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The Minister gave us a suitably elegant lecture. He has obviously been working hard on the plane from Edinburgh
Column 691this morning. He started with a stylish anti -climax that I found amusing. We were told, or there was an implication, that there would be an announcement about the rural practice fund, and that he was glad to have the opportunity to make that announcement. However, what we wanted to know about the rural practice fund was to what extent it has been increased, and that was the one fact that the Minister failed to give us.
We know that rural GPs will suffer particularly badly from the shift in the GP's contract towards an emphasis on capitation fees. If those GPs are to be fully compensated, the rural practice fund will have to be increased significantly above the cost of living figure. We will have to wait for an answer to that as well as to many other questions.
I shall make on diversion, and I make no apology to the House for that. I came down to London on the overnight sleeper from Glasgow, and found myself in conversation with two members of the ambulance service from the west of Scotland. [Interruption.] During the conversation they told me of their determination to achieve what they and the majority of the public see as a just settlement.
Mr. Dewar : I have been on my feet for one minute, and the most notable fact has been that my mention of the ambulance dispute was greeted by gales of laughter from Conservative Members and by a frivolous intervention. I think that the ambulance drivers will be interested to read of that reaction in Hansard.
I shall not speak at great length about the ambulance dispute, but I want to point out that the situation is deteriorating in Scotland. This week, staff in the west of Scotland have found themselves on and then off full pay three times. Many of them are getting as little as 25 per cent. of full pay, although they believe that they are honouring the agreed guidelines. The Government's insensitive approach, their machismo and the search for victory are doing an enormous amount of damage to morale and to the fabric of the service.
I repeat my view that if the Government's case is so strong, then there seems to me to be no reason why they should not submit the dispute to the independent judgment of an arbitrator. I hope that Ministers will understand in time that it is in their interests to do so, as well as in the interests of the service.
The Bill implements a White Paper which has been heavily and properly criticised. It is seen by many people as another campaign in the war of attrition that has been fought by the Government against the Health Service in recent years. We have had the regrading dispute, and competitive tendering, which makes workers struggle to save their own jobs at considerable cost to their terms and conditions. The threat of competitive tendering is getting nearer to the core of the Health Service.
Column 692Radiographers from Scotland are coming to London tomorrow to meet Opposition Members to put their case, and to express their fears and anxieties. Ministers have a duty to consider the effect on morale and to measure the difficulties against the proposals in the Bill. One minor point that I shall mention in passing is the meaning of paragraph 3 in schedule 5 of the Bill, which has had a number of public outings and has been a cause for concern. The Minister may remember that that paragraph refers to the transfer of officers and servants to other health boards in Scotland, and to the common services agency. I am not clear about the definition of a servant in that context, but I suspect that it means all employees, and I do not know the circumstances in which it is envisaged that the transfers will take place. Perhaps the Minister could give me that information by letter, if that is the most convenient, as I have received a number of representations about the matter, and I want to give accurate information in my replies.
The White Paper and the Bill have hardly a friend in Scotland. I do not wish to overstate my case, but the Bill is almost as unpopular as the Minister responsible for health in Scotland, and that is saying something. Perhaps that is not surprising as the Bill is seen as being built in his image.
There have been individual protests in plenty. One that I have mentioned before but that is worth recording again is the view of the hon. Member for Southend, East (Mr. Taylor). That gentleman has a special responsibility for the Conservative party's campaign tactics in Scotland. On 18 October he told The Guardian that the White Paper
"has caused so much unnecessary harm. Unless we are prepared to concede a lot, I think we should scrap it."
That is not a bad summing-up of what many people in Scotland feel. In July this year, at a conference in Inverness, a lady who is well known to many of us in Scotland, Mrs. Winnie Donaldson, a leading Conservative councillor in Edinburgh for many years, chairman of the social work committee of both the old Edinburgh corporation and the Lothian region and a former member of the Lothian health board, said :
"The White Paper absolutely appals me It seems to be like something out of another country when out of the blue comes this document, which seems to be something from another world. How do we get sense into people?"
That may not be the most technically complex of arguments, but it is a cry from the heart of somebody who, from a Conservative point of view, has given a great deal of service to the Health Service in Scotland.
I and my colleagues are often attacked. The hon. Member for Stirling (Mr. Forsyth) is never tired of telling us that we represent nothing more than a narrow vested interest, that we reflect unworthy and prejudiced views. If the House looks a little more closely, it will find that we are being accused of speaking for doctors, nurses, auxiliaries and ambulance drivers. I make no apology for expressing some of their anxieties, but the proposals affect thousands of people in Scotland.
This morning, I received a letter from the hon. Member for Stirling in his capacity as Minister with responsibility for health at the Scottish Office. He wrote :
"You recently delivered a number of postcards to St. Andrew's house".
Close to 50,000 postcards to be precise, each one completed and signed by a member of the public who had taken the trouble and was worried enough by what the
Column 693Government are proposing to fill it in. I gather--I welcome it--that each of those 50,000 is to receive a postcard from the Scottish health Minister. That is good news for the Post Office, although it might not have wished for it in view of the impending Christmas rush, but it will be a shock to many good, honest Scottish citizens who expect no such honour. Last year, by way of Christmas cheer, they got advertisements in almost every Scottish newspaper telling them of the joys of the poll tax. This year they will get a personalised postcard from the hon. Member for Stirling extolling the virtues of a business-oriented approach to the Health Service. It will be well calculated to take the bang out of anyone's cracker.
In any event, we can take one thing from the Minister's responses--we have drawn blood. He is obviously conscious of his weakness with public opinion and realises that he cannot just shrug off this substantial evidence of disquiet. He was kind enough to send me a copy of his pamphlet, complete with a second-class postage stamp carefully drawn in. I appreciate the artwork. It is clear that someone in a high grade in St. Andrew's house has a second talent. The Minister's little pamphlet illustrates the peculiarity of the debate.
That brings me to what the Secretary of State said. Many of the arguments are indeed common to both sides of the House. We both pay lip service to the concept, history and traditions of the Health Service. The question is not who uses that kind of rhetoric ; the question people have to make their minds up about is what is the reality of what is happening and who is committed to preserving the Health Service. The Minister's letter says :
"We support and will not change the principles that have guided it over the last 40 years The Labour Party campaign has therefore been built on a misapprehension. I intend to ensure that this is removed."
He sounds as though he is talking about an offensive gall stone. I do not think that he is likely to remove deeply-held convictions, based on the private experience of thousands of citizens, that the Government have got it wrong in terms of their fundamental theoretical approach to the Health Service. That is at the heart of the debate.
Of course there is a problem with how efficiently to deliver services and the commitment to escalating costs that new technology brings to health care, but my suspicion is that the Secretary of State, if I interpret his speech aright, is saying, "Look at all the money we have poured in and all the troubles we still have. We have to find another way. That other way will be followed because it is financially prudent. We shall push to one side the genuine byproducts and difficulties which will flow from that."
Much of what the Minister says in his little pamphlet cannot be sustained.
Mr. Kenneth Hind (Lancashire, West) : The hon. Gentleman speaks of the rhetoric that both sides of the House use in regard to the NHS and says that hon. Members and Governments will be judged by what they do. Will he cast his mind back to 1977-78, when Labour was in power and there was a 3 per cent. cut in real terms in the NHS? Surely that is the type of judgment that the public are entitled to make.
We are told in the pamphlet that the Government's proposals "do not involve patients having to pay for services currently provided free at the point of delivery."
I accept that. There is nothing in the Bill that say that they will have to pay, but I am entitled to observe that the claim sounds a little hollow bearing in mind what has happened to prescription, dental and eye test charges. There is overwhelming evidence, which my hon. Friend the Member for Livingston (Mr. Cook) has given, to show that people are doing without. The pamphlet continues--this is an important claim--
"The proposals do not involve any hospitals opting out of the NHS".
I understand the linguistic nicety on which that statement is based. They are not opting out of the Health Service. I am tempted to agree that that is a fair statement because, in Scotland, there is so little support for this crazy notion that I suspect that no hospital will opt out for that very reason. Nevertheless, we are entitled to some explanation. The Secretary of State said almost nothing about a timetable and what he expects. We know that the Minister with responsibility for health is anxious to be a front-runner--to blaze a trail with opting out and to maintain his claim. Perhaps it is all to maintain his place in "her" heart, which has led to his becoming the leader of the Scottish Tory party. In any event, we know from The Scotsman that among the Minister's claims is the
"creation of shadow' trusts. They would be ready to assume self-governing status and take over the running of hospitals immediately the necessary laws were approved He is known to be anxious that Scotland should lead the way on implementation of the reforms"--
then comes the sad anti-climax--
"which have, however, met general resistance from the medical profession."
I suppose that not everything can be perfect in this world. I listened in vain to the Secretary of State to learn what the plans are. There are few signs of genuine interest. We know that the target will be the 320 acute hospitals in the United Kingdom with 250 beds or more. The hospitals in Scotland that have been mentioned are peculiarly inappropriate. We are told that the Royal Scottish National hospital at Larbert is interested. It has 800 beds for mentally handicapped patients. Its aim under the new approach to care in the community is to work itself out of existence, not to become a brave new cutting edge for the peddling of services to other NHS agencies. We also have a group of three cottage hospitals in Forfar which I am told can muster 115 beds between them. I hope that I am not being unworthy when I say that they are interested because they fear for their survival in the brave new commercial world of the White Paper. That is not a good basis on which to become the favoured guinea pig in the opting out experiment.
Mr. Bill Walker (Tayside, North) : That is a frivolous comment. Forfar is the largest town in my constituency and it is the county town of Angus. The people of Forfar will find it offensive that the hon. Gentleman is so dismissive of it. Its hospitals are important to the people of Forfar. The hospitals are considering self-governing status because local general practitioners and others want it.
Column 695Mr. Dewar : The hon. Gentleman clearly wants to defend what is happening. As the constituency Member, he is entitled to do that, but on self-governing hospitals Scottish working paper No. 3 speaks of the target being
"major acute hospitals providing a reasonably comprehensive service."
Three cottage hospitals in the Forfar area do not spring immediately to mind as the most obvious example of that.
A more dangerous and more plausible example involves Stracathro and Forresterhill. If, for example, Forresterhill were to opt out, the Grampian health board would be left without its main provider of acute services, to use an up-to-date parliamentary expression. Forresterhill is a major complex with which I am familiar from my days as the Member for Aberdeen. If that hospital opted out, it would not create the market and competition which I understand is at the heart of the Government's arguments. If not the monopoly provider, the complex is the main provider of acute services to the Grampian health board. To introduce competition, it would be necessary to look to Dundee and Glasgow. That would not be meaningful competition. Perhaps the Minister will tell me if I am wrong, but I believe that Mr. Kyle, the chairman of the Grampian health board, is a great enthusiast of opting out for Forresterhill. Scottish Office selection procedures are admirable because in almost every health board area one can count on at least one enthusiast for opting out--the chair of the health board. When we spoke to the consultants in Forresterhill, over 80 per cent. wanted nothing to do with opting out. Perhaps the Minister will tell us what he thinks about Scottish working paper No. 3, issued by his Department not long ago, paragraph 55 of which says that the health boards
"will seek the views of those with an interest, particularly other health boards likely to be concerned, staff affected, general practitioners, local health councils and the local community." We know that the staff at Forresterhill are not interested and I defy the Minister to produce evidence that the local community will be interested in opting out. I do not believe that GPs or anyone else will support opting out. What are we to understand by paragraph 55? Was it just a deceitful aside to pad out the paragraph or will the health board have to consult before opting out? What form will consultation take and what will happen in cases such as that of Forresterhill where the overwhelming evidence is that there is no interest?
The reasons why people discuss the crazy scheme for opting out are simple. One is bureaucratic. That may seem an odd argument from the Labour party but we are not interested in bureaucracy if it is expensive and fulfils no useful social or administrative purpose. Separate hospitals will be separately managed and will have separate legal, personnel and purchasing departments.
Mr. Dewar : And possibly separate budgets. It is dishonest of the Secretary of State or at least highly misleading to suggest that a reference to budgets in the useful paper prepared by two of my colleagues can be equated with a trust which will own assets, hire and fire staff, borrow on the markets and buy and sell its services to the highest bidder at the most advantageous price in the market place. That is a completely different concept, and
Column 696the Secretary of State knows it. It is a mark of the weakness of his argument that he is reduced to drawing such false comparisons.
Mr. Rifkind : Perhaps the hon. Gentleman will do the House a service by explaining what the Labour party means when it says that it would issue hospitals with their own budgets? What kind of budgets would be provided? To what extent would the hospitals be committed to keep expenditure within the budget? What would be the effect if they exceed the level set down? Would budgets be a meaningful change or just a form of rhetoric?
Mr. Dewar : No doubt the Secretary of State will have time to discuss that on other occasions. We are discussing the Bill. [ Hon. Members :-- "Answer the question."] The Secretary of State may be interested to consider the possibility of a clinical budget for a ward and an extension of the principle of auditing. We are implacably opposed to the provisions for hospitals trusts outlined in the White Paper. They are divisive and will mean a loss of choice for patients and doctors. If, after discussion with a patient, a doctor decides that he wishes to send a patient not to the Western infirmary but to the Victoria infirmary or Southern General hospital, I am confident that he will be able to do so. However, if the patient needs a form of treatment for which the health board has drawn up a contract with a specific hospital, under the new market arrangements, clearly the patient will have to go to that hospital whether it is Ross Hall-- [Interruption.] I have taken the trouble to talk to the people involved and they believe that that will be the case. If the Secretary of State is saying that we have misunderstood, that is an appalling comment on the quality of explanation that has been offered. [Laughter.] The Secretary of State had better clear the matter up. If the famous hip operations to which the Parliamentary Under-Secretary of State always refers are contracted out to a certain hospital by the health board, and that is the only outlet for that treatment, where will be the choice? Can the patient refuse to go there and ask to go somewhere else?
Mr. Rifkind : Yes. The patient will be no more obliged to go to the hospital of the doctor's choice than he is now. Presumably a doctor will not enter into a contract with a hospital unless he believes that it gives a high quality of service. He may wish to recommend it to the patient, but it will be for the patient to decide whether he wishes to accept that advice. [ Hon. Members :-- "Rubbish."]
Mr. Dewar : On occasions I think that debates in the House are useful. The Secretary of State has made an interesting statement which we shall look at carefully. If it is true, it is another example of a feature of the Government's conduct of this case. Every time that we approach the logic of what they say, whether in White Paper or Bill, they hasten to deny the obvious consequences. The Bill will move the Health Service towards a two-tier service over a period of time.
It may not be the principle or immediate aim of the Government to create a two-tier service but it will be an acceptable by-product to the Government. The tax concessions announced in the Budget for those of
Column 697pensionable age who opt for private health care underlines that point. We shall see the private sector build wings on opted-out hospitals so that they can share facilities. We shall arrive at a point where a better service is available for those whose credit rating or employment conditions allow them to use private medicine than for those who are not in that position.
I now come to my final point because I do not wish to delay the House for too long. Opting out will disrupt and undermine the planning function of the health boards in Scotland. Perhaps the Secretary of State will tell me if I have misunderstood but I assure him that that misunderstanding is widely shared, particularly by members of the Greater Glasgow health board who have examined the matter carefully. The board is considering its acute services and producing an overall planning framework based on six centres for the whole area. I have had my disputes with the health board about cross-boundary flow, demographic factors and reductions in the number of acute beds and the social assumptions that they have made, but I do not dispute the need for an overall framework. I recognise that many difficult decisions have been taken. A row is already raging about the placement of obstetric units in the health board area. Whether it has got it right or wrong, it is entitled to make such decisions and to have an overall view of how it organises its resources.
What will happen to the overall strategy if a centre of acute care opts out and becomes a free-standing hospital? What will happen to the concept of overall planning and to the health board's role if a trust turns round and says, "The health board may think that the reorganisation is in the interests of patients and the community as a whole, but it is not in the interests of our hospital because we shall have to close wards and stop operations which are particularly profitable and bring us business. We shall not do it."? The Under-Secretary shakes his head fiercely, but many people in the Health Service at health board level see these problems as a negation of good management forced on the Health Service in the false name of efficiency. There will be casualties.
Mr. Robert Hughes (Aberdeen, North) : Is my hon. Friend aware that a new unit for psycho-geriatrics has been built in Grampian region and that the health board is actively pursuing the possibility of contracting every aspect of care, not just cleaning and catering, but medical care, to a private medical company? During discussions with the board, it could not say what the medical plans were because it had to discuss costs with the private company. Does my hon. Friend agree that that is a complete negation of planning and, indeed, of the ethos of the Health Service?
Mr. Dewar : I agree. These discrepancies and distortions will creep in increasingly. One of the tragedies is that there will be many casualties. I draw the attention of Tory Members to the view that : "Medical education, currently regarded as a proud obligation, will become merely tolerated under a market-led system."
The principal of Glasgow university also said that medical education was being seen as an
"add-on, a non-optional extra that NHS managers would have to put up with."
Column 698It would be sad if that were to emerge as the view on medical education. I would not think that Sir William Fraser, a former permanent secretary at the Scottish Office, was a tyro at looking behind the Scottish Office press releases to the reality of what is happening. Yet that is his considered view of the likely impact of the Government's plans on medical education in his university and in the west of Scotland.
I have dealt with the opting-out issue at some length, partly because of interruptions. General practitioner practice budgets are unlikely to be a major feature in Scotland as only 5 per cent. of Scottish practices reach the 11,000 mark. Where they are introduced, administration will be a major problem. It takes time and effort to negotiate a contract and to shop around as envisaged, and that time will be taken from patients. I plead guilty to finding the practical arrangements obscure. If a GP sends his patient for a barium meal and the patient requires further investigation and ultimately major abdominal surgery, that will come out of the practice budget. Presumably, there will be standard charges to even out costs, but at the end of the day there is little evidence that the service will be improved for patients. I genuinely do not believe that there is much point in the exercise or that anyone will benefit from it. It is like the switch to capitation fees. Ministers spend their time explaining that what everyone thinks will happen will not happen and that everything will go on as before. That is a futile argument. I accept that, despite the indicative drugs budget, GPs will always be able to prescribe. I shall not go in for scare stories. I am prepared to accept that assurance. Perhaps the Under- Secretary of State will listen to my next point. If we move away from local general practice committees monitoring drugs budgets, we are in danger of putting a cash test in the place of medical criteria. If a doctor pumps out valium and is irresponsible at that end of the trade, he may not reach his indicative budget, but he may prescribe in a way which is clinically damaging and, because of the switch in the criteria, that may not be picked up. I cannot welcome that proposal. Some provisions in the Bill are good. Health councils survive, although in a different form. There is a medical audit. More important, the Bill provides for Griffiths's key recommendation : that local authorities retain the key role in community care. That decision must have stuck in the Under-Secretary's craw. The key is resources. We can have jointly planned projects, but they must be jointly funded. We can have protections and plans that will be as naught if patients leaving hospital and being maintained in the community do not have the support and services that they require. Perhaps the Minister, again in a letter, can tell me a little about the status of grants to the mentally ill under clause 52. Is it new money or top sliced from existing resources? What arrangements will be made for the co-ordination of community care planning, given the provisions for separate submissions of plans by health boards and local authorities? Will the Minister sit down with the voluntary sector and local government and consider the matter?
I shall ignore the Government health warning that was given at the beginning of the debate. Whatever the precedents, I genuinely regret that there is no separate Scottish legislation. It would have made for better scrutiny and a more easily conducted debate. It is sad that good government has been subordinated to expediency.
Column 699Mr. Rifkind rose--
Mr. Rifkind rose--
Mr. Dewar : I apologise to the Secretary of State, but I have spoken for too long already. He knows that I normally give way to him, but he made his points about the statistics and precedents earlier. Whatever the precedents, it would have been better to have a separate Scottish Bill, particularly as we do not have a Select Committee on Scottish Affairs which could have provided useful back-up scrutiny.
I regret even more the Bill's contents. Ministers will continue to claim that the best is being preserved and nothing is being lost. I can only say to the Secretary of State that if he thinks that, he does not understand the implications of his legislation. We in the Labour party are strongly opposed to the measure which in the long term threatens the basic principle of a comprehensive Health Service fully available at the time of need. It is on that that we cannot compromise.
Mr. Roger Sims (Chislehurst) : Notwithstanding the stories that we hear from time to time from the Opposition, we have a good Health Service. Parts are very good and of a high standard. That was demonstrated last week at the Hospital of the Year awards which were sponsored by the Sunday Times. My right hon. and learned Friend the Secretary of State for Health attended the award ceremony. Throughout the proceedings emphasis was rightly placed on the quality of care. I enjoyed the high standards myself in a local National Health Service hospital during the summer when I underwent skilful surgery and received the most competent, sensitive nursing care. However, nobody would claim that all is as well as it could possibly be in the NHS. Each year more doctors and nurses are employed, more patients are treated and more money is spent. Yet each year we hear of longer waiting lists and more closed wards. That must show that more resources alone are simply not the answer. It points to the need to examine the structure of the Health Service, its administration and the way in which resources are distributed and used. It was just such an examination which the Government undertook two years ago. The key to success in the NHS must be the staff, from the bottom to the top and particularly the professionals. I understand why the Government in undertaking their review confined the involvement of those who work in the service to submitting papers. They were not involved in discussions. It was unfortunate that the Government then chose to publish the outcome of the review in a White Paper rather than a Green Paper and that in speaking to the White Paper Ministers used language that suggested to those in the service that the Government were presenting them with a fait accompli. It was a pity that the White Paper was not accompanied by a response to the Griffiths report. The review covers hospitals and general practice, but, as it does not refer to community care, it is rather like a three-legged stool with two legs. That omission has been remedied, but rather late in the day.
Column 700One result of the way in which the matter was handled was a somewhat hostile response to the review--much of it negative and some of it unpleasantly personal. The British Medical Association drew no credit to itself for the way in which it conducted its campaign. If we examine the reactions of some of the professional bodies, we find that they support many of the proposals and that their concern about some of the others relates to what could happen and what might be the result of implementing the proposals. Some of the comments and some of the literature were misleading ; some were downright wrong. They caused unnecessary distress to patients, in particular to the most vulnerable patients. Some of the concerns, however, were perfectly genuine. They sprang from uncertainty and from lack of detail. I hope that the professional bodies--the colleges and in particular the BMA--will accept that the Government are committed in principle to their proposals and that they will take part in a constructive dialogue about the details.
The differences are not all that great. For example, the BMA says that there should be pilot schemes for self-governing hospitals and practice budgets. My right hon. and learned Friend the Secretary of State has accepted that both will be introduced gradually, that each scheme will be a trial and that we shall learn as we go along. The difference between the two approaches does not seem to me to be very great. I am sure, therefore, that if both sides adopt a constructive approach, progress can be made.
I know that my right hon. and learned Friend is fully committed to the National Health Service, but some of the things that he has said and the way that he has said them--in the press, on television and at meetings-- have given the impression to the doctors and consultants to whom I have spoken that he is not concerned about their views. I am sure that that is not the case and that he will wish to correct that inaccurate image.
I welcome the principle that underlies the Bill : to ensure that increased resources are devoted to providing the highest possible standards of service and care in the most efficient manner--for example, by giving district health authorities and doctors the freedom to purchase operations and treatment, with the money following the patients. In a debate on the Queen's Speech the hon. Member for Livingston (Mr. Cook) referred to Queen Mary's hospital in the Bexley health authority area and said that it had had to close wards. However, he did not go into the details. One of the reasons for the closures is cross-border patients, some of whom come from my own constituency, but who are a charge on Bexley health authority. That will be put right.
It surely makes sense to bring responsibility down to local level, to let doctors have their own budgets, if they so wish, and to let hospitals be self governing. I am glad that Bromley district health authority's application has been approved. The corollary is local involvement in the service--especially for the local authority to be responsible for community care.
I hope that we shall examine again the proposed composition of health authorities and self-governing trusts. I note that Members of Parliament are to be specifically excluded. Many of us remember our erstwhile colleague, David Crouch, was a member of a health authority and a particularly valuable Member of this
Column 701House for that reason. My hon. Friend the Member for Gillingham (Mr. Couchman) served for a time on a health authority.
There are many examples of successful co-operation between the National Health Service and the private sector. It must be right to try to develop that co-operation. The private health sector is well established in community care. There is certainly scope for greater co-operation between local authorities and the private sector, as proposed in the Bill. However, standards must be set and maintained in all sectors--local, national, independent and voluntary. It is equally important that community care should be adequately funded. It is admirable that local authorities should be made responsible for this service, but they must be provided with adequate resources. They will be seeking assurances that sufficient cash will be made available to enable them to handle all the cases that come their way. I am sure that the Secretary of State does not underrate the strength of the ring fencing argument ; the money at present being paid for social security purposes must be made available in full specifically for community care.
I am particularly concerned about those who are living in residential homes and nursing homes. I am sure that all hon. Members could give examples of constituents whose social security benefit is insufficient to meet the cost of living in such homes. I am referring not to expensive private homes, but to places such as the Cheshire home in my constituency where the minimum cost for each resident is above the maximum social security benefit that some of the residents are able to obtain. I have been in correspondence with the Secretary of State for a long time about the problem. I was assured that it would be addressed in the Government's response to the Griffiths report. I was disappointed to find that it does not seem to have been adequately addressed in the report. I am particularly worried about those residents who, alas, may not be with us by 1991. The Government should take urgent steps to improve their position.
Mr. Mark Wolfson (Sevenoaks) : I support my hon. Friend's point as a result of my own experience of a Cheshire home in my constituency. Exactly the same problem has arisen and I, too, will be seeking reassurances from Ministers.
Many hon. Members would like to know more about a number of details. For example, what are to be the criteria for the approval of self-governing hospitals? I dissented from my Select Committee colleagues who advocated that there should be a local ballot. I do not think that that would be practicable. However, we should be given more details about the criteria that the Secretary of State will set. How will those who are parties to a contract be held to it if it does not have legal validity? What definitions will govern a core service? Many other details need to be clarified. It could rightly be argued that these are Committee points, but they are very important to those who are working in the National Health Service. They will
Column 702have to implement the Bill when it becomes an Act of Parliament. They are also very important to those who are involved with community care.
As these issues are so important, I hope that my right hon. and learned Friend will look sympathetically at the motion that I and other Select Committee members have signed. We urge that the Bill should be considered by a Special Standing Committee. I have some experience of this relatively little-used procedure and I commend it to my right hon. and learned Friend. It provides an opportunity for those who work in the National Health Service to put their point of view on how the Bill could best be implemented and the kind of problems that they envisage. The Secretary of State would then be able to consider those matters. The only alternative is that outside bodies have to find a friendly Back Bencher to present the case on their behalf. Even at this late stage, I hope that Ministers will be prepared to adopt that procedure. I do not believe that it would cause the proceedings to be unnecessarily delayed. In the long run, it may save time.
We all want to make this good Bill better. Politicians, professionals and patients are united, and, as my right hon. and learned Friend the Secretary of State said when he moved Second Reading on Thursday, we all want to make a good National Health Service even better.
Mr. Peter L. Pike (Burnley) : I oppose the Bill because I believe that it will be tremendously damaging to the Health Service in Britain. We all have to recognise the way in which the Government work. They often have to go part of the way in the direction they seek and then take it further in subsequent legislation. On Thursday, my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) set out the reasons why the Government, who do not like the Health Service and do not want it to work, dare not go any further than the proposals in the Bill. They recognise that the Health Service has massive public support, and, therefore, they have to tread more cautiously.
The Opposition believe that the two main priorities are that people are entitled to educational opportunities and to health care based on need and regardless of ability to pay. That is why we must not allow the Bill to make progress. It does not tackle the problems facing the Health Service which are based on resources and finances. I have copies of letters from a general practitioner to the hon. and learned Member for Putney (Mr. Mellor), now Minister of State, Home Department, and to the Under-Secretary of State for Health. After the correspondence had continued for some time the doctor's final letter concluded :
"Alternatively, of course, you could propose to your Government colleagues that all pretence at improving the NHS should be dropped, and it should instead be admitted to the voting public that the only way to assure ourselves of high quality treatment and freedom of choice under the proposed new arrangements will be to obtain private medical insurance."
The Bill underlines the fear that we are moving towards a two-tier Health Service ; a Health Service providing for basic needs, but a better level of service for those who have the ability to pay. That would be regrettable.
We have discussed the practice budgets and the indicative drug budgets. Whatever the Minister says about those figures, we all know that, although budgets might not be rigidly cash limited, they influence decisions. I have no doubt at all that when doctors are prescribing drugs,
Column 703although they accept that they may be permitted to prescribe a more costly drug, they will be influenced by that budget limit. The Minister should recognise that the Opposition know that to be true. We have only to look at what is happening in the Department of Social Security to community care grants. My local office recently wrote to me saying that it could no longer make certain community care grants for the remainder of the year because it had to retain enough of the budget to meet demands for the remainder of the year.
Although Ministers say that doctors will be able to prescribe, general practitioners, the public and Opposition Members fear that the new system will affect their decisions. When I met local GPs and the BMA in my constituency they made two points about budgets.
Mr. Nicholas Bennett (Pembroke) : Presumably in 1985 the hon. Gentleman opposed the limited list on drug prescribing about which the BMA also protested. Does he now accept that that was right and that £75 million has now been allocated to pay for other things in the Health Service?