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Mr. Hayes : The hon. Gentleman rather foolishly says that the Government and I are responsible. He knows nothing. The ludicrous and antiquated system of finance which the Bill will change is responsible. That is why I support the Bill.
Mrs. Rosie Barnes (Greenwich) : The Bill has much to commend it, but much more to condemn and criticise. I want to discuss the provision for hospital services in some detail and, if time permits, I will refer briefly to general practitioners and community care. The Secretary of State for Health must be congratulated on promoting a number of important initiatives within the hospital services--for example, the introduction of capital charging, the development of the resource management initiative and the empowering of the Audit Commission to scrutinise the NHS.
Those three moves should together encourage better financial management of the Health Service. Other welcome aspects include the differentiation between purchasers and providers of service which should clarify the responsibilities in planning and operations, the introduction of clinical audit which will form a better framework from which to assess the effectiveness of the service, the streamlining of district and regional health authorities and the full participation of executive directors which will enhance proper decision-making.
Why, if I find so much in the proposals to applaud, am I so adamantly opposed to them? First, the effectiveness of district health authorities will be seriously eroded by the operation of fund-holding general practitioner practices. It is ironic that after the Government have put so much effort into the development of the public health function within district health authorities over the past two years, they are about to undermine some of those achievements.
The public health departments have been developing two vital functions-- they have become increasingly powerful in promoting good clinical practice and they have been acquiring the necessary expertise to anticipate and thus facilitate the timely provision of the services that people need.
I challenge the appropriateness of general practitioners making the market in hospital care. If it is to be made, let the patient do it and let the DHAs play a more pivotal role.
Column 716The error will be compounded by the limited authority that a DHA will be able to exercise over a National Health Service trust hospital.
A trust hospital may become a model of good practice. If it does, will the local DHA be able to afford comprehensive access to its services? Conversely, a trust might become a bastion of backward-looking practice. Would a DHA then want access to its services?
It is far more likely that NHS trust hospitals will become more interested in the wider market at the expense of the local population. It is vital that a comprehensive definition of care services is incorporated in the Bill to safeguard the interests of local residents.
My third and very important point is that the Minister has failed satisfactorily to integrate the primary service provided by general practitioners and hospitals at local level. I urge him to consider that fundamental problem. District health trusts, as a sensible, comprehensive alternative to self-governing hospitals, would enable district health authorities to ensure that proper services were provided within their areas, and to plan strategically for all the local population. They would also facilitate smoother transition from one part of the service to another, and thus deal with a considerable flaw in the current proposals.
Fourthly, and critically, the Minister has failed to demonstrate any grasp of the dynamic relationship between quality, cost and timeliness. He talks glibly of raising the standards of all to the standard of the best, but fails to acknowledge that authorities have already been deciding on differing priorities for the best local use of scarce resources. We must ask the Minister to include absolute commitment to quality in the Bill, as well as clinical audit. Quality figures large in the White Paper but appears to be absent from the Bill, which is an unsatisfactory state of affairs. "Quality" must include adequate provision, accessibility and reasonable waiting times. While I am on the subject of quality, let me also ask the Government to make an unequivocal commitment to the work on "total quality" being carried out by the Kings Fund in its hospital accreditation programme.
The Minister is to be congratulated in part on the proposals for GPs, who will certainly be more accountable for the services that they provide. I doubt, however, whether the new contract arrangements imposed on them will resource them adequately for their new responsibilities. I have already spoken at length in the House on my misgivings about fund-holding GPs' practices in conjunction with NHS trust hospitals, and the unwelcome complication that financial considerations will introduce to the relationship between GPs and their patients.
Let me devote the remainder of my speech to the community care aspect of the Bill, which I think is long overdue and has tended to be ignored. Again, I must give credit where it is due : the Government must be congratulated on facilitating better differentiation between residential care, community or social care and the medical components of the service, while balancing that with a commitment to the joint working of all three. What is entirely unsatisfactory, however, is the lack of definition in the allocation of responsibilities.
We have two key anxieties. First, we fear that the Government will progressively make more demands on local authorities to fund local services directly--and, as we all know, the areas in greatest need are often those least able to afford such services. Secondly, the Government are
Column 717demonstrating an unnecessary bias against the direct provision of residential accommodation by local authorities. We support a mixed market ; if the Government truly supported that, they would have the courage of their convictions and allow local authority provision to flourish where it is working.
Finally, let me make some general points covering all aspects of the Bill. First, I am concerned about the speed of change. The problems involved in this development are highly complex, not least in the way in which they are interrelated, but the targets are over-ambitious in their timing and owe more to party-politial considerations than to professionalism and concern for patients' well-being.
Secondly, I am worried about the lack of genuine choice. There has been some slight modification to the way in which patients may choose their GPs, but the rest follows automatically and they will have very little say. As the hon. Member for Livingston (Mr. Cook) said earlier in the debate, the patient follows the money rather the money following the patient ; the patient travels with the money but the money does not travel with the patient, as Conservative Members claimed earlier this evening.
I am also very concerned about the lack of patients' rights. There are no tangible commitments or improvements, particularly as regards waiting time. I refer hon. Members to the amendment that I tabled, along with others, to the Health and Medicines Bill, proposing that statutory times should be laid down for treatment to be delivered, and for patients to exercise their right to go elsewhere if their own health authority could not deliver that treatment. If that provision were in the Bill the money would truly follow the patients, and they would have more control over their share of the Health Service's money.
Resourcing is a major problem. The Government's achievements in that respect--as we hear week after week from the Dispatch Box--cannot be ignored or denied, but in return they must acknowledge that genuine need continues to outstrip their commitment to provide, especially in view of the aging population and the increasingly technological service that is now available across the board. In particular, the Minister must acknowledge that the great majority of the development moneys that he gave the NHS recently will be absorbed by inflation and the financing of existing workloads.
I agree that the NHS requires organisational development to promote changes in its management and clinical practices, but I am concerned that the Government have responded by foisting on the service their uniform precription for the public sector : it is inadequate, it is dangerous and, in its present form, it must be rejected.
Mr. Michael Irvine (Ispwich) : Scaremongering and distortion have been the characteristics of the campaign against the Government's plans for reforming the National Health Service. I am afraid that both have been very much in evidence in many Labour speeches in this debate.
Another feature of the opposition to the proposals for reform, and to the Bill, has been the almost unremittingly negative character of the criticisms that have been made. It seems that the only answer to the problems of the National Health Service from Labour Members and
Column 718others who campaign against the Government's proposals is a call for more resources. They are on dangerous ground there, because the record shows that, far from being a poor provider of resources, the Government have been a very good provider. My hon. Friend the Member for Harlow (Mr. Hayes) produced the acid figure : a real-terms spending increase of 45 per cent. since the Government came to power in 1979. Such a figure really stands up to examination ; it shows the merit of the Government's health policy, and their ability to provide the necessary resources.
It is not just a matter of resources, however. The key question is how we apply those resources. The great weakness in the present structure of the NHS is that it simply does not give sufficient account to cost. It does not reward efficiency ; all too often indeed it stifles and suffocates good management. Several Conservative Members have given examples of how, time and again--especially at this time of year--hospital beds are left empty and operating facilities left unused.
Why does that happen? Sometimes, but not always, it is due to bad management. Sometimes, however, it is the hospitals that have been particularly efficient, have maintained a good patient throughput and carried out more than their fair share of operations that run short of resources. The proposals for self-governing hospitals are directed towards remedying that fundamental flaw in the system. The managers of self- governing hospitals will be free to manage. They will be free to attract to the National Health Service those staff for whom there is a particular need. They will be free to provide incentives to overcome shortages. They will be able to make their hospitals more efficient, to make the administration more flexible and to make their hospitals more responsive to patients' wishes and better able to provide a better quality of patient care.
That new freedom for management will have an additional effect. It will make it more likely that higher-calibre managers will be attracted into the National Health Service--
Mr. McCartney : Will the hon. Gentleman explain the new freedom for managers? I refer to the Atherleigh hospital near my constituency, which cares for the elderly confused and those with senile dementia. Because of the shortfall in his budget, the district general manager gave 24 hours' notice to the community health council that he was closing the hospital and moving out as many patients as possible to the private sector. That was done without consultation with patients' representatives, their families or the community health council. Is that the type of management decision that will be taken because of unit costs and the need for local decision-making at Health Service district management level?
Mr Irvine : I shall not follow the hon. Gentleman down that rather dangerous road into a precise problem affecting his constituency. However, perhaps the problem that he has identified shows that at the moment the National Health Service is not working as effectively as it should.
There is one element of the criticisms that have been made about self- governing hospitals of which the Government should take careful note. An effective point was put to me by hospital doctors and consultants in my constituency when I met them. It is that there is some risk that self- governing hospitals may be tempted to skimp on medical training and education. I have in mind the
Column 719education and training not only of doctors and consultants, but of radiographers, technicians, nurses and others. There is also a risk that self-governing hospitals might be tempted to skimp on research and development. There is just an element of risk that some self-governing hospitals might not provide the resources that they should in those directions. We need to guard against that risk. Therefore, I was glad to hear my right hon. and learned Friend the Secretary of State for Health say on Thursday that he will indeed be on guard against that risk, that there are powers in the Bill to enable him to intervene if he feels that that is the case in any particular self-governing hospital and that he will stand ready to use those powers.
Basically, I have no doubt that self-governing hospitals are an excellent idea. We should remember that they are optional. No hospital will be forced to become self governing against its will. Why then is there such hostility to the idea? I suspect that much of the opposition to self-governing hospitals is based on the fear that they will be successful and show up those hospitals that are badly administered and not up to standard. Self- governing hospitals will set a standard by which others are judged. That point is at the heart of much of the fear about self-governing hospitals and of the hysterical campaign that has been mounted against them.
If there has been scaremongering and distortion about self-governing hospitals, there has also been quite a bit of the same about indicative drug budgets. For the vast majority of responsible and able doctors who prescribe sensibly and effectively and who have a proper regard for costs, indicative drug budgets hold no fears. The budgets are directed against the minority of doctors who prescribe wastefully. They are directed against those who prescribe Valium as if it were bubble gum and who do not have a proper regard for costs. If good doctors who prescribe carefully overrun their budgets, they will be able to justify that overrun by referring to special aspects of their practice affecting their need to prescribe. It will be the small minority of wasteful doctors who have no regard for costs who will be caught out.
I am glad that the principle of the proper allocation of resources will characterise the new framework for community care. The great dangers to effective community care services are duplication, lack of co-ordination, overlap and fragmentation. By providing clear lines of accountability and care packages for individual patients, the Griffiths proposals will do a lot to overcome that risk. They will help to reduce waste and will save resources. Those resources will be needed because there is no doubt that community care will be expensive in the coming years, partly because of demography and the increase in the age of the population but also because the increased efficiency of the National Health Service, which I believe will result from these proposals, will place greater demands on community care. More operations will be carried out and people will be discharged from hospital at an earlier stage of their treatment. That in turn will place greater burdens on community care services. In my constituency of Ipswich much strain has been placed on the home help service, not because of any reduction in the amount of money being devoted to the home help service, but because people are being discharged from hospital at an earlier stage of their treatment. This means that personal care from the home help service is
Column 720becoming increasingly in demand. As a result, strains are building up on the home help service. However, by providing a more efficient framework--
Mr. Keith Bradley (Manchester, Withington) : I thank you for calling me to speak in the debate, Mr. Deputy Speaker, because this issue is of immense importance to my constituents. Indeed, no more important area of concern has been expressed in correspondence from consultants, doctors, and the general public than the reform of the National Health Service.
We cannot discuss the Bill without considering resource allocations--on which the Bill is silent. Whether we are talking about hospital services, community services or general practitioner services, the Government's proposals are silent on the need for extra resources. Ministers trot out figures time and again about the extra money that is spent on the Health Service, but they never put that in the context of the extra demands for health care, the growing numbers of elderly people who need health care and the new technologies that increase the cost of health care.
We should consider the Bill in the light of what is found in individual health authorities, such as my own in south Manchester. It has been suffering from a financial crisis for many years and, despite all the cost improvement programmes that it has implemented, it is now £1.5 million short in its budget for this financial year. The health authority has therefore had to freeze vacancies, and 120 posts in the provision of health care have been lost this year. Despite repeated representations to the Secretary of State for Health for more resources for south Manchester, he has refused to entertain our request. The latest letter that we have received from him shows his thinking on how that financial crisis has arisen. He says :
"I do not know whether the clinical regrading costs arise from previous errors in the original gradings or over-generous findings on appeal."
The Secretary of State says that one reason for the problem is that south Manchester health authority, when it was assessing the grade of staff in the nursing service, was overgenerous, and gave them more money than it should have. That is the sort of Secretary of State we have ; that is how he considers the needs of our staff.
What is the health authority now doing to save money because of the financial crisis? It has published a consultation document on rationalisation of the service. That means further cuts in service. The document does not identify how much money it intends to save or give the figures. We can be sure that two things will be lost in south Manchester : the accident and emergency department at Wythenshawe hospital will be closed for major accidents and transferred to Withington--Wythenshawe is next to Manchester airport, but it will not have a major accident service-- and Withington hospital maternity unit will be closed, with all mothers transferred to Wythenshawe. What patient choice does that mean?
Let us consider the Second Reading debate to date. When asked about obstetric services, the Secretary of State said :
"The other day, it was hinted that expectant mothers may lose local obstetric services because of our proposals. That is
Column 721nonsense. No right hon. or hon. Member would suggest any of that rubbish."--[ Official Report, 7 November 1989 ; Vol. 163, c. 503.] South Manchester is having to close maternity services to save money. Can we believe the Secretary of State's statements about the Bill?
I have the unhappy task of trying to defend one of the hospitals that is on the Government's long shortlist for opting out--Christie hospital in south Manchester.
The Secretary of State justified opting out, saying that it will free nurses and doctors who have been frustrated by the constraints of bureaucracy for years, and will allow them to use their abilities and to work as they wish. When I asked doctors, consultants and nurses why they had expressed an interest in opting out, they identified one reason--lack of cash. They are heartily sick of a Health Service in which they cannot provide care to the number of patients they want because they are short of resources. That is the only reason why they have expressed an interest in opting out. They do not want to go down that road, but they want to get more money out of the Government. They are appalled that the regional health authority is bringing in extra staff to develop plans for opting out when there is a freeze on nurses' jobs in the hospital. There is a freeze on nursing staff, but more accountants can come into the Health Service. That shows the strength of the Government's commitment.
A meeting of 185 local doctors in Manchester and of the local medical committee passed a resolution that was in absolute opposition to the Government's plans for GP services. GPs are fearful, regardless of the assurances given by the Secretary of State, about what cash-limited budgets will mean for the service delivered. As my hon. Friend the Member for Burnley (Mr. Pike) said, what is happening to the social fund is a good example.
Last weekend a constituent came to me because she had been refused a community care grant. She was told that there was no money left in the budget. After further investigation, I found out that the Department of Social Security is having to reassess priorities within the budget, because the cash is running out rapidly. If my constituent had gone to the DSS earlier in the year, she would have got a grant, but at this stage, because of the change in priorities, she will not. GPs fear that the same thing will happen with their practice budgets. They may be able to prescribe a particular treatment for one patient at the beginning of the year, but when money is getting short they may have to prescribe another treatment for a similar patient later in the year.
General practitioners are worried that they will not have the capital that they need to develop their clinics and practices to meet the demands of the extra treatment that they will have to undertake. In my area of Chorlton, the local health centre is already bursting at the seams. There is no room for a typewriter let alone a computer to undertake the administration that will be imposed by the Bill. General practitioners are anxious because they already face restrictions on where they can send patients. Last week they received a letter from the regional health authority which said that, because of financial and manpower resources constraints, neurosurgery would be
Column 722limited to which hospital a particular doctor in a particular area could send his patients. We already have restrictions on patient choice, and the Bill will make that worse.
Finally, GPs are concerned that waiting lists will be transferred from the hospital to the GP's practice. GPs will have to determine where to send patients, but the amount allowed for under the contract with a particular hospital for a range of services may have run out. The waiting list will be at the GP's door, not at the hospital's door.
Our opposition to the Bill is summed up best by a letter that I received from a constituent. He clearly reflects the Labour party's view when he says :
"I am an ordinary citizen, with a wife, three young children, and elderly parents. We all have cause to be thankful that our GPs have given us the best treatment they could provide to meet our needs, rather than the best treatment they could offer within the limits of their local budgets. And they have referred us to hospitals near our homes which provided services the population needed, rather than those which managers decided they could market efficiently. I would like it to stay that way, and if that means I must pay more in tax, I will pay more in tax. I have never before written to make my feelings known to a Member of Parliament. That I do so now is a measure of my profound opposition to the Government's proposals."
That letter is one of thousands that I have received. The people of Manchester and the other people of Britain will totally oppose the Bill.
Miss Ann Widdecombe (Maidstone) : I am grateful for the opportunity to speak in this debate because I am grateful for the Bill. It will herald a new era for the National Health Service and will turn it into the thriving, expanding concern that is should be.
My constituents will benefit substantially from the proposals for self- governing hospitals. They will also benefit substantially from the greater flexibility in referral patterns, and the greater knowledge that will be available to doctors about where waiting lists are shortest.
It is a matter of considerable regret to me that my constituents, in particular the elderly, the sick and the vulnerable, should have been frightened and misled by the utterly irresponsible campaign waged by the British Medical Association.
An example of the way that my constituents have been frightened is that sick and elderly people have been literally shaking with fear when they come to my surgery. They told me that they would not be able to get medicine because their doctors would no longer be allowed to prescribe it when it became too expensive.
The Secretary of State said, from the outset, that indicative budgets would not be cash limited. On the basis of those assurances, which he gave time and time again, I was able to circulate a leaflet to all my constituents, telling them that there was no truth in the BMA's claims.
Several months later, when the BMA realised that it could not sustain its lies any longer, it said that the Secretary of State had done a U-turn, and had now said that indicative budgets would not be cash limited. That leaves us with three possible options. First, that the BMA simply did not understand what the Secretary of State was saying right at the beginning, and genuinely did not realise that drug budgets would not be cash limited. If that is the case, it is too stupid to represent a highly-educated profession. Secondly, it is possible that the BMA understood perfectly but chose to ignore it, and pushed it to one side. In that case, it is too irresponsible to represent a highly-respected profession. The third option is that the
Column 723BMA understood, did not ignore it, but thought that it would be effective if it could frighten people, so deliberately deceived the elderly, sick and vulnerable into believing that drug budgets would be cash limited. If it did that, it is too thoroughly dishonest to represent any profession which acted more like trade union bully boys than a group of respectable professionals.
I am not surprised that two of the most respected local consultants in my constituency have resigned from the BMA and I am not surprised when local doctors tell me that they believe the BMA's campaign has been wholly unjustified. I think that, as the public realise that the BMA has misled them about indicative drug budgets, about the effects of opting out and about the effects of independent budget holding, the professional relationship between doctor and patient will be damaged far more than by anything that the Government are proposing. If the BMA wants to hold the confidence of the public, it should start to tell the truth pretty soon. I am delighted to have the Opposition Front Bench's confirmation that drug budgets will not be cash limited.
Meanwhile, my constituents can be assured that they will benefit from the fact that, if Maidstone hospital chooses to become self-governing--I do not know whether it will--it will be able to fix pay and conditions there. One of the biggest problems that we have in the south-east is recruitment. Flexibility on pay and conditions will make it much simpler to cope with that problem.
If there is one thing that I regret about the White Paper it is that it did not seize the opportunity to hold all consultant contracts at district rather than regional health authority level. It does not allow even self- governing hospitals to take on existing contracts rather than just new ones. For a self-governing hospital to be truly effective, it must have complete flexibility over who it employs, and consultants are obviously a key to the services that a hospital provides.
We in Maidstone are efficient. Every year we have an enormously ambitious budget, and every year we comfortably exceed our activity levels. In future, with money following the patient, that will not lead to our being confronted with budget problems at the end of the year. We shall no longer be penalised for being efficient. I believe that the people of Maidstone will benefit greatly from the Bill. When I first came to the House, many constituents came to me complaining that they had been on waiting lists for too long and asking me whether they could go anywhere else to get operations done more quickly. Although I willingly took it on, it did not seem my role as a Member of Parliament to shop around the country on behalf of my constituents, so it is much to be welcomed that the technology which is to be made available will enable doctors to get speedy and efficient information on where there are shorter waiting lists. They will be able to give their patients a better service, and patients will not have to ask their Member of Parliament to do the shopping around for them. That will be an enormous plus.
For all those reasons, I believe that the Bill is one of the best things that has happened for Britain, especially for my constituents. What I regret most is the party politicisation of a major asset such as the NHS. Opposition Members should join us to make these proposals work so that we can guarantee the future of the service.
Mrs. Alice Mahon (Halifax) : It is party political when the district health authority confronts massive cuts every year. This year, my local authority faces yet another £500,000 cut. How can the hon. Lady think that that is not a political issue? People on waiting lists in my constituency think that it is political, and blame the hon. Lady's party.
Miss Widdecombe : The hon. Lady should be honest enough to tell her constituents that my party is not to blame, and that the problem is a thoroughly over-burdened system that will be much relieved by these reforms. Precisely because we have such problems, we should pull together to make the reforms work. Subject to refinements of detail, which I think necessary, particularly in regard to referral patterns, these reforms provide a basis for the future. They should not have become the object of party politics. They should be the object of a good, thorough, thriving, expanding, researching, developing and serving British health service for a century to come.
Dr. Kim Howells (Pontypridd) : The National Health Service is not above criticism. It is not an untouchable monument. Indeed, it is no more unassailable than the former Chancellor of the Exchequer was. The NHS has been scarred by many shortcomings in many of its facets, whether lengthy waiting lists, miserable waiting rooms or a minority of consultants and registrars who seem to belong to a James Robertson Justice impersonators' club treating patients with all the sensitivity and delicacy of a vet treating sheep for wind. Likewise, the managers of the NHS, like any management of a large high-spending organisation, need constant monitoring. I do not argue with any of that. Whatever its faults, however, the NHS was recognised as being infinitely preferable to the private service and panel systems which it replaced in the late 1940s. Indeed, it became during subsequent decades the most public image of governments and societies which viewed the health of the nation as a matter not to be determined by the vagaries of personal wealth or the market. During the past 40 years, the British people have come to regard the NHS almost as a birthright--the right of access to the best health care that can be provided, regardless of personal or corporate wealth. Most of us have moaned and groaned about the Health Service, but most of us are also inordinately proud and fond of it. That is why, it seems to me, the British people have reacted with such vehemence and distaste to key aspects of the Government's proposals. They regard the Health Service--general practitioners, practices, local hospitals and the long-term care facilities for the chronically sick and infirm--as a keystone in the structure of their communities. They do not want that keystone to be loosened. They do not want their elderly and very young to be hawked around in search of health care as their young are now being made to hawk themselves around in search of jobs in a metropolis such as this. They do not believe that health is a marketable product, but the Government do. The proof is in the Bill, or rather it is evident in what is not in the Bill. It is evident in the lack of explanation of what is to happen to those vital elements of NHS provision which relate to care of the chronically ill, the elderly and the mentally ill and to those areas of the NHS which cannot be milked for a fast buck.
Column 725The Bill smells of the same oily rag which the Government have used to clear the decks for the privatisation of other public services. The people know that smell, and it angers them. They want to know why the Bill does not concern itself with resolving the many problems that beset the NHS. The Bill will solve none of those problems. It has been drafted by a Government who are deaf to the huge sigh of protest and concern that has greeted it. The Bill is an abrogation of responsibility. It is drafted by a Government who are drunk on bootleg privatisation. I rejoice in the knowledge that that deafness and this ideological drunkenness will drag the Government to a well-deserved resting place at some miserable footnote on a page of history that most of us would have much preferred never to have read.
Dr. Charles Goodson-Wickes (Wimbledon) : I have hitherto been reluctant to speak on the Government's proposals for the reform of the National Health Service. There are times when one is almost too close to an issue, caught between one's profession and one's political colleagues. Since becoming a medical student some 25 years ago, I have had more than a passing experience of the great matters involved, and I am grateful for the opportunity to comment on some of them today.
St. Bartholomew's, where I trained, is arguably the oldest London teaching hospital as it was founded in 1123. St. Bartholomew's hospital has continuously adapted and developed for the past 866 years. It strikes me as peculiar in the extreme to assume that, after a mere 41 years, the National Health Service is incapable of modification and improvement. Indeed, any suggestion of change is interpreted in some quarters as an attack on the whole concept of the NHS.
It was with distinct unease that I watched the posturing and skirmishes of the past few months. I imply a degree of blame on the Government, the Opposition and the British Medical Association respectively. I am utterly convinced that my right hon. and learned Friend the Secretary of State was right to extend to the NHS the challenge presented to so many of the institutions and vested interests in our society. We have tackled the City, trade unions, the teaching profession and the legal system. We have made them justify their practices or abandon them--all this in the interests of the consumer. Why should the medical profession be immune?
As a practising physician and a non-practising barrister I suppose that I have cause to feel singled out for persecution. I make no complaint about that, but it was as a member of a trade union--the BMA--that I felt most uncomfortable. It was with astonishment and sadness that I saw the discredited techniques of old-style trade unionism adopted by a professional body. I cannot believe that ultimately it was in the interest of anyone to frighten vulnerable people in surgeries across the country with alarmist and mischievous literature. From sheer misinformation to merely putting the worst possible construction on virtually all the proposals in "Working for Patients", the BMA let itself down. However, I have had a series of civilised and constructive meetings with the chairman of the BMA council and his senior colleagues. We all agreed that it was time that peace broke out.
Column 726In extensive consultations with general practitioners and hospital doctors in my constituency anxieties have been aired and misunderstandings ironed out. I welcome the Government's flexible reaction to various practical objections which proved valid. Nothing is more unsettling than uncertainty. The sooner that we move on the better.
The latest BMA literature uses the recurring theme of "risk of failure", a phrase which is hardly indicative of enlightened and optimistic thinking for the future. If the Government had baulked at the formidable range of problems presented to them during the past decade because of the risk of failure, their achievements would have been minimal.
I have worked as a hospital doctor in various parts of the country. Despite believing that NHS treatment is the best in the world from a professional point of view, I recoil with horror at memories of queues of out-patients where tens of people were given identical appointment times. They waited phlegmatically and passively in outdated and uncomfortable hospital buildings that were either too hot or too cold. I recall the impersonal, condescending and sometimes almost patronising attitude of administrators, doctors, clerks and technicians. I remember the wastage of materials and time. I remember the blunderbuss ordering of expensive, poorly directed investigations into problems and the haphazard methods by which patients were called forward for admission. In out-patient departments people traipsed from the examination cubicle to further waits outside the X-ray department or blood laboratory and so on. It would be a rash person who, including travel by public transport, assumed that the whole process would take less than half a day. What happened next? They were told to come back in a week's time. They were extremely lucky to see the same doctor. Results were often delayed or mislaid or fell foul of technical problems and tests would have to be repeated.
I make no apology for putting over that litany. I do not say that that position was universal, but in every constituency one could still walk into an out-patient department and see a picture similar to the one that I have painted. The medical treatment may have been excellent, but did the patient come away feeling that he had been served by the National Health Service?
In the first day of this debate, my right hon. and learned Friend the Secretary of State said : "Patients also tolerate variations in the times for which they must wait for treatment, and
facilities".--[ Official Report, 7 December 1989 ; Vol. 163, c. 500.]
He will agree with me that in the 1990s the time for tolerating inadequate services is over. His enlightened proposals should increase the pace of change for the better. Administrators and doctors should no longer communicate badly with each other, and with nurses, physiotherapists and technicians and all the people who make the management of a hospital possible. Good management and good morale follow each other inseparably.
So much for personal accountability. What about financial accountability? A whole generation of doctors, patients and politicians have grown up knowing nothing other than the welfare state and the NHS. It may be free
Column 727at the point of delivery and financed mainly out of general taxation, but who knows the cost of anything? Only relatively recently have the best GPs become conscious of the cost of drugs, dressings and so on. How many know the cost of operations in the local hospital? More importantly perhaps, do the hospitals themselves know the cost of the operations carried out in them? Do they ever question the bed-stay times in different hospitals for identical operations, or, indeed, the waiting lists in different hospitals where the same surgeon operates? It is hardly surprisng that doctors have been labelled bad managers when they lack the data on which to make decisions and thus the opportunity to debunk that fallacy. We know the argument that medicine cannot be equated with a production line. However, the NHS cannot be regarded as immune from normal financial pressures. There is nothing paradoxical about a service run on prudent and businesslike lines. For far too long, this Government as well as their predecessors have chucked money at problems instead of solving them--a palliative if ever there was one. If each family had been asked to write a cheque for £35 each week of the year, specifically for the NHS, I suspect that minds would have been concentrated earlier.
I commend wholeheartedly the combination of GP practice budgets, now called practice funds, and self-governing hospitals, now called NHS hospital trusts. I believe that each will play a part in increasing choice, efficiency and accountability linked to a developing internal market. I also hope that the new term "self-governing hospitals" will lay to rest the label "opting out" which is used with great effect but a lack of honesty by the Opposition. The Opposition's representation of self-governing hospitals has resulted in many people needing to be convinced that, far from opting out, NHS hospitals will opt in to a new standard of excellence in a service held in such great affection by the British people.
I entirely endorse my right hon. Friend the Prime Minister's statement that the NHS should be so good that no one will want to go to the private sector. I say that as a practising physician in the private sector-- [Interruption.] --no member of whose family has ever been treated other than in the NHS. My wife, my two sons and I have all been in-patients in the NHS during the past 10 years and have much admired the treatment that we were given.
I welcome the biggest ever increase in the health budget announced in the Autumn Statement. Extra resources will go towards provision of new consultant posts, proper audits for managers, improved information technology and medical audits. Now at last Britain's biggest enterprise will have the opportunity to move away from charity, paternalism and rationing as we prepare for the next century in a time of great demographic and technological change.
The ultimate test for the efficacy of the Government's proposals will be whether the changes are perceived to be for the better by the only person who matters--the patient. I am confident that owing to my right hon. and learned Friend's persistence--
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Mr. Tom Pendry (Stalybridge and Hyde) : I do not wish to follow the arguments of the hon. Member for Wimbledon (Dr. Goodson-Wickes) or those deployed by the hon. Member for Harlow (Mr. Hayes), whose contribution was a sharp reminder to us all that the pantomime season is upon us.
My hon. Friends and I could talk at great length about the deep resentment of our constituents--doctors, nurses, ancillary workers, patients and would -be patients--about the monstrous proposals in the Bill, but, because of the restriction on time, I shall confine my remarks to part III which relates to community care.
Many hon. Members said that the Secretary of State for Scotland did not mention the Bill when he introduced the debate. If hon. Members look at Hansard tomorrow, they will see that the words "community care" did not pass his lips. At least I can agree on one aspect of the Government's approach. Despite the shilly-shallying following the Griffiths report, they took notice of the advice of those consulted and agreed to let local authorities take charge of community care. That is where my appreciation ends. It is unfortunate and arouses much suspicion that the Government do not seem prepared to give the community care part of the Bill much debating time. That has been amply demonstrated.
Since the Bill was produced only five working days after the White Paper was published, there has been no time for consultation. If hon. Gentlemen wish confirmation of that, they should look at their postbags today. They will find that many organisations have submitted views on the White Paper and the Bill, but they are too late for inclusion in this debate.
Community care is of particular concern. As the House is aware, there are already some 6 million disabled people with about the same number of unpaid carers. By the year 2001, the number of people aged 65 and over will have reached 9 million, 1.15 million of whom will be over 85. The Bill in no way addresses itself to the magnitude of that problem.
The Government may well have appointed local authorities to play a leading role in community care, but as usual they are unwilling to provide the resources that are essential for the system to function properly. The Bill is insubstantial. It needs to spell out clearly what is expected of local authorities which are undergoing ever-increasing demand on their ever- decreasing resources. The rhetoric of the White Paper has not been translated by the Bill into definitive proposals for action.
To arrange, organise and devise the necessary services is a mammoth task which has huge resource implications. Again, the legislation lacks detail. How much cash will be available is open to speculation, as we know from arguments already made. By channelling money through the revenue support grant, there is every likelihood that some of it will be diverted into other urgent projects, and we cannot blame local authorities for doing so.
In order to force local authorities to put their elderly people's homes up for sale, or, as the Government put it, to give them "every incentive to make use of the independent sector", the funding policy of the legislation deliberately discriminates in favour of private residential care at the expense of public provision. Clearly, that enables the Government to deny that they are introducing compulsory