House of Commons Hansard Debates for 20 Jan 1994

Mrs. Bottomley : In just one example, in the constituency of the hon. Member for Wakefield (Mr. Hinchcliffe), energy management--

Mr. Sedgemore : Give way, give way.

Mr. Deputy Speaker : Order. It is a matter for the Secretary of State whether she gives way or not.

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Mr. Sedgemore : Why does she not give way? There is something wrong with her.

Mrs. Bottomley : One of the examples-- [Interruption.] Once again, Labour Members do not want to hear the facts of the situation. One of the examples in the "A to Z of Quality" concerns the constituency of the hon. Member for Wakefield, where the energy management project is saving £370,000 a year. That more than covers the costs of the "A to Z of Quality", and the money is all being spent on patient care. We have cut waste by contracting out services. Competitive tendering across an ever widening range of services has led to savings of at least £130 million a year. The Labour party fought those changes and it fights them still. That says more about its real commitment to rooting out waste in the health service than all the spurious facts and figures cited by the hon. Member for Brightside.

Mr. Campbell-Savours : Will the Secretary of State give way?

Mrs. Bottomley : The hon. Gentleman has ground me down, Mr. Deputy Speaker.

Mr. Campbell-Savours : Contrary to what the right hon. Lady has been saying, some Labour Members are very happy with the treatment that we have had in the national health service, and we are prepared to say so publicly.

Mr. Sedgemore : Where was the treatment? St. Bartholomew's.

Mr. Campbell-Savours : However--

Mr. Sedgemore : The Secretary of State is closing down the hospital that saved my hon. Friend's life.

Mr. Deputy Speaker : Order. The hon. Member for Hackney, South and Shoreditch (Mr. Sedgemore) must control himself.

Mr. Campbell-Savours : When one is in hospital one hears when things go wrong. I can tell the Secretary of State about an incident one evening in Bart's when the accident and emergency department was 33 beds short. The chap responsible for running the whole hospital decided that the staff had to put beds on the floor--

Mr. Sedgemore : Mattresses.

Mr. Campbell-Savours : I am sorry, it was mattresses. They had to put mattresses on the floor to take in the extra patients in accident and emergency. Someone then telephoned throughout London to find out whether there were additional beds available in any other accident and emergency department, or in any other ward in any other hospital. Bart's telephoned 17 hospitals, and could not find a bed. So we cannot understand why, at the same time

Mr. Sedgemore : She is shutting the A and E unit.

Mr. Campbell-Savours : We cannot understand why the right hon. Lady is deciding to shut the accident and emergency unit in the hospital where I was. Where is the sanity in that policy?

Mrs. Bottomley : Again, I ask Labour members to read the informed and sensible debate on change in London that was led by their spokesman in the House of Lords. She said, as the hon. Gentleman must also say in his more

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rational moments, that no change is no option in London. Of course having first-rate A and E services is essential for the change. That is why we are putting nearly £15 million more into the London ambulance service.

Meanwhile, there is a major development programme at the Homerton, increases at the Royal London, improvements in the A and E at St. Thomas's and £8 million being spent at King's. Those who take a more serious interest in the health service will know that one of the dilemmas in London is caused by the fact that people frequently use A and E services where elsewhere they would use primary care. If the hon. Gentleman cared to consult Professor Lesley Southgate, professor of general practice at St. Bartholomew's hospital, he could have an informed discussion about the importance of change in London and of developing primary care, and about the phenomenal unprecedented investment that is under way, taking forward 100 primary care schemes across London this year. That is a necessary programme of change. I understand the concerns of those most directly involved. I also know that it would be unforgivable, in the light of all the changes, and all the medical advances, to fail to grasp the nettle. I admire Labour Members who constructively and responsibly seek the right outcome rather than simply holding on to the latest fashion and resisting change. It is that approach which makes them unfit ever for government and ever again for stewardship of the national health service.

This debate is of great importance and there are further matters which I wish to raise. We have announced recently that we wish to streamline the management of the NHS. Every change requires review and further development. We have had a successful drive towards decentralisation. We want patients closely involved and we want decisions to be made as close to patients as possible. Now is the time to sweep away a layer of administration. That is why I have announced proposals to abolish the 14 regional health authorities, to reduce further the number of health authorities by allowing district and family health service authority mergers and by streamlining the management executive. Those proposals received a broad welcome, both inside and outside the health service.

Of course, as ever, the hon. Member for Brightside could not bring himself to share that welcome. Once again, he talked about cutting out waste and when we take action to do so, he is lost for words. The proposals will mean that the management of a decentralised health service is even more effective and they will save money on administration to be spent on patients. That process is already well under way. Take, for example, the Northern regional health authority.

Mrs. Fyfe : On a point of order, Mr. Deputy Speaker. Do you agree that it is a disgrace that there is no Minister from the Scottish Office present so that we have some idea of whether the Secretary of State's proposals will also apply to Scotland?

Mr. Deputy Speaker : That is not a matter for the Chair and the hon. Lady knows it.

Mrs. Bottomley : I was referring to the Northern regional health authority, which plans to save more than £3 million on administration over the next two years to be

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spent on patients--including reducing waiting times. East Anglia health authority expects to save £1.6 million and to use that extra money to deliver 4,000 patients treatment.

The hon. Member for Brightside referred to accountability, which is an enormously important subject in a service as sensitive and as complex as the NHS. We will uphold and strengthen the accountability of the NHS to Ministers and to Parliament. The public must continue to have confidence in the stewardship of the taxpayers' money spent by the health service. Citizens and taxpayers have a right to expect those who use their money to provide services to carry out their jobs with responsibility, with honesty and to the highest possible standards. No one can give a guarantee that nothing will ever go wrong, however the health service is managed. What matters is to throw the spotlight on such matters and to take the necessary action.

I remind hon. Members that it was this Government who opened the doors of the health service to the independent external scrutiny through the Audit Commission. The Labour party was quite content with the cosy, secret world of closed books behind closed doors. We are determined that there should be a rigorous system of accountability with external audit and that lessons should be learned when things go wrong. The vast majority of NHS work is characterised by dedication, responsibility and honesty. This year, the Audit Commission reported that the overall financial management of all NHS activities has shown a significant and welcome improvement. It is disgraceful that the Labour party should use isolated examples to cast a slur on the integrity of the majority of men and women who work in the health service.

It is right that in the light of the important Cadbury report on corporate governance, and in the light of recent, justified criticism from the Audit Commission and the Public Accounts Select Committee, we have been working to look again to develop codes of conduct and accountability in the NHS. Once again, the hon. Gentleman poured scorn on the use of task forces in the NHS. In a service as complex as ours, the involvement of people working, rather than the loudmouths of the Opposition, is a better way in which to deliver policies which will work in practice. I pay tribute to all those who have helped the task forces on corporate governance, on accountability and on the code of conduct.

Those codes will play a key role in strengthening accountability, probity and financial control. They re-affirm long-standing good practice in the NHS and state unambiguously that NHS boards are responsible for ensuring effective financial stewardship through value for money, financial control and financial planning strategy. The codes include new measures which will require the directors of boards to declare private interests, require boards to establish audit and remuneration and terms of service committees, to keep proper control over the pay of chief and senior executives, and will require pay and remuneration packages of both executive and non- executive board members to be published in annual reports. The information revolution is already under way. In the past, no one knew who was in charge of a hospital. The establishment of trusts, the requirement to produce annual reports, to produce accounts, to have a public meeting of the trusts, apart from the work of the health authority means that the amount of information that is now available is unprecedented. I look to chairmen personally, with the

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full support of non-executive members and chief executives, to take a lead in implementing those codes. They must lead by example. Labour Members delivered their usual catalogue of abuse against those who serve as non-executives on the NHS trusts and authorities. I find that unbelievable because I believe that there is a tradition in this country of public service and service for the NHS which transcends political parties. I remember Lady Callaghan only too well when she was chairman of Great Ormond Street hospital. I remember any number of spouses of Labour Members taking a key and influential role and that there are any number of individuals throughout the service of all political parties who are serving the NHS trusts.

I am pleased, from what I gather, that the Opposition are no longer actively discouraging their members to serve on trusts and authorities. Too often in the past, it was reported that there was pressure put on members of the Labour party not to serve on trusts and authorities.

The way in which chairmen of health authorities have been appointed has varied little over the years since 1948. I suggest that the Labour party puts forward its own good names and support people who are doing an extremely good job and recognise the great quality of the contribution of the non-executive members. For example, Dame Margaret Turner-Warwick, the previous president of the Royal College of Physicians, is now the chairman of the Exeter NHS trust. There are any number of examples of people from all ranges of activities who are contributing to the national health service.

The hon. Member for Brightside knows that whatever accusations he has made against the health reforms, they have been widely accepted in and beyond the NHS. His dilemma, and it is a real dilemma as my hon. Friends will know, was summed up by the founder of the Socialist Philosophy group, Professor Julian Le Grand, when he said of the Labour party in an article in the New Statesman :

"If they refuse to believe that there are positive features of the reforms, they can call for their complete withdrawal. But then they have to offer something else that would do better. It is far from clear what that would be. Certainly few who work in the NHS would want to go back to the old pre- reform system. And even fewer would relish the prospect of yet another dramatic upheaval regardless of what form it took."

Elsewhere in the article, the professor states wisely : "central planning was not a conspicuous success in the old health service"

and he describes GP fundholding, which is always denigrated by the Labour party, as "perhaps the biggest success story" of the NHS reforms. If that is what constitutes socialist philosophy in revisionist times, I have a great deal more time for it than the half-baked denigrating variety served up by the hon. Member for Brightside.

The hon. Member for Brightside has no answer to the increasing success of the health reforms, he has no answer to the improved efficiency of the health service, he has no answer to the extra spending, and he has no answer to the millions more patients who are treated. The hon. Gentleman has no answer to the dramatic falls in long waiting times, and no answer to the improvements in patient care which are taking place in every hospital, every clinic and every GP's surgery. His sole response is to spread scares, smears and innuendos against people in the NHS. His mean-spirited attacks lack recognition of all that the staff have achieved in the past three years. They have taken change on board and they have made it work for the benefit of patients.

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We have begun a great journey with our health reforms, and that journey must and will go on. We will make the health service even more responsive to the ever-changing needs of the population and the ever-widening capabilities of science. The hon. Gentleman, in one of the rare sane moments in his speech, referred to the important but deeply concerning matter of human fertilisation and embryology. I will certainly talk with others about a possible debate on it. This country was indeed ahead of others in setting in place legislation to control those new techniques. That was a forward-thinking and enlightened piece of legislation, and so also are the health reforms a forward-thinking, enlightened piece of legislation, which will encourage diversity of care, not just in hospital but across the range of settings.

We will harness the health service single-mindedly to the goal of improving the nation's health. We will keep the health service at the leading edge of modern medicine. In practice, it must always be informed by the best and the latest medical knowledge. It must be clinically effective as well as cost-effective. Above all, we shall ensure that patients are treated with the courtesy and dignity that they deserve. Their needs, their choices and their well-being come before all else. Our health reforms are the means to those ends. They will uphold and strengthen the integrity and dynamism and the value of our NHS now and into the next century.

5.21 pm

Mr. Martin Redmond (Don Valley) : I shall be brief. The Secretary of State and her mouthpiece, the right hon. Member for Peterborough (Dr. Mawhinney), should be congratulated on their skilful misuse of NHS statistics and accounts which could lead one to believe that they were the grandchildren of Goebbels, for they regularly use his propaganda skills. Two and a half decades ago, when he was a Health Minister, Enoch Powell referred to NHS statistics as a pack of lies. He would not be so complimentary now.

The Secretary of State continually claims that never before has the NHS been so well run. NHS trust chairmen and chief executives tell her that, but that is no surprise. She says that never before has so much been spent and so many patients treated. Those comments are the deliberate, cynical misuse and falsification of facts and statistics. The Secretary of State should know that the form of NHS accounts and statistics was so substantially changed on 1 April 1990 that comparisons before and after that date are virtually impossible. I am aware of an in-patient case which involved at least four consultants by the time surgery took place.

In recent days, the Secretary of State has thrust herself forward as an exponent and promoter of "back to basics". Although that was clearly designed to camouflage Government incompetence, she should at least present facts to the public without criminal distortion. Let us hear of a few basics which the Secretary of State has not seen fit to publicise.

First, no chairman or non-executive director of an NHS health authority or trust is democratically elected, yet we hear much criticism from Conservative Members about trade unions. Conservative NHS appointments are more akin to the Nazi gauleiter system. Secondly, in 1993-94, NHS chairmen and non-executive directors will receive about £50 million in salaries and expenses. That sum

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would pay for 40,000 in-patient cases. Some non-executive directors have received more than £500 per meeting attended.

Thirdly, since 1990, chief executives and immediate managers have doubled or trebled their pay. During the same period, caring staff received little more than a 10 per cent. increase. Fourthly, extravagance is rife. It is only in the past few years that a manager would have had the affront to travel by Concorde at public expense, without a word of criticism by the Secretary of State.

Fifthly, vastly increased expenditure on managers' cars has been incurred, despite their having little need for them. However, district nurses need cars. Sixthly, over the past three years, the cost of managers and management has increased by about 1,500 per cent.

Seventhly, contractual mismanagement on a scale unheard of in the public service has occurred in two regions, costing tens of millions of pounds and, sadly, depriving tens of thousands of patients of treatment. What has been the Secretary of State's reaction? She rewarded the chairman of one regional health authority with the chairmanship of the national supply committee, and, on his resignation, she made Sir James Ackers the unique gift of £10,000 from public funds, thereby happily compounding the regional health authority's action in making illegal payments to senior officers rather than dismissing them. The Secretary of State would learn something if she listened rather than rabbited.

Eighthly, nurses who were still waiting for grading settlements five years after their 1988 grading restructuring were refused interest on moneys outstanding. That is the meanness of the Secretary of State. Ninthly, in- patient waiting lists remain immense, despite dodges such as putting patients on 12-month out-patient review or delaying out-patient appointments falsely to understate the waiting list.

Tenthly, there has been the highest ever reduction in the number of posts for caring staff, to fund the highest ever costs and staffing levels of administration and management. Eleventhly, the sum of nearly £1 billion, which was spent on computers, management and accounting systems to support the market style of management, would have paid for the treatment of the greater part of the in-patient waiting list, as declared by the Secretary of State.

Twelfthly, the Secretary of State has consistently refused to order public inquiries into the deaths or permanent damage of children in hospital--no doubt, to suppress the truth--and, at the same time, delayed the payment of damages which could have improved the life styles of some unfortunate children. The Secretary of State should be ashamed of herself.

Last week, Public Finance and Accountancy quoted the Secretary of State as saying :

"Review bodies must look at pay in the context of what is affordable."

I have yet to hear her say that regional health authority corruption and incompetence are unaffordable. As stated earlier, they are well rewarded in the West Midlands regional health authority. It has also been feared that the 1,500 per cent. increase in managers' pay is not affordable. The statement of the junior Minister-- "we make no apology for the small real increase in senior managers--

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is pathetic and shows not only the Government's ignorance but their indifference to the sick. I call on that Government to order a 10 per cent. per annum reduction in the number of all health authority and trust managers and their pay over each of the next five years as a start to restoring the balance between those who care and those who live on their backs.

"Back to basics" in the health service creates unemployment among nurses and the lowest possible pay, with the exception of top management who are rewarded with massive pay and rewards for mindless loyalty. Back to basics- -so much for sound economic management. Anything is affordable to avoid publicity. Back to basics--justice and fairness are not applicable to nurses, only to those who promote Tory policies. Back to basics--never let the public know the truth. I could go on, but time is limited. In the past five years, we have seen a massive growth in corruption and gross management incompetence throughout the national health service at the same time as the last elements of accountability of chairmen and directors have been removed. The Secretary of State can take notice of whichever of the Prime Minister's back to basic principles she chooses. But she and her team should resign and let us get back to running the national health service.

5.31 pm

Mrs. Marion Roe (Broxbourne) : I am grateful to have the opportunity to speak in the debate. Unlike Labour Members, I see the latest management changes introduced by the Secretary of State as another constructive step towards the Government's goal of achieving an appropriate and accountable management structure in the national health service.

I remember that, not long ago, the national health service had no management structure of which to speak. Those were the days when no one could provide even the most basic information such as the number of doctors employed in the NHS, the bed occupancy rate or even treatment costs. As Sir Roy Griffiths said in 1984, there was no one "in charge" and no one could be held to account for the billions of pounds of public money that were being poured into the service. What was needed was nothing less than a management revolution to give the health services the sort of management that was capable of handling its huge resources.

I am proud that the Conservative Government grasped the nettle in the early 1980s and have continued to pursue their aim of improving management performance. I remain convinced that only through good management can the health service continue to deliver the range and high standard of services that are demanded by rising public expectations and increasing medical capability.

Anyone who is acquainted with the reforms introduced in the past 15 years will understand that changes on the scale that have been achieved could not be introduced overnight. There had to be a clear strategy with every stage building on the previous one. The introduction of general management and the various management initiatives of the 1980s strengthened and increased the role of management.

The breadth of the reforms introduced by the National Health Service and Community Care Act 1990 added new dimensions and new responsibilities as the internal market developed. I want to take this opportunity to congratulate

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the scores of managers who have worked stoically to improve services for patients as well as implement the many changes that are expected of them.

One year ago, the Select Committee of Health, which I am privileged to chair, published its interim report on the NHS trusts. The Committee recognised the long-term contribution that trusts are making, and will increasingly make, to the health service. However, we expressed the view that the rapid expansion of trusts was in danger of causing a potential loss of strategic planning, especially at the regional level. We asked that consideration be given to the way in which the roles of the regions and the NHS management executive outposts could be accommodated with the freedom of the trusts. It seemed to us that there was a proliferation of management as a result of the new system growing up alongside the old, largely centralised management structure.

I am satisfied that the Secretary of State has responded to that concern. Her latest announcement on the structure of NHS management will ensure that the best parts of the old system are fully integrated with the new. The reduction in number and slimming down of regions, the merger of the outposts with regions, the review of staffing in purchasing authorities and the merger of districts will all contribute to slimlining the management structure. In addition to that top-down rationalisation, as the structure settles down and individual managers gain confidence, they are achieving their own improvements.

In my constituency, the East Hertfordshire NHS trust, which covers patients living in my constituency, has reduced the number of its full-time managers by nearly one third, from 50 to 35, since trust status was achieved. Management costs are also down to less than 2 per cent. of the total budget. Yet all contracts in 1992-93 were delivered within budget, and it is expected that they will be again in 1993-94.

In any large organisation, integrity is an absolute prerequisite, especially when large public funds are at stake. I welcome the positive steps taken by the Secretary of State to strengthen accountability, probity and financial control in the NHS. The codes of conduct and accountability that she proposes to introduce will reaffirm the long-standing good practice in the NHS and set out clearly the corporate standards that people can expect from the NHS boards.

Mr. Nicholas Winterton (Macclesfield) : Will my hon. Friend give way?

Mrs. Roe : I will not give way at the moment. Mr. Deputy Speaker has already said that many hon. Members wish to speak. I know that my hon. Friend will be speaking later, and he can make his points then. With an organisation as vast as the NHS, good management is essential for higher productivity and better efficiency. Good management pays, as the performance of my local NHS trust has shown. I am proud to be able to tell the House that, without any subsidy, the trust complied with its financial duties in the first year and broke even. This year, it is on target to achieve a similar result. All that was achieved while there was an overall increase of 4 to 5 per cent. in patient care. Improvements in waiting times have been made--over 85 per cent. of patients are seen by a consultant within 30 minutes of the time of the original appointment ; improvements in support services have been made--for example,. 95 per cent. of

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patients attending the East Hertfordshire trust accident and emergency department are seen immediately by a senior triage nurse ; the trust has efficiently managed a 10 per cent. increase in attendees in the accident and emergency department in 1993-1994 ; and day surgery output increased by more than 20 per cent. in 1993. Those are facts. East Hertfordshire trust has been reported as the top provider in the North West Thames region on the patients charter monitoring. None of that suggests to me that this is a service in decline--far from it.

5.40 pm

Ms Liz Lynne (Rochdale) : I welcome the opportunity afforded by the debate to discuss the national health service. I know from my postbag that the state of the NHS continues to be one of the key issues for the public. People have written to me from all parts of the country--no doubt they have done to other hon. and right hon. Members--expressing their concern at the closure of beds, wards and hospitals.

One of the reasons for that state of affairs is surely the NHS's increasing bureaucracy and the seemingly endless stories of waste. I do not say that that is the only cause, but it is one. The Government claim to be opposed to a vast and bloated bureaucracy, but the whole nature of the changes that the Government have introduced meant that an increase in bureaucrats and managers was inevitable.

If one separates purchaser and provider functions, each with their own management structures, one inevitably creates more management posts. If one establishes a contractual relationship between purchasers and providers, one inevitably creates a new layer of bureaucrats dealing with negotiations and contracts.

The Government make great claims for their reforms, trumpteting the fact that many more patients are now being treated. However, there is considerable doubt about how meaningful those figures are. The figures that the Government provide are for "finished consultant episodes", but it has been shown that the treatment of an individual patient for a single illness can lead to several "finished consultant episodes".

A leading health economist, Professor Alan Maynard, stated in a recent article in the Health Service Journal :

"effects of the reforms are unknown due to the Government's decision not to evaluate them."

That is presumably on the ground that the Government cannot possibly be wrong. There are, however, numerous examples showing that they do appear to be wrong when it comes to running the NHS. Millions of pounds have been spent by health authorities in hiring head-hunting firms for senior managers--£10 million was wasted on business consultants by the West Midlands regional health authority, as has been mentioned in the debate ; £40 million was spent by the Department in setting up the NHS trusts, with no independent means of checking where the money has gone.

We have all heard of the loss of up to £63 million by Wessex regional health authority in its mismanaged computer scheme. Another example is the £100 million wasted by the NHS Supplies Authority through inefficient management techniques and muddled contracts. The catalogue goes on and on and on. It is no wonder that a "good news unit" has been set up by the NHS Management Executive in Leeds--it is more correctly titled the corporate affairs intelligence unit. Surely that is another example of waste and pointless bureaucracy.

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It would be wrong to say that the Government have not responded in a more concrete way to the reports of waste and failure in the NHS. Following the Public Accounts Committee report on West Midlands health authority, the Minister made it clear that Sir Duncan Nichol was developing guidance addressing the need

"to reinforce core public service values in the NHS."

That is quite laudable, one might think, but why does a task force have to be set up to reinforce public service values in what is supposed to be our greatest public service? My party would put the concept of public service at the heart of the NHS.

Our local hospitals should be accountable to the local people whom they are supposed to serve. The Government claim that they want to encourage the involvement of local people in decisions about health care provision for their area, but surely the creation of trust hospitals in their present form makes that more difficult. There is no effective local representation, with no real local accountability. Mind you, district health authorities are not really accountable, either. We need direct elections ; only then will we get proper accountability.

At the regional tier, while no one wants to see a bloated bureaucracy, an open form of regional planning and supervision would be far preferable to the closed and secretive system that the Government propose.

In the long term, we should also like to see merged district health authorities and social services departments, to reduce unnecessary bureaucracy, to ensure a seamless provision of care and to reinforce local accountability. The Government have failed to set up ways of evaluating the effectiveness of their changes and thereby establish mechanisms to put a check on wasteful expenditure and growing bureaucracy. However, others have been doing it for them. A recent key report from the British Medical Association underlined the fact that one of the damaging effects of the Government's changes has been to create a two-tier NHS. As a result of the so-called fast tracking procedure, patients of GP fundholders are receiving treatment ahead of patients whose services are purchased by the district health authority.

Such queue-jumping is happening even when district health authority contracts have not been fulfilled. That process is clearly undermining one of the fundamental principles of the NHS--that patients should be treated on the basis of need. Just because they happen to be patients of a particular doctor, people who are less seriously ill should not be able to jump ahead of people who are in greater need of treatment.

Much has been made recently of the increase in NHS bureaucracy, and the ever-increasing burden that pay and perks are loading on NHS finances. While nurses have to stick to 1.5 per cent. on average, trust chief executives are getting huge increases of 9 per cent. That is hardly fair.

What, therefore, is the future for the key workers in the NHS--the doctors and nurses who provide the care, and the many support workers ? The Government have come out in favour of the Calman report on specialist medical training, and I am pleased about that. Where, however, are the resources to enable an increase to be made in the number of consultants ? I shall be grateful if the Minister will answer when he replies.

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The Government are committed to action to reduce junior doctors' hours, which is another thing for which I am grateful, but another report from the BMA recently pointed out that that is being patchily implemented.

The position of nursing in the NHS looks even worse. The number to be trained will fall by 16 per cent. In England between 1993-94 and 1994-95. That is despite research by the NHS management executive that shows that better qualified and trained nurses are more cost-effective and provide higher quality care. Clearly, the decline in the number of trainee nurses will have a dramatic impact on the future quality of patient care.

Surely the purpose of the Government's changes, although I do not know what was in their minds, was to try to use the money in the NHS as effectively as possible, but the reverse seems to be the case. Or is it that, by some unfortunate chance, the changes have highlighted the one problem that the Government have tried to mask--underfunding? Of course, the Minister will try to blind us with statistics, and it is difficult to believe that over £20 billion is not enough. I agree with that, but we should remember that we spend less money on our health care as a percentage of GDP than almost every other major western country. In the light of that statistic, it is amazing that the NHS is as good as it is. For that, we must thank the dedicated people who staff the NHS at every level.

Mr. Day : The hon. Lady mentioned the total amount spent in this country. Is she aware that, in terms of public expenditure, this country leads Europe? In the rest of Europe, the figures for total spending as a percentage of GDP are different, because there is more personal input on health in other countries. That is not an argument for or against private health, but the hon. Lady must recognise that fact.

Ms Lynne : I recognise that more money has been spent on the health service, but it needs even more. Inflation in the health service is running at 3.9 per cent., so the money currently invested in it is not enough. The hon. Gentleman will be pleased to know that I am just about to discuss funding possibilities.

The Government should give careful consideration to the possible advantages to be gained from hypothecated taxation. It is often said that the British public want better public services, but are not prepared to pay for them. Perhaps that is because they do not trust us, the politicians, enough to handle their money. The catalogue of waste outlined today certainly gives them good cause to believe that.

We want a health service that is not plagued by ever-lengthening waiting lists. It is possible to manage other European health services to avoid such delays, so why not here? Perhaps if we politicians gave a commitment to spend resources and source revenue on specific health services, we might be able to convince the British people that we are committed to improving the services that they cherish. They might then believe that we can be trusted not to waste their money elsewhere.

Dr. Mawhinney : I want to be quite sure about what the hon. Lady is telling the House, because hypothecation would not, of itself, offer more money to the health service. Is she suggesting that the Liberal Democrats want to take more public expenditure from some other programme--and if so, which one--to give to health? Or is she

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announcing to the House and the country that after the Liberal Democrats have increased taxation to fund education, they will increase taxation even further to pay for greater spending on the health service?

Ms Lynne : I am glad to answer that question.

The Liberal Democrats have begun to study hypothecation in detail and I sincerely hope that the Government will do the same. We could explicitly earmark the money raised from tobacco and alcohol exise duties for spending on the health service. We could raise considerable amounts through those duties from hon. Members alone. It is not for politicians alone to decide on the appropriate way forward. We must open up the debate on how to fund our health services.

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