House of Commons Hansard Debates for 16 Jan 1991

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the waiting lists about which our constituents write to us and about the operations that they are waiting for and the countinuing physical discomfort, pain and sense of frustration that they feel when they encounter such a position? It is a pretty weak case for the hon. Member for Edgbaston to say that it represents "only" 2 per cent. or 3 per cent. of acute beds and that it is "only" 3,500 as opposed to 4,000.

It is worth putting that in the context of the Government's record since 1979. On that basis, over 70,000 beds have been lost from the 1979 United Kingdom total. That represents over 16 per cent. of all NHS beds, and it is an alarming figure. Upwards of one fifth of our NHS bed provision has gone during the lifetime of this Government. As well as the facts themselves, there is an aspect of the interpretation of the facts with which I wish to take issue with the hon. Member for Edgbaston. She said that we must look at numbers treated. I agree with her to a large extent, and the hon. Member for Livingston acknowledged that too. However, we must not allow the numbers treated to disguise the fact that, all too often, other pressures or considerations are creating the larger numbers being treated, making it look as if there is an improvement when it might be something else.

I give the hon. Gentleman two examples. First, we must judge the quality of care that is being provided, not just its rapidity. At times, those two concepts cannot, by definition, work together. A rush to get people out of available post-operative beds so that other people in the queue can use them may mean elderly people having to return to homes that have less than satisfactory standards of care. The quality of care is important, but, secondly, if that quality of care and post-hospital care is not sufficient, all too often it leads to the revolving-door syndrome, when the same person is readmitted for further treatment or because of additional complications or a recurrence of the original problem. The readmittance of that patient counts as a further treatment statistic, which is then trumpeted by the Minister as further evidence of the success of the Government's health policy. In many cases, the readmittance of that patient represents a failure of health care, but he has clocked up a further treatment point for NHS statistics. Those two major caveats weaken the case of the hon. Member for Edgbaston.

The figures on underfunding provided by NAHA--there has been no question of trying to discredit that organisation in previous debates--are alarming. I shall not cite all the statistics for the cumulative period of the past decade, but it estimates underfunding of the health service at about £3.25 billion. That is a substantial amount of money, and I notice that the hon. Member for Macclesfield (Mr. Winterton) is nodding in agreement. He is a long-standing member of the Select Committee on Social Services. Some years ago, I served on that Committee with him, and we undertook an analysis of real-terms growth expenditure in health care, as set against perceived need. We arrived at a distressing shortfall in aspiration and in what was being delivered. That earlier experience, taken with the up-to-date figures, shows that there is far more of a problem than the hon. Member for Edgbaston was willing to acknowledge. Hon. Members have mentioned the dreadful circumstances in the Gulf. I wish to raise an item that was not dealt with

satisfactorily--off-stage noises were being made

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by several hon. Members who are no longer present--concerning the role of the private sector, about which I wrote to the Secretary of State last week. Tragically, we are now on a national war footing, and it appears that we shall be involved in military conflict sooner rather than later.

It is right--I voted with the majority last night--that the best provision should be made for service personnel who return home injured and in need of treatment. If any of our troops are injured in carrying out their instructions with courage and skill, the whole country, irrespective of the divisions on the rights or wrongs of them being sent to the Gulf, will want the best possible standards of care to be made available to them. There can be no serious debate or argument about that.

The Secretary of State said that he has taken steps to encourage the provision of national health service beds and that, contractually, it is for health authorities to take decisions on available private sector provision in their areas ; but that is not good enough. I do not say that from an ideological standpoint of being anti-private sector, but if the Government are being consistent and are saying, as they do in so many cases, that there should be more mutual understanding, cross-exchange of information and co-operation between the private medical sector and the public sector, on an issue as fundamental as military conflict, with injured troops returning home, the private sector should subscribe to that aspect of Government policy and should co-operate.

If the Government can requisition boats, buildings and other private-sector installations, there is no logical reason why, similarly, ministerial action cannot be taken to requisition, where appropriate or relevant, private sector health facilities. The private sector in health care would do its public reputation some good if, rather than awaiting calls in Parliament for it to be seen to be involved or for the Minister to require it to be involved, it volunteered some of its facilities. However, we should leave the ideological sparring match between public and private health provision to one side and agree that all medical facilities should be regarded as legitimate for use in the war effort.

My understanding of the instructions that have been sent to general managers is that, as and when injured personnel return home from the Gulf, hospitals in London, in the major southern cities and military hospitals in the south will be used first and that provision will slowly spread north to Glasgow, Edinburgh and Inverness--I welcome Inverness's contribution in that respect. Given that geographical spread and the strain which the Secretary of State has acknowledged will be put on health service facilities, surely it would make sense to spread that burden as equally and fairly as possible.

Sir David Steel (Tweeddale, Ettrick and Lauderdale) : I understand that general practitioners who are called up for service in the Gulf receive simply their Army emoluments, and must provide a locum in their practice from their own pockets. It is wrong that medical practitioners who disrupt their careers to serve their country should be financially out of pocket. The Minister should comment on that.

Mr. Kennedy : I am grateful to my right hon. Friend. Hon. Members will have received direct representations or anecdotal evidence on that from their constituents. That

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follows the earlier points that I was making about some aspects of the dreadful problem in the Gulf. I hope that the Minister will take a few minutes to reply to that point, because the Secretary of State did not deal with it to a great extent. I share the sentiment that my right hon. Friend expressed.

There is no doubt that the treatment of casualties from the Gulf will place strain on the NHS. The Secretary of State has said that he will probably need to secure extra funding from the Treasury, and he will receive full all-party support for that. However, health authorities will have to take day-to-day decisions now without knowing what funding will be required, and the pressure on them will be greater because of that.

Will the Minister for Health comment on the suggestion that health authorities have been told to plan on the basis that, on average, Gulf casualties will need to be hospitalised for 12 days? I should be grateful if she would tell me whether the Department of Health has given those instructions and that advice to health managers. If so, it is widely optimistic, given the nature of some of the injuries that could be sustained, not least from burns. I hope that the Department of Health will keep that aspect closely under review. I have concentrated on the Gulf in my remarks, apart from my opening comments on the general level of underfunding and the general problems caused by bed losses in the hospital service. Although we heard more of a theoretical framework from the Secretary of State, there is unambiguous evidence that we still need much more in terms of practical delivery so that the hospital sector can begin to come up to the standard which the country needs and which, according to every available test of public opinion, the country clearly wants but does not believe it is getting from the Conservative Administration. 6.10 pm

Mr. Nicholas Winterton (Macclesfield) : I congratulate the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) on his constructive and measured contribution. I hope that my hon. Friend the Minister for Health will respond as much as she can to his somewhat detailed but relevant questions to the House and to the Treasury Bench. My right hon. Friend the Secretary of State referred to the sombre occasion of the debate, and we would all agree with him. As the Member for Macclesfield, I wish to pay tribute to those members of the Territorial Army division of the Royal Army Medical Corps in my constituency who volunteered to go to the Gulf and are serving there. I know from my regular contact with them that they are courageous, able and highly skilled and will do a wonderful job should casualties occur.

My district general hospital has been asked to accept a number of casualties. I know from my discussions with the local health authority chairman that they will be well looked after and will receive the best possible treatment. They will be welcomed to Macclesfield, where there is quite a military tradition.

This is a sombre debate. Whatever statistics and facts are bandied about by both sides of the House, problems face the national health service. It is incumbent on all hon. Members to reflect those problems as accurately as possible. My right hon. Friend the Secretary of State did not deal with the deficits for the current financial year

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faced by health authorities before the new system comes into operation on 1 April. I am sure that my hon. Friend the Minister is aware that many of those deficits arose because of the clawback of resources to meet the capital requirements resulting from the health authorities' failure to sell land which they had intended to sell prior to the capital contract beginning or because the price drop caused by the current economic situation meant that the money expected from the sale of land did not materialise. The Government must look at the deficits of some health authorities and take action so that they do not go forward from 1 April with millstones around their necks.

Some closures of hospital wards and beds have occurred because of improvements in medical techniques. For some operations people do not now have to stay overnight in hospital. There was some substance in the criticism by the hon. Member for Livingston (Mr. Cook) about the number of beds that have been closed. I wish to refer not to the statistics from the National Association of Health Authorities but to Macclesfield district general hospital, where 50 beds have been closed but there is a waiting list for urgent surgery. Because the beds have been closed, people cannot have the operations that would give them a more meaningful life or reduce their suffering and pain. As I said during Health questions, it is a false economy to build a wonderful new district general hospital--I pay credit to the Government for providing the wherewithal--only to have to close beds because of its success and because of the skill and expertise of the consultants who carried out many more operations than was originally budgeted for. Success should be rewarded, as I am sure my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) agrees. It cannot be satisfactory, financially or medically, to have 50 empty beds in a hospital when people are waiting for operations, theatres are available and consultants are ready to carry them out. It is a false economy and a terrible waste of capital expenditure to provide those beds in the first place.

I do not often pay tribute to the chairman of the Mersey regional health authority, Sir Donald Wilson, but I must this time. He has achieved the greatest reduction in waiting lists in any region, and Macclesfield health authority has achieved the biggest reduction in waiting lists in the Mersey region. I pay tribute to the management, consultants, nurses, paramedics and other staff in Macclesfield who achieved that splendid result.

Parkside hospital, which is close to my heart, deals with mental illness. I have often pleaded in the House for a moratorium on the closure of beds or of mental illness hospitals until adequate resources, facilities and qualified personnel are available to deal with those discharged into the community from those and other hospitals.

The hon. Member for Ross, Cromarty and Skye mentioned my service on the then Social Services Select Committee which highlighted in several reports the ongoing underfunding of the national health service. I shall not go into the substantial underfunding that occurred under the last Labour Government, but I shall refer to underfunding between 1981 and 1985 under the present Government. I do not believe that it was intentional Government policy ; it occurred because the Treasury and the then Department of Health and Social Services underestimated demographic changes and advances in medical techniques and medical science, which meant that much more expensive, sophisticated operations

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could take place, and did not budget for them. There was a huge advance in the use of magnetic resonance scanners and computerised tomography scanners, for example, which can do so much not only in tracing illness but in enabling surgeons and consultants to carry out successful surgery.

I should like to refer to self-governing trust status, about which much has been said by the Opposition and a little by Conservative Members. Nursing morale in my constituency is low and consultants are worried because of the problems facing the health service and bed closures and because they know that they could put people into beds and carry out operations but no money is available to do so because of the number of recent changes in the health service and the speed with which changes have occurred.

From the representations made to me by consultants, nurses, members of the public and general practitioners, I am led to believe that there is general support in my area for the principle of self-governing trust status. But those to whom I have spoken want self-governing status for the district as a whole.

The chairman of the regional health authority, Sir Donald Wilson, always appears to want to have his own way. We have various levels of health government--the Mersey region, and Macclesfield health authority--and I thought that the decision to go for trust status would lie with the management at district level, with the people served by the district general hospital and with the nurses, consultants, general practitioners and others involved with the provision of health care locally. Oh no ; it appears that the region is demanding not only that there should be the acute unit seeking self-governing trust status but that the community and mental health services should form a second self-governing trust. I strongly oppose that. I am already in communication with the Secretary of State. I do not know whether my right hon. Friend or my hon. Friend the Minister for Health will be prepared to see me but I have formally asked my hon. Friends on the Front Bench to discuss the matter with me because a substantial majority of those involved in health care in my constituency believe that patient care and the best interests of those who want to use the health service in my area would benefit from a single self-governing trust covering the district health authority as a whole. I look forward to meeting the Minister or the Secretary of State.

I am advised that, in my area, there is some problem in dealing with nurses who have taken advantage of the new structure to upgrade themselves from state enrolled nurses to state registered nurses. In all the cases that have been drawn to my attention, nurses were promised that they would be given positions when they obtained the new qualifications. Unfortunately, no such positions are now being offered to them. Some have been offered redundancy but the redundancy payments for which they qualify do not take account of their new qualifications. Bearing in mind the promises that were made when the new system came into being--many hon. Members on both sides of the House warmly welcomed it--I hope that, in her winding-up speech, or perhaps by letter, my hon. Friend the Minister will be able to give me information and assurances that I can pass to my constituents, who are deeply concerned.

The health service is close and dear to the hearts of all the people of this country. The health service and health care must never become the preserve and privilege of the

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wealthy. They must be available for all the people of this country. I, as a Conservative Member, must express my concern about the implications and possible results of some of the changes that we are introducing. I believe that we are going towards the North American system at the very time when the Americans are turning away from their system and looking to us with some envy.

Miss Emma Nicholson (Torridge and Devon, West) : Rubbish.

Mr. Winterton : My hon. Friend may say, "Rubbish." I shall not give way to her because she has not been present for the whole debate. I have served on the Select Committee on Social Services for 16 years without a break. I have met a great many people who take advantage of, and are interested in, health care. As a member of that Committee, I have had the privilege of travelling widely throughout the world. Having travelled throughout Europe and North America, I can only say that the United Kingdom national health service is the best and most comprehensive health care service in the world, and provides the very best value for money, despite the problems that it faces. It is in that spirit that I address my remarks to my right hon. and hon. Friends on the Front Bench.

6.24 pm

Mr. John Hughes (Coventry, North-East) : It is appropriate that this debate on the national health service--in particular, that part of the service known as the hospital and community health service--should take place now. The possibility of war in the Gulf should not be allowed to overshadow what is happening to the NHS. Hon. Members on both sides of the House, those in the media and members of the public at large would be well advised to take special note of what is said, because the hospital and community health service has never been less well prepared than it is now to cater for the additional demands that war will place on it. When I say that it is less well prepared, I do not mean that our doctors do not have the necessary ability, our nurses the necessary skills or our health workers the necessary compassion. I mean simply that the NHS does not have the money.

The Minister may be surprised at that remark. After all, he has not been the incumbent of his present post for very long, and, being less dependent on the NHS than many of my constituents, particularly many elderly people, he has not perhaps had time to realise the dreadful state to which the health service may have been reduced. Given the many distractions of the past few months--for example, the considerable Christmas cheer brought to many by the unseating of the previous Prime Minister, who was the jockey principally responsible for riding the NHS into the ground--it is not surprising that the right hon. Gentleman has not yet been able to discern what is happening to the service for which he is responsible. He has not perhaps discerned that the service is collapsing.

Even before Christmas, a newspaper reported that 4,500 beds--equal to 3 per cent. of acute beds--had been closed in an attempt to make ends meet. But that is only the tip of the iceberg. As the end of the year approached, more desperate measures were taken. Over the Christmas period, we heard of extensive ward closures, with hospitals

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reduced to emergency-only treatment. The closures were often described as extended breaks, but the truth is that every week during which a ward is closed represents a 2 per cent. cut in the annual service provided by that ward. For many hospitals, a three-week Christmas interval replaced a one-week interval. That meant a 4 per cent. reduction in non-urgent activity. That was still not enough. A recent Audit Commission report highlighted the importance of day surgery work, arguing strongly that day surgery meant that more cases could be handled by the NHS at a lower unit cost. It is certainly true that medical developments have enabled certain types of patient to be treated in greater numbers. Contrary to the view that the Government have attempted to foster, the ability to treat people effectively on a day basis has been the result of scientific and medical advance and improvements in medical procedures. It has not come about through the intervention of accountants, much less politicians. The credit for the developments in day surgery--and the reductions in the average length of in-patient stays resulting from improvements to treatments--lies with the NHS staff and medical researchers. They have come about in spite of--not because of--the Government's policies.

No better illustration of that point exists than the fact that the day surgery unit at Coventry and Warwickshire hospital in my own city has had to be closed for the remaining three months of the year. The authority has run out of cash. As a result, it is expected to be able to complete only 990 operations this year--only slightly more than half of what was achieved in former years.

The cumulative effect of thousands of crises such as that--some of which reach the public eye and some of which are buried in the private part of the health authority agenda--is likely to take the NHS waiting list over the 1 million mark for the first time in the history of the service, and that is before we take account of the impact of war in the Gulf.

Like the Government, I have been guilty of concentrating on the acute side of the health service coin--the operations and waiting lists. We should not forget the far more devastating effect on the services for the less privileged in our society, including those whose health is in one way or another permanently impaired and whose dependence on the NHS is not intermittent. In that group, I include large numbers of chronically ill elderly patients, the mentally ill and the mentally handicapped and the physically disabled. The number of beds available to those patients has fallen dramatically over the past 10 years. According to the Government's only published figures, the number of non-acute beds has fallen from 213,000 in 1979 to 149, 000 today, a fall of 64,000.

Ironically, a patient discharged from one of those beds--perhaps prematurely and possibly in need of constant care rather than intervention- -could be readmitted later, as the condition may have deteriorated. That patient will duly increase the Government's figure of the number of in- patients treated.

The prospects for that kind of patient are now bleaker. April 1991 will see the establishment of the first trusts, and the prospects are clearly so horrendous that the Government have chosen to throw a cloak of secrecy over the whole business. Whole chunks of what the Government claim will still be part of the NHS are subject to the rules of commercial confidentiality. As a

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consequence, the elected representatives of constituents cannot see a report commissioned by the Government about the financial plans for the trusts.

We have to be content with rumours that the report suggested that the financial plans were, to say the least, inadequate. It is rumoured that some of the more sensible civil servants may have advised the Secretary of State that the majority of trust applicants were unfit to run a whelk stall. Sadly, we cannot undertake our own analysis of the financial plans, because the trust applicants were forbidden to publish them. That in turn means that the Government expressly sanctioned a consultation exercise in which not only were staff ballots forbidden and community views discounted, but the communities were even forbidden to know what they were being consulted over, and they are not to be told now of the outcome. Having learned nothing, the farce is being repeated for another wave of misguided applicants. There is no sign, as all hon. Members are aware, of how the system will work in reality.

There has been much talk in recent years about improving the management of the health service. It is clear that the people responsible for the NHS White Paper are not managers : they are solicitors skilled in drawing up that which no one can understand and which never does what it is supposed to do. Its strategy would be to the detriment of my constituents.

6.33 pm

Mr. Jerry Hayes (Harlow) : It is a poor day for the Labour party when we have a Supply day debate on a major aspect of Government policy-- the health service--and at one stage only the shadow Secretary of State for Health, the hon. Member for Livingston (Mr. Cook), represented the Labour party in the Chamber. No Opposition Back-Benchers were present. The Labour Whips had to trawl round the streets, the bars and tearooms to drag in Opposition Members to say something and to show how desperately caring is the Labour party. That has been exposed--mercifully we have television and people outside will be able to see what happened.

I do not pretend for a moment that all is rosy in the national health service. Of course it is not. My right hon. and hon. Friends are aware of the terrible difficulties in my health authority in west Essex and I hope that those problems are being addressed at the moment.

However, this is a Supply day and as such we have a right to know what the Opposition are going to do. After all, the Opposition's health policy has been published for a year and a month, but we are none the wiser and we are not better informed.

Mr. Gerry Steinberg (City of Durham) : That is because the hon. Gentleman cannot read.

Mr. Hayes : I have read Labour's health policy, but we did not hear anything about it today. We have heard about cumulative underfunding and how the health service needs more money. Unfortunately, the hon. Member for Livingston did not tell us how much is needed, either because he does not know or because he is frightened of the hon. Member for Derby, South (Mrs. Beckett). I do not know what it is that ladies from Derbyshire do to hon. Members, but the hon. Member for Derby, South seems to

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frighten the hon. Member for Livingston. He would not tell us how much he was going to spend or where he was going to spend it. However, the hon. Member for Livingston was marvellous when he referred to history. He did for the history of the funding of the health service what King Herod did for babysitting. The hon. Gentleman told us that the Conservative Government have a habit of spending more on defence than on the health service. The Library was kind enough to provide me with the figures. In 1970-71 and 1971-72, defence spending was higher than health spending. At that time a Conservative Government was taking over from a Labour Government. From 1972-73 to 1975-76 health spending was higher than defence spending. In 1976-77, 1977-78 and 1978-79, defence spending was higher. From 1986 onwards this Government have been spending more on health than on defence. The hon. Member for Livingston did not tell the House about the massive cuts made in health spending by the last Labour Government. They cut 3 per cent. from the budget in real terms.

The hon. Gentleman did not tell us about the unions. He was right to tell us that the debate is about money and I know where he would have to spend the money that the hon. Member for Derby, South might just give him. He would have to spend it on his friends in the Confederation of Health Service Employees and in the National Union of Public Employees.

The hon. Member for Livingston should read the debates on health that took place during the dying days of the previous Labour Government. Those debates were not about patient care ; they were about the disasters that were occurring in the system when the dead were unburied and hospital waiting lists made our present problems look like a teddy bears' picnic. If the hon. Member for Livingston reads those debates, he will see that they referred to formulas and face-savers to help NUPE and COHSE in an attempt to get those people to see reason.

However, I was encouraged in some respects by the speech of the hon. Member for Livingston. There are signs of good sense in the Opposition's motion. The hon. Member for Livingston did not refer to opting out and that is very encouraging. I imagine that he now accepts that there is no such thing as an opting-out hospital. He referred to self-governing trusts and that is a step in the right direction. He did not talk about hidden agendas, which was very good, and he did not talk about privatisation. He did not talk about money either.

Mr. Robert N. Wareing (Liverpool, West Derby) : What is the hon. Gentleman talking about? [Laughter.]

Mr. Hayes : I will give that one to the hon. Gentleman on points. There have been some exciting reforms which have been overwhelmingly--80 per cent.--accepted by the medical and caring professions. The NHS has been lurching from crisis to crisis since it began in the 1940s because of the antiquated and ridiculous methods of funding. This Government have the courage to change that. The hon. Member for Livingston referred to the efficiency trap. The efficiency trap will stop when money travels with the patient. The present problem is to help the health authorities with particular difficulties to balance their budgets before April. That is a problem that my right hon. and hon. Friends must address.

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We were all delighted and reassured to hear that money will be given to hospitals such as my own in west Essex and Harlow for beds to be allocated to Gulf casualties. However, several health authorities, including my own, will not be able to balance their budgets in April. There is a great danger that some of them might do things that would be quite unconscionable and wrong and add to waiting lists to balance their budgets. That matter must be discussed.

I am not asking for vast sums to be poured into the regions. Usually, a region messes up the money in the first place. The Government provide enormous resources--something for which the hon. Gentleman should have given my right hon. Friend the Secretary of State credit. The hon. Gentleman did not talk about the extra £3 billion. He did not talk about the real-terms increase of 5.3 per cent. across the board. That is a great deal of money. He will say that it is not enough, and so will some of my constituents. It will never be enough. It is a significant, sizeable chunk of taxpayers' money. He did not talk about the £1.9 billion--a 6 per cent. increase in the hospital budget.

Mr. Dennis Turner (Wolverhampton, South-East) : Will the hon. Gentleman give way?

Mr. Hayes : I should love to give way, but the winding-up speeches are a minute away. I am terribly sorry, but it would not be fair to those who are to wind up the debate.

There is much that I should like to say about my district, but I do not have time to do so. All that I am trying to put across to the House is that at least the Government have the courage to put forward policies which, in the long term, will make the future of the health service much more rosy. The Government will help with waiting lists. The hon. Member for Livingston and my right hon. Friend the Secretary of State must address a matter that my hon. Friend the Member for Macclesfield (Mr. Winterton) mentioned--the terrible problem of capital projects. For one reason or another, capital projects from land sales fell by about 50 per cent. in the past year. That will cause tremendous revenue problems, particularly in the Thames region and certain areas of the north. There is no reason whatever why the Treasury cannot appraise some of the schemes that have revenue consequences, and sort out some form of mortgage arrangement so that the taxpayer, the patient and the health authority do not lose out. That is a perfectly sensible financial arrangement, and it should be considered.

The debate has been about money--money that will be spent on NUPE and COHSE --and has had nothing to do with patient care. It is rather sad that the hon. Member for Livingston said much about the producer and people being paid. He said nothing about more patients being treated with the money that he wants to give the health service. 6.42 pm

Ms. Harriet Harman (Peckham) : The two most striking aspects of the debate have been, first, the extent of the pain and suffering that people must undergo because they cannot get the treatment they need because of the hospital crisis and, secondly, the absolute refusal of the

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Government and the new Secretary of State to acknowledge that pain and suffering. The message is clear--the Government are pretending that the hospital crisis does not exist, because they are not prepared to act to end the crisis on our hospitals. The pain, anxiety and suffering are only too real.

For example, baby Sarah Goodings needs a kidney operation, yet, for the third time last week, her operation at Guy's hospital was cancelled. Without an operation, she must constantly be on antibiotics or risk permanent damage to her kidneys. Her doctor has been told that he is able to operate only one afternoon a week, to help Guy's hospital save money.

Miss Emma Nicholson : Will the hon. Lady give way?

Ms. Harman : I shall not give way, because I must be brief. The hon. Lady has not been present during the debate to which I am trying to respond ; she has only just arrived.

It is not only waiting lists that are being hit by the crisis. Even emergency patients are being hit by the crisis. Doctors are having to struggle to get even emergency patients into hospital, because ambulances are being diverted from hospital to hospital as more and more hospitals go on red alert.

The Secretary of State talked about bad management in the health service. Does he know what health service managers are doing? They are not managing the health service ; they are managing a crisis. They are sitting at their desks with two piles of letters in their out-trays. One pile contains standard letters to patients saying, "Don't come in for your operation. Don't come in for your long-awaited out-patient visit. The operation is cancelled. The out-patient clinic is cancelled because of lack of funds." The other pile contains letters to GPs saying, "Don't send in any patients ; we are short of funds. Cancel your out-patients' clinics and reduce your operating lists."

Tens of thousands of patients are receiving standard printed letters from district health authorities telling them that their out-patient appointments or their operations have been cancelled. Each time one of those letters arrives on the mat, there is more misery and disappointment for individuals and their families. It is extraordinary what fortitude and resilience some people show when waiting for their operations. Why should they have to suffer 24-hour pain and suffering? Why should there be stresses and strains on their families? Why should their jobs be threatened or put at risk when they need to be admitted to hospital to have an operation that could sort them out? Why should people have to lead their lives overshadowed by pain? It is because the Government are telling health authorities to balance their books so that they can operate like businesses.

Such cuts are not only cruel but stupid and a false economy. The longer a patient waits for a hip replacement--my hon. Friend the Member for Wakefield (Mr. Hinchliffe) referred to just such a case--the bigger the operation is and the lower the chances of making a complete recovery. It does not make financial or medical sense to make patients wait. The longer a heart patient waits for an operation, the less likely he or she is to survive.

According to an article in The Daily Telegraph, Mr. Tony Lees Jones, aged 59, has a leaky aortic valve. The results are fluid build-up in the lungs, breathlessness and increasing strain on an enlarged heart, and the longer the

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condition continues without an operation the greater the risk of permanent damage. The longer someone has to wait, the lower the chances of success. We should be concerned about the outcome of health care, rather than simply act like accountants and look at the balance sheet in the short term.

The Secretary of State talked about a new agenda for a health care strategy. He mentioned preventive health care. The menopause clinic in Dulwich hospital treats menopausal women who suffer from osteoporosis. It treats them with hormone replacement therapy and therefore reduces the chances of broken bones. That clinic has been cut. As a result, more women will suffer from osteoporosis, break their bones and end up in an already overcrowded hospital as emergency patients.

What about the family planning service--an obvious preventive service? Family planning services are cut, and as a result there is an alarming rise in the number of unplanned teenage pregnancies. My hon. Friend the Member for Renfrew, West and Inverclyde (Mr. Graham) asked me to draw to the attention of the House the fact that, in his area, the school eye service-- a preventive service if ever there was one--has been cut because of a shortage of money. Does the Secretary of State know that preventive services have been cut? Does he defend cuts in preventive services? Does he even know that cuts in preventive services are happening?

It is crisis management in the national health service, and it is making the national health service less efficient. Health service managers cannot plan from year to year--they cannot even plan from month to month. In some districts, they cannot even plan from day to day, as they try to manage the crisis, and that makes the health service less efficient.

The Secretary of State has said that there has been bad management, but does he know what his Department is asking managers to do? I have a copy of a circular from the district general manager of Bromley, David Milner, addressed to geriatricians about marketing geriatric services. It says that they must look to understanding and assessing the markets, determining pricing policies--that is what managers are doing--and understanding customers and their behaviour.

Of course, by "customers" he does not mean geriatric patients but the purchasing authorities who will be trying to beat the price down. He talks about communication with customers and advertising and promotion policies. That is what managers in the National Health Service are doing. They are not trying to improve preventive services or to reduce waiting lists ; they are trying to cut the deficits and commercialise the national health service.

I am disappointed that the Secretary of State has been peddling the same old myth of his predecessor that somehow we agree with the Government about their attempts to dismantle the health service and to introduce an internal market. We do not agree with them. We do not want to see hospitals competing on cost. We do not want patients to be denied choice as they are sent to the hospital where the cheapest contract has been placed by the district health authority. We are against that. If he is an honest man, I hope that the Secretary of State will stop peddling that myth.

Yes, as the Secretary of State said, there is a consensus between the Labour party and the public, and the Government are outside it. Despite the fact that there has been a change of face on the Government Front Bench, it

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is a pity that there seems to have been no change of heart on the health service. People want to hear that the Government recognise the problem, that they accept their responsibility and that they are determined to solve the problem that is causing pain and suffering to so many people. We have not heard that from the Government. 6.51 pm

The Minister for Health (Mrs. Virginia Bottomley) : We have heard again tonight the traditional rant of doom and gloom from the Labour party- -scaremongering, lowering morale and uttering irrelevance. Before the main part of my reply I refer the Opposition to a recent New Statesman article which said that it is time to realise that "the real agenda for health policy must be about making better, more informed decisions about what it is worth buying with the £30 billion we are already spending each year. So the absence of a really convincing means for moving resources out of their historical grooves amounts to a serious flaw in Labour's proposals To continue with a system where service providers determine spending priorities is unacceptable. Until Labour can be more convincing about shifting the balance of power it will have failed to address the central challenge for health policy."

We agree with the New Statesman.

Many of my hon. Friends have ably and articulately identified the reforms that we are trying to make in the health service. We are proud of the record investment of resources ; £30 billion next year is a remarkable achievement. But we do not think that money is the only way to success. Better health for the nation is the outcome which we want to achieve.

My right hon. Friend the Secretary of State outlined his strategy for health, on which we should all agree. It is irrelevant and ridiculous of the Labour party to try to pursue old hares rather than co-operate and collaborate on the real challenges and opportunities which we face. The hon. Member for Wakefield (Mr. Hinchliffe) talked about cataracts. In 10 years, the number of cataract operations has increased from 40,000 to 92,000. There has been an increase in the number of hip replacement operations and in the number of coronary artery by-pass operations. Above all, we have seen an increase in the number of people who work for the health service. We have seen a dramatic increase in the number of hospital doctors and general practitioners, so that each GP's list has come down.

Dame Elaine Kellett-Bowman : And nurses.

Mrs. Bottomley : Yes. My hon. Friend, who always supports matron, will be pleased about the increase in nurses. Not only are there more but they are much better paid. Their basic pay has gone up by over 41 per cent. Hon. Members should compare that with what happened under the Labour Government when it fell by 5 per cent.

We want to invest in our staff, not only through pay but through training and qualifications. That is why I was so pleased last week to announce an extra £71 million for Project 2000, which will make it possible to start 14 new schemes for nurses. The total of approved colleges of nursing will be 44, and half of our new nurses will have Project 2000 qualifications.

Hon. Members should note not only the professional but the vocational qualifications that we are bringing in for people who work and serve in the health service. They should note, too, the progress we are making with junior hospital doctors. We want to be a good employer. We

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want to serve patients, and we want to work with and for our staff. Bringing down the unacceptable, onerous rotas that generations of doctors had to live with under the Labour Government will be a major breakthrough. An extra 200 consultants and 50 more staff grade posts will help urgently to tackle that problem.

We are investing in research because, in our great health service, research and development are fundamental. The recent appointment of Professor Michael Peckham as the director of research and development is a great step forward. Only this week, we announced an extra £5.8 million to increase postgraduate training and education. About £1.5 billion is spent each year on health research in the United Kingdom. We want to get the best benefit from that. We want to improve quality. That is why we are spending £30 million on clinical audit. That shows that we are not just looking for the turnover of beds. We want quality and better patient care. That is the way forward. We have to accept the problem of waiting lists, to which many of my hon. Friends referred. We are pleased that the number waiting for more than a year has been reduced by 7 per cent. this year. That is important. My right hon. Friend the Secretary of State announced a £35 million initiative, building on the work that John Yates has done and that we have been doing to tackle the problem of people who have to wait an unnacceptable length of time.

There is an important distinction. Half the patients are admitted immediately. People are admitted on the basis of clinical priority. Of those who are taken off waiting lists, half wait five weeks. Some wait an unacceptable length of time. How pleased I am that Macclesfield is leading the way in coping with the problem. The chairman of Mersey region has shown an admirable example by deciding not to put up with long waiting lists. We fully endorse the move to deal with people who have to wait an unacceptable length of time. I want also to address the subject of beds. Listening to the hon. Member for Livingston (Mr. Cook), one would think that he was trying to be a shadow Minister of beds and warehousing, because of his preoccupation with beds in the health service. We have over 200,000 non- psychiatric beds. We have recently been censured by the Audit Commission for not moving to more day work. The introduction of endoscopes, laproscopes and all sorts of diagnostic techniques, which mean that we do not have to admit patients, has doubled bed occupancy in recent years. We have to do more. Certainly, at times, beds have closed because of financial pressure, but it is naive to think that that is the only reason for bed closures. Health authorities which have treated bed closure as an easy option when under financial pressure need to plan more carefully to balance their activity and their resources. That is the secret of the reforms that we are establishing in the health service, so that we can be rid of the perverse form of funding where, although a good hospital attracts more patients, the funding does not come with them. The reforms which we are seeking will ensure that resources are used to the best possible effect.

Following my right hon. Friend the Secretary of State's comments about this being a sober occasion, several hon. Members referred to the plans for the NHS response to casualties from possible fighting in the Gulf. Very careful, detailed planning has been taking place. All the regions are

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prepared to receive casualties. Casualties will go to each region in turn, as suggested by hon. Members. We are confident that all possible steps have been taken. Although our plans are not predictions, much care and thought have gone into them. I know that hon. Members welcomed the statement by my right hon. Friend that we will receive additional funding for that purpose.

A great deal is achieved by our excellent health service. It is a service to be proud of. I did not realise that I could ever agree so strongly with my hon. Friend the Member for Macclesfield (Mr. Winterton) : we have the best health service in the world, and we want to continue to improve and develop it. It is not in crisis. It is in change. This is a time of opportunity. We have a proud record, and we want to do more with the professionals and for the patients to develop, build and strengthen our national health service. Question put, That the original words stand part of the Question :--

The House divided : Ayes 238, Noes 309.

Division No. 38] [7.00 pm

AYES

Adams, Mrs. Irene (Paisley, N.)

Allen, Graham

Alton, David

Anderson, Donald

Armstrong, Hilary

Ashdown, Rt Hon Paddy

Ashley, Rt Hon Jack

Ashton, Joe

Barnes, Harry (Derbyshire NE)

Barnes, Mrs Rosie (Greenwich)

Barron, Kevin

Battle, John

Beckett, Margaret

Beggs, Roy

Beith, A. J.

Bell, Stuart

Bellotti, David

Benn, Rt Hon Tony

Bennett, A. F. (D'nt'n & R'dish)

Benton, Joseph

Bermingham, Gerald

Bidwell, Sydney

Blair, Tony

Blunkett, David

Boateng, Paul

Boyes, Roland

Bradley, Keith

Bray, Dr Jeremy

Brown, Gordon (D'mline E)

Brown, Nicholas (Newcastle E)

Brown, Ron (Edinburgh Leith)

Bruce, Malcolm (Gordon)

Buckley, George J.

Caborn, Richard

Callaghan, Jim

Campbell, Menzies (Fife NE)

Campbell, Ron (Blyth Valley)

Campbell-Savours, D. N.

Canavan, Dennis

Carlile, Alex (Mont'g)

Cartwright, John

Clarke, Tom (Monklands W)

Clay, Bob

Clelland, David

Clwyd, Mrs Ann

Cohen, Harry

Cook, Robin (Livingston)

Corbett, Robin

Corbyn, Jeremy

Cousins, Jim

Cryer, Bob

Cummings, John

Cunliffe, Lawrence

Cunningham, Dr John

Dalyell, Tam

Darling, Alistair

Davies, Rt Hon Denzil (Llanelli)

Davies, Ron (Caerphilly)

Davis, Terry (B'ham Hodge H'l)

Dewar, Donald

Dixon, Don

Dobson, Frank

Doran, Frank

Douglas, Dick

Dunnachie, Jimmy

Dunwoody, Hon Mrs Gwyneth

Eadie, Alexander

Eastham, Ken

Evans, John (St Helens N)

Ewing, Harry (Falkirk E)

Ewing, Mrs Margaret (Moray)

Fatchett, Derek

Faulds, Andrew

Fearn, Ronald

Field, Frank (Birkenhead)

Fisher, Mark

Flynn, Paul

Foot, Rt Hon Michael

Forsythe, Clifford (Antrim S)

Foster, Derek

Foulkes, George

Fraser, John

Fyfe, Maria

Galloway, George

Garrett, John (Norwich South)

Garrett, Ted (Wallsend)

George, Bruce

Gilbert, Rt Hon Dr John

Godman, Dr Norman A.

Golding, Mrs Llin

Gordon, Mildred

Gould, Bryan

Graham, Thomas

Grant, Bernie (Tottenham)

Griffiths, Nigel (Edinburgh S)

Griffiths, Win (Bridgend)

Grocott, Bruce

Hardy, Peter

Harman, Ms Harriet

Hattersley, Rt Hon Roy

Heal, Mrs Sylvia

Healey, Rt Hon Denis

Henderson, Doug

Hinchliffe, David

Hoey, Ms Kate (Vauxhall)

Hogg, N. (C'nauld & Kilsyth)

Home Robertson, John

Hood, Jimmy

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