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Ms. Harriet Harman (Peckham) : It was evident from the Secretary of State's speech that he did not welcome the debate this afternoon, but he rose to the occasion with his usual combination of trying to distract attention from the real issues and a dose of abuse for the doctors. [Interruption.] Hon. Members who were present will agree that that is a fair description of his speech.

Our main concern about the contract is the incentive that it provides to GPs to increase the number of patients on their lists. Successive Governments have encouraged GPs to reduce the number of patients on their lists. That was for the good reason that, if GPs are to make the correct diagnosis, give appropriate treatment and prescriptions, and manage long- term illnesses properly and sensitively, they require time. Doctors want more time for each patient and patients want more time from their doctor. Yet the Government will make good doctors into bad doctors by paying them to take more patients on to their lists, so that each patient will have less time.

Most people are happy with their GP. A poll in The Daily Telegraph showed that 80 per cent. of people were happy. The 20 per cent. who said that they were not happy said that the doctor always seemed rushed, did not have time to explain and was not interested in them as a person. Increased patient list sizes will increase dissatisfaction with GPs. Studies of what patients want from general practice

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consistently show that they want a doctor who listens, understands, takes trouble and is prepared to explain. In other words, they want a doctor who has time for them.

Not only doctors take the view that an increase in the percentage of doctors' pay attributable to capitation will result in increased list sizes. The Patients Association, the Association of Community Health Councils and a range of other voluntary organisations and academic institutions that have no vested interest and no axe to grind believe that that will be the effect. So do organisations such as the Centre for Policy on Aging, Age Concern, the Health Visitors' Association and the National Children's Bureau. The Government are alone in believing that performance relates to the number of patients treated rather than the quality of care.

The Government believe that the Health Service centres on cost rather than on care. That is why they are obsessed with the GPs who refer more than the average number of patients to hospital, but are blithely unconcerned about the GPs who under-refer and whose patients suffer because they are not referred to hospital.

The Government are obsessed, too, with GPs who prescribe more than the average for their patients, but they are blithely unconcerned about patients who suffer because their GPs under-prescribe. They are not concerned with the appropriateness of the referral or the prescription ; all they are concerned about is the cost. Their real interest is in cash, not care. Their prime concern is a healthy bank balance, not a healthy patient, and the doctors know that. We have seen what cash limits have done to hospital services and how hospital services have been squeezed. We all know that cash limits will come down on family doctors. The Health and Medicines Act 1988 put in place cash limits on ancillary services for GPs' practices and practice premises. The White Paper plans to cash-limit the rest of GP services--prescriptions and referrals to hospital. I do not see any shaking of heads, but the Government have up to the present day been denying cash limits on GP services. However, it is clear that they will be cash-limited. I shall use an example that makes it clear that that is what is intended by the White Paper. When a patient goes to the accident and emergency department and is subsequently admitted to hospital, the bill for that treatment will go to the hospital, if it is an opted-out hospital, or to the district health authority. When a patient is referred to hospital and is admitted on the basis of a GP's referral, the GP's practice budget will have to bear the cost of that treatment.

The Government are afraid that GPs faced with a cash-limited budget, who see a patient who needs treatment in hospital, will, instead of referring him to the out-patient department, advise him to go to the accident and emergency department, because then the bill will be paid by the hospital of the district health authority. That is why, in working paper 3, the Government are advising hospitals to have watchdogs in their accident and emergency departments to see whether the hapless patients are real accident or emergency cases or whether they are refugees from cash-limited GP budget holders. That is clear evidence that GP's practices will be cash-limited. The Government anticipate that GPs will try to escape the cash limit by advising their patients to go to accident and emergency departments rather than referring them to hospitals in the normal way.

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The most important difference that the Government have with just about everyone else is the substance of the proposals in the contract and the White Paper. We cannot let the debate pass without a comment on the way in which the Secretary of State has handled the issue. Doctors and the public have disagreed with him. His hon. Friend the Member for Ryedale (Mr. Greenway) said that the public were too thick to be allowed to have a say on the White Paper. On "Any Questions" a couple of weeks ago, when a doctor disagreed with him about the White Paper proposals, all the Secretary of State could do was to rubbish him and to say, "You have not read the White Paper." He has accused GPs of reaching for their wallets. Anyone who disagrees with him is accused of misunderstanding the proposals. Those people who want change other than that which he is proposing are told that they want no change at all.

The problem is that the Government have not been prepared to listen to those people who work in the Health Service, who use the Health Service and who have been crying out for change. That shows not just sluggishness or bullying, although it certainly shows that, but it shows the Government's inability, refusal and unpreparedness to listen to views that do not fit in with their ideological dogma. It is that same authoritarianism that will prevent people from having a say in whether their hospital opts out.

The Prime Minister has said that she will make the Health Service so good that no one will want to use private health care. Nobody believes that, but if that were the case, we should welcome it. However, as the Prime Minister wants competition and market forces in health care, it is clear that that statement has no credibility. When we return to the House in the autumn, the Government will try to impose the new contract on the doctors, despite a ballot in which there was a vote of three to one against. We are told that there will be no new discussions. We will oppose the Government's attempt to force a contract on the GPs. The Secretary of State will have to fight his contract through. Any time that Conservative Members vote to impose the new contract, that will simply serve to remind their constituents how little they now have in common with their Member of Parliament.

The more the Government berate the doctors, the more they widen the gulf between Government and public opinion because people do not accept that doctors are stupid or greedy. They do not accept that doctors are interested only in their pockets, not in their patients. When Conservative Members return to their constituencies for the recess, they will discover the huge consensus against the Government's proposals. There is literally nowhere in the country where they will find support for the contract or the White Paper. There are no places to which the Government can run with this proposal.

We often hear talk of Tory heartlands, but even the Tory heartlands are opposed to these proposals--to the contract and to the White Paper. There are no Tory heartlands when it comes to the National Health Service. When Conservative Members vote tonight, they will simply be voting to increase the gulf between themselves and the people they are supposed to represent.

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9.51 pm

The Minister of State, Department of Health (Mr. David Mellor) : I begin by thanking my hon. Friends the Members for Ryedale (Mr. Greenway), for Harlow (Mr. Hayes) and for Banbury (Mr. Baldry) for their supportive speeches. My hon. Friends' penetrating speeches have made my task easier. I must advise especially my hon. Friend the Member for Ryedale that I should like to write to him on the specific points that he raised because time is pressing and I want to make other points tonight.

It is clear that the Labour party has cobbled together an end-of-term assault on the Government based on the lowest common denominator of opposition to some of the moves to reform the Health Service. It is interesting that the hon. Member for Peckham (Ms. Harman) laboured so mightily to denounce a contract which, for the first time, offers the better doctors rewards for doing more to treat their patients.

What can be wrong with a contract which, for the first time, introduces basic payments to include opportunistic screening and check-up invitations for the healthy every few years to give us a chance to be a service for health, not just for sickness? What is wrong with a proposal that all newly registered patients should be offered a check-up? What is wrong with a proposal that doctors should be paid a higher capitation payment for having elderly patients on their lists--an argument that is totally distorted by the suggestion that the contract will somehow provide a disincentive to treat the elderly when the opposite is the case?

What is wrong with extra payments for looking after the very young and for immunising them against preventable diseases when our record on immunisation is far too low compared with that of many other countries and leaves a great deal to be desired? What is wrong--I should have thought that this point would be of particular interest to Opposition Members--with extra payments for doctors who practise in deprived areas to try to do something about the inequalities of health standards that so many research projects have shown exist in some inner-city practices and practices elsewhere?

It seems astonishing that, in the cynical cosy-up between the Labour party and the BMA, all those facts should be disregarded while both the hon. Members for Livingston (Mr. Cook) and for Peckham--the Opposition's Front- Bench spokesmen--have done nothing more than parrot the BMA's case. Indeed, that was taken to absurd lengths by the hon. Member for Livingston when he set out to prove that it is not possible to reach targets of 70 per cent. in inner-city areas. Nothing could be further from the truth. It is perfectly possible, as the public health laboratory service study showed in 1985, given proper incentives, for everyone in the country, wherever they live, to have the opportunity, and to take it up, to have their children immunized. It seems extraordinary that Labour Members should share the patronising view that somehow people who live in inner- city areas are less interested in the health care of their children. When places such as Doncaster and Rotherham, which are not exactly bastions of the middle class, can achieve 90 per cent. immunisation rates for polio, why cannot other parts of the country do the same? For the first time, we are giving people an incentive to do that. As the York university study showed only too clearly, the problem at the moment is that innovative practises sit

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alongside those which are practising the medicine of 20 years ago, but there is no difference in the remuneration to the innovative practice. How are we to redress the imbalance in quality between one group of GP practices and another unless we have a contract which, for the first time, rewards good performances? I am astonished that that view cannot be shared on both sides of the Chamber, as all our constituents will gain from the introduction of such a contract. It is even more astonishing that the Labour party should see fit to put forward the BMA's obstructive arguments against the contract, since whenever any Government have sought to make changes, whether those changes were right or wrong, they have run into difficulties with the BMA.

Mr. Sam Galbraith (Strathkelvin and Bearsden) : That is not true.

Mr. Mellor : The hon. Gentleman says that it is not true, but I shall demonstrate that it is.

In the past 25 years there have been two substantial periods of Labour Government. In the 1964 Parliament it took four months of a Labour Government before the BMA, in February 1965, was advising its members to give three months notice of termination of their contract with the NHS. That is the background against which the contract that we are now replacing was put into place by the Labour Government. In the 1974 Parliament, it took 18 months before the BMA council was condemning what the then Labour Government were doing as unsound and a threat to fundamental freedoms. In 1977 Mr. Anthony Grabbham, now Sir Anthony Grabbham, a spokesman for the BMA then as now, said of Labour's pay policy :

"It is a catalogue of broken promises, a cynical disregard of agreement and progressive emasculation of review body procedures all leading to inexorable degradation of consultants' status." The attempt to suggest a common cause between the BMA and the Labour party is specious, and the mess of potage which Labour Members have sold is the rights of their constituents to a good and consistent policy of health care that modern reforms can bring about.

Once again, we have heard so much from the Opposition, but not a word about a coherent alternative to address the NHS's central problems. The Opposition motion specifically criticises the Prime Minister's words when she set out the aspiration that she wants to see the National Health Service so good that people will not need private medicine. I consider that to be a perfectly estimable aspiration. It provides an interesting contrast with the Labour party. In the 1970s, the Labour party was prepared to drive the Health Service into total disarray to abolish private medicine. Its latest policy document shows that it seems to have learnt very little from that. The problems of the National Health Service, such as the long waiting lists which have caused some people to go private, are not the source of proper analysis by the Labour party, but simply used as a crude stick with which to beat the Government.

In a free society where people must have the right to make private provision out of taxed income if they choose, the best way is to make them feel that they do not need to do that. One way to make people sure that they do not need to do that is to cut waiting times. We have research that shows that if every district health authority was able to use its operating theatres as effectively as the average,

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we could get rid of long waiting times overnight. That will come about only if a coherent set of proposals is pursued, which involves not only additional resources for the National Health Service, but a proper and sensible way of ensuring that those resources are set in the right management framework. I hope that the House will reject the Labour party's opportunistic motion tonight.

Question put, That the original words stand part of the Question :--

The House divided : Ayes 207, Noes 315

Division No. 321] [10 pm

AYES

Adams, Allen (Paisley N)

Allen, Graham

Alton, David

Archer, Rt Hon Peter

Armstrong, Hilary

Ashdown, Rt Hon Paddy

Ashley, Rt Hon Jack

Ashton, Joe

Banks, Tony (Newham NW)

Barnes, Harry (Derbyshire NE)

Barnes, Mrs Rosie (Greenwich)

Barron, Kevin

Battle, John

Beckett, Margaret

Beggs, Roy

Bell, Stuart

Benn, Rt Hon Tony

Bennett, A. F. (D'nt'n & R'dish)

Bidwell, Sydney

Blair, Tony

Blunkett, David

Boateng, Paul

Boyes, Roland

Bradley, Keith

Bray, Dr Jeremy

Brown, Nicholas (Newcastle E)

Buckley, George J.

Caborn, Richard

Callaghan, Jim

Campbell, Menzies (Fife NE)

Campbell, Ron (Blyth Valley)

Campbell-Savours, D. N.

Canavan, Dennis

Cartwright, John

Clark, Dr David (S Shields)

Clarke, Tom (Monklands W)

Clelland, David

Clwyd, Mrs Ann

Cohen, Harry

Coleman, Donald

Cook, Frank (Stockton N)

Cook, Robin (Livingston)

Corbett, Robin

Corbyn, Jeremy

Cousins, Jim

Crowther, Stan

Cryer, Bob

Cummings, John

Cunliffe, Lawrence

Cunningham, Dr John

Darling, Alistair

Davies, Rt Hon Denzil (Llanelli)

Davies, Ron (Caerphilly)

Davis, Terry (B'ham Hodge H'l)

Dixon, Don

Dobson, Frank

Doran, Frank

Douglas, Dick

Duffy, A. E. P.

Dunnachie, Jimmy

Dunwoody, Hon Mrs Gwyneth

Eadie, Alexander

Eastham, Ken

Evans, John (St Helens N)

Ewing, Harry (Falkirk E)

Ewing, Mrs Margaret (Moray)

Fatchett, Derek

Fearn, Ronald

Field, Frank (Birkenhead)

Fields, Terry (L'pool B G'n)

Fisher, Mark

Flannery, Martin

Flynn, Paul

Foot, Rt Hon Michael

Forsythe, Clifford (Antrim S)

Foster, Derek

Fraser, John

Galbraith, Sam

Galloway, George

Garrett, John (Norwich South)

George, Bruce

Gilbert, Rt Hon Dr John

Godman, Dr Norman A.

Gordon, Mildred

Gould, Bryan

Graham, Thomas

Grant, Bernie (Tottenham)

Griffiths, Nigel (Edinburgh S)

Griffiths, Win (Bridgend)

Grocott, Bruce

Hardy, Peter

Harman, Ms Harriet

Hattersley, Rt Hon Roy

Heffer, Eric S.

Henderson, Doug

Hinchliffe, David

Hoey, Ms Kate (Vauxhall)

Hogg, N. (C'nauld & Kilsyth)

Home Robertson, John

Hood, Jimmy

Howarth, George (Knowsley N)

Howell, Rt Hon D. (S'heath)

Hoyle, Doug

Hughes, John (Coventry NE)

Hughes, Robert (Aberdeen N)

Hughes, Simon (Southwark)

Illsley, Eric

Ingram, Adam

Janner, Greville

Jones, Barry (Alyn & Deeside)

Jones, Martyn (Clwyd S W)

Kilfedder, James

Kinnock, Rt Hon Neil

Kirkwood, Archy

Leadbitter, Ted

Leighton, Ron

Litherland, Robert

Livsey, Richard

Lloyd, Tony (Stretford)

Lofthouse, Geoffrey

Loyden, Eddie

McAllion, John

McAvoy, Thomas

McCartney, Ian

Macdonald, Calum A.

McKay, Allen (Barnsley West)

McKelvey, William

McLeish, Henry

McNamara, Kevin

McWilliam, John

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