House of Commons Hansard Debates for 11 May 1989

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The doctors say that they will be offered rewards for not treating patients, or for delaying their care. That is a gross travesty : I cannot even find the proposal in the White Paper that they have twisted. It is complete invention. They also say that the Government want GPs to become "rationers" of health care, and thus take the blame for the underfunding of the NHS, which the Government will then use as an excuse to end the Health Service as we know it. The truth is that the Government want more partnership in the NHS, and want to carry GPs with them.

I hope that my right hon. and learned Friend will take note of the points that have been properly and courteously made by the majority of doctors in my constituency, both those that I have quoted in my speech and those included in my written representations. I also hope that he will refute the scurrilous, irresponsible and unprofessional propaganda from that other practice.

9.7 pm

Ms. Joan Walley (Stoke-on-Trent, North) : I, too, am here to represent my constituents, particularly the many women among them. I am extremely pleased to have an opportunity to speak. It should be pointed out that so far no woman Member has spoken, and the concerns of women-- especially the many women carers about whom we heard earlier, and who are given no information in the White Paper about the future of community care- -should be put on record.

We are talking about a paving Bill. There has already been a paving Bill for the privatisation of water ; now we have one to bring about--presumably following the next general election, which the Conservative party mistakenly thinks that it will win--the wholesale demolition of the National Health Service, privatisation and complete dependence on market forces.

We thought that the White Paper would deal with the crisis in the NHS. That crisis in north Staffordshire means that some of my constituents will have to wait until December 1990 for an orthopaedic out-patients appointment and there is a 30-week wait for ear, nose and throat appointments. There have been hospital closures, the Health Service uses rundown buildings and the ambulance service cannot operate within its guidelines. The area suffers from demographic changes and there is great concern about the future of community care.

It is disappointing that the White Paper addresses none of those issues. My constituents know that. Certainly the electorate in the Vale of Glamorgan know that, and I take great pleasure in welcoming my hon. Friend the Member for Vale of Glamorgan (Mr. Smith) to the House. The GPs also know that. The GPs in north Staffordshire with whom I have spoken, including those at the Tunstall practice who called me to an urgent meeting to brief me about the debate, said that they felt disquiet about the future of the Health Service. It is clear that in future health authorities will be brokers, handing out money for low-cost services. A letter from the north Staffordshire district sub-committee of the Staffordshire local medical committee expressed great concern about people who depend on prescriptions. The Secretary of State did not give us a categorical assurance that there will be sufficient money to cater for those people who, quite justifiably, depend on prescriptions, such as

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chronic asthmatics, those who suffer from cystic fibrosis, those who have severe angina and those who require dialysis. I feel strongly that, if the proposals are carried out, people who need eight or nine drugs will be paying a tax on illness, because they will have to pay more for those drugs. I noticed that the Secretary of State made no response to the intervention by my right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley).

As for the size of GPs' lists, the GPs in Tunstall told me that they will each have an extra 500 people to treat. It is quite clear that the more people there are on a GP's list, the less time there will be for minor surgery, immunisation, counselling following still births and all the essential aspects of preventive medicine. GPs who treat terminally ill patients, who require a considerable amount of time, will be penalised.

I am sponsored by COHSE, the Health Service union which has submitted detailed and responsible forecasts of how the Health Service could look in future, taking into account the need to use the present management structure to evaluate the information systems, which, together with new investment, could produce the Health Service we all require.

I know that many hon. Members wish to take part in the debate, so I conclude by quoting a letter from a constituent who, along with many other people, feels very strongly about the proposals. She wrote : "I hope public apathy does not allow these proposals to be passed as I am sure that the dark days of pre National Health Service days should not be allowed to return. I do not always support all Labour party issues but I think Mrs. Thatcher is a woman completely devoid of any compassion towards those less well off members of society and the sooner she is defeated the better for the country as a whole." The Opposition consider that there is nothing more important than the health of the people and that that should be the highest law. For that reason alone, I hope that the Government will take note of the many important points that have been raised in the debate. 9.13 pm

Mr. James Couchman (Gillingham) : I recognise that I have only two minutes and I shall make only one brief point. The first paragraph of the final chapter of the White Paper reads :

"The proposals in the White Paper put the interests and wishes of the patient first. They offer a new, exciting and potentially rewarding challenge for all who work in the NHS. They add up to the most significant review of the NHS in its 40-year history. And they amount to a formidable programme of reform which will require energy and commitment to carry it through."

The last sentence of that paragraph strikes a particular chord, because without energy and commitment on the part of all staff, from consultant to cleaner, the patient will certainly be denied his or her best interests.

The proposals are not revolutionary, but they are certainly not a gentle touch on the tiller. They will represent a substantial change in the relationship between the patient and the GP and between the GP and the hospital service. I welcome most, if not all, of the proposed changes. As a former health authority chairman, I am all too well aware of the inertial bureaucracy of the Service over the past 15 years.

I should like to ask my right hon. and learned Friend one question. Why did he not make the White Paper a Green Paper, or at least a White Paper with very green edges? If Health Service staff and consumers had felt that

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my right hon. and learned Friend was entering into genuine consultation on those far-reaching proposals, the hostility which has built up over the past three months and which has been echoed by the Opposition, would have been avoided. People who have had an input into change are much more committed by their contribution to that change, even if it is not precisely the change that they would have designed.

Even at this late stage, I urge my right hon. and learned Friend to dissipate the angst that has been created by greening up the edges of the White Paper and conceding that pilot studies in, say, two regions for a short time would strengthen the case for change and should be conceded.

My right hon. and learned Friend showed a commendable and statesmanlike willingness to compromise on the GPs' contract and achieved a result satisfactory to all of us. A demonstration of such flexibility would give credence to my hon. and learned Friend the Minister of State's statement to the Institute of Health Service Management that the plans contained in "Working for Patients" were not tablets of stone and that as a sensible person he was keeping his ears flapping. I trust that my right hon. and hon. Friends will keep their ears flapping.

9.15 pm

Ms. Harriet Harman (Peckham) : Conservative Members have scorned our assertions that the White Paper is about privatisation. The Secretary of State said that talk of privatisation is simply scaremongering. But it is evident that the White Paper is dripping with commitments to privatisation. GPs will be expected to use their budgets to buy private health care for their patients. District health authorities will be expected to use their budgets to buy health care in private hospitals. Opted-out hospitals will be expected to sell National Health Service treatment to private patients. Capital charges are being introduced to make NHS services more expensive compared with private health care, to drive more GPs and more district health authorities into the arms of private hospitals.

The Finance Bill contains a direct cash subsidy for private medicine, and, as my hon. friend the Member for Newcastle upon Tyne, Central (Mr. Cousins) pointed out, even blood and ambulance services are to be sized up for privatisation. Even if the Secretary of State believes his own denials that the White Paper is about privatisation, we set no store by that. The White Paper says that it is about privatisation and the Prime Minister means it to be about privatisation. She made that perfectly clear when she said in the House on 31 January :

"those who can afford to pay for themselves should not take beds from others."--[ Official Report, 31 January 1989 ; Vol. 146, c. 164.]

Even if the Secretary of State has not got the Prime Minister's message, doctors, nurses and the public have.

The White Paper aims to create a two-tier Health Service. The spirit in which the Prime Minister has produced the White Paper is truly authoritarian. The Government were to propose profound changes in one of our most important institutions, but there was to be no consultation-- doctors, nurses and patients were not to be consulted. Consultation was rejected because the

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Government believed that it would only slow things up. As the Secretary of State and his Ministers found, it was much quicker to insult people who dared to disagree.

From the outset, it was made clear that the only views to be sought were from those who could make suggestions about how the hare-brained schemes could be made to work. Counter-proposals were never allowed on the agenda and there was no Green Paper, as the hon. Member for Gillingham (Mr. Couchman) has pointed out. There are to be no pilot projects, and we have been told that those, too, would just waste time. This untried experiment is being unleashed on us with a haste that has astonished even those who credit themselves with thinking up the ideas in the first place.

The proposals are already being implemented even as we discuss the plans and long before Parliament has had time to approve them. Regions are already nominating hospitals for opting out. The London hospital has already advertised for a finance director to run it after the Secretary of State, in due course, makes his decision that it should opt out. The South East Thames regional health authority's general manager has given up his job to take up the post of running Guy's hospital, supposedly after the Secretary of State has decided to opt it out, and his salary is to be paid by a carpet millionaire, Sir Philip Harris.

Family practitioner committees are already identifying what the Government hope will be the first wave of GP budget holders. I suggest that all hon. Members obtain from their own family practitioner committees the papers drawn up to show how the proposals about GPs will work in the local area. I looked at the plans of my own family practitioner committee. They are interesting because they talk firmly about over-spending practices. The practices described as over-spending practices will be cash-limited. How are we supposed to believe that GP services will not be cash-limited if they are described by family practitioner committees as over-spending practices and when it is also mentioned that the sanction against over- spending practices will be the withholding of remuneration? If that is not a cash limit, I do not know what is. All that I have described is already happening, yet it is not until today that the Government have brought the proposals to this House for discussion. The White Paper lays down that those who work in hospitals, still less the community that depends on those services, will have no say in opting out. The decision is to lie simply with the Secretary of State. All the talk we have heard from Conservative Members about their hospitals deciding that they will opt out is nonsense. For a start, who in the hospital has made the decision? Who has been consulted? The White Paper makes it clear anyway that the decision is to lie with the Secretary of State and with him alone.

This week, the doctors at Guy's hospital have demanded a veto over the plans for Guy's to opt out. They want to have a say in the matter before Guy's is opted out of the National Health Service. Perhaps the Minister of State will tell us later whether he will respect the demands of those doctors to have a veto, or whether he will simply ride roughshod over their views.

Mr. John Redwood (Wokingham) : In November 1987, the hon. Lady said in the House that there was nothing wrong with the NHS that a couple of hundred million pounds extra would not put right. As the Government

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have put in 40 times that much in the past two years, does the hon. Lady agree that the funding problem she identified is now resolved?

Ms. Harman : No, I certainly do not agree that the funding problem we have talked about over and over again has been resolved. How can the hon. Gentleman say that the funding problem has been resolved when--[ Hon. Members-- : "You said it was."] No, we have complained constantly about the underfunding, which still causes long waiting lists. [Interruption.] I hope that hon. Members will listen. Forty-one per cent. of children have to wait more than six months for paediatric surgery. That is a problem of underfunding as beds are closed.

Local representation is to be struck off by local representatives being taken away from district health authorities and replaced by centrally appointed managers. The White Paper is the result of a review by closed minds behind closed doors.

In his speech today, the Secretary of State made great play of the agreement that he says exists around the stated objectives of the White Paper. It is true that his extraordinary political acumen has enabled him to recognise that every one wants better health care, but that is as far as the agreement goes. Everyone else believes that the objectives that he embraces will not be achieved by the plans in the White Paper and everyone else believes that the White Paper will frustrate attempts to improve the quality of care. The Secretary of State claims that one of his objectives is to improve the quality of care, but one of the strongest threads of criticism against the White Paper is the concern that it will undermine the quality of care. Health authority managers, who have no medical training and never see a patient, will negotiate where to place the contract for operations, and they will place the contract where it is cheapest. They know how to count costs--that is what they have been trained to do and the reason why the Government have recruited them--but neither they nor anyone else knows accurately how to measure quality and outcome.

The internal market of competition--which, extraordinarily enough, the Secretary of State failed to mention today, although it is the core of the White Paper--for contracts between opted-out hospitals and private hospitals would put at the very heart of the system a pressure to cut costs with no countervailing safeguard to protect standards. My hon. Friend the Member for Birmingham, Hodge Hill (Mr. Davis) rightly pointed out that, put simply, patients will be sent where treatment is cheapest, rather than where treatment is best. To compete, hospitals will have to cut costs and to cut costs, they will cut corners. When they cut corners it will cost lives.

The Government state that competition in health care will improve quality, but the opposite is the case. The more intense the competition, the worse the patient fares.

Mr. Phillip Oppenheim (Amber Valley) : Rubbish.

Ms. Harman : The hon. Gentleman may say it is rubbish, but he should listen to some of the evidence. A study in The New England Journal of Medicine, the most authoritative medical journal, found :

"There are significant associations between higher mortality rates and the intensity of competition in the market place."

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Professor Alan Maynard, who is the director of the Centre for Health Economics at York, which is a designated research establishment for the Department of Health, followed up that point by saying :

"The risk with competition is that inferior patient outcomes may result."

Mr. Hayes : The hon. Lady said that she wanted some evidence. I am sorry to keep harping on about it, but the South Glamorgan health authority has contracted out all its--

Ms. Harman rose --

Mr. Hayes : The hon. Lady gave way. Perhaps she will be courteous enough to allow me to finish the point. I am not aware of any rules of procedure that allow anyone but you, Mr. Deputy Speaker, to stop me. With the greatest respect, I shall finish my point. South Glamorgan health authority has contracted out all its open heart surgery to a private hospital in Southampton, which means that patients are moved to hospitals where their open heart surgery is dealt with quickly. It does not cost them a penny and the South Glamorgan health authority--

Hon. Members : Is this a speech?

Mr. Deputy Speaker (Mr. Harold Walker) : Order. Interventions must be brief.

Mr. Hayes : I was trying to make a brief intervention but the hon. Member for Peckham (Ms. Harman) would not--

Mr. Deputy Speaker : Order. Ms. Harman.

Ms. Harman : That intervention was a total waste of time. I obviously have a particular affect on the hon. Member for Harlow (Mr. Hayes), as he made exactly the same intervention in my last speech. I hope that in my next speech he will restrain himself.

The point is that the Government will not listen to any evidence about the destructive effects of competition because it does not fit in with their dogmatic allegiance to the free market. We should be encouraging co- operation between hospitals, not competition.

Dame Elaine Kellett-Bowman : On a point of order, Mr. Deputy Speaker. Is it in order for the hon. Lady to mislead the House by saying that the Secretary of State--

Mr. Deputy Speaker : Order. I hope that the hon. Lady is not alleging that the hon. Member for Peckham (Ms. Harman) is deliberately misleading the House. If she is, she must withdraw.

Dame Elaine Kellett-Bowman : I am suggesting that the hon. Lady did not listen and therefore did not hear the Secretary of State refer to the internal market.

Mr. Deputy Speaker : In that case, it is not a point of order.

Ms. Harman : Thank you, Mr. Deputy Speaker. I did not think that is was a point of order ; I could not tell what it was.

On the point about quality, perhaps we need look no further than private nursing homes. We shall then see how the quality of care suffers when there is an attempt to keep profits up. The Government have already privatised nursing homes--[ Hon. Members :-- "What about Southwark?"] I shall tell hon. Members about Southwark.

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The point about Nye Bevan lodge and Southwark invites a comparison between the council's response in that case and the Government's response to the numerous scandals of abuse, ill- treatment and neglect in private nursing homes. Southwark council learned hard lessons and was very concerned ; it acted with the Department of Health to try to ensure that it never happened again. The Government, on the other hand, have evidence before them but take no account of it. Let me remind the Government of some of that evidence. They have privatised nursing care without the consent of the House by shutting geriatric wards and cottage hospitals and providing a bottomless pit of social security subsidies to the private nursing sector. The Government are totally unconcerned about cruelty and neglect in those nursing homes because they are businesses, and the Government look only at the health of the bank balance, never at the health of the patient.

Take, for example, the private Old Rectory nursing home in Northampton. Patients there were assaulted, intimidated, taunted, tied into beds and chairs and left unsupervised. Staff levels were inadequate and prescriptions were altered.

Take the private Old Dairy nursing home in Enfield, where eight heavily dependent patients were routinely left completely on their own with no staff to look after them. And take the private nursing home near Colchester, where a 14-year-old girl doing a holiday job had to insert catheters in elderly women.

These cases are not isolated examples ; they are the tip of the iceberg. Yet the Government have done nothing about it. They have not acted on the recommendations of the registered homes tribunals. They do not give district health authorities enough resources to police the private nursing homes.

Mr. Kenneth Clarke : It was this Government who introduced legislation giving the health authorities the power to supervise the private homes sector and, if necessary, to refuse licences. We were concerned about allegations of low standards and gave local authorities, in the case of residential homes, and health authorities, in the case of nursing homes, legal powers that they have never had before so that they could license homes or decide not to license them. The complaint to which the hon. Lady referred should now be taken up with the authorities to which we have given these important powers.

Ms. Harman : The Government set up the registered homes tribunals but they file their decisions in the basement of the Department of Health. They never look at the recommendations made by the tribunals, which say that things are going badly wrong in the private nursing home sector. The right hon. and learned Gentleman cannot just shake his head, because even the private Registered Nursing Home Association has said that it is concerned about what it describes as "the cowboy element" in the industry.

The White Paper is a charter for that cowboy element to move into our hospital services. The Secretary of State has claimed that one of his objectives is to increase choice in health care. Under this White Paper, patients' choice will be restricted rather than widened. I challenge the Minister to respond to my next point ; he has not done so in the past. Where is the choice for the patient who is told that he can no longer go to his local

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hospital because the Secretary of State has opted it out and it has dropped the services that he needs? As my right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley) said, where is the choice for the chronically ill patient who cannot get the GP of his choice because the GP thinks that he cannot afford it under the practice budget cash limits? Where is the choice for the patient who wants to get a second opinion but whose GP is reluctant to authorise it because he is getting to the end of the financial year? Where is the choice for the patient who is told that he must go to the hospital picked by the DHA manager? Where is the choice for the patient who must go to the hospital where the GP placed the contract at the beginning of the year?

Certainly there are choices in the White Paper, but they are not choices for patients or doctors. The choices in the White Paper are for managers and accountants. The choices that they will make are cheap, cheaper and cheaper still.

Inequalities will occur in the Health Service at primary care level also as patients rally round GPs who have had their budgets cash-limited and make voluntary contributions into their health centres and local GP practices. As a result, inequalities in health care will increase. The Secretary of State has engaged in the bogus argument that everyone who objects to the White Paper is in favour of the status quo. That is absolute nonsense. The Health Service is buzzing with ideas for improving care and finding new ways of delivering services. There is no shortage of ideas in the Health Service, but there is a shortage of cash. There is also a shortage of preparedness on the part of the Government to listen to the ideas that are coming out of the Health Service. The Government are frightened of those ideas because they are frightened that they might have to invest in them.

It is nonsense to say that Labour has no alternative proposal. Unlike the Government, Opposition Members have consulted patients, doctors and nurses. Unlike the Government, we have emphasised the basic necessity of increasing resources. Unlike the Government, we have a programme for making a reality of community care. We want to see a localisation of services to make access easier. We want to see the integration of acute and community services so that services fit the patient, rather than the other way round. [Interruption.] It is Conservative Members' fault if the Secretary of State is complaining about the time. He cannot go forward with his proposals because the public are blocking his way, and he cannot go backward with them because the Prime Minister is blocking his way. I predict that he will need to seek treatment in the John Moore memorial hospital. The Prime Minister predicted that she would achieve victory in the Vale of Glamorgan. I am happy to welcome my new hon. Friend the Member for the Vale of Glamorgan (Mr. Smith), and I congratulate him on his excellent maiden speech.

The Prime Minister has done a remarkable thing with the White Paper. She has forced the nation to re-examine its values. That re-examination has reinforced those values, and this White Paper affronts them. The Prime Minister has finally gone too far. Whatever will happen in the vote tonight, the Government have lost. People realise that the real change that the Health Service needs is a change of Government.

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9.38 pm

The Minister of State, Department of Health (Mr. David Mellor) : I add to the welter of tributes that have been paid to the maiden speech by the hon. Member for the Vale of Glamorgan (Mr. Smith). It was a most graceful speech that was exceptionally well received by hon. Members. From that performance, the hon. Gentleman has won himself many friends in the House, and I wish him well in his career in the House.

Exactly a week ago, my right hon. and learned Friend was able to reach an agreement with the representatives of the General Medical Services Committee about the GPs' contract. That agreement reflected a willingness on the part of the negotiators to accept a performance-related contract that will make it much easier for the National Health Service--the primary care system that we depend on so much--to become much more comprehensive and to add several important stimuli to good performance, not least the move to a 60 per cent. capitation level.

It also reflects a willingness on the part of the Government to make some changes to the contract that was originally proposed. I shall not list those changes, but they pertain to important matters, such as the retention of seniority payments and a reduction in some of the target levels set for vaccinations and cervical smears. That, too, reflects a willingness on the part of the Government to listen to what was said either directly to us by doctors or by the representations that were made by hon. Members following meetings that they had had with general practitioners in their constituencies.

My hon. Friend the Member for Gillingham (Mr. Couchman) said that he hoped we would keep our ears flapping. That evidence has shown that we do flap our ears and that we shall continue to do so. My hon. Friend the Member for Rochford (Dr. Clark) said that he had met members of every practice in his constituency and that he had sent us representations. He did not propagandise about the proposals, but he joined many colleagues in sending us practical suggestions on how the contract should be improved. We have read, learnt and inwardly digested their points, and I hope that all those who have played a part in the process will have felt that it was worth while after the happy outcome of last week.

That is the way in which we will continue the task of implementing the White Paper. Of course, the White Paper sets a framework--which it is the duty of the Government to provide--for the future of this vital national institution. However, a great deal of the detail remains to be worked through following the lead given in the working papers. We welcome even critical contributions--provided that they are not empty attempts to do away with the debate--if they are genuine responses on the practicalities of schemes that in the end will be tested and judged by their practicality. In implementing the White Paper, we are looking for a phased implementation of those ideas. I say that especially to my hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle) and my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe). Every opportunity will be taken to look at what experience teaches us about those initiatives, so that others who come along behind can be influenced and, if necessary, adjustments can be made.

It is a crucial starting point in the debate to ask what has happened to the National Health Service over the past

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15 or 20 years. As Aneurin Bevan said, "Why look in the crystal ball, when you can read the book?" It is important before we start to look to the future--especially some of the things that Opposition Members have said about the future--that we look at what has happened in the past. I do not want to dwell on what happened in the 1970s, but we know that there were years, such as 1977-78, when there was a fall in NHS funding. Overall, during the years of the last Labour Goverment, there was a fall in the proportion of the gross domestic product that went on the National Health Service. We know that there was a cut of 33 per cent. in capital spend on the NHS during those periods.

Every hon. Member will have a similar story to tell about a hospital in their areas, but almost every year of this decade since the Government were elected, more than £1 million has been spent on capital improvements, such as new operating theatres and a new burns unit in the Queen Mary's hospital, Roehampton, which is in my constituency. In the last year of the Labour Government, £35,000 was spent on capital improvements at that hospital.

One of the extraordinary things about the speeches that we have heard from members of the Labour party today is that they have not contained one word of apology or explanation for what happened during those dismal years. Never was the National Health Service less safe in a Government's hands than it was when the Opposition were in power. Following a point made by my right hon. Friend the Member for Brentford and Isleworth, we have not heard a word of explanation of what would have been the consequences for the NHS in the 1980s if the economic policies of the Opposition in the 1970s had been pursued. What we know is that, if the NHS had been funded at the same level at which they left it, we would have been spending £18.5 billion on the NHS this year, instead of £26 billion. That is the difference between a Conservative and a Labour Government.

However, when one looks at what has happened in the 1980s, one finds a sharp contrast. Expenditure has tripled in money terms and has increased by 40 per cent. in real terms. About 1.5 million more in-patients are being treated and 3.5 million more out-patients. We have tens of thousands more medical staff and they are much better paid. A nursing sister who was paid £96 per week at the top of her scale in 1979 is now paid over £300 per week under this Government. We are beginning to reach a level where we need not be ashamed of what we pay our nurses.

In primary care, we have 20 per cent. more general practitioners, 20 per cent. more dentists and 50 per cent. more support staff. It is no wonder that the size of the average patient list has decreased. It is no wonder that, for the first time in this decade, we can move into preventive medicine. It is over 70 years since the first health committee recommended that we should have preventive medicine in this country.

When one considers the capital size of the equation, one sees much more starkly what benefits the wise and prudent financial management of this decade has brought the NHS. We have a forward programme of NHS capital building of over £4 billion, and 500 projects of over £1 million each are either being built or are rolling forward. What a difference from when the Labour party was in power.

The hon. Member for Livingston (Mr. Cook) pointed out how well the NHS has coped with the many tragedies that have taken place in the past 12 to 18 months. Sadly,

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however, he turned that into a point of criticism as if the facilities in those hospitals had been tried and found wanting. Far from it--he knows that the unfortunate people who were injured in the Clapham incident, the disaster in the borough for which I am a Member of Parliament, were taken to a brand new accident and emergency unit which had been opened only the week before in one of the largest new hospitals in Europe. Indeed, that hospital will soon have the largest medical school in Europe. That would not have been possible with the 33 per cent. cut in capital programmes that we had under the Labour Government. In their last year in office, they spent just over £300 million in capital spend. This year we expect to spend over £1 billion and perhaps as much as £1.2 billion.

That is not happening just because more money is coming from the Treasury. It is coming about because of better management and because what the Opposition sneer at as commercial principles have been brought to bear on the NHS. In their last year in office, under£10 million-worth of NHS property was sold ; this year we expect to sell nearly £300 million- worth of redundant land. That money will not go into the Chief Secretary's back pocket, but into further new building for tomorrow's NHS.

Mr. Morgan : It is evident that if tub-thumping were the same as health care, we would indeed have been doing well under this Government. However, if what the Minister has just said is correct, can he explain why a fortnight ago Gordon Harrhy, the general manager of the health authority in South Glamorgan, when attempting to explain why he has to close the children's ward in the Prince of Wales hospital in my constituency, said, "Although the Government go around saying that more money is being put into the Health Service, I can tell you"--he was talking to the audience of Radio Wales--"as a manager of the largest health authority in Wales but one, that we have actually had less money every year."

Mr. Mellor : It is not possible to have less money every year-- [Interruption.] --because in every year, both in cash terms and in real terms the money allocated to the NHS has increased.

The hon. Gentleman has touched on a point to which I am coming. It is said for those people who come to such debates--there are far too many among the Opposition--who simply say that a large cheque or an additional sum of money is what is needed. The reality, and one of the driving forces of the White Paper, is that, even with an expanding health budget, one must still be super-efficient to cope with the increasing demand being placed on the Service. That is why it is such nonsense for the hon. Member for Peckham (Ms. Harman) to say, as she always says, that at any given point in time we need a certain amount more money, because even if that amount is put into the Service, the problems are just as great as they were before, for all the reasons that I am about to come to.

Back in 1976 when the British Medical Association was abusing the Labour Government even more lustily than it is abusing us, a BMA spokesman said that the NHS needed an extra £2 billion. Since that time, the NHS has received an extra £20 billion, but it still faces difficulties, because of demographic pressure. As my hon. Friend the Member for Eastleigh (Sir D. Price) rather charmingly said, it is due to the increased shelf life of the oldies. I think

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that he included himself in that memorable phrase. Demographics means that an aging population will obviously require more intensive health care.

Other reasons for the difficulties include medical advances and the greatly improved capability of the Health Service to deal with many conditions that were not treatable years ago and the increased expectations of people who want operations for conditions such as hernias and varicose veins, which used not to be treated operatively years ago. There is also a call for preventive strategies. We do not have to provide a service merely for the sick but look after those who may think that they are well, but who are not. Such people may have a problem, perhaps breast cancer or cervical cancer, of which they are unaware. However, if they are screened properly, the condition will not only be picked up, but will be cured. Those are the improvements that we are seeking.

If the NHS is to cope with the pressures of the next decade, it has no choice but to change. I shall pick up two points made by my hon. Friend the Member for Brentwood and Ongar in a most compelling speech. There was no answer from the Opposition to his question : why should the NHS be the only institution that does not have to change? The people who care about the NHS are those who want it not to be a mausoleum but to move with the times. It is not a monument to some past era of Socialist domination but a living, vital part of a modern community and must be treated as such.

The White Paper seeks to establish three basic principles : first, the need for more consistent quality in the NHS ; secondly, that the NHS should be more responsive to its patients ; thirdly, that it should offer value for money. Value for money is a concept that has been sneered at monotonously by Opposition Members. My hon. Friend the Member for Stockport (Mr. Favell) presented a clear and compelling example of why value for money matters-- that of his own local hospital, Stepping Hill in Stockport, on which it is worth dwelling for a moment or two.

There are 11 hospitals in the north-western region that treat over 20,000 cases a year. The figures for 1986-87 show that Stepping Hill hospital treated 29,000 patients at an average cost of £605 per patient. In the other ten hospitals, the average cost per patient was between £630 and £1,107. However, Stepping Hill hospital offers an excellent service to my hon. Friend's constituents.

The question that must be asked when considering the problems in the NHS is whether the hospitals that are charging the taxpayer 50 per cent. more to carry out the same procedures offer a better service or merely charge more.

Mr. Andrew F. Bennett (Denton and Reddish) : Will the hon. and learned Gentleman confirm that Stepping Hill hospital does not have an accident department, and that therefore its costs are distorted? It would be helpful if we had the money for a first-class accident department in Stockport.

Mr. Mellor : I certainly take seriously the hon. Gentleman's comment, but he is wrong to think that the lack of an accident department influences the figures. I am sorry that he feels that, in the interests of defending his ideology, he has to sneer at the local hospital that looks after his constituents so well. That hospital is efficient and effective, and it also offers value for money for the NHS.

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That means that it can treat more patients. The NHS will never have anything but finite resources, so the less the unit cost of treating patients, the more patients can be treated. That is a fundamental point.

The problem with the Labour party was well pointed out by my right hon. Friend the Member for Brentford and Isleworth, who made it clear that, entertaining though the speech by the hon. Member for Livingston was, he completely wasted the opportunity to come to grips with the problems that the NHS faces and to set out what the Labour party would do about them. We are willing to defend our policies, but it would be interesting to know one day what the Opposition's policies are. I know that the hon. Member for Livingston will not tell us, but I am sure that he will not mind us basing our information on leaked documents which appeared in The Independent. The section on health has a strong flavour of the Government's White Paper-- there is plenty of emphasis on quality. It seems that health authorities will be repaid

"for the work they do",

which would appear to be a description of an internal market. What is missing is any way of bringing an internal market about. Ms. Harman rose--

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