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Ms. Joan Walley (Stoke-on-Trent, North) : May I point out that there are also honourable women here?

Mr. McCrindle : I beg the hon. Lady's pardon.

Do not hon. Members recall that, when an investigation was mounted a year and a half ago, the whole idea was that it would lead to privatisation? Some hon. Members on the Government side, including myself, expressed great concern about that. It is the fact that privatisation is not being proposed that allows me to lend my warm support to the proposals in the White Paper.

8.19 pm

Mr. Terry Davis (Birmingham, Hodge Hill) : I am delighted to have an opportunity to congratulate my hon. Friend the Member for Vale of Glamorgan (Mr. Smith) on his election and his speech. It is always exciting to be elected to the House of Commons, but it is especially exciting to be elected in the circumstances that he was. As for his speech, he combined humour with sincerity and we all look forward to listening to him again.

I have several things in common with my hon. Friend. One is that we are both members of the MSF which has a large number of its members working in the NHS, and I am sponsored by my trade union. I am also vice-president


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of the Socialist Health Association, which for decades campaigned to establish a national health service. It was on the basis of its work that the NHS was eventually created in 1948.

I have never heard anyone in the Socialist Health Association or in the Labour party claim that the NHS is a perfect institution. Nye Bevan himself would never have made that claim. We all know that the NHS needs to be improved and extended. It needs to be improved in the whole range of services known as community care and it needs to be extended in the sense that the influence of the Department of Health should be extended, into other policy areas, because we shall never improve the health of the British people unless we tackle the problems of unemployment, poverty, inadequate and unsuitable housing and a whole range of other social evils.

We have never pretended that the NHS is perfect, but the White Paper has nothing to do with those issues. It is concerned with one thing and one thing only--the cost of the NHS. That is not surprising, because it owes its origins to the traditional Tory obsession with keeping public expenditure as low as possible in order to make the maximum amount of room for tax cuts. That is what the White Paper is all about.

We all know that during the period of the Conservative Government the Health Service has had more money. Its money has increased by, on average, 1.6 per cent. in real terms every year. But we also know that the Health Service needs an extra 2 per cent. in real terms every year to take account of changes in population, improvements in medical techniques and other factors. The truth is that under this Government there has been a real cut in the money available for the NHS.

The Government are not concerned with trying to reduce the cost of the NHS by removing the causes of ill-health ; they are trying to do it by relying on the traditional Tory belief in competition. They are particularly concerned with reducing the cost of the hospital service and they want hospitals to compete for patients and to compete on price. The whole point of the White Paper is to bring the ethics of business and the economics and techniques of the retail trade into the NHS.

The Government want to convert hospitals into health supermarkets. Everything will depend on what can be done most profitably and on the relationship between what it costs to provide a particular treatment or perform a particular operation and what patients or their doctors are prepared or can afford to pay. That is what is at the heart of the White Paper.

People in hospitals will become used to phrases such as "what the market will bear". The criterion for deciding whether treatment or an operation can be provided will be the gross profit margin, not an assessment of need. The prime consideration will be the cost of treatment, not its effectiveness. Everything will be based on what is cheapest, not what is best, and particularly not what is best value for money.

It has been said that the White Paper is a charter for accountants. That may be true, but it does not stop there. It is not only accountancy that will be extended in the hospital service : a sales and marketing department will have to be introduced for the first time into local hospitals. What is the point of providing an operation at a lower price than any other hospital if that fact is not advertised? Hospitals, like supermarkets, will be driven to advertise their prices. Sales and promotion will become the order of


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the day. It is not just accountancy that will expand : there will be a new department to promote, advertise, peddle and push hospitals to doctors.

General practitioners will be on the receiving end not only of sales representatives of drug companies, as they are now, but of the same sales techniques and promotions from hospitals as well. General practitioners will become small traders with their practice budgets. It is bringing hospitals into a vast market place.

Forty years ago, the main achievement of a Labour Government was to take the health of the British people out of the market place. It must be the top priority of the next Labour Government to repeat that achievement.

8.25 pm

Mr. Alan Haselhurst (Saffron Walden) : I find it difficult to understand why the White Paper should be greeted with such an incredible fuss. I rather suspect that many people have not read it, and their reaction may be based on the BMA's reaction to it or on local comments put out by doctors and others, not least Labour politicians.

A number of factors have helped to make the reaction sharper than it deserves to have been. There has been some confusion over the general practitioner's contract. I hope that those issues have now been settled and that we can have a more rational debate about the White Paper. I made a summary of the points raised with me so far by local doctors and when the points relating to the contract were taken away there were many fewer controversial points left for discussion. There is a fear of change. People are extremely cautious about changes in the NHS. There is an element of the hypochondriac in everyone, and people are prepared to imagine the worst circumstances and wonder how they will fare.

The Government may have underestimated the yawning gap that already seems to exist between their record on the NHS and people's perception of it. Conservative Members take it for granted that the amount of money spent by the Government has increased from £8 billion per annum to more than £26 billion per annum. A constituent wrote to me the other day and said that those figures were widely accepted as false. The fact that someone can say that of publicly audited figures shows how far we have to go in proving our bona fides in our proposals for the NHS.

The other difficulty has been that the reorganisation towards the centralisation of acute services on a district general hospital, a process which began long before the Government took office, has had the effect of taking acute services away from people, making people suspicious of any reorganisation in the NHS. They feel that specialist services have had to go further away from them and they see that as deprivation.

The situation is ripe for misunderstanding and for mischief makers such as the hon. Member for Livingston (Mr. Cook), who made a disgraceful speech this afternoon. The difficulties for the Government may be compounded because the White Paper is long on description but short on explanation in some key areas. Many patients have got it wrong, many doctors are confused and there is genuine doubt in some quarters about how some of the new ideas will work when implemented.

One of the problems that we have experienced in my part of Essex for some time is that money has not been


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moving with patients, and I welcome the fact that it will do so under the new system. I am grateful for the idea that there should be per capita funding. That will be helpful to my constituents. The population of Essex has grown as the population of London has fallen, yet the resources have not come with those people at the same rate. If practice budgets will be a further reinforcement of the new arrangements I am prepared to welcome those as well. It is amazing how various aspects of that reform are being misrepresented. It is being suggested that patients may be forced to have the cheapest forms of treatment, but the matter should be examined from the other point of view, when it will be appreciated that the proposal will give doctors greater clout to obtain the better treatment that they want for their patients.

It is unsatisfactory that people must wait 24 months for a cataract operation if they want to go to their most local hospital in my constituency. If they were prepared to travel not a great distance, they could have the operation within a month. Under the present system, that choice is not represented to patients as clearly as it should be. I hope that it will be in future.

Some GPs in my area worry about access to other hospitals, especially when they are in other district health authority areas and, in some cases, in other regional health authority areas. There is great concern, for instance, about continuing access to Addenbrookes for people in the Saffron Walden area. I believe that, under the practice budget, doctors will have greater clout in securing access to Addenbrookes. Under the existing system they have come under threat of losing the right to refer patients to that impressive hospital.

But there is need for clarity on how contracts will operate in practice. By definition, a contract requires agreement on both sides, so while it may be said that a group practice or district health authority may negotiate a contract with a hospital, that does not mean that it will get a contract with a hospital. What will happen if a hospital refuses to make a contract with a DHA or group practice? Will there be a narrowing of choice for non- budget holding practices, whether they choose not to be budget holders or are not big enough to be budget holders?

Where the district health authority must negotiate on behalf of the GPs in its area to get in its contract the services that it wants, will there be a genuine meeting of minds between GPs and the DHA? GPs are sometimes influenced by their desire to refer patients to a particular consultant as opposed to a particular hospital. Can contracts be made so that GPs may pick and choose between consultants and hospitals?

As some of my hon. Friends have pointed out, there is fear in the minds of some patients, in relation to indicative drug budgets, that doctors will put cost before effectiveness in prescribing. I do not believe that there is any foundation in that fear. Doctors will not overturn all their professional judgment in such a way. It is unfortunate, however, that some doctors have been prepared to play to that fear, so I understand why people have become worried. The limited list experience shows that it is possible to achieve further savings. My father practised as a pharmacist for nearly 60 years. He regaled me with tales of the over-prescribing that could occur and the preference that some had for one drug over another when there was no generic difference between the two. There is scope for further improvement.


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To say that there is scope for improvement is not to castigate all doctors as irresponsible. My local doctors, favoured for the most part with modern premises for their practices, are working well with the PACT--prescribing analyses and costs--system, and some believe that that is the core of the future approach. They wonder whether we need move so fast to indicative drug budgets. At least the principle exists. I see nothing wrong with the idea of medical audit, especially when that audit on GPs is undertaken by other GPs. I hope that the Secretary of State will go to some trouble to persuade the more cautious GPs that there are new opportunities as a result of the Government's plans. The Government hope that the practice can be a place where more can be done at the expense of more being done of a minor nature in the hospitals, that in future GPs will be paid for their efforts in that respect, and that if GPs have a particular interest in pursuing a line of medicine, they will be rewarded for that in a way that they are not rewarded now. It must be made clearer that such opportunities exist and that general practice will become an enriching experience in the widest sense under these plans, rather than a narrower, restrictive experience.

The White Paper contains some interesting, radical and imaginative ideas which merit not hysterical rejection but careful study. The fact that the Government are prepared to face these issues should be warmly welcomed.

8.35 pm

Mr. John McFall (Dumbarton) : I begin by congratulating the Prime Minister on enabling me to hold a real old-style political meeting in my constituency. Such a meeting was called three weeks ago to discuss the National Health Service--it was convened by GPs in the area especially to discuss the White Paper proposals, and more than 350 people turned up.

They came from all social classes because of their concern about the effects of what the Government propose. At the conclusion of the meeting, a resolution was passed deploring the White Paper proposals, which I forwarded to the Minister. I shall therefore articulate the concerns of my constituents on some of the issues that concern them. On Sunday I met an 82 -year-old who has had his legs removed in recent months. He asked me to express his point of view to Parliament and to tell the Secretary of State that he wants to be looked after in the same way that my father was cared for after he had his legs off. For 10 years, my father was cared for by local district nurses. My constituent wants the same quality of care. I hope that the Secretary of State will take that and similar issues seriously and explain, when he replies to the debate, what proposals he has for people such as my constituent.

The Government have not been able to convince anyone of the wisdom of their proposals. Certainly they have not convinced the medical profession. They have not been able to convince the nation of the need for these changes because the blueprint for the White Paper plan was drawn up without reference to the users of the NHS. It was an exclusive group of people who drew it up. One had to be a Member of Parliament to be on the panel.


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Indeed, one had to be not just any Member, but a Tory Member. Even that was not enough. One had to be a Cabinet Minister.

That exclusive and closed group of people decided what was best for the NHS and the 55 million people of Britain. The changes sprang from an ideological perspective. They were not based on any objective analysis of the current position of the NHS or of the needs of society. That comes as no surprise to us, because the Prime Minister is on record as saying that there is no society. It must be easy for the Government to determine policy in that manner, because they have only ideological tenets to go on ; there is no pragmatism in their approach, and that means that inconvenient facts cannot get in the way of what they want to achieve.

I have had more than 200 responses from my constituents and over a score of GPs have put their views to me on this subject. It is only fair, therefore, that I should articulate to the House some of the points that they have made, and I trust that the Minister will give full answers to those points. For example, one GP wrote to me saying that he was already doing much of what was being proposed. He wrote :

"For the last 15 years as a practice we have performed paediatric developmental assessments on our pre-school population. More than 90 per cent. of children are given all their routine immunizations within the practice. My part-time female partner has organised within the practice a Well Woman Clinic for all our female patients aged between 25 and 60. We do all our own night visiting. Three years ago we produced a practice information leaflet for patients and last year the practice produced an annual report. We have just purchased a second computer. Finally, we are interested in health education, having been instrumental in setting up The Vale of Leven Health Promotion Project.' "

That GP went on to write :

"I point these facts out simply to show that this letter does not come from someone opposed to change or who practises medicine simply with the aim of maximising income. I firmly believe that the White Paper proposals will undermine good general practice."

Writing about capitations fees, he said that he failed to understand how his standard of medicine would be improved by increasing the emphasis on the capitation element of his remuneration. He wrote :

"If I set about chasing heads, since there are only 24 hours in the day, I will have less time to spend on each patient. Equating good medicine with high patient numbers is arrant nonsense."

He wrote about the money-follows-patient argument :

"The White Paper says that the GP is the patient's key adviser'. This is true but I can foresee my being unable to refer my patient to the most appropriate consultant if that consultant works in a hospital outwith my Health Board area. My ability to refer such a patient will depend on my Health Board having made sufficient provision with the outside hospital. This obviously will not be a restriction in areas where patients can afford private medical care and thus medicine will become two-tier, with those who can afford it getting high quality care but those who depend on the NHS getting what their local Health Authority can afford."

That is a perverse version of patient choice, particularly for the poor, who do not have the money to move from hospital to hospital. Even if the patient can rustle up the money, one can be sure that their relatives might not be able to afford it.

In their White Paper, the Government insist on 20 hours' consultation per week, when GPs must see their patients face to face in their surgeries. One general practitioner writes :

"At present, I do not do so but in an average week I do spend 45 hours in clinical medicine, 3 hours in practice


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administration and am on call for a further 25 hours (and being on call' usually entails going out in the evening to see patients and having disturbed sleep one night in four)."

What price the Government's rationale for 20 hours' consultation in the light of that?

As to increased choice, another GP writes :

"The principle that practice budgets will lead to increased choice for patients is fundamentally flawed. I have freedom of choice at present to refer my patients to any specialist that I like and the proposals in this White Paper can only restrict that. These proposals if implemented will also mean that some of my patients will have to travel longer distances for their care."

Another general practitioner writes about the place of women doctors :

"As a woman doing part-time work in general practice, it appears that the present proposals may well prevent me continuing to practise medicine."

In Scotland just the other day, the organisation Women Doctors for Choice was reported as commenting that

"the emphasis on capitation payments discourages doctors from taking on extra partners, as that would reduce their income." That provision will discriminate against women GPs, and when one remembers that females consult their doctors four times more frequently than males, that must mean less choice for female patients too. One doctor also comments :

"I note that the needs of the chronic ill, elderly, mentally ill and mentally handicapped appear not to warrant comment in the Paper."

The White Paper puts a price on the patient's head. The Government say that it is their intention to help people, but they will do so only in part. They will not go the whole way. The White Paper proposes a system such as that of the United States, where 40 million people have no private health insurance whatsoever and in addition, 1 million people every year transfer to a different hospital purely on financial grounds. The White Paper will do nothing for the community. My constituents tell me so, and I hope that the Minister will listen and will at least give them an intellectual response to the points they make.

8.42 pm

Mr. Richard Alexander (Newark) : I join other right hon. and hon. Members in congratulating the hon. Member for the Vale of Glamorgan (Mr. Smith) on his excellent and enjoyable maiden speech. My right hon. and hon. Friends will clearly endeavour to win back that seat in the next general election, but meanwhile we wish the hon. Gentleman well, hope that he will enjoy his time in the House, and look forward to hearing him speak again.

To listen to some of the attacks made on the White Paper in the House this afternoon and outside it on other occasions, one would think that all was well with the Health Service and always had been. Basically all is well, but our critics ignore the fact that just over a year ago, people were marching in the streets and constituents were writing to us about the Government's intentions. Despite ever-increasing funding, the Health Service seemed to be failing to deliver in certain respects. The public were asking where the money was going and what was wrong.

As a consequence, the most fundamental review of the Health Service since it began 40 years ago was undertaken. Since the conclusions of that review and the publication of the White Paper, my right hon. and learned Friend the Secretary of State and virtually every Conservative Member has been subjected to one of the most abusive, damaging and misleading campaigns that I can remember


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since first entering the House. The Opposition's knee-jerk reaction was predictable. They shamelessly used the Health Service and the public's concern as a political weapon, and their allies in the British Medical Association conducted a campaign of misinformation that was at the very least unhelpful, and which in many cases unjustifiably played on the fears of the most vulnerable in our society--the old and the sick.

Some of that propaganda was contradictory. It was claimed both that the Government were forcing doctors to take on more patients than they could cope with, and that they were forcing doctors to turn away the old or chronically sick. The contradictory nature of those accusations seems to have gone unnoticed, for smear and innuendo are what matter. Some patients are told that doctors may be limited in the extent to which they can investigate unusual symptoms, while others are warned that restrictions will be placed on the amount of money that doctors can spend on drugs. Some critics send out letters with death's heads on them. One of my constituents wrote to the local newspaper saying that she was told that the number of doctors would be reduced as a consequence of the White Paper. That is all very nasty stuff, and completely one-sided. The White Paper's critics never tell patients that some doctors have been over-prescribing for years and that the monitoring of drug budgets is meant not to cut necessary expenditure but to defeat unnecessary prescribing. Neither do the critics reveal that the cost of drugs is now more than the cost of the doctors prescribing them, that some doctors prescribe twice as much as others, and that the White Paper's objective is to root out bad practice and to encourage the best. The critics' motto is, carry on, doctor ; throw more money at the problem and then ignore it.

That is not the way in which I want to see the Health Service progress. Instead, we must honour the principle that has held good for 40 years of a comprehensive Health Service available to all regardless of income, and financed mainly from taxation. Instead of guerrilla warfare, let us start again, by accepting my right hon. and learned Friend's total commitment to the NHS. Let us recognise that funding has increased by 40 per cent. even after inflation, from £8, 000 million in 1979 to £26,000 million this year. Let us accept that there are now 7,000 more nursing and midwifery staff and 14,000 more doctors, enabling many more people to be treated.

We must recognise also that wide variations in the provision of health care still occur throughout the country ; that people wait much longer for operations in some areas than others ; that the cost of treatment differs by as much as 50 per cent. between hospitals ; and that there are enormous variations in drugs bills as between one GP and another. We should start by accepting those indisputable facts, and conclude that improvements can be made to the overall operation of the Health Service that have very little to do with the amount of money that is spent.

My right hon. and learned Friend the Secretary of State should acknowledge in turn the genuine concern felt by Health Service professionals that certain significant details have yet to be spelt out. Most right hon. and hon. Members have received a helpful briefing from the Royal College of Nursing and from the Association of Community Health Councils that are couched in much less strident language than that used by the BMA. Their concerns should be examined and my right hon. and learned Friend should respond to them directly. So much


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opportunity for excellence is provided by the White Paper that one can only be saddened by the hostility with which it has been met by some Health Service professionals.

A shining exception to some of the attitudes of the Health Service to the White Paper concerns the proposal to allow health authorities and hospitals to become self-governing trusts. The Opposition's reaction to this locally and nationally--the hon. Member for Bassetlaw (Mr. Ashton), who is in his place, referred to it this afternoon--was predictable. They called it back- door nationalisation and said that real patients would not be treated, that it was just taking the Health Service into a privatised area. Such fears are nonsense, but the fact that nowhere in the White Paper are these things ever suggested does not deter the Opposition at all.

The Bassetlaw health authority, which partly covers my constituency, has expressed an interest in becoming a National Health Service trust. It is not proposing to opt out. It has not even decided to become a trust. It has simply expressed an interest. It has consulted widely, with consultants, with the staff and with the Manchester health authority. The opposition has been totally political and I condemn the blanket refusal even to consider looking at the proposal. It gives an opportunity and a possibility for our health authority to come out of the clutches of the region and be able to run its affairs as it knows best. It will, I believe, be the patients who gain, and the losers will be the party politicians and those of the Left who try to deprive the patients of its benefits.

8.51 pm

Mr. Ieuan Wyn Jones (Ynys Mo n) : I have listened with great care to Conservative Members trying to defend the NHS proposals. There has been great paranoia on that side as they have constantly tried to defend proposals which are clearly indefensible.

I listened with great care to the hon. Member for Brentwood and Ongar (Mr. McCrindle). He came to the House tonight, apparently, to nail a few lies, as he put it. He came to the House to tell us that self-governing hospitals will not be outside the NHS. I have read the White Paper and I agree with him that that is what is proposed in it. But what we, our constituents and doctors worry about is what it will lead to eventually. It is the first step towards privatisation and that is what Conservative Members have failed to tell us tonight. They hide behind the words in the White Paper, knowing perfectly well that the Government really want to privatise the NHS.

The Prime Minister herself prefaced the White Paper by saying that the needs of the patient would be paramount. That word is used in the Children Bill as those of us who have been on the Committee on that Bill know. The Minister of State knows exactly what I am talking about because he, too, is on that Committee. We have looked in the dictionary and we find that "paramount" means of the greatest importance, or pre-eminent. But we do not get the impression that the paramountcy of the patient's needs is the thread that runs through the White Paper.

The Prime Minister uses another phrase :

"to secure the best value for money."

That, in my view, more accurately describes the way the Government look at the changes in the NHS. To be charitable, on the one hand it means keeping a tight


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budget, but on the other it means making do with fewer resources by imposing budgetary controls on doctors' practices and self-governing hospitals.

The Government claim that the overwhelming hostility to their proposals stems from wicked doctors spreading fishermen's tales. They also hide under the cloak of that now well-worn phrase "We cannot get our message across." We have heard it all again tonight--a combination of doctors, an antagonistic press and a hostile Opposition making matters worse for the Government in trying to get their message across.

My belief, shared by my constituents, is that these proposals are inherently wrong and that the public have been right. Time after time in the last few weeks we have heard the public speak with a united voice. That is why the hon. Member for the Vale of Glamorgan (Mr. Smith) is in his seat ; the public of Wales spoke on the Government's proposals for the NHS. I congratulate him on his victory and it would be churlish for any hon. Member to deny that it was due to the fact that the Government have failed miserably to tell us what they really mean by the NHS proposals.

What is also significant, and the Government must take this on board, is that in that same election a GP stood on an

anti-NHS-proposals platform and he did not gather the small number of votes a normal fringe candidate gets ; he polled almost 1,000 votes. The Government must surely remember that lesson.

Why are people unhappy with these plans? It may be unpalatable for those on the Government Benches, but it is true to say that we in Wales have an emotional attachment to the National Health Service because we know that the architect of that Service came from Wales. But even judged against hard facts, this review will spell disaster for the patients and hospital services in Wales. In Gwynedd, for example, we have seen this year proposals to close small village or community hospitals because the area health authority has, it says, been starved of cash. I am pleased to see the Minister who has responsibility for health at the Welsh Office in his place. He and I have debated these issues about hospitals in Gwynedd.

We have heard even from Conservative Members tonight the view that the community care provisions of the Griffiths report have not been debated. There is not a single community hospital in my constituency that meets the criteria set out by the Department of Health and there is no plan to build one in the immediate future. In addition, very much as the right hon. Member for Stoke-on-Trent, South (Mr. Ashley) said about disability, there are no discernible plans to develop services for the elderly. We all know of terrible situations in which constituents ring hon. Members late at night distressed because hospitals have told them that their elderly relatives have to leave and find a home elsewhere. This lack of co- ordination between the Health Service and social services departments of local authorities is something we must discuss. That is why it is vital that we discuss the Griffiths report quickly.

In terms of the rural scene in Wales, the element of choice is meaningless. How can a doctor in Holyhead make a choice about which hospital is most suitable for his patient? The nearest acute hospital is 20 miles away and he has to make arrangements to travel there. Where does he go if Bangor cannot take the patient or the waiting list is too long? He goes to Bodelwyddan, which is 70 miles away. The choice is meaningless in rural Wales.


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I believe that these plans are doomed to failure. All the brave words of the Secretary of State, and, I expect, of the Minister in responding, will not convince people that the reforms are necessary and in the best interests of our people. It would be far better for the Government to save face tonight and withdraw these plans than to destroy the Health Service and be destroyed at the next election. 8.59 pm

Dr. Michael Clark (Rochford) : There is little doubt that the National Health Service is a respected British institution, and those who have used it seldom criticise it. Until recently, however, most of us received complaints in our postbag from people who had not used it, and who wanted a better service. Those complaints came because expectation was greater than provision.

Now we find that there is nothing wrong with the Health Service at all. Constituents are writing to us, "Please do not change the Health Service : leave it as it is." Doctors, too, are writing to say, "Do not change anything. We have the finest health service in the world." Even doctors who have, in the past, written to complain are telling us to leave the service as it is. They are saying that for the time being, that is : I suspect that if we leave the service as it is it will not be long before they write again to complain that they want a review of the Health Service because they think that it should be improved.

Those who say that we should leave the service as it is add a proviso. They say, "Leave it as it is, but give us more money." They do not acknowledge that, over the past 10 years, real-terms funding has increased by 40 per cent.

Following the introduction of the White Paper, I met doctors in my constituency in small groups of four or five. I managed to see between 25 and 30. I did a deal with them : I said that I would see them whenever they wanted, wherever they wanted and, within reason, for as long as they wanted. I would listen to and respect their views, and would put them to the Minister even if I did not entirely agree with them. [Interruption.] Are not hon. Members in the House to represent the views of their constituents? Do we represent only the views with which we agree? I think that most hon. Members on both sides of the House would agree that they represent their constituents' views.

The doctors' side of the bargain was that their views would be put to me first hand, not second hand through the agitation of the old, the sick and others in need of health care. The doctors respected the deal, with the exception of one practice. I have listened to their views : I have read the report of the general medical services committee ; I have made written and oral representations to my right hon. and hon. Friends. I have honoured my side of the bargain with doctors in Rochford, Rayleigh, Runwell and South Woodham Ferrers. Unfortunately, as I have said, one practice did not honour its side. My speech has two aims. The first is to represent again the doctors with whom I struck a bargain ; the second is to refute the misleading information put out by the practice to which I have referred. Let me begin by saying that it is a shame that the White Paper and the GPs' contract were allowed to be on the agenda on the same time. I agree entirely with my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) that the contract should have been dealt with eeparately, and should have been out of the way before the White Paper came into the arena.


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What did the doctors whom I saw wish me to communicate to the Health Ministers? First, on the contract side, they were worried about the targets for immunisation and cervical smears. I am delighted that there has been agreement on two levels of target, a higher payment at high percentage levels and a lower payment at lower percentage levels.

The doctors were also worried about the "face-to-face" rules, which they feared would be too bureaucratic, and about the fact that the target of 20 hours excluded home visits, which they considered unfair. I tended to agree with them about that, and I am delighted that my right hon. and learned Friend has amended that proposal as well.

Some senior doctors were naturally concerned that their pensions would be affected by withdrawal of seniority payments. They also made the fair point that someone who has been a GP for a long time is worth more than someone straight out of university who still has considerable experience to gather. I am pleased that, in consultations with the GPs' negotiating committee, my right hon. and learned Friend has amended that as well.

The doctors were also apprehensive about practice budgeting, which they thought might be time-consuming and complicated. They feared that it would be difficult to budget for outside patient services. I did not necessarily agree with what they said, but I promised to make their views known. They were also anxious that commercial decisions should not override medical ones--and rightly too--but they had no objection to any pay review looking at their expenditure, whether budgetary or otherwise.

Doctors and, indeed, some of my constituents are concerned about the make- up of the family practitioners committee. The doctors point out that it is proposed to include only one medical man among the 11 members. My constituents say that there will not be enough lay people on the committee : there will be far too many administrators, and it should be more evenly balanced.

Of course, some doctors were sceptical about self-budgeting hospitals. The Southend and Rochford hospitals, however, have seized the opportunity to volunteer to become self-budgeting, and are looking forward to better funding as a result.

The practice that put out false propaganda made none of its views known to me at first hand : they all came through sick and elderly people who were anxious about that false propaganda. Let me give some examples. It was claimed that GP services would be cash-limited, leading to a rationing of care. The truth is that any savings from efficiency will lead to extended care. The practice said that hospitals would be encouraged to become budget holders, whereas in fact they are to volunteer. It also said that the sum of money per patient was equivalent to an X-ray or a short course of drugs, and that if a patient needed a hysterectomy she would use up the share of the whole street in which she lived. The truth is that there will be no cut -off of funds, as was pointed out by my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle).

The practice said that doctors would receive financial incentives to ask patients to go private, and that if they did not go private, doctors would have to put them in the cheapest possible hospital. The truth is that there are very few incentives--the only incentive to go private is the tax relief for old-age pensioners--and doctors will be encouraged to send patients to the most convenient hospital with the shortest waiting list.


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