House of Commons Hansard Debates for 7 Dec 1989

Mr. Kenneth Clarke : I apologise for the length of time that I am taking. I believe that the television cameras stopped transmitting at 5 o'clock and I thought that that might reduce the number of interventions that I would be

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obliged to take during my speech. I am talking faster than usual, because I share the hon. Gentleman's concern for the community care part of the Bill, which is vital and must be subjected to debate over the next two days. I shall anticipate what I intended to say later, which is that my hon. Friend the Minister for Health will reply to the debate on Monday. She has particular responsibility for community care and will put heavier emphasis on it in her speech than it seems I am likely to have time for in mine. I agree with the hon. Gentleman that it is an equally important subject.

The Bill paves the way for GPs' fund holdings. As everybody, knows, I frequently state my enthusiasm for the family doctor service in the British NHS. It must play a key part in any service which is truly patient- oriented. The new contract will raise the quality and boost the service to the public. The system will also give GPs much more influence over what resources are spent on and much more contact with their DHAs than ever before.

The proposals for fund-holding general practitioners will give those who choose to develop it the opportunity to provide the patients in their practices with high-quality care. It will give GPs much greater control over the resources they deploy in any event in their referral patterns and much more influence that they have ever had over the development of the local services used by their patients.

The Bill provides the framework for the scheme to get under way, and I trust that it will be welcomed as it gets better understood. I never understood why the British Medical Association opposed the proposal, as I felt it was on the wrong side of the barricade. The BMA represents GPs in particular and it should have recommended to the Government a system that placed funds in the hands of GPs and gave them more influence over how resources are deployed. If I said that doctors would abuse that power, refuse the treatment needed by their patients or seek to make a surreptitious profit out of it, the BBC--sorry, I mean the BMA,in fact--the BBC and the BMA--would get extremely excited about my disgraceful slur on the medical profession. The BMA has occasionally argued that it does not believe that all its members would use those powers properly. I hope that, eventually, the BMA is on the right side of the barricade as fund-holding for general practice is an exciting concept for family doctors of which many will want to take advantage.

During the discussion of the Bill, we shall issue the programme needed for GP practice budgets in the near future.

Mr. Nicholas Winterton : What level of budget?

Mr. Sedgemore : What level of budget?

Mr. Skinner : What level of budget?

Mr. Clarke : When three of the noisiest Members of the House make a sedentary intervention, I feel obliged to respond to it, but I do not believe that two of them understand the matter. In reply to my hon. Friend the Member for Macclesfield (Mr. Winterton), in the first place the budget will be negotiated by the practice contemplating having that fund-holding budget with the regional health authority as the Bill provides. Eventually

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we hope to devolve the negotiating responsibilities to the family practitioner service authorities, which will replace the FPCs. I have dealt already in passing with prescribing budgets, but I shall do so again now. Clauses 17 and 31 contain the proposals for indicative prescribing budgets. "Indicative" is the key word. Those budgets will be targets that will be assessed as a reasonable expectation of what the prescribing costs should be for a practice. If a practice goes above that expectation it may well be obliged to answer to a professionally qualified group and to give an explanation as to why its prescribing costs are out of line.

The indicative prescribing budgets will be the machinery whereby the regional health authorities and the FPCs can manage prescribing costs more effectively than they have in the past. In that way, money will be targeted on effective patient care.

Sir Michael McNair-Wilson (Newbury) : If it is true that GPs will be able to prescribe whatever drugs they believe necessary and that that will not be a limiting factor on their drug budget, will the same be true of hospitals when a wonder drug is created? What will happen if a hospital wants to prescribe such a drug to its patients, but its existing budget is inadequate?

Mr. Clarke : Hospitals have always had to provide for their drug costs within the cash-limited provision. When a wonder drug is created, it has an inevitable impact on cash limits and, inevitably, it forms part of the claims that the Department of Health makes year in, year out, on the Treasury. In health care, when deciding what one must spend, one must pay regard to advances in the pharmaceutical industry. It is our intention that hospital and community service budgets and the GP indicative budget should reflect such expensive advances. Such advances are often counterbalanced by other medical advances that produce lower-cost alternatives to expensive hospital care for which GPs may opt. We must manage the budgets with common sense to ensure that essential needs are met and the best value obtained throughout the Health Service.

Clause 19 and schedule 4 allow the Audit Commission to take over the statutory audit of Health Service bodies from the Department of Health and the Welsh Office. My right hon. and learned Friend the Secretary of State for Scotland will introduce an amendment in Committee to permit a similar transfer of responsibility to the Commission for Local Authority Accounts in Scotland. My right hon. and learned Friend has taken no decision on whether to transfer his responsibilities, but he wishes to remove the statutory bar to the Scottish body taking on that role. He will make a final decision in the light of his review of the current arrangements for NHS statutory audit in Scotland.

The hon. Member for Monklands, West (Mr. Clarke) has already said that the Bill covers the legislation needed to implement the White Paper "Caring for People". Fortunately, we have a two-day Second Reading debate so that we can cover the NHS reforms and the future of care in the community. The policy aim of the Government is to give a better deal for people who need care in or near their own homes and a better deal for the relatives and friends who make considerable sacrifice to care for them. We announced our proposals first in the House and then in the

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White Paper. The Bill builds on the existing powers of local authorities--they have many existing statutory powers--and gives them new supplementary powers.

The key policy changes mean that we shall move to a system where local authorities clearly have the overall role in community care. They will provide services based on a proper assessment of the needs of individuals. They will use that assessment to make a more suitable provision for services than has sometimes been made in the past when there was an undesirable bias towards social security support for patients in private nursing homes. That was done without first exploring the possibility of the provision of better services in or near the patient's home. We shall also require local authorities to produce community care plans and added powers will be given to my inspectorate to check on their performance.

I have largely concerned myself with the NHS. I believe that the Bill paves the way for fairly rapid progress towards big improvements to the NHS. Some critics say that the pace is too fast, and I do not know how long they will want to take debating the Bill in this House. The talk is always about the need for pilot schemes and experiments to test our proposals. So far, the critics who have advocated pilots to me do not appear to know what they mean. Some people have asked me why we do not try out part of the reforms in a certain area of the country, but, in my discussions with them, no sensible explanation has been produced as to exactly how such an experiment would be made. One cannot pilot any of the things we are proposing without the legislation to enable the health authorities to establish a network of agreements under the new arrangements that we contemplate. There is plenty of experiment built into what we are doing. The ideas on the NHS trusts and GP fund holding will be developed by people inside the Health Service who have chosen to come forward to volunteer to work out the details with the Government. The whole process of reform will be based on working with people in the Health Service who want to see us make a success of our proposals. We shall learn from experience as we go along. I am sure that, at first, most parts of the country will use the contracts to put in place the existing pattern of care with which they are familiar. Once it is established what service is delivered with what resources, everyone will take advantage of the opportunity for choice offered by the new arrangements.

I trust that the debates in this House will enable us to reassure and appease the fears expressed by the professions. I hope that we explain to them that we shall learn from experience. Above all, we will be able to explain what we are doing for the patients. Patients are looking for shorter waiting times, a better appointments system and a much more personalised and friendly service. They want to know that everyone in the Health Service is striving for higher standards of care.

The critics of the reforms are trying to scare the life out of patients by suggesting that basic services will be lost. Those criticisms are not in the public interest. We are aiming for a better NHS for all, free for the patients regardless of need, financed out of taxation. We are looking for a great public service.

When we give the Bill a Second Reading, we shall give the NHS a new lease of life. We shall put it in good shape to provide an even better service in the next 40 years than it has provided for our people in the past 40 years.

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5.28 pm

Mr. Robin Cook (Livingston) : For the avoidance of doubt, it may be helpful to the House if I say at this stage that the Opposition do not propose to table a reasoned amendment before Monday. We are fundamentally opposed to the principle of the Bill and shall vote against it on Second Reading. We believe that it will destroy the public sector ethos of the National Health Service, and that it is designed to do so. Should the House be so illadvised as to pass this measure, it will prove in the future as unworkable as it has already proved unpopular in the present.

The Secretary of State and I have frequently jousted over the past 18 months since he returned to his office at the Department of Health. This is only the second time that he has appeared at the Dispatch Box with legislation since his return. The last time that he appeared before the House with legislation was a year ago, when he appeared in order to defend the abolition of the free eye test. I hope that the right hon. and learned Gentleman will forgive me if I begin by reminding him of the terms in which he recommended that measure to the House. He told the House that he did not believe the optometrists when they warned that abolition would result in what he described as an eye charge of "anything up to £10". The right hon. and learned Gentleman went on to ask the House this question : even if there were a charge of anything up to £10 for an eye test, how many people would be deterred by it?

Earlier this week, fortunately, we had the latest return of the quarterly survey of the Association of Optometrists. It shows that the Secretary of State was right to advise the House that we should not believe that the charge for an eye test would be anything up to £10. In fact, the average has been between £11.50 and £12 per eye test.

We are able to see from that survey the answer to the question put by the Secretary of State when he recommended that legislation to the House and asked how many people would be deterred by it. On the present trends revealed by that survey for the first six months of this year, we are on course for 2.5 million fewer eye tests than in the year before. That is the result of the measure that the Secretary of State last recommended to the House. By commercialising the eye test, he has removed a public service and has seriously damaged a vital screening service. It is against that record that we must measure his promises on this Bill.

Mr. Kenneth Clarke : I promise that I will not intervene often, but the hon. Gentleman has specifically raised this point. He knows perfectly well that the figures which he uses reflect the inevitable fall in the number of eye tests. There was a terrific increase in the number of eye tests taken out before April last year. People have the test once every two years. Everyone in the profession will tell the hon. Gentleman that it is nonsense to suggest that the number will not return to normal in due course. If the hon. Gentleman wants to have a free eye test, I can refer him to an optician service on Walworth road which is only one of many offering such free eye tests.

Mr. Cook : I am glad that the Secretary of State gave me that opening. I have heard him make that point before. The facts, as confirmed by his Department in parliamentary answers to me, show that in 1988, in the period after the announcement that a charge would be introduced for eye tests, the number of eye tests increased

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by 400,000. That is less than the increase in 1987, before the announcement, when the number increased by 600,000. In 1988, the increase was less than the year before.

Mr. Bill Walker (Tayside, North) rose --

Mr. Cook : The Secretary of State chose to intervene and I think that he can claim precedence even over the hon. Member for Tayside, North.

The increase last year was 400,000, less than the average for the previous two years. Because of the introduction of the charges, there has been a reduction not of 400,000 but of 2.5 million. That dramatic drop plainly shows that many people now find that the eye test is priced beyond their reach, although their sight may be fading and an eye test may well reveal much more serious medical problems than the mere failing of their eyesight.

Mr. Bill Walker rose --

Mr. Cook : I shall not give way at this point.

It is against that record of the promises of the Secretary of State--that there would not be charges of anything up to £10 and that they would not deter people--and the record of what happened when he put the eye test on a commercial footing that we must measure his proposals in the Bill to put the whole NHS on a commercial footing. Once again, the Secretary of State is doing this on the basis that he does not believe the warnings of the professions that care for the patients. Once again, the House is being presented with a measure on the now familiar basis that this Secretary of State knows better than any of the people who care for the patients.

The Secretary of State had the temerity to refer to a changing atmosphere among professionals and hospitals towards his Bill. It took brass neck to make that claim the day after the case for a judicial review was won on an application by over 3,000 consultants--10 times the number of doctors that the right hon. and learned Gentleman has been able to recruit for his own entryist front to support the White Paper.

The Secretary of State is fond of claiming that 80 per cent. agree with the objectives of the Bill. At the beginning of his speech, he claimed that the whole House agreed with the Bill's general objectives. That is hardly surprising, given the bland nature of those objectives as frequently stated by the right hon. and learned Gentleman. Those objectives are to increase patient choice, devolve more decisions to local level and improve value for money. The argument turns not on whether we all agree with those platitudes but on whether the Bill is any more likely to achieve any of them than it is to promote warmer winters. The Secretary of State uses the language of contract. As a barrister, he will know that the sensible thing to do with a contract is to study the fine print. I therefore warmly commend to the House the idea that it examine the fine print of the Bill to see whether it matches the rhetoric that we are promised by the Secretary of State.

Mr. Hayes : Will the hon. Gentleman give way?

Mr. Cook : I am happy to get my weekly intervention from the hon. Gentleman over as quickly as possible.

Mr. Hayes : I am grateful to the hon. Gentleman. I have listened closely to every speech that he has made on this subject. It is clearly time that he came clean and told the

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House whether he is committing his party to reject money travelling with the patients. For the first time, this will mean giving hospitals the financial incentive to treat more people. Is the hon. Gentleman committing his party to rejecting the idea of doctors and consultants finding out their basic unit costs so that they can treat more people more effectively? Is he going to commit his party to rejecting medical audit resource management? The hon. Gentleman should tell us the answers. We have a right to know, and so do the electorate.

Mr. Cook : I am sorry to disappoint the hon. Gentleman. There is nothing in the Bill about a medical audit. If he is thinking of voting for the Bill because he supports the idea of a medical audit, I would strongly recommend that the hon. Gentleman--I would warmly welcome his joining me in the Division Lobby--think again about where he will cast his vote. Of course we do not oppose the idea of money following the patient. The question is whether the Bill does anything to provide for money following the patient, rather than providing for a situation in which the patient follows the money and the contract. I shall explain that point when I reach that passage in my speech. Let us begin with the patient. The Secretary of State has frequently said--as he said again this afternoon--that his Bill will increase patient choice. The phrase which was in vogue in January when the White Paper was unveiled was that it would "put the patient in the driving seat". There is not much for the patient in the Bill. I have had the Bill read from cover to cover, and we could find only one reference to the word "patient" in the Bill. It is found in clause 14 where, characteristically, the word "patient" arises solely as a basis on which the money to be paid to the doctors is counted. How little choice will be given to patients by the Bill is graphically revealed by the fact that there is to be no consultation with the patients. In February, the Secretary of State made a speech in which he said that his proposal would encourage

"local pride in our hospitals"

and would give local people

"more ability to take the big decisions in their own part of the service."

What could be a bigger decision than whether one's local hospital goes into one of the NHS trusts and out of the local district health authority? Yet that big decision is to be taken without the by-your-leave of the patients of that hospital service. The person who takes it is the Secretary of State ; clause 5 simply states : "The Secretary of State may by order establish NHS trusts." I must draw the attention of the House to the fact that, ironically, schedule 2 stipulates that there must be consultation before such a trust is wound up. In other words, there will be more consultation before such a trust can opt back into the NHS than before it can opt out in the first place.

Any doubt about whether there will be greater choice for local people in what happens to their local service is removed by the advice on self- governing trusts that the Secretary of State has sent to health authorities :

"It would not be sensible to organise ballots of staff or any other groups with an interest."

This Bill does not extend choice to patients. The Secretary of State is terrified to offer them the choice, because he knows that they would give these plans the

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thumbs down. I had not intended to refer to this, but since the Secretary of State mentioned it, I shall. The ballot in Redditch was held in a borough in which 57 per cent. of the electorate voted--a commendable turnout for a local vote. It is not a Labour stronghold ; it is represented by one of the right hon. and learned Gentleman's colleagues in Government. In a large turnout in an area that is not in our Labour heartland, 81 per cent. of those responding declared themselves not in favour of the Alexander hospital opting out. It will not do to dismiss this result by saying that the wrong type of leaflets were given out. This type of result is known as democracy. It would be flagrantly undemocratic if, as well as ignoring the views of those who work in hospitals, the Secretary of State were now to ignore the choice of the patients they serve. There is another collision between all the promises of choice and local decision-making. That collision is to be found in the composition of the new district health authorities which exclude anyone who might choose to do something different from what the Secretary of State wanted. Out go the representatives of local authorities, who are the only people in the health authorities who are elected by patients. Out go the representatives of the professions that treat the patients. Instead, everyone on every district health authority will be appointed by the regional health authority, and everyone on every regional health authority will be appointed by the Secretary of State.

Just in case someone with an independent mind slips through this process, out goes the tradition of voluntary services on health authorities. All the non-executive directors are to draw a salary, at a total cost of £10.5 million, which is more than the entire budget for all the community health councils in England and Wales to represent the views of patients.

The Secretary of State has not come up with a system in which health authorities will be staffed by people who are respected in their local communities, as he put it. He has come up with health authorities that will have no pretence of representing local choices or interpreting local preferences. He has come up with a board of management that will exist to implement central policy--exactly the sort of machinery of the clapped-out centralised state which is being dismantled all over eastern Europe.

I know that the Secretary of State will say that this is not the sort of choice he meant, that he meant more choice for individual patients. So let us look at what will happen to them. This brings me also to the point made by the hon. Member for Harlow. There will be less choice for individual patients : less choice over which hospital to go to, for instance. The patient will go where the district health authority has placed a contract. It is curious to claim that that means money following the patient. I invite the hon. Member for Harlow or any of his constituents, once this Bill is law, to turn up at any hospital of their choice at which the district health authority does not have a contract and to tell that hospital, "It is all right--the money will follow me afterwards." Anyone who did that would be lucky to get past the reception desk.

Mr. Hayes : The hon. Gentleman is not quite accurate ; indeed, he is wholly inaccurate. He should look at the Department's guidance to district health authorities which, at this very moment, are exercising their right to speak to doctors on their referral practices.

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The hon. Gentleman should be honest enough to tell the House that the referral practices of general practitioners will remain the same.

Mr. Cook : That is not so. Under this Bill, the GP will not have the opportunity to send his patients to hospitals at which the district health authority does not have a contract. Nowhere in the Bill is that right of the GP defended.

If the hon. Member for Harlow turns up at a hospital in these circumstances, he will be asked where the money is coming from, and that is a question that the House should ask in a more general context. I have, as the Secretary of State knows, just completed a survey of the financial state of health authorities. It showed that three our of four--

Mr. Nicholas Bennett (Pembroke) : At House of Commons' expense.

Mr. Cook : I am delighted to tell the hon. Gentleman that two out of three general managers were content to reply to me, not to him. Three out of four of those responding reported that they were under-funded for present levels of service. All those three quarters are now taking emergency measures to avoid a deficit. Many of them are closing beds and freezing vacancies. Some of them are cancelling operating sessions and will no doubt feature in a future league table drawn up by the Secretary of State as people who are under-managing and under-performing.

In a rare passing moment, I shall seek some common ground with the Secretary of State. I agree that some of the variations in performance are not related to resources. Having looked at the figures, I agree that that is manifestly true, but as I have acknowledged that, I invite the right hon. and learned Gentleman to acknowledge that most of the frozen vacancies and cancelled operation sessions revealed in my survey are due to a shortage of resources. The financial pressures do not vary ; the picture of financial pressure is the same in every region in Britain.

In the north, Newcastle district health authority reports under-funding by £2 million--a gap that it cannot fill without redundancies. In the midlands, Rugby reports that next year looks particularly grim. In the south, East Hertfordshire reports that the short-term outlook is extremely bleak. And Barnet district health authority, covering the constituency of the Prime Minister, reports that it is closing 10 paediatric beds and 14 gynaecological beds. That is the state of the Health Service after 10 years of her stewardship-- [Interruption.] I am sure that the hon. Member for Harlow will return to the Chamber to intervene before I can finish. There is a desperately worrying message for the hon. Member for Harlow, before he departs, and for all other Conservative Back Benchers in the results of my survey. I have been interrupted by enough Back Benchers in the past few months to know that every single one of them believes that it is his hospital that has a problem of success and a financial problem because it is treating more than its fair share of patients. They all believe that, when money follows the patient, the financial pressures will be magicked away.

I have never yet been interrupted by a Conservative Back Bencher anxious to tell me that the staff at his or her hospital are pretty useless and treat fewer than their fair share of patients, and that the sooner the Bill is passed the

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better because then the money from the hospitals in their constituencies can be transferred to the over-performing hospitals in the constituencies of their neighbours. I can understand why they do not make that point. It is not that they do not relish the thought of the local paper holding its front page to capture their remarkable statements. It is because, as this survey shows, across Britain--

Dame Elaine Kellett-Bowman : Statistics prove that we take in 29 per cent. from outside our district.

Mr. Cook : All Conservative Members share the hon. Lady's view--that is precisely my point. Everyone's hospital has the same desperate problem of trying to make ends meet, and most hospitals cannot do that without a deficit. Conservative Members deceive no one but themselves by believing that the under-funding of the hospitals that they represent will disappear under this monumental and monumentally irrelevant upheaval in the administration of the NHS.

The Secretary of State assures us that, if this upheaval does not produce more choice, it will at least result in value for money. He will apply the magic potion of competition, as a result of which we will apparently achieve more output for the same input. The right hon. and learned Gentleman has certainly mastered the language of competition. I read with fascination last night the circular that his Department has issued to health authorities on the pricing of contracts. [Interruption.] My hon. Friends elected me to carry out these distasteful tasks on their behalf.

The circular contains a section headed, "Competition and the invisible hand". Someone from the Adam Smith Institute obviously slipped into Richmond terrace by the back door. I shall quote two sentences from the section. The circular says :

"it may be desirable, to have a spot' market as well as a long-term market. It may also be desirable to cater for peak and off-peak demand by differential pricing."

Even more remarkable than reading through such circulars, I have waded through the submissions sent to the Secretary of State by hospitals that seek to be self-governing. I know that such language is also catching on with district general managers. Basildon and Thurrock say that they want to set up a self-governing hospital to prevent what they describe as "predatory hospitals" picking out their patients. The use of such language shows how quickly the new market discipline leads to the end of other hospitals being regarded as colleagues in the same service and the start of their being seen as competitors in the same market.

South Yorkshire set up a task force to advise on the change in management that was necessary to make self-governing hospitals work. One of the major injunctions that came back to the management of that hospital was the wonderful advice that, in order to maintain its market share, it should "keep changing the product lines."

Mr. Bill Walker : The hon. Gentleman declined to give way before. He is speaking about competition. [Interruption.] The hon. Gentleman is usually polite ; the fact that he did not give way must mean that he was on a weak spot. He is aware that competition in Scotland resulted in extensive advertising for free eye tests. That has been going on for some time in Scotland.

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Mr. Cook : Plainly, the hon. Gentleman had only one matter to raise in an intervention, and when he was allowed to make it it was the only point that he could raise. I am aware of the company that is advertising free eye tests and have had some correspondence with it. The company is Duncan and Todd. Before it issued the advertisements for free eye tests, it got in touch with me to seek my assurance that the next Labour Government would abolish the charges for eye tests, because only on that basis could it carry the two-year loss of providing free eye tests. That is the reality of the advertisements to which the hon. Gentleman refers.

Conservative Members are so besotted with the market that it is an article of faith with them that haggling in the marketplace is the best way to achieve efficiency, even in health care. I view with profound distaste the allocation of health care discussed in the patter of a salesman. I do not want a health service of spot markets, predatory hospitals and product lines. I want it run as a public service to meet the need for health care and not the need to cater for market demand.

Thousands of consultants and sisters and even district general managers will take the deepest offence at the Secretary of State's remark that no one has any motive to cut waiting lists. That remark betrays the fact that the Secretary of State does not understand what motivates professional commitment to a service to patients. Of course he meant that no one has any financial incentive to get rid of waiting lists. That confirms that Ministers are incapable of recognising any motivation that is not financial. I shall be happy to be disabused of that view if the Secretary of State can do so.

Mr. Kenneth Clarke : I am used to the hon. Gentleman giving dark paraphrases of what he says I have said, and I am used to some of my critics outside leaping on to those paraphrases. I said that the present system gives no incentive to anybody to reduce waiting lists, and that is true. I described how the new system would give rewards and incentives in terms of resources for the unit if waiting lists were brought down. The hon. Gentleman is extracting curious phrases from the thousands of pages that he has read. As a would-be Secretary of State for Health, is he talking about the prospect of handling £28 billion of public money without any regard to elementary financial management and with a disdain for any system of matching resources to the work load?

Mr. Cook : The Secretary of State confirms exactly the interpretation that I put on his remarks. He sees only a financial incentive and does not recognise the clear motivation of the staff in the Health Service to tackle waiting lists. He is perfectly right to anticipate the next Labour Government ; I am pleased to hear that from his own lips. He is concerned about what we will do. I assure him that I do not believe that spot markets are the best way to allocate £20 billion within the Health Service.

Mr. David Nicholson (Taunton) : Will the hon. Gentleman give way?

Mr. Cook : No. I have given way twice to the Secretary of State, who must take precedence over the Back Benchers. The more he intervenes, the more difficult it is to give way to Back Benchers, much as I should like to give way to the hon. Member for Taunton (Mr. Nicholson).

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We are being offered an eccentric market, in which there will be no consumers. It is not the patients who will strike the bargain about where they go and what is to be done to them. Health authorities will bargain with one or other, and the vast majority of those health authorities are already in deficit. They will not bargain about quality, because, as a result of the financial pressures on them, they will be obliged to go where care is cheapest.

There are some missing commitments in the Bill. It contains no commitment to ensuring that quality is reflected in the contract ; nor is there a commitment to the core services that are promised to self-governing trusts. In the absence of legal protection for those core services, we know what will happen. We can predict now which services the hospitals are most likely to shed. They will be chemotherapy, renal dialysis, geriatric care and community psychiatry--all the specialties which require a long-term commitment to high expenditure, with a low expectation that the patient can be finally cured and taken off the books. We can predict what will happen, because those are precisely the procedures that the private sector will not touch because they cannot be delivered at a mark-up. Whether the end result of all this is value for money is a matter of taste.

I noted the candid evidence of Dr. Ken Grant, who is the district general manager of City and Hackney. He has been one of the star turns at the conferences trying to make sense of the White Paper for the last nine months. My hon. Friends will know about Dr. Grant. Last week, he made the candid statement that at the moment, when St. Bartholomew's accepts an emergency admission from another district, it has an incentive to keep down the costs because it will be left with the bill. He said that, under the new scheme, St. Bartholomew's would have the incentive to do as much as possible to that patient in order to generate income from the health authority that will pick up the bill.

That is a perfectly rational response to the market opportunity with which Dr. Grant has been presented, and it would be wrong to criticise him for it. As a manager, he had a predictable solution to the problem that he had identified : his solution was more managers to comb through the bills to make sure that they were not being rooked.

There is one stark consequence of the Bill, and that is more administrative staff to try to make it work. The memorandum to the Bill states that we shall require 3,800 additional staff. I thought that it was a piece of unusual impertinence by the Secretary of State to accuse Opposition Members of being in favour of bureaucracy. The additional bureaucracy will cost him £200 million. Whether that is desirable expenditure is, I suppose, a matter of taste. I find it an odd priority in a Bill that is supposed to be about value for money, when health authorities throughout Britain are freezing vacancies because they cannot afford to pay the nurses and doctors to fill them.

I cannot see that the nation has received value for money from the White Paper entitled "Community Care". It was published on the Thursday of one week and the clauses of the Bill that is now before us fell fully formed on the Wednesday of the following week. I know of the Government's perfunctory commitment to consultation, but I believe that this time they have set an all-time record.

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As the White Paper was published only as a collector's item, the Secretary of State might have been advised to spare the taxpayer the expense of footing the bill.

There is nothing in the Bill on community care to show that the Secretary of State has heard the criticism that broke out on the publication of the White Paper. I found it regrettable that, in a speech which lasted a full hour, the right hon. and learned Gentleman was able to find only one minute to discuss community care.

Dame Elaine Kellett-Bowman : My right hon. and learned Friend explained why.

Mr. Cook : The Secretary of State said that the Minister for Health will refer to community care when she replies to the debate late on Monday night. This is a two-day Second Reading debate, and the Secretary of State might legitimately be expected to set out the priorities for debate and the ground to be covered, and at least one of the priorities is the future of community care.

We find that even the rhetoric of competition parts company with sections of the Bill. There is no perfect competition to be found. Roy Griffiths proposed that there should be a level playing field for fair competition between the public and private sectors, and the Opposition are prepared to go snap on that. We are happy to accept the challenge of competing with the private sector at level weight. I believe that, without a partnership between public and private provision, we have no hope of meeting the explosion of need of the very elderly in the next 10 years.

Instead, the Bill offers us a rigged market. Perversely, someone retains his right to public benefits, income support and housing benefit only if he goes into a private residential home. If he goes into public residential care, he will have no right to public benefits. It would be difficult to produce a more flagrant example of unfair competition.

What happened to choice? Why should those who go into residential care not have a free and fair choice whether they go into public or private care? The purpose of the rigged market is clear : it is intended to reduce available choice by obliging local authorities to privatise their homes so that they may qualify for subsidy from public benefits. It is not only local authorities that are worried. The Spastics Society stated :

"We are deeply concerned about any assumptions that the public provision of care for disabled people can be in the main shifted to the private and not for profit sector without devastating consequences for disabled people."

What about the choice of those who live in residential care homes that are provided by local authorities? Should not they be able to choose whether their home stays in the public sector or is sold to the private sector? There is no such right in the Bill. The Government are fond of talking about individual choice, but they have produced a Bill that is curiously silent on the rights of the user of the service. Not once in the Bill is the user of community care services mentioned. Nor are carers mentioned.

The National Carers Association responded to the White Paper on care by saying :

"The White Paper contains all the right rhetoric about helping carers, yet in spite of a 106 page document the practical reality of how this will happen is still unclear."

It is even more unclear after the printing of the Bill. The Bill does not once mention carers, does not give them one new right, does not place on local authorities one new duty in respect of care, and does not place upon them an

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obligation to assess the needs of carers, or even to consult carers about the community care services that they provide.

In the clauses on community care, we find the widest chasm between the promise of local decision making and the reality of central control. This is not a Bill that gives power to local authorities. Instead, the Bill gives all the powers to the Secretary of State. I have been through the Bill and I have counted the number of times that the Secretary of State is mentioned ; the total is 127 times. That does not include the references to the Secretary of State for Scotland. The Secretary of State for Health is the one who will make the regulations. It is he who will lay orders and give directions. I understand that it is fashionable to describe this arrangement as enabling legislation. That is a misuse of our language. This is not an enabling Bill. It is a Bill for arbitrary government by whomever happens to be Secretary of State at the time. We know who the present Secretary of State is. I have no doubt that in his own way he is lovable. We have certainly grown to know his face. He has been in his present post since July 1988, and the Bill will not become law until April 1991. That is a long time for anyone in this Government to hold office. We all know that by April 1991, the Secretary of State will want to be at Victoria street, Marsham street or the Paris embassy at rue du Faubourg St. Honore . He wants to be anywhere but on the bed of nails at Richmond terrace.

What if, in April 1991, the Secretary of State for Health is the right hon. Member for Cirencester and Tewkesbury (Mr. Ridley)? What use would he make of the powers that he would then hold? What powers will he inherit? Clause 44 sets out the Secretary of State's duties in respect of community care :

"every local authority shall exercise their social service functions in accordance with such directions as may be given to them under this section by the Secretary of State."

That is all we are told. We are not given any guidance on what the directions might be.

I must be fair and candid to the House and say that there is a limitation of the directions. There is one qualification of what the direction must be. Clause 44 (2)(a) states that the directions "shall be given in writing".

That is the sole restriction on what direction the Secretary of State may give to local authorities in their use of community care powers. Even Erich Honecker would not have imagined that he could give directions that were not in writing. Clause 44 gives whomever is the Secretary of State the power to use directions without even the process of scrutiny of parliamentary approval, in so far as I can describe the rubber stamps on the Benches behind the Secretary of State as a process of scrutiny.

We are talking of directions to health authorities that have not been appointed by the Secretary of State. I ask my hon. Friends to mark this well : they are directions to local authorities elected by local people and accountable to local people. That brings us to the greatest reason of all for suspecting that rhetoric is running ahead of reality in the Bill.

The Government and the Bill are loading local authorities with responsibilities without disclosing what they will do to increase resources for local authorities. Here is another major departure from the Griffiths report.

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