House of Commons Hansard Debates for 7 Dec 1989

Madam Deputy Speaker (Miss Betty Boothroyd) : Order. I regret that I have to call the hon. Gentleman to order. His time is up. 8.17 pm

Mr. Jim Cousins (Newcastle upon Tyne, Central) : As the Secretary of State suggested, clause 4 of the Bill, which introduces the concept of universal contracts, is at the heart of the proposed legislation. Section 8 of the White Paper on community care, which makes the disastrous distinction between the cost of care and the cost of keep and attempts to stitch plans together for people on the basis of that distinction, is at the heart of the White Paper. That is where the difficulty lies. For many years the Government have tried to operate a network of clumsy cash limits. The Bill does not lead us away from those limits but clones and reproduces them on a massive scale. Through the network of care plans, keep plans and universal contracts, it extends those cash limits into every region of the service, thus controlling the experience of every patient. Eminase has already been cited as a drug treatment which is difficult to fit into a contract, format. Another example is hormone replacement therapy. How do we put speech therapy into a contract, when 80 per cent. of referrals come not from doctors but from schools, health visitors, self-referrals and concerned parents? The Government will have to face those difficulties.

My city of Newcastle upon Tyne has one of the six centres of the resource management initiative. The products of that initiative are interesting. They clearly show that, given time and money--far more time and far more money than the Bill allows--one can formulate the cost of individual patient treatment plans. That can be done by eliminating the costs associated with long-term support which is hard to fit into the format. The result will be a system which cannot survive in a system of block contracts which are looked upon as rationing cards, whereby every patient is treated as a unit with absolutely identical needs. That is the deficiency of the contract system, and that is where it will fail. In the same hospital at Newcastle, which is a world centre for transplant surgery, no food is served from 5 pm until 8 am the next day. Only a few weeks ago, patients were asked to bring

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pillows because they were in short supply. That situation will be reproduced on a massive scale if the Bill is implemented. There are further examples of the same sort in the same city. The regional health authority is privatising some of its staff and handing them over to a company which includes BUPA membership in its employment contract. There could be no greater testimony to the direction in which such a system will lead us. In the same city we have one of the finest networks in Britain of community residential care provision for the mentally handicapped. As a cost-saving measure, and to meet the needs of community care within the administrators' understanding of the Bill, those facilities will be disposed of to the private sector. That will be a calamity and a disgrace. In the same city, the regional blood transfusion service--responding to the terms of the Bill--is proposing to convert itself into a trading agency which will sell blood to hospitals. Blood that is freely given will be converted into a commodity that is traded. It will be sold to hospitals.Is that the sort of spot market in blood to which my hon. Friend the Member for Livingston (Mr. Cook) referred in his compelling and brilliant speech? That, too, is a disgrace. As my hon. Friend the Member for Livingston said, the lines of power in the Bill all radiate from the Secretary of State. That is its central defect. But the lines of responsibility also lead back to the Secretary of State, and it is for that reason that Conservative Members will regret the confetti of controls and cash limits that they are creating.

8.22 pm

Mr. Quentin Davies (Stamford and Spalding) : The essence of the debate is that the Opposition seem determined to present themselves as the defenders of the National Health Service in its present form and to be blind to its shortcomings and deficiencies. The Government have recognised those shortcomings and deficiencies and--in my view with considerable courage--are trying to remedy them.

What are the key deficiencies? First, there are the excessively long average waiting times for a range of non-emergency hospital treatments, including some key areas of elective and orthopaedic surgery. Ours is the only country in the European Community to suffer from that problem on such a scale. No Member of Parliament should remain content with that. I refer advisedly to average waiting times and not to waiting lists. It might be satisfactory to have 2 million people waiting a month, on average, for non- emergency operations, but to have 100,000 people waiting 20 months would be entirely unsatisfactory. I hope that the Opposition will recognise that important distinction.

Secondly, there is a lack of patient choice in the NHS, which means that, against a background of generally dedicated and devoted care, for which many of my constituents and members of my family are deeply grateful, there are too many instances of perfunctory or arrogant care. There are take-it- or-leave-it attitudes--for instance, or "Strip off and wait for three hours"--and I fear that such attitudes are inseparable from monopoly provision in any area of human activity. Thirdly, and most seriously of all, is the slow rate at which new life-saving therapeutic and diagnostic

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techniques, even those invented in Britain, have been incorporated in the NHS. I have in mind the number of kidney dialysers per 1,000 people in this country compared with the number elsewhere in the western world. I think, too, of the insufficient use in Britain of colorectal scanning, computerised tomography, magnetic resonance imaging, ultrasound scanning and other diagnostic techniques. I have the figures on MRI and CT, thanks to a recent answer from my right hon. and learned Friend the Secretary of State. There are 198 CT scanners in this country, compared with 450 in West Germany, 3,000 in Japan and 3,600 in the United States. In the United States there are 1,300 MRI machines, compared with 275 in Japan, 85 in West Germany and 15 in the United Kingdom.

We pay a heavy price for that. The figures reinforce the conclusion that the NHS has had a tendency over the past 40 years to be not so much the National Health Service as a national illness service. We neglect modern diagnostic techniques at our peril. In the past half century, as in the first half of the century, the general health of the population has improved markedly, but in the second half it has improved at a much slower rate than the average rate of improvement in the rest of the western world. In 1948, we were in the first quartile among western countries for life expectancy and the last for infant mortality. I fear that we are now in the third quartile in both respects. We should not be satisfied with that.

The Opposition have a simple answer to such problems. It is a mindlessly simple answer--the five-word answer "Throw more money at it". If one thing has been proved by the Government's experience, it is that throwing more and more money at the NHS is not a sufficient response. Of course we must spend more money on the nation's health, and we have thrown enormous amounts of new money at it, yet by all available measures patient satisfaction has continued to decline. I fear that that demonstrates incontrovertibly that the money has too often been spent by the wrong people in an inefficient way or on the wrong things.

I shall give four important examples of how spending has gone badly wrong. First, until now there has been no effective cost information in the NHS. Managers have not known whether it was cheaper to perform operations, or to deliver other treatments in their own units or to farm them out to the private sector. They have not known their own costs. My right hon. and learned Friend the Secretary of State and his predecessor, for the first time since 1948, have now addressed that problem.

Secondly, until now there has been no notion of depreciation in the NHS. That is extraordinary. The idea of taking rational management or investment decisions without any idea of the cost of capital is ludicrous. Yet until my right hon. and learned Friend came along, that was exactly the position in the NHS.

Thirdly, there are perverse incentives, some of which my right hon. and learned Friend mentioned briefly today. Time and again performance is penalised and failure or mediocrity rewarded. The hospital manager who increases his throughput runs through his budget and is penalised. The manager who wishes to stay within his budget by cutting his variable costs and leaving wards empty at the end of the year is patted on the head. Under the Resource

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Allocation Working Group system, a health authority which has been successful in improving the morbidity rate in its area to a greater extent than the national average will be penalised. For the first time, my right hon and learned Friend has faced these problems head on, and these at least of the bad practices of the past are coming to an end. I thank the Lord for that.

Fourthly, I come to the heart of the great devotion which Opposition Members have to the present structure of the NHS, including the right hon. Member for Blaenau Gwent (Mr. Foot), for whom I have the greatest personal regard. Opposition Members display this great devotion precisely because the NHS enshrines to the supreme degree the model of paternalistic, bureaucratic provision which lies at the heart of Socialism.

The great and the good in Westminster and Whitehall decide what proportion of national income should be spent on health. That money is handed down through the RAWG system to the regions. They arbitrarily and unaccountably distribute it to district health authorities, which equally arbitrarily and unaccountably allocate it to whatever purpose they choose--more intensive care beds, another orthopaedic unit, more chronic care for psychiatric and geriatric patients or just doing the garden or painting the staff canteen. There is no assurance that the actual distribution of resources and the pattern of outputs under this system will in any way correspond to what would be the aggregate choice of patients if they could express such a choice. There is every reason to suppose that, as the volume of outputs and services under such a system increases, the correlation between that selection and potential patient choice declines.

This is a historic moment in the NHS because the Government have had the courage to face those problems head on. In all the years that I have taken an interest in politics--long before I came to this House--I have never known as man so subject to such sustained, ill-informed and hysterical vituperation as my right hon. and learned Friend the Secretary of State. I have also never known a man who would be less affected by it than he appears to be. I salute his courage and greatly support his Bill. I look forward to supporting both him and it during its passage through the House.

8.31 pm

Mr. Jeremy Corbyn (Islington, North) : For the greater part of the past two hours, there has been no Minister in the Chamber. We are now graced with the presence of the Adam Smith look-alike, who has just returned to the Chamber but who is not even replying to the debate. It is disgraceful. The Government claim that the Bill is important and they have spent £5 million telling people how good it is, yet Ministers cannot be bothered to be here to listen to hon. Members responding to the Government's consultation and the Government's publicity.

There is a fundamental difference between the two sides of the House. We believe that health care should be a right, free at the point of use for everybody irrespective of background, social standing or ability to pay. The hon. Member for Stamford and Spalding (Mr. Davies) is a good, true Tory who understands only pounds and pence. He understands only the cost of something--he does not have any idea of the value of anything.

Mr. Davies rose --

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Mr. Corbyn : No, I shall not give way.

Mr. Quentin Davies : The hon. Gentleman has spoken about me in the most unflattering terms.

Mr. Corbyn : I am not giving way.

Mr. Davies rose --

Madam Deputy Speaker : Order. The hon. Member for Islington, North (Mr. Corbyn) is not giving way.

Mr. Corbyn : Hon. Members are limited to 10 minutes. The hon. Gentleman had plenty of opportunity to tell us about the value of the market economy in health care. I think that I should take this opportunity to tell him about the value of socialism in health care. Does the hon. Gentleman honestly believe that everything should be bought and sold? Must every operation be judged against its cost? At no time did the hon. Gentleman mention the convenience of the patient, his safety or his comfort. He knows that the Bill's aim is for every hospital to become a company. Every doctor must look to his accountant before doing anything--

Mr. Quentin Davies : On a point of order, Madam Deputy Speaker. Would it not be in accordance with the best traditions of this House for an hon. Member who attributes to me opinions that I did not express, and who is giving a summary of my speech that I seriously dispute, at least to give way to allow me to correct the position?

Madam Deputy Speaker : The hon. Gentleman has made his point, but it is for the hon. Member who has the floor to decide whether to give way.

Mr. Corbyn : I plead for injury time because of that intervention.

Madam Deputy Speaker : I am not sure that the hon. Member will get it.

Mr. Corbyn : The House can judge for itself which side of the argument it wished to support. The problem for my constituents is that for many years there has been persistent underfunding of our health authority, which each autumn leads to the spending crisis faced by most inner-city health authorities. My authority has met that crisis by taking more than 100 beds out of use. That is happening throughout the country and is a measure of the crisis in health care.

Conservative Members lecture us and claim 10 years of success under successive Secretaries of State, yet hospitals and wards have been closed. I accept that new hospitals have been built, but there are fewer beds available, there is a worse service and there are longer waiting lists than there were 10 years ago. Conservative Members should recognise those facts. They should study a few of the international comparisons. By every index on health spending in industrialised countries, this country comes very low if not bottom. The solution is not to bring in the accountants, the market economy, the sales people and the idea that every hospital must have a commercial manager to decide what can be sold to make some money ; the solution is to begin thinking about the health needs of our people.

Why is the life expectancy of working-class people shorter than that of middle-class people? Why do people living in overcrowded accommodation have a shorter life expectancy than those living in salubrious suburbs? Why

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do children living in high-rise council flats or the slums in every one of our major cities suffer more bronchial problems than children living in suburban areas? Why are all those inequalities in health ignored by the Government in favour of the market economy? They know that the market economy means that those who can afford to pay can buy their way past the queues. The Bill is a massive attempt to privatise the entire National Health Service by stealth.

The other matter that I wish to raise, and which I predict will be guillotined off the agenda in Committee, is that of community care. Conservative Members have lectured us for a long time about the needs of community care. Those who honestly believe that community care is working should, when they leave the House tonight, walk across the river, go along the south bank and talk to those living in cardboard city. They should talk to the people at Charing Cross station. There are 10,000 people sleeping on the streets of this city ; some, although not all, have been in long-stay institutions. There is not much community care for them in living in a cardboard box outside a tube station on a cold winter's night in London. That is the sort of issue that should be dealt with in the Bill. It is the reality of the inequality of health care, the inequality of life expectancy, the inequality of community care--inequalities that are exacerbated, not lessened, by the Bill.

I make no apology for being sponsored by the National Union of Public Employees. The question of very low pay for Health Service workers is not dealt with by the Bill and neither is the question of their conditions if a hospital decides to opt out. They are not protected--they are given away, along with the hospital, to any trust that it chooses. There is an attempt to break up the national negotiating machinery that has been some protection for some of the lowest paid and most dedicated people in the NHS.

The Government often lecture us on the freedom of choice--the freedom to lead one's life as one wishes. It is true that there is freedom of choice. We are all free to go out and buy a

Rolls-Royce--the only problem is that 98 per cent. of the population cannot afford it. We are all free to buy a house--the only problem is that as thousands cannot afford to do so they go homeless. We are all free to pay high rents--the problem is that most people are too poor to pay them. The Government now say that we are free to choose the health care that we want. The Prime Minister said that she wants her health care when she wants it, how she wants it and from whom she wants it. For her there is freedom of choice, but for the majority of the population there is not.

The Government talk about protecting and defending democracy in this country. Every health authority that has, in the past 10 years, attempted to stand up against the Government's attempts to cut resources and, when RAWP was in operation, to take money away from inner-city areas, found itself in receipt of a letter either from the chair of the regional health authority or from the Secretary of State, announcing that its services were no longer required because it had attempted to represent its community. Now, what vestiges of democracy remain in local health authorities will be taken away by the Bill because health authorities will be stuffed full of placepersons put there by the Secretary of State, and representing the local business community. The idea that local authorities have no part to play in health matters is both insulting and disgusting.

The centralisation of powers that the Secretary of State is taking unto himself through the Bill would do credit to

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the most authoritarian of states. He should remember that what comes out from Richmond terrace to the health authorities also goes back to Richmond terrace and when an election finally comes, people will have one person and one person alone to blame for the inadequacies of their Health Service, and that is the Secretary of State.

Many of those who work in the NHS, as nurses, ancillary workers such as porters or gardeners, doctors or consultants and all those who work in community care, attendance or long-stay institutions, are frightened and fearful of the Bill. There is little protection for them. There is no ring fencing to protect the salaries of those who are transferred. There is no protection for the money transferred into local authorities from the long- stay institutions. The treatment that the Government mete out to the ambulance workers, in their attempt to destroy the dispute when those workers are providing the only real emergency service, shows the Government's contempt for people who are genuinely trying to run a Health Service. The Bill may not be defeated in the House, but it will be defeated eventually, because the principles on which it is based are wholly and odiously wrong.

8.41 pm

Mr. Andrew Rowe (Mid-Kent) : This autumn, our youngest child, an extrovert and articulate girl, went away to university. Soon after she arrived there, she telephoned home. It was, in family terms, an epoch- making call. It lasted for three minutes and ended when she said, "Must stop, can't afford any more." It was her first telephone call as a budget holder. How many parents recognise the changes in behaviour that come when their children have to start paying for the services that they use? Even when the budget is £28 billion, the same principles are at work.

The hon. Member for Livingston (Mr. Cook), like a Savonarola of the social services, is roaming the country urging citizens to burn the Bill on a bonfire of Socialist sentimentality, just as his Florentine predecessor forced Botticelli to burn his easel and paintbrushes in front of the Duomo. I am not suggested that my right hon. and learned Friend the Secretary of State is the Botticelli of the Front Bench, but I am clear that subsequent generations would be impoverished if the Bill were to be destroyed.

The hon. Member for Livingston excoriated the Bill for leaning on incentives, where he would trust that enormous sum solely to the staff's good will. I share his admiration for the generosity and altruism of NHS staff at all levels, but under the present system, the disincentives are acute. For example, what about the departmental head who, in my district health authority, on his own initiative saved the hospital thousands of pounds, but saw it all disappear into the district funding and found his enthusiasm for making further savings sorely blunted?

We are talking not about personal gain, but about the salutary effect of letting staff see gains for their own unit as a result of their better use of their resources. What about the supplier to a great hospital, who, week in and week out, sees over-ordering of perishable goods, but sees no evidence of management concern about it?

"Cost-effectiveness" is not a dirty phrase. It is not, as the hon. Member for Livingston and his friends suggest, a device for making cuts. Rather, it is a necessary discipline for ensuring that money is spent on patient care and not on

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wasted food or dependence-generating tranquillisers. The Government will always find it hard to win the rhetorical argument on the NHS, but they have to find the money. They do that very well, as is shown by the 25 per cent. increase in cash terms in the past two years. The hon. Member for Livingston and his colleagues have no such need. They can, as they have done again today, leave the nation with the implied suggestion that, if they were in power, the resources for the NHS and for community care would somehow be limitless. That works because all of us would love it to be true and because the public, after 10 years of Conservative increases in NHS funding, have forgotten just how deep and savage were the cuts made in NHS funding by the Labour party when in power.

I do not wish to follow my right hon. and learned Friend the Secretary of State down his path of leaving community care to another occasion. I have already told him and my right hon. Friend the Leader of the House that it would be a disaster if the partisan dispute over the NHS proposals cut out a full and proper debate on the Bill's proposals on community care. Those proposals are both important and overdue. The level of service depends on the level of resources available, but the Bill sets out to do what Griffiths saw it was vital to do--make the best use of whatever level of resources is achievable at any particular time, and remove the perverse incentives that waste money by making it hugely profitable for a local authority to send clients into expensive residential care at the expense of the Department of Social Security, when it would be both cheaper and better care to keep them in their own homes at local authority expense. That is an important advance, and it has met with widespread approval.

The Bill requires local authorities to create a care plan for every client, and that, too, is an advance. However, in Committee, we shall need to look in detail at how that should be done. First, we must make sure that the client is properly heard. The Bill must have no more to do with paternalist prescription ; we must listen to the client's preferences. Where a client cannot state them for himself, he should be afforded a friend or volunteer to speak for him. We must make sure that the assessment is well founded. It will be no service to anyone if the natural suspicion and ignorance that social services staff have of NHS staff and vice versa leads to lopsided and partial assessments. For example, the contribution that can be made by occupational therapists, speech therapists, voluntary alcohol abuse counsellors and so on has to be understood and incorporated in the assessment. That will mean a large exercise in co-operative working, and to the extent that it can be addressed by training, that joint training should be started now.

I welcome the recognition of voluntary organisations, which have done so much to pioneer new patterns of caring and carried so much of the load that the aging of our population, and their rising expectations, lay upon them. I share their unease lest their initiatives and priorities should be distorted by having too many public priorities pushed upon them. A huge amount of work must be done in the development of community care, and my time is too short to go through it all. The truth is that we shall always have a crisis, both in health and in community care, because the expectations of the public rise, quite properly, every year and there is no possibility whatever of

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any Government ever being able to provide enough resources to meet the growing needs that our own success in solving many problems has called into being.

Ring fencing is not the answer. Everybody who has a special interest in politics, whatever it may be, clamours to have that part of Government expenditure which is devoted to their interests ring-fenced. Somehow that seems to be a way of keeping the thieving hands of more powerful committee chairmen off their precious budget. Ring fencing is a recipe for conservative structural developments. The moment someone is inside a ring fence, he is reluctant to pioneer services which spread outside it ; most of the advances in community care, and many of the advances in health care, will come from that kind of lateral pioneering co-operation between services which, if they were ring-fenced, would never extend a hand across the boundary to one another.

8.50 pm

Mr. Ieuan Wyn Jones (Ynys Mo n) : I listened with great care to the Secretary of State. He was at great pains to explain once again to the House that the Government's plans for the NHS will not lead to privatisation. But it is not so much the right hon. and learned Gentleman's speech that worries many hon. Members, as the Bill, because in many respects privatisation is clearly behind it. When one looks at the new- style management of the district health authorities, as they are to be called, and the family practitioner services authorities, as the family practitioner committees are to be called, it is clear that they are to be run along the lines of private companies. In other words, there will be no room on the new-style boards for local authority representatives. As other hon. Members have said, that is a retrograde step.

Paragraph 8.5 of the White Paper says :

"The Government believes that authorities based on this confusion of roles would not be equipped to handle the complex managerial and contractual issues that the new system of matching resources to performance will demand."

That is the official reason why local authorities are not to be included on the new management-style boards. But the real reason is that the Government believe that local authorities will not do what they are told--that they will not be party to cuts in health provision.

Another vital point is the way in which the Government seem to want to set up NHS trusts. In particular, the management boards of those trusts will have no provision to ensure that patients' needs are taken into account. In the White Paper, the Prime Minister says that the needs of the patient are to be paramount. But when one considers the way in which the new trusts are to be set up, one sees that there is no way in which patients are to be consulted. In Committee, we shall need to look at ways in which patients are represented on those boards at area or district health authority level and in the trusts. We shall also need to consider the way in which the NHS contract principle is included in the Bill. Traditionally, the Health Service has been based on the statutory responsibility of hospitals to provide care. In the private sector, there is a contractual relationship. It is that contractual relationship that is now being brought into the Health Service between health boards and those services which provide health care. We are moving away from the traditional statutory responsibility to provide health care that we have known in the Health Service and into a contractual conception.

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A general practice which is large enough will be given a budget, which will clearly be cash-limited because budgets cannot mean anything else. If a practice is not big enough to acquire a budget, the district health authority will force doctors to choose health care for their patients, not according to their needs but according to the cost of that provision. In other words, as the cash limits bite, they will be shunted from hospital to hospital.

All the provision for a privatised Health Service--the NHS trust hospitals, the new board managements and GP budgets--are now in place. We may not have a Secretary of State today who believes in a privatised Health Service, but if a future Secretary of State does, the structures are there. It is only a small step between the Bill and a fully privatised service.

Hon. Members on both sides of the House have said that the great danger is that that will lead to a two-tier Health Service. Moreover, it will mean that the Health Service provision in rural areas will be drastically affected. There is no question about that.

The Bill's central provisions are completely irrevelant to Wales. I asked the Secretary of State for Wales two questions, which were answered yesterday. First, I asked how many hospitals in Wales want to opt out under the new system. The answer was none. That is because no GP in Wales wants a budget, and so cannot buy in services. There is no private provision in Wales. As the White Paper makes clear, that is underdeveloped. Therefore, the hospitals cannot buy in from the private sector. That is completely irrelevant. Secondly, I asked how many general practices in Wales want their own budgets. The Secretary of State made it clear that none of them wants that. Those provisions are irrelevant to Wales, and in Committee we shall be seeking to exempt Wales from the Bill. If the Committee will not agree to that, the only sensible course will be for each area health authority to have a referendum of all the electors in that authority to decide whether a hospital should opt out. Consultation is not sufficient, because all the patients who may be affected by such a decision should be consulted in a referendum.

I welcome the news that local authorities are to be given responsibility for assessing the needs of individuals : that seems sensible. However, as Opposition Members have pointed out, there is no obligation on local authority social services departments to carry out such assessments, and I feel that we should do something about that.

I disagree with the hon. Member for Mid-Kent (Mr. Rowe), who said that funding for community care should not be ring-fenced. He should look at the submission sent to all hon. Members by the voluntary agencies and local authorities that will have to operate the scheme. They all say that, unless a community care budget is specified, money will simply go into the local authority pot without being earmarked for community care. Such specification is necessary to ensure that both current and future needs are met. If there is to be a partnership between the social service departments and the voluntary agencies, they must know how much they can spend on community care from year to year.

We in Wales have a passion for the Health Service, and we speak of it with passion. We know that its guiding principles were based not in City boardrooms but in the mining communities of Wales, Scotland and northern England. Those principles were born not in the rich pastures of the south- east but in communities that have had to fight for everything they have ever owned. If the

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Government will not pay attention to the need to retain the Health Service as it is--free at the point of delivery for every patient who needs it--the people will vote them out in the next election. 9 pm

Mr. Tim Devlin (Stockton, South) : As the hon. Member for Ynys Mo n (Mr. Jones) has just said, the National Health Service is every bit as valued in the north of England as it is in Wales and Scotland. It is valued, indeed, throughout the length and breadth of the country, for it is a national Health Service--and it is in pretty good shape, considering that it is 41 years old this year.

Despite soaring costs and increasing demand, coupled with the pressures of an aging population and expensive leading-edge technology, the service is still free to all, and funded mainly from taxation. It is still equally available to all types of patients from all parts of the country. It still provides a system of primary health care, giving each person his or her own GP, and a referral system for specialist consultations of every kind. It is still highly regarded internationally, and it provides good-quality training for doctors who come here from all over the world. Each and every one of us, whether we are for or against the reforms suggested by my right hon. and learned Friend, should begin our speeches by paying tribute to an excellent service in which many people give of their best to provide help for us all.

The Government, however, have played an essential part. It is their fine record in running the nation's economy soundly that has enabled total spending to rise from £166 per head in 1979-80 to £444 per head in 1989-90. My hon. Friend the Member for Macclesfield (Mr. Winterton) suggested that we should fund any treatment that came on the market regardless of cost, but I cannot stand idly by and listen to such a suggestion. I have seen at first hand--because all my family were in the NHS--the effect of diverting resources to expensive procedures with indifferent or uncertain outcomes, at the cost of many thousands of "bread- and-butter" operations which could otherwise be carried out. Under the last Labour Government, a Royal Commission found that, even if the country spent its entire gross domestic product on the NHS, there would still be unsatisfied demand for services.

The hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) asked us to look at our own communities, and when my hon. Friend the Member for Tayside, North (Mr. Walker) was looking at his, I happened to remark jovially--and jokingly, I must add--that spending in his region was too high. Spending per head on the NHS is indeed far higher in Scotland than in England, but after tabling some parliamentary questions I have been able to obtain the figures for my part of the country. Hon. Members may think that I am going to recite the usual cash figures--revealing that in 1982 the figure for the northern region was £520 million, compared with £802 million this year--but I have had all the figures recalculated at constant 1989-90 prices. In 1982, the figure was £741.8 million, while in 1989--at constant prices--it had reached £846.8 million. That is a significant improvement.

Services have also improved. In 1983, 409,000 in-patients were treated in the north ; by 1988, the figure has risen to 462,000. The number of new out -patients rose

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from 550,000 to 590,000. None of that is possible unless the money can first be made available by running the economy correctly. There are 22 major capital schemes worth over £1 million under way in the Northern Region health authority. That has to be compared with the cut of over one third in the region's funding that was imposed by the last Labour Government.

My own hospital, North Tees, has only just been given the new roof that it should have had in 1977, but for the cuts that were imposed by the last Labour Government. The figures for the Darlington, North Tees and South Tees health authorities show that there has been a significant improvement in their funding under a Conservative Government.

Amid all the good news, however, a major case for change can still be made. It is not quite a mid-life crisis ; I shall be 40 in 10 years, and I should not like to have to regard myself then as being old. A structural change is needed. Woman's Realm asked 10,000 of its readers what they expected from their GP services. Less than half of those who responded thought that their GPs were sympathetic and took their problems seriously ; 60 per cent. considered that most GPs were helpful, whereas 43 per cent. were only "satisfied" with the treatment that they had received.

A recently undertaken "Which?" survey commented that the "Consumers' Association welcomes the stated objectives of the Bill. In particular we applaud the Government's commitment to putting the needs of the patient first.' Consumers' Association wants consumers to have a greater choice of better quality health care, wherever they live. In pursuit of these objectives we support the major principles behind the Bill--of promoting efficiency and value for money ; bringing all parts of the NHS up to the standards of the best ; and developing a system which rewards those who work hardest." The standard of care in and the performance of different hospitals varies greatly. The average stay in hospital for the same treatment varies from three and a half days to nine and a half days. The average cost of treatment can range from £450 to £1,300. How can that possibly be justified? It must be right in a compassionate society to seek to maximise the performance of a service that has to rely on limited resources. However great those resources may be, that will always ultimately be limited.

The hon. Member for Livingston (Mr. Cook) said that there should have been consultation before the reforms were implemented. However, the right hon. Member for Blaenau Gwent (Mr. Foot) said that, when the National Health Service was established, there was no consultation--for the very good reason that the Labour Government knew that a National Health Service was not what the providers of health in the country wanted. It is interesting to note the different arguments on just that one point.

Payment should be linked to performance. The Bill will ensure that additional payments are made to general practitioners for health screening, the elderly and patients with persistent health problems. Additional money will be provided for those who work in the inner cities, under the Jarman index. Additional money will also be provided for those who work in distant rural areas. All the various factors that ought to be taken into account will be taken into account.

GP practices will be provided with much greater powers as a result of the budget-holding provisions in the Bill. It is right to make the point that many practices do not yet

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possess the information technology that they will need if they are to carry out their responsibilities. Many forward- looking practices have, however, already installed the technology. Many of the GP practices in my constituency and in other areas have already bought computers and are considering how they can best improve the range and quality of the services that they offer to their patients. The real power of this reform is that it is patient-led and patient-driven. It is up to the patient to obtain more information about health services in his area. He has to make the comparisons and find the doctor who suits him best.

As for hospitals, the funding will, quite rightly, follow the patient. However, a contracting system, which is regarded as the central provision of the Bill, already exists in many parts of the country. The waiting list initiative has already been introduced on a contractual basis. It is only right that we should cease rewarding the bad performers in the Health Service.

There are two adjacent health authorities in my constituency. One has a waiting list in one specialty and the other does not. The Government came along with their waiting list initiative and paid money to the poor performer--the authority with the waiting list. The authority without a waiting list came to me and said that they had never had a waiting list for that particular discipline but, for the first time, they thought that it might be a good idea if they did, because otherwise the money would go to the authority across the river. I have never understood why that kind of resource allocation took place. Managers who save money by making sensible economies within their local unit find that the money is taken away and reallocated to a less efficient manager. That cannot be right. Surgeons within the Health Service know which are the bad surgeons and which are the good--my father is a surgeon. They know which surgeons turn out a large number of good quality operations, and which turn out either a low quantity or low quality. Good surgeons are happy to bid for work from other areas. We must get rid of the boundary problem that prevents patients from going across the river, or across the line. Then improvements will follow and that will be the reward for popular and successful units.

Ms. Harriet Harman (Peckham) : Will the hon. Gentleman give way?

Mr. Devlin : I am trying to get on as quickly as possible, and I am sure that the hon. Lady will have many more opportunities to speak about health than I shall have.

Let us consider the information that is available at the moment. For example, only recently have figures for post-operative complication rates become available. The confidential inquiry into peri-operative deaths showed that some 1,000 unnecessary deaths each year result from inappropriate surgical procedures. That information has only recently become known because the Government, during the past 10 years, have progressively increased information requirements and the information technology to bring them to light.

The internal market will result in patients being referred to more specialised units, and that will mean that costly, post-operative complications must decrease.

I welcome the fact that audit is part of the Bill, as it is critical to its success. Unless clinicians can get to grips with

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their costs, we will never get to grips with the overall funding problems of the NHS. People must know what they are expected to do. Clinicians must realise that they have a responsibility to manage expensive resources well.

In an article in the Daily Mail on 27 November 1989, Dr. Colin Leon said :

"It's about time the medical profession accepted the need for some kind of accountability. We spend public money so should be called upon to explain what we do with it."

He continued :

"I have always voted Labour and have always believed socialism to be more attractive than capitalism, but I do not share Labour's belief that the Health Service is under threat from these reforms." Consultants have a closed shop and they must regulate themselves. The royal colleges do not deny the need for change in the NHS. There are several pleas for improvements of the NHS, resourcing must be made available for information technology, and more imaginative powers are needed for patients.

I say to Ministers that if we are to gain the hearts and minds of the British people, we have to explain, in a patients' charter, exactly what rights and abilities they will have after legislation has been passed. That is the one thing that is not in the Bill, and it should be in it. That would solve all the arguments for us. If we were able to present a shopping list of rights and abilities for patients vis-a-vis their own doctor, or hospital and other NHS, services, they would be a lot happier.

At the top of the shopping list, they would see the one thing that we should have made clear time and time again--that there is no proposal in the Bill for any hospital to be privatised. No one can opt out of the NHS, and it will be disciplined--business not oriented. The service will be better organised and better disciplined. I commend the Bill to the House.

9.14 pm

Mr. David Hinchliffe (Wakefield) : I shall concentrate on community care and express some regret that the Secretary of State for Health had to be reminded by Opposition Members that it is affected by the Bill. It is quite clear that there is an urgent need for change in the Government's policies on community care, and the reasons are precisely the legacy of the policies they have pursued since 1979. One of my worries is the indecent haste with which large psychiatric hospitals are being run down because of financial pressure on the Health Service. That process is also influenced by performance-related pay for general managers, who have had incentives to get people out into cardboard boxes, rather than proper community care, and have discharged patients in questionable circumstances. The huge explosion in private institutional care is the direct result of the publicly funded experiment in free-market provision. People are being forced into institutional care because of the contraction of an alternative to it in their communities. A letter from Pat and Michael Frobisher, who live in Walton in Wakefield, arrived on my desk here last week. With their permission, I should like to quote it, as it illustrates my argument. Pat Frobisher writes :

"Michael was diagnosed with MS in 1970. I have nursed him since he gave up work in 1975. I had help from a nurse to bath him once a week after 1981 and respite care one week in 6 in the YDU at Pinderfields since then. Last year, in 1988, I begged for more help from the Health Authority. No dice.

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