House of Commons Hansard Debates for 7 Dec 1989

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Mr. Clarke : I accept that there is a wide variety of reasons for drugs not being taken. There are repeat prescriptions for many patients who have not seen their doctor for a long time. Drugs can be prescribed automatically and the doctor does not know whether the patient is taking them. No one should defend the wasteful prescription of drugs. The National Health Service needs to introduce effective methods to ensure that variations in the prescription of drugs do not occur.

Mr. Nicholas Winterton (Macclesfield) : Will my right hon. and learned Friend give way on that point?

Mr. Clarke : No. I shall return to prescribing costs when I deal with indicative drug budgets.

There are also wide variations in the performance of the hospital services. That is most apparent in the time that people have to wait for particular services. It is all too easy with waiting times, as with everything else, to put it all down to lack of money. For years and years the Opposition and far too many people in the National Health Service have said that whenever there is a variation in performance it is due to lack of resources. Variations in performance can never be attributable to resources. Variations reflect local efficiency and effectiveness in making the maximum use of all the resources, including cash, at their disposal.

There is a variation in performance when one considers theatre sessions cancelled in different district health authorities. The worst districts cancel one in six theatre sessions. The best districts cancel only 1.3 per cent. of their theatre sessions--in other words, one in 77 theatre sessions. Far more work is done in a district where only one in 77 of the theatre sessions is cancelled than in another district where the performance is so poor that one in six of the theatre sessions has to be cancelled.

To give similar statistics about the number of operations per scheduled session, in the worst 10 per cent. of districts, according to the best measure of performance that we have, the average is 3.29 cases per session. In the best 10 per cent. of districts, there are 5.19 cases per session. In the best districts, therefore, half as much again is done per session compared with the worst 10 per cent. In a statement that was issued in the summer, the previous Minister for Health said that, if all our districts could raise the efficiency of their management of theatre sessions and waiting lists to the level of the best, we should be very near to eliminating most of the waiting time.

Mr. Graham Allen (Nottingham, North) : The Secretary of State will be aware that quite recently the Public Accounts Committee closely examined operating theatre use. The Committee found that operating theatres are used as a financial regulator by local hospitals and that, were they to be run at full efficiency, they would come up against financial constraints that the Secretary of State has imposed.

Mr. Clarke : If the PAC said that--I think that was a bit of a paraphrase--I do not agree with all of it. I agree that one of the weaknesses of the present system is that if an efficient district increases its throughput of patients and raises its work load it finds, in the unreformed National Health Service, that it comes up against financial constraints. The districts that do not increase their

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throughput do not get into such difficulties. It is no good saying that the only reason for variations is lack of resources. To take the Sheffield district health authority as an example, great variations are to be found in different parts of the service. There are some examples of excellence, but there are others where a great deal could be done to improve the service.

Let us consider what is good about the Health Service in Sheffield. The authority has a new department to give stereotactic radio surgery at Weston Park hospital. It is an advanced form of radiotherapy, which makes the hospital a world leader. Heart transplantations are about to start at the Northern General hospital from 1 April next year. There is a lithotripter at the Royal Hallamshire hospital, which is at the forefront of treatment for gallstones, and clinical services for patients with diabetes there are amongst the best in the country. Pioneering work is being done. The spinal injuries unit in Sheffield is one of the two biggest centres in Britain. However, Sheffield combines those good points with the huge waiting list for trauma and orthopaedic surgery and one of the longest waiting lists for routine orthopaedic surgery in the country.

In the course of the waiting list initiative, we are subjecting such districts to studies. We have studied 22 with the longest waiting lists. The main cause for long waiting lists that emerged in Sheffield was the under-use of theatre sessions and the low level of work by surgeons in relation to a high level of surgical manpower--higher levels than those in 80 per cent. of other district health authorities.

Even though the Sheffield district has teaching responsibilities, there are few provincial teaching authorities with such consistently low output per surgeon and per theatre. It has low activity per surgeon and a lower number of cases per theatre session than one would expect, with huge variations between individual surgeons. Other districts had a better case for resources from the waiting lists initiative when we were deciding how to put the money to best effect to increase the number of cases treated.

In Sheffield we have had co-operation, and an agreement to tackle the management and work load problems, and given some extra money to set new work load targets, to increase the throughput and to improve waiting list management.

All that can be done when the cause of deficiencies is tackled and when the argument that they are all due to the Government's underfunding of the Health Service is not simply accepted, and when the co-operation of local doctors is forthcoming. As the hon. Member for Nottingham, North (Mr. Allen) pointed out, further reforms are needed because we have to ensure that money is distributed in the service so that, when the work load increases, patients can be dealt with more effectively, GPs will be attracted to refer more patients to a unit and the resources will be there to back up that improved performance.

At the moment, efficiency tends to be penalised due to the way in which the Health Service is run. In the future, we will ensure that those authorities that are efficient or that raise their efficiency thrive by attracting more work.

Dame Elaine Kellett-Bowman (Lancaster) : My right hon. and learned Friend must be aware that a very expensive lithotripter was installed at Withington hospital

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to serve the whole of the north-west two years ago--it cost almost £1 million. In the first year it was allowed 400 cases fully funded, but unfortunately Withington hospital has now run out of its budget and has done 400. It is trying to persuade hospitals like mine to pay £500 to take people there to have their gallstones removed. The alternative is to have to spend between seven and 10 days in hospital for an operation. Can my right hon. and learned Friend persuade the regional health authority to fund more of those operations to remove gallstones?

Mr. Clarke : A lithotripter lends itself to doctors arranging to have a given quantity of work done for their patients, because they believe that that method of treating gallstones is preferable to intervention by surgery and they can give the resources to the particular unit that they want to deliver the service. At the moment, because we do not have the ability to enter into contracts that the Bill will give the Health Service, my hon. Friend is reduced to lobbying the regional health authority and, in Withington, great confusion occurs about where money is going, and how much it may be able to divert into the lithotripter.

When the Bill becomes law, we will have clearer, better ways to organise the distribution of money--for example, in this case to the Lancaster district health authority, if it wishes to use its resources to provide a particular system of care.

So far, I have described the objectives for the Health Service and the problems that need to be tackled. We seem to be a long way from the attitude in many of the debates in which I took part in the summer, and a long way away from the initial reaction from too many people in the National Health Service. I shall not go back over that old ground, because the atmosphere seems to be improving. Unfortunately, there have been attempts to frighten patients by inventing a series of claims that had nothing to do with the White Paper, the Bill or any of the reforms that someone like me, who is committed to the National Health Service, is likely to put forward. I have been accused of sending people 60 miles to hospitals that they do not want to go to. People have said that doctors are running out of money that they need for drugs. The other day, it was hinted that expectant mothers may lose local obstetric services because of our proposals. That is nonsense. No right hon. or hon. Member would suggest any of that rubbish.

Now that the proposals are being discussed on the Floor of the House, and we have left the posters and the postcards behind, we can move to a serious discussion of what the reforms are about. The hon. Member for Livingston (Mr. Cook) promised me hundreds of thousands of postcards but he could find only 50,000--obviously membership of the Labour party is falling to a greater degree than even I would have expected. Now the debate will have to move from fantasy to reality.

Mr. Rhodri Morgan (Cardiff, West) : The Secretary of State says that we have been spreading scare stories about the problem of patients going 60 miles to hospitals that they do not want to go to. If he confers with the right hon. Member for Worcester (Mr. Walker), he will find out that a hospital in my constituency has been working on a proposal since 1 December that will involve patients being sent 160 miles for surgery. Previously they would have had surgery at a local hospital. Will the Secretary of State tell his colleague that it is not a scare story, but reality? The

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same thing could happen in several other hospitals in Wales, and instead of people being able to have surgery locally, they will be taken long distances.

Mr. Clarke : There will be Welsh wind-up speeches tonight, and hon. Members from both sides of the House will have an opportunity to comment on that, so I shall not intervene in the affairs of South Glamorgan. The Health Service in Wales has benefited from expansion and increased expenditure that at least matches that in England, for which I am responsible.

Of course, people may choose to travel some distance for better service. That possibility will be more available in the future. It is not true that the White Paper reforms will lead to people having to go miles down the road to have cheaper services.

Mr. Barry Jones (Alyn and Deeside) rose --

Mr. Clarke : I shall not give way on the subject of south Glamorgan.

Mr. Tony Marlow (Northampton, North) : On a point of order, Mr. Deputy Speaker. It could be argued that this is the most important Bill of the Session. So far, a series of hon. Members have got up and abused the procedures of the House, because it is stuffed full of television cameras, by raising constituency points. I wonder whether you could help the House to keep to issues of principle rather than allow pettifogging matters, aimed at gaining support from constituents, to be raised.

Mr. Deputy Speaker (Sir Paul Dean) : Order. We had better get on.

Mr. Clarke : The hon. Member for Alyn and Deeside (Mr. Jones) is winding up tonight on behalf of the Opposition. Some hon. Members wish to intervene about South Glamorgan. I am not responsible for that. My right hon. Friend the Secretary of State for Wales is responsible for South Glamorgan, which is an extremely successful district health authority.

Mr. Barry Jones rose--

Mr. Deputy Speaker : Order.

Mr. Clarke : With the greatest respect, I would not normally refuse to give way to the hon. Gentleman but I cannot be expected to diverge into discussions about the work of a health authority for which I have no departmental responsibility. When my hon. Friend the Under-Secretary of State for Wales replies, I am sure that he will be delighted to talk about the arrangements for care there.

Mr. Robert Hughes (Aberdeen, North) : On a point of order, Mr. Deputy Speaker. Is it not intolerable that the Secretary of State should spend two thirds of his speech so far dealing with detailed matters in specific health authorities, but refuses to give way to Opposition Members who wish to raise issues relevant to other specific health authorities?

Mr. Deputy Speaker : The Secretary of State must be allowed to make his own speech in his own way.

Mr. Clarke : I quoted the example of Sheffield, with which nobody quarrelled, so it was an excellent example of a national point. I cannot be expected to trot around the House dealing with district health authority after district

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health authority. Many Adjournment debates are held in which such issues are dealt with by my hon. Friend the Minister.

Mr. Ray Powell (Ogmore) : On a point of order, Mr. Deputy Speaker. The Secretary of State said that he does not have a certain responsibility. I assume that the right hon. and learned Gentleman has responsibility for the whole of the Bill as he is presenting it, so he should answer questions about the whole country, including Wales.

Mr. Deputy Speaker : Order. I remind the House that, as Mr. Speaker said at the beginning, a very large number of right hon. and hon. Members wish to speak in the debate. I think that we should get on with it.

Mr. Clarke : I knew that it was a mistake to say that the debate was moving on to more sensible ground than it has been on for most of the summer, but I believe that to be the case. We should build on what is accepted by everyone in the service.

Hon. Members will have seen a press statement put out by the professions last week that still contained many criticisms of proposals in the Bill, which had then just been published. The press release included the following passage, which I commend to the House :

"We wish to work with the Government, not against it, because like the Government we are committed to the principle of a National Health Service financed out of public funds and free at the point of delivery. We welcome the Prime Minister's statement that her sole aim is to develop a better Health Service, and we share this aim. We wish to co-operate in the improvement of standards through professional audit, through proper resource management, through research into disease prevention and treatment, including the most cost effective methods of care, and through the introduction of better information technology to enable informed management decisions to be taken." The professions then made general criticisms which I have rebuffed. Some of the wilder ones that caught the headlines seem to have no sensible or factual basis. The Bill accepts that common ground, which is the widely accepted need to improve resource management and for quality control and the provision of a good basis for education and research, and enables us to put into effect the benefits of better resource management, which will be more effective patient care.

Mr. Michael Foot (Blaenau Gwent) : As the right hon. and learned Gentleman has thought it worth while to quote to the House the representations made by people in the service, why did the Prime Minister refuse to receive a delegation of them so that they could put their case directly?

Mr. Clarke : Because she referred the leaders concerned, as she would in any other similar case, to me and my colleagues as the Ministers responsible. Indeed, I had met all those people frequently during the previous few months. We recently answered a parliamentary question which showed that my ministerial colleagues and the chief medical officer could easily produce a list of well over 100 meetings with leaders of the medical and nursing professions during the past six months. I have no doubt that we shall have more. There have been constructive meetings designed to ensure that we implement the

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changes and get the benefits of better information technology and quality control, which will be welcomed as we go along.

Mr. Nicholas Winterton : If my right hon. and learned Friend is so determined--rightly--to press ahead with resource management, which is so important for the efficient management of the Health Service, why was he not prepared to analyse and properly assess the resource management initiative in six hospitals, most of which the Social Services Select Committee visited during its recent inquiry, before rushing forward into the dark with unproven proposals which could do so much damage to the Health Service? I might add that those resource management initiatives were fully supported by everyone in the Health Service.

Mr. Clarke : We shall evaluate those six initiatives. Everybody accepts the need for better resource management in the Health Service. Change cannot be made conditional on a protracted academic appraisal of six particular experiments. Of course, we shall build on the experience of those experiments--

Mr. Winterton : My right hon. and learned Friend set them up.

Mr. Clarke : And, of course, we set them up. We shall evaluate them. We did not set them up, however, on the basis that nothing would be done anywhere else in any other hospital until Brunel university had finished the evaluation. The crying need for resource management is obvious. The pace at which we proceed must, with respect, be somewhat more purposeful.

I always tell the business men whom I introduce to give advice on better management in the Health Service that, when they go into the public service, they must expect the clock to go rather more slowly than they have experienced in any other organisation. Sometimes, however, people in the Health Service want to make the clock crawl. They contemplate years of discussion before getting on with implementing such obvious improvements as a better system of financial management.

The Bill will enable us to build on the progress being made in resource management. It will enable money to be spent more sensibly and effectively. The key theme of the proposals is to have more real responsibility for decision making at the local level. We are putting it in the hands of the managers, doctors and nurses who are delivering care in hospitals and units. It has been the common experience for years that most people in the Health Service have, until I proposed the reforms, suffered from the feeling that there are far too many layers of authority above them and far too many constraints on running units better. The Bill will give much more automony within the Health Service to the people who are delivering care.

We need better decision making, which depends on better local leadership. Clauses 1 and 2 reconstitute district health authorities and the bodies who are responsible for decision making. The aim is to make them smaller and more effective. In my opinion, health authorities have never been able to make up their minds whether they are a kind of local government committee or a decision-making executive body for the health authority. We obviously want smaller, more effective decision-making bodies.

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We are bringing executives in for the first time. We are building on all we have achieved with the introduction of general managers. It is absurd that there have been no executives on the boards. They have had to sit and watch. Others debate an agenda which, in the opinion of some executives, sometimes bears little relation to the real decisions and problems that face the authority. There will be a combination of chairman, non-executive members--local people appointed for the individual contribution and skills that they can bring--and executives. That will create a fuss because we are removing the arrangement by which local authority members are put on as of right. I quite expect many non- executive members to combine their public service on a health body with service as local councillors, but the system under which local authority representatives go directly on to the health authority does not always produce desirable results. Recently, there has been a growing tendency, sometimes by supporters of my party and frequently by supporters of the Labour party, to put on local authority members who are mandated to pursue local political aims, and then to remove them when changes of political control or nuances in the local Labour group determine that a new political input must be made.

Mr. Harry Greenway (Ealing, North) : Will my right hon. and learned Friend make it clear whether family practitioner services authorities will employ medical advisers to examine the effectiveness of prescribing? If so, will they consider quality as well as expense?

Mr. Clarke : Yes, surely. FPSAs will certainly need professional advice when deciding on prescribing practices. The judgments that may in some cases have to be made about the prescribing practices of individual general practitioners or partnerships will be made by people who have professional qualifications and are therefore able to do so. Nobody will evaluate prescribing habits solely on the ground of cost. That is not my point. The quality of prescribing and the necessity for it in such quantity will also be considered in each case.

The Bill also introduces the possibility of a quite new method of distributing taxpayers' money. In future, it will be distributed according to a method which is loosely called contracts, but I should make it clear that it is certainly not my intention that any of the agreements about what service a unit should provide in exchange for a given level of resources should be made the subject of litigation between different parts of the Health Service, or be subject to over-legalistic interpretations.

The Bill allows NHS bodies to make administrative arrangements with each other for the provision of services as they have not been able to do previously. Those administrative arrangements will be a network of agreements whereby a district health authority or a general practitioner, using the funds he holds in his budget, will decide which unit they want to provide a given level of service and, when they have stipulated what they want and the quality that should be achieved in exchange, an agreed sum of resources will be accepted by the unit to deliver it.

It greatly alters the responsibility of people in the NHS. District health authorities will find their role considerably changed. They will have a vital responsibility to act on behalf of all the residents in their catchment area. They will need to assess the health needs of their districts and identify where the local service is not as good as it might be and could be improved. They will have to determine

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what is required to provide a reasonably accessible comprehensive service in each locality. The money will be placed in their hands to finance the best pattern of service for patients.

District health authorities will enter into agreements with hospital units to specify what is required in terms of both quality and quantity. I expect that at first they will be broad-brush agreements. Nevertheless, authorities will stipulate a level of service in exchange for an agreed level of resources. As we develop the concept of resource management, both sides of the bargain will wish to include more sophisticated terms and details.

To go back to the jargon, we have stressed in the Bill and in the working papers that support it that district health authorities must respond to the wishes of general practitioners in placing contracts. In putting agreements in place, they will have to find out about GPs' referral patterns and reflect them wherever practicable and sensible. In their turn, GPs as well as the district health authorities will reflect the wishes of their patients both in terms of convenience of locality and expectations of service and allow for a reasonable degree of patient choice, which we on this side wish to reinforce in every case.

Mr. D. N. Campbell-Savours (Workington) rose --

Mr. Clarke : I shall give way in a moment. The system will allow for individual referrals to be made and financed properly within the contractual system that we propose.

Mr. Campbell-Savours : Does the Secretary of State understand that many of us find it difficult to accept his reassurances because it was he who came to the House only just over a year ago to give us reassurances about the sale of Rover to British Aerospace? He was the Minister responsible for misleading the Commons on issues which are now being unravelled in the midst of a row. How can he expect Parliament and the British people to believe a word he says on the basis of his track record?

Mr. Clarke : If it were in order to do so, I should give way to the desire that I have had for the past few weeks to join in the exchanges on the sale of the Rover Group to British Aerospace. I have listened to a great deal of rubbish from the Opposition about the sale, under which a company was transferred into the hands of an extremely successful British engineering company and taxpayers were relieved of the risk of losing millions of pounds on the scale previously incurred under public ownership. I think that if I digressed further, you might call me to order, Mr. Deputy Speaker. I look forward to answering on that matter when I have the chance. To return to contracts, I realise that it is difficult for those who work in the service to become familiar with the concept. It is a concept that is easy to attack. It is worth while bearing in mind the fact that the network of agreements will involve people making considerable choices about where best to place a service and how best to allow for patient referrals and make sure that the service provided is properly integrated and not broken up. The first key point that I would emphasise is that we intend and shall insist that all decisions about placing contracts will have as much regard to the quality of service that the district health authority and GPs seek as to cost.

Some critics have attacked the system on the basis that doctors will be made to obtain the service from wherever it is cheapest. That is nonsense. Every hon. Member in the

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House makes the same judgment when he or she is ill as GPs and people outside the House make. The first thing that one wishes to know is where one will be best treated. Judgments about quality are as important as judgments about cost.

As I have already said, one great benefit of the system will be that where a unit is efficient, it will no longer have to cut back towards the end of the year, perhaps by closing wards, because it has outstripped its budget, however fast that budget has grown. In future, it will be possible to stimulate good performance in the Service. People are committed to their own units, hospitals and clinical units. In future, units will thrive and attract more patients to the extent that they succeed in cutting waiting times and demonstrating a high quality of care. By providing a friendly personal service they will be more likely to attract referrals and contracts from their district health authority and surrounding authorities and thereby increase their resources.

Mr. Simon Hughes (Southwark and Bermondsey) rose --

Mr. Robert Hughes rose --

Mr. Clarke : That will be the opposite of the present position. I do not wish to attribute ill will to anyone in the Health Service, but no one has an incentive to reduce waiting lists. People strive to do so because they want to keep up with the work, but no reputable consultant would be without a waiting list, because it is a badge of status. District health authorities are not anxious to reduce waiting lists, because they are used by Members of Parliament to reinforce authorities, claims for more resources. We shall have to take care that our waiting list initiative does not reward units for having a long waiting list.

Mr. Brian Sedgemore (Hackney, South and Shoreditch) : Cheek.

Mr. Clarke : It is no use the hon. Gentleman saying, "Cheek." No doubt if he were making his speech he would say that waiting lists were good for private practice. I would not allege that that plays too great a part in keeping waiting lists high.

In future, units which succeed in reducing waiting times will have more prospect of attracting patients, and NHS resources will flow in with the patients. That is one of the main ways in which the Bill will reduce waiting times, when it is fully implemented.

Mr. Simon Hughes : The precondition for what the Secretary of State says about the relationship between districts and hospitals is NHS trusts, for which the Bill provides. The Secretary of State will be aware that people have an honest fear that, because the contract will be placed by the district with the best hospital, it will not necessarily be given to the local hospital. If the Bill is all about choice, why does the Secretary of State not amend his plans in this respect, as some of his colleagues did in other legislation last year, to allow people who work in or use local NHS hospitals to choose by voting whether the hospital should become an NHS trust instead of a decision

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being imposed on them by the Secretary of State? That happens in schools and in housing action trusts, so why not in hospitals?

Mr. Clarke : The hon. Gentleman is mistaken in one of his premises. It is not the case that the so-called contract system that I have just described will apply only where there is a self-governing NHS trust. What I described is a key element of our NHS reforms and will apply to the whole National Health Service, both to hospitals and community units. It will apply to hospitals run by the district and to those which are self- governing NHS trusts. The difference with a trust is that it will play its part within the system with a local board to manage it and make the day-to- day decisions. Hospitals run by the district will continue to be managed directly. I shall come to NHS trusts later--they are dealt with in the next part of the Bill.

Mr. Simon Hughes : Why not let them decide?

Mr. Clarke : On the matter of who decides, we have always said that we shall consult on applications from hospitals to become self-governing trusts. I cannot receive such applications until the Bill has Royal Assent. People contemplate, "What if one has a self-governing trust?" Propositions will not even be worked out until next summer, and they will include plans for the development of services. We can have proper consultations then. I suspect that that is one of the many strange leaflets kicking around the Health Service on the subject of self-governing hospitals.

Several Hon. Members rose--

Mr. Clarke : I am happy to talk about the creation of NHSTs, if hon. Members wish to return to that point, but first I should like to stress the main point of the Bill.

These self-governing hospitals--that is what people want to call them--or NHSTs will be firmly anchored in the NHS. The clause provided for that. They set out the procedure for establishing the new bodies, their specific powers and freedoms, my reserve powers, which will ensure that they continue to meet their NHS obligations, and the basis of their funding. On establishment, the trusts will have boards of directors with substantial health, professional and outside expertise to provide the necessary range of skills and strong leadership on the ground. There will be special provision for medical school or university representation on boards should it be needed. Schedules 2 and 6 set out the freedoms of the NHSTs which we have been expounding since we produced the White Paper. They include the freedom to employ their own staff, to conduct research and to provide facilities for medical education and other forms of training. NHSTs will have the same income-generation powers as other health authorities. The schedules also contain safeguards in the form of specific powers of direction which the Secretary of State will have over the trusts. These powers will allow me and my successors to direct all trusts on matters of safety or ethics where a common policy will be pursued throughout the Health Service and, in exceptional circumstances, to direct an individual trust where there is justified cause for concern.

My hon. Friend the Member for Leeds, North-West (Dr. Hampson), who told me that he had to leave to catch a train to his constituency, whispered to me about educational research. I referred him to the powers which cover the provision of education and research and the

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powers of the Secretary of State to insist that proper arrangements are made in the unlikely event that any self- governing trust would wish to cease to play its part. The Government are certainly committed to high quality medical research and education in the Health Service and we propose to ensure that self-governing trusts play their part.

Mr. Derek Fatchett (Leeds, Central) : The Secretary of State mentioned his discussions with the hon. Member for Leeds, North-West (Dr. Hampson). Earlier he seemed to deny that health authorities had been spending taxpayers' money on working up proposals for hospital trusts. Where in the Leeds Western health authority does money come from to employ the consultant, Professor Bosanquet, and to produce and publish a report which advocates that Leeds general infirmary should become a hospital trust? Where is the legal power to spend that money, particularly bearing in mind that at a formal meeting the health authority voted against the proposal for the infirmary to become a hospital trust? Where is the power, or is taxpayers' money being used without legal authority?

Mr. Clarke : I know from my information that nobody is exceeding his legal powers in the Health Service or my Department. For as long as I can remember when a Government announce policy changes, a White Paper or an intention to legislate, it has been the obvious sensible practice for preparatory work to be done and for people to exchange ideas with the Government on how the concepts might work out in practice when they are introduced. The hon. Gentleman will know that that is the subject of litigation. Professor Harry Keen at Guys has been passing the hat round to employ lawyers to argue this for him. I would not dream of intruding on the litigation that will ensue. I am satisfied that we are acting within our legal powers and that what we have done is not out of line with previous practice. No doubt in due course that will be determined by the courts.

Mr. Matthew Taylor (Truro) : Will the Secretary of State give way?

Mr. Clarke : With the greatest of respect, I am sure that the courts will be seized of this and I do not think that the House should spend more time on it. What we are doing is not out of line with usual practice. It is most certainly not an unlawful use of money. Professor Harry Keen and his colleagues think otherwise, so the whole matter is sub judice and will be determined by the courts.

Mr. Taylor : Will the Secretary of State give way on a different point?

Mr. Clarke : No ; first, I should like to make a little more progress on NHSTs. I do not think that at the moment there is a proposal coming from Cornwall.

Throughout the country, partly as a result of this preparatory work, I detect mounting enthusiasm among many people in the service and among units and hospitals of all kinds about the possibilities that may arise from the establishment of NHSTs. It is not true, as some commentators have claimed, that interest is confined to the giant hospitals. Some small units have expressed interest. Indeed, interest has been expressed from outside the hospital service altogether. In some places, community services are being put forward and two ambulance services

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are contemplating self-governing status inside the Health Service. They see the possibility for new freedoms for local people and new opportunities to develop their services.

Many doctors and nurses have for years been frustrated by the constraints which in the olds days the bureaucracy of the NHS, through my Department, RHAs and DHAs, undoubtedly used to impose on their ability to work as they wished. All those who work in the NHS have a great sense of pride and it is strongest when it is attached to a particular hospital or unit. That can be used for the benefit of all by developing the NHST concept.

Success will depend above all on the strength of local leadership that emerges and the quality of the plans for the future of the unit which are produced. Sensible local discussion and the eventual decision must wait for the production of those plans so that their quality can be evaluated.

For some reason, the Labour party has latched on to self-governing hospitals as a focus for opposition. The enthusiasm of the Labour party and trade union movement for bureaucracy and red tape knows no limit. The most amazing nonsense is being canvassed in support of votes. The hon. Member for Southwark and Bermondsey (Mr. Hughes) is the latest to impress that on me. People have been told that these units are opting out of the NHS, a point which I have dealt with ; that this is a step towards privatisation, which nobody believes any longer ; that it is the end of job security for the staff ; and that vital local services will be closed in the interest of seeking profitable areas. I look forward to any hon. Member describing in Committee how that nonsense is to be put together. In places such as Redditch, the local council has spent a fortune of ratepayers' money to put out tendentious leaflets, with the result that people write back to say that they are against the curious nature of the proposals described.

Given that plans are beginning to develop in parts of the Service, next summer proper plans will be proposed by the Secretary of State in the normal way and consultations will take place. I am sure that in Committee we shall have many Divisions. Nobody has explained to me who on earth the electorate would be in those decisions, because hospitals do not belong to any particular section of the public. Even the Labour Government in their more foolish moments when they were responsible for these matters never held a referendum on local management structures for the Health Service, so far as I am aware. That is not a sensible way to run any service.

Mr. Tom Clarke (Monklands, West) : The Secretary of State will recall that he has been on his feet for almost exactly 50 minutes.

Mr. Kenneth Clarke : There were many interventions.

Mr. Tom Clarke : I accept that there were interventions. In that time the Secretary of State has not said one word about community care, which appears in the short title of the Bill. Is that consistent with the low profile of the Griffiths report, the publication of the White Paper the day after the House adjourned and the Government's low priority for the whole issue?

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