House of Commons Hansard Debates for 25 Oct 1994

Mrs. Bottomley: I am tempted, but I shall not give way. I must make headway.

Dr. Jones: I want to make an important point.

Mrs. Bottomley: If I do not make headway, other hon. Members will not be able to speak and I shall be severely rebuked later. I give the right hon. Member for Derby, South credit. She is at least conscious of her limited grasp of what has been happening in the NHS. When asked by Matthew Parris on BBC "Breakfast News" this summer whether she would keep any elements of the Government's health reforms, she replied:

"Yes that's a good question Matthew. I am trying hard to think whether there are any I would wish to preserve. I can't call one to mind at the moment, but don't hold me to that because I might realise afterwards that there was something that they have done that has been beneficial."

Conservative Members would be glad to help the right hon. Lady out of her difficulty. Scores of changes to the health service are beneficial to patients. We shall let pass no opportunity to tell her about them.

The right hon. Lady has been given an onerous brief by the Leader of the Opposition--to modernise her party's policies, to make them more positive and to bring them up to date with the reality of the new NHS. Oh dear; no wonder we are told that she is so miserable, and no wonder she has had such difficulty today.

The right hon. Lady's predecessor, the hon. Member for Sheffield, Brightside (Mr. Blunkett), spent two and a half years deciding what he opposed and fudging what he supported. He opposed GP fundholding. I wonder whether the right hon. Lady will hold that opinion. Seventy-four per cent. of patients in the area where she lives already have the benefit of GP fundholding. There is only another 25 per cent. to go and they will all have a top-tier service--but no, I suppose that it has to be equal misery for all in the right hon. Lady's book.

The right hon. Lady's predecessor opposed competitive tendering. He opposed pay beds in spite of the new modern Labour party. Then he went to Blackpool, boasting at the Labour party conference that a Labour Government would abolish trusts. He lapped up applause from union delegates. He basked in their admiration for his dogged refusal to accept the Tories' agenda. What was his reward for that ideological triumph? Two weeks later, he came fourth from bottom in the shadow Cabinet poll and was sacked from the position of shadow Health Secretary by the Leader of the Opposition.

Oh dear. It falls awkwardly to the right hon. Lady, who scarcely has a reputation as a moderniser of her party, to pick up the pieces, but she has frankly inherited a time capsule. While all around her is going forward, she looks backwards to the old days. In the meantime, independent commentators, such as the Organisation for Economic Co-operation and Development, recognise that Britain, whose NHS has long been the envy of the world, is now setting the pace in health care reform. The Labour party wants to

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go back to the oppressive, centralising state control that has been rejected, not simply here, but throughout the world.

The challenge is to seize the reforms and to build for the future. I suggest the following to the right hon. Lady:

"Central planning was not a conspicuous success in the health service; decentralised sources of information close to local needs, like GP fundholders, may provide a better base for long-term decisions than a centralised planning agency."

Those are not my words, but those of Professor Julian Le Grand, the founder of the Socialist Health Group and one of the foremost advocates of our reforms.

The right hon. Lady will have to decide whether she will abolish 419 trusts when almost every hospital is now a trust, and doctors, nurses and managers are using the freedoms of trust status to innovate and to improve benefits for patients. Is she serious about abolishing fundholding? Does she believe, for example, in decentralisation, or is she more interested in the doctrinaire pursuit of uniformity over diversity? Is she really committed to patient power and patient choice--there has been no evidence of that today--or is she simply a poodle of the trade union movement? I challenge the right hon. Lady: if her commitment to patients is genuine, she should renounce her sponsorship by the Transport and General Workers Union, so that we may be sure in whose interest she is speaking. Does she want to? No; there is silence.

The right hon. Lady resorted to the old scares and smears about privatisation. She produced no new evidence--simply peddled more of what my right hon. Friend the Prime Minister described as the most insidious lie in politics. That privatisation scare story, which she regurgitated today, discredits the Labour party and dishonours the truth. Labour Members have been running it for years; they paid the electoral price for it in 1992 and they will pay the price again.

Mrs. Fyfe: The right hon. Lady claims that Opposition Members are wrong to say that the health service is being privatised. What else does she call it when the Secretary of State for Scotland gives £30 million and more to a private hospital that is allegedly built to take overseas patients and, when it fails to succeed in that objective, survives by moving in patients from Manchester, Birmingham and anywhere else that it cares to dip into when it cannot obtain patients of its own from overseas? How can one plan for a national health service and national health service care of patients when that is allowed to happen?

Mrs. Bottomley: I think that the hon. Lady knows that there is everlastingly a call for inward investment in Scotland, and it was in that context that the Secretary of State made that decision. It was not money that came from the health budget, but the hospital is providing health care for many NHS patients, and I care about patients. The Labour party's real agenda is not about patients; it is not about the so-called public alarm. It is about trade union power; it is about the old clause IV preoccupation.

Let me make it clear, as the Prime Minister did at Bournemouth, that the Government will not deviate one dot or comma from the fundamental underlying principle of the NHS. Care is provided for everyone on the basis of clinical need, regardless of ability to pay. However, where

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there are benefits to be gained for patients from working more closely with the independent sector, we will pursue those benefits. Where there is scope for innovation, flexibility and choice, we will let those qualities have their head. When we can secure additional investment in the NHS through private finance, we will seek to reap those opportunities soon.

We spoke during health questions about the importance of the private finance initiative. We welcome the extra resources that result from that initiative. We want a modern service for patients. We also welcome the £1 billion of efficiency savings that have been secured as a result of market testing.

Ms Armstrong: Will the right hon. Lady give way?

Mrs. Bottomley: I have already given way to the hon. Lady, and it was not very rewarding.

The Labour party would deny NHS patients that money and the benefits from it. The price tag of that is all for the Labour party's blinkered dogma; another little sweetener promised to the unions. The Labour party must make up its mind. Who was it, as I said earlier, who said that the Government had to ensure that the public and private sector worked together? I may have given the hon. Member for Newcastle upon Tyne, East (Mr. Brown) the credit, but I was quoting the Leader of the Opposition. I hope that the hon. Gentleman will understand if I have promoted him in that short space of time--not before time.

Mr. Nicholas Brown (Newcastle upon Tyne, East): It happens all the time.

Mr. Hugh Bayley (York): The Secretary of State was reaffirming the Government's commitment to equity--to equal access to care. Would the Secretary of State care to say why there are such wide differences in health among people from different social classes in different parts of the country, why those health inequalities are widening, and what the Government intend to do to narrow them?

Mrs. Bottomley: The hon. Gentleman needs only to look at "The Health of the Nation" strategy. That is designed precisely to ensure that we consider variations in health, so that we can make progress. I do not accept the view almost espoused by the Labour party that somehow it is so distressing for the healthier to become more healthy faster that one would rather hold them back than see progress throughout the range.

There have been major improvements in maternal and child health for all social groups, for all income groups and throughout the country. That is the significance of the distinction between the purchaser and the provider- -that the health authority is tasked with assessing health need and setting priorities. It is one of the many reasons why we would never turn the clock back to a monolithic, bureaucratic health service, as espoused by the Labour party. It does not allow the flexibility for local strategies and approaches to tackle the specific health needs of different parts of the country.

When looking at its agenda, the Labour party will have to come to terms with fundholding. I have already said that in the region of the right hon. Member for Derby, South, 74 per cent. of patients benefit from a GP fundholder. We recently announced that we shall extend the scheme--lower the list entry size, widen the range of services available and introduce new community fundholding schemes--to give even more practices the chance to

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experience its benefits. We have pledged to level up and extend the benefits. We will deliver that pledge to the patients of this country so that they see similar improvements.

I would commend to the right hon. Lady the new, independent evaluation of fundholding by professor Howard Glennerster. A first-wave fundholder states:

"For the first time, we had managed to get to talk to consultants about the standard of care they were giving our patients". That is the essence of the scheme--clinicians talking to clinicians about patient care.

Fundholding is rewriting the rules in the patients' favour. That marks, as Professor Glennerster states,

"a shift in the balance of power back to general practice for the first time this century".

General practitioners like it, patients like it and we like it.

Mr. Malone: Labour Members do not like it.

Mrs. Bottomley: They do not like it.

Nowhere is the Government's commitment to patients more obvious. Nowhere is it having a more dramatic practical effect. The Labour party takes a vindicative approach and always wants to level down, not up.

Mr. Kevin Hughes (Doncaster, North): I am grateful to the right hon. Lady and want to pick up something that she said earlier when talking about the constituency of my right hon. Friend the Member for Derby, South (Mrs. Beckett). The Secretary of State said that 74 per cent. of my right hon. Friend's constituents came under GP fundholders and that soon all of them would have a top-tier service. Will she explain what that means? Does it mean that other people do not receive a top-tier service?

Mrs. Bottomley: The key point about GP fundholding is that when the GP is in control and autonomous, and has control over the budget, he is able to secure improvements and has a flexibility and responsiveness which, with the best will in the world, is almost impossible to achieve unless he is in the driving seat. GP fundholding is a voluntary scheme, but we have made it as simple as possible for more GPs to join.

I simply commend again Professor Howard Glennerster's book in which he talks time and again about the commitment of GPs who come into fundholding and the benefits that they have been achieving, not just for their own patients, but for all patients in primary care. Their relationship with the hospital has also benefited.

The hon. Member for Doncaster, North (Mr. Hughes) should talk to Dr. David Colin Thome in Runcorn who fought as a Labour candidate in a previous election. He is a champion of fundholding and has pioneered changes and improvements for patients. Were the hon. Gentleman to spend time talking to that doctor it would be difficult for the hon. Gentleman to come away with any other view than that the future lay in fundholding and all GPs should pursue that option.

Dame Elaine Kellett-Bowman: I recall calling to my right hon. Friend's attention the fact that in my district the hospital fundholders had carefully husbanded their resources. When the trust was beginning to run out of funds at the end of the year, the patients of the fundholders were still able to be admitted. My right hon. Friend was good enough to give the hospital another £250,000 to

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catch up, but it was because the fundholders had carefully spread their resources over the year that their patients benefited.

Mrs. Bottomley: My hon. Friend has it. With that, I will try not to take any more interventions.

The important subject that we have been debating today is that of accountability. The Labour party has failed to grasp the fact that, under the old system, accountability went by the board. There was little information, less transparency and an opaque and impenetrable bureaucracy where no one knew what was happening or what anything cost, and few people even bothered to ask. Decisions were taken, not just behind closed doors, but behind closed doors tens or even hundreds of miles away. There has been a dramatic change--health authorities and trusts have clear and separate roles and identities. The patients charter sets out for the first time patients' rights in the NHS and their means of redress if things go wrong. We have opened up the service to independent, external scrutiny through the Audit Commission. We have thrown the light on the health service. We have dramatically improved openness and the information available throughout the service.

Mr. Denis MacShane (Rotherham) rose --

Mrs. Bottomley: We have reinforced our deep and abiding commitment to the values and ethos that underpin public service in the NHS. We expect from the service the highest standards of both personal and corporate conduct. That is why when Sir Adrian Cadbury first published his report, I invited him to meet me and a number of leaders in the health service to discuss the principles of corporate governance. I believed that they were appropriate to the NHS and took steps to introduce them. In April this year, after widespread consultation, I issued codes of conduct and accountability for trust boards and their members that closely followed the Cadbury principles. They represent a landmark for the health service. For the first time, we have set out the need for audit and remuneration commitments to ensure the proper stewardship of the vast resources at the disposal of the health service. For the first time, we have required members' relevant interests to be declared and established in registers of those interests. Throughout the years of health appointments, which have changed little since 1948, we have never before had registers of interests and proper codes of accountability and conduct. Those codes have been widely welcomed by Sir Adrian Cadbury, the Audit Commission, the Public Accounts Committee and, not least, the right hon. Member for Ashton-under- Lyne (Mr. Sheldon), who chairs that Committee.

The Labour party talks a lot about accountability in a sort of Islington dinner party way. But when it comes to the accountability that really matters to patients, it changes its tune. We have increased accountability by bringing decision making closer to patients through local health authorities and trusts. The Labour party resisted it. We have set in hand an information revolution throughout the service--through annual reports, annual accounts, access to medical records and other means. The Labour party carped and criticised. We published the information that patients and the public want about their local hospital in performance tables. The Labour party poured scorn on

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that initiative. Time and again when we make information available the Labour party does not seem interested in what the patient wants to hear.

The right hon. Member for Derby, South made a number of disparaging remarks about appointments to health authority trusts. I am sorry that she comes to the job so encumbered by that prejudice. I am sorry that she finds it necessary to attack non-executives with business backgrounds in the same way as she goes for knee-jerk attacks on managers. We need the skills of a great range of people to deliver the improvements in patient care.

When we consider the number of patients being treated now, we have to pay tribute to all those whose different talents, skills and expertise have made that possible. Sir Adrian Cadbury took a similar view; his report welcomed the role of strong non-executives who bring the insight of an outsider into the NHS. We endorse his view. Anyone who knows anything about running a service that spends £100 million a day would endorse that view.

If the right hon. Lady wonders why she can identify fewer of her supporters on NHS trusts, I have already today made the reason only too clear. If she constantly denigrates and attacks the non-executives on NHS trusts, what encouragement is that to members of the Labour party who want to undertake that sort of public service? Can the lack of supporters on NHS trusts be anything to do with the Labour party's history of putting the frighteners on its members who seek to serve on trusts--as we saw before the last election? Is it any wonder that the hon. Lady cannot succeed in getting Labour members onto trusts when she pledges to abolish trusts given half the chance?

The right hon. Lady and the Labour party politicise trusts by making them part of the party political debate. Everywhere else they are part of the landscape, not part of the debate. Unlike the Labour party, we appreciate the talent that is brought to the trusts by non-executives and leaders of the profession such as Dame Margaret Turner Warwick, a former president of the Royal College of Physicians and now chairman of the Royal Devon and Exeter trust.

My challenge to the right hon. Lady is to turn the clock forward and to recognise that trusts are good for patients and staff. She must recognise that there is a place on health boards for people of genuine merit who will bring to them their skills, experience, energy and commitment. She must accept that serving on a trust is like being a magistrate--it is something in which people of all political parties should be engaged as a form of public service. That is not a party political statement: it is a statement of fact.

Let me now reveal some of the Labour party's hypocrisy. The policy of appointing chairmen has changed very little since 1948. We have reduced, and are reducing, the number of appointments as we streamline authorities and boards and make them decision-making groups. Does the right hon. Lady know which party, before our reforms, nominated three disqualified Lambeth Labour councillors

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to the West Lambeth health authority? Which party put forward its three prospective parliamentary candidates as its nominees for the Greenwich health authority?

Mr. Nick Raynsford (Greenwich) rose --

Mrs. Bottomley: Which Secretary of State sacked--

Mr. Raynsford: On a point of order, Madam Deputy Speaker. Is it in order for the Secretary of State to decline to give way to me when naming for the second time today an hon. Member of this House?

Madam Deputy Speaker: It is entirely a matter for whoever has the Floor to decide whether to give way.

Mr. Raynsford: She is frit.

Mrs. Bottomley: No; she has given way much more often than she ought to have--

Mr. Raynsford rose --

Mrs. Bottomley: However, in the interests of neighbourliness to my husband, I shall give way.

Mr. Raynsford: Does the Secretary of State think it right that people who have been proposed perfectly legitimately by a local authority, and who have a deep concern for that authority, should be replaced, for health authority membership, by double glazing salesmen--because that is what her party did? Does she think it right that the Greenwich health authority subsequently reduced the health situation there to chaos--so much so that when her appointee in the region visited recently he had to recognise that the whole system was not working, and the chair and chief executive of the local healthcare trust have had to be replaced? Is the right hon. Lady proud of that record?

Mrs. Bottomley: The hon. Gentleman is being extremely mischievous. He must know that Rosie Barnes, a former Liberal Member of Parliament, serves in his part of the world. He may also like to know that two Labour councillors serve on the Leeds community and mental health trust. Of course there are times in particular hospitals when certain management issues need to be tackled and some key people need to be replaced--that has nothing to do with the system of appointments-- [Interruption.]

Madam Deputy Speaker: Order. The House will be aware of my views on seated interventions. The hon. Member for Greenwich (Mr. Raynsford) has been allowed to intervene; I do not expect sedentary interventions to follow.

Mrs. Bottomley: I had expected the hon. Gentleman to deny that the Greenwich authority proposed three prospective parliamentary candidates as its nominees for the health authority. I wonder what their agenda would be? David Ennals, a former holder of my office, sacked 32 health authority chairmen purely and simply because they did not support the Labour party. Where is the integrity, the accountability or even the common sense in that?

We believe that the service benefits greatly from its non-executives, whatever their party. That is why we are establishing an even more transparent and accessible system. We are widening the pool of candidates, drawing in people from an even broader range of backgrounds and expertise. We have already greatly increased the number

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of women on trusts and in health authorities, and we have encouraged people from black and ethnic minorities. We are advertising widely for applicants, and independent panels of trust and authority members will sift and scrutinise applicants to ensure that the best people continue to be selected.

I share the Prime Minister's absolute commitment to the highest possible standards in public life, and we shall participate fully in the committee that he has announced today, but I believe that it will be found that the systems that we have set in hand in the health service are models to follow. If they need modifying in any way we shall not hesitate to modify them. Already, we have embraced the Cadbury principles, we have opened up our system of finding people to serve as non-executives, and we have made enormous progress. We need only one thing more--we need the Labour party to take the frighteners off the people who serve on the trusts and to support them. The real dilemma that the right hon. Member for Derby, South faces is how to tackle the feud raging in the Labour party over who should run the health service. She should act now to stop that feuding. She must say what her policy is. Does she seek to re-open the 1948 debate? Does she favour a local authority takeover of the NHS? Such a takeover would be deeply unpopular. Who believes that Derek Hatton running Merseyside would have had anything like the success of Sir Donald Wilson? Perhaps the right hon. Lady has a lingering affection for David Bookbinder in Derbyshire? We believe that the task of the health service is to serve patients, not to get tangled up with local authority control and involvement.

This was the old battle that Nye Bevan fought with Herbert Morrison, and it would be a great shame if the Labour party reopened the feud--but that is the problem that the right hon. Lady will have to deal with urgently in her party. Her predecessor was clearly moving in that direction, and we wait for the uncertainty to be resolved. The Royal College of Nursing has said that it believes that equity, one of the founding principles of the health service, would be undermined by local authority control of health services. If the right hon. Lady will not take my word on the issue, let her listen to Christine Hancock, who has said that such a proposal would at best block progress towards achieving the highest standards of care and equity throughout the service and at worst be the end of a national health service.

So if the right hon. Lady wants to reopen the wounds that were patched up in her party 40 years ago, let her say so--but let her also recognise the massive increase in bureaucracy that such policies would bring about. Let her confirm that, while the Government are abolishing regional health authorities, a Labour Government would bring them back. Let her come clean about her party's proposals for regional government; bureaucratic tentacles would then be wrapped around the health service. Let her admit that by abolishing trusts the Labour party would be reinventing the old command and control bureaucracies that we have swept away.

We will take no lessons from the champions of bureaucracy in the Labour party. They are committed to cumbersome regional bureaucracies; we want to sweep them away. We have cut the number of health authorities by 70. We shall reduce their numbers further by enabling family health services authorities and DHAs to merge. We have also reduced the number of regions, before their abolition.

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Over the past year alone, administrative savings at regional and district level have led to an extra £34 million being invested in patient care. During the summer, I visited every region and spoke to every trust and every health authority chairman, and I heard about the savings that are already being secured: £4.7 million in Northern and Yorkshire, £6 million in South West, £15 million in the two Thames regions--all by streamlining.

I have already mentioned Sir Donald Wilson in the north-west saving £8 million by streamlining and investing the money in better primary care in Liverpool's most deprived area. I cannot remember when Liverpool last saved £8 million for anyone.

All trusts must be accountable for what they spend on management and for how they spend it. That is why I announced that all trusts will publish their management costs in their annual reports so that the public can see and compare the figures. They will be published alongside the performance tables so that people can see the added value that management is bringing to the NHS. That is better than indulging in knee-jerk attacks on managers.

All I ask is that we are judged by our results. The achievement of the reforms has been to put the right structures in place for a flexible and responsive service. The reforms have been tried and tested in practice and endorsed by independent evaluation, by the OECD and by experts and commentators. All over Britain, NHS staff have worked hard for those changes. They take pride in their work and want to realise the full benefits. The last thing that they want is the Labour party's recipe for a return to a centralised and inefficient bureaucracy.

Our policies are delivering results by which we shall be judged. We are prepared to be judged by the 3,000 more patients being treated every day in trusts, by the growth in childhood immunisation, by the improvement in the health of the nation, by the innovations in quality care which are to be seen in our health centres and hospitals. We are also prepared to be judged on our record in reducing waiting times, junior doctors' hours and the size of GP lists.

We offer progress for patients. Our policies present a chance to tackle the problems which remain and to rise to the challenges and pressures that lie ahead. Labour is backward and inward looking. It looks back to the failed structures of the past and inward to its own vested interests. It is the old Labour party with old, failed and discredited policies. We have created a new national health service for a modern world, and I commend it to the House.

6 pm

Mr. Stephen Timms (Newham, North-East): Many facets of the health service worry hon. Members, and some of those worries have been mentioned in the debate. Since my election in June, I have had the opportunity to talk to many people who work in the health service in Newham and to patients who depend on it, and I have discovered enormous unhappiness about the state of the service. People are worried about the unexplained and steady rise in emergency hospital admissions. They are worried about the falling number of visits to dentists and opticians, because that means that problems which would have been found in check-ups now go undetected until they are far more serious.

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People are worried about proposed changes to the rules for pharmacies, because it is widely felt that they will drive many local chemists to the wall. Health officials are frustrated by restrictive rules on new medical premises, which are delaying improvements to primary care in London.

Above all, people feel that enormous decisions are being made by an invisible and anonymous bureaucracy which could not care less about what people think. The Prime Minister's pledge a couple of weeks ago that the health service would never be privatised has been mentioned in the debate. Will the Secretary of State stop the bureaucrats behaving as if the health service has already been privatised? People want the Government to listen. The August King's Fund report hit the nail on the head about the effect of the changes in London. Dealing with the Government's policies, it stated:

"The effect on public confidence has been severe. Patients have a confidence in their nurses and their doctors that they do not have in the managers and politicians. With tense negotiations continuing behind closed doors, most staff simply do not know where they stand. Public confidence has plummeted."

Just after I was elected, I contacted the local health care trust to inquire about the delay in carrying out an operation for an elderly constituent. The reply took some time, and when it came it was just an apology that the trust could not tell me anything. The operation was contracted out to a different health care trust, and although the patient had seen the consultant in our local hospital and was, as far as he was aware, a patient there, it could provide no information at all about when the operation would be carried out. People inside the service do not understand what has happened, let alone the patients.

A much more serious issue has arisen in east London about the future organisation of community health services. The City and East London family and community health services, or CELFACS, was set up to manage community health services in the short term after their separation from the new acute trusts, and to review the long-term options for their management. Nobody was too surprised when, no doubt after due and careful consideration, CELFACS recommended that the best option was for it to run the services.

The proposal went out to consultation and overwhelmingly, those who were consulted preferred an alternative structure with locally based trusts for Newham, Hackney and the City and Tower Hamlets. Their experience was that the CELFACS organisation was an unresponsive, top-heavy bureaucracy and which adopted a narrow and inflexible approach to services, which has failed to reflect the different needs in the different areas of east London. In the view of those involved, it is not an appropriate body to run community health services for so large an area.

I know that, in Newham, staff put in enormous effort on top of their existing heavy work loads to develop the local trust proposal, and the same happened in Hackney and the City. However, it was clear that, despite local strength of feeling, CELFACS had, quite properly, strong support from a small number of senior health managers, which, of course, included those who were running CELFACS.

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The issue went to the district health authority, which voted narrowly for the locally based trusts. The voting was four to three, all the non-executive members of the authority supporting the locally-based trusts while all the managers, the executive members, favoured CELFACS. One might have expected that that would be that, but the matter then appeared on the agenda of the executive committee of the regional health authority, comprising only authority managers. Predictably, they overruled the district view and recommended the CELFACS option. We gather that that has been forwarded to the Secretary of State as the final recommendation.

The Secretary of State alleged that Opposition Members denigrate non- executives. I do not denigrate them at all, and in the instance that I have cited, they were certainly carrying out their task conscientiously. But they were overruled by managers who are a step higher in the bureaucracy, and who have forwarded a different view to the Secretary of State.

I hope against hope that the Government will not simply rubber-stamp the view of the regional executive, because that would unleash a tidal wave of cynicism among the practitioners on which the services depend. It cannot be right to impose on those who will deliver the services the views of a small group of managers for what, as far as I or anyone else can establish, is no good reason. Is it not time that the Government adopted the motto, "Front Line First", not just for defence but for other public services? Constantly consulting the front-line providers and then ignoring them, preferring instead the views of managers, is terribly damaging to the services. That process is not the right way to make decisions about our vital public services. It is not so much the decision that is the problem as the transparently unacceptable way that it has been arrived at.

At the start of my speech, I asked what the Secretary of State proposed to do about managers behaving as if the health service were already a private corporation. I hope that, at least in this instance, she will overrule them.

Finally, I should like to address the issue of decision-making on the allocation of resources. I welcome the publication last week of the long- awaited York university report, with its recognition at last of the need for adequate funding for deprived areas, reversing the recent trend to take resources away from them. Earlier this year, my hon. Friend the Member for Bristol, South (Ms Primarolo) asked the Secretary of State which were the top 10 deprived health areas in London. My hon. Friend was told that my borough of Newham is the most deprived.

All the key indicators show that the severity of health problems in Newham justifies additional resources. Those problems relate to perinatal mortality and infant mortality rates, the standardised fertility ratio, the hospitalisation rate, the rate of HIV infection affecting children and families, income levels, and simply the need to provide translators to communicate with many people in the borough who can speak no English.

Government figures show that Newham has the most severe deprivation in the country, but its capitation has been cut, while capitation to other parts of the same region with much better starting points in terms of quality service provision has been raised. I have no problems about raising the funding for other areas, but it should not be done at the expense of areas that are acutely struggling.

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In publishing its research, York university rightly commented that the old formula produced in the early 1990s has resulted in a shift of resources away from poorer and sicker areas. Our family health services authority, the City and East London authority, has the highest level of deprivation in the country, but the FHSA spending per head in Newham was less than in Dorset, Cornwall, the Isle of Wight or Lincolnshire. Our services have far greater needs to contend with, yet they have been allocated fewer resources. That problem has been made worse since 1990. Again, that cannot be right.

I am delighted that the research by York university has vindicated what we have been saying for a long time. Can the Secretary of State now assure us that the findings of the York research will be implemented in full, allocating additional resources to the inner city areas where they are needed? Will she refute reports that efforts are being made to find ways of avoiding the implementation of the York university recommendations?

What will be done to put right the distribution of resources for primary care? Precisely the same problem exists there, with poorer and sicker parts of the community receiving inadequate resources. Is that problem now to be addressed?

People must be able to see who is making the decisions that affect their health service and to know the reasons for decisions that affect their lives and their futures. Inexplicable decisions cannot be allowed to continue descending anonymously from invisible layers of bureaucracy--a faceless, bureaucratic brick wall.

The country desperately needs the Minister to go some way to dispel the tide of cynicism and despair which, as anybody who speaks to those involved will report, is engulfing the health service; to acknowledge there are real problems to overcome instead of simply continually telling us that there is not really a problem at all; to make it clear that the Government are listening to what people are saying, not simply dismissing it; and to announce that the Government are prepared to change their mind where plainly they have been wrong.

6.11 pm

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