are satisfied with the service. The main thing is to get the patients into hospital.

The crucial thing about this whole review--my right hon. and learned Friend said this at the beginning of his speech--is that the efficiency trap will be abolished. We have a ridiculous state of affairs at the moment. We are paying hospitals to close beds for economic reasons. More

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patients are being treated, more operations are being performed--this is happening every day--but approximately 20 per cent. of National Health Service beds are being closed. That will cease if the money travels with the patient because it will then be in the interests of hospitals to keep beds open.

I turn briefly to the private sector. There will be shock and gasps of horror from Opposition Members who will ask how one dares to mention the private sector. The private sector is working at about 45 per cent. capacity. Let us examine what is happening in, dare I say it, South Glamorgan where the South Glamorgan health authority has done a deal with an excellent private hospital in Southampton called Chalybeate. The South Glamorgan health authority has contracted all its open heart surgery to that private hospital. The families of the patients are looked after. They are transported to Southampton and put up in hotels. The operations are carried out speedily and efficiently. There is absolutely no cost to the patient. What is more, because of surplus capacity the South Glamorgan health authority is saving money. If ever there was an example of co- operation between the private and public sectors, that is it. That is what we are aiming for in the White Paper because what is happening in South Glamorgan should be happening all over the country and we should have the opportunity to let it happen.

The last point that I wish to raise with my right hon. and learned Friend--

Mr. David Hinchliffe (Wakefield) rose --

Mr. Hayes : No, on another occasion. I shall not give way because other hon. Members wish to speak in the debate.

I should like to say a few brief words about the Treasury. It is important to mention the Treasury because in the past the Treasury has been able to play all sorts of people off against each other. The Select Committee may say, "£2 billion is needed for the Health Service", the nurses can say, "£X billion" and the doctors, "£Y billion", but no one really knows how much the Health Service really needs because no one knows the cost of an operation or a treatment.

Mr. Battle : What about tax cuts on private health?

Mr. Hayes : The hon. Gentleman refers to tax cuts, but they are totally irrelevant to what we are talking about.

How can one plan for the future unless one knows how much operations and treatment cost? When information technology comes in and when doctors know the cost of an operation, persuasive and almost unanswerable arguments will be put to the Treasury about putting more money into the Health Service. In the past no one has known where the money has been going, but at least we will now be able to know that. Before I sit down, I should like to say a few brief words about the existing system because in the meantime we have a problem, especially in areas with large waiting lists. My own West Essex health authority is in the top 22. My right hon. and learned Friend has helpfully given us waiting list initiative money and, although we have also been given £800,000 in growth money, we have suddenly been told that the North East Thames regional health authority, which has loaned us £1.5 million to be paid back over three years, is going back on its agreement and wants to take that £800,000 growth money. I ask my right hon. and

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learned Friend to look carefully at that instance of gross mismanagement, which must be totally contrary to his wishes and those of his health team. Growth money must be for growth and must be specifically earmarked.

All in all, there may be difficulties with my right hon. and learned Friend's White Paper and with the working document, but I advise him to listen to the views of the general practitioners and of the Health Service professionals because I further advise him that when they hear what the White Paper is trying to do and that it will work for patients, they will support it.

6.6 pm

Mr. Andrew Welsh (Angus, East) : I shall be as brief as possible, simply because I wish to let as many other hon. Members as possible speak in the debate. I shall speak faster than my normally fast pace because I want to put on the record some of the comments that have been put to me by local doctors ; after all, this is their debate. One depressing development, both in the debate and before we reached this stage, has been the vitriolic language of the Government and their supporters and the abuse that they have hurled at general practitioners because of their opposition to the National Health Service proposals. In choosing to react with the language of confrontation and abuse, the Secretary of State is making a big mistake and is completely misunderstanding the mood and reasoned arguments of the profession, which will be faced with implementing the changes if they are passed by the House.

General practitioners are opposed to these provisions not for the sake of opposition, but because they genuinely feel that patient care and the National Health Service will be the losers if the proposals are not amended drastically. I have received the highest ever mailing in my constituency from individuals and groups opposed to the Government's proposals. In the words of Angus district health authority, its members are agreed that

"The proposals in the White Paper are so far reaching and so unwarranted that the Council should take immediate action in an effort to enlist the help and support of every inhabitant in Angus in fighting against implementation of these proposals".

Let the Government be in no doubt about the strength of opposition to these White Paper proposals. I have never heard doctors so united, so angry and so opposed to any set of measures as they are to these Government proposals. I am sure that the situation in my constituency is no different from that in many others.

The doctors' basic argument is not about money. It is based purely on the relationship between doctor and patient and is about their ability to provide the best quality of service as professionals and at reasonable cost to the taxpayer. Doctors have told me that there are fundamental and dangerous trends in the Government's proposals that will inevitably strike at the heart of the National Health Service.

Unamended, the proposals will mean that cost rather than care will become the criterion for health provision. Medical professionals will become more like accountants, bargaining over prices and debt collection. Inevitably, it will be in the interests of health boards and GP budget holders to look for the cheapest service in order to direct cash to other areas. Inevitably, under these proposals, there will be an inbuilt bias towards offering only the most convenient and profitable services. The Minister should

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make that clear to the general public, because in every survey the public have made it clear to the Government that people's preference is for the maximum service delivered as close to their own homes as possible.

That will simply not happen under the Government's proposals. Indeed, the opposite will occur. The accent will be on delivery of uncomplicated care for the young and generally fit adults, not on complex, unprofitable services. That will inevitably lead to poorer facilities and opportunities for patients, particularly the elderly or chronically sick. I always thought that those were the people for whom the National Health Service was designed to cater, but the proposals will take us in the opposite direction.

Scarce resources will mean that medical treatment is placed to one side while doctors are placed in a new bureaucracy, and it will mean the advertising which this system will, by definition, spawn. There will be fragmentation--I find this the least forgivable thing that the Government are introducing--of the National Health Service into a two-tier hospital system, thus ending the national, comprehensive system of care that we have so far enjoyed.

My local doctors want to make it very clear to the Government that they see dangers in the proposals--dangers that budgets will dictate treatment, and that there will be a financial inducement not to treat. For example, regarding tests and referrals, doctors will be given an incentive to use only the cheapest hospitals, and there will be a break in the close relationship between GPs and locally based consultants. The GPs will be drawn towards refusing new patients who require long-term, expensive treatment, putting at risk the worst off in deprived areas, the old and the disabled. Because of budgetary restraints, general practitioners may well not accept patients who need expensive drugs.

Mr. Kenneth Hind (Lancashire, West) rose --

Mr. Welsh : If the hon. Member does not mind, I will not give way. He may get a chance to speak later.

Mr. Hind : But the BMA--

Mr. Welsh : This is not the BMA ; these are my local doctors. It is the doctors who are the profesionals and who have to deal with this and they have a right to be heard in the House.

There is a fear that doctors will increase the number of young, generally fit adults on their lists, and be forced to do so by their competitors. The very thing that the Government are introducing--the force of competition-- will lead to doctors taking a path that they would not normally take, instead of giving treatment to all their patients as they need and deserve. That is inevitable and inbuilt in the arrangements.

I want to use the words of the general practitioners to describe their concern, because they will have the reality on their hands if the Government push these measures through. One doctor says : "The introduction of practice budgets and indicative drug budgets is seen as a cost-cutting exercise which serves to put financial pressures on the GP and undoubtedly will lead to a deterioration in the doctor-patient relationship. All doctors are aware that economies can be made in drug prescribing and the profession should be supported in their attempts to

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diminish costs in such a way that it will not adversely affect patient care, rather than have radical, ill-conceived methods imposed on it. The increase in remuneration from capitation fees will lead to a rise in list sizes rather than the reduction we have seen in recent years. This means less time per patient, a decline in the quality of care and ultimately a decrease in the number of GPs."

I put again to the Minister the point regarding women general practitioners. Women have a right to expect that the Minister will have regard to their problems and address them. What is their future under the Government's proposals? Can he guarantee that women doctors will not be adversely treated and will be allowed to carry on making their very important contribution to the medical profession? I hope that the Minister will answer that point.

My local doctors have made detailed, reasoned criticisms of the Government's proposals on budgeting, capitation fees, effects on partnerships and women doctors and drug budgeting. Only time prevents me from analysing them. No doubt they will be raised as the debate continues and as the Government move towards legislation. I want to put one more point to the Government. One doctor says : "my colleagues and I do not see the new proposals as working for patients but rather as working against patients. The new charter will provide less time and less choice for patients and will engender within the profession a mentality more akin to achieving personal wealth rather than patients' health. The knock-on effects will be to accelerate the rate of litigation in this country and a litigation strewn profession is ultimately damaging for patients and more expensive. I must condemn ... the Secretary for Health for attempting to bluster and hustle the profession on this matter and I must further condemn him for throwing up a smoke screen over the real issues. It is particularly noticeable that, when asked pertinent questions, he merely diverts the discussion by blaming us for feeling for our wallets'. It is the Secretary of State who is feeling for the NHS wallet and he is prepared to see patient care suffer in the execution of this."

I have tried to state how my doctors feel, because this debate is about them. My plea is quite simply for the Government to think again. If they insist on these changes, they should introduce them gradually on an experimental basis to see whether they work. If there are all these great benefits to be gained from such experiments, let them be tried and tested and let everybody see them. If this scheme is simply imposed on the medical profession we may well find that the loser will be the nation, because our National Health Service will suffer a massive trauma and its essence will be destroyed if the Government go ahead unhindered. My message is clear and my plea is, quite simply, that the Government think again.

6.16 pm

Sir Michael McNair-Wilson (Newbury) : If I really believed all the dire warnings that we have heard from all parts of the House, I should be the most frightened man in the House tonight because I am numbered among the chronically sick and am on extremely expensive medication. As it is, however, I believe what my right hon. and learned Friend has said, I believe in his White Paper and he has my support. The White Paper is a most far-reaching document that will undoubtedly set the course for the Health Service in the future. In the 40 years since its inception the National Health Service has transformed the general practitioner from a family doctor who had both to provide for his patients and his community's care and win for himself an income into

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a Government servant who no longer has to consider the budget he spends. That is a very far cry indeed from what existed before the NHS was set up.

Now, as we know, when a young doctor wants to enter general practice he can get a start only if there is a vacancy in a group practice or if that group practice decides to take on an additional partner. At least, thanks to the White Paper, more vacancies should occur when doctors have to retire at 65.

Before the NHS existed doctors were practising in a competitive world. In the world before the NHS any doctor who chose to go into practice could put up his plate and see what patients he could pick up. My father, who practised in Argyllshire and in Northumberland, told me that in those days when one got a call late at night one did not hesitate to go, because if one did not another doctor got the patient. That was a competitive edge that does not exist any more. In the past 40 years of the NHS the balance has changed so that the modern GP, while he is no doubt just as dedicated as his predecessor and a great deal more effective as a provider of cures for diseases which were once incurable, has not had to consider or take responsibility for the financial consequences of his action. He has become a different type of practitioner. His salary is not won in competition with his fellows. He is a state servant answerable to the family practitioner service, which is currently funded by the Department of Health on an open- ended contract to the tune of £4.2 billion a year--a threefold increase since 1978-79.

To change that and to impose budgetary limits is bound to be seen as an assault on a situation that suits GPs very well. Suddenly they are being asked to relearn those financial skills that their predecessors took for granted. It would be surprising if they did not protest, especially as some of them may be affected by the changes in a way that may reduce their incomes.

I want now to refer to a question that I asked my hon. and learned Friend the Minister of State during Question Time last week concerning rural practices. I was not talking about a rural practice in a sparsely populated area that, according to the White Paper, is to receive special help, but one which is to some extent restricted by the ward limitations in the White Paper. A country practice, such as many in my constituency, cannot significantly increase its list size however hard its doctors work. Even if it could physically cope with an increased patient load, there are no other patients for that practice to treat. I do not see how it can have the basic practice allowance reduced from 60 to 40 per cent. and be expected to make up the difference out of capitation if the patients are not there. By the same token, such a practice is to lose the rural practice allowance. My right hon. and learned Friend will know that that allowance really relates to the mileage that the doctor does in his constituency. It is the sort of thing that each one of us, as Members of Parliament, accepts as part of our constituency expenses. If a rural practitioner sees his basic practice allowance reduced, and is required to make up the difference from a capitation that he cannot achieve, and he loses his rural practice allowance, how can he possibly feel other than that his remuneration is being reduced? Although I heard my right hon. and learned Friend give the average figure for GPs' salaries after the White Paper, nevertheless it is an average figure. I would be grateful if in that connection he would look at the situation of rural practitioners.

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The downward pressure on drug budgets, which will have the greatest effect on the pharmaceutical industry and make it look at its pricing in a way it has never done before, may make isolated dispensaries in country areas less viable. Again, the rural practitioner could find himself at a disadvantage. As ancillary and attached staff are probably more important to country practices, cost-limiting that section of the allowance may endanger such services as the mini-buses that many practices run to take their patients to and from surgery. Then there is the position of women GPs referred to by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood). Many women GPs are part-timers, because they are married. They are concerned that the new proposals will militate against them and practices will prefer a full-time male doctor to, for sake of argument, two part-time women assistants. I understand that more than 50 per cent. of doctors training for general practice are women. As matters now stand, there is a financial advantage to be gained by a group practice in taking on women as part-timers, but that advantage will disappear if the White Paper proposals go through as they are at present. I believe that those proposals must be reconsidered. I do not believe that there should be financial disadvantages that could militate against women remaining as part -time GPs. They are popular, excellent and a valuable asset to the service.

The question of screening, and especially the surveillance of elderly patients, is set out on page 30, paragraph II of the new contract. A doctor from a practice in my constituency, which has 500 patients of 75 years and over, told me that surveillance would cost that practice 500 man hours per year, yet he doubted the value of that exercise because of the age of the patients. That point was supported by a doctor in a BBC medical programme. In that doctor's view, screening can produce psychological distress without achieving anything worthwhile. He said that, unless definite and provable benefits can be demonstrated from such screening of the elderly, the programme will simply be a waste of money and doctors' time. The White Paper rightly places emphasis on preventive medicine, vaccinations, immunisation and cervical smears. It sets a very high target for GPs to reach before they receive payment for that work, unlike the present situation where they are paid for each treatment. I question whether the target for cervical smears is realistic. I shall cite the figures given to me by one doctor for his practice. Of the women he tested, 10 per cent. had had a hysterectomy and 8 per cent. refused a smear. In his practice, the annual turnover of women patients was 20 per cent. Accepting those figures, he claimed that a figure of 82 per cent. was achieveable if one included women who had had hysterectomies, or 71 per cent. if, and reasonably, one did not. One might honestly question the value of a cervical smear on a woman who has had a hysterectomy. If he is right--and I know how dangerous it is to generalise from the particular--is 80 per cent. the right target for cervical smears or is that a target beyond the reach of the average practice?

One of the points that has been raised with me in so many of the letters that I, too, have received about the White Paper concerns the status of the chronically sick--someone like myself who requires expensive medical treatment to stay alive. From my reading of the White Paper and the working documents, I believe that I am right

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in believing that the chronically sick have an inalienable right to be on a GP's list, to be treated in hospital and to receive whatever medication is laid down for them. What is more, no GP will be put at a financial disadvantage by having such a patient on his or her list, nor will his drug budget be considered to be overspent because that patient requires very expensive drugs, which takes the GP over his or her stated target. I believe that to be the case, but I would be grateful if my right hon. and learned Friend could reinforce that point in his reply. By the same token, can my right hon. and learned Friend state categorically that, whether a hospital chooses to be self-governing or not, it will be required to provide certain essential core services to its local community?

During my time in hospital and having talked over a number of years to those who run hospitals, I have been told again and again how much they wished they had control of their budgets and were allowed to develop the assets of their hospitals to maximise resources. I remember a consultant at the Battle hospital in Reading telling me that, if he had his way, he would build a 10-bedded private unit in the grounds of the hospital because of the funds that that would generate for the hospital overall. He was not interested in the out-of-date, political point-scoring about a two-tier system. He was interested in getting the maximum resources for a large general hospital. When I asked him why he did not do so, he said that it was because the regional health authority would consider that the additional funds were its and that the Battle hospital might not benefit at all. Therefore, nothing was done.

The White Paper encourages me to think that in future hospitals--especially those that are self-governing--will be able to make the best use of their assets knowing that by doing so they can improve their cash flows and their services. I welcome such a proposal.

6.27 pm

Mr. Bill Michie (Sheffield, Heeley) : I am happy and grateful to speak in this short debate. I have been instructed that I have no more than five minutes in which to do it. It is obviously an important debate and many Opposition Members have talked about what is, perhaps, the first love of anyone in the Labour party--the National Health Service. My hon. Friend the Member for Livingston (Mr. Cook) was right when he said that many doctors, and indeed many patients, feel that they have been deceived by the Government. Nobody at the last election realised what was in the mind of the Government. It was obvious that the Government were not prepared to put that in their manifesto to the people.

Doctors and patients know very well that, if one increases the number of patients, one cannot increase the number of hours in a day, so there must be less time per patient. That strikes me as simple arithmetic. We know that in future the prosperous surgeries will be in areas where people are generally prosperous. In areas such as Sheffield, which I represent--the inner cities, the poor areas and certainly some of the rural areas-- practices will have certain difficulties that will not be resolved by the White Paper. The Secretary of State has got angry about this issue and has hit out at the Labour party for exploiting the situation for political purposes. The only reason why the

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Secretary of State has attacked politicians, patients and doctors is that he must defend thin ground and he finds it difficult to do so. Instead of attempting to explain the Government's case, he has gone on the attack.

The Secretary of State has said that doctors' opposition to the proposals is based on different motives from the Labour party's opposition. From my discussions with doctors, I believe that their motives are similar to mine- -they are worried about the future state of the Health Service rather than their wages or anything else. The right hon. and learned Gentleman has said that, as a result of the proposals, GPs' pay will rise substantially, but their main concern is not pay, but patient care and what will happen to their surgeries. If the scheme is so good, why are so many doctors against it? Where are all the doctors who are in favour?

Mrs. Mahon : Does my hon. Friend share my disgust at the hon. Member for Harlow (Mr. Hayes), who could not produce a single letter from a GP in support of the proposals? I found it contemptible when he said that, when he had gone along to talk to doctors, they had changed their minds. He must think that we are all daft and that GPs are thick, which is insulting.

Mr. Michie : My hon. Friend took the words out of my mouth. There is no doubt that doctors are concerned about their patients rather than their own skins. Doctors know that they will spend more time checking the accounts than checking their patients, more time looking for the cheap hospital instead of looking at each patient and deciding how to treat that person.

In my constituency, a meeting of the regional branch of the BMA attracted 200 doctors, which was almost a record ; doctors do not always turn up at those meetings, as they are such busy people. Those doctors watched the video that has been produced by the Government--they have spent millions on that propaganda. Those doctors were so impressed by that video that they voted, almost unanimously, against the White Paper. The video is a waste of taxpayers' money. Those doctors were horrified by it. It is supposed to be subtle stuff, but the doctors understood it and they voted on a motion tantamount to resignation.

Local doctors are not thick ; they understand the situation. They are not greedy ; all they want is to be assured that everything will be all right for their patients.

Mr. Allen McKay : Does my hon. Friend agree that the argument that the doctors have been brainwashed by the BMA is a slur on doctors who have been in practice all their lives, often following their fathers and grandfathers? Such an argument implies that they cannot think for themselves.

Mr. Michie : My hon. Friend is correct. The only person who has been indoctrinated is the Secretary of State. He was not keen when he started off, but now he is convinced that his proposals will work. He has tried to reverse the argument by maintaining that doctors have been brainwashed.

Doctors are keen and dedicated. I have had my disagreements, political or otherwise, with my local doctors. On this occasion, however, we are not arguing about politics ; that is why I was so annoyed with the Secretary of State when he tried to make it a political issue.

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He tried to argue about what the Labour party would say rather than what doctors and others have said about the proposals.

I know that the Secretary of State has received a letter from one doctor in my constituency. At the end of that letter, the doctor says that the Secretary of State should resign, or change his mind ; otherwise, he will resign. That doctor has not been indoctrinated in any way. He is a strong practising Christian in the community and he feels so strongly about the White Paper that he believes that the Secretary of State should give up his job or he will give up his. When the Government decide to give us time for a major debate on the White Paper, I hope that they will think again. If they really believe that the White Paper is a marvellous idea, they should follow the advice in the Opposition motion--they should delay the changes for the time being and put them to the people at the next general election. If they do that, the Labour party will be home and dry. 6.34 pm

Mr. Douglas French (Gloucester) : My remarks are based on extensive consultation with many doctors who are practising in Gloucester and the Gloucestershire district, who are a highly professional and effective group of practitioners. The Gloucestershire district has one of the best patient- doctor ratios in the country and it has one of the lowest FPC average prescription costs. It also carries out a high percentage of cervical smears in comparison with other districts.

I hope that the Secretary of State will be able to confirm that, as a result of his proposals, such an area will not witness a relative outflow of funds. There may be other areas that need funds, but if the declared aim of the proposals is to bring the worst up to the standards of the best, that cannot be done unless the best retain all the funding that they already receive.

I acknowledge what my right hon. and learned Friend has said on other occasions : that the proposed new system will not force--I emphasise that word--doctors to take on more patients, and that their overriding aim will be to please patients so as to retain them. For many years, list sizes in the Gloucestershire district have been gradually reducing. They are now down to below 1,800, compared with the national average of 1,969. That does not mean that doctors are having an easy time, but it is one of the reasons for the district's good patient care figures. I believe that that evidence proves that there is a relationship between shorter lists and good patient care. One of my chief anxieties is that there is an incentive within the new system to build up lists. I know that the new system can be presented in different ways, but I believe that that incentive exists. The doctor can make up his income from other services, but an increased list appears to be one way in which to do so. That would come about not because increased income is of paramount importance, but because increased income happens to be one result of larger lists. Therefore, the proposed system pulls in an opposite direction from shorter lists which, historically, have achieved good results in the Gloucestershire district. It is true that the reduced list may provide the lazy doctor with an easy life, but it also provides the hard-working, diligent doctor with the best possible opportunity to give his patients the best attention.

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I have two comments to make about the capitation proposals. First, my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) has already referred to the likely effect on the enlistment of women doctors who perform an important role, often in a part-time capacity. The White Paper makes reference to incentives for female doctors, but paragraph 47a of the new contract is far from clear on this matter. I want to be assured that the new arrangements will not mean women doctors failing to be offered appointments that might otherwise have been open to them. Secondly, there may be pressure against taking on new doctors who do not bring personal lists to a practice. When some doctors reach retirement, their posts may not be filled automatically by new doctors.

Although I have reservations about the greater emphasis on capitation as proposed in the new system, I support the emphasis on new services and the incentives to provide comprehensive services to the patient covering prevention and treatment. The emphasis on health promotion, disease prevention, screening and check-ups is welcome. I hope that the value put on services such as minor operations will be realistic and cover the initial outlay not only for the instruments that may be required, but for the costs of consumables. That figure should be based on a proper costing rather than on a subjective judgment about what figure may or may not be sufficient encouragement for a doctor to undertake an operation.

On other occasions, my right hon. and learned Friend has said that the targets that he has set for immunisation and cervical smear tests may be subject to some modification. In Gloucestershire, the number of women having cervical smears is greater than in any other district, but in some cases an 80 per cent. target would be unrealistic. In a practice in Gloucester city, 19 per cent. of the female patients aged between 35 and 65 have had a hysterectomy, 5 per cent. decided against the test, 6 per cent. failed to respond to letters and 14 per cent. are over the age of 70. It is hardly appropriate to apply such a percentage in that type of practice.

There has been much talk about doctors being available for consultation in the surgery for 20 hours a week. I find the opposition to that requirement less persuasive than the other points that have been made to me. There may be individual cases where it would cause hardship, but it seems illogical to be saying, on the one hand, that more time is needed with individual patients and, on the other, that 20 hours in the surgery is too much.

I believe that many of the proposals will enhance choice, competition, accountability and responsibility, and all those are to be welcomed. But the reservations I have mentioned will, I hope, be addressed by the Secretary of State before he reaches any final conclusions on the package to be adopted.

6.41 pm

Ms. Harriet Harman (Peckham) : It is clear from the debate this afternoon that the Government have lost the argument-- [Interruption.] Conservative Members who have just drifted into the Chamber may care to know that only one Government Back Bencher, the hon. Member for Lancaster (Dame E. Kellett-Bowman), unreservedly supported the Government's plans-- [Interruption.] The day the Government pray in aid the hon. Member for Harlow (Mr. Hayes) is the day when they are really facing hard times selling their proposals.

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It is clear that the concerns of the Government are completely different from the concerns of everybody else. The Government are talking about accounting, costing and pricing. Everyone else is talking about people, health and wellbeing. The Government are concerned about a healthy bank balance. Everyone else is concerned about a healthy patient.

The Government think that the major battle for the next century is to make the NHS cheaper. All their plans go towards achieving that. We and everyone else believe that the major battle is to make the NHS better and to move on to conquer the major killer diseases such as cancer and heart disease. The Tories simply do not understand. They think that doctors are interested only in money, because that is all that interests them.

The Government do not understand that they cannot bully and bribe their way out of this. By accusing the doctors, first, of stupidity--by saying, "They do not understand our plans"--and, secondly, of greediness, they have simply hardened the attitude of doctors and astounded the public. The Tories do not understand that they are up against a profound NHS culture which affects Tory voting doctors in the shires as much as it affects working class communities in inner cities. The Government will discover that on Thursday in the Vale of Glamorgan. They are badly out of touch with the popular pulse. The Secretary of State cannot have it both ways. In his amendment to our motion he

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

In his speech, however, he did little more than berate what he was pleased to describe as "the British Medical opposition."

Conservative Members cannot say that the doctors do not understand and that they are being led by the nose by their leaders. The BMA's general medical services committee sent to every GP reprints of every working paper as well as the general medical services committee's comments. The thoroughness with which the doctors went about their consultations stands in marked contrast with the total failure of the Government to carry out any consultations. Having failed to consult anyone, as my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) pointed out, they went on to spend over £1 million of taxpayers' money trying to persuade us that it is a good idea. The Government must accept that it is not because doctors do not understand the plans that they are against them. They are against them because they understand them and do not like the way they will work. That must be clear to all Conservative Members when they read the letters that are swamping their postbags from local GPs.

Mr. Hind : The hon. Lady claims that by reading letters from GPs we become aware of their views. That is so, but most of the letters I have received show that the GPs in question have not read the detailed working papers properly-- [Interruption.] --and that some of them are listening to the sort of propaganda that the hon. Lady has been sending to weekly newspapers such as I have in my constituency suggesting that, in some way, my local hospital will be opted out. She and many of her colleagues are responsible for the disinformation that is currently being disseminated.

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Ms. Harman : I challenge the hon. Gentleman to send me copies of letters he has received from GPs whom he claims have not read the working papers and do not understand what is proposed in the White Paper. We shall then be able to see whether what he says is simply bluff and bluster.

The message from every independent medical organisation is twofold--that the plans will harm patients and that the timetable for their implementation is wildly unrealistic. Even the American professor who is credited with thinking up some of these proposals cannot understand why they are not being preceded by pilot schemes and believes that the Government are attempting to implement them with amazing speed.

Five out of six of the consultant teams who have pioneered the resource management initiative have rejected the timetable for opt-out because they say that they--the front line, the six leaders--will not be ready, and the sixth is Guy's hospital, where profound concern exists because of the feeling that they are being steamrollered into opt-out.

The pressure on hospital consultants to support opting out has been shameful. It has been a disgraceful combination of bribery and blackmail along the lines of, "If you are good boys and girls and among the first to opt out, we will see you all right, but if you do not, we will leave you to sink under your budget deficits." That is disgraceful and senior consultants are up in arms about being subjected to that sort of treatment.

The working paper on capital charges sets out the small print about which the BMA has warned consultants--the small print that the Government opt-out salesmen never mention. The Secretary of State talks a great deal about medical audit, but there is only a thin working paper on that saying, basically, "The chaps have thought up medical audit. It is clearly a good idea for the chaps to get on with it." There is little substance in that working paper. The fattest working paper is about capital charges--the "more work for accountants" paper--and it is clear that the Government have really thought about that, though the opt-out salesmen never mention it. When the Secretary of State decides that a hospital will opt out--and the decision will be his and not that of the hospital--the hospital will take with it into independence all of its debts for its land, buildings and equipment, on which it will have to pay full rates of interest.

St. Thomas's, across the river, estimates that this will mean it having to pay the Treasury about £40 million a year extra. Guy's, a mile or so down the river, will have to pay an extra £27 million a year. This is pressure for the greatest asset-strip of all time. London hospitals in particular, because land values are so high, will simply close down, sell up and move out, leaving the sites of our great London hospitals-- [Interruption] I challenge the Secretary of State to deny that, if it is not the case. The sites of our great London hospitals will be snapped up for offices or luxury riverside apartments.

Department of Health officials have already said that two fifths of hospital sites will be sold in this great asset-strip. Conservative Members should read the information that the Department has disseminated. The effect of the capital charges is that opting out for many is likely to spell financial suicide rather than financial freedom.

The Government have said that their plans will increase choice. In fact, choice will be reduced. What choice will

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there be for the patient of a GP budget- holder? The patient will have no choice of hospital for tests or treatment because the decision will have been made at the start of the year by the GP negotiating contracts for bulk buys of certain operations and treatments. Those negotiations will take place at the beginning of the year, probably long before the patient has got ill, let alone walked into the surgery. There will be no choice for the patient of a GP budget-holder.

There will be even less choice for the patient of a GP who is not a budget- holder. The decision on where that patient will go if in need of hospital tests or treatment will not rest with the GP but will be made at the start of the year by health authority managers who never see the patient. They will make a decision based on cost. They will get the cheapest buy. There is no requirement for them to get the approval of local GPs before contracts are placed. Managers who are not recruited or trained to know anything about clinical standards will make decisions on the basis of cost for patients whom they never see.

That is the absolute opposite of the Prime Minister's wish for treatment at the time of her choice, in the hospital of her choice. Under the NHS as she plans it, the patient will get the hospital of a manager's choice, at the place of the manager's choice and at the cheapest cost. No doubt the Government hope that that will join waiting lists as another powerful incentive for patients to go private and will drive patients out of the NHS.

Despite what the hon. Member for Newbury (Sir M. McNair-Wilson) asked the Secretary of State about, there will be less choice for patients who are elderly or who have long-term illnesses because, as the Royal College of Nursing so aptly described it, for the first time every patient will have a price tag on his head and for the first time doctors will have a financial disincentive to take on to their lists patients who will be expensive in requiring drugs or hospital treatment.

The right to choose a GP is not matched anywhere in the White Paper or in the working papers by a right to be accepted by that GP. The GP could say that his list was full. How will the Government police that? GPs will not refuse to take on more patients because they are lazy or heartless but because, with cash limits, they will have to balance the resources available for existing patients against the demands of future patients.

The greatest cheek is for the Government to offer us a choice that we already have--the chance of travelling hundreds of miles away from home to get treatment. We already have the possibility of travelling across boundaries, but people do not often do that because no one in his right mind wants to travel hundreds of miles to get treatment. What happens if there is a problem and the patient is stranded at the hospital? What happens if there is a need for post-operative care and the patient is unable to go back easily to that hospital? The Government do not understand those arguments because they are about the patient and not about cost. The Government think only of the cost and never of the patient. GPs have seen what fierce spending limits have done to patients waiting for hospital treatment. They do not relish cash limits on GP services. Despite the fact that only last week the Secretary of State was still asserting that there will not be cash limits, it is clear from the working papers, and clear already from the Health and Medicines Act 1988, that cash limits on GP services are planned.

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The White Paper says that GP budgets will not be underwritten for what are described as too high referral rates. The Government have no idea what a too high or a too low referral rate is. What is needed is not an average referral rate but appropriate referral decisions. The Government do not see that because they are considering not the quality of decisions but only the cost. The same is true of prescribing patterns. The Government are using the blunt instrument of cash limits when they should be using the instrument of training and education.

The Government have said that they have no plans to allow topping-up by patients of GP practice budgets but, if the proposals go ahead, that is inevitable. Even if we do not have the scenario of an individual patient handing over a bundle of notes to back up his demand to go to a particular hospital, we shall see groups of patients getting together for voluntary fund-raising for their own practice to get equipment for a new play area or new reception facilities. In the better-off areas that will free more money for hospital referrals.

The health divide that has already been referred to by my hon. Friend the Member for Sheffield, Heeley (Mr. Michie) will widen. The patients who need most health care will probably get inferior care and the well-off surgeries will depend on their communities to put their hands in their pockets to finance them in the face of cash limiting. That is how communities have responded when hospitals have been cash-limited. We have already seen that skew the service on the basis of hospitals providing what they think they can get money for rather than what they know the community needs.

The Secretary of State is beginning to look as though he is in as bad shape as his predecessor. He cannot blunder on with his plans because of the weight of public and professional opinion that is so heavily against him. If he falls forward, the doctors, assisted by the public, will get him ; if he falls backward, the Prime Minister will get him. Conservative Members should listen to their constituents and to the doctors rather than deride them. Hon. Members have a chance to tell the Government this evening that they cannot press on with their plans before the next general election. They have no mandate to destroy the Health Service. I hope that Conservative Members will join us in voting for the motion.

6.54 pm

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