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Department of Health programme for total quality management. The Kingston NHS trust has reduced its staff by 7 per cent. while productivity has increased by 23 per cent. There is multi- skilling of staff, and clinical staff are now released from administrative duties to do the job for which they were trained.

In summary, there is solid evidence that Conservative policies work. In 1948, Nye Bevan said :

"The House of Commons only produces Bills, but it is the men and women outside who can make the living realities."

How ashamed he would have been if he had heard the Labour speeches today. They contain no policies whatever. I have the greatest confidence in my right hon. Friend the Secretary of State, and she is running the largest organisation in Europe--for the benefit of patients.

7.29 pm

Mr. Richard Burden (Birmingham, Northfield) : On 8 January last year, Sir James Ackers resigned as chair of the West Midlands regional health authority. His resignation was greeted by a letter from the Secretary of State, who said today that, occasionally, things go wrong in the national health service. The letter she wrote to Sir James Ackers included the words :

"You have strongly supported the reforms of the NHS and have overseen their successful implementation in the region. In addition you recently initiated some important improvements in the managerial structure of the region. Underpinning all this has been your personal commitment to the health service and its patients."

Clearly, the Secretary of State thought that he had done a rather good job. One or two people disagree with her on that. The Public Accounts Select Committee disagrees with her, because its report into goings on inside the West Midlands regional health authority during Sir James's stewardship began with the following words :

"The use of National Health Service funds by the West Midlands Regional Health Authority has been characterised by serious shortcomings in the management, control and accountability of the Authority's Regionally Managed Services Organisation. These shortcomings have led to the waste of at least £10 million." The Committee looked at the engagement of a consultancy firm to consider the supplies organisation, which promised to save £50 million. It ended up costing the West Midlands regional health authority, and ultimately the patients in the west midlands, between £2.5 million and £4 million. There were no terms of reference or financial conditions in the arrangements established and the report of the Comptroller and Auditor General noted that the consultants' expenses amounted over one year to some £350,000, and included such items as leased houses, aircraft hire and lavish entertainment. Clearly, that was the kind of good job being done at the time. Of course, many such projects were the brainchild of the former director of the regionally managed services department--a man who had a penchant for privatisation. Privatisation has been something of a theme of West Midlands regional health authority. One instance was the privatisation of the management services division, which was turned into a company called Qa Business Services, for £750,000. It went bust in 18 months and the consequences have so far cost the West Midlands regional health service £928,000.

The staff did not do too well from that privatisation. I find it interesting that Conservative Members have said that Opposition Members do not care about white-collar staff. I would like to know what they would say to former

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employees of Qa Business Services, who lost their jobs. Many did not get redundancy payments and some lost up to two thirds of their pension entitlement because the pension fund that was set up could not cover its liabilities.

When I and other hon. Members have tried to raise the issue of the pensioners of Qa Business Services, we have been fobbed off time and again and after all the reports, the answer given was that the national health service had

"no moral or legal responsibility"

to those people. What a travesty and an insult. Even after that, Conservative Members have the gall to say that we do not care about white collar staff in the national health service.

Of course, others did rather better. Sir James Ackers, the man who was praised in the letter from the Secretary of State, received a pay-off of £10,000. That pay-off was not in his contract, but was a discretionary payment. The man who oversaw the consultancy to which I referred received a pay-off in excess of £80,000. There is a small problem with that, because it was subsequently discovered that he was overpaid by about £41,000. Attempts to recover that money are still going on.

The gentleman who authorised that overpayment was Mr. Mel Nock, who was in charge of the personnel function and has since left the regional authority. He has recently been appointed as the consultant to advise on personnel matters for the new North Birmingham health consortium by Malcolm Skilliorn, a colleague from the regional health authority and other places before.

That is the reality of the serial sleaze of the national health service today and the Secretary of State has the gall to say that things go wrong from time to time. Such things are endemic in the mentality that the Government have introduced into the NHS ; a mentality of bureaucracy and unaccountability and an obsession with the market.

In my own district, South Birmingham, we have experienced the operation of that market. We were told that, under the market, money would follow the patients. I can tell the Minister that we have plenty of patients in South Birmingham, but we have a little difficulty getting hold of the money to treat them. The Royal Orthopaedic hospital, adjacent to my constituency of Northfield and internationally renowned for orthopaedic services, is currently under threat of closure because of the way in which the market is operating. The hospital runs at a surplus, yet it is still under threat of closure. It has been reprieved for a short time for consultation.

That is not all that is happening. One thousand five hundred acute hospital beds in Birmingham are under threat. Birmingham also has examples of patients waiting for up to 22 hours on trolleys. Elective work has virtually dried up in many hospitals because emergency patients are taking all the beds. The future of Selly Oak district general hospital is also under threat.

Perhaps Ministers will have an answer for that great beds crisis. They may suggest sharing beds. That always saves a little money. However, that is not much of an answer to patients in the south of Birmingham. That area is short of between £12 million and £16 million every year.

The massive organisational changes that have been brought about by the Government and the effects of their reforms were blamed in a report as contributory factors to a well publicised case over the summer of maldiagnosis of bone tumours, which meant that large numbers of patients may have been wrongly diagnosed.

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One of the most insidious effects of the market is the way in which it sets hospital against hospital ; purchaser against so-called provider. For instance, the Royal Orthopaedic hospital, to which I referred earlier, is in surplus but under threat of closure. Let us imagine that the health authority sees sense and reprieves that hospital, not in the short term, but in the longer term. The health authority would still be short of money. It would still have to close something, so it would perhaps consider the number of beds and would take some beds from Selly Oak district general hospital.

The health authority could decide that it should not cut beds, because the emergency beds were already overflowing. What could it do as a result? It would have to cut what is called its purchasing allocation and cut the services that could be provided by the very hospital that it had decided to keep open.

What would happen then? Local people would not be able to receive treatment at their local hospital, because the local health authority would not have the money to purchase the service. The hospital would have to raise income to pay for that service. How? An interesting scheme in Birmingham Heartlands hospital in east Birmingham over the summer determined that a sophisticated scanner, intended to treat patients, was used to treat pigs and sheep. It was hired to the Meat and Livestock Commission because it was described by the West Midlands regional health authority as a "form of income generation". That was one rather interesting scam.

A more likely outcome is that the hospital under threat would end up only treating patients from doctors who are GP fundholders or those who were able to pay for themselves through the private sector. It is a ridiculous merry-go-round on which a hospital is reprieved, but the health authority cannot buy services from that very hospital. That is the real effect of the market. That is what is happening in Birmingham and in other parts of the country.

In June, during health questions, I raised an incident in my constituency with the Secretary of State, which applied to that same orthopaedic hospital. A patient was told that he would have to wait six months for a knee operation, but that it would be only six weeks if he came from a GP fundholder. That is a distortion of the principles on which the national health service was founded. The sooner we get rid of the market mechanism, the better.

7.39 pm

Mr. Jerry Hayes (Harlow) : I declare an interest. I advise the Western Provident Association, which, as most people know, is involved in health and is non-profit making.

This has been a particularly depressing debate. We heard from the hon. Member for Sheffield, Brightside (Mr. Blunkett) one of the most disgraceful speeches that I have ever heard from an Opposition spokesman in my 10 years in the House of Commons.

Mr. Jim Dowd (Lewisham, West) : The hon. Gentleman always says that.

Mr. Hayes : I say that only when the hon. Member for Brightside speaks. He accused the Government of sleaze, yet he had the nerve to attack the Conservative Members' wives who served on health authorities. He criticised the number of appointments of Conservatives. He should mug

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up on his history of the health service. There are slightly more Conservatives on health authorities because the hon. Gentleman's predecessor, the hon. Member for Livingston (Mr. Cook), forbade members of the Labour party to take such appointments. The hon. Member for Brightside cannot have it both ways. If air miles were given for sleaze, the hon. Member for Brightside would be the first man on Mars.

Talking of interplanetary activities, it is remarkable that no Opposition Member has had the grace to mention that far more people than ever before are being treated every year--more than 1 million people since the health service reforms came into operation.

Ms Jowell : Will the hon. Gentleman give way?

Mr. Hayes : We are constrained by time. I would be delighted to give way to the hon. Lady, but I am unable to do so.

We are now spending more than ever before--£100 million a day. Efficiency savings are being made. We are talking about 2 per cent. this year and, perhaps, 2.5 per cent. next year. An extra £450 million will be spent directly on patients. It will not go to the Treasury.

The other amazing thing that I could not believe was that the hon. Member for Brightside could not tell us what his policy is. That is one matter on which I profoundly disagree with my right hon. Friend the Secretary of State. She called the hon. Gentleman the man ana man because he was so slow. The word "man ana" in connection with the hon. Gentleman implies far too much urgency. However, he gave us a little clue. He said, "I will tell the House what the policy will be about. It has something to do with treating patients." Wow! I can imagine the great slogan when that policy document is produced in perhaps two or three years, after the next general

election--"Something to do with treating patients."

The one thing that the hon. Gentleman did right was to introduce the debate on wasting resources and on bureaucracy. If anyone knows all about wasting resources and all about bureacuracy, it is the hon. Gentleman. Just a little clue about what would happen if he became Secretary of State for Health is what happened when he was the leader of Sheffield council. Under his leadership, the number of committees increased from 97 to 247. No Opposition Member had the grace to tell the House that, for every 100 patients treated before the reforms, there are 116 now.

Ms Primarolo : They are patient episodes.

Mr. Hayes : They are not patient episodes. With the greatest respect, the hon. Lady does not know what she is talking about. We are talking about the number of people being treated, and that is just in the short period since the reforms. Opposition Members should be proud of that. Anyone who works for the health service would feel nothing but despondency and misery at the dangerous nonsense that comes from the Labour party.

By April, national health service trusts will provide 90 per cent. of health and community care. Have they been a disaster? Opposition Members will say, "Of course they have." They have not, because trust activity has grown by 5.3 per cent. compared with an average of 4.3 per cent. in the other sector, and that growth is continuing.

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When we have the great policy document from Opposition Members, what will they do ? Will they abolish trusts, as they promised to do ? The hon. Member for Bristol, South (Ms Primarolo), who will delight us with a speech a little later, is nodding her head. I can only assume that we now have a policy.

Let us have a few more. What about GP fundholding ? Six thousand GPs have become fundholders. One in four of the population are covered by them and by April it will be one in three. What will the Labour party do about fundholders ? They have been a manifest success. The British Medical Association is in favour of them, GPs are in favour of them and, clearly, patients are in favour of them. I am looking for an inclination of the hon. Lady's head--just a little clue, perhaps.

Ms Primarolo rose --

Mr. Hayes : I will happily give way to the hon. Lady.

Ms Primarolo : The hon. Gentleman knows that the BMA has denounced the Government's two-tier health system, which was created by fundholders who allow patients to jump the queue, ahead of other people in greater need. The hon. Gentleman also knows--

[Interruption.] The hon. Gentleman asked me a question : shall I sit down, or would he like me to answer it ? He asked whether we are in favour of a two-tier system and GP fundholders. We have said before that we do not support GP fundholders. We believe that they are wrecking the national health service, as the Government intend, and they will not exist in this form.

Mr. Hayes : "In this form"--if ever there was the small print, that was it. Why does the hon. Lady not tell the House that, for every manager-- [Interruption.] The hon. Lady is having a fascinating conversation with my hon. Friend the Member for Wyre (Mr. Mans), but perhaps she would like to listen to me, because she will hear even more exciting information.

For every manager in the national health service there are 26 doctors and nurses. Why do Opposition Members not say that? National health service managers in the over-bloated service that we are told about account for 2 per cent. of the national health service work force and 3 per cent. of the wages bill, and administrative and clerical managers account for 11 per cent. of the wages bill. The hon. Lady should be telling the country about those facts and figures. The proportion of national health service staff who provide care directly to patients increased from 60 per cent. in 1981 to 65 per cent. now. That trend will continue.

I will tell the House what the Government are doing about waste. There is bound to be waste in an organisation the size of the national health service. What are we doing to cut bureaucracy? We are allowing health authorities to merge--a perfectly sensible reform.

Mr. David Hinchliffe (Wakefield) : Labour proposed it.

Mr. Hayes The hon. Member for Wakefield (Mr. Hinchliffe) says that Labour proposed it. He should welcome what we are doing rather than attack the Government.

Some years ago we abolished area health authorities, and now, thank heaven, we are abolishing regional health authorities. Why do Opposition Members not give us some good news? There is a lot of good news? Opposition Front- Bench Members should read the King's Fund

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Institute report, and they should read about health care in London. The hon. Member for Dulwich (Ms Jowell) in particular should listen to what is happening in London.

Ms Jowell : I know what is happening in London.

Mr. Hayes She says that she knows, but if the hon. Lady reads the latest issue of "London Monitor" she will see that it states "For the first time in history, primary care will be tailored to meet the needs of all London's population, regardless of age, gender, socio-economic status and community origin."That is good news. Opposition Members should read the views of Rosalind Wilkinson and Hilary Scott, who said that the City and East London family community health service organisation will be discussing exciting new developments in the provision of health services in the east end of London.

There is a lot of good news on the health service, and Conservative Members are sick to death of it being ignored.

7.49 pm

Dr. Joe Hendron (Belfast, West) : Thank you, Mr. Deputy Speaker, for calling me.

I have listened carefully to the debate and to the speech of the hon. Member for Wimbledon (Dr. Goodson-Wickes). I have been involved in primary health care for 30 years in west Belfast, but I must be living in a different world from the hon. Member. The fact that most of the population in my constituency are from social class groups 4 and 5 may have something to do with it.

I find the attitude of Conservative Members incomprehensible. This is the 20th century and we are about to move into the 21st. We should expect health services to improve : they are improving in every western European country. Why have Conservative Members been crowing? One after another has shouted about all the fantastic things that are happening. Of course, improvements have been made. Perinatal mortality rates, which were higher in Northern Ireland than elsewhere, have come down. We expect better maternity and geriatric services and better care for handicapped children.

Why cannot Conservative Members accept objective criticism from the Opposition? Why is a debate like a boy scout game, with hon. Members trying to catch each other out on point after point? Genuine criticism has been made but does not seem to have been accepted. If Conservative Members were to point out that they had achieved A, B, C and D but were having problems in other sectors, they might have some credibility.

My experience of these matters has been in Northern Ireland and I make no apology for referring to it. I pay tribute to the outstanding hospital staff of Northern Ireland, especially those in Belfast, where there is the violence factor, which I need not touch on now. Staff at the Royal group of hospitals--not just doctors and nurses but right across the board--deserve our appreciation. I should especially like to mention ambulance drivers. Throughout the trouble, I have never known one to refuse or to object to going into any situation, despite there being destruction all around them.

There have been achievements in cardiac surgery. The number of cardiac units at the Royal Victoria hospital has increased from three to five. Belfast and, I think, Glasgow

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have the highest incidence of coronary- artery disease in the world. I do not have the figures to hand, but I know that they are very high.

I accept that improvements have been made in Belfast, which serves the whole of the north of Ireland, yet patients are still being transferred to London and elsewhere for cardiac surgery. More people in their late twenties and thirties are suffering from ischaemic heart disease. They are mostly in social class groups 4 and 5--unemployed people, who cannot afford to look after their health by eating nutritional food. I pay tribute to the health promotion unit of the Eastern health and social services board, which has done a good job in trying to convey that message to people.

I should like to give an outstanding example of the deficiency of hospital trusts. The Royal group of hospitals was the first such group to have trust status in Northern Ireland. That caused great celebration among those who had sought it. Despite the objections of Belfast city council, trade unions, medical and nursing staff and local people, the group gained trust status. Once that had happened, I said that they should accept it.

Within months of the trust being set up, the Eastern health board offered Royal Victoria hospital a contract for 3,000 general surgical and ear nose and throat operations, which was less than it had had in the previous year. If that contract had gone through, it would have been the beginning of the end of the Royal Victoria as a general hospital. It would have continued as a regional hospital. How was that contract stopped? It was done by a massive campaign in which, thankfully, Catholic nationalists from the Falls road and Unionists and Protestants from the Shankhill road came together to join trade unions in opposing the contract. An Adjournment debate was held on the matter. We spoke to the Secretary of State about it. The result was that Lord Arran, the former health spokesman, would not allow the contract to proceed.

That happened only a short while ago. The next proposal is for the Royal group of hospitals trust to merge with the City hospital, which was made a trust. Where will it all end? The Eastern health board, which offered the contract in the first place, did not even keep to the criteria that were laid down by the management executive of the Department of Health and Social Security in Northern Ireland. I read the criteria carefully, and I assure hon. Members that the contract did not keep to them. If I had more than 10 minutes, I would go into that matter.

Obstetric services are being closed. Lagan Valley, Mater, and Down hospitals are under threat. We are told that, for a service to be viable, 2,000 deliveries are needed. At the same time, a maternity committee has been set up to consider midwifery-led and GP-led childbirth, which I support. How can a committee consider such a proposal when a major maternity hospital is being closed and three others are under threat ? It does not make sense.

Fundholding seems to work on Humberside, but I do not see it working in Belfast. It is early days, however, and there are few fundholders at present. I understand that if a fundholder can save money and use it to care for patients, his allocation for the following year is reduced.

Musgrave Park hospital is the main orthopaedic centre for Northern Ireland. It is a fantastic hospital. If any hon. Members need a new hip, I recommend that hospital, which will measure them up as if they were being fitted with a suit. Threats hang over that hospital as well.

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Belvoir Park hospital, the main unit for oncology and cancer services, is also under threat. It is located in beautiful green territory and the proposal is to move services to one of the main Belfast hospitals, which would be a disaster. Orthopaedic waiting lists are massive. People on the cardiac waiting list die as they wait for surgery.

There are no problems with acute services and admissions, but people who may have cancer have to wait for proper investigations to be conducted. If the cancer is at an advanced stage, they may be treated too late.

The idea of community care and of elderly and handicapped people being kept in the community, which all hon. Members would support, is not new. Assessment of such people is important. Everybody wants to keep their grandmother or friend with a failing mind in the community for as long as possible, but somewhere along the line, if it is unavoidable, those elderly people have to go into an institution. Elderly people's homes are being closed, so something is wrong with social policy.

The issue of accountability appears in Labour's motion. Where is the accountability ? I have not heard Conservative Members talking about accountability. They do not accept that the health service has any faults, yet there is no accountability.

Legislation on child care in Northern Ireland, where it is a major problem, has to be considered.

The Huston report, which deals with Northern Ireland, will come out either tonight or tomorrow morning. It investigated major cases of sexual abuse in Belfast. It contains 52 recommendations and is about the breakdown of information between statutory and voluntary bodies and it should be sent to every hon. Member.

7.59 pm

Mr. Sebastian Coe (Falmouth and Camborne) : My immediate remarks are directed at the hon. Member for Belfast, West (Dr. Hendron). I do not wish to question his knowledge of community care in that area, but Tory Members have not been crowing. Nor do we wear rose-tinted spectacles. We are rightly proud of the changes in health care in this country recently. That must be set alongside the system that was changed.

It must be remembered that, for every pound that was designated for patient care before the reforms, significantly more was being spent on a system that was simply waiting for reform to happen. Money was spent on funding a creaking management structure which was allowing it to happen. By most assessments, the organisation lacked sense, magnitude and direction. That was rationale enough for our recent reforms. The concern of Tory Members for a considered evolution to an institution that has at its core a focus for the needs of patients and its users is laudable and undiminished.

There was no overt conspiracy in the past to subvert the national health service from considerations of good management, effective resource allocation and monitoring. It did not happen because no culture or environment expected it, or even demanded it. It was a culture where costs were never properly assessed, altered demographics were not taken into consideration and advances in technology were discounted. Such advances have provided a raft of new techniques and disciplines which were the stuff of fertile imaginations and daydreams only a few

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years ago. Of course, they are now the everyday reality for many people, freeing them from pain and discomfort, and badly curtailed life styles.

One of the inevitable results is that people live longer. The Secretary of State was right to point out that, in living longer, people may also need more expensive and technical treatment. All of that adds up to the overall resource implications and cost of patient care which should lie at the heart of this debate. It goes without saying--and here lies some criticism- -that those who conceived the idea of a national health service did not anticipate the rapidly rising costs with which it was presented almost from the word go. Confronting the issue of resources and their effective allocation is one that Opposition parties have simply failed to confront in any systematic way--certainly, so far in this debate. But that is hardly surprising. To imply that the path to salvation lies only in a greater level of funding is certainly not surprising. But to pass off that rhetoric as a coherent strategy--even if they believe it--poses the greatest threat to the national health service and patient care in this country.

Equal in that danger is the elevation of the national health service to the point at which it remains untouched by the realities of greater demand and the ever-increasing public expectation of improved conditions, care and service. It sets deliberately false trails. It is misleading and makes no serious contribution whatever to the debate about how the national health service should be judged.

There can be only two indices of assessment. Efficiency and effectiveness can be measured only by the quality and quantity of patient care that it delivers. On both counts, the reforms have produced quantitative improvement. My hon. Friend the Member for Harlow (Mr. Hayes) was right to mention that, and I am not ashamed to repeat it. More patients are being treated than ever before. The length of time that patients wait for treatment has fallen sharply. There have been increases in spending each and every year. The proportion of our national income which is devoted to the national health service will rise this year to an estimated 6 per cent. --1.5 percentage points higher than when the Government came to power. Those realities are neither the politics nor the statistics of neglect. To suggest otherwise is disingenuous. In fact, it is downright dishonest.

The national health service is the largest employer in Europe. One could be forgiven for thinking that for some, that is the only indicator which will be considered. The proper use of the public purse, the efficient use of scarce resources and the better care of patients are not a happy accident. This is not the managerial version of "It'll be all right on the night". It comes about by one thing, and one thing alone--good, effective and sensitive management, and committed medical professionals.

To push through operational changes without necessary management changes would be ridiculous. That is why, since the mid-1980s, the Government have progressively--strengthened national health service management. The populist view that an under-managed service and weak management--and worse, under-valued management--are compatible with the pursuit of an ever- improved service is a dangerous myth.

It is interesting that most debates in the House dealing with the provision of public services are spiced with spurious Opposition claims of rock- bottom staff morale, whether they be teachers, local authority workers or the police. Yet I have heard only the most demotivating

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barrage of abuse about dedicated professionals. I am sure that Unison was listening with great interest to the support from its comrades in arms and the comments about many of its members. Does the morale of management not count when it comes to fraternal concern? Apparently not.

Managing the new NHS cannot be done on the cheap. It certainly will not be done by abusing managers and staff. Of course, we must be alert to the need at all times to keep management cost effective and streamlined, and keep waste to a minimum. It was right that my hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) put this into perspective. General and senior managers in the national health service still account for little over 2 per cent. of the NHS work force and about 3 per cent. of the annual wage bill. I should, add that, in any management model, those are not unacceptable statistics. Administrative and clerical staff, many of whom directly support nurses and doctors, account for 11 per cent. of the wage bill. The overwhelming draw on the budget remains those staff who provide care to patients directly ; they account for some 65 per cent. of the wage bill.

The reforms of the late 1980s paved the way for the recent changes in management structure which were aimed at reducing bureaucracy, minimising administrative costs and aligning the structure of the NHS more closely with the purpose of the reforms. The merger of district health authorities with family health service authorities will simplify and clarify managerial roles and responsibilities. Regional health authorities were part of that outdated culture. Their abolition was rightly welcomed by health professionals across the board. The streamlining of NHS management executive supports those changes taking place lower down the management dynamic.

Taken as a group of measures, there is much to be welcomed in the Government's plans. As with previous reforms, their success will depend on the careful monitoring and constant control of management costs--both set against explicit targets. But we must never forget that these controls should not become so restrictive that they prevent managers from carrying out their duties effectively. The national health service must be run by managers on the ground with doctors and nurses contributing to the decision -making process in the wards and in surgery. The most fundamental aim must be to improve health care.

The majority of people who use the national health service are satisfied users. Poll after poll has identifield that. People are not scared of the changes. Improved management touches large parts of their lives, whether in the public sector or in the private sector. They are right to demand it-- they want to embrace it.

8.8 pm

Mr. Jim Dowd (Lewisham, West) : Earlier, a Tory Member put up what is a fairly usual smokescreen for the Tories by saying that they have a right to claim that all the parties in the House can take credit for the national health service. It is certainly true that all the parties would like to take credit for the NHS. However, the Tories have the greatest difficultly because, of course, about 40 years ago they voted against the establishment of the national health service. That has proved a great difficulty for them ever since. It is the one issue which cuts most directly against

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the free-booting rhetoric of the market that is so beloved by the simple-minded ideologues who seem to have taken the Conservative party hostage for the moment.

They have the greatest difficulty with the NHS--it is the rock upon which they founder--because the NHS accords with the highest ideals and the fundamental needs of the British people. The Government's approach to the NHS must be set against that. The NHS will not stand the full frontal assault which they have exhorted in other areas, so their approach needs to be far more subtle.

The motion tonight relates to waste and bureaucracy in the NHS. I want to go back over a few Tory reforms, not just the most recent reforms but those which immediately preceded them. Every Conservative Government have seen it as their role to reconcile their initial, fundamental and innate hostility to the principles of the NHS with the fact that they have to run it.

In 1974, for example, there was a reorganisation under Sir Keith Joseph, as he then was, which established the area health authorities. I was appointed to the area health authority, then called Lambeth, Lewisham and Southwark, that was formed as a result of the reorganisation in 1974. In 1984, we had the district health authorities. I went on to serve on Lewisham and North Southwark district health authority, which principally embraced Guy's hospital, Lewisham and a few others.

There was then the cash crisis of the winter of 1987-88, when the previous Prime Minister was forced on one of the few occasions during her premiership to back down in the face of public pressure. Rather paralleling her similar experience in 1981 with the miners, she did not take the matter lying down and set in train a series of events which was designed to reorganise the NHS and, more particularly, to wreak her revenge upon it. The consequence of that came to fruition in 1990, when we got the regime under which the NHS currently operates, with the emergence of self- governing trusts.

What are those trusts? They are collections of self-appointed individuals, who asked nobody whether they wanted them to take over the health service. They have consulted no one who would be a beneficiary of those services. They just selected themselves and decided that they would provide the health services in an area because they knew best. We have particular experience of that in Lewisham and North Southwark, because we had the flagship trust of Guy's and Lewisham launched upon us.

Those of us at the Lewisham end of that were particularly concerned. We were told that Lewisham hospital, as a relatively insignificant district general hospital in the shadow of a major international institution like Guy's, had no conceivable future away from Guy's hospital. We were told that there was an umbilical and incontrovertible link between Lewisham and Guy's. To coin a phrase, what was needed to improve the health services in our part of south-east London was an ever-growing union.

Then came the Tomlinson report. More than anything, that report was a substitute for the fact that there is no single regional health authority in London. Many of the problems in London's health services will not be solved until such a time as there is a region-wide London health authority. The other reason for the emergence of Tomlinson was the immense distortion which the internal market was creating, not just across the country, but in London in particular.

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