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That is the advice sent out by the Department of Health, not an Opposition spokesman or a critic from within the Health Service. Opposition Members should not feel so sad or frustrated about the Secretary of State. We know that he does not listen to nurses or to patients, he does not pay any attention to doctors and he rides roughshod over views expressed in Parliament. We can seek reassurance from the fact that he does not pay a blind bit of notice to what his own Department are saying about the centrepiece of the proposal--the flagship of self-governing hospitals. We will deal with that in detail in Committee, but I shall touch on three important issues. First, the proposal turns the clock back. As the right hon. Member for Blaenau Gwent said, there has been a steady, if not always perfect, attempt to expand a truly planned National Health Service. Enshrined in that aim was the belief that, wherever one lived, one should have access, as far as possible, to the same level of treatment. The proposal can only erode that principle.

Secondly, the proposal will further entrench the importance of cash over care, with the result that the less profit-making services will have to be sacrificed to build an attractive and glamorous national image. The services that are most likely to go are basic services to the local community, such as geriatric and maternity services. I find it amazing that the Secretary of State could not say any more about that issue in his opening speech. We shall seek further clarification about what the Government and the Department think constitutes a core service that must be maintained by a district or regional general hospital.

Mr. Matthew Taylor : I have handed to the Secretary of State today a petition with 7,500 signatures from my constituents, who are concerned about the proposals. Are the problems of the scheme not best illustrated by hospital trusts? People feel that they are not being consulted about the future of a National Health Service that they are proud of and depend on. That problem is stirring up concern among ordinary people, not just among doctors, and Front-Bench Labour or Conservative spokesmen.

Mr. Kennedy : I am grateful to my hon. Friend and pay tribute to the work that he has done in his constituency to alert people to the dangers. I know of one direct consultation exercise. It was conducted in the constituency of my right hon. Friend the Member for Yeovil (Mr. Ashdown). Some 96 per cent. of those who registered an opinion were unambiguous about their desire for the local hospital not to opt out of the National Health Service. That was a very good judgment. Education and training is a deep worry to the Committee of Vice-Chancellors and Principals.

Mr. Tim Devlin (Stockton, South) rose--

Mr. Kennedy : I shall not give way.

Mr. Deputy Speaker : Order. The hon. Member has already overrun his time.

Mr. Kennedy : With deference to the Chair, I am trying to finish my speech.

Mr. Deputy Speaker : Order. I am required to ask the hon. Member to finish his speech.

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7.10 pm

Mr. James Couchman (Gillingham) : It is flattering to have the whole Liberal doughnut to speak to. Perhaps Liberal Members will leave quitly.

I have taken a part in the management of the Health Service for much of the past 15 years, from membership of an area health authority and chairmanship of a social services committee in the middle 1970s to the chairmanship of a district health authority in 1982. My first year here was spent on the Social Services Select Committee, before I was invited to join the Department of Health and Social Security team as Parliamentary Private Secretary to my right hon. Friend the Member for Braintree (Mr. Newton).

From those diverse vantage points, I have become convinced of the urgent need for reform of the National Health Service. It has tottered from one crisis to the next for all of those 15 years. The symptom of the crisis has usually been a comparatively small apparent shortfall in the NHS budget. There appears to be a recurring £200 million shortage which suddenly manifests itself around Christmas time and causes panic among managers, who always try to resolve their imagined problem by closing beds, wards, or even hospitals, and by curtailing other sharp-end patient services. I deliberately used the terms "apparent shortfall" and "imagined problem", for £200 million represents less than 1 per cent. of the Health Service's enormous budget, and it requires much more sophisticated financial management to foretell an overspend of less than 1 per cent. four to five months before the end of the financial year.

Just two years ago, when my right hon. Friend the Member for Braintree was Minister for Health, there was a particularly severe dose of the pre- Christmas wobblies. As ever, 100 per cent. of the service was plunged into crisis for a 1 to 2 per cent. predicted cash shortfall. After some especially unsavoury examples of shroud-waving around the country, additional money was given to the Health Service, but the time had finally come to investigate the cause rather than the symptoms of the recurring crisis.

A committee to review the Health Serice chaired by my right hon. Friend the Prime Minister was convened. The result was "Working for Patients", which I welcome, for it challenges some of the most sacred cows of the service. The review recognises for the first time--the Bill tries to tackle it--the essential changing nature of health care, from the fairly simple public health service remedies of the 1940s to all the marvellous modern techniques which we increasingly regard as commonplace today. It recognises that the Health Service has become a victim of its own success, as each new therapy, whether surgical or medical, adds to everybody's life expectancy, but particularly that of the very elderly, and produces its own waiting list.

The Labour party uses waiting lists, or waiting times, as a stick to beat the Government because the last time Labour Members were in government, they allowed their union paymasters to force the devastating strike that we now remember as part of the winter of discontent. They remember the mismanagement of the economy, which led to the International Monetary Fund demanding major cuts in public spending, and the effect that that had on the NHS. The increase in waiting lists to an all-time record in 1979 was indeed a measure of failure. I believe that, today, the waiting list is largely a measure of the NHS's success.

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There was no waiting list in 1959 for hip joint replacement or coronary bypass grafts. Those techniques were at an early stage of development. The lack of waiting lists for those and many other procedures was hardly a measure of success. Today, the waiting list is a good indication of people's vastly increased aspiration for life- saving and quality-of-life-improving treatments.

The review also recognised the rigidities in the present system which arise out of the NHS's very size, its massive work force, its inertia and the inefficiency with which its resources can be deployed. In short, the review recognises the near-impossibility of managing the Health Service in its present corporate or conglomerate form, and seeks to break it up into smaller, more manageable, and more reactive parts.

Waste is endemic in all very large organisations, and the Health Service is typical of that. Successive reorganisations have recognised, but not tackled, that problem of waste of resource, largely because they have not recognised the fundamental inefficiency of a vast monopoly purchaser of health care which is also a vast monopoly provider. The Bill tries to tackle that, but of course the Labour party, with its reverence for Aneurin Bevan's memorial, and its consciousness of its trade union masters, recognises the great danger of fragmentation to the trade unions. The Health Service is uniquely vulnerable to industrial dispute because of its national negotiating machinery and national wage agreements, which take almost no note of local circumstance. There is no doubt in my mind that it is this aspect of self-governing trusts which most frightens Opposition Members--that local pay and conditions will be negotiated without reference to the thrall of national union leaders. The emphasis which the review and the Bill put on outcomes is to be welcomed. Medical accountability and clinical audit are long overdue. I believe that the vast majority of good clinicians will welcome the opportunity to have their dedicated efforts measured against sensible benchmarks. If the monitoring process highlights those few whose productivity is compromised either by idleness or by their assiduous promotion of their private practices, the Health Service will be the winner.

It is in regard to the outcomes that I should like to express one of my two reservations about the Bill. I refer to indicative drug budgets. I must declare that I have had many discussions with the pharmaceutical industry, and I have lately advised one company on matters pertaining to the Bill. It makes no sense to save a few pounds by denying a patient the most modern and efficacious medication if the outcome is that he or she lands up in hospital. That is a poor outcome for the patient, and a poor outcome for the service, but it is a risk if the only sanctioned or monitored measure of a doctor is his prescribing habits. Doctors who have practice budgets will have wider choices to make, but those without practice budgets may have care only for their indicative drug budget. I should like to give an example of an extreme case. The new British drug eminase is a thrombolytic drug with the most exciting potential. It is given as a one-shot emergency injection to heart atttack victims. It dissolves the life-threatening clots and limits the amount of heart muscle that is destroyed by the atack. Moreover, its chemistry controls the rate of delivery over several hours. It is a very clever drug which markedly improves the

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immediate prognosis for the patient, reduces the time likely to be spent in intensive care and reduces the likelihood of the victim being left a cardiac cripple.

Eminase offers excellent outcomes all round, but it is expensive. It costs about £500 for the single emergency shot. I should like to think that no doctor is mindful of his indicative drug budget when I fall victim to a heart attack and my condition indicates the need for an urgent shot of eminase.

While considering how to bring into line the minority of general practitioners who are bad prescribers--it is worth noting that under- prescription can be as detrimental as over-prescription--it behoves my right hon. and learned Friend the Secretary of State to remember his days at the Department of Trade and Industry, and the battle for a positive trade balance. The pharmaceutical industry is a rare star in that area, having an annual positive trade balance of some £850 million, but it is an industry in which decisions about investment are particularly susceptible to whether the market is perceived to be hostile or favourable. Investment decisions about where to put new research and development, manufacturing and distribution, especially by multinationals, but also by British companies, will determine whether that favourable trade balance is maintained.

The Henley centre has recently suggested that imprudent implementation of the White Paper proposals could be highly detrimental and cost far more than will be saved by the indicative drugs budget. That would be a poor outcome.

My second reservation is about the explanatory memorandum, which sets out in bland terms the costs of the Bill in financial terms and in manpower. That section sends shivers down my spine, for I have watched at first hand as a district health authority chairman the Health Service's infinite capacity for creating bureaucracy. The systems under which the purchaser, whether health authority or general practice, will contract with the provider for services offers scope hitherto undreamed of by bureaucreators. The method of tracing through and monitoring payment for service by the Health Service to the Health Service could make the reorganisations of 1974 and 1982 look positively transparent. Beware of the bureaucreator, who is already alive and well and flourishing among the regions, including my own region of South-East Thames.

As a former chairman of social services, I should have liked to speak about the community care proposals but I hope that I shall be allowed to contribute to the debate on them in Committee. I recognise that many other hon. Members wish to speak tonight. I believe that the Bill will take the NHS into the 21st century in a healthy and vigorous form. I wish it well and will support it enthusiastically. 7.21 pm

Mrs. Gwyneth Dunwoody (Crewe and Nantwich) : For 10 years I have listened to Conservative Ministers say how strongly they are committed to the National Health Service and how simply it could be improved if only it had less money at its disposal. "Efficiency, efficiency, efficiency", we are told. More than one reorganisation of the Health Service has been masterminded by the great brains of the Conservative party resulting in chaos from which it usually takes the NHS a considerable time to

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recover. But the present Bill is a real corker. One might call the ability to produce such a Bill a unique gift, even for the Conservative party. It is a Bill spawned in dislike, produced out of ignorance and apparently being pushed with malice.

The Secretary of State seems to have come to the House today, not to detail the changes that he genuinely believes will produce positive results for patients but to say that people in the Health Service who do not instantly agree with the mess of pottage that he is presenting to them are automatically ignorant, incompetent and malicious. That is the only explanation for his constant attacks on all sections of the NHS. He says that consultants keep up their waiting lists as part of their prestige, the nurses questioned their upgrading because they did not understand that it would put them on a better footing, and that the ambulance men must be starved into submission because they are just taxi drivers who do not understand patient care. I find that despicable. There are no words strong enough to condemn the performance of a Secretary of State who is not stupid and who knows that what he says is based irrevocably in deep contempt for the NHS.

The Conservative party has opposed every positive move since the Health Service was first suggested, and now it is coming forward with suggestions somehow to transform the NHS into a commercial organisation. I have received in my post an interesting glossy brochure emotively headed, "Not for Sale". One might think that that referred to some political party, but not on your life: it refers to the creation of hospital trusts among the mid-Cheshire hospitals. The brochure contains pictures of the district general hospital--in the centre of my constituency and the only one for a considerable distance--and the Victoria infirmary, telling us that they are not for sale.

Only towards the end of the brochure is one told that other hospitals will not be included in the opted-out independent NHS trusts. Those hospitals have one thing in common--all of them provide high-cost, important, long- term services for the mentally handicapped, for psychiatric and geriatric patients, and for others who require support services due to long-term chronic illness. The hospitals involved have one other thing in common--all have large acreages of land suitable for sale by an independent trust.

The Secretary of State says, "Don't worry, we shall have contracts, " and that they will not really be contracts but agreements. If anything makes the hair on the back of my neck wave, it is a barrister who tells me, "Don't worry, it is not what it says but what I say it says." A contract is a contract. What will happen to services which are not provided to a standard that the people responsible for the bills regard as acceptable? Will there be constant litigation between sections of the NHS? When GPs find that they cannot obtain suitable services from hospitals, will they take some form of legal action against the hospitals concerned? It may seem absurd, but in my view it is all too possible.

What will happen under the Bill is quite different. It will be particularly damaging for rural general practices in my constituency. It is not true that the Bill will help women doctors. Many women doctors who have families like to provide single-session services, not just to keep up the standard of their medicine but to provide a useful service. General practices faced with a limited budget--we have been given no assurance that they will have sufficient

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resources to run a proper service--will almost automatically cut down on use of single-session part-time doctors because, even if those doctors provide an essential service, the doctors in the practice will prefer to provide the service themselves even if it is less adequate. So long as they deal with sufficient numbers, that will be all that counts. They will say, "We can provide a sufficient level of care to ensure that we can put in the figures at the end of the quarter and get the cash back." That will be an increasingly frequent occurrence and those who wish to continue working on a single-session basis will have real problems.

There will also be problems of trust between patients and GPs. General practice is, after all, the best way of delivering health care to patients when they most need it. GPs are the best clinicians and they know when people need to talk and when they need medication. The GP should provide the services that have been paraded before us this evening as though they were revolutionary innovations. Twenty-four years ago I worked in a general practice where it would have been regarded as a disgrace not to be able to take out a verruca without being told by someone else that it was a brilliant idea. We are talking not about the level of patient care but about money and the provision of more accountancy services. We are constantly being told of the huge sums put into the NHS in the past three years, but where has that money gone? It has gone to provide accountants and the modern equivalent of the cash register--the computer. Like all good computers, the NHS computers will no doubt lose as much detailed NHS work as they manage to lose political work.

There will be a fragmentation of the NHS. That was the word used by the Secretary of State. That is clear from the brochures that have been circulated to staff and it is clear to everyone who looks at the details of the Bill. The balkanisation of the NHS is what the Bill is all about. Increasingly, hospitals will compete with and not complement one another. They will not say, "Where are the services that are helpful?" They will not talk to GPs about the need to plan the integration of services so that practice nurses, physiotherapists and others can be provided. The Labour party has been asking for that for the past 10 years, ever since the massive investigation into NHS needs which was wholly ignored by the incoming Conservative Government.

I am still a softie at heart and I want to believe that the good, kind gentlemen in the Conservative party mean what they say when they talk about their commitment to patient care. Throughout the passage of the Bill, there will be repeated opportunities for them to prove that. They will be able to tell us how rural practices will carry on, and how inner-city practices, which already have difficulties with shifting populations, will be able to show that they have maintained the level of specialised care that they are told is essential. Conservative Members can also explain to us how the staff and, above all, the patients in my constituency are to discover what core services are.

The Bill does not make it clear what core services will be, but I can tell the House what the core of the Bill is--it is a deep contempt for the concept of the National Health Service, and the sooner the Government make that plain, the sooner patients will tell them where to go.

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7.31 pm

Mr. David Atkinson (Bournemouth, East) : This has been an exciting week in the Health Service for my constituents. On Monday, phase 1 of our new Bournemouth general hospital opened its doors to patients. It is a magnificent hospital, of which the East Dorset health authority has every reason to be proud. I congratulate all those responsible for it.

I take this opportunity to pay particular tribute to the people of Bournemouth and the surrounding districts for raising £2 million for the new Bournemouth hospital appeal. That enabled this already well equipped, new hospital to have the additional facility of a body scanner, which I had the pleasure to see in operation on Monday. It would be well to remind the House, if it needs reminding after three Adjournment debates on this subject, why there were delays in starting the hospital. It was planned to be built more than 10 years ago, but together with many other hospitals it was a casualty of the cuts which the Labour Government imposed on their hospital building programmes. On behalf of my constituents and my hon. Friends the Members for Bournemouth, West (Mr. Butterfill), for Christchurch (Mr. Adley), for Poole (Mr. Ward), for Dorset, North (Mr. Baker) and for New Forest (Sir P. McNair-Wilson), I thank my right hon. and learned Friend the Secretary of State and the Government for making the money available for phase 1 to be completed and for the second phase now to commence.

Now I must be a little critical of my right hon. and learned Friend. I regret that he has combined in one Bill his White Paper proposals on the NHS with his White Paper proposals on community care. I know that the Bill is comparatively short, but these are two vital and distinct matters. One is primarily concerned with returning people to health, while the other is about keeping people in health at home. However, I welcome the Government's response to the Griffiths report, confirming his recommendation that it will be for local authorities to prepare plans for community care.

I wish to draw attention to several points which arise from the Bill and I look forward to hearing the response of my hon. Friend the Minister for Health on Monday. First, the need to ensure that schizophrenics are registered with a GP or are on a psychiatrist's out-patient list appears to have been overlooked. Clause 3 is not definite on that point. Secondly, mentally ill people are prone to moving around and to be of no fixed abode. How, then, will remuneration for health authorities on the basis of residence be made? Should the provisions in the Bill not be clearer on that? Thirdly, clause 41 does not make it clear that local authorities should agree their plans for community care with health authorities, as the White Paper suggested. I should be grateful for confirmation that the Bill provides for that. Fourthly, clause 46(3) provides for Scottish health boards to consult voluntary organisations in preparing their community care plan, but there appears to be no similar provision for England and Wales. I should be grateful for a response on that.

As one who helped to steer through the Schizophrenia After Care Bill [Lords] during the past Session, I was dismayed that clause 42 does not provide for community care packages for mentally ill patients to be specifically linked to their discharge from hospital. It is essential that this legislation is wholly meaningful for the mentally ill,

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particularly for schizophrenia sufferers. The House will be aware of the widespread public awareness, support and concern for care of the mentally ill. Social workers will require new and specific training in the needs of the mentally ill to satisfy the complex community care needs which they will inevitably face. That will represent one of the major challenges of this legislation for local authorities.

I congratulate my right hon. and learned Friend on sticking so firmly to his original proposals, despite the unethical and highly misleading campaigns of the BMA and other unions. I welcome the opportunity for hospitals to free themselves from bureaucratic health authority control by applying to become self-governing trusts, if that is what they want. One of the essential points, which has not been accepted, is that that is voluntary and for local hospitals to decide.

All but one hospital in my health district have signalled to my right hon. and learned Friend their interest in becoming self-governing because of the opportunities that they foresee in developing the services and treatments which local patients and doctors want and which they can offer in services elsewhere. I expect that hospitals will return to being much more like the local community hospitals--which they were before nationalisation. I welcome the opportunity for larger general practices to apply to manage their funds, if that is what they want. Again, it is entirely voluntary. In October I had a meeting with most of my GPs to discuss the contents of the White Paper, and, yes, I was disappointed that so few saw the advantages to develop their practice which would come with having their own budgets or the greater flexibility on treatment and waiting times for patients. Many of my doctors fear future underfunding, conflicts between partners, conflicts with the local family practitioner committee, conflicts of interests with patients and the need to employ accountants to control their budgets. I appreciate those fears, but I hope that practices that recognise the advantages and volunteer to have their own practice funds will prove that those fears are groundless.

I welcome the introduction of indicative drug budgets which build on the experience of the limited list, encouraging more cost-effective prescribing, which will release more resources to be spent elsewhere in the NHS. However, I must voice the concerns of some members of my local health authority who feel that the proposed smaller membership may mean too few members capable of adequately fulfilling the responsibilities and considerable commitments which membership entails. They also fear that there will be insufficient scope for a broad base of experience and representation.

A number of hon. Members have already said that my right hon. Friend the Prime Minister supports the reforms. She does so because she wants the NHS to be so good that no one will want to go private. The proposals are the last chance for the NHS to remove all the reasons why people are still prepared to sacrifice and to pay twice for an alternative service. If the reforms are not allowed to improve the service to patients so that waiting times are reduced a two-tier service will inevitably follow with the NHS as the safety net. My right hon. and learned Friend the Secretary of State has repeatedly said that he does not want such a service. It must be in the interests of all those in the NHS to make the proposals work.

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7.40 pm

Rev. Martin Smyth (Belfast, South) : I welcome the opportunity to follow the hon. Member for Bournemouth, East (Mr. Atkinson). I support his plea in aid of the mentally handicapped and schizophrenics. I also underscore what he said about local management. When the Secretary of State spoke about local management I began to wonder whether I was reading the Bill and the background to it in the same way as the right hon. and learned Gentleman. He talked about the need for smaller and more effective leadership and I can understand that. When he spoke of better local leadership, however, I could not understand him. He spoke about looking for respected people in the community to provide that leadership, but it appears that locally elected representatives will be dropped. I find it strange that one should remove the local input and yet still expect the local leadership to be better than in the past. I support the motion tabled by members of the Select Committee on Social Services which calls for a Special Standing Committee to be established after the Second Reading. Such a Committee would offer an opportunity to listen to and to cross-examine those involved in the NHS. That Committee hearing would last three days at the most and I believe that it would enhance the passage of the Bill.

I recognise that it is not always possible for Ministers to listen to everybody. Last week some people were so keen to speak to the Under- Secretary for Northern Ireland with responsibility for health care that they pursued him over a roof. In the confines of the Committee Room I should like to think that the Committee, in the presence of the Minister, would be able to cross-examine NHS staff much more effectively.

Proper consideration should be given to special financing. When it was proposed that the finance specifically set aside for community care should be ring-fenced a Minister said that that meant that trust was not put in local authorities. The harsh reality is that the Government have rate- capped local authorities and come down on them in different ways. If the House budgets funds for community care, they should not be frittered away on other local authority services. If extra money is needed it should be raised in some other way and should not be taken from the funds for community care as that deprives people who require that care.

The National Consumer Council has pointed out that consumer input on the community care provisions in the Bill is inadequate. There is also no means by which local authorities can have a say and no provision for an appeal system to ensure that patients are treated where they want to be treated. In the Bill, no mention is made of community health councils. As far as I can tell, there is no requirement properly to consult those councils on community care plans. There is no provision for an appeal against a local authority social services department decision on community care, and there is no duty to assess that care. I know that that remark will be met with an immediate response that there is such a duty to assess. If one looks carefully at the Bill, however, it is clear that the duty to assess operates only when a need is identified. I believe that that leaves the door wide open.

When the Bill is in Committee I hope that careful examination will be made of its implications for the Disabled Persons (Services, Consultation and Representation) Act 1986. All over the nation the cries are

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for the implementation of sections 1, 3, 2 and 7 of that Act. The White Paper promised that those sections would be implemented in the Bill, but there is no mention of that.

One of my medical friends in Northern Ireland who is generally sympathetic to the proposals wrote to me about one aspect which he felt limited the original emphasis of the Bill--patient choice. It appears that authorities and health boards will have the right to restrict the choice of the GP and the patient to be referred to a particular hospital if those bodies have no contact with that hospital. Perhaps that decision can be defended in terms of distance and finance, as suggested by the guidelines, but how does one equate finance with providing the right treatment for a patient? How does distance come into it when we have already heard about people being referred to a hospital 160 miles from their home? If the doctor and his patient believe that that is the place where he should receive treatment, why should an authority or a health board have the right to say no? That important consideration should be borne in mind. As I represent a university constituency, I am especially concerned about research. The Bill provides little to require the NHS trusts to undertake and to commission such research. They are empowered so to do, but they are not required to do so. That will have an adverse influence on the proposed reforms.

I do not wish to prolong my contribution as I want other hon. Members to be able to participate. My specific request is for the appointment of a Special Standing Committee which can consider ring-fencing the necessary finance.

7.47 pm

Mr. Nicholas Winterton (Macclesfield) : I am delighted to follow my hon. Friend the Member for Belfast, South (Rev. Martin Smyth). He and I have served on the Select Committee on Social Services for many years. The views that we express have been gained from the experience and knowledge derived from many years of service on that Committee. I commend my hon. Friend the Member for Gillingham (Mr. Couchman) who sadly is no longer in his place, on the mention that he made of the indicative drug budget. The Government will neglect at their peril the pharmaceutical industries of the country. They make a major contribution to our balance of trade and they generate a surplus of more than £850 million. If we proceed with some of the proposals in the White Paper that seek, unjustifiably, to contain prescribing, we shall drive investment out of this country to the detriment of employment and the economy of our nation.

I speak with a constituency vested interest as ICI Pharmaceuticals, a massive employer in this country, employs some 5,000 people in my constituency. It puts about £50 million a year into new investment. We should bear such investment in mind. As my hon. Friend the Member for Gillingham has said, however, it is most important that the people who require treatment feel that they will get the best possible medication that they require.

When new drugs come on to the market and do dramatic things--such as the drugs to which my hon. Friend the Member for Gillingham referred--people should not be deprived of that beneficial medication

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because of cost, especially as it often probably means that if they do not have it, they will spend much longer in hospital. That is far more costly to the health service, whether in the private sector or the NHS.

My hon. Friend the Member for Stockton, South (Mr. Devlin) should look at the American experiment. The Americans have tried formularies, which is the direction in which we are moving. That has imposed an extra cost on health service expenditure in that country. Medication can reduce the need to put a person in hospital.

I do not support the Bill and I will not vote for it on Monday evening. It is severely flawed and, in the limited time available, I intend to tell the House why. I do this not for reasons of prejudice or malice but from the immense knowledge which I have managed to glean from the more than 14 years that I have been on the Social Services Select Committee and its predecessor. The White Paper "Working for Patients" and the Bill, which implements its reforms, propose to improve cost and outcome information and tackle the problems arising from what many may describe as the lethargy of the medical profession in monitoring and evaluating its services. The NHS could be improved considerably with the reforms contained in the Bill. Those reforms may enable the objective of the NHS--to provide health care on the basis of need, measured by the capacity of the patient to benefit from care--to be achieved much more cost effectively. I accept that view. I believe that the objectives behind the Bill and the White Paper are laudable in every way.

However, the other proposed reforms in the Bill--GP budget holders, or fund -holding practices, independent NHS hospitals and tax breaks to increase the purchase of private health care insurance by the elderly--may undermine the NHS as we know it. As a Tory, I am deeply committed to the NHS. There are many within the independent and private hospital sector who are deeply unhappy about what the Government are doing because they believe that it will prejudice them in acting complementary to, not in competition with, the NHS. These other reforms--GP budget holders, independent NHS hospitals and tax breaks--may undermine the NHS, but of the three, the independent NHS hospitals may have the greatest adverse effects on access, quality and costs. With independent NHS hospital managers free to fix pay and prices and the removal of the NHS monopoly on purchasing power, which has held costs and expenditure in check, there is likely to be massive cost- inflation. If the Government hold cash limits, district general manager budget holders will face increasing pressures and the quality of care is likely to be eroded, as was shown in evidence to the Select Committee. If due to these pressures the NHS produces increased waiting lists and times and declining quality of care, the incentive to buy private health care insurance will be sharply increased.

The overall effect of these pressures may be increased expenditure on health care which is financed largely from private sources. Much of this increased expenditure may well represent increased rewards to providers rather than increases in the volume and quality of health care for United Kingdom citizens. This outcome--increased expenditure on health care from private sources--may be the Government's implicit objective. Their explicit objective is to defend the NHS, but that objective may not be achieved through the existing provisions of the White Paper, which are encapsulated in the Bill.

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The likely outcome of these proposals is greater inequality in access to health care, provision of health care of inadequate quality and cost-inflation. [Interruption.] I hope that my hon. Friend the Under-Secretary of State is listening. Sadly, the Government appear from time to time not to listen to those who have some knowledge. I am delighted that my right hon. and learned Friend the Secretary of State said in responding to my intervention that I had some knowledge of this matter.

Having well and truly put my views on the Bill as it relates to the reforms to the Health Service, I should like to put my worries about community care. We are moving much too fast. The policy of community care is being introduced too rapidly, too soon and for the wrong reasons. It is returning patients to a community which is unwilling and unable to welcome them. We are losing centres of excellence and denying some patients the security and stability which they need and which they can find only in long-term residential care. Before disposing of all these centres of excellence, I hope that we will think again to ensure that we are genuinely improving the lot of the mentally ill, the mentally handicapped, those suffering from Alzheimer's disease and the elderly who need residential care. My county of Cheshire, which is Labour-controlled with Liberal support, is being forced to dispose of its residential homes. This is disastrous. It is wrong that the private sector should have a monopoly of care for the elderly. I do not believe that the monitoring of the private sector is likely to be adequate. We are perhaps debating one of the most important Bills of the past 10 years, not just of this Parliament. I therefore hope that, in Committee, the Government will listen closely and sensibly to the amendments that are proposed. I regret that I cannot support the Bill in the Lobby on Monday evening.

7.57 pm

Mr. Jack Ashley (Stoke-on-Trent, South) : The views of the hon. Member for Macclesfield (Mr. Winterton) on community care are respected on both sides of the House and, as usual, they were vigorously expressed. The Government's proposal to end Crown immunity for all Health Service bodies is welcome, but suspect. If the Government are converted to my belief that Crown immunity is an unjust anachronism, all Crown immunity should be abolished, but that is not happening. Crown immunity cannot apply to private institutions. The Government are obviously paving the way for the future, privatising by this selective means. That is deplorable if health services are privatised.

Millions of people rely on community care for their wefare. The Bill is crucial to them, and I am glad that this matter has been raised in the debate. However, there should have been a separate Bill to ensure proper consideration of that aspect of the problems. I ask for a commitment from the Minister that discussion of the community care clauses will not be guillotined in Committee.

Disabled people demand very little, but they ask for some fundamental rights. Section 4 of the Disabled Persons (Services, Consultation and Representation) Act 1986 gives them the right to assessment of their needs, if they request it, but they also want the right to make

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representations about that assessment. They want the ordinary right to appeal against decisions. Above all, they want the right to properly funded community care.

Assessment is the key to the new system, but unfortunately the way in which it will operate has been left entirely to the discretion or whim of local authorities. There are no requirements for local authorities, there is no guidance, and they are not committed to involving the disabled person in the way proposed in section 3 of the Act. There is also no right of appeal. Local authorities--the good and the bad--can do as they please, and there are some very bad ones. The Government are abdicating their responsibility.

Who would be assessed and reassessed under this provision? Reassessment can be as crucial as assessment. If this Bill had been in force, would deaf- blind Beverley Lewis, who died weighing four stone, have been reassessed? Would her life have been saved? Would disabled people and their carers be affected by the Bill? They are now at the end of their tether, trying desperately to cope. The answer is that Beverley Lewis would not have been saved ; nor would severely disabled people be affected, because the Bill will do nothing to avert future tragedies in community care or to raise the present inadequate levels of care. The provisions of the Bill give local authorities the right to assess on whatever criteria they choose--it is a charter for evasion. It is essential that section 3 of the 1986 Act be implemented. It is also essential that centrally decided requirements be placed on all local authorities.

The Bill and the White Paper on which it is based view community care provision from the providers' perspective, not from that of the consumer. The truth is that the Government have been worried by the escalating costs of care in private residential homes and have decided to put a stop to them. They thought that they would ditch that commitment, and indeed they have done so. They are now talking in terms of administrative change, cost- effective provision and simplicity--fine-sounding words which permeate the White Paper and the Bill, but little attention is paid to the level and quality of care for the consumer.

The specific grant to local authorities for people with mental illness is welcome, but it has not been ring-fenced. That means that it will be vulnerable to the vultures. One of the main failures of the Bill is the refusal to allocate a specific grant for community care in general, as Griffiths recommended. The Government apparently intend to provide additional resources only for demographic change and for the new tasks related to the new procedures, but they have failed to recognise that today's unacceptable black spots of community care must be erased and that community care money must be used only for the people for whom it is intended. We do not want councils to spend the money on bypasses and other daft things. The Griffiths proposal will come to naught if his recommendation for a specific grant is disregarded. Nothing could be more crucial for the future of community care.

Devoted family carers are the kingpins of community care, but despite the bromides there are no specific proposals to help them--merely a mention in the White Paper that, when possible, their ability to continue to provide care should be considered and their participation included in the assessment. Who is to say whether that is possible? Again it will be the local authorities.

The Bill fails to recognise the army of carers who are being exploited and overstretched, many of whom are

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themselves very frail. No one should be forced to care for a disabled relative if they feel that they cannot handle it, but local authorities are only too happy to turn the problem over to the family. Some local authorities are very negligent, and that is intolerable for the carers. There should be a commitment to seeking out carers, easing their burden and recognising that they should not be pushed to the point of total exhaustion.

I make this appeal to the House. The problems of carers and of disabled people will not be solved by the Bill, which fails to provide them with essential rights. It also fails to provide adequate cash and to provide comfort for carers. I hope that the Government will listen to the voices of disabled people, carers and voluntary organisations, and think again.

8.6 pm

Mr. Bill Walker (Tayside, North) : The right hon. Member for Stoke- on-Trent, South (Mr. Ashley) has a distinguished record of defending the interests of the disabled, and I am sure that his words have been listened to with care throughout the House.

The proposals in this Bill are designed to increase choice in the National Health Service and make the service more responsive to patient needs. The Bill is also designed to raise standards of care in all health board areas and to bring them up to the level of the best. It is also designed to improve the efficiency and effectiveness of the services provided by the Health Service, and to ensure that the maximum possible resources go directly into patient care. The Bill must be seen against the background of the continuing increase in Government support for the NHS--in the amount of taxpayers' money going to the service.

In Committee, I believe that we shall have ample opportunity to study the Bill's details in depth, and in the limited time that I have this evening no one would expect me to do that now.

It will come as no surprise that I want to concentrate on the Scottish aspects of the Bill. Reaction in my constituency to the Government's proposals can best be described as mixed. Some in the Health Service are wholly opposed and have made their views clearly known. I have met a number of those who are concerned, but they are unable to define precisely the causes of their worry. I know that because I have had a number of meetings with people in the Health Service--with GPs and others. I am pleased to inform the House that others have seen the proposals as a means of obtaining long-promised but never delivered new facilities.

I cite, for example, the county town of Forfar in Angus which, 25 years ago, was promised a new community hospital. Twenty-five years later it is still waiting.

Forfar GPs are trying to set up a budget. They are supported by many people in the area and are looking at the possibility of a self-governing hospital trust. That is no surprise to me, because I have always viewed health as I view education. In the House, a great deal of rot is talked about rural areas. My constituency covers 2,000 square miles of rural Scotland and I think that I can claim to know something about the problems of hospitals and Health Service facilities in rural Scotland.

There is a good Health Service in north Tayside and we are proud of it. However, it can and must be improved to

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meet the demands of today. The Service is far better than it was 10, 20 or 30 years ago, but it must continue to improve because the demands upon it increase every year. Stracathrow hospital is not in my constituency but my constituents use its services and the GPs regularly use it. There have also been rumblings of interest about a self-governing trust for that hospital.

Anyone with any sense realises that the changes proposed in the Bill are fundamental and will cause concern. It is up to us to deal with that concern and we must get through to the people to make them understand. Our education reforms are beginning to be appreciated and understood and people are supporting them in my constituency and looking at self-governing schools. It was once suggested that no rural school would consider that. The school that I have in mind is very rural because it is in one of the remote parts of my constituency.

We must first deal with the misinformation that is being spread about the Bill. It is also important to recognise that there are problems within the British Medical Association. Its negotiators are not trusted and their recommendations have been rejected. That is hardly the way to move forward. I draw the attention of the House to early-day motion 63 about the leak of a BMA letter. The motion, in the name of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) who speaks for the Opposition on Scottish health matters, states :

"That this House condemns the leak of a confidential letter from the BMA to the Scottish Office ; and asks for an investigation to find out who was responsible for this letter coming into the possession of the Sunday Times (Scotland)."

I tabled an amendment to the motion. It says :

"Line 1, leave out from House' to end and add notes that a copy of the BMA letter, which is not confidential, has been placed in the Library where honourable Members can note that the British Medical Association Scottish Office is not interested in negotiating a special deal for Scottish general practitioners'."

That comes out clearly in the third paragraph of the BMA letter, which says :

"The first point to make is that there is no question here nor has there ever been of making a special deal' for Scottish GPs." That is news to the GPs in Scotland and to most of us. We always thought that we negotiated things differently for our separate Health Service in Scotland, but now we are told that Scottish GPs cannot be treated differently as they have been for a long time. When the BMA is so divided and uncertain, one must be careful about what one takes from the kind of literature that the BMA has been putting out. I repeat that there is a superb Health Service in north Tayside. That is because it is a lovely part of the world in which to live. We have no problems about recruiting teachers or doctors or anyone else from the professions because people go there for the quality of life.

Another reason for our good Health Service in that area is the spending by the Government. That needs to be mentioned. It has been said that the only thing that Conservative Members talk about is expenditure. I have news for everyone. If we had not spent that money, hon. Members would be talking about the lack of expenditure. The planned spending in Scotland for 1989-90 is £2,800 million. In 1990-91, that will be increased by £220 million. That will bring expenditure on the Health Service in Scotland to over £3,000 million. That is an interesting figure because it is three times the size of the Health Service budget 10 years ago when we came to office. Spending on health in Scotland is now £550 per head.

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Mr. Devlin : It is far too much ; more than in England.

Mr. Walker : It is not far too much. It is what is needed. The proposals in the Bill, which I support, require additional funding and the Government have pledged that. That is unlike the Labour party, which sets out what it will do but when it comes to office it cuts expenditure and hospital building programmes. This Government make a pledge and then deliver.

Since 1979 there have been 61 major new hospital developments in Scotland, providing 6,777 beds, and there are 40 major hospital developments in the pipeline. That is a 44 per cent. increase over the rate of inflation since 1978-79. If I had gone to the electorate in 1979 and said that we would increase expenditure by 44 per cent. on house and hospital building programmes people would have laughed at me, but that is what has happened. More people are being treated than ever before both in and out of hospital and we have more doctors, dentists and nurses.

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