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present, it is not the Government's policy to defeat terrorism but to react to it--to wait until the IRA strikes and then try to parry the blow. That is not the way to defeat terrorism. There must be a strong and resolute security initiative against the IRA. The Government must be prepared to corner and to catch the IRA, and when the terrorists are caught to ensure that they are given a sentence that fits the crime.

I do not believe that the Secretary of State for Northern Ireland was acting in the best interests of the Province when he suggested that at some time in the future, there may be an opportunity for IRA representatives to sit down with the Government. Such a comment is an act of folly and encourages terrorism. Terrorists breed on hope--the hope that they can achieve by violence that which they could never achieve through reasoned debate, argument or the ballot box. The IRA believes that, if it can continue to press the Government to appease it, then the IRA is on the winning road. Comments such as those made by the Secretary of State give the succour that the IRA wants and the justification that it needs among its own people to continue its campaign of violence.

I do not deny that the task of defeating terrorism would be made easier even if Northern Ireland had a stable political structure, and neither do I believe that the search for one should be halted until the IRA is defeated. Nor do I believe that the battle against the IRA should wait until the Province has a stable political structure. The search must go on for a means whereby Northern Ireland can be governed in peace and enjoy reconciliation. However, the means by which Northern Ireland is presently governed will not produce peace, stability and reconciliation. The Anglo- Irish Agreement is not working ; it has failed. We must search for an alternative, and I urge the Secretary of State for Northern Ireland and the Government to show some flexibility in relation to negotiating an alternative. It is interesting that leading players in the Republic have shown greater flexibility than the British Government in a suspension of the Anglo-Irish Agreement to allow new negotiations to begin. There has been a clear indication from the leader of the SDLP that he is prepared to negotiate an agreement that would transcend in importance the Anglo-Irish Agreement. The two Unionist party leaders have indicated that they are prepared to negotiate an alternative to and the replacement of the Anglo- Irish Agreement. I urge the Government to make that their second priority in Ulster. Their first priority should be the defeat of terrorism and their second the attainment of stable political structures in the Province so that our people can consider, as can the people of Britain, the social and economic matters that concern all of us in the Province but which must come behind the primary issues of the life and death of our fellow citizens in Northern Ireland.

7.55 pm

Mr. Dafydd Wigley (Caernarfon) : I shall not follow the hon. Member for Belfast, East (Mr. Robinson) down the road to Northern Ireland, although I am sure that right hon. and hon. Members in all parts of the House join him in hoping that there will be growing peace in the Province.

I shall first take up a point made by the hon. Member for Hampshire, North- East (Sir D. Mitchell) in respect of the possible conflict of interests that might arise in the allocation of National Health Service resources-- whether


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they would be better spent on patients or on people making wage claims. I suggest that such is an artificial divide. If patients are to receive the level of service that they need, they must enjoy back-up facilities such as the ambulance service. I place it on record that the ambulance workers of Wales and particularly of my own county of Gwynedd have my wholehearted support for the stand that they are making. I cannot fathom why the Government are not prepared to go to arbitration, other than to dictate that ambulance workers must be employed on the Government's terms alone and because the Government are not prepared to yield an inch even if independent arbitration attempts to move them in that direction.

The right hon. Member for Castle Point (Sir B. Braine), the Father of the House, referred to the Human Fertilisation and Embryology Bill, which I understand will go first to another place before coming to this Chamber. I hope that the House will give the utmost consideration and sympathy to those people who are experiencing difficulty in having children and who need to resort to in vitro fertilisation techniques--techniques that would not be available today had the restrictive clause that is now to be considered been on the statute book 30 years ago.

I ask the House to consider also the plight of those families with children suffering from genetic diseases. There is hope of progress being made in respect of conditions such as muscular dystrophy and cystic fibrosis, and it would be a tragedy and a crime if we were to close the door to the research that is now being undertaken. I regret that questions relating to abortion and to implementation of the Warnock report should be mixed together in one Bill. Both issues are important, but they should be treated on their own merits. I hope that that may yet be the case.

I want to set the question of the Health Service, social services and care in the community in Wales in the context of the politics of my country and of the Queen's Speech. The Gracious Speech had little relevance to Wales. We are governed by the Welsh Office, which has a budget of £3.5 billion per year. The Secretary of State for Wales has 2,500 staff, yet as a Department the Welsh Office has not brought forward any legislation in the past 10 years. There are different aspirations in Wales, as can be seen from the political pattern of election after election.

I do not mean to be unkind to Conservative Members, but never in 120 years have the people of Wales elected a majority of Conservative Members of Parliament. Nevertheless, we are governed by a Welsh Office that is headed by someone akin to a governor-general, who promotes policies that may suit the hopes and aspirations of south-east England but which certainly do not suit the hopes, aspirations and community values of the people of Wales.

We celebrated only last week the 25th anniversary of the Welsh Office, which has responsibility for health in Wales, and I hope that its Ministers will take heed of a comment made yesterday on radio by a former senior civil servant from their midst, Mr. Richard Hall-Williams, that the overriding question now is how democratic accountability can be achieved for the Welsh Office, which currently is not democratically answerable to the people of Wales.


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We hope that, in the course of the parliamentary year, policies relevant to Wales will be developed. Regrettably, the priorities of the NHS Bill are not those that we seek. Only a handful of doctors' practices in Wales would cross the 11,000 threshold, and none of our hospitals has shown any interest in self- government. The first part of the Bill is irrelevant to Welsh circumstances, while the second part does not appear to have responded to the Welsh community care angle.

The Secretary of State for Health today said candidly that he spoke as Health Secretary for England, and that explains much of what we see, and do not see, in the Bill. A few weeks ago, at the Conservative party conference, he made considerable play of the importance of cottage hospitals, whose protection, he said, was part of the rationale for the legislation. It is ironic that the present incumbents in the Welsh Office are rapidly closing down community hospitals in Porthmadog, Caernarfon and Llangefni in my constituency--and, indeed, throughout Wales. Last week the hon. Member for Cardiff, Central (Mr. Grist)--the Parliamentary Under- Secretary of State for Wales responsible for health--said that the Welsh Office did not recognise the concept of the cottage hospital. There are times when I would take the word of the Secretary of State for Health in England before I would take that of the Welsh Office.

The White Paper on care in the community--published only a few hours before the Queen's Speech : this must be one of the most rapid metamorphoses from White Paper to legislation--contains a section relating to the needs of Wales. The latter section referred to those needs in detail, and said that a separate section to deal with them was necessary because of the different circumstances of Wales ; the Bill, however, makes no independent provision for Wales.

Conservative Members have raised another matter that affects health care-- that of housing standards. A housing crisis is developing in some areas, including mine. Housing waiting lists are shooting up : in the past two years they have risen from 800 to 1,400 in the Arfon borough, and from 350 to 550 in the Dwyfor district, both areas in my constituency. People who have bought their council houses have found themselves in difficulties, and have been forced to sell them and go back on to the council house waiting list ; young people with no hope of being able to buy their houses are unable to rent in the private sector because rents are too high. Given the available resources, surely we can overcome our housing crisis.

We hoped that the Queen's Speech would deal with regional economic problems by attempting to redress the balance between the overheating of the economy in the south-east of England and the continuing high unemployment levels in many of the Welsh valley areas, as well as rural north-west and south-west Wales. Unfortunately, it made no reference to such problems. When unemployment is between 10 and 12 per cent. in some areas and down to 2 per cent. in others, something is clearly wrong. As we approach 1992, and as the forces of the European Community superimpose themselves on the centralising forces that already exist, we need a much more radical regional policy if we are to retain a semblance of balance between developments in the various countries and regions in these islands.

The Disabled Persons (Services, Consultation and Representation) Act 1986-- of which the hon. Member for Monklands, West (Mr. Clarke) was the author-- has still


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not been fully implemented, although, as other hon. Members have pointed out, many parts of it are an essential feature to any provision for community care. That Act should be implemented in full. If the Government do not intend to give the starting orders for that to happen, they should spell out clearly what alternative provision is made in this or other legislation to meet the needs of disabled or mentally ill people who are transferred from hospitals into the community.

The Queen's Speech is largely irrelevant to Wales ; the NHS Bill does not meet our needs. Until Wales has its own Parliament, which can make decisions in line with the needs and hopes of its people, we do not believe that we shall be given the justice that we deserve. 8.4 pm

Mrs. Edwina Currie (Derbyshire, South) : I shall follow the remarks of the hon. Member for Caernarfon (Mr. Wigley) about the Human Fertilisation and Embryology Bill and community care in a moment. First, however, let me say that several items in the Queen's Speech are very good news. Any of us who have ever worked in that appalling building at Elephant and Castle will be delighted to learn that the demise of the Property Services Agency is on the cards ; if ever there was a case for getting rid of direct labour and the old gang, this is it, and it should have been done years ago.

The news that there is to be a Bill on food safety is also immensely welcome. That will put us ahead of the rest of Europe. It will bring us into the age of the microwave and the blast chiller, intensive farming and irradiation. We do not yet know whether the general public will accept irradiated food ; the point is, however, that consumers want to know that health and hygiene standards are strictly monitored and controlled, and they want more information. That will mean better labelling--not just little lions--to give them some choice.

The food safety legislation has been in preparation for a long time. Perhaps, if it had been in last year's Gracious Speech, we should all have been spared a good deal of trouble. Nevertheless, I welcome the Bill and urge hon. Members on both sides of the House to do the same.

We should reflect on the extra money for the NHS that my right hon. and learned Friend the Secretary of State mentioned so proudly : an extra £2.4 billion this year, or £2.6 billion when increased efficiency is taken into account--sales of surplus stock, for example. As my right hon. and learned Friend pointed out, it means a total of £5.2 billion in cash over two years. That is the biggest increase that the NHS has ever seen, and compares with the total of just over £7 billion that the Opposition parties put into it 10 years ago. It will help to raise all activity to record levels, including staff, the capital programme and patient care. It gives the lie to Opposition claims that we intend to destroy the NHS. No wonder they sat there looking glum as the Chancellor announced the extra cash in his Autumn Statement.

The only solution offered by such people as the hon. Member for Liverpool, Broadgreen (Mr. Fields)--who, having made his intervention, has now left-- was the nationalisation of the pharmaceutical companies. Let me put on record that many of my constituents work at Boots in Nottingham ; we shall remember the Labour party's


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offer, and we shall make darned sure that the general public are reminded of it in Nottingham, in Derbyshire and everywhere else. Here is the precious balm of more money : let me rub it in a little more. This is the first Government to spend more on health than on defence. Perhaps that means that the House should change some of its procedures. At present we have a two-day debate on the defence estimates, and other debates on the Army, the Air Force and the Navy ; but we have no debate on NHS estimates. Yet we spend far more on the Health Service than on defence. Perhaps the time has come to have such a debate : certainly my right hon. and hon. Friends on the Front Bench need no longer feel defensive about NHS funding.

It is also worth reflecting that the Labour party has voted against every one of the proposals that have brought about these developments. I have no doubt that they will fight to the last ditch the proposals in the Gracious Speech to help the NHS to use its money better. Left to their devices, we would never close a clinic or a hospital, even to replace it with a new one in a more convenient place. There are 10 hospitals in the centre of Liverpool, all within a mile of each other. It makes no sense to spend money on such property when it could go into patient services.

If matters have been left to the Labour party, we would never have made the progress on preventive medicine--not in a million years. When Opposition Members talk about women's health and cervical cancer, I wonder what they are doing to encourage their women constituents to take advantage of the screening programmes that we have introduced and that are already in place. They could be used far more by their constituents. The Opposition have opposed every effort made by my right hon. and learned Friend to improve the dreadful old contract for doctors, which had not been changed for a quarter of a century. They should be ashamed of their opposition to change.

Left to the Opposition, a new telephone system would never be installed in a hospital, a filing cabinet would never be replaced by a desk-top computer, just because somebody in NUPE might be miffed about it. Left to the Opposition, we should not have the foggiest idea of how much anything in the NHS cost. That information is essential when trying to work out whether one form of treatment is more attractive than another. The Opposition would rather waste money and trust to luck.

Left to them, NHS employees and workers in many other essential services who take industrial action would be paid more than those who do not and who will not take industrial action. That cannot be countenanced by a fair and just society. Fortunately, it is not left to the Opposition. It is all right, left to us.

The National Health Service and Community Care Bill includes the Griffiths reforms of community care. It is in the nature of care in the community that patients become ex-patients. They disappear and lose contact with those who are employed to help them. I am therefore glad that the Department of Health has already announced that it is to tighten up its supervision of the hospital closure programme. The large-scale transfer of funds to local authorities to enable them to purchase community care does not mean that the Government can wash their hands of it and feel satisfied. In a county such as Derbyshire, there is no guarantee that all the funds will be used for their intended purpose. The county's pension funds, for example, are not all used for their intended purpose. There is some


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likelihood that the rather dotty version of the Labour party that is now in control in Derbyshire will deliberately discriminate against the excellent private sector in favour of its own council-run homes. I hope that the principles of strict standard setting and of monitoring, inspection and enforcement, which are so much a feature of other proposed legislation in the Gracious Speech, will also be part of the Griffiths reforms ; otherwise, the Government will be spending money but leaving my constituents no better off. The hon. Member for Caernarfon (Mr. Wigley) and my right hon. Friend the Member for Castle Point (Sir B. Braine), the father of the House, referred to the Warnock reforms. I agree with my right hon. Friend that the reforms are long overdue. It is iniquitous that so many dreadful practices, such as cloning and the creation of hybrids, have been legal in this country for so long. Even if they have not been practised, they have not been banned by law. It is good that that legislation is to be introduced. However, much though I respect my right hon. Friend the father of the House and understand the sincerity and the passion with which he speaks, I believe that to legalise some research within very strict limits is sensible and desirable. I am happy to vote for it. When I look at my own two healthy children, I wish every family in the country to have the same opportunity. Therefore, I have to vote for any possibility of extending such an opportunity to others.

We should, however, put on record our thanks to Lady Mary Donaldson, whom I met last year. She has led the voluntary licensing authority with great skill and tact. She has taken up the cudgels against a few doctors and hospitals who seem to think that anything goes in this most difficult and emotive field. Of course it does not.

If it is the will of the House, I should like to serve on the Committee that considers the Bill. I hope that we shall also have an opportunity to debate changes to the Abortion Act 1967. That, too, is out of date, but most people do not want it to be drastically altered. It would be sufficient to bring down the 28-week limit to 24 weeks, or perhaps a little less, if the legislation is to hold good for more than just a year or two. I hope that there will be an opportunity in Government time during this Session to hold such a debate to settle the matter once and for all.

Miss Widdecombe : Does my hon. Friend also hope that, even if the limit were lower than that which she would welcome, the House should have an opportunity to vote freely and fairly and that this House should decide the matter?

Mrs. Currie : I understand that, if motions to that effect are tabled, the Government do not intend to force hon. Members to vote in a particular way. I hope that there will be an opportunity in this House this Session in Government time for right hon. and hon. Members to debate the matter. We cannot continue for very much longer with legislation that is so much out of kilter with scientific fact and that is clearly not what people want. However, I repeat that I believe that most people do not want a wholesale change in the legislation ; they want it to be more closely in line with scientific developments.

The Gracious Speech has set out a programme of dramatic reforms in health and community care and many related issues. It will take us well and strongly into the


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1990s. It will keep everyone, Front Benchers and Back Benchers, very busy indeed. I am glad to give it my support.

8.15 pm

Mr. Eric Martlew (Carlisle) : I am pleased to be following the hon. Member for Derbyshire, South (Mrs. Currie). I remind the House that if it had been up to the hon. Lady, there would be no hens left in the country.

The Government intend to ensure that legislation is passed that will get the National Health Service ready for privatisation. Conservative Members are often dishonest about such matters. We have listened to some of their propaganda today. One would think that the National Health Service had not been reformed since 1948. The Secretary of State for Health referred to it as a museum piece. The hon. Member for Dartford (Mr. Dunn) said that it had not been reformed for 41 years. The National Health Service is very different from what it was then. This will be the fourth reorganisation since 1974.

Each reorganisation has taken place under a Conservative Government, and on each occasion they said that it was needed to improve efficiency. The 1974 White Paper said :

"We are issuing a White Paper, and promoting legislation about the administration of the National Health Service, solely in order to improve the health care of the public. Administrative reorganisation within a unified health service that is closely linked with parallel local government services will provide a sure foundation for better services for all."

It was signed by Keith Joseph, the former Secretary of State for Social Services, now Lord Joseph.

That reorganisation did not last very long. In 1979 there was another White Paper, which said :

"It is clear that the organisation of the NHS--the way it delivers health care to the individual patient--also needs to be reformed." That was signed by Patrick Jenkin, now Lord Jenkin. In 1984, a report was prepared by Sir Roy Griffiths--soon, I am sure, to become Lord Griffiths. He said that we needed to reorganise the management of the NHS. That led to the appointment of regional and district general managers, the ayatollahs of the NHS, in 1984. Now, in 1989, we have "Working for Patients." That is signed by the Prime Minister. I have a feeling that she will soon be ennobled and in another place as well.

We do not need another reorganisation in the Health Service. We need organisational stability. There is nothing wrong with the Health Service that a good dose of money could not cure. Conservative Members said that last year the Government put £24 billion into the NHS. That is all very well, but it means nothing unless it can be compared with something else.

As time is pressing and other hon. Members want to speak, I shall be brief. Unfortunately, my figures are not up to date. They are in dollars and were calculated before the fall in the pound since the former Chancellor of the Exchequer resigned. In 1987-88, the United Kingdom spent $627 per head of population on health care. Germany spent $983, France spent $1,072 and the United States spent $1,776. That shows that our Health Service is grossly under-funded in comparison with our economic competitors and partners. It also shows that we get very good value for money and that our Health Service is very efficient. Therefore, why are we saying that it must become more efficient--


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Mr. Stephen Day (Cheadle) : Will the hon. Gentleman give way?

Mr. Martlew : I will not give way. Some of the hon. Gentleman's Conservative colleagues were very mean and did not give way earlier. There have been four reorganisations of the NHS, but gross underfunding has taken its toll on the service and on the morale of its workers. Morale is probably lower than at any time since 1948. To prove this, I cite representations from speech therapists at my surgery on Friday. They complained rightly that they were being offered a 6.5 per cent. pay rise when inflation is nearly 8 per cent. They were as appalled as I was that speech therapists are being asked to take a cut in their standard of living. I hope that the Minister will consider that.

I also received representations from midwives, whom I will meet next Monday. They complained about the disgraceful regrading which is affecting them and the nurses. That is a totally inept piece of management by the Government.

I also received representations from the ambulance workers, to whom I was glad to give my total support. I was pleased to go into the beautiful centre of Carlisle on Saturday morning with the ambulance workers. We demonstrated and 6,000 people signed our petition. I have been involved in a great deal of political action over the years, but I have never before seen people queuing up to give money. In four hours we collected £1,800 for the ambulance workers.

My constituents are totally behind the ambulance workers and will not see them starved back to work. They will not see the ambulance workers' children going without a Christmas--if that is what the Government are planning. The Government should settle the ambulance dispute now because they cannot win it. They should also scrap the new reform of the NHS and give the Health Service more money. Through this reorganisation, the Government are helping to destroy the service and they will also destroy their chances in the next election.

8.24 pm

Mr. Stephen Day (Cheadle) : I want to confine my comments to the health reforms. The hon. Member for Carlisle (Mr. Martlew) said that only the Tories have reformed the Health Service. That says something about the Labour party's attitude to the Health Service, of which the Labour party claims to be the friend. However, if it was wrong for us to reform the NHS on so many occasions, it would apparently be right that a system designed to meet the needs of the 1940s should be left to meet the needs of the 1980s and 1990s. That is plainly nonsense. Conservative Governments have reformed the NHS to ensure that it meets the needs of the people in any given decade of its history. That remains the case with the present proposals.

On occasions I have not supported the Government on health issues. If I believe that half the allegations made against the reforms were true, I would not support the Government. However, today I have heard only wild accusations, none of which has been substantiated and which have been repeated around the country in leaflets distributed by the BMA.

The hon. Member for Livingston (Mr. Cook) said that Conservative Members should be aware of the dangers of not listening to our electorate. I am aware that many of my


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constituents do not support the reforms. I am not surprised about that because if I had not taken part in debates in the House or read the briefing notes or the BMA material properly, I would perhaps not be so informed as I should be. If that was the case and I had read in a BMA leaflet or been told by Opposition Members that I would have to go without the drugs that I need and that my hospital would be made private and independent and leave the NHS, perhaps I might be concerned. Perhaps I would vote against the reforms in a poll in a Labour constituency. However, that is manifestly not the case. The charges have not been substantiated by the BMA or by the Opposition. One of the main charges set out in letters that I have received from my constituents is the accusation that patients will not receive the drugs that they need. I have not heard one Opposition Member make it clear to the House or to his electorate that the BMA has withdrawn its opposition to the indicative drugs budget. The BMA has stated clearly that it firmly accepts the assurances of my right hon. and learned Friend the Secretary of State for Health that no patient will go without the drugs that are required.

If that is the case, why has the BMA not withdrawn from surgeries around the country leaflets containing claims which the BMA now says are not true? I have seen those leaflets in many surgeries. Hon. Members must make that important matter clear. I welcome the National Health Service and Community Care Bill because we can begin to deal with the real issues and aims of the legislation. When the Bill becomes law, with my support and that of the vast majority of my colleagues, it will become clear that the charges against it were not true.

Perhaps the hon. Member for Livingston will consider his charge about the concern of Conservative Members. When it is clear that the charges are not true, the Opposition will pay the price at the hands of the public who have been worried and alarmed unnecessarily by those accusations. I have seen patients who attend doctors regularly enter my advice surgery almost in tears. They were worried sick that they would not get the drugs that they need. That shows that the Opposition's real purpose today is to disparage what the Government are trying to do.

Any responsible Government with the interests of the NHS at heart must ensure that we have an NHS to go to. The pressures on the National Health Service are enormous and they will increase. If the answer to the problems of the NHS was to throw money at it, the Government would have solved the problems years ago. Year after year they have put extra finance into the NHS. Of course that alone does not solve the problems. To tell patients that it does is to mislead them into thinking that matters are easily solved. That is no answer to the problems of the NHS. We must increase funds--the Government recognise that--but that is merely to keep pace with today's demands. To ensure that the NHS exists for future patients, we must bring it into the 1990s. That is what the reforms are about. That is why I shall support the Government and why, when the proposals are in place, people will thank us for them.


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8.30 pm

Mrs. Rosie Barnes (Greenwich) : There is consensus about what should be achieved within the National Health Service. There is a commitment to the best clinical practices and a growing acceptance of the best management practices and the best use of resources. Patients' rights and choices are coming to the forefront. Everyone wants quality assurance. However, we should also consider a degree of patient or consumer responsibility. People want the finest National Health Service. They want to know that whatever technical innovation is developed will be available for them and their families if they need it. They must be prepared to pay for it. Survey after survey has demonstrated that they are prepared to pay for their National Health Service out of their direct taxation.

I have looked carefully at the Government's proposals as they have evolved. I was not one of those who were against further reform of the National Health Service. I did not consider that a large dollop of money and a good stir would sort out the problem. I recognised the need for innovation and change and a more responsive and sensitive Health Service if it is to serve us as well in the next 40 years as it has in the past.

For several key reasons, I reject the proposals. The speed with which they will be introduced is a travesty. There have been management studies of what is proposed and how such plans would be affected if they were in the private sector. They would be given a decade to be implemented--slowly but surely, one stage at a time, and one bit built on the next, not thrown willy-nilly into a service which is totally ill-prepared, unsuited and ill- equipped to cope. The medical audits which are gaining acceptance are inadequate to cope with what is suggested. No account has been taken of the massive organisational changes involved. The fact that there is no pilot study for such a major change will haunt the Government in the long run.

The lack of proper consultation with the professionals is another matter of concern. My major objection to the proposals is that their oucome will be contrary to the Government's objectives. I will dwell on patients' rights and choice and whether they will be enhanced by the proposals.

When hon. Members were considering the Health and Medicines Act 1988, I tabled an amendment suggesting some form of patients' rights or an internal market for the Health Service. The term "internal market" has been hijacked and abused by the proposals. My party suggested that we should make the Health Service a National Health Service, rather than the series of local services that we have at present. As hon. Members know, if one needs a hip replacement, depending on where one lives, one may get one in three months, three years, or not at all. That is not right.

My amendment in Committee suggested that, for every specialty, we should take the current good practice, perhaps based on the top 20 per cent. of health authorities in the area, and the average delivery time of the service concerned, and make them the national benchmark. With hip replacements, if it turns out that the average for good health authorities is eight months--that is, not a pie in the sky figure but one based on current good practice--it should become the national benchmark for hip replacement availability. If a health authority is not able to


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deliver a hip replacement within eight months, a patient should have the right to go to another health authority or to the private sector through their health authority if the price can be agreed and the money can follow the patient.

Many Conservative Members have said that the Bill will be about patients' choice and patients' rights. It will not. The proposals for which I strongly argued in Committee would provide patients' rights. It would give them some control over their share of National Health Service money. It would also give health authorities an incentive to be efficient and to deliver effective services. It would also make it sensible, where health authorities are close together, as in London, for there to be cross- fertilisation and specialisation. That constitutes patients' rights and giving patients more control over their money and destiny within the Health Service.

The Bill will be quite different. It will give doctors and health authorities more rights and it will make money a more determining factor than it has been to date, but patients will have fewer rights. For example, if a GP becomes part of a group practice, patients will have to go where the GP decides to contract his services. If one's GP is not contracted, one will have to go where the health authority says. As a patient, one will have no right to go to a certain hospital because it is nearer or its service is quicker. Although there is a case for saying that the money will follow the patient, it will not follow the patient at the instigation of the patient : it will follow the patient only if the doctor or the health authority says so.

We must also consider what is proposed for self-governing hospitals. Core services must be provided within a health authority, but not necessarily within each hospital. Certain basic services may be lacking in particular communities. I refer to geriatric services and psychiatric services. Even midwifery is not listed as a core service. Hospitals that choose to become self-governing first will be able to pick what services they can drop. The Cinderella services will be the first to go. Some patients may find that their health authority draws the line and says, "No, this must be included in your area." That may encourage a rush to become self-governing. Practice budgets change the relationship between a doctor and a patient. As never before, when patients consult doctors, they will have in their minds the query that a financial consideration will determine what the doctor prescribes or where he sends them. I accept the Government's assurance that no one will go short of drugs at the end of a financial year. Nevertheless, there is a financial consideration in the doctor-patient relationship which has never existed before, and it is a distortion of what was once a much more professional and ethical relationship.

I should like to conclude now to enable those hon. Members who have waited so patiently to have a chance to speak. Perhaps the Government can get off the hook in their dilemma by looking more seriously at what some health authorities are interested in doing for themselves, which we in the SDP have certainly supported. This is the possibility of health authorities themselves becoming self-governing, as opposed to the hospitals within them. That would eliminate a major dilemma for self-governing hospitals, because it would enable the health authority to have a proper comprehensive strategy for its whole area and to take into account the needs of all its citizens, whenever and wherever they may require its services. In many ways, that proposal has some of the best features of


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the idea of self-governing hospitals--I admit that there are some--while avoiding many of its major pitfalls. It should be looked at far more carefully.

8.40 pm

Mr. Andrew Mitchell (Gedling) : I am grateful for the chance to follow the hon. Member for Greenwich (Mrs. Barnes) and find encouraging the extent to which, from what she said, the Government can expect to receive support from the Social Democratic party when the health Bill which was published last week comes before the House.

Although we are primarily discussing health today, this is a debate on the Loyal Address and I should like to comment on one or two other matters in the Gracious Speech. I am one of those hon. Members who voted against televising the House, but I must admit that I have been pleasantly surprised by the effect of the first week. However, I hope that our approach to debates will not become too sanitised. Indeed, this afternoon's performance by the two Front-Bench spokesmen makes it reasonably clear that the effect of television on the House is already wearing off, which must be a good thing. I hope that we shall range widely in the next few months before the experiment draws to a close in July, because it is important that our constituents get the feel of this place. After all, it is the people's Parliament. At the moment, we are focusing too much on the man with the ball, and not enough on the whole football pitch, but I hope that that can be remedied in the period between now and the end of the experiment. The Gracious Speech includes important measures that will be of great advantage to my constituents. I was especially pleased to see that there will be legislation on food safety and consumer protection, and a Bill designed to improve co-operation with other countries in the investigation of crime. Those Bills are extremely important and I hope that they will command widespread support in the House. The third measure that I was delighted to see was the environment Bill. A co-ordinated approach to the environment at local, national and international level is extremely important. At the international level, it is vital that we achieve two things : first, a wide consensus, among as many countries as possible on the measures to which the international community agrees ; and, secondly, as wide a scientific consensus on the major problems as possible. I refer especially to the problems of climate change.

In respect of our national policy on the environment, I was delighted to see that the principle of the "polluter pays" will be enshrined in the Bill and that industry will be seen not so much as the problem, but as the solution to many of the difficulties. In my constituency, I have been pleased by the environmental sensitivity shown by Gedling borough council. It is justly known as a trail blazer in environmental matters in the east midlands. Litter irritates many of our constituents enormously. Indeed, no issue irritates my constituents more. The Government have listened and I was grateful to have been able to join my hon. Friend the Member for Chelmsford (Mr. Burns) in co-sponsoring his excellent Control of Litter (Fines) Bill, much of which has been taken on board by the Government.


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If I might make one mild criticism, it is that I wish we could have gone a little further on graffiti. I understand the difficulties facing local authorities when given the power to deal with grafitti, such as the question of legal responsibility, but if the local authority is not responsible for removing grafitti from public buildings, who on earth is?

With the hon. Member for Mansfield (Mr. Meale), who in this respect alone is perhaps my hon. Friend, I am hoping to bring before the House legislation to enable the courts to take more effective action against people convicted of badger-baiting. We are in an advanced state of agreement with the Home Office and I hope that the House will unanimously pass the Bill.

There are two measures in particular this year, Mr. Deputy Speaker, upon which I hope to catch your eye from time to time. One is health, which I shall discuss in a moment, and the other is the Coal Industry Bill which I understand will come before the House next week. I have a particular constituency interest, as well as a personal interest, in that Bill. I look forward to the time when our coal industry has made as much progress as the steel industry. We should recognise the reconstruction that has already taken place in coal and the success that has already been achieved, in terms of competitiveness and productivity, especially in the Nottinghamshire coalfields. One can see that success from the figures. Manpower is now one third what it was before the strike. Although the number of pits has decreased from 190 to 74, production has decreased by only 15 per cent. At a time of a 70 per cent. increase in world coal prices, there has been a £1 billion reduction in the cost of British coal to its customers. We must support new coal technologies and advanced coal technologies because they will increase efficiency, improve the economics of the industry and reduce greenhouse gases. That must be our goal if we are to make the industry truly march along with the tide of time. I look forward to the Second Reading of this very good Bill.

Health is a particular interest of mine, and I shall have a number of detailed points to make in support of the Bill, perhaps on Second Reading or in Committee. My right hon. and learned Friend the Secretary of State is to be congratulated on the remarkable fact that he has managed to keep the Bill to a reasonable size. Some of us feared that it might be a lot longer than it is, but given how much is in it, it seems manageable.

I am not prepared to take lessons from the Opposition on devotion to the National Health Service. I spent two happy years serving on a health authority and my wife is a doctor in the NHS and gives more hours to it than I care to mention. I am a passionate and devoted supporter of the Health Service. However, I share with Opposition Members a sense of frustration that, although we are putting so much money into the Health Service, the queues still seem to lengthen. There is nothing more frustrating than hearing from my constituents that they cannot receive the treatment which I believe that they should receive at once.

But we also hear that there are 20 per cent. more doctors and an unprecedented capital building programme. I believe that at the moment no fewer than 530 capital projects worth £1 million or more are in the pipeline. This year there has effectively been an 11.5 per cent. increase in resources. Therefore, the funding is there. We know that it is there and the record speaks for itself, yet we are not getting to grips with these difficult problems.


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I was astonished to hear the Leader of the Opposition, when he replied to the Loyal Address, say that competition has no place in the National Health Service. I thought that Labour's policy review had established that competition works for the good of the customer, the client, and the patient. It may be controversial, but the process that district health authorities are undertaking to specify what they need and on what terms they are prepared to pay has been singularly lacking throughout the history of the National Health Service, which has been concerned almost entirely with what we put into the service, without looking at what we get out of that enormous investment. I have come to the conclusion that the National Health Service is not primarily short of funds. Many Opposition Members have said that it needs a 3 per cent. real increase in funding, but it has had that. As far as I can see, this year the increase has been nearly 6 per cent. The critical area that the Health Service must now get right is effective management. Sir Roy made a great start on that earlier in the 1980s with his new system of management, and I believe that the bulk of what my right hon. and learned Friend the Secretary of State is proposing will build on the excellent reforms of the 1980s. Sir Roy has made a start and this excellent legislation must follow that.

I welcome the devolution enshrined in the health Bill. We have always encouraged such devolution in Nottingham, which has some excellent managers and a great pool of talent. It operates, however, with one hand tied firmly behind its back and I welcome the fact that, in future, we shall be able to determine locally the terms and conditions of those who work in the Health Service.

It is extremely important that we stop looking at the NHS as one big amorphous organisation. We know that there are huge differentials in the quality of service across the country. We know that some surgeons undertake only 20 per cent. of the work load of other colleagues in exactly the same discipline. In London the cost of a particular operation can be four times as much in one hospital as it is in a hospital a quarter of a mile away. The NHS is a vastly different organisation with varying levels of efficiency, medical standards and costs. The sooner we realise that the better. The concept of money following the patient is excellent. My hon. Friends and the hon. Member for Greenwich (Mrs. Barnes) have already drawn attention to the absurdity of the present system under which highly efficient units spend their budgets and must then close. Under the new system, I hope that good management will be rewarded instead of being shot in the foot. The clarity offered by the separation of the provider from the purchaser is a major step forward. Even without competition, the district health authority will now be able to concentrate on its crucial area of responsibility--determining need and how best to meet it--without the confusion and conflict inherent in managing its services.

That means, however, that management must be able to manage its resources and assets, including its senior medical staff. We cannot have employees, no matter how senior, leapfrogging unit managers in a bid for support outside the unit. The need for a better and more efficient management of the service goes to the heart of the relationship between the management of that service and the clinicians who work in it.


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Clause 19 ensures that the Audit Commission will be more involved with the NHS, which is an excellent step forward. The commission should do as much value-for-money work as possible. I am glad that the Secretary of State listened to what my hon. Friends and I have said about the commission.

Clause 18 deals with capital charging, which is an extremely complex area. It must not become an accountant's dream and no one else's. I hope that such charging will get us away from present practices when, all too often, NHS management reach for new projects and new build instead of maintenance. The NHS is not charged for the cost of the capital projects, but is charged in a different way for maintenance work. I hope that the clause will deal with that problem.

I welcome the great investment in new management systems for the NHS. Those systems were stimulated by the White Paper as well as by the review of the NHS. In the past the NHS has suffered greatly from the lack of accurate, rapid information to help managers to manage. My right hon. and learned Friend will know that Nottingham has been at the forefront in dealing with that problem and in recent years the district has spent more than £2 million a year on it. It is already seeing the benefit of that investment, but there is still a considerable way to go.

I welcome the Gracious Speech and I look forward to the measures enshrined in it passing into law. If I am successful in catching the eye of the Chairman of the Committee of Selection, I particularly look forward to serving on the Committee which will deal with these momentous and important health changes.

8.53 pm

Mr. David Hinchliffe (Wakefield) : One area that has received scant attention in today's debate is community care. The people concerned about that issue have been treated shabbily by the Government in terms of the time scale allowed for consideration of community care. After the report published by Sir Roy Griffiths, we had to wait 18 months for the Government's response. After the publication of the White Paper last week, we effectively had three working days for consultation before publication of the National Health and Community Care Bill. Such consultation is inadequate, given the serious implications of the proposals for those concerned with community care.

As community care is included in the Bill, I am extremely worried that that aspect will be overlooked and forgotten because of the understandable concerns about the other radical proposals relating to the NHS. I note that part III of the Bill relates to community care. I suspect--I would place money on it if I were a betting man--that the guillotine will be operating by the time we come to discuss community care.

The Government have treated with contempt the many thousands of people who work in community care, the many people who are carers and who voluntarily look after those less fortunate. Above all, the Government have treated with contempt those people who depend upon that community care.

When the Secretary of State responded to a point of order raised shortly before Prorogation he said that the White Paper on community care was non- contentious. I take exception to that, because I take exception to the


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Government's basic definition of community care as set out in that White Paper. By their definition, isolated private institutional settings are deemed to be part of community care. The process of discharging the mentally ill and the mentally handicapped from isolated, Victorian public institutions to isolated, Victorian private institutions is deemed to be community care. In my view, community care means that people are based in the community, whether that means residential care or not. Because of the Government's policy on community care, people are now moving miles from their homes and their communities into isolated institutions. In no way can those institutions be described as part of the community. The White Paper is riddled with a number of fundamental contradictions. The central priority in the White Paper--I believe it is the right one--is to avoid unnecessary institutional care. That aim, however, is contradicted by the key objective of a flourishing independent sector. With the development of the independent sector, more and more people have been pushed into institutional care which, in many instances, they do not need. The independent sector has shown no interest in alternatives to the provision of institutional care, because the easiest way to make profits is to provide such care. That is not the answer to the needs expressed by vast numbers of people in the community who require some form of domiciliary, preventive support to remain in their homes.

The other fundamental contradiction is that the White Paper makes it virtually impossible financially for local authorities to continue directly to provide their own part III residential care for the elderly and handicapped. Given the financial arrangements introduced by the Bill, it will be virtually impossible for local authorities to provide such care. The White Paper, however, states :

"The Government will expect local authorities to retain the ability to act as direct service providers, if other forms of service provisions are unforthcoming or unsuitable."

In other words, the local authorities are expected to continue to provide residential care when the private sector says, as frequently happens, "I am sorry, my friend, you are unsuitable. You cannot pay the money we want from you." When that happens, those people are dumped into local authority part III accommodation. That is a fundamental contradiction which should be sorted out, because it will give local authorities an impossible task.

The White Paper is based on a series of myths ; the central one is the idea of promoting choice. "Choice" is a nice word which the Government have brought in, but in reality choice is different. What choice do the majority of people have who enter residential care, and what choice will they have when the Bill is enacted? Experience has shown us that the only choice that they have will be determined by where there is a vacancy for them when they need residential care. What choice will there be for people who want to enter local authority care--not private care--when local authorities can no longer offer that care? What will the choice be for many of the people of my constituency who do not want to go into private care? Such people will say, "I grew up under the welfare state. I fought for a welfare state and I want to go into my own local authority's accommodation in my home area on my estate." What choice will they have when the residential care they want is not available because of the new funding arrangements in the Bill?


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