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Points of Order

3.31 pm

Mr. Kevin Barron (Rother Valley): On a point of order, Madam Speaker. May I ask you for some advice? During the passage of the private Member's Bill that I promoted last Session, the Tobacco Advertising Bill, there were denials in the Chamber about the involvement of people who were against that Bill and denials about the involvement of lobbyists. On the front of The Guardian newspaper this morning, it has become quite clear that the lobbyists Ian Greer Associates have been approaching individual Members of Parliament, including Ministers and, I must say, even the Prime Minister's former Parliamentary Private Secretary, in relation to assisting them in cutting back on the Bill and on any tightening of a voluntary code on tobacco advertising, which was taking place at the same time.

I have now received a copy of a letter, which clearly states that on one occasion that company was also approaching Members of Parliament on the basis that bus shelters in their constituencies would be provided free by the advertising industry. It is quite clear that the company was using that issue to get at Members of Parliament. Would you, Madam Speaker, advise me what redress there may be and whether such lobbying is a breach of the rules of the House?

Madam Speaker: I have allowed the hon. Gentleman to raise his long point of order. I listened to it very carefully as I, too, saw the report and was very concerned about it. But, having listened, I am afraid that I conclude that what he has said does not raise a matter on which the Chair can rule and, as he knows, I do not offer advice across the Floor of the House. He will have to find other ways in which to raise the matter. Indeed, I would not rule him out of order if he wished to use the information in the debate today. If the hon. Gentleman would like to come and see me, I will advise him as best I can on the issue that he has raised.

Mr. Nicholas Budgen (Wolverhampton, South-West): On a point of order, Madam Speaker. May I draw your attention to the motion on the Order Paper concerning the business of the House, which, as you will see, has no second paragraph? You will recall, Madam Speaker, that in the motion on the business of the House tabled yesterday, there was a second paragraph--a sittings motion concerning the European Communities 1995 budget. That motion would have limited discussion of a very important matter to one and a half hours.

You will know, Madam Speaker, that a number of us objected to the sittings motion last night, which meant that it had to be tabled for consideration again today. It has been tabled again, but in truncated form. Paragraph (ii) has been omitted, which means that those of us who believe that we should press the Government for lengthier and more detailed discussion of the European budget have lost the opportunity of raising the matter on the Floor of the House. I am sure that it will not be argued by my right hon. Friend the Leader of the House that paragraph (ii) was unnecessary yesterday. If it was necessary yesterday, it is necessary today. The grave suspicion is left in the House that the rights of many hon. Members are being denied as

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a result of the threat of dissolution, and that we are even being deprived of the right to debate properly the European budget.

Mr. Dennis Skinner (Bolsover): Further to that point of order, Madam Speaker. It is conceivable that the Government realised very quickly that they would be unable to allow a debate on the motion. May I suggest that they leave it on the agenda, which means that the matter will be open- ended. The advice that I should like to give, through the Chair, is for the hon. Member for Wolverhampton, South-West (Mr. Budgen) to join those of us who will oppose the Government closing the motion. In that way we can put a stop to it all.

Madam Speaker: As the hon. Member for Wolverhampton, South-West (Mr. Budgen) has rightly observed, the motion on today's Order Paper is not the same as that which was objected to yesterday, and also last Friday. There is nothing wrong, however, with the Government tabling a different motion today. They are at liberty to do that. Mr. Budgen rose --

Madam Speaker: Order. I have not finished yet.

The motion that the hon. Gentleman is discussing is not on the Order Paper. We have to discuss that which is on the Order Paper. If he had cared to consult the Clerks, I think that they would have been able to demonstrate to him that there may have been some purpose in the original text which he has failed to detect.

Mr. Skinner: Yes, that's right.

Madam Speaker: Exactly.

If the hon. Member for Wolverhampton, South-West is asking for further time, that is a matter not for me but for the Leader of the House.

Mrs. Alice Mahon (Halifax): On a point of order, Madam Speaker. I know that you will share my concern about the matter that was raised by my hon. Friend the Member for Rother Valley (Mr. Barron). As you will be aware, the Select Committee on Health produced a report on tobacco advertising. If Chairs of Select Committees agree to one-to-one meetings that are arranged by lobbyists, are there any rules obliging them to report back to Select Committees after those meetings? I am a member of the Select Committee on Health and I have no recollection of being told of the meeting that took place, involving the Chair, which was arranged by a lobbyist. The members of the Select Committee have an interest because we produced a report.

Madam Speaker: I must tell the hon. Lady clearly that there are no rules of the sort to which she is referring. I hope that that makes the matter clear.

Mr. D. N. Campbell-Savours (Workington): Further to that point of order, Madam Speaker. I am sorry to press the issue, but is it not true that when a Chairman of a Select Committee meets a person who otherwise might be in a position to give evidence to that Committee, there is an onus on the Chairman or Chairwoman to report the meeting to the members of the Committee? In this instance that clearly did not happen. Will you ask your Clerks, Madam Speaker, to ascertain specifically what happened in this case? On what date did the Chairwoman

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meet representatives of the tobacco industry? On what occasion did she indicate to some members of the Committee--

Madam Speaker: Order. Of course I shall make further inquiries. I was correct in saying that there are no rules. It is for Committees and Chairmen to regulate how they proceed. As I have said, I shall make some inquiries, as the hon. Member has asked me so to do.


Health Authorities

Mrs. Secretary Bottomley, supported by Mr. Chancellor of the Exchequer, Mr. Secretary Redwood and Mr. Gerald Malone, presented a Bill to abolish Regional Health Authorities, District Health Authorities and Family Health Services Authorities, require the establishment of Health Authorities and make provision in relation to Health Authorities and Special Health Authorities and for connected purposes: And the same was read the First time; and ordered to be read a Second time tomorrow, and to be printed. [Bill 2.]




(1) Standing Order No. 13 (Arrangement of public business) shall have effect for this Session with the following modifications, namely:

In paragraph (4) the word `thirteen' shall be substituted for the word `ten' in line 44; in paragraph (5) the word `eighth' shall be substituted for the word `seventh' in line 46;

(2) Standing Order No. 90 (Second reading committees) shall have effect for this Session with the following modification, namely: In paragraph (2) the word `eighth' shall be substituted for the word `seventh' in line 23;

(3) Private Members' Bills shall have precedence over Government business on 20th and 27th January, 3rd, 10th, 17th and 24th February, 3rd, 17th, 24th and 31st March, 21st and 28th April and 14th July.--[ Mr. Newton .]

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Orders of the Day

Debate on the Address

[Fifth Day]

Order read for resuming adjourned debate on Question,

That an humble Address be presented to Her Majesty as follows:-- Most Gracious Sovereign,

We, Your Majesty's most dutiful and loyal subjects, the Commons of the United Kingdom of Great Britain and Northern Ireland in Parliament assembled, beg leave to offer our humble thanks to Your Majesty for the Gracious Speech which Your Majesty has addressed to both Houses of Parliament.-- [Mr. Dunn.]

Question again proposed.

Health and Social Security

Madam Speaker: I have selected the amendment in the name of the Leader of the Opposition.

3.39 pm

Mrs. Margaret Beckett (Derby, South): I beg to move, as an amendment to the Address, at the end of the Question to add: But humbly regret that the Gracious Speech omits measures which either address the fears or advance the hopes of the British people; calls instead for a commitment to provide a National Health Service which offers equal access to care for all, is run for the public good and has clear accountability to those it serves, and for a commitment to build a Social Security system designed to take people out of poverty, offer opportunity and enhance skills; and further calls for a legislative framework for occupational pensions fully implementing the Pension Law Review Committee's report, for regulations to control the mis-selling of private pensions, for the abandonment of Incapacity Benefit and the Jobseekers Allowance, which both target vulnerable people in society, for the early and urgent reform of the Child Support Agency, and for the introduction of comprehensive civil rights legislation outlawing discrimination against disabled people. The Queen's Speech has left a dominant impression with everyone, from Members of the House, through the news media to the nation as a whole: it is of a Government not only dithering, divided and demoralised, but hopelessly out of touch with the reality as well as the challenges facing the people of Britain. It is a Queen's Speech which could have been computer-generated. Like three-dimensional computer graphics, it allows the Prime Minister and his colleagues at least to imagine that they are interacting with reality. However, like computer users with their mouses or space balls, the image and view of the world reflected back through the speech is a virtual world. It is an encounter with virtual reality, not with the real world.

The Prime Minister and all his colleagues, including the Secretary of State for Health, have retreated into a two-dimensional world of their own. It is a world in which the Maples memo so clearly and chillingly reveals the priorities set by the Government. We are told that it contains a long analysis of what the Tory party should do about health--not, please note, what it should do to redress the damage done to the national health service, but what the Government should do to conceal that damage from the public.

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Mr. Maples recommends slowing down the process of change, to conceal its full effects, if possible, until safely after the election. Meanwhile, he says that the Secretary of State should silence the staff and keep flannelling away with so-called killer facts. However, the Secretary of State for Health has been doing that for years. That is how the Tories ended up 55 points behind in the polls.

What are those killer facts? They seem to me to be what Norman Mailer famously called factoids. According to the dictionary, they are statements that take on the reality of a fact simply by virtue of being uttered and repeated and repeated. They are factoids like, "The national health service is safe with us." They are factoids like the Prime Minister's, "The national health service will not be privatised while I live and breathe." They are factoids like, "The old NHS was a centralised bureaucracy," when, in 1986, there were only 500 general and senior managers in England in the NHS and by 1992, there were 16, 700. They are factoids like, "The national health service now treats 3,000 extra patients a day," when the truth is that those figures refer not to patients, but to finished consultant episodes. Patients can be double counted if they see more than one consultant or if they are discharged too soon and have to be readmitted.

Those are factoids. The killer facts are those which the Government seek to suppress. They are killer facts like that pointed out by the chairman of the British Medical Association recently:

"there is no longer one National Health Service. There are 100 purchasing consortia and 400 provider units each with its own self-serving view of its best interests."

Another killer fact is that there are fewer nurses in the health service today than 10 years ago and more accountants. There are killer facts like the one in the press today that 18 county councils are close to running out of money for community care. There is the killer fact that thousands of families in every part of Britain are finding out that there are no longer any NHS dentistry facilities in their area.

In the real world, there is deep disquiet about the state of our national health service. In an Opposition day debate a few days ago, we referred to the Secretary of State for Health as the Madame Mao of the health service, embarked on a process of continual revolution. The structural proposals contained in legislation to abolish regional health authorities are the latest development in that process. Those proposals, together with the others referred to in the Gracious Speech, demand and will receive careful scrutiny in the House. Both on Second Reading and in Committee, we shall want to explore in depth the worth of the Government's justification for their proposals; what else might be the effect--intended or otherwise--of them as they stand and thus what amendment might be required; and last, but by no means least, the background against which the legislative changes will operate.

The questions that we want to ask about the structural changes, which will be explored in depth when the Bill is introduced, have been thrown into sharp relief by other statements made during the past few days--statements far more revealing than the Secretary of State's factoids about what the Government's so-called reforms are doing to the

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national health service. They are revealing, too, of what her public relations drive seeks to conceal and what the reforms are intended to achieve.

Mr. Alan Duncan (Rutland and Melton): Will the right hon. Lady give way?

Mrs. Beckett: I take it that the hon. Gentleman is in training to be one of Ryder's wreckers.

Mr. Duncan: Before my hon. Friend the Member for Woodspring (Dr. Fox) gives the right hon. Lady some cream to cure her factoids, will she refer to the amendment, which demands clear accountability to those whom the NHS serves, and explain in detail what she means by structural reforms? Is she suggesting that, once again, local councillors should have a hand in deciding how the NHS is run? [Interruption.]

Mrs. Beckett: I hear from my hon. Friends behind me that that is precisely the idea being floated in Wandsworth, but I would not care to take responsibility for anything that the Conservative council there might propose.

I say to the hon. Gentleman what has been said repeatedly in the House, in the hope that neither he nor anyone else will feel the need to raise the matter again for a while--that we have produced a consultation document that is being considered across the country. I know that Conservative Members are unfamiliar with such a process. We have identified the key questions and problems raised by the Government's reforms and we have invited suggestions on what should be put in their place. We have given people months to complete that process. Conferences have been held by a variety of interested bodies, such as the British Medical Association, to discuss what should replace the Government's reforms. That process is under way and we expect responses within, we hope, another couple of months. We shall then consider what policy to put forward.

I fully understand that that process is completely foreign to Conservative Members. They think that consultation means that first they make up their mind, then they give everybody else three weeks to digest at least some sign of what they have in mind and then they rush through the legislation and we all pick up the pieces afterwards. That is not consultation as the Opposition understand it. It is because we want to preserve the NHS as the British people cherish it that we are undergoing a proper consultation process. I hope that I have made the matter quite clear to the hon. Gentleman. The first of the observations to which I referred emanated from one of those people hand-picked by the Secretary of State to carry out Government policy--Mr. Roy Lilley, the chair of the Homewood trust. We have questioned the degree to which those appointed to trust boards have overwhelmingly, although not exclusively, been drawn from the ranks of members and supporters of or contributors to the Tory party. We recognise that within even those exclusive and fast-diminishing ranks there appears to have been a bias in selection towards those so in tune with the Government's health policy that they can be instinctively relied upon to understand what the Government are really about and so quietly help them to pursue their objectives, stated or unstated.

Mr. Lilley has always been seen as, in the Secretary of State's terms, the creme de la creme; one of her red guards. When he says that the first duty of a doctor is to

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the organisation in which he works and that his duty to patients comes in only third place, we know that the British people are absolutely right to be deeply distrustful of the intentions of both the Government and the Secretary of State. Now, the truth is out. Roy Lilley has done for trusts what Gerald Ratner did for his jewellery business--he has told us what the consumers are really getting from the Secretary of State.

Again, Mr. Lilley said:

"The proposition that a doctor's first duty is to his patient, is without question, definitely, positively, wrong . . . The more I think about it the more I am convinced it is not only wrong. It is stupid and dangerous to entertain the thought that it might be, even partly, right. No it is out of the question. The doctor's first duty is not to the patient."

Those words, coming as they do from one of the Secretary of State's hand- picked appointees and one of those closest to the pace and direction of her reforms, carry more significance than do 55 copies of the patients charter.

Astonishingly, despite what the Secretary of State said in our previous debate, the view that patients should not come first does not seem too unhinged to command her support. To be fair, at first she dithered a little. One member of the Department's army of press officers was instructed to issue a press release that seemed to distance her from Mr. Lilley's remarks. But when she was questioned at another press conference, she blurted out a ringing endorsement of Mr. Lilley and his bona fides. The Secretary of State endorses Roy Lilley's vision that a hospital should be run like a giant store, with the major imperatives being maximum throughput and commercial gain. That may be Mr. Lilley's vision of the national health service. It is not what the British people expect, or what they were told to expect, from the Government.

I have no doubt that the Secretary of State will argue that her vision is a little more upmarket. She prefers, after all, to shop not in such a giant store but in Marks and Spencers when there is no one else about. She took a lot of stick, I know, after her special treatment was made public. I could not set foot in Marks and Spencers for weeks afterwards without complete strangers stopping me to chortle, "I see they have not made any special arrangements for you, then."

It is much more worrying that, when it comes to health, the Secretary of State can tolerate a two-tier system which allows people like herself to sail through undisturbed while most of the community are expected to jostle and muscle their way through the crowds for a little service from their consultant and a little decent health care.

I have no doubt that the Secretary of State will tell us that the social attitudes survey published recently shows a smaller degree of dissatisfaction with the health service than has been the case on some occasions in the past 10 years. I certainly accept that, but lest the Secretary of State intends to dwell at length on what the social attitudes survey reveals, let me make sure that the House is clear that from 1983 to 1989 there was a continuous increase in dissatisfaction with the health service which reached major, unprecedented proportions. All that we have seen is that in the past 12 months or so there has been a slight decline in the degree of dissatisfaction.

Moreover, we are indebted even more recently than we are indebted to Mr. Lilley to Eric Caines, professor of health service management at Nottingham university, for

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a further revealing insight into today's national health service. Professor Caines said in an article in The Times on 17 November this year:

"public service never had a very solid foundation, and is now commonly regarded as something either to be avoided or exploited." Professor Caines is not any old professor of health service management, but a former senior civil servant in the Department of Health, a deputy secretary no less, and the former director of personnel for the NHS.-- [Interruption.] I will say that again, especially as the Minister of State seems to find it amusing. The man who tells us that public service has never had a solid foundation was, until last year, the director of personnel for the NHS. What, for heaven's sake, was he doing in that job? He was the man responsible for the employment of doctors, nurses and ancillary staff. What does he say in praise of the new system over which the Secretary of State presides? He says:

"Competition is the new form of motivation--based on the recognition that when all else fails, anxiety is the most effective motivator."

That is his vision of the health service in the hands of the right hon. Lady and her colleagues. He describes a climate of fear--fear in the absence of a public service ethos. That climate of fear ties in all too well with existing and expected developments in the NHS.

Mr. Peter Thurnham (Bolton, North-East): Everything that I have heard the right hon. Lady say so far supports the case for the reforms and shows how well they are working. While she is quoting professors, should she not also quote Professor Julian Le Grand, founder of the Socialist Health Group, who has said:

"Few in the NHS would want to go back to the old pre-reform system"?

Mrs. Beckett: The hon. Gentleman cannot conceivably have been listening if he thinks that that is what I have just said. I have been quoting supporters of the Government and of the reforms, to show that they believe that they are there to build a health service in which competition is king; a health service that is run as a business; a health service in which members of staff are to be set at each other's throats and put in fear of their jobs. That is not the health service that the hon. Gentleman promised the British people at the last--or any other--general election.

Professor Caines is describing a climate of fear, as I said, and it ties in all too well with what is happening in the NHS. There are, for instance, what I understand to be the Secretary of State's long-standing instructions that, nationally and locally, it is the job of press officers to keep bad news about the health service out of the media. Their task is to keep the Secretary of State in the limelight but out of the firing line. Suppression of information and/or promoting misinformation along the lines advocated by John Maples is already much too widespread a feature of the health service under the right hon. Lady.

Quite apart from the misuse of civil service press officers to serve political interests instead of the public interest, there are also the notorious gagging clauses which are now widely imposed in the new health service contracts that staff at all levels are being required to sign.

Just in case anyone is in any doubt as to where performance-related pay might lead us, Mr. Lilley gives us a helpful steer. Staff are expected to promote the trusts'

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interests, not patient care, and it is presumably on that basis that the quality of their contribution, and presumably their pay, will chiefly be judged.

I am well aware that in recent days the Government have been claiming that there has never been any suggestion that pay should be related to the performance in service of individuals; rather it should be related to the overall performance of a trust. That still raises questions about the dangers of giving trusts a greater incentive to concentrate on more straightforward or more lucrative areas of treatment at the expense of those that are difficult or costly. Of more significance in this context, however, is the fact that it appears to be untrue that individual performance-related pay is not what the Government first proposed or intended.

As I recall, in November last year the Government referred to performance- related elements for doctors. On 19 October the Minister of State spoke of local pay being based on organisation-wide performance, but the fact is that trusts will still have complete freedom to organise whatever pay structures they want, and individual PRP is still on many of their agendas.

In any case, as I have said, organisation-wide PRP does not appear to be what the Government initially proposed. In 1993 they said: "each scheme should have clear objectives linked directly to the organisation's business needs"--

yet another sign of how the Government see the health service. The Government maintained that

"systematic assessment should be the backbone of performance pay schemes",

and went on to refer to the

"positioning of staff on PRP scales".

That has to mean individual performance-related pay: the statement can be read in no other way. I recognise, of course, that it suits the Government now to pretend that they had something less direct in mind, but their own statements do not bear that out.

Lady Olga Maitland (Sutton and Cheam): I thank the right hon. Lady for giving way, but I have to say that her script, which clearly is produced for her by her spin doctors, is serving only to alarm and to frighten patients. Is she aware that my constituents, who are patients of the St. Helier trust hospital, are delighted with the service that they are getting? They are grateful for the result of the health service reforms, which are giving them faster and speedier treatment.

Perhaps the right hon. Lady might care to comment on one factor. Does she regret the fact that, when she was a member of the Labour Government, she supported a programme that cut doctors' pay, cut nurses' pay and cut health spending?

Mrs. Beckett: I think that the hon. Lady does not need lessons from anybody on how to perform to a script. I am delighted, of course, if the patients in her part of Britain are receiving exactly the treatment that they want and deserve from their local trust. It is just a pity that that is not the case everywhere else. I will say quite bluntly to the hon. Lady that it is not Opposition Members who are raising fears that are unjustified. It is not we who are ignoring the reality of the health service. Why, I ask the hon. Lady, does the Secretary of State come lowest- -even

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among the Cabinet--in the public ratings for sincerity? Why, I ask the hon. Lady, does she think that the Conservatives are 50 percentage points behind in the opinion polls if it is not we who are describing the reality of the national health service? She is living in an unreal world.

The Minister tried to pretend that the Government did not originally intend to create a system of individual

performance-related pay. I am afraid that that is not the only recent example of a Minister being parsimonious with the actualite . In the previous debate on the health service, the Minister for Health was good enough to quote a headline in a recent edition of the Derby Evening Telegraph , my local paper, which talked about the people whom we can trust. Because it referred to the people who manned the boards of the health trusts in our locality, he said that that showed that what we were saying--about how difficult it was to get information on why the matters were not in the public domain--was ill founded and untrue.

I have, especially for the Minister, a fresh copy of the Derby Evening Telegraph from the following day. As he will see, its headline is, "No Minister!" In a most interesting observation, the editor said:

"Mr. Malone has shot himself in the foot. It took us . . . weeks to prise those names out of the authorities.

No-one would tell us who was going to be in charge of running our hospital, how much they would be paid or how they came to be given the posts.

And when we did manage to find out who the chairman would be, and that he was to be paid £20,000 a year for a few hours work a week, the powers- that-be went into an immediate sulk and refused"--

Dame Jill Knight (Birmingham, Edgbaston): On a point of order, Madam Speaker. After some years as a Member of the House, I thought that it was not usually the done thing to read verbatim at length from a newspaper report during the course of a debate, but merely to quote.

Madam Speaker: I thought that the right hon. Lady for Derby, South (Mrs. Beckett) was quoting from a newspaper. It did not seem to me to be unduly long. Perhaps I was distracted from what was happening. Has the right hon. Lady finished her quote?

Mrs. Beckett: Only a very few more words, Madam Speaker. As the hon. Member for Birmingham, Edgbaston (Dame J. Knight) will realise, I am most anxious to be accurate, because I do not wish to be unfair to the Minister.

The editor went on to say that the spokespeople

"refused to tell us anything about the rest of the unelected board members."

He continued:

"When you consider that the old district health authority was required by law to hold public meetings every two months, while the new trusts are obliged to have one public meeting a year, it makes a mockery of the minister's assertion that there is no secrecy." I am grateful to the Minister for allowing me to make clear the view of public commentators in our locality. I do him the justice of assuming that--at least on that occasion--he simply did not know any better. Somebody gave him a handy headline and he did not bother to make inquiries about the facts behind it. It is part of our charge

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against the Government, as it is our charge against the Gracious Speech, that, on so many occasions, they are simply and completely out of touch with real life in Britain today.

In fact, the Secretary of State is not only out of touch with the people; she is out of touch with her party--whose activists attacked her at its conference on just that basis--and with the experts, the City of London, the chattering classes and even some of her ministerial colleagues. The City of London clashed with her over Bart's. Hardly a journalist in the land will write copy in defence of her new health service.

Indeed, things have become so bad that the Secretary of State is not even in touch with the Daily Mail any longer. Let me quote--briefly, of course-- what Lynda Lee-Potter wrote in that paper: "Maybe Margaret Thatcher will finally concede that she made the greatest error of judgment of her political life when she instigated the so-called health reforms without any consultation with the medical profession."

The Secretary of State is out of touch even with her own colleagues. Only two weeks ago, the Secretary of State for Wales--who does not seem to be with us now--complained to a conference on health managers that there was too much jargon, and that it was about time that they got out from behind their desks. He said:

"When I visit a hospital I would like to be greeted with news of medical triumphs . . . not with more views on hospital


I never thought to see the day when I would agree with the Secretary of State for Wales, but it has clearly dawned.

It already seems clear that, whatever the merits of the legislative proposals for reorganisation contained in the Queen's Speech, they will need careful examination so that their potential drawbacks can be explored. We are prepared in principle, for example, to give a fair wind to proposals to allow the General Medical Council to address the question of the service and care provided by general practitioners; and we have no great quarrel with the strategy to bring together the work of family and district health authorities. We view with a degree of mild cynicism the trumpeting of claims that abolishing regional health authorities will be a triumph for the reduction of bureaucracy, coming as they do from a Government who have presided over an unprecedented explosion of bureaucracy and costs in recent years, most of which will be left completely untouched by their proposals. We shall, however, want to explore the practical effects of those proposals.

As the Secretary of State must know, there is concern about the consequences for medical education and training. We shall be seeking assurances that some of the specialised patient services that are provided at regional level will not be disbanded if they cannot be provided at district level: there is real anxiety about services such as cancer registries, NHS screening programmes, surveillance and control of communicable diseases, health promotion and environmental health.

There is also anxiety about the implications for the wider community of the alternative means of consultation and representation that will be created. Medical, nursing and other staff wonder if and when their voice and experience will find an outlet.

All who noticed the Secretary of State's first stab at a replacement for existing sources of advice about such matters as appointments--the idea that a respected local

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