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Sir Barney Hayhoe : I normally give way but I will not on this occasion. More than 90 minutes of the time available for the debate has already been used by the Front Bench speakers. Mr. Speaker has appealed for short speeches because so many hon. Members are anxious to take part.

The White Paper contains much that is good but, regrettably, too much that is questionable and ill-defined. Although the review arose from the funding crisis in the NHS of 1987-88, the White Paper says little, if anything, about money. To borrow a comment from a distinguished former Prime Minister, it is a menu without prices. I am quick to welcome the increased funding that was announced by the Secretary of State this afternoon to help with some of the proposals in the White Paper, and I welcome the substantially increased resources for the NHS announced in the White Paper on public expenditure. But the White Paper that we are discussing is not only a menu without prices ; it is a menu with attractive dishes, some without recipes and others untried and untested.

The White Paper is strong on objectives. Who can quarrel with seeking to improve consumer choice, with pressure to achieve higher standards and extended medical audits, with exerting market pressures to try to ensure the most effective use of resources, with more local control, whether in hospitals or elsewhere in the service, and with measures designed to use more effectively the taxpayers' money that is devoted to the NHS?

The White Paper is, however, weak on detail. The hon. Member for Livingston referred to the serious and notable omission of anything about community care. As I said,

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more must come from the Government soon for that area. The White Paper is a brilliant piece of Civil Service drafting because it is capable of sharply differing interpretations by those who read it. True to form, the Opposition parties have gone over the top with their criticisms and forecasts of doom and disaster, never recognising-- they have not said a word about this today--that if their economic policies had been pursued, the resources to provide improved health care, better education and improved social security benefits would not have been available. One must always remember that we are able to devote more resources to these services because of the success of our economic policies.

Not surprisingly, the response of the British Medical Association, the doctors' trade union, was shrill. However, the considered criticisms made by the Joint Consultants Committee deserve careful consideration. The JCC speaks on behalf of the royal colleges and its views must be taken carefully into account by the Ministers concerned. The consultants' co- operation is of the highest importance in any change within or development of the Health Service. The Government's decision to reject the recommendation in the doctors' and dentists' pay review body award of £1,000 extra for consultants was a perverse and curious way of seeking those consultants' co-operation with the reforms that lay ahead.

The White Paper is capable of differing interpretations. The subject of drug budgets was referred to a few minutes ago in a slightly acrimonious exchange. The White Paper makes it clear that drug budgets for GPs and for practices are indicative. My right hon. and learned Friend the Secretary of State has emphasised time and time again that no patient will be denied required medication because of lack of money. However, there is a basic inconsistency between that clear statement and the firm drug budgets that will be imposed on regions and on family practitioner committees.

The Minister of State, Department of Health (Mr. David Mellor) indicated dissent.

Sir Barney Hayhoe : My hon. and learned Friend the Minister shakes his head, but I have yet to see spelt out any assurance to the contrary. I shall be very pleased if that is given. It appears that, because mention has been made of firm budgets at the regional level--my right hon. and learned Friend himself used the phrase "cash-limited"--those outside the House have interpreted that as overriding my right hon. and learned Friend's comments about indicative budgets and there being no possibility of a patient suffering as a result of them.

Mr. Mellor rose--

Sir Barney Hayhoe : Perhaps my hon. and learned Friend will allow me to finish making this point.

My right hon. and learned Friend the Secretary of State stresses, quite rightly, the vital point that general practitioners will not run out of money for their patients' prescriptions and that there is no question of their scrips bouncing when they are presented at the chemist, as would a cheque if no resources were available to meet it. Nevertheless the dilemma remains, and it would be helpful if it could be resolved.

I remember well that when I served in the Treasury and in the Department of Health and Social Security, the

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Treasury was always seeking to cash-limit the drug budget. In seeking to control public expenditure, obviously it would do so. However, the reference in the White Paper to firm drug budgets for the Health Service as a whole and at the regional level owes nothing to the Department of Health but I suspect was inserted by the Treasury representative. I am pleased that my right hon. and learned Friend has repeatedly stressed the importance of general practitioners remaining unconstrained by cash limits. I am happy to leave it at that.

Mr. Mellor rose--

Sir Barney Hayhoe : The same rule must apply to my hon. and learned Friend the Minister as to others. He will have an opportunity to respond when he winds up.

I congratulate my right hon. and learned Friend the Secretary of State on reaching agreement on a contract for GPs. This matter should not have been muddled up with the White Paper anyway. I shall not apportion blame, but it is a pity that the contract could not have been got out of the way before publication of the White Paper. It is splendid that agreement has now been reached. I only hope that, when the members of the BMA meet in larger numbers, they will not disown their negotiators. That would be very serious and would damage the prospect of making real progress in improving health care in this country.

My right hon. and learned Friend made reference to another dilemma when he spoke about the speed at which the proposals could be implemented. The White Paper is clearly unrealistic in its apparent time scales. I am glad that the words now being used by Ministers appear to qualify these timings. Professor Alan Williams of the centre for health economics at York university, in commenting on the proposals for improving the efficiency of the NHS, stated that they "have much to commend them. But they are thrown together with all sorts of untried ideas, and set for implementation in a recklessly short time span, mostly without pilot testing, experimentation or evaluation. Pursued in a more deliberative and selective manner, with time for the collection of evidence and mature reflection, they could do the NHS a lot of good. Pursued with such haste, in this authoritarian and dictatorial manner, it just seems irresponsible." My right hon. and learned Friend confirms that pilot projects and controlled experiments are not buzz words either at Richmond house or at No. 10 Downing street--but perhaps staged implementation or realistic programmes will be adopted. They are essential for success. Steady progress and development are better than a wild rush to upheaval--and perhaps to electoral disaster.

I am glad that the White Paper contains none of the wilder radical proposals for overturning the present, largely tax-funded, basis of a Health Service that is available to all and free at the point of delivery.

I have sought to make it clear that I am not all that enamoured by the White Paper. Parts of it could certainly have been much better, but it could have been much worse. At least it is clear that its desirable objectives provide a basis for sensible and reasonable development and for discussion between Ministers, civil servants and representatives of the professions. I am prepared to give my right hon. and learned Friend the Secretary of State the benefit of the doubt--perhaps I should say of many doubts--as I

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believe that we both want a better National Health Service providing better patient care. With good will, that objective can command general support.

6.27 pm

Mr. Ronnie Fearn (Southport) : There has been attack, counter- attack, accusation following accusation, words spoken, written and shouted about the National Health Service review and its implications, which has led to the burying of the reasons for that review in the first place. Not long ago, the House was in the throes of a debate about the Health Service crisis in response to the almost nightly scenes of young children, the elderly, and other seriously ill and chronically sick patients being refused admission to our hospitals and to the life-saving treatment that they desperately needed. All that was the result of a lack of beds and resources. We all agree that that situation was brought about by systematic and chronic underfunding. A consequence of those debates and of the general furore over the crisis in the hospital services was that the Prime Minister announced a thorough and extensive review of NHS resources.

One year later, we find not only a White Paper full of holes and omissions that are not filled by the working papers, but one that fails to examine in any detail the financing and funding of the country's Health Service. There is no commitment to inject new resources ; merely a tinkering at the edges with the old by transferring them from one area to another, including in and out of the private sector, in the hope that this will in some way cut costs while improving services. This purely a pipe dream.

The Health Service needs more hard and ready cash. Just this week, the National Association of Health Authorities has provided evidence that the review completely ignores. Its report shows an underfunding in England alone of £490 million this year with cumulative underfunding of £3 billion. Those figures show that the pressures on the National Health Service are continuing at an alarming rate and are likely to do so in the foreseeable future--something of which those who work in and those who use the service are very well aware. It is hardly surprising, therefore, that the lack of any commitment to the adequate funding of these services is clear from the Government's White Paper. This has led patients and professionals to believe that the review was designed not to improve care but to cut costs.

Mr. Philip Hunt of the National Association of Health Authorities, which is by no means a blanket critic of the review, is reported to have said :

"It is very vital for the government to recognise and understand this history of financial pressures on health authorities if the reforms proposed by the white paper are to be successful or for the benefit of patients."

There has been much publicity over the opposition by doctors to the Government White Paper. I know that many of my hon. Friends have received very many letters and have been besieged by general practitioners and hospital doctors all expressing their concerns. But perhaps Dr. F. J. Parkinson of Redditch, who is not at all impressed by the Government's commitment to funding, is the best example. In a letter to the newspaper Pulse on 6 May this year, he wrote : "I believe that the NHS review is a smokescreen for the underlying problem with the NHS. As the Commons Select Committee so rightly stated, the service is grossly underfunded. The proposals do nothing to tackle this problem and offer little that will benefit ordinary patients."

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The writer describes himself as a member of the Conservative Medical Society. He continues :

"As a Conservative I feel very ashamed at the manner in which the review has been presented--the white paper is a thoroughly bad document. The schemes outlined are vague, untried and really do not seem likely to benefit patients."

It is not very often that I find myself in agreement with a Conservative gentleman, but in this case I am in complete agreement. My own stand on the matter of resources for the NHS has never been in doubt. I have often said, and said in the House, that how much a country can afford to pay for its health service is a matter of political will. We can afford a lot more than we are paying now and I would like to see a minimum of 2 per cent. increase over and above the NHS pay and price inflator on a long-term plan. I would like to see pay awards fully funded and proper provision made for any reforms or projects that the Government introduce. For instance, I would have no hesitation in committing Social and Liberal Democrats to fully funding the restructuring of the nurses' profession along the lines of Project 2000.

While on the subject of funding, I want to make it clear that Social and Liberal Democrats continue to oppose and would like to see abolished the recent tax relief to the elderly for private health insurance. We would also like to see the charges for eye tests and teeth checks abolished immediately and, in the long term, all such charges dispensed with.

One of the biggest failures of the White Paper is the total lack of costing of any of the proposals. This is very odd coming from a Government which prides itself on the use of marketplace methods. It is even more strange to watch the full-blown attempts to sell the product when the Government have no idea of the cost of the product, whether there is a market for it or, worse still, if the product is capable of working at all. It is even more disconcerting when I realise that it is my and other taxpayers' money that is paying for this folly.

I cannot understand why the Government did not attempt to test this product first. Is the Prime Minister concerned that pilot projects may show too many faults in the design, or is it due to sheer arrogance that pilot schemes have not been introduced? Worse still--I hesitate to make such a suggestion--is it that the proposals are all part and parcel of the Prime Minister's proclaimed aim to roll back the state, and will it therefore be implemented whatever the cost, in both financial and human terms?

Ministers justify these proposals with claims that they will improve patient choice and patient care. I agree that it may be easier for patients to change doctors but, with doctors rushing to increase their list sizes and incentives given to encourage them to form large group practices, how much choice will the average patient have? How many doctors will be within easy reach? How many of them will be women? There are patients who prefer to see a women doctor but, with the pressures to increase list sizes, many women will find it difficult to run or even join a practice, as has been mentioned already. In rural areas--this was referred to in the debate the other night--where doctors are few and far between, choice is already limited and will remain so.

In 1983, the Social Services Committee recommended an optimum list size of 1,700. Will the Minister tell me what has changed since that time? Social and Liberal

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Democrats believe that doctors need to spend time with their patients, and we would seek to lower the list size at present proposed.

Primary health teams with greater involvement for district and practice nurses, midwives and health visitors would free the doctor for more active diagnostic and preventive medicine and create a real community health service--a concept obviously alien to the authors of the present proposals.

The White Paper makes little provision for particular groups, such as the elderly, many of whom rely on community-based health services. Where is the guarantee of choice and improved care for them? In many respects the proposals may lead to a reduction in services as a result of hospitals becoming self-governing trusts.

These proposals will diminish health care in the hospital catchment area. Core services are imprecise and the term "local area" is not defined, making it very difficult to know whether people will have access to a full range of services within their own area. As the market and profit play a vital part in the Government's view of the Health Service, it is doubtful whether the present range of services will stay intact. This is even more doubtful when it comes to resource-draining services such as geriatric and long-stay care. The White Paper takes very little account of discharge procedures, after-care services, ambulance and transport services and many other aspects of patient care.

Major hospitals opting to become self-governing trusts will have a knock-on effect on other hospitals and services. The problems of lack of funding, lack of staff and poor pay will be shifted round the country, which will merely exacerbate them. Already many hospitals are suffering not only from a shortage of nursing staff but from shortages in all staff groups. The private sector, as well as other industries, contribute to this shortage. Obviously, hospitals not restricted by national pay agreements will attract the most qualified staff, making it very difficult for other hospitals in the same area or adjoining areas to attract the necessary personnel.

I know that the university medical schools are very concerned about how this proposal will affect their interrelations and

responsibilities. They, of course, play a very important part in teaching, training and research. Centres of excellence will destroy the aim of universal provision of health care and the concept of a community-based comprehensive Health Service.

Dr. Michael Clark (Rochford) : I am surprised to hear the hon. Gentleman say that the creation of centres of excellence will destroy universal provision. Surely the whole idea of such centres--whether they specialise in health care, science, education or any other subject--is to set examples for others, and a centre of excellence in the Health Service will provide such an example. It will lift the quality of provision, and should not be criticised.

Mr. Fearn : I hope that the hon. Gentleman does not think that I was criticising. Centres of excellence already exist which are doing a good job. I feel, however, that my point is a good one. The Government are embarking on a course that has not been navigated. Ray Robinson of the King's Fund Institute, writing in the British Medical Journal, has said :

"Self governing hospitals will represent an untried form of organisation operating within an untested market environment."

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He continues :

"The white paper is about implementation not experimentation." The review is certainly not about patients and health care. It is about management systems, accounting and information systems, and virtually nothing else. It ignores community care and the effects that the proposals will have on such services. Social and Liberal Democrats believe that community care should be a major priority for any Government, and we would introduce proposals along the lines of those recommended by Griffiths--which we consider solid and strong--with a commitment to provide adequate funds.

Where in the proposals is the "broad front" approach that Social and Liberal Democrats believe is so necessary for good health promotion? Where does it mention accident prevention, occupational health, social policy and environmental pollution, among other issues? Where does it discuss additional taxes on industries whose products lead to ill health?

Where is the patients' charter--mentioned in three speeches so far--to show that the Government really have the patients' interests at heart? We should like to see a guarantee of patients' rights, including the right to full information about their own medical condition and the options for treatment, the right to hospital treatment within a specified period and the right of access to a comprehensive complaints procedure. Where are the proposals to allow a patient to choose one of the alternative disciplines in medicine and treatment? Where is the choice of care for pregnant women? The White Paper virtually ignores maternity care and midwifery. Where in working paper No. 5 is the guarantee that NHS buildings, of which most date back to 1918, will be brought up to an acceptable standard? We believe that an ambitious building programme is required to bring those buildings into the 21st century. In my constituency, Southport, a new hospital was opened last week by His Royal Highness Prince Charles. That hospital is the latest in the country and is exceptionally good : it will be a centre of excellence. We are very lucky, but many others are not so lucky.

Where in the proposals is the chapter on democracy and accountability? Social and Liberal Democrats believe that there should be a decentralisation of power in the Health Service, along with decentralisation of accountability. Elected representatives of the public should be involved in supervising the management of services.

At best the review is totally inadequate and a missed opportunity ; at worst it will destroy the basic principles of our National Health Service. I would, however, commend it for one reason : it has united the nation in opposition.

6.43 pm

Sir David Price (Eastleigh) : One of the documents referred to on the Order Paper as relevant to our debate is the fifth report from the Select Committee on Social Services. I suggest to hon. Members who are not entirely enamoured of the White Paper that they may prefer to rally round the consensus politics contained in the Committee's 64 conclusions and recommendations. We reported seven months before the Government produced

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their White Paper, and having read the White Paper more than once--as well as the eight working documents--I still prefer our report.

Let me join every other hon. Member who has spoken so far in complaining that the White Paper says nothing about care in the community. The subtitle of the White Paper is "The Health Service : Caring for the 1990s", yet 14 months after the Griffiths report the Government are still saying that they will tell us "quite soon." In my view, community care is central to a future strategy for the Health Service.

I think that most people who have studied the service over the years will agree that it has handled critical cases remarkably efficiently ; their criticisms relate to deficiencies in the treatment of chronic cases. The majority of such cases are not in hospitals but out in the community, and with the "greying" of Britain they are becoming increasingly significant. Put in supermarket terms, it is the rising problem of the shelf life of us oldies. I trust that I carry the House with me when I say that future policy on community care is mainstream in any sound strategy for health care as a whole. As you have invited us to be brief, Madam Deputy Speaker, I shall deal with only one point. In my view the central proposal in the White Paper is the concept of an internal market within a publicly financed Health Service. My right hon. and learned Friend hopes that, by introducing the spur of competition--that is the phrase that he uses--by distributing funds for health care through a system of contractual relationships and by separating purchasing from providing bodies, the Government will make the NHS more efficient and services for patients--now to be regarded as consumers--will improve. That, I think, is a fair potted version of the essence of the White Paper. This is an entirely new method of distributing health care. I am aware of no example elsewhere in the world of such an internal market within the public sector. It is therefore an entirely unproven proposition, which is why, in its report last July, the Select Committee recommended caution and trial. We said :

"If the concept of the internal market is to be taken further, it will require to be very carefully planned, monitored and assessed to ensure that too high a price is not paid for its benefits. It should not be introduced nationally before thorough piloting has been done."

That remains my view.

I know that my right hon. and learned Friend has thought about pilot schemes and has so far rejected them. I beg him to think again, particularly as the Health Service has not sufficient accountants, computer staff, personnel managers or contract managers to move at the pace that he intends. Let me remind him of what the late Lord Hugh Cecil wrote as long ago as 1912 in his famous book on "Conservatism" :

"The surgeon dissects a dead body before he operates on a living one and operates upon an animal before he operates upon a human being : the mechanic makes a working model and tests it before he builds the full-sized machine. Every step is, whenever possible, tested by experiment in these matters before risks are run. In this way the unknown is robbed of most of its terrors".

That is precisely what my right hon. and learned Friend has failed to do. He has not robbed the unknown of most of its terrors, as the reactions of the medical and nursing professions have shown. His basic premise that the

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introduction of competition in to the National Health Service will ensure a better deal for patients is highly questionable. It is certainly unproven.

I refer the House to what the Financial Times said in its leader on 21 April :

"The United States, the country with the most competitive system, has by far the highest costs : it spends around 12 per cent. of GDP on health care compared with 8 to 9 per cent. in Europe. Britain, the country with the least competitive system, has the lowest costs, spending less than 6 per cent. of GDP. Yet there is no evidence that the average Briton is less healthy than the average West German or American. Nor is the United Kingdom record on innovation poor : in many fields the treatment available in the United Kingdom is among the best in the world."

Thus the basic premise of my right hon. and learned Friend's White Paper that increased competition will provide better health care remains totally unproven. The NHS would be once again reorganised, this time on an unproven premise. I do not know whose bright idea it was--some anonymous economic guru? I respect my right hon. and learned Friend's common sense too much to ascribe authorship of the White Paper to him. I have a feeling that he is arguing a dock brief. Does that mean that nothing should be done about the known weaknesses of the National Health Service? Certainly not. I remind the House of what we said in the Select Committee report last July : "Our principal recommendation in this Report is that the strengths of the National Health Service should not be cast aside in a short term effort to remedy some of its weaknesses. At present it is not possible to demonstrate which of the weaknesses of the National Health Service are a consequence of lack of funding and which reflect institutional deficiencies."

We went on to declare :

"A programme of persistent improvement will provide a more effective way forward for the National Health Service than the search for a radical reconstruction of the service".

That may seem to my right hon. and learned Friend to be too slow a way of reforming the National Health Service. He appears to be a Secretary of State in a hurry, but what is the hurry? The National Health Service is not collapsing around his head.

I repeat my warning to my right hon. and learned Friend not to cast aside the strengths of the National Health Service in a short-term effort to remedy some of its weaknesses. I ask him to reflect upon the Aesop fable of the tortoise and the hare. He may fancy himself as the hare in the outside track, but I remind him that the tortoise won that famous race. My right hon. and learned Friend must try to carry public opinion with him, especially the medical and nursing professions, many of whom are not employees but independent contractors within the service.

I am not convinced that my constituents wish to see their GPs become born- again competitors, let alone medical yuppies. If the House thinks that I exaggerate, let me quote from my right hon. and learned Friend's speech to the annual dinner of the Royal College of General Practitioners :

"So in the coming months I will be asking patients to ignore the complaints of GPs who are reluctant to compete. GPs are being asked to compete for each individual's custom as a patient and they are being asked to compete for each individual's money as a taxpayer. We will all get an even better standard of service from those who compete successfully".

I wonder whether we will. A good bedside manner or a good bazaar manner--I know which I prefer and which my constituents prefer.

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I therefore beg my right hon. and learned Friend to abandon his ambitious idea to be a hare, to be a pace-setter, and to content himself with being a good, efficient tortoise. I invite him to take his time about the proposed reforms ; to initiate some pilot schemes ; to add a lot of green edges to his White Paper ; and above all to consult and discuss with an open mind. If he bounds ahead at his present pace, he may well end up not a victorious hare, but politically a jugged hare. That would be very nasty for him. It is not a fate I would wish upon him. I invite him to join us tortoises. 6.54 pm

Mr. Doug Hoyle (Warrington, North) : Unlike at least one Conservative Member, I wish to declare an interest. I am the joint president of Manufacturing, Science and Finance--a union with 40,000 members ranging from consultants to professional white collar workers, junior hospital doctors and GPs. I also speak on behalf of the 625, 000 other members of the union and their families who use the National Health Service.

I have followed the Secretary of State's career with great interest. I have seen him in the Department of Health, I have seen him as the Chancellor of the Duchy of Lancaster at the Department of Trade and Industry and I have seen him back at the Department of Health. Today he seemed most uncomfortable. He appeared to be what he is by profession, a barrister, reading a brief with which he was not particularly happy. He did not give us the answers that we were waiting to hear and, as we have heard, he did not provide the answers that his hon. Friends expected. The best advice I can give the Secretary of State is to go away and think again.

No right hon. or hon. Member would deny that there is room for improvement in the National Health Service. It is highly successful and cost-effective, but we must always consider the priorities. The National Health Service demands money. As the hon. Member for Eastleigh (Sir D. Price) said, Britain spends a smaller proportion of GDP on the National Health Service than other European countries do, certainly less than our fellow members of the EEC, except Spain, Portugal and Greece. Surely we do not want to be reduced to that level.

I believe that by providing a universal Health Service, we provide a better service than other European countries. Certainly it is extremely efficient. The White Paper does not take into account what is at stake. The National Health Service is treating people. We are not dealing with items on a production line. The White Paper is all about cost-efficiency. It is not about providing more resources and, of course, it will lead to higher administrative costs but not a better service to the people who use it.

When the Secretary of State was discussing the White Paper--and there was very little discussion of it--why were the people who use the Health Service not consulted? I suggest that had the people who use the Service been consulted, quite a different White Paper would have been presented to us today. If the Secretary of State had consulted those who use the National Health Service he would know their opinion. I see that the hon. Member for Birmingham, Northfield (Mr. King) is in his place. No doubt he will make a speech later. I do not know whether he uses the Health Service, but certainly the Ministers at the Department of Health do not use it, apart from the Secretary of State who always claims to do so.

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It is a great pity that Ministers do not use the service more, especially the Prime Minister. If they did, we should have a different White Paper. If people had been consulted, they would have said that rather than urging GPs to have bigger lists, it would have been better to have a reduction in the number of people each GP treats, so that hard-working GPs would have more time for each patient.

I will now deal, specifically, with the proposals in the White paper. Paragraph 2.13 says :

"Local managers will re-examine all areas of work to identify the most cost -effective use of professional skills there is also scope for more cost- effective working in other professions, some of which, such as physiotherapists, speech therapists and chiropodists, make little use of non-professional helpers."

What does that mean? Does it mean that non-professional people will give physiotherapy? The mind boggles if that is the intention. Does it mean that there will be non-professional speech therapists? How will that help people with speech deficiencies? We need more speech therapists who are paid decent salaries, which is quite the opposite of the proposal.

Mr. Jim Cousins (Newcastle upon Tyne, Central) : Is my hon. Friend aware that already there are speech therapists who are, in a sense, non- professionals? Areas where the pay that speech therapists can command is low are unable to recruit them, so some hospital administrations have reclassified speech therapists as clerical and administrative workers so that they can pay them higher wages surreptitiously and so attract more staff.

Mr. Hoyle : I am grateful for that intervention. I am sure that my hon. Friend agrees that that situation is nonsense. The truth is that the pay of speech therapists is low because it is an almost 100 per cent. female profession and that is one of the problems. Shall we have non- professional chiropodists attending to people's feet? The mind boggles.

Paragraph 3.12 says :

"NHS Hospital Trusts will be free to settle the pay and conditions of their staff, including doctors, nurses and others covered by the national pay review bodies."

What does that mean? The MSF has already been told by a leading London teaching hospital that it will pay more in certain grades, but that there will be fewer people in those grades. People such as speech therapists are already overworked and they can hardly cope with their work loads. If some of them are paid more and there is a reduction in numbers, an inferior service will be offered. Paragraph 9.12 says :

"The Government believes that there is scope for much wider use of competitive tendering beyond the non-clinical support services". One of the lessons already learned from competitive tendering in the Health Service is that it gives an inferior and less effective service and the person who suffers is the patient. God forbid that competitive tendering should be applied to professions.

According to today's newspapers, at least 140 hospitals are interested in opting out, which means that 200 hospital units could be affected. In Warrington district health authority, Warrington district general hospital is interested in opting out. If the core hospital opts out, it will be impossible for Warrington health authority to plan

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health care for an expanding area. That will be the case for many health authorities where major hospitals are intent on opting out and it will be impossible to plan health care.

Mr. Flannery : When the Secretary of State was speaking, a whole crowd of us wanted to know who would take the decision to opt out, and although he later intervened four times himself, he would not give way. We do not know whether it will be a democratic process or an undemocratic process. The Secretary of State funked the question every time and would not tell us who will take the decision to opt out.

Mr. Hoyle : I agree with my hon. Friend that we want the answer from the Dispatch Box tonight and I hope that the Minister of State will take note of our comments. From the White Paper, it appears that almost anyone can ask for opting out, including the loosely termed "leagues of friends"-- whatever that means. Ultimately, it will be the Secretary of State who will decide, not the people who know about the health priorities in their area. That is the wrong way to run the Health Service, especially as it will mean that local needs will not be taken into account.

We know that the hospitals that opt out will receive a major share of resources, which will be their pay-off for opting out. If the hospitals that opt out receive more, they will attract more consultants, more nurses and more hospital staff. As a result, hospitals that have not opted out will become inferior. They will be unable to attract staff or to provide the same medical services to the people who need them. That is not a desirable state of affairs. Until now, health authorities have been able to plan for the needs of their area. We want to retain that local input and we want them to be able to plan in that way. The White Paper says :

"Health authorities are neither truly representative nor management bodies."

That is correct in a sense, but the White Paper proposes to take away the representative bodies by taking away the people from local authorities who serve on them. There will be five non-executive members, probably drawn from business, five executive members who are managers of the health authorities and hospitals, and a non-executive chairman.

To what extent will the new bodies be accountable for the health of the district? The Minister must give us an answer. What say will local people who use the Service and the staff have in whether local hospitals opt out? What say will they have in how the health authorities conduct their business? There will be no local input. How will local people who are patients be able to affect decisions about health care in their district? The Minister must answer that question.

Is it desirable that the managers of hospitals should be members of the governing body and so run them? If managers are below par, who will bring them up to scratch? Managers on the management body are hardly likely to bring themselves up to scratch, so surely independent people should do so. I can envisage great difficulties arising.

I might say something about all this other nonsense--for example, the suggestion that to raise money local health authorities might sell insurance services in hospitals. I suggest that the last thing that people want to be offered when they are ill in hospital is an insurance policy. An even more nonsensical suggestion is that health authorities might sell cars on hospital forecourts. I do not

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know where that suggestion came from, but having heard the Secretary of State try to sell his White Paper I am inclined to ask who would buy a used car from him ; it would be a brave person indeed. Let us stop all this nonsense.

I think that what is in prospect is privatisation little by little. The Government are afraid of saying, "We will privatise the NHS"--

Madam Deputy Speaker (Miss Betty Boothroyd) : Order. I remind the hon. Gentleman that Mr. Speaker announced that the 10 minutes rule would be applied.

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