House of Commons Hansard Debates for 25 Jul 1989

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service better than private treatment. Fortunately, there are those in the Health Service who share that concern about where the Health Service is going.

I turn now to the other development last week which has prompted this week's debate on health.

Mr. Nigel Spearing (Newham, South) : Does my hon. Friend agree that many people feel that the White Paper's ethics are distinctly rocky? This has driven me, as my hon. Friend may recall, to make a challenge at a public meeting in Newham town hall to any supporter of the Government to debate in my constituency, and his or hers, the neutral question--I hope that it is neutral--whether the Government's domestic policies, particular those relating to the Health Service, are compatible with Christian values. I have tried to make that challenge public, but have had no takers yet. I should be glad to meet Government supporters in Nottingham, Putney or anywhere else. I hope that Conservative Members will advertise that challenge far and wide, and that it will be taken up in the recess.

Mr. Cook : I well remember that occasion. At the end of of the debate, in order to be present for a vote at 10 o'clock in the House, I left Newham town hall by car and my hon. Friend left by bicycle. I arrived only two minutes ahead of him.

My hon. Friend made an eloquent and moving plea. It was a pity that the only way in which one could fill up the platform was with supporters of his case against the White Paper. I should like to share my hon. Friend's challenge to any member of the Government who wishes to go to Newham and take part in a public debate with my hon. Friend. I am sure that any such person will be made welcome by my hon. Friend--provided, of course, there is a reciprocal agreement by which my hon. Friend can go into that person's constituency and carry the message to his or her constituents.

The Secretary of State for Health (Mr. Kenneth Clarke) : Come on.

Mr. Cooke : My hon. Friend the Member for Newham, South (Mr. Spearing) intervened just as I was about to move on to a matter to which, I am delighted to hear, the Secretary of State wishes to come. Only a couple of months ago, the right hon. and learned Gentleman made a triumphal statement to the House that he had secured agreement with the British Medical Association on the GPs' contract. He said : "I am glad to say that it has been my experience that after a dispute is over, people appear to forget it entirely and no one can quite remember what the fuss was all about."--[ Official Report, 5 May 1989 ; Vol. 152, c. 484.]

On this occasion, the GPs have not forgotten entirely what the fuss was all about. Last week, they voted by 24.1 per cent. to accept the contract and by 75.9 per cent. to reject it. That is not the kind of result for which one needs a recount to get the picture.

On radio last week, I heard the Secretary of State commenting, no doubt under the pressure of interview, that good doctors had nothing to fear from the new contract, that only the lazy doctor need fear--all 75.9 per cent. of them, I suppose. It is not just laziness that has

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prompted GPs to put the contract into the incinerator. It is worth examining, more seriously than the Secretary of State has attempted to do, why they said no.

There is much in what the Secretary of State proposes to which I could say yes. I could give a mark of five out of 10 on the 10 major proposals for change. For reasons to which I shall come, I do not quite regard that as a pass mark. For instance, I would welcome his proposal to pay more to GPs who make their own night visits.

Mr. Kenneth Clarke : They are against that.

Mr. Cook : I well understand--the right hon. and learned Gentleman says that the doctors are against that. I think that he is right. I shall come to those proposals about which he is wrong. His concession that those night visits may be shared with nine colleagues is generous, and it is not unreasonable to ask GPs to do one night in 10 on call.

I agree also with what I understand the Secretary of State is trying to do on targets for screening, but the way in which he is going about it is misconceived. The problem is that the targets set by the Secretary of State for full payment--90 per cent. for child immunisation and 80 per cent. for screening for cervical cancer--are so heroic, so far beyond the present figure for most practices, that there is a danger that many doctors will simply give up trying. I noticed at Question Time today that the Secretary of State said that most practices met those targets. I have since checked on those figures for district health authorities. Only one in England has reached 90 per cent. immunisation for children, and that is High Wycombe.

Mr. Kenneth Clarke : It is 70 per cent.

Mr. Cook : The Secretary of State says that it is 70 per cent. I concede that most district health authorities certainly meet the target of 70 per cent. I am sure that, in return, he will concede that for 70 per cent. the doctors get only one third of the payment. Full payment starts at 90 per cent., and only one district health authority is eligible.

This is not a matter on which it is necessary to have a party political debate. I refer the Secretary of State to the full scientific article in a recent edition of the British Medical Journal by a woman GP who, after working in a practice that has placed special stress on cervical smears and has been running a recall system for 15 years, still has not reached the target of 80 per cent. of the target population. Moreover, that GP was working in a suburban surgery. Achieving that target would be even more difficult in inner-city areas.

I should like to have the attention of the Minister of State, the hon. and learned Member for Putney (Mr. Mellor), who, I well understand, will wish to impress himself on the powerful friend next to him--the Secretary of State. In a television debate, the Minister of State made a statement that at the time rendered me speechless. He said that there was no evidence that it was more difficult to meet screening targets in areas of social deprivation.

I have since been through the figures for district health authorities. The percentages of immunisation by district health authority reads like a map of Britain by socio-economic indicators. The three lowest areas of immunisation are Merseyside, inner London and Manchester, none of which reaches 70 per cent. The three highest districts are Huntingdon, Winchester and High Wycombe. The only conclusion that one can draw from

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the way in which the Government have devised the centres for screening is that they are providing incentives for GPs to move into those areas that already have the most GPs and the fewest health problems.

It is not that the contract flopped on those matters. Anyone listening to GPs, rather than lecturing them, already knows what the key issue was : the proposal to increase the proportion received by GPs from capitation fees. GPs already get almost half their income from payments directly related to the numbers of patients. Under the proposal in the new contract, that proportion will increase from almost half to three fifths. This will give even more to those doctors who go for more patients, at the expense of those GPs who limit themselves to the number of patients that they can handle to a professional standard.

This is a flat reversal of a policy pursued for 20 years by successive Government, whether Labour or Conservative, which has aimed at reducing the number of people on patient lists. The Secretary of State proposes to turn the clock back, not to the last Labour Government, but to the Labour Administration before that. One must go back to 1966 before finding a time when the capitation element was so high.

The Secretary of State understands, of course, that more patients means more patient care. We know that he understands that, because he vigorously denies that his proposal can result in more people on each patient list. He claims that he is giving doctors the incentive to increase patient lists, while at the same time assuring patients that it cannot happen--that there will not be any more patients to go round, so the average will stay the same.

Unfortunately, I have to warn the Secretary of State that the number of GPs may not stay the same--at any rate, it will stop expanding. Already, practices from Devon to Glasgow have decided not to proceed with the additional partnership that they had intended to advertise. Their response to the Secretary of State's new contract is entirely rational. They are responding in Thatcherite terms to the financial incentives that they have been given to lengthen the patient list in the practice--although, as they understand, the result in terms of patient care is utterly perverse.

There is a simple way for the Secretary of State to demonstrate his good faith on this question of longer patient lists. He will be aware that the BMA, which he keeps telling us is opposed to any change, has proposed that the ceiling on patient lists should be reduced from 3, 200 to 2,500. I ask the Secretary of State whether he will accept that reduction in the upper limit on patient lists. Will he take that obvious precaution to prevent GPs from doing what he assures us he does not want them to do--indeed, he keeps assuring us that they cannot do it--namely, going for longer patient lists? If he will not, there is an obvious conclusion to be drawn. The Secretary of State has designed, as a matter of policy, a contract that will sharpen the competition between GPs for patients, with an incentive to go for longer patient lists, and he has no intention of putting in their way an obstacle to prevent them from doing so.

The last word on the contract, however, must be left to an academic study which the Secretary of State himself chose as relevant to the new contract. On 27 June, in answer to a written question, the Secretary of State said :

"Recent research by York university's centre for economics has demonstrated the wide range of quality of

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service to patients provided in different parts of the country under the old contract."--[ Official Report, 27 June 1989 ; Vol. 155, c. 422. ]

The Secretary of State is perfectly correct that the study drew attention to the variations in quality provided by GPs and highlighted the fact that the poorer regions of Britain get a poorer service from GPs.

It is perhaps unfortunate that whoever drafted the reply for the Secretary of State did not draw his attention to the full press comments of the authors of the report, who said :

"The new contract is likely to widen the gap even further Our prediction is that in five to 10 years there will be an even greater difference in standards of service."

It is a mark of desperation on the part of the Secretary of State to find friends for his new contract that he is driven to cite academics who believe that his contract will make matters worse. This is a short debate, and I wish in conclusion to discuss the response of the Secretary of State to the result of the ballot. As I understand the Secretary of State's position, as far as he is concerned, the BMA need not have bothered balloting members. The GPs will get the contract whether they want it or not, because he will impose it on them. It does not count that 76 per cent. of GPs oppose the contract; nor, for that matter, does it count that, last month, the National Association of Health Authorities found in its opinion poll survey that 90 per cent. of patients were satisfied with GPs. But the Secretary of State reserves the right to know better than 76 per cent. of GPs and 90 per cent. of patients.

The Secretary of State will be aware that there is a small problem in imposing the contract. It is not for him to impose it; he requires a vote in the House in the autumn. I am happy to say that there has fallen into my hands a letter which turns out to be a letter from the Secretary of State to all his hon. Friends, which he ends by wishing them a good recess. Let me take this opportunity to associate myself with that wish to Conservative Back Benchers. I wish them a happy recess in their constituencies explaining to GPs why they propose to ignore the results of the ballot and vote to impose the contract all the same. Not that either they or we need be surprised by the Secretary of State's reaction : it is utterly characteristic and entirely in line with the attitude that he has adopted to the NHS since he returned to his post.

The Secretary of State presides over the largest resource of professional advice and scientific expertise anywhere in Britain. It is a matter of regret that he has shown no interest in listening to any of it. This year, it is the turn of the GPs. Last summer, it was the turn of the nurses who had imposed on them the guidelines in the regrading agreement. Last autumn, it was the turn of the opticians, who warned him that ending free eye tests would result in charges of more than £10 and a drop in the number of tests. I vividly remember the Secretary of State assuring the House that he did not believe them. This spring has been marked by the refusal of the Secretary of State to listen to the chorus of criticism of his White Paper from nurses, doctors, patients and the rest of the public.

The right hon. and learned Gentleman's own limited tolerance of criticism was expressed vividly in the circular that he sent out on consultation on the White Paper. This is how he defined consultation :

"I look forward to receiving contributions, constructive criticisms and alternative suggestions"--

so far, so good--

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"so long as they are aimed at putting the White Paper proposals into practice by 1991."

In other words, consultation is welcome as long as those consulted agree with the proposals. The right hon. and learned Gentleman's impatience of any other criticism was perfectly caught this afternoon when he told my hon. Friend the Member for Halifax (Mrs. Mahon) that she was not qualified to vote on whether a hospital should opt out. The Secretary of State has defined a system of opting out that matches his view that his opinion is the only one that matters : he is the only person with a vote on whether a hospital should opt out. It should not surprise anyone that the Secretary of State has chosen to ignore a defeat of three to one. It is of a piece with his management style, which, we are bound to suspect, he copies from the Prime Minister. They are both stubborn and opinionated in their own views and contemptuous and dismissive of the views of everyone else. It is a style of government of which the nation is now heartily sick, and I warn the Secretary of State that if he persists with it, he may succeed in his given task of undermining the NHS but he will almost certainly succeed in undermining support for the Government. 7.36 pm

The Secretary of State for Health (Mr. Kenneth Clarke) : I beg to move, to leave out from "House" to the end of the Question and to add instead thereof :

"welcomes the Government's proposals for reform in the National Health Service which will bring all parts of the health service up to the very high standards now achieved by the best, put the needs of patients first and secure the best value for money ; recognises that to make the health service more responsive to the needs of patients as much power and responsibility as possible need to be delegated to local level in future, whether in directly managed or self-governing National Health Service hospitals ; looks forward to large general practitioner practices being able to apply for their own budgets to obtain a defined range of hospital services so as to improve the quality of service to their patients ; and fully supports the Government's decision to proceed with the implementation of the general practitioners' new contract, the contents of which were agreed with the general practitioners' leaders on 4th May." The hon. Member for Livingston (Mr. Cook) has made his last speech before the recess, which, as he said, we all confidently expect to come shortly. The hon. Gentleman opened the debate rather like a football player who expected to be playing an end of season game before a rather desultory crowd. He produced a speech and an Opposition motion which simply do not contain any new or good ideas. He showed yet again that his role in echoing the criticism that exists outside the House of our NHS reforms is to represent the views of those who have absolutely no proposals of their own to introduce. The hon. Gentleman continues to do that.

I can recall being in opposition and I know of the difficulties involved in finding ways in which to fill the time on Supply days. The hon. Gentleman was reduced to going through his newspaper clippings to see what has happened in the health world over the past few weeks. He has composed an extraordinary motion combining a quotation from the Prime Minister at a meeting of the 1922 Committee with some of the newspaper reports that followed the GPs' ballot on their contract. His speech, though concise, hardly covered the great problems of the Health Service that we are tackling at the moment.

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There is a problem with the quotation from the Prime Minister. As the hon. Gentleman said, I am not allowed to attend meetings of the 1922 Committee and, by singular good fortune, I seem unlikely to be attending a meeting of that committee for some little time yet. I have therefore had to rely on my hon. Friends for the quotation. Not for the first time, my hon. Friends do not entirely agree. My hon. Friend the Member for Harlow (Mr. Hayes) has helpfully given us his account of what was said at the meeting but the recollection of my hon. Friend the Member for Derby, North (Mr. Knight) is that the Prime Minister said, "The National Health Service will be so good that no one will want to go private again." [ Hon. Members :-- "Yes."] That recollection seems to be shared by the majority of my hon. Friends on the Back Benches.

I am not surprised by that quotation, although I was not there to hear it and I did not know that my right hon. Friend was going to make it. It touched on conversations that my right hon. Friend and I had from time to time during the review. It is obvious that in our reforms to improve the NHS we shall aim at the best standards achieved anywhere and pose a formidable challenge to the private sector to maintain its standards to keep its appeal to those patients who want to use it for health care.

We intend that the better National Health Service that we aim to create will not set itself lower standards or goals than the private sector aims to achieve. The private sector would have less to fear from an unreformed NHS coping with out-of-date organisation and management and coming under ever-increasing strain to keep up with demand, despite all the extra resources that the Government keep pouring into it.

Patients turn to the private sector for two reasons. First, they exercise their undoubted choice to opt for private medicine for their family and secondly because of their perception of the shortcomings and inadequacies of the NHS. People have an exaggerated view of those inadequacies because they are fed by Opposition spokesmen who seize on local problems in this giant service and give the impression that waiting lists and shortages are a universal problem, when they are usually the result of purely local problems.

It is not new for the Opposition to feed critical views of the Health Service to the general public. I have said before that the best allies of private medicine in the past 10 years have been Barbara Castle and the National Union of Public Employees, whose behaviour in the late 1970s was of particular help. The Labour Front Bench team continue that unintended support for the private sector by defending the NHS against any attempt to improve it and continually producing a highly coloured version of the difficulties facing patients. We shall tackle the problems of the Health Service, and as a result of our reforms it will be a much more powerful competitor of the private sector.

Mr. Allan Rogers (Rhondda) : The Secretary of State said that there were two reasons why people choose the private sector rather than the NHS. First, he said that they want to exercise their choice and secondly, that they perceived inadequacies in the NHS. Does he accept that one of the main reasons why people use the private sector is that they can jump the queue and get in early? They cheat the queue.

Mr. Clarke : That is why we need reforms to tackle the queues and to reduce waiting times. As my hon. Friend the

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Minister of State said at Question Time, we could do that by making all operating theatres as efficient as the best. To resist reform is to preserve excessive waiting times and queues, which helps the private sector.

The hon. Member for Livingston included the quotation in his motion merely to make the unoriginal point about tax relief for the elderly, which we included in our White Paper. As he knows, the case for tax relief is based on our belief that, while we intend to make the NHS a competitor of the private sector and able to offer high standards, it is right that patients should have the choice. As society becomes increasingly affluent, people will have more disposable income and some will wish to choose private medicine for various reasons, including convenience and personal predilection. We have offered tax relief to address the particular injustice felt by many elderly people who chose private medical insurance during their working lives but then found that the premiums rose steeply in retirement, when their income dropped. I do not understand the disporportionate attack that is always made on the tax relief proposal, which has been widely welcomed by many elderly people and is a part of the White Paper that has caused the least fuss among the non-ideological public. The hon. Gentleman raised the more substantial item of the GPs' contract. I am grateful to him for opening up that issue, because it enables me to explain it. I am grateful to him for conceding that he recognises the case for a new contract and that he sees merit in our proposals. He is therefore urging the General Medical Services Committee to accept the need for a performance-related contract which is more in tune with the needs of the late 1980s.

I would have preferred to reach an agreed contract with the GPs and the GMSC. My predecessors and I have bent over backwards to achieve just that. The origins of the new contract go back to the Green Paper of three years ago. Many public meetings were held as the basis for consultation. We had 19 meetings with the negotiators and 110 hours of discussion on 38 documents. Eventually, we reached agreement with the formidable team of GMSC negotiators representing GPs. The negotiators commended our package to GPs. At a local medical committee conference, it was only just rejected by local medical committee representatives in a tight vote. Then a general ballot was held. So far as I can see, although the package continued to be commended, nobody made any attempt to campaign in support of the commendation. Few local medical committees tried to explain to GPs who had not followed the details where we were in the negotiations. In the past few weeks I have met GPs from rural areas who thought that rural payments would be abolished and did not know that we had reinstituted seniority allowances in response to the negotiators' requests. As a result of widespread public campaigning against the reforms, there was a heavy vote against the commendation. The Opposition must address the problem and say what we should do in response to that ballot. Undoubtedly, the Labour party will say that we should accept it and start all over again. That, indeed, is the position of the GMSC, which I met yesterday. I met exactly the same negotiators with whom I reached agreement on 4 May. At that time they left with what they regarded as a satisfactory package of arrangements which they commended to GPs. [Interruption.] I was at the meeting. The negotiators do not require the hon. Member for Peckham (Ms. Harman)

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to speak on their behalf. They had agreed a satisfactory package which they commended to their members. Faced with a vote which did not endorse their commendation, they came back to me yesterday wishing to reopen negotiations on every item on which we had reached agreement on 4 May. [Hon. Members :-- "Why not?"] They suggested a timetable that would take us until Christmas for reconsidering the whole matter.

The hon. Member for Livingston was good enough to say that he supports the principle of higher payments for the majority of practitioners who make their own night visits. The negotiators intend that to be the subject of fresh negotiations. He said that targets were a desirable principle, although he raised some points about the details, which I shall deal with in a moment. They wish to reopen negotiations about the basis for incentive payments for higher rates of vaccination and cervical cytology. They wish us to reconsider basic practice allowances although we had already made considerable changes. I asked whether the 26-hour availability for direct contact with patients each week was settled, but they said no, that could not be regarded as such. They wish to reopen negotiations on that as well as on capitation, to which the hon. Gentleman referred and to which I shall return.

The negotiators are in no position to agree to any changes. They already have many concessions in the bag ; concessions which I made last time and which they offered to members. They now take them as read and wish me to contemplate further concessions although they have no negotiating mandate. Scarred by its experience, the GMSC did not feel able to say that it would be able to agree to any of this. Presumably, I was to make concessions on all those fronts, including those supported by the hon. Member for Livingston, and then it would put it to the local medical committees, and perhaps, in due course to another ballot of general practitioners.

Mr. Spearing : That is democracy.

Mr. Clarke : No, it is not democracy. I have to say that it is damn near anarchy.

I understand that in settling, in this case, the basis of payment to independent contractors, or more normally the terms and conditions of employees, that is a negotiation in which the person who pays and the person who is being paid have an interest. Obviously, it is right to seek a compromise between my role, which is to look after the interests of the patients and the service and to have a contract that stimulates higher standards, and the GMSC's legitimate role to have something that is acceptable to its members. If we concede everything and the GMSC keeps going back for a vote, we will wind up with a contract that is so completely dominated by those things that make life comfortable for the doctors and the medical profession that we will sacrifice all the aims of higher quality care, which must be a legitimate interest for a sensible and responsible Government to look after in such discussions.

Mr. Spearing rose --

Mrs. Alice Mahon (Halifax) rose --

Mr. Bob Cryer (Bradford, South) rose --

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Mr. Clarke : I shall give way in a moment, but I want first to deal with two matters that I mentioned, which appear to be the only major doubts of the hon. Member for Livingston--targets and capitation.

It is a fond belief on his part that they are the only matters that need to be reopened at the request of the GMSC. I have said that the 70 per cent. target could be hit by most practices in England. I believe that is so in the case of vaccination. I introduced that as a big concession last time, because it is comparatively easily obtained by most of our English practices. My understanding is, however, that many Welsh and Scottish practices will have to raise their performance to get there--as, too, will some English practices. Therefore, a lower target was justifiable and I made a concession. It will stimulate practices to raise their performances to those that are being readily achieved in wide parts of England.

The 90 per cent. target is a World Health Organisation target. It is always stated that our agreed aim is for the National Health Service to be one of the best health care systems in the world. I cannot accept that the performance targets for vaccinations in our National Health Service should be below the level accepted by the World Health Organisation. The hon. Member for Livingston may be right--I have not looked it up--in saying that only High Wycombe hits 90 per cent. Why on earth should High Wycombe be the only place in the United Kingdom where it is legitimate for the GPs to strive to reach the best international standards? I believe that the hon. Gentleman should be committed to my principle of a performance-based contract.

When people looked around for other reasons why the GPs rejected the contract, the capitation argument was raised. As the hon. Member for Livingston said, we are talking about a contract where capitation is by far the largest single element. We are moving from 48 per cent. to 60 per cent., although that includes some new elements that we are counting as capitation. I do not accept, for the reasons that the hon. Gentleman has given, that that will have the slightest effect on average lists. The situation in the 1960s must be compared with one where we will make it much easier for patients to change their practice and for them to have access to information about the kind of services that their doctors will provide. We believe that it is right to spread the work load more fairly and to reinforce the efforts of those GPs to attract and retain their patients. However, they will not do so if they build up enormous lists. Any GP with an average or near-average list will strive to get performance payments that arise under the other part of the contract.

The hon. Member for Livingston claimed that partners are being turned away in some practices and that the number of GPs is being reduced. If that is happening, it can only be because the GPs have been carried away with their own campaigning. The only reason for not replacing a partner who has retired is that GPs are taking the view that they can earn more with four partners in the practice than they can with five. They are, therefore, somewhat irresponsibly deciding to increase their work loads, not to replace a partner when he retires and to cut back on the amount of time that they give to their patients. However, GPs will not benefit from such actions. They will lose their patients to those other GPs who will be inspired by the contract to set themselves a reasonable work load and to go after the performance payments that we are making for a good delivery of service to patients.

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Mr. Robin Cook : If the Secretary of State accepts that longer patient lists would be at the expense of patient care and that it is not his intention that GPs should go for longer patient lists, will he accept the proposal that the upper limit for patient lists should be reduced from 3,200 to 2,500? If not, why not?

Mr. Clark : The extent to which any given number of patients reduces or does not reduce the amount of time given to patients depends on the amount of time that the doctor puts into his practice. We know from the last study of GPs that the average commitment of a GP to his practice is 38 hours a week. The contract requirement is for a minimum of 26 hours direct availability to patients. I do not see, however, why a GP who wants to have a larger than average list could not make himself available for more than 26 hours and still provide an adequate standard of service.

Patients will judge for themselves whether the amount of time that they receive from their doctors is adequate. I hope that, as we open the eyes of more patients as to what can be achieved by modern general practice, they will be particularly attracted to those doctors who have good standards of vaccination, who go in for the health promotion and the prevention of disease that we are stimulating and who offer minor surgery and all the other advantages to patients.

Mr. Spearing : The Secretary of State has ranged at great speed over other matters, but I wish to take him back to his complaint that the doctors wished to take up matters after the ballot. Does he recall that about 40 years ago, when the Health Service was founded, one of the big issues was that doctors were to be independent contractors and not employees? Is not the Secretary of State's complaint completely invalid, because he must accept that they are independent professional contractors providing a professional service, not employees like people on the railways or on the docks?

Mr. Clarke : That works both ways. I accept that they are independent contractors. However, I do not accept the Labour party's claim that, if one is an independent contractor, one is entitled to dictate from one's own side of the table all the terms of the contract.

Mr. Spearing : I am not saying that.

Mr. Clarke : That is exactly what the Labour party is saying. The motion says that, if the doctors do not want it, the matter should be reopened and we should carry on producing terms until they are wholly acceptable to the GMSC. Is the Labour party saying that, if they vote against it 60 : 40 next time, it might accept that some duty falls on the Government to ensure that the patients are looked after?

Dame Elaine Kellett-Bowman (Lancaster) : Will my right hon. and learned Friend give way?

Mr. Clarke : There are two sides to the contract. The hon. Member for Newham, South (Mr. Spearing) is right to say that history repeats itself in many ways. The extraordinary way in which the Labour party-- bereft of any ideas of its own on the Health Service--simply follows through newspaper cuttings of what the GMSC or the BMA is currently arguing is a strange reversal of previous form.

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I shall not go back to the 1970s, when the Labour party had great battles with the doctors and the nurses and did not accept votes and the terms and conditions that they wished. I shall not go back either to the 1960s, when the Labour party had equally dramatic battles with the GPs, among others, and it settled the last contract when faced with industrial action by the GPs. It started with the whole National Health Service in 1946.

It is astonishing, when one looks at the present controversy, how much history has so far repeated itself. In March 1946, the BMA's main objection to the then Labour Government's White Paper was that it had not been consulted during the course of it being drawn up. Aneurin Bevan was repeatedly attacked for what was described as a dictatorial attitude and his insistence on imposing things on the profession. The BMA's main argument was that the new health centres should be introduced on an experimental basis and not introduced nationwide. A BMA member even compared Aneurin Bevan's proposals to a "regime which is now coming to its sorry end in Nuremburg". I regret to say that, in reply, Aneurin Bevan called them

"a small body of politically poisoned people".

That is language to which my hon. Friend and myself would never resort.

About 56 per cent. of doctors opposed co-operation with Nye Bevan's proposed creation of the National Health Service. Indeed, they voted by 9:1 against accepting the terms and conditions offered in the Health Service. However, history has not repeated itself entirely, because I do not recall that the Labour party was on the side of the nine. Today's Labour party-- the very much lesser figures who occupy their predecessor's shoes--are prepared to accept a re-run of history so far--

Mr. Nicholas Winterton (Macclesfield) rose --

Dame Elaine Kellett-Bowman rose --

Mr. Winterton : I am grateful to my right hon. and learned Friend--

Dame Elaine Kellett-Bowman : Hang on-- [Interruption.]

Mr. Winterton : I take my right hon. and learned Friend's remarks seriously. There is considerable sense in what he says. However, will he pay credit to the overwhelming majority of general practitioners who play a vital part in the health care of this country and will he admit that they have done so since the foundation of the National Health Service? Will he also admit that the overwhelming majority of people in this country have confidence in our general practitioners? I hope that, later in his constructive speech, my right hon. and learned Friend will say that he is prepared to enter into on-going discussions with the general practitioners to seek a satisfactory solution which, I believe, will be in the interests, not only of the doctors but of the patients.

Mr. Clarke : I am grateful for part of my hon. Friend's advice because I should acknowledge that our general practitioners provide a valuable service to the public and are committed to the National Health Service. Many of them voted as they did, believing that they would lose money through our proposals, when they will not. We are proposing to reward the services and work load that the

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best doctors already operate. Many of them will benefit from our proposals. It is up to the GMSC and ourselves--or certainly it should be--to explain yet again to the doctors what we have agreed. As I made clear yesterday, I am prepared to listen to the GMSC if it comes forward with any proposals, and to explain the difficulties.

Dame Elaine Kellett-Bowman : Will my right hon. and learned Friend give way on that point?

Mr. Clarke : Yesterday I was faced with negotiators who have now lost all their negotiating mandate. There is nothing that they can conceivably agree to. They do not know what they want and wish to reopen the whole thing over a prolonged time scale, presumably then resorting--as the Opposition wish--to another attempt to ascertain whether that is acceptable.

Dame Elaine Kellett-Bowman : Is my right hon. and learned Friend aware that the trend that he referred to about five minutes ago of patients transferring to doctors who offer a better service is already happening in my constituency, where some go-ahead GPs have set up exceptionally good premises, with a well-man and well-woman clinic, a hyper-tension clinic, their own night service and a 24-hour on-call service? Patients are already transferring to that practice from practices that do not supply such facilities. The doctors who are supplying these facilities will be infinitely better off in the future because at the moment they are providing those facilities out of sheer professionalism, but in the future they will be paid for what they are doing.

Mr. Clarke : My hon. Friend knows and supports the fact that we will make it easier for patients to change practices and that we will make it possible for them to be given more attractive information about what their practice offers.

The position of the Opposition and of some people in the profession is that rewards to attractive practices, such as my hon. Friend has just described, should not be so great in order to protect the position of those who are not offering new services or achieving the higher standards. That is not a glorious position for either the Opposition or the profession to accept. Indeed, it was not the position adoped by the GMSC. I pay tribute to the negotiators that I faced on 4 May, because they drove a hard bargain on behalf of their GPs. They got me to make concessions which, frankly, I would not otherwise have been minded to make, and they came up with a fair package. We should now explain to the doctors that we have achieved a fair balance in the interests of the patients as well as of themselves.

We are drawn over the history of these matters partly because we are going over the history of the Labour party's objections to our reforms as they pick them up as we go along. However, history needs not repeat itself. Indeed, it is not doing so, because the Labour party is on the wrong side of the barricades at the moment. As I keep saying to the BMA, the barricades should come down. It is a needless and continuing controversy--

Mr. Spearing : It was the Secretary of State himself who put up those barricades.

Mr. Clarke : If the BMA would abandon its extremely indiscreet newspaper campaign, if its members would stop frightening their elderly patients and if we got back to the

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undoubted agreement that exists between us on the future of the National Health Service and the principles upon which it is based, we could make progress.

Behind all the newspaper cuttings which the hon. Member for Livingston draws upon and the continuing controversy over the contract, the fact is that the common interest in the Service between many doctors and other professionals and the Government, and the common interest among most people in this country in seeing a better Health Service, is being put into effect. Yet again, as on previous occasions, I must advise the hon. Gentleman that he will be horrified to hear that the implementation of our White Paper reforms is going smoothly and well.

I shall shortly be sending members of all parties a briefing pack giving them all the detailed information that they require. The pack has recently been sent to managers and itemises in considerable detail the progress that has been made in preparing for the reforms and in putting them into place.

The review has already changed the climate in the Health Service to an extent that I would never had expected. I have never known a service which, in the past, has been so resistant to change, engaging in planning for so much change on such a wide scale.

Although all our debates are dominated by our unfortunate problems with the medical profession, we should remember that there are many other people in the Service. The chairmen and the managers of the National Health Service authorities are extremely keen on our reforms and are pressing on with them purposefully and well. There are wide agreements between doctors and nurses, who have not been mentioned so far, on a number of systems--

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