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Ms. Primarolo : My hon. Friend has summed up what is happening in the national health service. There are jobs for the boys ; jobs in return for past work ; jobs as a reward. But there are no prescriptions for those who need them.

The market, we were told, would eradicate the crisis. We would have a lean, finely tuned, responsive national health service. Let me give the House an example by describing a day in Bristol's health service. Bristol has three large teaching hospitals and a number of other hospitals.

This is what happened on 7 January. All through the night, Manor Park hospital had no female beds available. Before 8 am, the Bristol Royal infirmary and the Frenchay hospital had no coronary care beds available. The Southmead had one. The Frenchay refused to take patients from outside its catchment area. The BRI started at 9 am with no medical beds, and, by 2 pm, was completely closed ; it had no beds. By 12 o'clock, the Southmead had no available beds, and Western General was closed to all admissions. Shortly after lunch, the Bristol general hospital had no beds. By 8 pm, the Frenchay, the BRI and the Southmead all had no medical beds available. Some time after 9 pm, the Southmead decided to accept medical admissions, but only from within the Southmead area.

The crisis in the NHS has been documented by everyone except the Government and their Department of Health. It has been demonstrated that patients wait in casualty for hours on end, and hospitals go on and off red and yellow alert.

Job losses among health workers rose by more than 50 per cent. in the first year of the Government's market-style

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changes to the NHS. Junior doctors are reportedly working more than the legal number of hours, despite the Government's pledge that the NHS would meet its first major deadline. Hospitals run out of beds and emergency admissions are not allowed as the money dries up. The BMA says that hospitals are facing financial collapse because of the ravages of the internal market. The mechanism that the Government told us would save the health service is destroying it.

We are seeing queue jumping ; patients are refused treatment ; people's working conditions deteriorate further ; yet the Government do nothing except peer at the world through the rose-tinted glasses of Richmond house. An editorial in the Doctor, in absolute desperation, advised doctors to

"Bend Virginia's ear with proof of the crisis. The Secretary of State's underlings do not tell her the extent of the bad news." What can doctors do to persuade her that the present crisis is the most catastrophic but can be avoided?

One day the Secretary of State is full of praise for those who work in the national health service and is proud of their professionalism and commitment--rightly so--but the next she shifts the blame for the chaos on inept managers, greedy consultants or whingeing GPs. She should make up her mind about who is to blame, what is going wrong and how it should be put right. It is her fault and her Government's fault. Her reforms have demonstrated the persistent underfunding of the national health service : the very thing that the Government wished to disguise has been exposed by their own reforms. The Secretary of State tells us that pacing work in hospitals is important. Hospital resources stay underused for three or four months of the year. How do doctors pace themselves when they are faced with seriously ill patients? I shall give an example of how they pace themselves from the intensive care unit admission policy of Gloucester health authority. This is what the reforms mean : "Any surgical patients who are expected to require post operative intensive care will be deferred or transferred to another hospital pre operatively In addition the following ... patients will not be admitted. Patients with acute chronic lung disease Patients with chronic poor quality of life"--

goodness knows what that means--

"Patients 70 years or over with : Acute Renal failure Respiratory failure due to pneumonia".

That is what pacing is. Those are the priorities of the budget sheet.

Waiting lists, perversely, allow people to be treated not according to clinical need but on the period of time and political priorities of the Government. People are called finished consultative episodes instead of people. Refurbishment means closure ; in the Secretary of State's national health service, any word can be used. Prevention is distorted. Breast cancer services are a clear example. There are 1, 400 victims in the United Kingdom every year--the highest number of deaths in Europe. We have the fewest cancer specialists in Europe, yet the Secretary of State tells us that prevention is better than addressing the need for such facilities. Prevention is a good strategy, but 4 million women in this country, 2 million of whom live in London, have not had a cervical smear in the past five and a half years. It is about time that that was addressed. Patients' choice has been eradicated ; patients cannot choose their hospitals. Money does not follow them--they follow the money.

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In Bristol we are about to have catchment areas for hospitals--if one does not live in the catchment area, one cannot go to the hospital. It is interesting that we are not allowed to have catchment areas in education, but we are allowed them in health. Frenchay health authority is already proposing to administer such a scheme. We are in the ridiculous position where the hospital in

Truro--Treliske--faces financial difficulty because tourism has dropped in the west country as a result of the Government's failure with the economy. That shows the state of the national health service under the Government's reforms.

We have tried today to show the perverse incentives that the Government have introduced into the national health service. The reforms have not worked, but are making the situation worse. It is about time that the crises were dealt with. I urge my hon. Friends to support our motion, as I know they will. If the Government continue to preside over this crisis, they will carry the shame in years to come.

9.35 pm

The Minister for Health (Dr. Brian Mawhinney) : In view of the self- proclaimed importance that the Opposition attach to the health service, some of us have wondered why they have not called such a debate for so long into this Parliament. Now we understand : they have not had such a debate because they had nothing to say. Indeed, some of us are driven to conclude that today's debate has more to do with the standing of the hon. Member for Sheffield, Brightside (Mr. Blunkett) in the shadow Cabinet than with the health service. I am sorry that the hon. Gentleman had the flu, and I hope that he will soon be feeling better. I shall not go into his speech in great detail. However, he talked about records of which Labour and Labour Governments were proud.

I need to remind the hon. Gentleman, as did my hon. Friend the Member for Woodspring (Dr. Fox), that he forgot to mention the record of a real cut in NHS spending under the previous Labour Government. He also forgot another record which will have great relevance against his hon. Friends' rhetoric during the debate : in four of the five years of the previous Labour Government, nurses' pay was cut in real terms. I hope that the hon. Member for Darlington (Mr. Milburn) will take careful note of that point.

Another of the hon. Gentleman's points that interested me involved accountability. My right hon. Friend the Secretary of State dealt with that in political terms, but I am genuinely surprised that the hon. Gentleman and the hon. Member for Bristol, South (Ms. Primarolo) have taken such a jaundiced view of the Government's attempts to empower patients by giving them as much information as they possibly can to enable them, in turn, to have informed conversations with their general practitioners, the better to get the type of care in the location and in the time frame most suitable for them. Not only is the help line being launched today but regional health authorities have had a number of similar schemes available for some time. Indeed, some have been publishing waiting list times in local newspapers. I believe that The Citizen in Peterborough was the first in the country to do so, and I applaud it. We believe that patients

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should have as much information as possible because, after all, the service is designed to benefit them and to deal with their needs. The hon. Member for Bristol, South invited me to comment on the Bloomfield report and on selective lists. When the Government said that they would listen to the views of people in the NHS, of dentists and patients before reaching a conclusion on the report, they meant what they said. On the whole, the hon. Lady is encouraging us to consult and listen and to try to find common ground, so she will not take it amiss if I do not accept her generous invitation but stick to the consistency which, as she is learning to appreciate, is shown by the Government.

I sum up the speeches of Opposition Front-Bench Members as follows : nothing should change in our thinking in a world that is changing. To paraphrase more neatly, they seemed to say, "Stop the world, I want to get off."

My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) raised two important points. First, she asked about AIDS testing. I can confirm that the arrangements that she set out are those contained in the General Medical Council guidance. I listened carefully to her speech, and I and my right hon. Friend the Secretary of State will reflect on it.

Secondly, my hon. Friend the Member for Edgbaston spoke about an adoption story. I am sure that I am not alone in the House in being shocked by the details she gave. We have a strong commitment to and a strong appreciation of the work of social workers, but we draw definite lines beyond which they should not go. From what my hon. Friend has said, it seems that she knows of a case in which those lines were transgressed. If she would be kind enough to let me have the details of the case, I will ask my hon. Friend the Parliamentary Under-Secretary, the hon. Member for Suffolk, South (Mr. Yeo), who has responsibility for these matters, to investigate the case in depth.

Mr. John Marshall (Hendon, South) : Will my hon. Friend give way?

Dr. Mawhinney : No, because I should like to make a little progress.

The hon. Member for Rochdale (Ms. Lynne) encouraged us to consult. She was, if she will forgive me for saying so, rather churlish about the efforts that the Government are making legitimately, sensibly and sensitively to do exactly what she wants us to do. I am pleased that she was gracious enough to recognise that, when she and her colleagues came to see me, I was genuinely consulting and genuinely listening. I assure her that I took note of the points they made. My hon. Friend the Member for Broxbourne (Mrs. Roe) made an important point. She said that management cannot be taken out of the context of care, and she was right. Some peddle the false argument that we have to choose between care, and the efficient and effective use of resources. That is a spurious dichotomy. As we use resources efficiently and effectively, we enable more patients to be treated. There is nothing from which to resile in wanting to see the £100 million a day we spend on the health service used to best effect. My hon. Friend the Member for Chislehurst (Mr. Sims) raised a number of questions about London to which I shall return in a few moments. He also expressed his

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concern and regret about our decision on nurse prescribing. I pay tribute to my hon. Friend, who has been one of the strongest advocates in the House of nurse prescribing. The genesis of the policy, to which we are still committed and about which we are still enthusiastic, owes much to his advocacy.

We are concerned to ensure that nurse prescribing is launched in an environment that is as conducive as possible to its success. We are not at all certain that the present climate, in which there is to be an extended discussion about the drugs bill and about prescribing generally, is the best in which to move forward that policy. My hon. Friend the Member for Chislehurst paid an appropriate tribute to the hospice movement and to its work. I am sure that that is a matter for appreciation across the House. There is nothing partisan in our appreciation of the work done by hospices. I am pleased to announce to the House a £43 million extra payment to charitable hospices through health authorities in the coming year to help them to provide support for voluntary hospices. The Department will provide £32.3 million for voluntary hospices. A further £5 million is to be given to health authorities to help them to pay for hospice care for terminally ill people as part of the community care changes, and £5.6 million is to give voluntary hospices access to drugs supplied by health authorities. That means that the total Government funding to voluntary hospices since 1991 is £105.3 million.

Mr. Blunkett : As we are not having an evening of churlishness, I should like to put it on record that the Opposition welcome that statement and wholeheartedly give their backing to the allocation of those resources to hospices, which do such good work.

Dr. Mawhinney : I am grateful to the hon. Gentleman. I appreciate the generosity of his statement and of his gesture in making it. I pay tribute to the hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) for the assiduous way in which he has represented his constituents' views on the future of St. Bartholomew's hospital. Indeed, outside my family, I have probably written more letters to him than to anyone else in the whole world in the whole of my life. The hon. Gentleman is in danger of going down in this debate as a tease because he raised my expectations to fever pitch and was cut off in his prime. So exceptionally- -I hope that you will not feel that I am transgressing your 10-minute rule, Madam Deputy Speaker--I am happy to give way to the hon. Gentleman to let him have his expectation.

Mr. Sedgemore : I am grateful to the Minister for allowing me to intervene. I received a telephone call from Professor Besser, the chief executive of Bart's, this morning. He said that Bart's should be making an announcement in the next few days that it can finance the whole of its non- recurring deficit and that its recurring deficit should so be slashed that it will be close to having a balanced budget.

Dr. Mawhinney : The hon. Gentleman will understand, given the discussions that we have had in the past few months, if I hang on to my ecstasy for a little longer until I see the small print.

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While the hon. Gentleman was personally generous, I deplored the attack that he launched on my right hon. Friend the Secretary of State. It was without justification or foundation. I hope that he will find it possible to withdraw it on a suitable occasion. My hon. Friend the Member for Beverley (Mr. Cran) was entirely right to draw attention to the importance of day care surgery and the effect that it is having on the ability of the NHS to treat patients.

I intended to dissect the Opposition motion this evening, but my hon. Friend the Member for Harlow (Mr. Hayes) did it for me and probably did it better than I could. He pointed out that for every claim in a newspaper there was a counter-claim in another newspaper and that mutually exclusive statements were made elsewhere. He said that, while the Opposition Front- Bench team had been busy, it did not have an idea what it had been busy about.

Only a fraction of hospitals are affected by the crisis that Opposition Members have unsuccessfully tried to sell to the House this evening. We spend £100 million a day on the NHS. It has treated 600,000 more patients on average every year since the reforms were introduced. The number of people who wait between one and two years is down by more than 50 per cent. since the reforms were introduced. According to a recent survey in Doctor magazine, 70 per cent. of GP fund holders recorded reduced waits and improvements in efficiency. The NHS trusts treated 8.2 per cent. more patients in the first year of operation, compared with 7.2 per cent. for the directly managed units. In other words, no matter how we approach the reforms--whether it is trusts, GP fund holders, quality, waiting lists or convenience to patients--they are delivering better services for patients.

Mr. David Trimble (Upper Bann) : Not only the Opposition Front-Bench team is in two minds. As the Minister knows, in Northern Ireland the boards of both the local health authorities and the hospital trusts are composed of Government appointees. He may also be aware that a trust will come into operation in my constituency in a couple of months. However,, the health board is rushing through a review which threatens to close two hospitals, thus pre-empting what the trust might do. We have good reason to believe that the trust will keep at least one and perhaps both hospitals open. Is not that an example of bad co-ordination and management?

Dr. Mawhinney : The hon. Gentleman's constituents are fortunate if they are to have a trust in a couple of months because they can look forward to better patient care and more treatments. I was in the Province for six and a quarter years and it may have appeared to the hon. Gentleman that I was a permanent fixture. However I was not, and he will have to raise those issues with my right hon. and learned Friend the Secretary of State for Northern Ireland.

Mr. John Marshall : My hon. Friend will be aware that the London gender clinic is in my constituency and that its activity has caused great concern. Will he ensure that it operates within the law and look at any lacuna by which it may have breached the law?

Dr. Mawhinney : As my hon. Friend may be aware, the British Medical Association has expressed some views

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about the clinic and the HEFEA committee has published a paper on the issue. We are looking carefully at the matter.

The characteristic feature of the debate is that, while we have been speaking about patient treatment and care and numbers of patients, the Opposition have spoken about beds and buildings. I suppose that that represents the division on thinking between us. For more than 40 years the health service was provider driven. As a result of the reforms, it should become purchaser driven, with the needs of the patient at the centre.

I accept without embarrassment or difficulty that a service that has been running for more than 40 years on provider lines and has to start running on purchaser lines will find that that line is not unlikely to be as strong as the previous one. There are obvious reasons for that and it takes time to build expertise. It would be absurd to suggest that there is not a single case among the 45 million people whose lives are touched by the NHS in any one year in which the system has not worked to maximum advantage. We are debating 1 million employees, 45 million patients and an organisation with a budget in England of £30 billion.

However, I am perfectly prepared to defend the reforms, to laud the advantages that they are bringing to patients, to confirm the strengthening of the purchasing line year by year and to recognise that the contracting process needs to be properly managed. It is more likely to be properly managed if hospitals, doctors and consultants are included at an early stage in management discussions. It is likely to be even better managed if GPs who are not fund holders enter into early discussions with purchasers, with the district health authorities, so that when those authorities are putting contracts to providers they will do so in a way that satisfies the GPs in the area.

We have heard much about GPs. It is quite wrong to assume that GPs who are not fund holders are unable to influence the standard of care that is available to their patients. I should like to see more influence exercised by GPs on the district health authorities as they prepare contracts for hospitals. I hope that those with management responsibilities in the trusts will recognise that their ability to deliver consistent health care throughout the year will be improved if doctors are involved in the process from the beginning. My hon. Friend the Member for Havant (Mr. Willetts) made an excellent speech, as one would expect because he clearly understands the importance of the freedoms-- [Interruption.]

Madam Speaker : Order. I should be obliged if hon. Members on both front Benches below the Gangway ceased their conversations so that I might hear the Minister.

Dr. Mawhinney : My hon. Friend clearly understands the importance of the freedoms that we have given to GPs and the importance that we attach to their fundamental role. If the service is to be as sensitive as possible to the needs of the patient, the GP must be involved in the system as much as possible.

My hon. Friend was right. The proof of the pudding is in the eating. We are not coercing, forcing or cajoling GPs to become fund holders. The debate on trusts is over. By April 1994, something like 95 per cent. of all the provider units in the country will be trusts, and if the Opposition

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ever come up with a policy they will not be able to put it into effect if that policy in any way involves dismantling trusts. Of course they will not get into office, so it is a bit of a hypothetical point.

At the heart of the reforms is the role of the GP and of the GP fund holder, and GP fund holders are increasing in number precisely because they recognise that they can provide more, better and more sensitive services to their patients.

It is worth reminding Opposition Members that we have made it easier for patients to move from their GPs if they are dissatisfied. What is happening to GP fund holders? Their lists are not going down but up. To talk about a two-tier system is totally to misunderstand the heart of the Government's reforms. It is not a two-tier system but a shared purchasing system. I am very clear, particularly given the record of Opposition Members in this debate, that we shall have to keep on saying that to them regularly month by month for a long time until finally the penny drops. The penny will need to drop because GP fund holders are at the heart of the reforms and will drive forward the improvements we are all committed to making. Turning to the question of London, I wish to pay tribute to Sir Bernard Tomlinson, a distinguished academic and public servant who has produced an excellent report. He does not deserve some of the personal abuse which has been heaped on him over the past three months. It is important to understand that the Tomlinson report, which remains, until my right hon. Friend makes her decisions, advice to Government, is not about whether one closes a hospital here or merges a couple of hospitals there but rather about the re -configuring of health care in London. The fact is that change is taking place and even the hon. Member for Brightside once recognised that London's status quo could not be maintained. He has wobbled a bit and waffled a bit since, but he did at least recognise that. Part of the change is reflected in increased standards of health care provision in hospitals outside London so that those who used to send their patients to London no longer have to do so, because the patients do not want to travel if they do not have to and they can get treatment at home.

We have been consulting. I have been listening to representatives of the users, of the providers and of the purchasers as well as to the politicians, and I recognise the importance of primary care. Tomlinson does and so do we. In addressing primary and community care, we recognise that we have to address the problems of bed blocking in hospitals. All of my conversations have been confidential, but I will give the House one piece of information from a medium sized teaching hospital in London, which told me that on every day of the year between 60 and 100 of its beds are blocked by people who are clinically discharged but cannot go home because of inadequacies in primary care. We recognise the importance of addressing that issue. It is easy to sum up this debate. There is a crisis. It is a crisis in the Labour party ; and those who do not believe it should have been watching the face of the Leader of the Opposition when the hon. Member for Brightside was speaking. The Labour party policy on the NHS was rejected by the public in April. Now there is not even a policy, not a whiff of a policy. The Opposition have elevated the whinge to an art form.

Labour Members have a concern for individuals, as do all of us. The difference between us is that we are

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developing systems that ensure that more patients are treated to higher standards and with more regard to their wishes than ever before. GP fund holding is at the heart of those reforms. The public's appreciation of the NHS is far greater than the Opposition's. Its appreciation of what we have done to improve the NHS is far greater than the Opposition's. Our commitment to the NHS is clearly far greater than the Opposition's. For those reasons, our vote tonight will be far greater than the Opposition's.

Question put , That the original words stand part of the Question :

The House divided : Ayes 281, Noes 316.

Division No. 125] [9.59 pm

AYES

Abbott, Ms Diane

Adams, Mrs Irene

Ainger, Nick

Ainsworth, Robert (Cov'try NE)

Allen, Graham

Alton, David

Anderson, Donald (Swansea E)

Anderson, Ms Janet (Ros'dale)

Armstrong, Hilary

Ashton, Joe

Austin-Walker, John

Banks, Tony (Newham NW)

Barnes, Harry

Battle, John

Bayley, Hugh

Beckett, Margaret

Beggs, Roy

Beith, Rt Hon A. J.

Bell, Stuart

Benn, Rt Hon Tony

Bennett, Andrew F.

Benton, Joe

Bermingham, Gerald

Berry, Dr. Roger

Betts, Clive

Blair, Tony

Blunkett, David

Boateng, Paul

Boyce, Jimmy

Boyes, Roland

Bradley, Keith

Bray, Dr Jeremy

Brown, Gordon (Dunfermline E)

Brown, N. (N'c'tle upon Tyne E)

Bruce, Malcolm (Gordon)

Burden, Richard

Byers, Stephen

Caborn, Richard

Callaghan, Jim

Campbell, Mrs Anne (C'bridge)

Campbell, Menzies (Fife NE)

Campbell, Ronnie (Blyth V)

Campbell-Savours, D. N.

Canavan, Dennis

Cann, Jamie

Carlile, Alexander (Montgomry)

Chisholm, Malcolm

Clapham, Michael

Clarke, Eric (Midlothian)

Clarke, Tom (Monklands W)

Clelland, David

Clwyd, Mrs Ann

Coffey, Ann

Cohen, Harry

Connarty, Michael

Cook, Robin (Livingston)

Corbett, Robin

Corbyn, Jeremy

Corston, Ms Jean

Cousins, Jim

Cox, Tom

Cryer, Bob

Cummings, John

Cunliffe, Lawrence

Cunningham, Dr John (C'p'l'nd)

Dafis, Cynog

Dalyell, Tam

Darling, Alistair

Davidson, Ian

Davies, Bryan (Oldham C'tral)

Davies, Rt Hon Denzil (Llanelli)

Davies, Ron (Caerphilly)

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

Denham, John

Dewar, Donald

Dixon, Don

Dobson, Frank

Donohoe, Brian H.

Dowd, Jim

Dunnachie, Jimmy

Dunwoody, Mrs Gwyneth

Eagle, Ms Angela

Eastham, Ken

Enright, Derek

Etherington, Bill

Evans, John (St Helens N)

Ewing, Mrs Margaret

Fatchett, Derek

Faulds, Andrew

Field, Frank (Birkenhead)

Fisher, Mark

Flynn, Paul

Foster, Derek (B'p Auckland)

Foster, Don (Bath)

Foulkes, George

Fraser, John

Fyfe, Maria

Galbraith, Sam

Galloway, George

Gapes, Mike

Garrett, John

George, Bruce

Gerrard, Neil

Gilbert, Rt Hon Dr John

Godman, Dr Norman A.

Godsiff, Roger

Golding, Mrs Llin

Gordon, Mildred

Gould, Bryan

Graham, Thomas

Grant, Bernie (Tottenham)

Griffiths, Win (Bridgend)

Grocott, Bruce

Gunnell, John

Hain, Peter

Hall, Mike

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