House of Commons Hansard Debates for 11 May 1989

Mr. Hoyle : As you know, Madam Deputy Speaker, I have given way to one or two of my colleagues, but I shall finish my speech within my 10 minutes. I have nearly

Madam Deputy Speaker : Order. The hon. Gentleman has had his allocation of time--10 minutes from 7 o'clock.

Mr. Hoyle : Indeed, Madam Deputy Speaker, and I am almost ready to finish. [ Hon. Members-- : "Oh."]

We shall end up with what they have in the United States--a cheque-book service with high administrative costs which takes into account people's means rather than their needs when they go for treatment. What we need in this country is a service financed

Madam Deputy Speaker : Order. I must ask the hon. Gentleman to resume his seat.

7.11 pm

Mr. Tony Favell (Stockport) : I shall confine my remarks to the proposals for self-governing hospitals. I do that because today Stepping Hill hospital, together with Stockport infirmary in my constituency, announced that it was one of six units in the north-west to express an interest in becoming self-governing. I, for one, am mightily pleased. For many years now, I have felt that the two hospitals in my constituency offering acute services would be far better placed if they ran their own affairs, free from influence and interference from the region or from Whitehall.

I must declare an interest because long before I was elected to the House in 1983 I was a director of a retail pharmacist. I have had an interest in health in a minor way--first as the secretary of the Conservative health committee, then as a member of the Select Committee on Social Services, then as a PPS in the old Department of Health and Social Security and now as a PPS in that most benevolent godfather to the NHS of all, the Treasury.

I have been convinced that the real power over what goes on in hospitals-- in wards, operating theatres and out-patient departments--is far too remote from the people who actually administer health care. The proposals for self -governing hospitals will give units the opportunity to control their own destiny, and I am delighted to hear that Stepping Hill hospital, with Stockport infirmary, could be one of them.

The accident and emergency department, orthopaedic department and ENT facilities are at the Stockport infirmary while all the other facilities are at Stepping Hill. Perhaps my hon. and learned Friend the Minister will give me a little of his time to allow me to explain the difficulties that Stockport infirmary and Stepping Hill are experiencing because they are on separate sites. Between them they have 930 beds. Because they are on a split site, there is a

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constant parade not only of specialists but of patients between them. Not only is that far from satisfactory ; it is dangerous to patients.

At present, we have a once-in-a-lifetime chance of disposing of the infirmary and I would wholeheartedly support such a move because the neighbouring Station approach in Stockport is being developed and the infirmary could be disposed of for a small fortune. The unit could then be placed on one site at Stepping Hill, thereby enhancing services and making life a great deal more satisfactory for the staff.

Despite the problems that arise because the unit is on a split site, the standard of treatment is high. The service is caring and cheerful and in recent years--as I said in an intervention in the speech of the hon. Member for Livingston (Mr. Cook)--the unit has come top of the north-west value- for-money league for both in-patient and out-patient cases.

I pay tribute to Fred Richards, the district health authority chairman and Peter Milnes, its general manager and to other members of the authority who have had the confidence in Stepping Hill and the Stockport infirmary to suggest them for self-governing status. If the proposal is accepted by my right hon. and learned Friend the Secretary of State I have no doubt that the hospital services in Stockport will be even better for staff and patients alike and I believe that the same consideration would apply to general hospitals throughout the country.

I am convinced, as I said, that the decision-making process is far too remote. The unit in my constituency has an annual turnover of £25 million, yet a capital scheme of more than £15,000 has to be referred to the district health authority. Larger schemes go to the regional health authority, to Elephant and Castle and then to Whitehall, passing through dozens of bureaucratic hands and committees. Far too much information on day-to-day management matters is referred upwards to Richmond house and, as my right hon. and learned Friend the Secretary of State said earlier, far too little finds its way into the hands of those who really know what is going on--the sister, the consultant and the unit manager, who constantly complain that very little of the information that they collect, which is subsequently processed, finds its way back to them. I am glad to hear that my right hon. and learned Friend has plans to correct that.

The long tail of bureaucracy will be docked when hospitals become self- governing. Information systems will be needed but it will be much easier to have an information system for a single unit than a system serving the whole of the acute hospital sector.

Staff are bound to fear the unknown ; we all would. My right hon. and learned Friend has made it crystal clear, however, that the salaries of personnel will be unaffected, as will their terms and conditions, unless they opt for a package that they consider advantageous. That could well happen, as free-standing hospitals will have a keen interest in retaining the best of their staff. Today I spoke to Derek Caldwell, the excellent unit general manager of Stepping Hill about the proposals to make Stockport infirmary and the Stepping Hill hospital self-governing. He said that he looks forward to the change and to being able to provide far better conditions for the nurses who work there. He is enthusiastic about the possibility of creche and welfare facilities and better shift patterns to give those who work at the unit a better quality of life.

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Patients, too, are bound to be better off. Recently, I went to Belgium, and I think that my experience will be of interest to the House. In Belgium, the percentage of GDP spent on health is very similar to that spent here. Some of the hospitals are built by local communes, some by the state, some by universities and some by groups of doctors. There is a multiplicity of providers of care. The cost of treatment is met by national insurance schemes and, as here, treatment is largely free. The national insurance scheme covers virtually the whole of the population and is popular with doctors, patients and staff.

I met the chief administrator of Antwerp university hospital. I asked him, "What is happening with the waiting lists in your hospital?" He said, "What do you mean?" I said, "How long would one wait for a hip replacement?" He said, "About a week." I said, "How can they do it within that time?" He said, "If we do not do it, the hospital down the road will do it." That is precisely what my right hon. and learned Friend is proposing for patients in the United Kingdom. He has my wholehearted support. I cannot wait to support him in the Lobby tonight.

7.19 pm

Mr. Jack Ashley (Stoke-on-Trent, South) : I warmly congratulate my hon. Friend for the Vale of Glamorgan (Mr. Smith) on his fine maiden speech. He will make a major contribution in the next two years, and an even bigger contribution two years after that when our party forms a Labour Government.

A special group is affected by the proposals ; I refer to disabled people. For them, the White Paper is a menacing document. The omission to mention disabled people is menacing. It demonstrates that their long-standing problems will be neglected. There is no mention in the White Paper of disability, and only a passing mention of the mentally handicapped. Bearing in mind that 6.2 million disabled people are important customers of the National Health Service, such studied neglect and total disregard is disturbing.

Despite its name, the National Health Service is not solely concerned with health. For some people, perfect health is not possible. The National Health Service rightly concerns itself with their welfare and rehabilitation and doing what it can to improve health and the quality of life.

Disabled people today are apprehensive and anxious because their needs, which are different from those with acute illnesses, will be even more neglected after the Government use their usual majority to implement their proposals. There is no reference to the serious shortage of qualified therapists whose skills do much to make disabled people's lives tolerable when their limbs malfunction. People who need hip operations rightly get operations, but those whose limbs do not work are not given proper provision. There is no mention of staffing improvements to care for people with hearing difficulties, and there is nothing about vital support services. There is not even a suggestion of safeguards to reassure disabled people that existing services will be maintained. Let me quote one glaring example. Many people in this country need wheelchairs and artificial limbs. That service is to be incorporated into health authorities in 1991. It is not mentioned in the White Paper, either, and I do not understand why.

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The health of disabled people is just as important as that of anybody else. When people lose their limbs and become immobile, they will find that the Disablement Service Authority has advised general practitioners to look hard at whether artificial limbs or wheelchairs are needed. That means that they will be carefully scrutinised before they get an artificial limb or a wheelchair. They will be means- tested. What sort of Government would impose that kind of hard, steely approach on people who require that vital service? For the first time in decades, severely disabled people will have to fight to get artificial limbs or wheelchairs.

There is nothing for which the Secretary of State or his sidekick, the Minister of State, should be proud. Those people should be properly assessed, fitted with limbs and provided with wheelchairs, rather than be deprived of them. [Interruption.] There is absolutely no point in the hon. Member grinning. I am making a serious point about disabled people. There is nothing to smile about. I am accusing not the Secretary of State but one of the Government Whips.

The major deficiency of the White Paper is its failure to acknowledge and react to the importance of co-operation between the agencies that give disabled people essential support. I refer to the hospital service, primary medical care, and social service departments. All those agencies act in concert to provide whatever pattern of services is required for each disabled person. They are inextricably interlinked and intertwined. If there is reduced NHS commitment, there will be less co-operation and no certainty that essential information is transmitted and that each piece of the jigsaw will be present when it is required. As a result, a disabled person's quality of life will be diminished.

The philosophy behind the White Paper is that we will no longer aim for the best possible treatment for everyone but will focus on value for money. Of course it is right to examine and improve the efficiency of acute services. I do not blame the Secretary of State for doing that. He is quite right to attempt it. But disabled peoples' problems do not respond to the cut of the surgeon's knife. How will value for them be measured?

I hope that the Minister of State will listen to my next point, because I did him a disservice a moment ago. I want the Secretary of State also to listen. The White Paper includes some words about a Health Service being more responsible to patients' needs. However, a doctor at the BMA conference said that the White Paper proposals would act as a great disincentive to GPs to take disabled people into their practices. Their needs could fall by the wayside.

Disabled organisations are unhappy about the proposed changes that give financial incentives to doctors to have a minimum of costly patients. For example, diabetics cost £500 more a year than the average patient. If a diabetic family were to move into an area, how welcoming would a local GP be? GPs have always been the gatekeepers of hospital provision, but, for the first time, they will have an interest in restricting it. Even though most GPs are people of integrity and humanity, it is a backward step to create a system that provides incentives of precisely the wrong kind.

Before the Secretary of State gets too annoyed, I inform him that I challenged him when I said that the Minister of State had said that special provision would be made only in exceptional circumstances for chronically sick and

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disabled people, who would be more expensive to the Health Service. In his reply, the Secretary of State said that the Minister of State had denied using the words I had attributed to him. The Minister was right to deny those words, because they had been, in fact, used by the Secretary of State. The Secretary of State was asked whether doctors would seek to remove patients from their lists on budgetary grounds. His reply included the words

"in exceptional cases adjustments will be made in respect of individual patients who need more costly treatment."--[ Official Report, 4 April 1989 ; Vol. 150, c. 85.]

Madam Deputy Speaker : Order. I remind the right hon. Gentleman that he has had his ten minutes.

Mr. Ashley : I am sorry if I have exceeded my time. I must sit down now. If I have done any injustice to the Secretary of State, I am sure that the Minister of State will correct me.

7.30 pm

Mr. Patrick Ground (Feltham and Heston) : At the end of his speech, the hon. Member for Livingston (Mr. Cook) made a comparison between operations carried out in hospitals in the United States of America and those carried out in this country. He said that a substantial number of operations carried out in American hospitals were of dubious value. I think that he was really saying that he was proud of the Health Service, because fewer such dubious operations are carried out in National Health hospitals.

I found that to be one of the hon. Gentleman's most interesting comments, because, for the first time, he was holding up a standard for the Health Service. I believe that that is of considerable value and is, perhaps, the core of the philosophy behind the Health Service, which is that the aim of the Service should be to provide medicine and treatment for everyone who needs it, based on sound medical judgment. I hope that whoever winds up for the Opposition will give an indication of whether they accept that basic philosophy of the Health Service, which was touched on by the hon. Member for Livingston. It is not simply a question of the number of operations or treatments performed ; there is also the fact that necessary and useful treatment is being given to everybody who needs it. I find it difficult to understand in the present structure of the Health Service how that standard can be obtained, and how we can be sensibly advised about the attainment of that standard, without doctors in hospitals and in general practice playing a much bigger role in determining the priorities of the Health Service, which too often are determined, in effect, by administrators and by constraints on budgets at the end of the year. Therefore, one of the features that I welcome in the White Paper is the greater potential role that will be given to consultants and to general practitioners in determining those matters within the limits, and perhaps to some extent beyond the limits, of their practices.

I believe that the principal fear to which the proposals have given rise is the fear of a significant number of patients that, as a result of the proposed indicative budgets, they will not get the medicines and the treatment that they need under the Health Service. I have read the White Paper and the working papers that touched upon that subject and I believe that, on a fair reading of those papers, there is no need for those people to have such fears. It is plainly not intended in the White Paper to do much

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more than to give a nudge to practitioners, who are or may be over-prescribing or who have the most expensive drug budgets, to consider other ways of treating their patients which are more in line with general practice and which would be equally good, and probably better, professionally. Paragraph 7.15 of the White Paper makes it clear that the White Paper's proposals are certainly not intended to prevent people from receiving the medicine that they need. It has never been possible in the Health Service for a doctor to have unlimited powers of prescription. There have always been means of dealing in one way or another with over-prescribing. I believe that most people with whom one discusses the Health Service, and who have a good knowledge of what is going on within it, accept that there is some over-prescribing, and many think that there is a substantial amount.

Some patients feel that their doctors have not done their jobs unless they have given them a prescription at the end of their visit. It is too easy for many doctors to satisfy their patients in that respect, because they feel that that is what is required of them. Publicity is needed to encourage patients to question the treatment that their doctors recommend, to ask them to justify the medicines that they are being prescribed and to satisfy themselves that they are useful and that they will not have side effects that will nullify any benefit.

The variations in prescribing that are reported in the White Paper are striking. There are variations between £26 a head in some practices and £48 a head--nearly double--in other practices. It is clear that there is an immense variation, too, in the practices of general practitioners in referring patients to hospitals. In fact, there is a variation of as much as twentyfold. Some general practitioners do the parliamentary equivalent of hon. Members writing to the Minister on virtually every matter that comes before them. Obviously, there is room for a much more sensible practice for prescribing medicines and referring patients to hospital. Some Opposition Members have exaggerated the rigidity of the indicative budgets, because paragraph 7.17 of the White Paper makes it clear that practices may exceed their indicative budgets for good reasons. Good reasons will be acceptable reasons for going over the top of the budget.

Taken as a whole, the fears that some hon. Members have expressed about the proposals in connection with general practitioners are exaggerated. The proposals should be applauded for the opportunities that they will give for better standards of medical practice, better prescribing and for a more sensible method of referral. Above all, they should be applauded because they will involve general practitioners and consultants much more in the determination of priorities and in the actual spending of money in the Health Service and I believe that that could be of considerable benefit to the Service.

7.40 pm

Mr. John Hughes (Coventry, North-East) : It is possible that the Government's White Paper would never have come to the House if the quotation above Southwark council house was enshrined above the entrance to this Chamber and reminded each hon. Member that the people's health is the highest law. Unfortunately, that philosophy is not contained in the White Paper.

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If there has been one constant and unchanging facet of the Government in the past 10 years, it has been their attitude towards the National Health Service and in this instance the constant has been their duplicity. The recently published White Paper is the culmination of that duplicity and it is a good illustration of the dictum that you can fool some of the people all of the time and all of the people some of the time, but you cannot fool all of the people all of the time.

No one in the real world is under any illusion other than that the White Paper is simply one more step in the deconstruction of the Health Service. It is privatisation by another name. Although some commentators are happy to parrot the Downing street advice and may believe that devolution and improvements are part of an agenda for change, their voices are outnumbered. The Secretary of State's White Paper has invited almost universal scorn and has forged some unlikely alliances.

The people who have spoken up against the White Paper--the GPs, the consultants, the junior doctors, the nurses, the Health Service workers and, most importantly, the public and the patients--may have been ignored by the Government but they have not been misled by a Government headed by the greatest scalpel wielder of all, who is not noted for her sensitivity when wielding that instrument and whose cutting philosophy has savaged the Health Service.

The proposals reflect that inhumane philosophy. They are accountancy proposals, set to balance the books numerically at a grossly under-funded level. They are asset-stripping proposals, which will fragment and decimate the Health Service. They will spawn a Health Service unable to respond to a crisis situation and unable to provide in a foreseeable and especially cold winter the future urgent treatment that will be required by 40,000 to 60,000 elderly citizens who cannot afford to heat their homes or to pay for gas or electricity and whose lives are at risk from hypothermia. The proposals ignore the reality of life in Tory Britain. They gloss over the decimation of service in the past 10 years.

The proposals also ignore and gloss over the treatment of the mentally ill who are now subjected to a conveyor-belt system in which they occupy beds on throughput basis. The pertinent fact that has not escaped the Government --the accountants--is that more hospital beds are required for mentally ill patients than for any other type of patient. The Government have realised that if they can get rid of those mentally ill patients, they can either close the hospitals or push other patients through the system. That is being encouraged by the new management pay structures, by which managers are paid bonuses on the rapid discharge of mentally ill patients. Those patients are sent home on a weekend's leave and when they return, their beds are occupied. They become community flotsam and eke out a miserable existence, roaming the streets.

A crisis exists and the Government's proposals will compound the problem with the voluntary organisations being left to pick up the bill. The Salvation Army carries the brunt of the problem. It provides shelter for the mentally ill who are forced to roam the streets. However,

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even the Salvation Army is under constraints and that is why so many people with a history of mental illness now exist in squalid bedsits or cardboard boxes.

The Government's proposals fail to make allowances for the disparities in health that can still be observed. Far removed from this cosseted Chamber exist members of our society whose circumstances are a condemnation of the callous system. We step over them when we use the Underground and we see them sleeping in doorways, but we ignore them, and these proposals also ignore them. The great inequalities and disparities that exist between communities that live side by side in the same region are becoming increasingly clear from fresh evidence. Numerous studies at local authority and ward level have pinpointed pockets of poor health that correspond to areas of social and material deprivation.

One advantage of the present National Health Service is that an overview of the health needs of the nation could be given consideration and that that could be reflected in long-term strategic planning. The nation's health would suffer if long-term planning were inhibited.

The Government and their advisers follow the outlook of Burke and Hare. The Government, the Tory think-tanks, the Adam Smith Institute and all the other scavengers and agents of scavengers have had their eyes on the Health Service for a long time. They measured it for a coffin years ago. One can only imagine how they must have salivated as they studied the books, how their palms must have begun to sweat as they read the accounts and the inventories, and how they must have sighed when they began to comprehend just how much of the people's money was wrapped up in the National Health Service, just waiting to be liberated into their clammy little hands.

However, there was an obstacle--the public would not wear it. Opinion poll after opinion poll told the Government of that, so it was necessary to plan a waiting game. The Health Service was kept short of funds and in due course it was forced to begin a sale of its assets. We know the formula. Bed closures plus rationalisation of service equals closures of hospitals plus disposal of sites. In Coventry, where my constituency lies, this has meant the closure of two hospitals and a number of smaller units in the 10 years of this Prime Minister's Government.

Nevertheless, it was still just a trickle. The problem confronting the Government was how to turn this trickle of equity leakage into a flood, on to which a fully privatised Health Service could be launched.

The White Paper is the solution to that dilemma. Having starved the National Health Service for 10 years of the revenue allocations with which to run its service and having starved it of the capital resources with which to develop its sites, the National Health Service has a good deal of excess capacity. In my constituency, for example, the Coventry Walsgrave hospital has the capacity to handle 8,000 more operations annually, yet patients suffer unnecessarily because the surgeons are prevented from carrying out as many operations as they would like despite the obvious demand. Although theatres are available to carry out the operations, they cannot be staffed because of lack of money.

Having dictated that health authorities must appoint new managers for each of their hospitals, having encouraged them to employ managers with experience in industry, the Government are now proposing to create hundreds of little businesses out of those hospitals--

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businesses which undertake work on behalf of the health authority but which can just as easily undertake work on behalf of the private sector. That is the crux of the matter.

The proposals are supposed to be based on the Government's belief that the market is a superior mechanism for the allocation of resources. I do not believe that, because there is not a shred of evidence to support it and although I might believe many things of this Government, I do not believe that they cannot read. They know that private health services throughout the world are a shambles and that they are inefficient and costly to run. We need only to look at the number of unnecessary operations carried out in the United States of America, the vastly greater administrative costs of private systems, the tangle of litigation with massive amounts of money diverted, not into better health care, but into solving the legal mess. Those systems fail to provide for the elderly, mentally ill, physically handicapped and so on.

The Government's White Paper will reduce the National Health Service to the same sort of shambles as a private health care system. It will sink a greater proportion of resources into the pit of that adminstration, reduce the responsiveness of the National Health Service to be able to identify the need, and divert the nation's resources to those who are already well served. The key to that is the privatisation of hospitals, to remove them from public control and put them in the hands of managers in ready-made or

management-manufactured groups who are prepared to soil their hands.

Madam Deputy Speaker : Order. The hon. Gentleman has used his allocation of time.

7.51 pm

Mr. David Atkinson (Bournemouth, East) : The review of which the White Paper is the outcome was called for by my right hon. Friend the Prime Minister in reponse to widespread concerns about the performance of the National Health Service. My response to previous concerns over the years has been that the NHS, like the welfare state, was conceived during the last war and was based on the conditions that existed before it, and that half a century later, our health services should be encouraged to reflect the ambitions of today's families and their ability to afford to provide for their health needs privately.

For some time, I have supported the concept of a health tax, which would be separate from income tax, which would bring home the real cost of the NHS to taxpayers and which could be rebated for private cover. There was no other solution to remedy the unrelenting growth in the demand for resources, and the sheer cost to the Health Service of the growing number of elderly people and of advanced medical technology. The royal commission said as much in 1979.

There was no other way to avoid the series of crises that have scandalised the NHS over the years, or to end the more recent horror stories about health authorities running out of money, wards being closed and operations being postponed that prompted this review. In 1982, the think tank report to the Cabinet recommended precisely that : a shift from a tax-based Health Service to private insurance. As the House knows, the Prime Minister was totally opposed to this privatisation of the Health Service, and she abolished the think tank that proposed it.

Surely there can be no greater evidence than this, together with the massive increases in resources that the

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Government have provided, of their commitment to a state-run, National Health Service, paid for out of general taxation and free at the point of delivery. The White Paper confirms that commitment, and I congratulate my right hon. and learned Friend on its aims and the ingenuity of its proposals. I bitterly regret the reactions that we have received from the British Medical Association and from our constituents who have been inspired by some of its members. I accept that some reactions that I have received from my doctors have been constructive and helpful. However, I utterly condemn the way that some doctors, although by no means all, have totally misled their patients into writing to us, without having any idea what the White Paper proposes. I have received far too many sad and distressing letters from patients such as diabetics, who rely on continuous medication and have been told that, in future, they could be denied treatment. I have received letters from patients who have been told that hospitals are to go private, doctors will be forced to take on more patients than they can handle and to limit the cost of medicines that they prescribe and that treatment will be related to income. None of those statements is true, and it is wholly irresponsible for doctors to scare patients, especially elderly ones, in this way. I believe that the BMA has lost much good will as a result of its campaign.

I turn to what is actually proposed in the White Paper. I welcome the downward delegation of responsibilities to local level, and the option for hospitals to become self governing within the NHS. That will result in the sort of better-organised, more personal hospital service of which local communities were once proud and which many of my constituents feel has been lost in recent years due to excessive bureaucracy and the disappearance of matrons and local hospital boards.

There is no reason why any hospital should not be free to offer its services to health authorities and practices outside its own area. Every hospital is different and develops its own expertise and specialities. My right hon. and learned Friend has emphasised that there is no question of hospitals ceasing to provide non-profitable services. The opportunities that will arise from the proposed new funding arrangements, with money following the patient and the ending of RAWP, the Resource Allocation Working Party--which has been so unfair to my own district health authority --will be better appreciated when they are better understood.

The availability of practice budgets is an imaginative idea which, I am sorry to say, appears to have been widely misunderstood by GPs, who have overlooked the fact that it is optional and entirely voluntary, and is available only to those larger practices already experienced in handling larger budgets. A budget-holding practice will have greater flexibility to use on behalf of its patients and wider opportunities to obtain quicker treatment from the most appropriate hospitals at a price that can be negotiated. That must be in everybody's interest and will bring down waiting times considerably.

It cannot be right to permit a system that tolerates waiting times of a year or more for treatment in one district, when the same operation can be obtained in a few weeks in another district. In my district, the current waiting time for dermatology is five months, for neurology nine months, and for ophthalmology six months. Those waiting times are totally unacceptable. The White Paper proposals will enable GPs to know where the quickest

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treatment can be obtained and make it available to their patients. My only concern is that there will be adequate transport arrangements for patients who seek treatment outside their own areas and adequate post-operative treatment when they return. I look forward to my hon. learned Friend assuring me on both those points in his wind-up speech.

The proposed encouragement of longer patients lists has also been misunderstood. No professionally responsible practice will give less time to patients because it has opted to accept those who have asked to be added to its lists. It is in demand because of its good reputation, which it has earned at the expense of other practices known to be less caring. Patients usually know who are the best doctors and who are the ones who are never there. Under the proposals, the hardest-working doctors will be properly rewarded, and that has to be right.

Similarly, no good doctor will prescribe inappropriate medication because of the introduction of indicative drug budgets. There was no evidence that this was the case following the introduction of the limited list, which was greeted with howls of protest five years ago and which has now enabled an extra £300 million to be spent elsewhere on improving health services. When it is realised that only 3.5 per cent. of all prescriptions are for patented products, it becomes self-evident that the remaining 96.5 per cent. of the drugs bill open to generic prescriptions represents an enormous potential for savings that has been estimated at an annual saving of £700 million. It has been clear for some time that the Griffiths reforms for more efficient management of our health authorities have proved a disappointment. I fully accept the White Paper's proposals for streamlining their management. I should, however, record the opposition of my borough council to the proposed removal of councillors from the local authorities, although they will not be precluded from serving on local authorities if they have a management role to contribute.

I am glad that the White Paper does not seek to abolish the community health councils, one of which I served on myself. They can provide a much more effective channel for local views, including those of local authorities, on the quality of local services. It will be up to them to hold local health authorities, hospitals and practices accountable for their findings.

As my right hon. and learned Friend knows, I remain critical of him for not referring in the White Paper to the Griffiths report on community care, which is now more than a year old. I anticipate that he will put that right as soon as possible. Apart from that, I offer a warm welcome for his proposals. Given our record of more resources, doctors, nurses and treatment than ever before, they can only help to make a good National Health Service even better.

8.1 pm

Mr. Jim Cousins (Newcastle upon Tyne, Central) : As the Secretary of State said, the debate on these proposals is moving on. It is moving on from the ground of principle, which the Government have already decisively lost, to the ground of the implementation of this extraordinary contraption --the network of cash limits and contracts. On

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this new ground, the Government's prospects are, if anything, much worse than they were on the ground of principle.

Wriggle though the Government may, it is clear that the network of budgets is intended to constitute cash limits. Cash limits have already been extended for the first time to family practitioner services under the Health and Medicines Act 1988 which recently became law. GPs fully expect, and are entitled to expect--and the wording of the working papers gives them good grounds to expect--that these budgets will become cash limits.

We are also told in the working papers that the contracts which hospitals which opt out make for their patients are to be legally enforceable. We are told that it is to be hoped that that will not necessitate too much litigation, and that some arbitration mechanism may be introduced. I suppose that, if a person has a coronary bypass operation at an opted-out hospital, and it goes wrong, he will be uncertain whether to head for the High Court or the hospital. These are real anxieties. The administrative machinery that these working papers are intended to promote gives grounds for considerable anxiety. On 22 March, a document was sent out from the NHS management executive to regional health authorities, and it has received all too little publicity. It set out what the regional health authorities must do by 5 May--a date that has already passed. Among the proposals in the document are not only suggestions for employing a great many extra staff administrative staff and for the creation of a great many administrative positions in all sorts of individually specified support services, but a hard-to-find proposal that regional health authorities should have expressed a view by 5 May on whether blood transfusion and ambulance services should be put out to contract. These are the forced administrative marches on which the Government are having to embark to get the proposals through.

The Secretary of State has repeatedly said that the doctors have started from a basis of outright rejection of the proposals, but some of the most telling criticisms of the proposals have come from doctors who support them. I instance, from my region, Mr. Brendan Devlin, who supports the White Paper's proposals and is a consultant at North Tees general hospital. He says that he is worried that the consultants' car park will be completely taken up by the Porsches of yuppie accountants. It is clear from that that many people who have a right to be wary of what the future holds, and who have already expressed themselves on political and administrative grounds supporters of the White Paper's proposals, are fearful about whether they can be implemented.

The Government will also change the mechanism by which cash allocations start to flow through the system. The principal element in these cash allocations is to be a bob-a-nob one-allocation per head of population. We are assured in the White Paper that that means that resources will automatically flow to areas of growing population, but it is not pointed out that they will also automatically flow away from areas in which the population is declining.

The system of allocations proposed for practice budgets, prescription budgets, and regional and district health authority budgets cannot be implemented merely on a per capita basis. The system will not bear the weight. The hon. Member for Bournemouth, East (Mr. Atkinson) has already celebrated the end of the RAWP mechanism, but he should be careful lest, as the Government's

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proposals go into operation, something far more horrendous than RAWP replaces it--a mini-RAWP for every NHS authority and hospital, and for every general practitioner in the country. The information that the Government have at their disposal cannot bear the weight of such a system, and they are foolish to try it.

Our information about prescription budgets leads to the amazing conclusion that the lowest spend per head is in Oxfordshire, and the highest spends are in Merseyside, the north-west and the north. There is nothing surprising about that ; what is surprising is the belief, in the face of that information, that the Government can allocate these resources on a per capita basis and expect matters to continue just as they are now in the north-west, Merseyside and the north. There are certainly grounds for grave concern. Abolition of RAWP and the introduction of per capita budgeting is disastrous news for areas which have depended upon RAWP and in which per capita spends are higher than the national average because of the make-up of the population. It may be of interest to note that this is not just a north versus south issue. Areas where prescription spending is very high in the south include Dorset, which includes Bournemouth, and the Isle of Wight, which includes Ryde, Shanklin and Ventnor--all areas in which inconvenient elderly people hang on and in which per capita spending will work against them.

These proposals are an administrative nightmare and an absurdity. The Government should be cautious about pressing forward too rapidly with this sort of proposal. We do not have the administrative machinery in place to support their implementation or to protect the Government from the inevitable disasters that will ensue. For several years now, the Government have cash-limited hospital services ; now they are starting to cash-limit general practitioner services. By means of the poll tax/community charge, they are cash-limiting local authorities' social services. How will the strain of caring for the growing numbers of elderly people on whom the bulk of health and social service money in spent be taken up? We cannot put a price tag on a stroke patient, a mentally handicapped patient or mentally ill person. The attempt to do so will be foolish and will produce widespread public unrest : it will not work. When I visited the largest voluntary aided hospital in central Brussels recently and saw over the door the sign, "We take American Express", I saw what the Government intend. The proposals are not working for patients ; they are working for lawyers and accountants.

8.9 pm

Mr. Robert McCrindle (Brentwood and Ongar) : I support at least the broad thrust of what the Government are seeking to achieve in the proposals outlined in the White Paper. Unlike those who are wholly critical and negative in their submissions on the White Paper, I do not see the proposals as necessarily cast in stone. I hope during the next few minutes to express a few reservations, all within the general ambit of broad support for the Government's proposals. I can never understand why those who oppose the Government's proposals for reform of the National Health Service seem to consider that, alone among our national institutions, after 40 years and with some obvious imperfections, the National Health Service should remain

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unchanged. There are many things that few of us wish to change, but there are areas that demand attention as the whole structure of the country changes during the 1980s and as we move towards the 1990s. I am slightly concerned about the speed with which the Government seem to be aiming to introduce the changes. There has been a good deal of discussion in the debate about the hare and tortoise and so on. While I do not want pilot schemes, inevitably some self-governing hospitals will get into operation more quickly than others. We should watch carefully the progress of the early self-governing experiments. I should be happy if my hon. and learned Friend the Minister could assure me that that is the broad intention of the Government. It is difficult to understand why critics of the proposals assume that we have either the proposals for change embodied in the White Paper or increased funding of the National Health Service. By no means are the two mutually exclusive. The reason why there is no reference in the White Paper to increased National Health Service funding is that is not a new policy. We have been increasing beyond the rate of inflation the amount spent on the National Health Service all through the decade during which we have been in office. I am irritated when some people, instead of submitting positive proposals, assume that we have the White Paper proposals or increased funding. My support for the proposals depends upon the assumption that we shall continue to improve funding of the National Health Service. Although the Secretary of State has dealt with the matter already, I hope that the Minister will forgive me if I return to the point about the elderly people who have been frightened by the expressions of opinion of a number of people opposed to the proposals. They have said that, when the proposals are fully implemented, there will be real difficulties in taking care of the elderly patients on doctors' lists. As I understand it, the allocation which it is proposed to make to a general practitioner will take full account of the fact that there is an age relationship in the composition of the doctor's list. I note with approval that my hon. and learned Friend the Minister is indicating assent. He cannot repeat that assurance too often.

In a wholly irresponsible way those who have been criticising the proposals have been unnecessarily and cruelly frightening old people. Old people have come to me--I suspect that my hon. Friends have had the same experience-- saying that they are fearful of the consequences of the proposals ; they think that they will be excluded from their GP's list for no other reason that the fact that they are aged. It is high time we nailed that lie.

I approve of the concept of self-governing hospitals, although we should be careful not to pursue the idea at such a pace that we risk damaging a new tier of choice for medical care. We already have the private sector and the National Health Service. They will continue, but an additional tier of choice for medical care should be welcomed rather than criticised.

Critics have given the firm impression that self-governing hospitals will be outside the National Health Service. I hope that my hon. Friend the Minister will take the opportunity in reply to the debate to make it crystal clear to people outside the Chamber that self-governing the hospitals may be, but outside the Health Service they will not be. I cannot stress that sufficiently. Malign

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propaganda of the blackest sort has been put around by, I regret to say, some members of the British Medical Association who should be ashamed of having done so.

In self-governing hospitals we are talking about an experiment. Certainly they will be a new dimension in health care. If a hospital decides to go along the self-financing route and finds later, for one reason or another, that that is not successful or if it wants to reconsider its decision, what will happen? I am not clear about whether such a hospital could be readmitted to the National Health Service. I should be grateful if the Minister would turn his attention to that.

On the question of prescribing, I have no doubt that there is a vast amount of over-prescribing by some doctors. The implication that the Goverment, as the representative of the taxpayer, have no responsibility for taking account of wide disparities in prescribing is folly in the extreme. I support the discouragement of expensive over-provision of drugs by some GPs in comparison to others that we have all noticed.

About five years ago we were told that the introduction of the limited list would affect the clinical judgment of general practitioners and that all we were interested in was saving money. In one year of operation of the limited list, we have saved £75 million. I ask hon. Gentlemen on both sides of the Chamber how many complaints they get today from GPs or from patients that we are providing a less good service than we set out to do when the National Health Service was introduced.

I echo the sentiment of some of my hon. Friends that the White Paper proposals are one arm of an important reform. The other arm must inevitably be community care. We are having a slightly disjointed debate in that we cannot relate some of the attractive proposals to what we plan to do on community care. I hope that we shall get a response to the Griffiths report as soon as possible. We are accused of privatisation of the Health Service. Do not hon. Gentlemen on the Opposition side--

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