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Ms Harman : --Ministers never talk about these cases.

[Interruption.] Perhaps they do not even read the reports of such tribunals. Conservative Members do not care, because these homes are private. [Interruption.] The Government's commitment to the market takes priority over their commitment to the vulnerable and the dependent.

Several Hon. Members rose --

Ms. Harman : The Bill will--

Hon. Members : Give way--

Ms. Harman : The Bill will-- [Interruption.]

Mr. Deputy Speaker : Order. The hon. Lady has made it quite plain that she does not intend to give way.

Ms. Harman : The Bill will do nothing to ensure that councils have the resources to provide the care that people need to stay in their own homes. It will do nothing to ensure that councils have the resources to monitor private care homes, or to provide resources so that people can choose whether to go into a council home. It will do nothing about giving carers a voice or about giving disabled people the chance to have the services that they need. Having established the supremacy of the private market in residential care homes, the Government now seek to bring market forces into health care.

Mr. Hind : On a point of order, Mr. Deputy Speaker. In the circumstances, is it right that the hon. Lady should cast a slur-- [Interruption.]

Mr. Deputy Speaker : Order. I have heard nothing out of order in the hon. Lady's speech and bogus points of order only delay the progress of the debate.

Ms. Harman : I have put on record on numerous occasions my condemnation of what happened in the Nye Bevan lodge. I should like to hear whether Conservative Members, and in particular Ministers, will condemn or at least show some concern about these cases.

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The Secretary of State for Health (Mr. Kenneth Clarke) : Would the hon. Lady not concede that the Government introduced legislation giving local authorities and health authorities powers to inspect private nursing homes to expose just those cases? A moment ago the hon. Lady was making the absurd case that somehow such cases are typical of private nursing home care provision when hon. Members on both sides of the House are extremely anxious to stamp out all such behaviour whether it be in the private or the public sector. We are interested in the quality of care, not in whether it is run by the council or by a private owner.

Ms. Harman : The Secretary of State appears not to be interested in facing up to the inability to monitor what happens in private homes. The Registered Nursing Homes Association, the organisation which represents the owners of private nursing homes, has said that the Government's expansion of private nursing homes through the social security system has led to such an enormous increase in the number of those homes that a cowboy element has entered the market. The Bill, inasmuch as it will fuel further the private sector and stamp out council homes, will make it more difficult to monitor the quality of care in the private sector.

Having established the supremacy of the private market in residential care homes, the Government now seek to bring market forces into health care, and GP services are to be cash limited. Drug budgets will be cash limited as will GPs' practice budgets. That will have three disastrous consequences. First, some patients will not get the treatment they need because their GPs will be running out of money. Secondly, people with long-term chronic illnesses will be unattractive patients and will have less chance of getting the GP they want. Thirdly, it will poison the doctor-patient relationship. If GPs advise patients that they do not need drugs or tests, patients will not know whether that advice is based on their medical condition or on the GP's financial condition.

Miss Widdecombe : Did the hon. Lady hear the clear statement from the hon. Member for Glasgow, Garscadden (Mr. Dewar) accepting that the drugs budget will not be cash limited?

Ms. Harman : The hon. Lady misunderstands what my hon. Friend said. What he said clearly showed that he understands that there will be a chilling effect on GPs' prescriptions. Although the Government deny that there will be cash limits, if there are not to be cash limits, why are family practitioner committees drawing up plans to dock GPs' pay if they overspend their indicative drugs budget? If there are not to be cash limits on GPs' practice budgets, why did the White Paper consider it necessary to set up a system of watchdogs in accident and emergency departments of hospitals to find out whether all the patients are emergencies or whether some of them have been sent there by their GPs who cannot afford to get them into hospital under a normal contract because they had run out of money and had advised them to go to accident and emergency?

The Government clearly believe that the family doctor service is costing too much. That is why in the Bill for the first time they have taken the power to restrict the number of doctors going into general practice. The Secretary of

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State and the Secretary of State for Scotland talked about the money following the patient, but the Bill makes the patient follow the money.

Either the Secretary of State for Scotland has not read the Bill and the White Paper or, if he has, he does not understand how things work at present. Let me give the example of maternity services. A pregnant woman has a choice of hospital in which she can have her baby delivered. She may choose to have her baby at the hospital closest to home, but she may decide that a hospital in a neighbouring district provides the care that she would choose for her delivery. Every year, thousands of women make exactly that choice, but under the Bill it will be taken away and she will have to go where managers have placed the contract. The Secretary of State shakes his head, but what is the point of a contract system if no one has to follow the contract?

GPs, who at present advise their patients which hospital to go to, will find that they are locked in the straitjacket of the National Health Service contract and that they will no longer have the choice of where to refer their patients. That choice will have been made by managers and a patient who has a hernia will have to go where the block booking is for hernia-- [Interruption.] I am basing my speech on the White Paper and the Bill, unlike the Secretary of State, who feels that he can make any claim whatever.

The only way that GPs will retain their rights of where to refer a patient will be if they opt out of the frying pan and into the fire by opting for a cash-limited practice budget. Otherwise, managers will make all the decisions.

What will a manager consider when placing a contract? The first thing will be cost. They are not recruited to know about quality, but they certainly will know about cost. To win contracts, hospitals will compete to cut costs. As they do so, they will cut corners, and that will cost lives. The lessons from America are clear--the fiercer the competition, the higher the mortality rate. Patients will be sent where care is cheapest rather than where it is best, and they will be required to travel anywhere managers see fit to place a contract. The core services that were mentioned in the White Paper, which were supposed to guarantee patients access to local services and to some crucial services, have not found their way into the Bill ; they have stopped dead in the White Paper. People will no longer have automatic access to their local hospital if the Secretary of State opts-out their hospital. My hon. Friend the Member for Bassetlaw (Mr. Ashton) rightly said that the people who use the hospital, those who work in it and even its doctors will have no say in whether it opts out.

Knowing how controversial the plans will be, the Secretary of State is going about them with secrecy and stealth, an example of which is the advertisement for shadow finance manager to make the application for the London hospital to opt out without telling the district health authority, its patients or even the general manager what will happen.

The Government have sought to disguise the aim of the Bill. The only response that they have made to criticism is to change its language. They know that to have a cash-limited budget for GPs is unpopular, so it is now called not a budget-holding practice but a fund-holding practice. Clearly, they got out their "Roget's Thesaurus"

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and thought that "a fund" sounded as though it had more money than "a budget". They know that local representatives are to be knocked off district health authorities, so we no longer mention the word "accountability"--that is a non-word--but use instead the word "leadership", which is a code for the Secretary of State deciding everything and local people having no say. The Government realised that people did not like the idea of people buying and selling health care, so we are told that the "purchaser" is to be called "the acquirer". The Secretary of State has just about trained himself to stop describing "opted -out" hospitals as such and now calls them "NHS trusts". We know that, whatever they are called--whether NHS trusts or anything else--they will be opted out of the local health authority. The Government imply that anyone who is against the Bill is against change in the NHS. That is a travesty. If we had a Government who could listen, they would know that the Health Service and patients' organisations are abuzz with ideas for changing and improving service deliveries. The real reason that people do not want the Bill--

Mr. Michael Colvin (Romsey and Waterside) : On a point of order, Mr. Speaker. I have no objection to the hon. Member for Peckham (Ms. Harman) reading her speech, but I object to her reading it to the Serjeant at Arms rather than to the Chair.

Mr. Speaker : I think that the hon. Lady was turning from one side to the other.

Ms. Harman : The real reason why people do not want the Bill is that they do not want to see their Health Service broken into a thousand fragments ready for privatisation. That is why we shall vote against the Bill.

9.40 pm

The Minister for Health (Mrs. Virginia Bottomley) : The Government's overriding aim is to achieve the best for the individual patient, the individual carer and the dependant who requires social care. Our policy depends on caring for the patients, not scaring the patients. What we have heard from the Labour party is alarmist, frightening misinformation, calculated to misinform and to stir up people's strongest fears.

We have had a lengthy debate about extremely important proposals. We speak at a time when the Government are spending more than ever before on the Health Service. The Conservative party has delivered improved health care. Where we have a competition in terms of the rhetoric of compassion, it may be that the Labour party could outbid us. If it comes to a competition in terms of delivery of health care, there is no doubt that the frail, the vulnerable and the sick have every reason to have confidence and to put their trust in the Conservative party. Every week of the year, 25,000 more patients are treated because of our investment in and commitment to the NHS. These proposals are intended to develop and build on our NHS.

The management changes, which are fundamental in terms of producing health care of the highest quality in an age of rapidly increasing science and technology, are intended to benefit the individual users of our health and social care services. All our plans put the individual at the heart of things. My hon. Friend the Member for Newbury (Sir. M. McNair-Wilson) called last Thursday for a

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patients' charter. As my right hon. and learned Friend the Secretary of State said after First Reading, the Bill is just that. I pay tribute to all the hon. Members who so fulsomely participated in the debate. There has been a robust exposition of Government proposals and a rebuttal of many of the more ludicrous Labour suggestions by my hon. Friends the Members for Harlow (Mr. Hayes), for Ipswich (Mr. Irvine), for Maidstone (Miss Widdecombe), for Wimbledon (Dr. Goodson-Wickes)--who speaks with special knowledge, having worked as a medical practitioner for many years--for Lancashire, West (Mr. Hind) and for Pembroke (Mr. Bennett). As they make clear, under the Labour Government, the National Health Service was run by the International Monetary Fund. We would rather leave our health care in the hands of the NHS.

Only today we are announcing an increase of about 25 per cent. in NHS consultants in the past 10 years. There are 60 per cent. more female consultants. The number of hospital medical staff has increased by over 17 per cent. in the same period and, again, many more women are working in the Health Service.

A major mechanism for improvement will be the new funding systems. Hospitals will be funded more directly for the patients whom they treat. Where they offer high quality service, they will find that additional patients and additional resources will flow towards them. The present system can all too often work against patients who are caught by a geographical boundary or by the so-called "efficiency trap". We are putting in place a system that will work for patients, not against them, and a system that will favour rather then frustrate the most efficient medical practitioners.

My hon. Friends the Members for Harlow and for Ipswich talked about the perverse incentives of the present funding arrangements. We want to have a virtuous effect, not a vicious effect. Managing that system will be the central task of the strengthened district health authorities. They will look at all suppliers of services in their areas to find the best mix of NHS contracts to provide comprehensive services for their residents. It will be an open process--far more so than it is now. Each health authority will undertake extensive discussions with local general practitioners to ensure that the pattern of contracts properly reflects local referral patterns. The community health councils will have their voice heard. It is a recipe for patients and their representatives to have a far greater input in the decisions about their care.

Much mention has been made about National Health Service trusts. Once again, this is not an attempt for hospitals to opt out of the NHS and it is not the first step to privatisation. The alarmist and irresponsible scare stories put about by the hon. Members for Glasgow, Garscadden (Mr. Dewar), for Bassetlaw (Mr. Ashton), for Halifax (Mrs. Mahon) and for Hackney, North and Stoke Newington (Ms. Abbott) have no part in our proposals for the Health Service. The fact is that the opportunities offered by the National Health Service trusts are not simply freedom from the shackles of unnecessary central control, but a new freedom to use resources more flexibly to raise standards of care.

We mean standards in the widest sense. Shorter waiting time for admission is central, as are satisfactory systems of medical audit, better out- patient appointment systems and the personal treatment of all visitors and patients received

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from each member of staff. There is every incentive for quality to run through every aspect of National Health Service work. Both patients and staff will have reason to be proud of what their local National Health Service has been able to achieve. The importance of quality has been registered by several hon. Members and we fully and warmly endorse that.

My hon. Friend the Member for Chislehurst (Mr. Sims) asked about the definition of "core services". It will be for each district health authority to decide the precise pattern of services to meet its needs. We cannot and should not prescribe for that from the centre, but the Bill gives the Secretary of State powers of direction over the NHS trusts' ability to enter into contracts, which can be used to safeguard local access to services in the unlikely event of difficulties arising.

My hon. Friend the Member for Chislehurst raised a further point about NHS contracts being enforced if they are to have legal status. NHS contracts will contain provision for the resolution of any disputes that may arise. The Secretary of State will be able to investigate any disagreements and to enforce a solution. That is a more appropriate response than the sight of two NHS bodies fighting each other through the courts. These are management rather than legal documents.

My hon. Friend the Member for Rutland and Melton (Mr. Latham) asked about the size of the NHS trusts. We shall not be prescriptive about the type or size of unit that can apply for self-governing status. The reason why the Bill refers to NHS trusts, rather than NHS hospital trusts as we called them in the White Paper, is that the concept is proving attractive to all kinds of candidate, not just to the major acute hospitals. Many other hon. Members raised points about the trusts, but I shall not be able to do justice to all of them. The key point is to release NHS units from some of the shackles of bureaucratic control and interference and to allow centres of excellence with a corporate ethos to develop and flourish. Several hon. Members talked about the importance of dialogue with the medical profession. My hon. Friends the Members for Chislehurst, for Rutland and Melton, for Northampton, South (Mr. Morris) and for Sevenoaks (Mr. Wolfson) all spoke about the importance of discussion. I want to make it clear that all of us at the Department of Health have met about 100 different groups from the medical profession since last January. We are working closely on resource management and on many medically-led initiatives such as medical audit, and we shall continue to do so. Further, we are funding a range of pilot schemes so that we can learn lessons for implementing the Bill when it completes its passage through Parliament. I cite, for example, the enhanced role of the district health authority, the development of contracts, management budgets, and information to assist with the determination of cross-boundary flows.

I turn now to the substantial part of the remarks made by the hon. Member for Peckham (Ms. Harman)--

Dame Elaine Kellett-Bowman : There was nothing substantial in them.

Mrs. Bottomley : I appreciate that, but I want to talk about some proposals of great importance--those on community care. It is deplorable to exploit people's fears about divisiveness and scandals in the public or the private

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sectors. We want high quality community care for people ; we want choice and proper standards and we shall ensure that we achieve precisely that in this Bill.

In the Bill we set out the framework for care in the community for the next decade. The proposals will secure the delivery of successful community care services, ensuring the best use of resources to achieve diversity and flexibility of provision. That is welcome for local authorities, which have long argued that responsibility for social care should rest with them. I wondered, as she spoke, whether the hon. Member for Peckham wanted to deprive local authorities of this important responsibility, which is intended to build on the substantial work that they already undertake planning for the overall social care needs of their populations. I know that local authorities are keen to rise to the challenge, and there have already been many examples of innovative and pioneering work providing community care.

Mr. Nigel Spearing (Newham, South) : I am grateful to the hon. Lady for giving way and for rightly emphasising the importance of local councils in social services. If the Government are determined to retain councils' part in this area, why are they excluding them from the district health authorities in which co-operation and knowledge of what is going on in the community are almost as important?

Mrs. Bottomley : It is clear from our proposals on district health management that the NHS--a £28 billion organisation--requires clear and decisive management. There will certainly be scope for consulting local people about their needs. I am not sure whether the hon. Gentleman wants to deprive local authorities of their important new responsibility of providing care in the community.

Many local authorities are already developing excellent projects. I hope to take up the invitation of my hon. Friend the Member for Bolton, North-East (Mr. Thurnham), whose scheme is one of 28 pilot projects set up some time ago by the Department to develop new forms of care in the community. There are similar projects and developments in Kent, Newcastle and Bolton to ensure that people can live dignified and independent lives at home.

Community care has too long been the victim of confusion over where responsibility lies for the public support of people in residential care and nursing homes. Not enough priority has always been given by local authorities to the development of high quality care, and we intend to set that right so that local authorities fulfil their responsibilities and high standards and choice are available. Some hon. Members have suggested that the proposals have come forward too swiftly. That lies ill with the former allegation that there has been a certain amount of delay. After Sir Roy Griffiths' report on community care, a great deal of detailed consultation on his recommendations was entered into. My right hon. and learned Friend made a statement last July, since when there have been further detailed discussions about the proposals. There was a full day's debate in the House to which many hon. Members contributed ; then, last month, we brought forward our White Paper.

It is right that the responsibility for providing all forms of community care should be entrusted to local

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authorities, but equally it is essential that we ensure that local authorities fulfil those important responsibilities. Community care extends from good neighbourliness to 24- hour-a-day residential home care provision. Having heard Opposition Members, it would seem that their course of action would be to nationalise good neighbourliness. Government recognise that the majority of care is frequently provided by family, friends and neighbours. Most carers take on those responsibilities willingly. However, many need help to manage before they become overwhelmed with what can become a considerable burden.

Mr. Tom Clarke (Monklands, West) : The Minister referred to consultation. I presume that that was a reference to the week between the White Paper being published and the week the Bill was published. Does that consultation mean that the Government accept the view of the Association of County Councils and the Association of Metropolitan Authorities that allocations for community care should be ring-fenced?

Mrs. Bottomley : The key point is that my right hon. and learned Friend the Secretary of State made our intentions clear last July. At that time there were a great many allegations that it was high time that the proposals on care in the community were forthcoming. I shall refer to the particular point about resources shortly.

This is the first time that the needs of carers have been properly recognised. The Bill is a very important mark in terms of our legislation for the dependent and the frail. The White Paper states that the key components of community care should be that

"services should respond flexibly and sensitively to the needs of individuals and their carers"

and to

"ensure that service providers make practical support for carers a high priority."

That is an important step forward from the time when the Labour party was in office. At that time I was involved in an organisation concerned with carers which received no assistance under that Labour Government. The carers' national association, with which I was involved, now receives £77,000. We give about £350,000 annually to various organisations supporting carers. We recognise the pivotal role that carers play and that the views of carers, their ability to provide care and their needs for support should all be fully acknowledged.

It is important that there should be adequate resources for the provision of care in the community. We have made it clear that the amount of money presently used to fund those in private residential homes will be made available for the development of care in the community services. There have been several entirely unfounded allegations about the level playing field between public and private residential homes.

The present situation inordinately favours the use of private residential homes as the local authority involved does not need to find any money. In future, we will establish a more level and fairer system. We will ensure that those in local authority homes receive the same personal allowances. At the moment they receive less. We will ensure that everyone entering a residential home will have a full assessment to discover whether the money that is currently used for residential care could be more

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appropriately used to preserve their dignity and privacy and bring forward a package of domiciliary care to meet their needs. It was deplorable of the hon. Member for Peckham to try to arouse people's greatest fears about the provision of care in private homes. All the residents of Nye Bevan house would have wanted the structure of care in the community including the inspections and local authority control that we are introducing in our measures. There is much to be done to translate our community care proposals into a successful and working reality. This is a Bill for people--the people who need care, and the people who provide it-- and concern for individuals lies at the heart of our action in the NHS and community care. It is because of their importance that we are right to act quickly and decisively.

We have clear and common aims : we intend to move from policy to implementation. The Bill is a key step along that road, and I heartily commend it to the House.

Question put, That the Bill be now read a Second time : The House divided : Ayes 323, Noes 247.

Division No. 12] [10 pm


Adley, Robert

Aitken, Jonathan

Alexander, Richard

Alison, Rt Hon Michael

Allason, Rupert

Amess, David

Amos, Alan

Arbuthnot, James

Arnold, Jacques (Gravesham)

Arnold, Tom (Hazel Grove)

Ashby, David

Aspinwall, Jack

Atkinson, David

Baker, Rt Hon K. (Mole Valley)

Baker, Nicholas (Dorset N)

Baldry, Tony

Banks, Robert (Harrogate)

Batiste, Spencer

Beaumont-Dark, Anthony

Bellingham, Henry

Bendall, Vivian

Bennett, Nicholas (Pembroke)

Benyon, W.

Bevan, David Gilroy

Blaker, Rt Hon Sir Peter

Body, Sir Richard

Bonsor, Sir Nicholas

Boscawen, Hon Robert

Boswell, Tim

Bottomley, Peter

Bottomley, Mrs Virginia

Bowden, A (Brighton K'pto'n)

Bowden, Gerald (Dulwich)

Bowis, John

Boyson, Rt Hon Dr Sir Rhodes

Braine, Rt Hon Sir Bernard

Brandon-Bravo, Martin

Brazier, Julian

Bright, Graham

Brown, Michael (Brigg & Cl't's)

Browne, John (Winchester)

Bruce, Ian (Dorset South)

Buck, Sir Antony

Budgen, Nicholas

Burns, Simon

Burt, Alistair

Butler, Chris

Butterfill, John

Carlisle, John, (Luton N)

Carlisle, Kenneth (Lincoln)

Carrington, Matthew

Carttiss, Michael

Cash, William

Channon, Rt Hon Paul

Chapman, Sydney

Chope, Christopher

Churchill, Mr

Clark, Hon Alan (Plym'th S'n)

Clark, Dr Michael (Rochford)

Clark, Sir W. (Croydon S)

Clarke, Rt Hon K. (Rushcliffe)

Colvin, Michael

Conway, Derek

Coombs, Anthony (Wyre F'rest)

Coombs, Simon (Swindon)

Cope, Rt Hon John

Cormack, Patrick

Couchman, James

Cran, James

Critchley, Julian

Currie, Mrs Edwina

Davies, Q. (Stamf'd & Spald'g)

Davis, David (Boothferry)

Day, Stephen

Devlin, Tim

Dorrell, Stephen

Douglas-Hamilton, Lord James

Dover, Den

Dunn, Bob

Dykes, Hugh

Eggar, Tim

Emery, Sir Peter

Evans, David (Welwyn Hatf'd)

Evennett, David

Fairbairn, Sir Nicholas

Fallon, Michael

Farr, Sir John

Favell, Tony

Fenner, Dame Peggy

Field, Barry (Isle of Wight)

Finsberg, Sir Geoffrey

Fishburn, John Dudley

Fookes, Dame Janet

Forman, Nigel

Forsyth, Michael (Stirling)

Forth, Eric

Fowler, Rt Hon Norman

Fox, Sir Marcus

Franks, Cecil

Freeman, Roger

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