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The Secretary of State for Health (Mr. Kenneth Clarke) : I am glad to say that the Gracious Speech reveals that the agenda for the new Session of Parliament will be very much dominated by social affairs and social issues of many
Column 450kinds. That is because we have now reached the stage where we are determining the nature of the modern welfare state and the nature of our great public services for the next decade. After 10 years of this Government, we have produced a position in which the country is much more able than ever before to create wealth and earn prosperity. I therefore believe that we have a greater duty than any previous generation to provide high quality public services and to care effectively for the vulnerable members of society. That should be the aim of all Members on all sides of the House.
That aim will not be contributed to by the kind of speech made by the hon. Member for Livingston (Mr. Cook), who is the Opposition spokesman on National Health Service matters. Frankly, at times his debating points were childish in their inaccuracy and wide of the point of our proposals.
Mr. D. N. Campbell-Savours (Workington) : On a point of order, Mr. Deputy Speaker. How can the Secretary of State make allegations about the speech made by my hon. Friend the Member for Livingston (Mr. Cook) when those allegations were written down on a piece of paper which was handed to him prior to the debate commencing?
Mr. Clarke : The comments are written in my own fair hand because those thoughts occurred to me while listening to the speech made by the hon. Member for Livingston. The hon. Member for Workington (Mr. Campbell- Savours) may not be so capable of spontaneous thought or writing that down as he thinks of it. However, some of us can do that.
Debate in this House has reached the stage where we should move beyond posters, postcards and slogans of the kind produced by the hon. Member for Livingston. During the winter, we will debate the most important piece of legislation to affect the NHS since its foundation in 1948. When the hon. Member for Livingston is forced to debate, clause by clause, proposal by proposal, he will find that the issues posed deserve far greater accuracy than he brought to them this afternoon. They deserve far more serious consideration. If he continues as he has done, the poverty of ideas about the modern welfare state in today's Labour party will rapidly be exposed. The Health Service Bill will indeed be controversial. However, the outside world, which is seeing us to a greater extent than ever before, may be surprised to discover that the House is united on the principles that lie behind the NHS. I do not believe that any hon. Member from any political party will challenge the principle that medical treatment should be given free to NHS patients at the time of delivery. Everyone shares the objective of providing a comprehensive medical service accessible to all members of the population, regardless of their means. We are all contemplating a National Health Service to be financed out of general taxation.
Frankly, it is rather silly for the Opposition to try to invent a division on principle between us when they argue about
commercialisation, privatisation and patients following money--whatever that is meant to mean--to create a political debate on a subject about which there is no division of intention between us. It should be taken as axiomatic in all debates on this subject in the House that the basis of all judgments on
Column 451health care matters should be the aim of curing disease and caring for disability. The sensible debate between us should be about how best to deliver the high quality care and best treatment required in a great public service.
Mr. Archy Kirkwood (Roxburgh and Berwickshire) : Does the Secretary of State accept that one of the questions requiring an answer is what resources must be applied to the reforms? As neutrally as I can, can I ask him whether the British public would be in favour of increasing expenditure substantially on the NHS if the matter was put to the public properly?
Mr. Clarke : I agree. Again, before we launch into the actual amounts, it is fair to say that all hon. Members have agreed that the National Health Service will cost the British taxpayer more. When we look ahead and see the demands that will come upon us in the next decade, it is quite obvious that it will cost the taxpayer much more.
Several Hon. Members rose --
Mr. Clarke : I will gladly give way on resources, when I have finished dealing with how we should find the resources and the extent to which it is realistic to look for them. In health care debates it is too easy for our opponents, from whatever party, to listen to our description of the sums of money that we are putting in and then simply outbid us, as though, somehow, despite Labour's record, they would be capable of finding more than the present Government have found.
So far, I have been involved in two public spending rounds since I came back to this Department and came to my present office in July of 1988. When I took over my position as Secretary of State, gross expenditure in the National Health Service was estimated to be £23.49 billion per annum. After the two public spending rounds that I have been through, planned expenditure for 1990-91 is £28.71 billion. That is a cash increase, in two public spending rounds, of £5.2 billion. That is an increase in two public spending rounds of 22 per cent. in cash. Spending on the Health Service has gone up. The average rate of spending has gone up by over one fifth in cash terms. The real-terms increase in spending that that represents over and above inflation--actual inflation last year and anticipated inflation now--is 8.8 per cent.
This Government, in two public spending rounds, plan to increase annual spending on the National Health Service by almost one tenth in real terms. That is a considerable achievement, first, for two Chief Secretaries to the Treasury, the present Chancellor of the Exchequer, my right hon. Friend the Member for Huntingdon, (Mr. Major) and the present Chief Secretary, my right hon. Friend the Member for Kingston upon Thames (Mr. Lamont), and secondly, for this Government. That enormous increase in resources represents a deliberate choice by this Government to give the very highest priority to spending on the National Health Service, among all the other demands on the public purse.
Therefore, if we are to be faced by people claiming that they can simply outbid us in public spending terms, they must reflect on the fact that, in 1990-91, the level of spending of taxpayers' money on the National Health Service will be 45 per cent. higher in real terms, over and above inflation, than when we took over from the Labour party in 1979.
Mr. Dennis Turner (Wolverhampton, South-East) : Will the Secretary of State please accept that people have the greatest difficulty in coming to terms with his credibility? The right hon. and learned Gentleman is trotting out all those figures, but 127 beds have been closed in my area of Wolverhampton. We have a longer waiting list that will not be met, even with his last bonanza. We can do nothing about the fabric of our hospitals. People are dying. They cannot get into our hospitals. The Secretary of State tells us that everything is going well. The people know that they have a service that the Secretary of State set for them at 1986 standards. For our electors we want standards for the 1990s, not for the 1980s.
Mr. Clarke : The Wolverhampton district health authority is spending more money now than it did last year, over and above inflation, and it is treating more patients this year than it was last year. I will refer to Wolverhampton district health authority and others--
Mr. Clarke : The hon. Gentleman says that that is untrue, but he is not familiar with what is happening in his own hospitals. Wolverhampton is spending more money and treating more patients than last year. I shall turn to short-term promises-- [Interruption.] I have just explained that we have increased spending now by 45 per cent. in real terms over and above the level of spending that we inherited from the Labour Government who, in 1979, were spending £8 billion in total on the National Health Service -- [Interruption.]
Mr. Clarke : It is plain that the Labour party is claiming that it can somehow exceed the public spending rounds in which we have raised public spending now by over £5 billion in two spending rounds alone. However, no Opposition spokesman has ever given any substance to that claim. Against our record of increased spending, the nearest that the Labour party has ever got to explaining what it would do about National Health spending was earlier this year when the right hon. Member for Islwyn (Mr. Kinnock) gave a press conference setting out what he expected would happen to NHS spending.
My source is the Evening Standard of Thursday 8 June 1989. Charles Reiss, the political editor, whose accuracy as a journalist is rarely if ever challenged in this House, quotes the Leader of the Opposition as follows :
"The Health Service cannot expect a blank cheque from next Labour Government, Neil Kinnock said today.
Although the aim would be only the best', he said that the NHS would have to live in the real world where resources were limited. We would not taunt the National Health Service with the implausible idea of a blank cheque. Indeed, that would be very inefficient in NHS terms.'"
Mr. Turner : We would spend more.
"Mr. Kinnock said that over a period of Government' "
which I take to mean the lifetime of a Government-- " Labour would make up the shortfall in health service funds, reckoned to be running at £3 bn a year. The extra money would have to be delivered over time, and based on properly calculated needs' "--
whatever that may mean. A Labour Government obviously would not employ any staff to discover what those needs would be.
Column 453Opposition Members who think that they can win the argument--
Mr. Neil Kinnock (Islwyn) : Before the Secretary of State leaves that point, I am sure that he will be well aware that the figures to which I and many others have referred arise from the calculations efficiently made by a Select Committee of this House, demonstrating the difference between the Government's expenditure, related to the general rate of inflation, and the actual rate of rising costs to the National Health Service to meet the needs of the elderly in our society and the development costs facing the Health Service. The difference between the two sums is calculated by experts outside this place and by the Select Committee to be around £3 billion. That is the target at which we should be aiming, in addition to what the Government were committed to spending. If the Secretary of State does not understand that, he is not only deficient in his commitment to meet the realities facing the National Health Service, he is deficient in his arithmetic as well.
Mr. Clarke : The sums of money that I have just described and the most enormous increase in real terms expenditure have run ahead of the demands on the Health Service, as we inherited them, and have enabled us to expand the service as never before. I ask the public to make a comparison between the protestations of the Labour party to outbid us and our real record of putting money in. A proper comparison is between the over £5 billion that we have produced in the last two public spending rounds and the half-baked promise of £3 billion over a lifetime of a Government, which is all that the Opposition have put forward--
Several Hon. Members rose--
Mr. Clarke : Well, let me just turn to where the money actually goes as a measure of whether our increased expenditure has enabled the Health Service to expand and whether the public are getting the benefit of the extra expenditure I am talking about.
As one of my hon. Friends pointed out earlier, the main effect of a 45 per cent. real terms increase in expenditure has been a great expansion in the number of patients treated and in the number of front-line staff--not accountants and so on--employed in the National Health Service.
In the past decade, the number of people treated each year in hospital has risen from 5.3 million to 6.6 million. For every five patients treated in 1979, six patients are now treated and they are receiving better and more sophisticated care as standards of medical treatment have advanced. There are 67,000 more nurses and 14,000 more doctors working in the Health Service now than there were in 1979, and they are better paid, as their pay had declined under the previous Labour Government. All that represents the best and most accurate reflection of the resources put in.
Mr. Geoffrey Lofthouse (Pontefract and Castleford) : The Secretary of State has referred to an expansion in services. Twelve months ago, the Pontefract health authority transferred money that had been made available by his Department to ease waiting lists to a private hospital, Methley Park hospital. The operations were
Column 454carried out by the same consultants who work for the NHS in Pontefract. The money covered 230 operations in the private sector, but it could have covered 500 at the Pontefract general infirmary. How can the right hon. Gentleman agree with a health authority passing over funds when 300 of my constituents are still on the waiting list because of that transfer of money to the private sector?
Mr. Clarke : If the hon. Gentleman puts that in a letter, I shall check out the accuracy of his claims. Contracts with private-sector hospitals of the kind described by the hon. Gentleman are made only when health authorities find that they can increase the level of service that they give to their patients in a cost-effective manner, which is acceptable to those patients. If the hon. Gentleman gives me the opportunity to do so, I shall check out his allegations. Several Hon. Members rose --
In reality, there has been a huge expansion of resources, which has been matched by an expansion in the number of patients treated and the professional staff employed. How is it then that, each year, hon. Members on both sides of the Chamber, especially Opposition Members, leap to their feet at this stage of the financial year to talk about beds being closed? They always talk about the furniture rather than the patients. They talk about beds being closed and apparent cuts in the service provided in their locality. Each year, regardless of how much money is put into the Health Service to expand it, many district health authorities find that they are subject to end-of-year pressures and find that they must make sudden adjustments to their plans. That practice shows the need for reform in the way in which the large sums of money I have described are spent, which the Government are committed to put into the Health Service.
Mr. William O'Brien (Normanton) rose --
I dare say--I challenge any hon. Member to prove me to the contrary--that every district health authority in this country, by which I mean England for which I am responsible for this purpose, is spending more money in real terms than it was last year. They have all received much larger sums of growth money than they have had before. All district health authorities are treating more patients than they were this time last year, they are expanding their services and carrying out service developments. The trouble is that, as things are presently organised in the NHS, they have no means of controlling the pace at which they expand their services or of matching the release of resources to the growth of patient services to avoid the chopping and changing and other short-term expedients.
The hon. Member for Livingston intervened with the example of St. Mary's, Sidcup. I have just written a letter in response to the rather startling assertions by a consultant at that hospital who said that services are being cut. That is total nonsense. The regional allocation to that district health authority is carried out by the regional health authority, not by me. I give money to the region, and it in turn decides how best to distribute that among its
Column 455individual districts, but within certain guidelines issued by us. I believe that that would be the case under any Government. My letter states :
"the Region and the District are spending their share of record-breaking levels of public spending on the NHS this year. I allocated £1,083 million to South East Thames for 1989/90, which is a 4.2 per cent. increase on the previous year."
As for the supposed cuts at Queen Mary's hospital, as I say in my letter :
"The position is, in fact, that acute patient activity is presently expanding so quickly that it is running about 4 per cent ahead of the level planned for 1989/90. That clearly has financial consequences, so in order to comply with its original plans, Bexley Health Authority is controlling the level of patient activity by reducing the volume of facilities which are available for up to three months by a net reduction of 17 surgical beds. The important point is that the number of patients treated will be maintained at the levels planned for 1989/90. This will be nearly 500 more patients than were treated in 1988/89,".
That position could be repeated. My guess is that it is repeated in Colchester and Wolverhampton. The hon. Member for Nottingham, North (Mr. Allen) is trying to get in for Nottingham. He and I constantly talk about such matters in the Nottingham area. All these authorities are treating more patients than last year. At the moment, the way in which the system is run means that they have no means of knowing how to respond when their expansion runs ahead of their plans, and they often have to cut facilities to ensure that growth in their services does not outrun the extra money which they have received. This does not mean that there is a lack of money going into the service. Instead of defending the way in which the NHS is currently run, protesting that it needs no reform and that it is sensible to have a row every winter in Wolverhampton about which beds should be closed when expansion occurs too quickly, hon. Members representing Wolverhampton should press for more common sense to be used in running the system.
As my hon. Friend the Member for Mid-Kent (Mr. Rowe) said, the hospitals which expand their services most quickly tend to get into most trouble. The unreformed National Health Service, run as it has been for so many years, tends to lead to the best units getting into difficulty and the poorest and weakest units having a quiet life. It is that system which the hon. Member for Nottingham, North wishes to preserve.
Mr. Michael Grylls (Surrey, North-West) : My right hon. and learned Friend has described in great detail this afternoon the huge and increasing sums of taxpayers' money being put into the Health Service. Does he agree that, as it is likely that this will be a permanent, large part of the British budget, it is absolutely essential to give good value for money in the Health Service if we are to get the best pound for pound out of it? Therefore, is that not a good reason to support the Government's reforms, a large number of which are aimed at giving good value for money?
Mr. Clarke : I entirely agree with my hon. Friend. The Opposition seek to dismiss the vast sums of money coming in and respond with vague descriptions of how much extra they would put in. They are not remotely interested in the number of extra patients treated and dismiss the fact that the service is expanding in all their district health authorities, as it is in ours. They obstinately oppose any attempt to improve the way in which we spend the money
Column 456in order to maximise what we receive for it, avoid the frustrations faced by consultants year in and year out and maintain patient growth.
Mr. Tony Banks (Newham, North-West) rose--
My hon. Friend for Surrey, North-West (Mr. Grylls) is right to say that we must pave the way in our legislation for reforms to obtain certain self- obvious goals which no future Government could go back on. We need to match the growth in money with the growth in services which we want. The National Health Service must have greater ability to decide where the public need for growth in services is currently greatest. It needs better management to target growing resources on the units best able to meet public need. Those are self-obvious observations. Future generations will wonder why the Labour party lined itself up with reactionary vested interests inside the service to try to oppose the reforms.
We shall tackle the problems I have just described by making it much clearer where responsibility lies for deciding which are the most urgent public needs in each locality. It will fall to the district health authority to decide what the public need for services will be, using judgments based on quality, convenience for patients and the need to raise the quality of care for their residents. It will not be based, as the hon. Member for Livingston casually claimed, on an appraisal of costs alone. The district authorities will also have a duty to base the contracts, which the hon. Gentleman so bitterly attacked, on the advice of GPs and, as far as is practicable, to reflect their wishes.
Certain general practitioners will, if they wish, take the responsibility for handling funds so that they can determine where those resources are best targeted for the benefit of their patients. Rather than increasing central control, it is our desire to devolve more of the responsibility for management and decision making to the sharp end. Local managers, doctors and nurses, and others responsible in hospitals and in community units will have more freedom to determine how the units run and what their priorities are, under the proposals which I have made. In those places where we have put together self-governing National Health Service trusts, people will be free from the bureaucracy and many of the frustrations which come from the present inadequate way of doing things. They will be able to put their best efforts into forging closer links between local hospitals and local people and developing services in the best way. Difficult problems have to be tackled to put this in place. We must measure the quality of care in the National Health Service and find out what the costs are and where the money is being spent. As has been said, everyone in the service understands the need for a better system for measuring quality. The British Medical Association has joined me in saying that we must have better financial management and control. It has said that the NHS could benefit if it knew where the money went and what the costs were. That is why the clinical auditing proposals have received widespread welcome throughout health care professions and among doctors and nurses, and why the development of resource
Column 457management systems in the Health Service has the full and active support of doctors and nurses throughout the country.
Our reforms will produce a system which can match the huge sums of money that we are putting in with better quality and work load. Everyone in the service will be responsible and accountable. They will know exactly what their units are meant to deliver and what resources are available for them to deliver it with. The whole system will be made for the consumer.
I heard somebody ask why the public do not believe that. Right hon. and hon. Members are challenging the public's reaction. We must compare the two reactions that we have had to the present state of our NHS proposals. The hon. Member for Livingston rarely addressed the contents of the Bill which is to be introduced, but he referred again and again to opinion polls and the public reaction. Today, we have seen the products of Labour's post a protest campaign and, as a contrast, the launching of the Health Reform Group, which is made up of professionals who support our reform.
In my opinion, like the British Medical Association's opinion polls in the summer, the Labour party's postcard campaign is a measure of the number of people who they have succeeded in misleading and frightening the public about the contents of our reform.
I have in my hand a document issued by the Labour party as part of its postcard protest campaign. It does not contain a solitary true statement about the reforms in the Bill. It is clearly being used for two purposes-- first, to get people to send in sackfuls of postcards and secondly, to get people to contribute to Labour party funds, which are obviously urgently in need of replenishment.
The headlines on the back of the document say :
"The Government wants to give your doctor a fixed budget." That is not true. The fund-holding and practice budget proposals will be taken up by those doctors who wish to manage the funds and who find that it is to the advantage of their practice to do so. The document then says :
"If the money runs out you could pay with your health." Most definitely not true. I cannot believe that hon. Members in this honourable House will nod, apparently in assent, at a statement which they know to be a lie. It has been explained to them repeatedly that, if a budget-holding doctor runs above his budget, the penalty will be his being deprived of the right to control the budget. No penalties fall on his patients.
The postcard highlights four issues and says :
"Doctors compete for extra patients--even though that means less time for each patient."
I believe that GPs will attract patients to their lists by responding to their greatest need, which is more time. As I explained when we debated this subject, it is plain what will happen as a result of GP contracts. The postcard continues :
"Local hospitals should opt our of local health authority control. Then they no longer have to offer a comprehensive range of services--which could mean fewer accident and emergency and maternity wards."
I shall save for another occasion the tortuous and fanciful argument which leads to the claim that there will be fewer accidents and emergency and maternity wards. The postcard repeats the allegation :
Column 458"No one knows what will happen when the money runs out' "-- a quotation which has no source.
"When you want an operation, your GP or your health authority arranges a contract so your operation could be in a hospital miles away, simply because that's cheaper."
That is simply not true either. There is no point in declaring to the House that one has postcard and opinion poll results showing that people oppose reforms when the postcards have been systematically collected by asserting untruths.
Mr. Robin Cook : I am most grateful to the Secretary of State for flattering me by encouraging the view that I and my hon. Friends alone can influence so many people. While I entirely accept the flattering assertion that I have been able to get, allegedly through misrepresentation, such support among people who vote Labour against these proposals, can the right hon. and learned Gentleman enlighten us as to why more Conservative voters oppose the proposals than support them? Is he saying that that is entirely down to the influence of the hon. Member for Livingston and his right hon. and hon. Friends? Is there nowhere in the Secretary of State's mind lurking the possibility that the electorate have minds of their own, and intelligence, that they have applied their intelligence and have been unconvinced by his proposals, and that, for once in his life, he ought to listen to what people are trying to tell the Government?
Mr. Clarke : I believe that patients will steadily be reassured as they discover that nobody will privatise the National Health Service, that nobody will deprive their doctor of the ability to prescribe the drugs that they require and that nobody will stop a doctor giving treatment when he has taken a fund-holding budget. As time goes on, and as we debate these proposals more seriously, that type of attack will be exposed as fraudulent, and indeed scandalous, from a party which purports to support the NHS.
I contrast the complaining and the speech made by the hon. Member for Livingston with today's announcement of the formation of the Health Reform Group. I commend to Opposition Members the article that appeared today-- [Interruption.] It is by Dr. Colin Leon-- [Interruption.] -- and appears in the Daily Mail -- [Interruption.] If it has not yet come to Opposition Members' notice, perhaps they will let me read it. Dr. Leon wrote :
"I have always voted Labour and have always believed socialism to be more attractive than capitalism, but I do not share Labour's belief that the Health Service is under threat from these reforms. Labour's opposition has nothing to do with logic--it is mere party politics. The truth is that, whichever party were in power, only a fool would deny the need for thorough reform
The Government has proposed that large hospitals will have the right to opt out', to become self-governing, with freedom to develop the services their patients need, and fix their own rates of pay, and staff numbers.
Opponents say this will produce hospitals run by accountants for the sole purpose of making profits. What nonsense. Hospitals which opt out' will not leave the NHS but will be given more responsibility for their activities and more opportunities to manage their own affairs. What doctor could oppose that?
Hospitals need less bureaucracy and stronger management. It's about time the medical profession accepted the need for some kind of accountability. We spend public money so should be called upon to explain what we do with it."
I commend that article to the House.
Column 459I remind Opposition Members of the welcome for our reforms, which I have mentioned in previous debates, that appear in the columns of Marxism Today and the New Statesman. People with a wide range of political opinions on other subjects are united in the desire to have a better National Health Service. They accept the case for better management. They accept that it is possible to improve the service by getting better value for all the extra money that we put into it. I look forward to dealing with the Health Reform Group, as it is made up of people who want to support our reforms and to make a constructive contribution to their implementation. Of course the Government will listen, and of course we need a contribution from the medical and nursing professions. We also need a contribution from people of all political views if they are genuinely motivated by a desire to have the Health Service run more sensibly. That is why, when we talk about the possibilities of GPs fund- holding and holding practice budgets, we are asking GPs to volunteer to develop that idea with us. We are working with doctors who want to make a success of the reforms for the benefit of their patients. That is why, when we talk about self-governing NHS trusts, we are looking for local groups of doctors, nurses and leading business men to come together and make propositions explaining what they want to do with their local services and then work with us on the experiment to make it a success.
I believe that such an approach, and looking for people of good will in the service to work with us to preserve what is best in the NHS but to run it better in the 1990s, will in the end win more support for the Government than can possibly be swept away by the silly postcards, the silly posters and the foolish attacks of the Labour party. Mr. Campbell-Savours : My hon. Friend the Member for Livingston (Mr. Cook) asked the Secretary of State for a clear answer in regard to an incident in London and the ambulance service. Can we have an answer? Secondly, can the right hon. and learned Gentleman give us an assurance that he is not trying to press privatisation of the ambulance service during the ambulance dispute?
Mr. Clarke : I know when the Labour party has had enough of the Health Service--it gets back to the shop stewards bit, the strikes and the pay claims. That is when the Labour party comes to life when we are debating our great public services. [Hon. Members :-- "Answer the question."] Of course I shall answer.
Mrs. Mahon rose --
Mr. Clarke : I apologise to the hon. Lady for the lack of time. We have moved off the NHS reforms now. We have moved to the point at which the hon. Member who aspires to be Secretary of State for Health acts as a shop steward for the National Union of Public Employees and presses
Column 460its current pay claim. The hon. Member for Workington (Mr. Campbell-Savours) also wishes to press a pay claim against the service.
The fact that there is a dispute with the ambulance men is obviously a source of regret to the whole House. It should be resolved as soon as possible. I never want management of the NHS to have a conflict with the ambulance men and I deeply regret that the trade unions who lead the ambulance men have brought us to the present position. The hon. Members for Livingston and for Workington pursue every claim the union makes and, as far as I can see, press resolutely on with their support for extreme industrial action in support of a very high claim.
I repeated last week the reports that have come to me from the management of the London ambulance service and that of the west midlands service, who have lost patience at the gap between the public assertions of the trade union leaders involved and what was happening in those great cities. I readily accept that, in the bulk of the country, ordinary ambulance men and women will not withdraw the accident and emergency service. Although I may disagree with their taking action against the non-emergency services, I am not aware of anybody in my county of Nottinghamshire failing to respond to an accident or emergency call, but in London they did.