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Mr. Clarke : I shall remind the House yet again that the doctors and the nurses--indeed, the great bulk of both professions--support the need to introduce new financial management systems. They support the need for clinical audit as a form of quality control. They all support the need to devise better methods of distributing our resources so that the money follows the patient. We are still discussing the details of our contract system.
There continues to be controversy about self-governing hospitals and about GPs' practice budgets. They are the very systems that are causing most controversy, but they are also the areas in which we are proceeding most cautiously. We have said that we will expand them where we have people who wish to make a go of it, who see the potential and who are prepared to work hard with us. I expect only a limited number in 1991. However, as the volunteers develop those ideas, I believe that their great potential will be shown and it will be recognised that that
Column 922is the way to organise both hospitals and practices to take advantage of the new systems, and that that will eventually move the debate on.
Mr. Cryer rose--
Mr. Robin Maxwell-Hyslop (Tiverton) rose --
Mr. Maxwell-Hyslop : I am grateful. Would my right hon. and learned Friend tell the House why the letter from Mr. Nichol in his Department, which said that expressions of interest in going to National Health trust status by hospitals should be referred to regional health authorities for their comments before being sent to his Department when, in fact, those authorities have been completely bypassed, and that the expressions of interest have been sent to his Department without being placed before the South Western regional health authority, for instance, whose members have had no opportunity therefore to comment on them, contrary to the letter which was sent out?
Mr. Clarke rose --
Mr. Cryer : On a point of order, Mr. Deputy Speaker. I wonder whether we could have a brief Adjournment. The Minister of State has been giving information to the Secretary of State who clearly has not a clue about the point that has been raised and he obviously needs some conversation with the specific Minister so that he can answer his hon. Friend.
Mr. Clarke : I know that the hon. Member for Bradford, South (Mr. Cryer) is always desperate to get his name into Hansard, but I have never known him reduced to quite that desperation before. Duncan Nichol, the chief executive of the Health Service, is perfectly entitled to ask for expressions of interest in self-governing status. Such expressions of interest are being handled at regional level in the first place and are then being passed on to us with the comments and judgment of the regional health authority management.
I understand that there is some controversy in the south-west about exactly who has seen them, but I have no doubt that that matter could properly be sorted out by the south western regional health authority, which is responsible for managing its own affairs. The process followed by Mr. Duncan Nichol, the chief executive of the Health Service, was perfectly proper and carried out with my knowledge and approval. He produced 178 expressions of interest in self-governing status from people who saw the potential of what we are proposing for their particular units.
The debate will move on as implementation proceeds. I have no doubt that a momentum for change will build up inside the Health Service and will at last oblige the Opposition to move on and to face up to the fact that the actions of my right hon. Friends and myself are the actions
Column 923of friends of the National Health Service who see the way in which it should be reformed to improve the standards of service for patients in future years.
I believe that the Labour party and its allies and the more reactionary people in the professions and elsewhere will be overtaken by great events in the National Health Service over the coming years. The debate will be regarded as a footnote to the events taking place at the moment. I believe that the GPs' contract will shortly be resolved to the satisfaction of the best doctors and certainly their patients. That will be only the first step in a great process of reform which the Labour party cannot stop and of which we will be extremely proud when we have completed it.
Mr. William McKelvey (Kilmarnock and Loudoun) : I make a brief foray into the debate on behalf of Opposition Back-Bench Members to say that today the alternative select committee on Scottish affairs published its first report on the Health Service in Scotland. I recommend that the Secretary of State reads the document, which contradicts much of what he said. The vast majority of the evidence that we collected from people in Scotland working in and for the Health Service, from those who have benefited from the Health Service and from medical practitioners bears out much of what was said by my hon. Friend the Member for Livingston (Mr. Cook) from the Opposition Front Bench.
Much of the document is relevant only to Scotland, and I shall not bore the House with details in which hon. Members may not be particularly interested. But there are great similarities between the Health Service in Scotland and in England and great comparisons are made in our document. I shall read out some of the document, a copy of which is in the Library. Additional copies can be purchased from my good self at the price of £1.50. The reason for the charge is that the alternative select committee for Scottish affairs has to provide its own funds for its investigations, due to the failure of the House to set up a proper Select Committee on Scottish Affairs. As we are not allowed to be financed by the establishment, perhaps on Thursday the new Leader of the House will be convinced to attempt to get Scottish Conservative Back-Bench Members interested in the Health Service and all Scottish affairs, and to organise a proper Select Committee to look into these matters.
We did quite well with the resources that we had, and the document is quite well presented. In its evidence to the committee, the British Medical Association voiced some of its worries. It said : "The introduction of an extended internal market, could have a number of adverse effects for consumers :
1. More patients would have to travel more often.
2. There could be particular problems for the elderly of those who have young children and friends/relatives could find visiting more difficult.
3. Post-operative follow up at out-patient clinics might not be carried out by the same consultant who performed the surgery." The document continued :
"The Committee was also unconvinced by the assertion that the form of internal market being proposed would increase consumer' choice. At present the decision as to where treatment will take place is made individually between the patient and his or her GP or consultant. The patient's relatives may also be involved, especially if the patient is mentally ill, mentally handicapped or elderly. If Health
Column 924Boards entered into trading agreements with each other or with third parties to provide blocks of patient services, this individual choice would inevitably be reduced."
That is quite the opposite of what the Secretary of State was saying at the Dispatch Box. That difference should be noted. The report continued :
"Some witnesses raised concern that English codes of practice were inappropriate for Scotland. The Scottish Association of Local Health Councils pointed out that Scottish lists sizes are approximately 1, 600, whereas English list sizes are approximately 2,000, that is 25 per cent. larger. The minimum list size for a General Practitioner to receive a budgetary allowance is 1,100. However there are increasing concerns that this is far too small."
I know that discussions are taking place, and perhaps agreement is being reached on these matters.
The report continued :
"North American researchers have shown how volatile such budgeting would be if implemented at this level (for example, R. Scheffler writing in the Lancet, 1989). Alain Enthoven, the American economist who first proposed the concept of the internal market, has recently suggested in the British Medical Journal that the minimum size would have to be 50,000 if the scheme was to be operational. The Committee is concerned that if the minimum list size which determines the viability of budgetary-based trading is not known, then the proposals themselves will not be viable. The Committee recommends that some degree of experimentation is undertaken before any policy is implemented."
I picked up in my mail the "Parliamentary Newsheet" from the Market Research Society--a document which I seldom read or quote. It contained an interesting article entitled "GPs' reaction to the White paper".
It said :
"Recent research by the British Pharmaceutical Market Research Group has found that GPs have become considerably more negative in response to the Government's White Paper proposals in the period since those proposals were first published. This is the overall finding of a study of 466 GPs.
An earlier study was conducted immediately after the publication of the White Paper and revealed that half of GPs questioned disagreed that there were any patient benefits. That figure has now risen to 84 per cent. disagreeing that patients would benefit overall." That was despite, or perhaps because of, the Government's propaganda on the White Paper, and their explanations, which were certainly not plausible to general practitioners or to members of the public.
The most mail that I have had for a considerable time comes from ordinary people who write to me--not the photocopied letters or postcards provided by general practitioners--with real concern that the Government are not genuinely attempting to improve the lot of patients in the National Health Service. My constituents are worried that we are turning the National Health Service into a profit-making business and putting that before patient care. I have received hundreds of letters, which I shall eventually dispatch to the Secretary of State, as I have promised my constituents, so that he can read some of the comments in them.
When the Secretary of State outlined his discussions with the British Medical Association, and said that an agreement had been reached by its representatives and then overturned by a small majority at its subsequent conference, he did not provide the figures. I agree that there was a small majority. On 21 June 1989, a special conference of local medical committees voted against by 166 to 150. In anybody's language that was a majority, so
Column 925the representatives of the local medical committees did not agree with the General Medical Services Committee, which had agreed the deal with the Secretary of State.
The representatives of the local medical committees then insisted that a referendum was held of all general practitioners. I assume that they would have had to insist on that, whatever decision the majority had taken. Had the numbers been reversed, would the Secretary of State have said today that the majority was very narrow? Would the Secretary of State have demanded that, as the majority had accepted it, the majority should rule, and that the acceptance should be final and a burden on the rest of the medical practitioners? When the general practitioners examined the offer which had been agreed by the GMSC negotiators, they disagreed completely with the representations made on acceptance. About 82.1 per cent. of doctors who work in the National Health Service voted and, of those, 24 per cent. voted to accept. There was a massive majority and the more the Secretary of State hurls insults at general practitioners rather than trying to explain the deal, the worse matters will become. I hope that, as a mere Back-Bench Member, I may have the temerity to offer some advice to the Secretary of State. There are many people whose integrity one can attack. It is difficult to attack an hon. Member's integrity in the House, as it is not allowed, but outside the House, the integrity of Members of Parliament is attacked daily by their constituents ; they seem to be fair game. It would be extremely difficult if one was to start to attack the integrity of some of the professional people whom we must regard with respect. In Scotland, we may get away with attacking the legal
profession--sometimes that is quite fashionable. We may even get away with attacking ministers of religion, depending on which side of the fence we are on and the company we are keeping at the time. However, neither in Scotland nor in the whole of Great Britain will one get away with attacking the integrity of doctors working in the National Health Service, who put in extraordinarily long hours on behalf of their patients, who look after the sick and the elderly and who do their best to look after the handicapped, often with services that are stretched to the limit. The public do not need a propaganda exercise to tell them that the doctors are under attack when the Secretary of State goes on television to say that doctors are reaching for their wallets.
The elderly in particular depend on their general practitioners, often in the middle of the night, when they are under stress and when there are epidemics of flu, for example. Elderly people feel passionately strongly for those who give them such good service, and they appreciate the kindness when they are under severe stress. I am afraid that on this occasion, as on other occasions, the Secretary of State has made a severe gaffe. He would do better to try to resolve the position by getting the general practitioners round the table to start afresh, if necessary.
As long ago as 1985, the general practitioners in the British Medical Association were seeking meetings with the Secretary of State on negotiations for a new contract. If such negotiations were resumed, if the Secretary of State took into consideration the genuine feelings of members of the public who, from the responses to our review, are
Column 926almost 100 per cent. in support not only of the National Health Service, but of those who work in it, and if we tried to use the money that we have to inject more cash into the National Health Service, and use and monitor it properly, instead of trying to make the National Health Service cheaper--to make those who work at the Cinderella end of the National Health Service pay the price for the money that has to be saved to buy equipment that should have been provided anyway--I shall believe that we are making the real progress that people demand and will demand through the ballot box at the next election.
Mr. John Greenway (Ryedale) : It is worth stressing that the Government's record on the National Health Service and their proposals for the future of that service are arguably the most misrepresented feature of their policy. Over the past 10 years, we have seen resources increase by 40 per cent. in real terms. Organisation for Economic Co-operation and Development figures now show that we are talking of 6.1 per cent. of gross domestic product spent on health care, as opposed to 5.3 per cent. 10 years ago. That is a tribute to the efforts the Government have made.
I am sorry to see that the hon. Member for Livingston (Mr. Cook) has left the Chamber. He alone is responsible for the most blatant misrepresentation of the Government's reforms. Even before the White Paper was published, he said that there were plans for hospitals to opt out of the NHS. There are no such plans. I see in the longer term--perhaps a decade and a half--a system in which there will be commissioning agents and bodies providing the service on a self-governing basis, whether hospitals or community services. The Opposition motion seeks to exploit last week's vote by GPs to reject the contract agreed on 4 May between my right hon. and learned Friend the Secretary of State and the General Medical Services Committee. I must declare a personal interest in the matter in the sense that, as my hon. Friends are aware, the chairman of the General Medical Services Committee, Dr. Michael Wilson, is my own GP and a personal friend. I have had opportunities to discuss the matter with him on a number of occasions to a greater extent than one would normally expect as a Back-Bench Conservative Member.
I am pleased that my right hon. and learned Friend referred to the negotiations which took place in the weeks leading up to 4 May and the events of 4 May. There is no doubt that a fair and reasonable compromise was reached in those negotiations. My right hon. and learned Friend will accept that the many representations from hon. Members of all parties about features of the first version of the contract were helpful, especially in relation to rural practice payments, part-time allowances and targets for screening and immunisation.
I was interested to hear my right hon. and learned Friend's remark about yesterday's discussion, from which some believe that all the contract is up for renegotiation. Clearly, that is not possible. If I heard my right hon. and learned Friend correctly, he said that if there were some specific details in the contract on which further discussion might be appropriate, we should enter into further negotiations on them. However, there can be only a few. I have asked the chairman of the GMSC to let me and colleagues know whether there are any particular points that they feel are still a problem. I say that because I do not
Column 927believe that it does either side of the argument any benefit to perpetuate a war of words. We now need constructive proposals for the future of the Health Service, and we must take the White Paper proposals forward as quickly as we can.
Conservative Members have had many letters that reflect the misinformation and misrepresentation that abounds about the White Paper. I received one letter from a lady who said :
"I have been told by a visitor that when the new NHS starts, my GP will have a limited amount of money to spend on his patients. Because of this, when the money runs out, he will not be able to pay the District Nurses."
Fortunately, I was able quickly to send her a reply from the district general manager of the York health authority, in which he said that he could reassure the lady
"completely that there will be no risk, whatsoever, of reducing our District Nursing Service there are plans for a substantial increase in the number of nurses and physiotherapists and occupational therapists."
It goes on to say that there is every sign that the district health authorities would be able to increase community services because, in the world which the White Paper envisages, they
"will have much more time to focus on determining what the public actually want and will get hold of the purse strings so as to be able to ensure that they get it."
At the 1922 Committee meeting last week, the Prime Minister stated a clear objective that we would want to see--namely, a National Health Service that is so good that people will not want private treatment. That is an objective for the future. Nevertheless, yet again it shows the Government's clear commitment to improving the NHS for the benefit of patients. In those circumstances, in trying to help doctors and their representatives to achieve the best for the NHS, Conservative Members have a right to ask them to reconsider whether the slogan of their current campaign, "SOS for the NHS", is appropriate. There is a meeting going on in York tonight under that very banner. It is sad that misrepresentations that will create yet more fear and anxiety in the minds of vulnerable patients are still being perpetuated, despite the comments of my right hon. Friend the Prime Minister.
We need a constructive debate. Patients are rightly asked what difference the White Paper proposals would make for them. District health authorities will have a much stronger brief to find out from patients what they consider should be provided, rather than rely entirely on staff saying what they think they should have. In the York health authority area, several changes are to be implemented over the next two years, taking very much the same stance as the White Paper, to improve the Health Service, make it more responsive to patients, and cut waiting lists. That would inevitably mean changes for the staff. Perhaps one can begin to understand why some staff elements are opposed to further development towards a more flexible response.
Flexibility is one of the key strengths of the White Paper. It is not prescriptive. It provides freedom to develop the service that a regional health authority considers best for its region. Only today I spoke to the chairman of Yorkshire regional health authority, and it is his view that we in Yorkshire can develop the kind of service that we believe is best for Yorkshire. That is because the White Paper offers opportunities. As I have already said, it is not prescriptive.
In their misrepresentation of the Government's proposals, the Opposition have attempted to give the
Column 928impression that the changes in the White Paper will be steamrollered through. That is not the case. The more one discusses these plans with district and regional health authorities and with FPCs, the more it becomes clear that they are long-term reforms. The implementation of the proposals will take time. It is clear also that, initially, it will be largely experimental.
Ms. Harriet Harman (Peckham) : Will the hon. Gentleman support people in Yorkshire who want a say before any of their hospitals become self-governing NHS hospital trusts and opt out of the district health authority?
Mr. Greenway : They are not going to opt out of the district health authority. As I understand it from the working papers that have been issued, the district health authority will still have power to decide where contracts are placed.
Mr. Hayes : Is my hon. Friend saying that it is ridiculous to have ballots either in a hospital or the community at large and that, perhaps, the proper focus of attention, as happens now when a hospital opens or closes, is through a community health council?
Mr. Greenway : There will be improved opportunities for CHCs when health authorities are slimmed down in the way the White Paper proposes. If there were any kind of ballot, referendum, or public opinion test about the White Paper proposals, it would be difficult to see how the public could express a clear view, given the degree of misrepresentation about the White Paper proposals.
It is difficult to reconcile hon. Members' arguments on radio and television that the Government are steamrolling through the White Paper proposals, when every serious major structural change will be voluntary. Following my right hon. and learned Friend's statement two weeks ago about community care--we are to implement by April 1991 a positive and absolute change, when local social services departments will have responsibility for community care--we are accused of prevarication and delay. It will not be too many weeks or months before some social services directors begin to think that perhaps 1991 is too soon. Clearly, people will argue for or against the White Paper according to how it suits their political persuasions. I am much more concerned that we should now advance the proposals and take the next necessary steps to put the much-needed and imaginative reforms into place.
Task forces will have to be set up by regions to examine the opportunity for each hospital that has expressed an interest in self-governing status. From my discussions about what might happen in our area in Yorkshire, it is clear that consultants, district general managers and their management teams want more information. I understand that an additional working paper will be issued shortly. I should be most grateful if my hon. Friend the Minister of
Column 929State would refer to the timetable that he envisages. We need to know how the trust will increase choice, which hospitals may want to be self-governing, how the management of self- governing hospitals will work, and what discussions about contract details must take place with the district health authorities.
In other words, before any hospital becomes self-governing, we need to establish whether a proposed self-governing hospital can deliver something that improves the current arrangements. In answer to the hon. Member for Peckham (Ms. Harman), when we have got that far and we can publicise those arrangements, the public will have a much clearer impression of what is proposed.
Mr. Greenway : What I recommend will depend entirely on what is proposed. There is a community hospital in my constituency to which I referred my right hon. and learned Friend during Question Time several weeks ago--
Mr. Greenway : No, he is not going to close it. That hospital has expressed an interest in self-government. The doctors concerned have expressed a clear interest in having their own practice budget, combined with self-governing status for the community hospital. The Yorkshire regional health authority chairman and the family practitioner committee clerk have expressed the view that that is an exciting prospect.
In answer to the point by the hon. Member for Peckham, it is too early to tell whether that proposal can become a reality for that hospital. We need the information that I have mentioned, and we need to look at each case. That is why I am asking my hon. Friend the Minister of State to tell the House what further proposals there are for the additional working papers.
Ms. Harman : The hon. Gentleman misunderstands my question. I did not ask whether he would recommend that a hospital in his constituency should become self-governing. I asked whether he would recommend that people in his constituency should have a say in whether that hospital becomes self-governing.
Mr. Greenway : The Friends of Malton Hospital is an active association which, I am sure, would want to test local opinion on opting out. My right hon. and learned Friend the Secretary of State has made it clear that any hospital that wishes to become self-governing must provide clear information on whether that will be to the benefit of the patients. There will have to be a proper management structure. At this stage, it is not valid to ask people about their reactions to the proposals when the necessary additional information is not available.
Once the contract for GPs is settled, health authorities will need to encourage their bigger practices to adopt a budget. My impression is that GPs are aware that they will face a choice between adopting a budget and being left behind. By voting against the contract last week, they have perpetuated the confusion about the contract and the
Column 930White Paper. It is difficult not to conclude that the confusion of the two issues is a delaying tactic by some members of the medical profession.
It must be recognised that some elements of the Government's plans require more detailed explanation. That is especially so for indicative drug budgets. Initially, they will need to be very indicative if the reassurance that patients will not go without medicine and appliances is to be honoured. We must also take care not to discourage pharmaceutical research. Nevertheless, one question about drug budgets needs to be asked : why the Government are aiming to curb the worst excesses of drugs spending only by GPs and not by hospitals. The answer, of course, is that hospitals already have proper arrangements for generic prescribing to curb spending. When the proposals in the White Paper are in place, there will be an opportunity for regional health authorities to hold the budget for drugs. That will create the opportunity for bulk purchasing. Will such opportunities be exploited? What purchasing role is envisaged for regional pharmaceutical officers appointed by regional health authorities? Surely their role should include ensuring value for money for regional health authorities as well as protecting the pharmacists.
There was some discussion earlier about how to square the circle between the Government's desire to introduce tax relief or private medical insurance for pensioners with the stated objective of my right hon. Friend the Prime Minister, to which I have already referred. Opposition Members may be interested--I can obtain copies for them if they are--in Post Magazine The Insurance Weekly last week, which published a series of articles about the future of private medical insurance. One article deals with the reasons why some people prefer private medical care. It states :
"Why do people choose to go for private treatment when there is a free National Health Service? Market research indicates the reasons are that they can enter hospital quickly and they can choose their admission date, and thus avoid holidays and particular business commitments. They have a choice of which hospital they wish to be treated in, and they can choose their specialist when there is no choice on the NHS. They can have a single room with telephone and their own bathroom and there are flexible visiting hours for family, colleagues and friends."
It then states--this is the key point :
"The NHS is making improvements as private hospitals have demonstrated how the patient environment can be improved." Putting the patient first, as the White Paper states, is the purpose of the reforms.
I welcome the opportunity that the House has been given to debate these matters tonight. However, in securing this debate, the Opposition have scored something of an own goal. The vote against the contract last week was a sad embarrassment for the General Medical Services Committee, not for the Government. As my right hon. and learned Friend said, if he is forced to impose a contract, it will be the contract agreed to by the GMSC.
Mr. Archy Kirkwood (Roxburgh and Berwickshire) : The hon. Member for Ryedale (Mr. Greenway) made an interesting speech, although he looked very uncomfortable throughout most of it, especially when he was referring to the potential closure or opting-out of hospitals in his area.
Column 931I understood the hon. Gentleman to say that he was in favour of the Secretary of State renegotiating certain aspects of the proposed GP contract. I agree with that. He referred to his distinguished constituent Dr. Wilson, chairman of the General Medical Services Committee, who negotiated the contract that was so resoundingly rejected in the ballot. I am sure that Dr. Wilson conducted his negotiations in good faith and that he recommended the deal to GPs only because he thought that he could not get the Secretary of State to move an inch further. It remains to be seen whether he is right, but certainly the Secretary of State appears to be setting his face against any further movement--despite the advice of the hon. Member for Ryedale.
It is silly nonsense for good and useful hospitals such as Malton, in the hon. Gentleman's constituency, to consider opting out just to preserve their existence. I am sure that Dr. Wilson would agree that it would be better to turn it into a community hospital, run by GPs, to serve the local community.
I do not agree with the hon. Gentleman that the Opposition have shot themselves in the foot. The debate is both timely and important because of the result of the GPs' ballot last week. I shall concentrate my brief remarks on that. More than anything else, the profession is suffering from the Secretary of State's adopted attitude during the negotiations. I for one was surprised by the size of the vote to reject the proposed contract. It might, however, have been different had the right hon. and learned Gentleman been a little more conciliatory during the negotiations. He used insults when GPs needed answers ; he used threats when he should have negotiated. He lost the argument not only because of the detail but because of his hostility to people's genuine concerns. It would be a major breakthrough if he accepted that doctors and patients have genuine concerns that need to be dealt with rather than sneered at. The proposed contract is not entirely about pay and conditions of service ; it goes much wider. It embraces the whole future of the development of primary care. I profoundly reject the Government's view that the row is simply one about how much income GPs will receive in the future. I object to the Secretary of State writing letters to Members of Parliament which include sentences such as : "The current argument over the GPs' contract which is often confused with the White Paper arises from contract negotiations involving doctors' salaries."
A great deal of the argument is about the future of primary care--and, for rural areas, the very existence of primary health care. The Government are attempting to switch the focus of the argument and make pay the issue, so that they can use salaries as a weapon to cut costs and to impose their vision of a market-led NHS.
Doctors would respond positively to a new and radically different contract. They are not interested only in pay and conditions. As evidence of that, as far back as 1985, the eminent Dr. Wilson wrote to the Department expressing his disappointment at the speed of progress on the contract. At that time he called for the development of
"a comprehensive system of paediatric surveillance, by extending the cervical screening programmes and by encouraging GPs to undertake minor surgery for their NHS patients."
In that letter, Dr. Wilson outlined other proposals, including reducing the maximum list size, improving incentives to appoint additional partners to practices,