House of Commons Hansard Debates for 14 May 1991

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Points of Order

3.30 pm

Mr. Patrick Nicholls (Teignbridge) : On a point of order, Mr. Speaker. I seek your guidance about an exchange of correspondence to which some of today's newspapers refer. Apparently, there has been an exchange of correspondence between my right hon. Friend the Chief Secretary to the Treasury and the Leader of the Opposition. In his letter, my right hon. Friend calls upon the Leader of the Opposition to clarify how the next Labour Government would spend more than the present Government by actually spending less--

Mr. Speaker : Order. I see that the hon. Member has a copy of "Erskine May" in his hands. So have I. Can he come to a point of order for me? I am not responsible for exchanges of letters.

Mr. Nicholls : It is indeed a point of order for you, Mr. Speaker. It touches on your responsibility for the Library of the House, to which "Erskine May", on page 196 of the 21st edition, refers. I have been able to ascertain that the Chief Secretary's letter is in the Library. Can you, Sir, take steps to ensure that the response will be available in the Library within the next 24 hours?

Mr. Speaker : So far as I know, it has never been the responsibility of the Chair to see that exchanges of that kind are placed in the Library.

Mr. Gerald Bermingham (St. Helens, South) : On a point of order, Mr. Speaker. The Secretary of State for Health is still in his place. In answer to question No. 9 from the hon. Member for the Isle of Wight (Mr. Field), during the chaos of Question Time--

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Mr. Speaker : Order. This sounds like an extension of Question Time. What is the point of order for me?

Mr. Bermingham : The point of order is that the Secretary of State, in reply to the question, indicated that a member of the British Medical Association, who happens to be a doctor in the Isle of Wight, ought not to perform his functions as an elected member, but should stay in his surgery. It has always been a convention of this House--

Mr. Speaker : Order. I am not responsible for questions that are asked or for answers that are given, provided that they are in order. So far as I am aware, these were in order.

Mrs. Alice Mahon (Halifax) : On a point of order, Mr. Speaker.

Mr. Speaker : Does the hon. Lady wish to take time from that allotted to the Opposition?

Mrs. Mahon : On a genuine point of order, Mr. Speaker. I wonder if you have received a communication from a constituent of mine who is writing to you about a £364,000 city grant given to Barratt, the building company, to build homes in my constituency. My constituent wrote to you because of serious allegations that have arisen in recent days. On receipt of that communication, would you allow time for an inquiry into those allegations about the misuse of public funds?

Mr. Speaker : I have to say that I have not received that letter, although I receive a wide range of letters from members of the general public. At first sight, I cannot see that it has much to do with me. However, when I receive the letter, I shall consider it carefully.

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Opposition Day

[ 11th Allotted Day

]

Health Service and Community Care

Mr. Speaker : I must announce to the House that I have selected the amendment in the name of the Prime Minister.

Mr. Andrew Mitchell (Gedling) : On a point of order, Mr. Speaker.

Mr. Speaker : Order. I am on my feet.

Many right hon. and hon. Members are seeking to participate. I have no authority to propose a 10-minute limit on speeches in a half-day debate, but I hope that hon. Members who are called to speak will be brief so that many of their colleagues can participate. What is the hon. Gentleman's point of order?

Mr. Mitchell : I seek your guidance, Mr. Speaker. There is a ten- minute Bill on the Order Paper in the name of a Labour Member.

Mr. Speaker : Order. I said that it is perfectly in order for an hon. Member who, for good reasons which he has explained to me cannot be present, to withdraw his motion.

Mr. Mitchell : The point on which I seek your guidance, Mr. Speaker, is that the Bill dealt with removing restrictions on immigration. It is extremely offensive to me, to many of my hon. Friends and to many of my constituents. It is, however, an important matter, and I seek your guidance as to whether it might be--

Mr. Speaker : Order. It is perfectly in order for an hon. Member who cannot be present not to move his motion, and that is what has happened today. Nothing out of order has occurred.

3.36 pm

Mr. Robin Cook (Livingston) : I beg to move,

That this House records its concern at the damage to the National Health Service from the implementation of the National Health Service and Community Care Act ; condemns the pressure created by the new system for a two-tier health service in which waiting time is determined not by clinical need but by commercial priorities ; is disturbed that the introduction of block contracts had reduced patient choice of hospital and restricted general practitioners' freedom of referral ; regrets the shortage of people representative of their local community among the businessmen appointed by Her Majesty's Government to decide local health priorities ; notes with alarm the financial instability that has already become evident among hospitals that have formed self-governing trusts ; deplores the decision of the Secretary of State to approve 57 health units for trust status despite advice that there were financial problems with 45 of them ; and calls upon Her Majesty's Government to abandon its plans for a second wave of health units to form such trusts. It is just under four weeks since the House last debated health, yet so much has happened in those four weeks that it is almost unkind to remind Ministers of what they said in that debate.

The Secretary of State for Health took pleasure in the fact that the changes had been introduced with, as he said,

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"no significant problems." The Minister of State, eight days before the cuts were announced at Guy's hospital, announced to the House : "It will not be long before the noise about trusts abates."--[ Official Report, 17 April 1991 ; Vol. 189, c. 512.]

I took the precaution of checking Hansard last night in the Library in case a member of the Prime Minister's private office had been down with an errata slip.

My favourite passage was from the Secretary of State's speech in which he complimented the British Medical Association on--in his words--moving on and "becoming sensible." The Secretary of State will have followed with interest the views expressed by the new, sensible BMA over the past couple of weeks, culminating last Thursday after his meeting with it when it reported :

"the Secretary of State was not open to reason."

That is from the very medical people who, 20 minutes ago, the Prime Minister said should take the decisions on whether a hospital should seek self-governing trust. Try telling that to the BMA.

There have been two developments since our last debate, which have given Ministers' speeches a near-comic irony which they lacked on first hearing. First, events have exposed the gulf between what Ministers promised as a result of the changes and the real effect of the changes. Last autumn, staff at Guy's were promised that the hospital would make a surplus of £1.5 million in its first year of trading. A month after the new system was introduced, the same staff at Guy's were told that the hospital was predicting a deficit of almost £7 million. At the beginning of April, the staff at Guy's received a circular from Mr. Peter Griffiths in which, under the heading "We are friendly and we are fun", he assured the staff : "The management cares, really cares, about people, about their staff."

At the end of April, 600 of the staff who had received that letter discovered that they might be made redundant over the next two years.

Whenever I refer to trusts as opting out, Conservative Members shout me down. I am bound to say that nothing has more convinced the public that a hospital that has formed a trust has opted out than the speed with which Ministers let it be known, when the cuts at Guy's became evident, that Guy's was on its own, that it was no responsibility of theirs, that what the board of directors did to staff jobs or patient care had nothing to do with them.

The Secretary of State cannot have it both ways. He cannot on the one hand assure us that trusts have not opted out and, on the other hand, wash his hands whenever they hit trouble. He cannot have it both ways, because his own reputation is on the line. He approved the very business plan that is now in such trouble. The Secretary of State has not been allowed by the media to ignore the crisis at Guy's.

Sir Anthony Grant (Cambridgeshire, South-West) : What trouble?

Mr. Cook : The hon. Member below the Gangway asks, "What trouble?" I do not know whether the hon. Gentleman has been out of the country for the last four weeks, but the rest of the nation knows that the trouble at Guy's is the turnround of a £1.5 million surplus, as promised in the business plan last autumn, to a £7 million deficit, with a 10 per cent. cut in staff and the dropping of

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whole specialties. If the hon. Gentleman does not recognise that as trouble, I do not know what he would recognise as trouble in the health service.

I was intrigued to note that the Secretary of State has now produced a novel defence of the new structure. I paraphrase his argument, but the nub of it--rehearsed several times on television and rehearsed again a few moments ago at Question Time--is that there is too much hospital capacity in London, that the advantage of the new commercial competition is not that it will strengthen the London hospital service but that it will show which London hospital should go under. On that basis, it is no doubt sensible to throw in a few high-risk cases such as Guy's.

If it is the Secretary of State's view that the problem is that there are too many hospitals in London, I cannot imagine a worse solution than throwing them all out into the market to see which sinks. We cannot plan an essential public service by waiting to see who goes bankrupt. While we wait, as the Universities Funding Council reminded us last week, we could disrupt the training of a whole generation of medical students.

I must remind the Secretary of State that the House was not sold the Government's changes on the basis that they would show which hospital should close. The Secretary of State is still comparatively new to his portfolio. He is the third Secretary of State that we have had during the process of these changes. Now that the general election is unlikely to be held until 1992, we have time for a fourth.

May I remind the right hon. Gentleman, however, that the national health service review that led to these changes was born out of the closures in the winter of 1987-88? It was presented to the House as the solution to those closures. The right hon. Gentleman's predecessor was lavish with his promises. There were promises about what would happen after the changes-- that money would follow the patient. As we all know, there is never any shortage of patients. The implication was that, when money followed the patients, there would be no shortage of money, either.

I treasure in particular this passage from the speech of the right hon. Gentleman's predecessor in January 1990.

"Next year,"

he said,

"in April 1991, we propose to reform the NHS : the coming winter will end the last year of an entirely unreformed service. The winter of next year will not be dominated by cancelled operations, closed wards and cuts in services".--[ Official Report, 11 January 1990 ; Vol. 164, c. 1124.]

Indeed not. The net effect of the changes has been to bring the cuts and closures forward this financial year from the winter to the spring.

A whole new lexicon of cuts is being used in the Minister's Department. I saw the other week an internal Department of Health memorandum which no longer talks about closing wards but about "downsizing hospitals". I noticed last week that Guy's no longer talked about specialties but about "reprofiling services".

Mr. Kenneth Hind (Lancashire, West) : The flaw in the hon. Gentleman's argument is that the purchasers of health care in and around the environs of London have realised that they do not have to send their their patients to London teaching hospitals. They can send them down the road to the local district general hospitals. When the

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hon. Gentleman talks about NHS trust hospitals, he fails to look at the same time at the same problem that is being faced by those that have not yet opted out.

Mr. Cook : I have heard that argument before. I noticed with interest that Dr. Ken Grant deployed it in relation to the problems that he faces at Bart's. Hon. Members who represent districts in the inner city of London and deprived areas such as Hackney, which Bart's serves, find it incomprehensible that if, all of a sudden, there is spare capacity as a result of people from the home counties no longer coming to London, waiting lists in their areas for their constituents continue to grow.

They find it unacceptable to be told by the manager of Bart's that they will have to admit people from Essex in two weeks when they cannot admit people from Hackney within a year. If that surplus capacity is there, surely we should be using it for the people served by those hospitals.

I was recalling the new way in which cuts, which occur not just in London, are described. My hon. Friends who represent constituencies such as Bradford, Leeds and Newcastle have talked about the cuts that are now being made by trusts in their cities. Nor are just trusts in difficulty. One of the most breathtaking interviews that the Secretary of State gave in the wake of the crisis at Guy's was when he defended the trusts against criticism by pointing out that other hospitals that were not trusts were in just as big a financial hole. I congratulate the right hon. Gentleman on his candour, although I do not understand why he imagined that viewers would be reassured by the news that trusts were all right because everybody else was in the same financial boat.

From a flurry of press cuttings on closures--I should refer not to closures but to the downsizing of hospitals that are now trusts--I single out one. That is about the closure two weeks ago of a ward for elderly patients in Bath. I choose that press cutting because the report was accompanied by a charming photograph of the right hon. Member for Bath (Mr. Patten), the Chancellor of the Duchy of Lancaster, shown smiling beside a plaque recording that it was opened by him in October last year.

I could find no better illustration than that photograph of the gulf between what was promised and what has happened. It was a photograph taken the month before the right hon. Gentleman became chairman of the Tory party, showing him opening a ward. That very ward, within four weeks of the changes introduced by the Government, has been reprofiled and closed.

Mrs. Maureen Hicks (Wolverhampton, North-East) : I recall that, only a year ago, the hon. Gentleman, when making a financial assessment of the requirements of the NHS, maintained that, if we injected just £3 billion, all our problems would be solved--that no reforms or control of union power in hospitals would be necessary, and all would be magic. Since then, an extra £6 billion has been injected into the NHS. Is he aware that, if he continues to ignore the need to reform the NHS, no progress will ever be made? I am increasingly coming to the view that the hon. Gentleman is interested only in orchestrating events to take advantage of vulnerable people who depend on the NHS-- [Interruption.] --and he is playing, as he knows, into the hands of the unions.

Mr. Speaker : Order. This sounds like a good speech for later on.

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Mr. Cook : Will the hon. Lady allow me to intervene? I did not produce a figure of £3 billion but quoted the estimate of the National Association of Health Authorities for the cumulative underfunding of the health service. She was right to say that, when I quoted that figure in the spring of last year, that organisation's estimate for cumulative underfunding was £3 billion. In view of the hon. Lady's complacency about the funding of the health service since then, she should know that the National Association of Health Authorities has now revised that figure to £4.5 billion.

Mr. Phillip Oppenheim (Amber Valley) : Will the hon. Gentleman give way?

Mr. Cook : I shall give way to the hon. Gentleman

Mr. Speaker : Order. The hon. Member for Livingston (Mr. Cook) was seeking to answer a point that was put to him. It would be disruptive to have another question before he has finished answering the first.

Mr. Cook : I shall seek to give way to the hon. Gentleman when I can, as he is always worth it.

The figure of £4.5 billion is extremely interesting. The Chancellor of the Exchequer produced precisely the same figure out of a hat to deaden the political pain of the poll tax. If Conservative Members can find £4.5 billion to save their political skins, they can find it to save the national health service.

Mr. Oppenheim : While the hon. Gentleman is on the subject of funding, did not the shadow Chief Secretary originally tell the House that the only priorities under a future Labour Government would be pensions and child benefit? The hon. Member for Livingston then told the House that spending on health would also be a priority. However, the Leader of the Opposition has just told us that spending on the health service would increase only in line with economic growth. Is not the Labour party playing its old cynical game of trying to be all things to all men as usual?

Mr. Cook : I have the advantage over the hon. Gentleman, because I heard my right hon. Friend make his speech, and very well received it was, too. I know that my right hon. Friend said no such thing-- [Interruption.] I merely seek to serve. My right hon. Friend the Leader of the Opposition said that the extra tax that comes from growth should be used for health and other essential services, which is entirely different from the slant being put on it by the hon. Gentleman and the Secretary of State, who imply that the Labour party was committing itself to spending no more on health than the growth of the economy. As my right hon. Friend said, that extra money will ensure that underfunding can be tackled from the start.

Sir Nicholas Bonsor (Upminster) : Will the hon. Gentleman give way?

Mr. Cook : I should like to return to my own speech at some stage, but I shall make a bargain with Conservative Members. I shall give way now to any Conservative Member who can explain to the House and to the country how the Government propose to find £30 billion to reduce the basic rate of tax, without ripping it out of the national health service.

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Mr. Jerry Hayes (Harlow) : Will the hon. Gentleman give way?

Mr. Cook : Yes, I knew that the hon. Gentleman would not fail me.

Mr. Hayes : The hon. Gentleman is a man of great integrity. After all, he voted against the 48 per cent. rise in waiting lists when the Labour party was last in office. Nevertheless, he has proposed a simple challenge. There is something called the Laffer curve, and I suspect that the last Laffer will be that of the Conservative Government. Quite simply, we have reduced taxes, as opposed to the plans of the hon. Member for Livingston (Mr. Cook), who intends to increase them. In 1979, the top 5 per cent. of taxpayers were paying-- [Interruption.] The hon. Gentleman should listen carefully, because he asked a question--

Mr. Speaker : The hon. Gentleman was challenged by the hon. Member for Livingston (Mr. Cook) but should come to the point, not make a speech which he might make later.

Mr. Hayes : I shall make it clear--in 1979, the top 5 per cent. of British taxpayers contributed 24 per cent. of the volume of taxes coming in to this country. Since the Conservative Government reduced taxes, the top 5 per cent. now contribute more than 31 per cent.--which means that there is more money for the health service. We are able to cut taxes and spend more money on public services, which is more than a Labour Government could ever do.

Mr. Cook : My question was about a cut in the basic rate. The hon. Gentleman referred simply to cuts in the top rate. We should welcome the insight that he has given us into what will happen if the Conservatives are re-elected--the clear sign is that they will cut the top rate. If the hon. Gentleman hopes to sell the paradox that he offers the House today, even to the good electors of Harlow, he must explain why, whenever the Government cut the rate of income tax, they have to compensate by increasing indirect taxation through VAT, which people who may well not pay income tax will have to pay when they buy their goods in the shops.

We have had good, clean, knockabout fun, which I thoroughly enjoy, but I shall now return to my speech. There is no better illustration of the gulf between what Conservative Members promised and what happened than that photograph of the Conservative party chairman. I want to leave the last word on the emptiness of the rhetoric that the Government wrapped around the reforms to Lothian health board, which has just dropped from its stationery and logos the term "Putting Patients First". That logo was dropped from all publications by the Lothian health board last week because, as its manager revealingly said on Sunday,

"management figures are sick of having the phrase used as a stick to beat them"--

[Laughter.] --my hon. Friends have missed the punch line-- "every time they make cuts".

There has been only one poll since the Government ran into problems with its NHS changes. Last week, a poll carried out by The Scotsman found that 58 per cent. of those replying believed that the Government changes would make the health service worse. A total of 9 per cent. believed that it would increase the health service. That

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response makes even the poll tax--the Secretary of State's last invention--look like a runaway success in popular support. It is not the Labour party but the voters who are currently making health the main issue of the Monmouth by-election and who will make Thursday's vote a referendum on NHS changes.

That prompts me to ask my next question of the Secretary of State. Given the overwhelming rejection by the public of those changes, how can the Secretary of State persist with his plans for a second wave of more than 100 hospitals to opt out and form trusts? Why does he not let people decide for themselves in a general election, which not even this Prime Minister can keep putting off for ever? If the Secretary of State does persist in his plans, and as the hospitals contemplate opting out, will he let the staff at those hospitals have a proper ballot?

I ask that question because the Conservative Monmouth candidate said that such a ballot would be "sensible and proper". Does the Secretary of State endorse the candidate's view? I would not ask the Secretary of State to endorse all the views of the Conservative candidate in Monmouth--I realise that that would be too painful--but will he endorse this one? It looks as though he could do with a lifeline. Or are we to take it from the Secretary of State's silence that on that point, as on so many others, the Conservative candidate for Monmouth is an embarrassment to his party?

The second development since our debate last month

Sir Nicholas Bonsor : I am grateful to the hon. Gentleman for giving way, especially in view of the pressure of time. He should not give too much weight to what the candidates in Monmouth say-- [Laughter.]

Mr. Speaker : Order. These interruptions take up a great deal of time.

Sir Nicholas Bonsor : --given that the Labour party candidate in Monmouth is putting up an appalling performance.

Does the hon. Gentleman acknowledge that efficiency in hospitals is essential in order to give patients a proper service? Does he not realise that hospitals under the NHS have been unable to account properly for the use of blankets, penicillin or anything else allowed for in their budgets? Because they have not had proper hospital accounting, they have not been able to deliver the service to patients. Is it not right to insist that hospitals have proper accountability and economic controls? Surely that is the best way of doing things.

Mr. Cook : I shall make a deal with the hon. Gentleman. I shall offer to concede that, as in any multi-million pound business--the NHS is a multi-billion pound business--there are always opportunities--[ Hon. Members :-- "Answer the question."] I am trying to use language that Conservative Members will understand. There are always opportunities for geater efficiency and greater savings ; I would not deny that for one moment. But does the hon. Member for Upminister (Sir N. Bonsor) agree that the worst cases of waste that we have witnessed in the NHS have involved surgeons being paid salaries to stand idle and do no operations, operating theatres paid for and equipped but not used, and wards lying empty because

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hospitals cannot afford to admit patients? That is waste and inefficiency on a colossal scale, which dwarfs potential savings on blankets.

The second development since our previous debate is that events have proved how right Opposition warnings were. We warned that the new commercial system would result not only in less choice, but in a less fair health service. We warned that, if hospitals were to survive by making money from contracts, they would be quick to give priority to the contracts that made the most money. They have indeed been quick to do that. There have already been several sightings of GP fund holders securing a fast track to put their patients in front of everyone else. One of the directors of the board at Watford observed as much, when he said :

"the board are aware that the implication of agreeing these contracts is a two-tier service."

Appropriately, that statement was made by the new marketing manager of Watford hospital.

There is a simple way to describe the new

arrangements--queue-jumping. Over the past week it has been fascinating to see how Ministers have tried to defend and deny the double standards in patient care that break out on a waiting list when a market behaves like a market. On Tuesday, the Prime Minister was still trying to maintain that admissions would be made according to clinical priority--the only difference, presumably, being that, since 1 April, clinical priority has been decided by marketing managers. By Thursday, his position had been overtaken by the evidence. The Secretary of State defined a new bolthole for Ministers, drawing a distinction between urgent cases, which must be dealt with according to what he described as proper priorities, and non- urgent cases, for which it is presumably acceptable to use the improper priorities of the market.

Let us not deceive ourselves by the comfortable term "non-urgent". When we speak about non-urgent patients, we mean elderly women who are crippled and housebound because they cannot get a hip replacement operation, about middle-aged men who cannot work because of a painful hernia, and about pensioners going blind because they need a cataract operation. The right hon. Gentleman may describe such people as non-urgent patients, but they are people suffering from pain, discomfort and indignity, who want an urgent cure. How can Conservative Members justify admitting such people in order of commercial priority? How will they sell that to patients at the end of the queue?

It is not only GP fund holders who are producing the double standard on waiting lists. Last week, I published correspondence from Alderhey children's hospital in Liverpool, a hospital which formed a trust in the first wave. That letter bluntly told north-western districts that Mersey district had agreed to pay a premium for each case of child heart surgery. The letter said that, unless the north-western districts agreed to pay the same premium,

"It is not possible for us to guarantee that any children currently waiting will be treated in the financial year". There is no mention there of clinical priority.

The Secretary of State for Health (Mr. William Waldegrave) : I am used to the stories that the hon. Gentleman puts about, which turn out on closer examination to be not quite what they seem. As he knows, for many years we have had money which is used to diminish waiting lists. All that the hon. Gentleman's story shows is that various districts were choosing from among

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