House of Commons Hansard Debates for 11 May 1989

Mrs. Ann Winterton (Congleton) : Will my right hon. and learned Friend give way?

Mr. Clarke : I shall give way in a moment, but I wish to continue for a little longer.

The discussion on the Health Service has already moved on from when the White Paper was published. Many hon. Members on both sides of the House have been approached by people concerned about the Health Service in the past three or four months, and I have no doubt that we have all been approached in the past week or two. Currently, the debate appears to be that we should go more slowly. All occupations have their buzz words, and

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the current buzz words are that it is all very interesting but we should have pilot studies, change the timetable and slow down. Another theme that comes through strongly is the fear about the cost of taking on board the modern management systems which the Health Service, unlike other large businesslike organisations, has never had before.

Mr. Nigel Spearing (Newham, South) : It is not a business.

Mr. Ashton : It is not a business.

Mr. Clarke : I said that it was businesslike. I welcome all those suggestions and I shall address them in my speech. I welcome them for one important reason. When people come to me suggesting that we should study and go more slowly and asking about the cost of introducing the new system, they are talking about how the changes should be implemented. Already, within three months the debate has moved on, except possibly in the Labour party. The debate among everyone else has moved on to how we implement and not whether we implement. It is that matter which I propose to address now.

Mr. Geoffrey Lofthouse (Pontefract and Castleford) : Will the Secretary of State give way?

Mr. Clarke : I shall give way in a little while.

First, how we implement depends on what people mean by pace. We no longer have time for some traditional ways of tackling issues in the Health Service because they have not been so successful in the past. I will not agree to some great multidisciplinary committee being set up, which starts by studying a small number of pilot schemes and takes years over discussion and evaluation. In great public services of all kinds, one makes little progress by that means.

We had an experiment on financial management--the resource management initiative--which began on six pilot sites. There are still people at the head of the profession who say that we should not have extended that initiative until we had evaluated fully those six pilot schemes and there are even those who claim that we are in breach of an agreement. I must spell it out to such people that we are in breach of neither the spirit nor the letter of that agreement in the resource management initiative.

The initiative was so popular at the six pilot sites that we are now extending it to 50 more hospitals, which were contenders for the right to take part in the next phase of the resource management initiative. As the initiative rolls out, our methods will, of course, evolve. There will still be plenty of time to evaluate the first six sites and to apply the lessons as we extend the initiative to all hospitals. The rolling out of a process that we steadily evolve with the help of those who work on it--the doctors and nurses in the case of the resource management initiative--is a principle we can apply to other areas.

There are consultants who say they need financial management systems, but ask about the cost. We must be careful about the cost. We do not need all- singing, all-dancing computer and information technology systems straight away in every hospital and we should all be in favour of resisting salesmen who sell expensive equipment in the belief that everyone needs it. However, there will be costs. I have made it clear that, where cost is required up

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front for investment in new systems, we will provide it, over and above the money required to maintain progress in expanding patients' services.

We had already made £42 million available in the last public expenditure round in the autumn for rolling out the resource management initiative and other programmes for this year. Having seen where we are now and how matters are progressing, I can tell the House that there will be another £40 million of new money, over and above last year's settlement, available for the predictable costs of extending financial management systems in 1989-90. For the sake of accuracy, I had better tell the House about that in the words agreed with my right hon. Friend the Chief Secretary to the Treasury, who, as ever, has been helpful on these matters because he is committed to the National Health Service. I will be making available an extra £40 million in the current financial year to cover the additional work in the National Health Service and in my Department to begin implementing the review. That brings the total available for implementation this year to over £82 million, which will be used to provide financial information to doctors, to fund preparatory work and projects in, for example, general practitioner referral patterns and to provide resources both in staff and consultancy in my Department for the implementation of my proposals.

That new £40 million is intended to enable us to introduce the measures the doctors want. They are measures that the consultants inside the service welcome. The new money is being provided so that the costs of implementation do not cut into the provision of medical care for the patients and the planned rate of expansion. That is the second area in which there has been great progress since we produced the White Paper.

The third area in which we see progress in the Health Service was touched on by the hon. Member for Bassetlaw a moment ago. It is now being reported in the newspapers because of local discussions. Many units in the National Health Service are expressing interest in what we describe as self- governing status under the new contracting arrangements for the National Health Service. Moreover, although this has not yet appeared in the newspapers, large numbers of general practitioners are interested in the practice budgets that we propose, which give GPs more influence than ever before and more say about where their funds should go.

Let me return to the intervention of the hon. Member for Bassetlaw, as the same questions will be asked in many other places. Let us be clear what is coming in from National Health Service units to the regions. At the moment, we are receiving expressions of interest, and only expressions of interest. No hospital has yet decided to become a self-governing hospital ; hospitals are in no position to decide that yet. At the moment we are receiving approaches from people who work in the service who are attracted by our new ideas and who recognise the potential for their patients. Very detailed discussions will have to follow before anyone can contemplate whether applications for self-governing status can go any further. We shall work on the applications, and the hospitals and units will acquire much more information about what is required. Everyone will be able to reach a more sensible conclusion once we know what is involved.

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In the case of self-governing hospitals, everyone in the locality affected will want to know what care services the district health authority will require the self-governing hospital to provide-- [Interruption.] I know that Opposition Members want to leap to oppose what they call opting out before they even know what it entails but we have reached a stage at which an explanation of what it entails might be forthcoming. We shall also need to know, in the case of every unit, what capital costs will be passed to the accounts of that unit. We shall need to know that in order to measure the unit's use of resources in future.

Mr. Spearing : This is all about money ; it has nothing to do with health.

Mr. Clarke : The Labour party does not have a policy on health, except in so far as it relates to money. When asked what their policy on the Health Service is, all Labour Members ever say is that they will spend more money on it.

Our proposals are not all about money. I was about to say that there is another thing that we shall need to know about every self-governing unit. Given that all the units are attracted to our proposals by the proposition that they could improve the services that they offer their patients, they will need to work out their plans for the development and improvement of their services. We shall need to consider how the board of trustees should be formed. We shall need to evaluate whether they are competent to run the unit. As the White Paper said, we shall also need to ensure that the consultants in the hospital are involved in the process of management.

At the moment, therefore, we are receiving expressions of interest in a proposal which is deemed to be a good idea by those who work in the Health Service. That process will be followed by a protracted period of discussion of all the details before any decisions are made. Whether we have a self- governing hospital anywhere in the National Health Service will depend on decisions made individually and case by case and probably at least a year from now. [Interruption.] Despite the wishes of the Opposition, we shall have an intelligent and continuing discussion with the units of what self-government will mean.

Mr. Hugh Dykes (Harrow, East) : Does my right hon. and learned Friend agree that, given the old-fashioned and myopic attitude of the Labour party, it is interesting that more and more staffs, patients and expert managers are keen on the idea of opting out?

Hon. Members : That is not true.

Mr. Clarke : Yes, and the reward that some of them will receive for expressing interest is the same absurd barracking from the Labour party with which it is greeting our proposals today. The Opposition have attempted to misrepresent our proposals by implying that the hospitals will be leaving the National Health Service and suggesting that the idea poses a threat to staff and patients. Despite all that, the idea has been recognised as being of substantial interest to those who work in well over 100 units in the National Health Service, who see an advantage in having more freedom of action to develop their services and use their resources as they think best. Several hon. Members rose --

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Mr. Clarke : No. [ Hon. Members :-- "Give way."] I shall not give way to barracking.

Mr. Martin Flannery (Sheffield, Hillsborough) : It is not barracking.

Hon. Members : Give way.

Mr. Clarke : It is not barracking? The hon. Gentleman surprises me. I fail to see why I should give way to hon. Members who are already making all the noise that they want to make.

In due course we shall proceed in the same way with general practice budgets. I think that a large proportion of GPs with lists large enough to make them eligible for the first wave are very interested in the idea of controlling resources. [Interruption.] Of course ; I am dealing with the pace at and methods by which we shall proceed. Of course no GP will tell anyone at the moment that he will have a practice budget. What he wants to know-- [Hon. Members :-- "They are not interested."] They are interested ; they are in favour of the idea. What they and we will now need to do is to discuss how a general practice budget would operate. We shall need to discuss the level of resources required by a practice to have a GP budget and negotiate the right level of resources to enable GPs to feel confident that the system is, indeed, an advantage to them and to their patients.

The method of proceeding that I have described is based on the substantial response that we have had, which shows great interest in our ideas on the part of those engaged in hospitals and in general practice. We shall work on those ideas with people who have expressed willingness to discuss them. They will now be involved in a most protracted process of debate and discussion about the implications of the idea for the National Health Service and for their units, their hospitals and their practices in particular.

This is a careful, measured method of progressing with reform, working in partnership with those in the Health Service who want to work with us so that we can ensure that we make the use that we must make of the new information available to the service, in concert with those who recognise the new potential for improving the service.

Mr. Lofthouse : The Minister may be aware that, in the Pontefract health authority area, we are used to opting out. In 1987, on the basis of the allocation allowed by Government to shorten waiting lists, the Pontefract area health authority decided on a scheme to cover 500 operations at Pontefract general infirmary. It later changed its mind and allocated that money to the private hospital at Methley park which ended up performing 200 operations instead of 500. Three hundred of my constituents did not get their operations. That is the effect of opting out.

Mr. Clarke : The use of "opting out" to describe the process by which hospitals become self-governing is a grotesque misuse of the phrase. It says something for the parliamentary skills of the hon. Member for Pontefract and Castleford (Mr. Lofthouse) that he gave the words a completely different meaning so that he could introduce a completely different issue. All health authorities are charged with the responsibility of using their resources in the most effective way for their patients. If health authorities can find a way of using spare capacity in the private sector to the benefit of their patients, paying

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marginal costs with part of their funds, I would encourage them to do so. I shall discuss with the hon. Gentleman at some other point the success or otherwise of the exercise in Pontefract.

Several hon. Members rose--

Mr. Clarke : I shall not give way again immediately.

There are other important matters to which we must address ourselves now that the Health Service is beginning to move down the path of reform. With everyone accepting the need for new systems and quality control and with many people exploring the prospects for self-governing hospitals and for GP practice budgets, countless questions will need to be considered. That is why we produced eight working papers, although we could have produced twice that number with little difficulty. There are many other details to be worked out in concert with the profession.

People ask about the planning for a comprehensive service. District health authorities will remain charged with the legal duty to provide a comprehensive service. They will retain all the money in their hands apart from that which goes to GPs with practice budgets who will be providing their contribution to the service, to ensure that their funds are used and distributed in the locality to ensure ready access of all their residents to a comprehensive range of services of the required quality.

People ask about limitations on GPs' rights to refer. I have dealt with GPs' rights to refer. Many people have asked about what the GPs' position will be if the DHA has the money to place contracts and plan local services. They ask whether it will inhibit the GP's right to refer where he wishes. Under the present system, if it remains unreformed, the GP's theoretical total freedom to refer to whomever he or she wants is steadily diminishing. There is no ability to refer across administrative boundaries with any funds to finance the receiving hospital for the treatment of patients.

Mrs. Alice Mahon (Halifax) : When will the Secretary of State talk about patients, not money?

Mr. Clarke : One million patients every year are transferred, and the money does not go with them, and that is a principal cause of a large number of the financial crises that hit the newspapers. The hon. Lady is so wedded to what we have that she will preserve it. She likes the fact that, sometimes, efficient units run out of money precisely because there is no finance to go with the patients when a referral is made across administrative boundaries.

GPs will be involved in the new system. If they do not have practice budgets, they will be far more involved than ever before with district health authorities in deciding how a district authority uses its funds to provide a pattern of service, first, to meet its obligation to give a comprehensive service to their patients, and, secondly, to reflect that GPs' chosen pattern of referrals for the area. Our new system will give GPs much more ability than ever before to influence how resources are distributed, particularly in referring their own patients.

Sir Michael McNair-Wilson (Newbury) : One group of people whom I should like to be especially considered are the chronically sick on expensive medication. They believe that they will be unattractive to the average GP, particularly a GP on a practice budget, who will say, "This

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patient will take too much of my budget, so I will try to push him somewhere else." Will such people be properly considered?

Mr. Clarke : I can give my hon. Friend an absolute assurance that, in a practice budget--[ Hon. Members :-- "How?"] A practice budget will be constructed to protect the clinical needs of the patient list. It is not even a new point ; we thought of it miles before we published the White Paper. That is why we say that practice budgets should be negotiated. We cannot work on so much per head. We must negotiate with GPs a practice budget that reflects the age and chronic sickness of some of their patients and the actual costs that they are likely to incur. I give my hon. Friend an absolute assurance that nothing in our proposals will ever threaten a chronically sick patient with the risk of being refused the treatment or medicine that he or she will require.

Mr. Jack Ashley (Stoke-on-Trent, South) : I am sorry to interrupt the right hon. and learned Gentleman after so many interruptions. His answer seems to be at variance with an answer given by the Minister of State, who said that only in exceptional circumstances would that kind of provision be made. That worries those of us who are concerned about the chronically sick and disabled. Is the Minister giving the House a categorical assurance that all chronically sick and severely disabled people will have special provision with their GPs?

Mr. Clarke : My hon. and learned Friend the Minister of State, who is sitting alongside me, will speak later. He told me that he does not believe that he said what the right hon. Gentleman alleged. No doubt any misunderstanding can be sorted out later.

As I have said, a practice budget will be negotiated on the basis that it needs to reflect the likely costs of dealing with a collection of patients, taking account of their age and chronic sickness. Obviously, it will proceed only on that basis.

There are other matters with which I have no time to deal now, but they are of great importance to those who work in the service and we must resolve them by the process of careful discussion over the coming months to make sure that our changes are implemented in the right way. First, medical teaching causes a great deal of concern. On undergraduate teaching, a working party is already established, involving my Department, the Department of Education and Science, the General Medical Council and the General Dental Council--all professional interests--to make sure that the need for medical teaching is protected.

Sir Gerard Vaughan (Reading, East) : I am glad that my right hon. and learned Friend has referred to that matter, as anxieties are building up in medical schools and universities. Representatives of the Committee of Vice-Chancellors and Principals and the medical schools are anxious to help, but they would like to know what their position will be as soon as possible.

Mr. Clarke : I realise that they are anxious about undergraduate teaching. Of course, a steering group reflecting the full range of interests is already considering that matter. There is also medical and nurse training. It is essential that the National Health Service, however organised, continues to produce the right supply of trained

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medical and nursing manpower. We must ensure that the training needs of the service are protected by our proposals, that medical schools are not threatened and that any additional costs are covered by our proposals. We must ensure that self-governing hospitals can be required to make their contribution to the required training effort of new doctors and nurses. Plainly, standards must be the same throughout the service, and they must be set by the royal colleges, as they are now. We need to talk through all those points. For example, I refer to an extremely important policy contained in the document entitled "Achieving a Balance", which is of great importance to the Health Service. I remain totally committed to the principle of achieving a balance. However we organise the Health Service and however many hospitals are or are not self-governing, we must retain the ability to ensure that the possibility of achieving a balance is continued so that we have the right balance between training posts and career posts. That is what I see occupying the real debate.

Mrs. Ann Winterton : Will my right hon. and learned Friend give way?

Mr. Clarke : I will give way for definitely the last time.

Mrs. Winterton : Is my right hon. and learned Friend aware that over 40 per cent. of students reading medicine are women? Is he aware also that there are real anxieties that qualified women will not be able to get partnerships in practices and that medicine for women will be greatly affected by his proposals?

Mr. Clarke : I think that the proportion is a bit higher than that. It is my personal prediction, based on no expertise in the matter, that fairly early in the next century, the majority of doctors in this country will be female. We are obviously going in that direction.

Last week, we made changes in the GP contract, designed to meet the fear that we might unintentionally deter women from entering general practice. Changes are to be made in the system of basic practice allowance, and the way in which we look at practices as opposed to individual partners for GP contract purposes, which will meet those fears. I have always thought that the fears about deterring women from general practice were exaggerated. Nevertheless, we made moves to try to accommodate them, because we were anxious to ensure that we should not create any new artificial barriers to women entering general practice. The agreement shows that we thought we had reached--

Mr. Rhodri Morgan (Cardiff, West) : Quite right.

Mr. Clarke : It is no good the hon. Gentleman trying to be more catholic than the Pope. The BMA is satisfied that we met that agreement. I fear that the hon. Gentleman is out of date. We will proceed on the same basis. The matters to which I referred are ones on which we need a constructive dialogue with the profession. If people in the profession have fears about medical training, research and achieving a balance, they should first discuss them with us and accept our undertaking that we intend to meet them and, secondly, make a constructive contribution to the proposals about how to tackle them.

We have reached the stage at which everybody should move on from trying to find reasons why they are against

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each and every proposal for change contained in the White Paper to making some contributions of their own if they can think of a better alternative. Some quite senior bodies in the Health Service have not yet reached the stage of putting forward anything other than criticism of what we put forward. The time has come for us to ask for their considered reactions on subjects such as research, medical training, and so on. They are beginning to come in.

I am sure that we will get no such contribution from the Labour party, but we will get a contribution from the service. Just as the Labour party has been left behind by our move on GPs' contracts, it will be left behind by its position on Health Service reform, as it sees the Health Service being transformed in front of its eyes, so that it provides a service that is better for the patients, allows patients a bigger influence on priorities inside the service, delegates more real management responsibilities locally and produces a service of which we can all be more proud.

The common sense of last Thursday will be carried forward in future discussions to ensure that we produce a better Health Service. No doubt sometimes we will face controversy and sometimes we will find persuasion easy. The Government are determined to fight for a better Health Service to the extent that we need to. I would like to reason for a better National Health Service. I believe that all reasonable people inside the service will work with us to attain the aim of a much improved Health Service--one which will work not only for patients, as the main title of our White Paper implied, but for care for the 1990s as its subtitle implied.

5.10 pm

Mr. Robin Cook (Livingston) : I beg to move, to leave out from "House" to the end of the Question and to add instead thereof : "recognises that the programme of fundamental changes to the structure of the National Health Service set out in the White Paper, Working for Patients (Cm. 555), will fragment the health service, undermine continuity of care and reduce patient choice ; believes that competition on the basis of price will threaten quality of patient care and standards of professional training ; rejects the White Paper's proposals for increased commercial use of National Health Service funds and National Health Service facilities for the treatment of private patients ; notes that there was no reference in the Conservative manifesto to these sweeping changes in the National Health Service and that since their publication they have been rejected by every organisation representing medical opinion and by an overwhelming majority of public opinion ; deplores the persistent failure of Her Majesty's Government to respond to the Griffiths Report on Community Care ; and calls upon Her Majesty's Government to postpone any major structural changes to the National Health Service until they can be submitted to the electorate in a General Election."

I shall begin by agreeing with one of the Secretary of State's observations from the Dispatch Box. I entirely agree that we must be aware of salesmen selling very expensive products. He does, of course, come to the Chamber to sell the most expensive White Paper in the life of the Government, and possibly the most expensive in the history of Her Majesty's Stationery Office. At the end of January, the Secretary of State answered a parliamentary question in which he said that the budget for the launch of the White Paper would be £1 million. A couple of weeks later, when replying to a parliamentary question from myself, he said that the outturn cost on the budget for the launch of the White Paper had been £1,400,000. I am advised that that sum comfortably exceeds the launch cost of the last Jeffrey Archer novel.

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There are a couple of ironies about that expenditure. First, there is the obvious irony of a Secretary of State producing a White Paper that claims that it will achieve cost-effectiveness within the NHS, when he cannot keep the budget for the launch of that White Paper to within 40 per cent. of the budget. An even greater irony--the one obvious way to measure the outstanding waste of his largesse--is that he does not appear to have persuaded anyone to be taken in by it. If the Secretary of State was a Labour councillor and had spent so much money to so little purpose, he would have been in severe danger of being surcharged by the Prime Minister to get her money back. Last week I drew attention to the fact that the White Paper had been rejected by just about every shade of medical opinion. I must say that on one point I was wrong, and I shall therefore make a correction to what I said. I indicated that the one medical body that was the exception to the rule was the Conservative Medical Society. At the weekend I was distressed to read in a Sunday newspaper that the Secretary of State

"came under criticism yesterday from members of the Conservative Medical Society, who expressed worries about the proposals in the White Paper. Mr. Frank Ellis, a consultant surgeon from Guy's thought the proposals for some hospitals to opt out would create a two-tier system. He said : Those who conform will be favoured and those who won't will tend to be neglected'."

There we have it--even the Conservative Medical Society has gone overboard. I apologise to the House if I misled it last week. I wish to draw attention to the way in which the White Paper has been rejected not only by the people who work in the NHS, but by the public who depend on the NHS. There is no better demonstration of the way in which the public have demonstrated their rejection of the White Paper than by the presence on the Benches behind me of my new hon. Friend the Member for the Vale of Glamorgan (Mr. Smith), whose spectacular victory last week was not just a remarkable victory for the Labour party, but a victory for the National Health Service. I take some satisfaction in that I was able to make my modest contribution to my hon. Friend's election. However, the 36 hours that I spent in the Vale of Glamorgan were nothing like as influential in winning votes for my hon. Friend as the three hours that the Secretary of State spent.

Last Friday I heard the Secretary of State several times express regret on television and radio that he had reached agreement with the doctors over GPs' contracts only an hour after the polls had closed, which was too late to rescue his candidate in the Vale of Glamorgan. The voters in the Vale of Glamorgan, who switched to us, were not doing so because they were distresssed by the fine print of the GPs' contracts. There were not clusters of voters hanging about outside the polling booths just before closing time, delaying their decisions until they heard what concessions had been given on the minimum list size that would qualify for the basic practice allowance. The Secretary of State deludes himself--although I suspect that he does not delude his Back Benchers--if he believes that that was the issue. The voters were sending a clear message to the House that they do not want to see a Health Service driven by commercial demand rather than medical needs.

The voters of Glamorgan are not alone in that view. All the evidence that we have acquired in the past three

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months from opinion polls, hon. Members' correspondence and public meetings gives a resounding thumbs down to the White Paper. I concede that there are members of the public who have supported the White Paper. I was interested to read a report in The Scotsman on Tuesday of a public meeting in Dumfries which overwhelmingly came out against the Government's White Paper. There was, however, one voice raised at the meeting in support of the White Paper's proposals ; to the distress of the Secretary of State, that one voice was raised by the town's local undertaker.

The Secretary of State keeps telling us that his intention is that the NHS should be more responsive to its consumers. In the light of all that evidence of public opinion, I suggest that he should listen to what the consumers are trying to tell him.

I was interested that the Secretary of State spent yesterday in Geneva. I confess that I only made it to the Westminster Grand Committee Room, where I met a large number of organisations representing those same consumers. There were more than 50 representatives of more than 20 organisations. Twenty of those organisations completed a questionnaire as part of the consultation. All were organisations representing particular groups of patients and users of the NHS, such as RADAR--the Royal Association for Disability and Rehabilitation--the National Schizophrenia Fellowship, the Family Planning Association, the National Federation of the Blind of the United Kingdom and the National Association for the Welfare of Children in Hospital. The answers of those 20 organisations revealed an overwhelming and profound anxiety about the White Paper's proposals. When we asked them if they believed that budgets for GPs would make them more cost-effective without affecting patient care, five of the 20 disagreed, 14 strongly disagreed and one did not know. When we asked them whether hospitals should opt for self-governing status, I concede that one out of 20 agreed. However, three disagreed and 15 strongly disagreed.

I admit that it was not a representative gathering. It was a gathering that differed from any random sampling of the public in that it consisted solely of people who were well informed about the Health Service and who had given years of service to voluntary organisations concerned with health. Their opinion was a resounding no to the White Paper.

Mr. Tim Yeo (Suffolk, South) : What will the hon. Gentleman say to the 1,000 consultants who will need to be sacked when the £43 million saved by competitive tendering under the Government is thrown away by the Labour party, if it ever gets the chance to put into practice the proposals published earlier this week?

Mr. Cook : I have met many consultants in the past three months. It has been an interesting experience for me and, I expect, for them, because there has been a degree of therapy when I have consoled them for the loss of the affection of their Government. I suspect that I have probably met 1,000 consultants during that time, but I have not met one who has expressed the least anxiety about losing his job under a future Labour Government. However, I have met many consultants who have expressed some surprise at the priorities of this

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Government who, as a result of their White Paper, proposed to increase the number of accountants in the Health Service by 1,000 while increasing the number of consultants by only 100, which gives a neat arithmetical guide to the priorities of the White Paper.

Mr. Kenneth Clarke : The hon. Gentleman is trying to avoid the question asked of him by my hon. Friend the Member for Suffolk, South (Mr. Yeo). If the hon. Gentleman believes that the test of a Health Service policy is to ask 20 group representatives his chosen questions on that matter in the Grand Committee Room, will he ask those groups whether they would support his party's proposals to end competitive tendering in the Health Service, which would cost the Health Service £100 million? That is the sum that we have saved by the policy that the Labour party has always opposed.

Mr. Cook : We asked precisely that question in the consultative document that I issued last September. I assure the Secretary of State that the overwhelming majority of the responses that we have received have been supportive of the fact that if one wants to run a Health Service, one needs a health team that is motivated and committed to the Health Service. Such a health team would not consist simply of consultants and the Royal College of Nursing ; it would also include ambulancemen, porters, cooks, domestics and everybody who keeps a hospital functioning.

On the Secretary of State's extraordinary point that the response from those 20 organisations reflected any loading in the question, let me put this challenge to him. I will happily recall all those 20 organisations and put to them questions on GPs' practice budgets and on hospital self- governing status in any terms in which the Secretary of State cares to frame them--I should be extremely surprised if the answers were any different.

I should add that the questions raised at the meeting yesterday were much more penetrating than those in the intervention of the hon. Member for Suffolk, South (Mr. Yeo). The National Council for Carers and their Elderly Dependants asked reasonably, "What will happen to respite care when every bed in the hospital has to be paid for by contract?" Life is only just bearable for many carers because their GP colludes with them in arranging temporary admission to geriatric wards for their elderly relatives to give the carers a break. How many GPs will still do that if they have to pay for it out of their fixed budget? What price will be placed on the sanity and family life of carers in the new cost-effective Health Service?

The association called Asthma Care asked what would happen to the prescriptions of its members under the new limits on drugs budgets. The progressive management of asthma is now based on preventive medication. It is not based on waiting for acute attacks and then remedying them ; it is based on prescribing before attacks happen. However, that preventive medicine can cost between £20 and £40 per month for cases of serious asthma. Because of the new drugs limits, how many GPs will feel obliged to revert to the old method of "wait and see" and wait for the acute attack--

Mr. Kenneth Clarke. None.

Mr. Cook : The Secretary of State assures us that there will be none, but he has been much less robust and blunt

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in his explanation of the drugs budgets to the House and to the public than he has been in his explanation to doctors of how they must buckle-to under the new GPs' contract.

The Secretary of State would have us believe that the drugs budget is not firm and fixed but that it is elastic and will bend and give. However, I refer the right hon. and learned Gentleman to pragraph 7.16 of the White Paper, which is explicit in stating :

"Each year the provision made for FPS drug costs in the Parliamentary Estimates will be divided into separate firm budgets among the 14 health Regions RHAs and FPCs will be expected to work to the budget they have been given."

I do not deny that the Secretary of State is technically correct. Yes, those authorities can exceed their budget, but only if they meet the extra cost by cutting it out of other expenditure on patient care. That is freedom, but it is the freedom to freeze expenditure on prescriptions and to cut expenditure on other services.

It is dishonest to pretend that that freedom is anything other than cash limits by any other name-- [Interruption.] That is perfectly true, because it is in the right hon. and learned Gentleman's own White Paper. It is also true that it is disingenuous of the Secretary of State and his hon. Friends to complain that patient organisations have been misled when they reasonably argue their well-informed anxieties about that paragraph--

Mr. Clarke : I apologise to the hon. Gentleman for intervening twice when at first I did not intend to intervene as all, but his speech is solely designed to raise fears among all the groups that he is talking about. If the hon. Gentleman is quoting the White Paper about the effect on GPs, will he quote from the relevant part, paragraph 7.19, which states :

"Where a GP practice exceeds its indicative budget, the FPC's first recourse will be to offer advice and"--

[Interruption.] --

"where necessary, to bring a process of peer review to bear on the GPs' prescribing practices"?

That means that another doctor will give advice. Further steps will be taken only if there is no clinical reason for prescribing excessive quantities of drugs.

The hon. Gentleman's description of the White Paper is designed to instil fears into asthma sufferers or whichever group he is talking to. Does he really think that that is rising to the challenge of the events in the National Health Service, to which he should rise if he is serious about its future?

Mr. Cook : The question that I asked was not of my devising. It was brought to me by those asthma sufferers who had looked at the White Paper and felt anxiety.

Is the Secretary of State willing to say now that he will withdraw the clear and explicit statement in paragraph 7.16 and say that there will not be firm budgets in the regional health authorities, that the regional health authorities will not be expected to work to such a budget, and that he will compensate them if they exceed that budget-- [Interruption.] The right hon. Gentleman cannot claim that those questions are irrelevant. If GPs are to remain free to exceed their indicative budgets, will the Secretary of State advise the Southwark and Lambeth family practitioner committee--

Mr. Jerry Hayes (Harlow) rose --

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