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Mr. Streeter: So the Labour party will abolish them?

Mrs. Beckett: What does the hon. Gentleman mean by "abolish"? Those trusts exist, and the hospitals and services that they run exist; of course we do not want to get rid of those services--no one does. If the hon. Gentleman is asking me whether we intend to continue with the structure of those individual health businesses, as set up by the Government, the answer is most certainly not--everyone is aware of that.

What causes huge resentment in the House and widely outside is the Government's attempt to outlaw the questioning and criticism of their policies towards the health service by insisting that anyone who attacks those policies is attacking the service itself. Let me, once again, put it clearly on the record that the Opposition are not attacking the health service, whether that means the staff, the patients or anyone else involved in its efficient

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operation. We are, however, attacking what the Government are doing to the health service and we have not the slightest intention of being deflected from that attack.

Part of the problem is that the health service is under attack--from the Government. In particular, all the staff who work in the health service, at every level, are under attack because the Government are attacking them. They are under attack by threats that their pay will be linked to their individual performance. They are also under attack because that performance will obviously be measured, at least partly, against the yardstick of loyalty to the organisation and the extent to which staff are prepared, as they were recently urged by one of the Secretary of State's most loyal supporters, to put the interests of the organisation before the interests of the patient.

They are under attack because, should they dare to speak out about their concerns and anxieties in relation to patient care, their very livelihood is threatened by the new gagging contracts issued by so many of the trusts which have been set up by the Government's legislative changes. Finally, and perhaps most insidiously of all, staff feel themselves to be under attack when they hear people like Professor Caines say that the very notion of public service is at an end, when it was exactly to engage in the service of the public that most of them joined the health service in the first place, and they still take pride in that concept.

The Secretary of State is seeking wide powers in the Bill--in many cases, wider powers than those available to previous Secretaries of State through earlier legislation under Governments of every political shade. Much of the detail of what is intended to be done with those powers is left unstated in the Bill. Yet again, we are witnessing sweeping enabling legislation from the Government, with an immense amount of the detail and execution of it left to regulations which, of course, cannot be amended. We are greatly concerned about that aspect of the Bill and we shall seek to explore it in Committee.

One thing that is clear from the Bill and the schedules to it is that, apart from taking substantial powers, the Secretary of State seems potentially to be removing from the arena others who might possibly have a different point of view or a different perspective to express. For instance, I was surprised as well as dismayed to see that the Government intend to abolish local advisory committees. According to another proposal in the Bill--exactly the type that will cause public concern--in future when a local hospital is thinking of applying for trust status, consultation--which in the past had been compulsory--will be carried out only if the Secretary of State thinks that is necessary, and then under terms that the right hon. Lady will decide sometime between now and when the regulations are published. The Bill contains no suggestion as to what those criteria might be. One thing that I should have thought that everyone in the House had learnt, at least from the experience of the workings of the Child Support Agency, is just how dangerous it is to leave all the detail--the framework of proposals--to regulations rather than just matters such as exact figures or precise dates, which have always been properly matters for regulation.

I listened with care to what the Secretary of State eventually said about the Bill. There are elements in it to which we can offer support--in particular, the proposal that district health authorities and family health services authorities should be merged. As my hon. Friends pointed

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out in sedentary interventions, the Labour party has long advocated that. Like the Government, we believe that such a merger could and should lead to more efficient management of resources, better planning and ultimately a better service for patients. We shall look forward to exploring in Committee the detailed implementation of that proposal.

That proposal, however, sits alongside the proposed abolition of regional health authorities. The removal of some functions from regional level and the apparent intention to devolve them to local level is a matter of concern not only to the Opposition but to people throughout the health service. We shall want to explore that issue, too.

As I am sure that the Secretary of State must be aware, widespread anxiety has been expressed about the loss from regional level of the maintenance of cancer registries or the handling of national confidential inquiries. However, the main matter that I shall first discuss is the Secretary of State's claim that those proposals and that aspect of the Bill are not merely part of the Government's so-called reforms of the health service, but a necessary part of completing the process of reorganisation.

It seems to us that that specific proposal is neither necessary nor desirable, and it leads us to have grave doubts about the real intentions behind that part of the Bill. We treat with considerable cynicism the Secretary of State's assertion that the changes that she proposes will automatically lead to improvements in patient care. The Government appear to be managing the operation of the national health service with the same level of competence that they apply to managing the Conservative party. Indeed, if the Government were a privatised trust and not a publicly financed, publicly accountable, publicly run Administration they would definitely be in severe difficulty. Their public relations consultant, Mr. John Maples, has just advised them that the British electorate are unwilling to renew their contracts and that they, the Conservatives, can never win on that issue. In consequence, he advises:

"The best result for the next 12 months would be zero media coverage of the National Health Service"--

not the best result for the national health service, but the best result for the interests of the Conservative party, to which alone the Government's concern appears to be directed.

Mrs. Virginia Bottomley: Will the right hon. Lady give way?

Mrs. Beckett: I am delighted to give way to the Secretary of State on the subject of the interests of the Conservative party.

Mrs. Bottomley: The right hon. Lady's account is bizarre. As I told the House this afternoon, in five years there has been a 65 per cent. increase in heart operations, a 44 per cent. increase in cataract operations and a24 per cent. increase in hip operations. Those are dramatic achievements. The number of patients being treated now--

Mr. Morgan: What was the increase in the previous five years?

Mrs. Bottomley: I can tell the hon. Gentleman that the increase in activity during the 1970s, when the Labour party was in power, was about 1 per cent. a year. The

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increase in activity throughout the 1980s was about 2.5 per cent. a year. Since our reforms, the NHS has been increasing the number of patients treated by about 5 per cent. a year. It is a much better, more efficient service, delivering much better quality.

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse): Order. I address these remarks not just to the Secretary of State but to everyone in the House. This afternoon it seems that the interventions have been speeches and not to the point. In future, let us have interventions to the point and on the subject in question. [Interruption.] Order. I was directing my remarks not only to the Secretary of State but to everyone in the House.

Mrs. Beckett: The Secretary of State tells us, as she did in her speech, about some of the achievements of the national health service. However, she was selective in the figures that she gave, quoting areas in which new technology is coming into play as well as changes in the manner of treatment. It is not at all clear to me that the figures that she gave my hon. Friend the Member for Cardiff, West (Mr. Morgan) were for a comparable area of health care, but never mind--we are used to Ministers not giving accurate figures in the House or, indeed, anywhere else.

Although the Secretary of State highlights some of the genuine achievements of the staff of the health service and the development of health care, not only Labour Members but people throughout the country resent the Government claiming credit for those improvements, as though they all flow from the Government's reforms and changes. In fact, they have absolutely nothing to do with the Government's reforms and changes. Indeed, in many cases, those changes have seriously impeded the development of better health care, as everyone in the country recognises, except those on the Conservative Benches. The Conservatives are seeking to avoid media coverage for the national health service, and if they were an organisation like a national health service trust they would be in serious trouble. Their professional team cannot be relied on any longer. As a result of a revolt last week by junior members of the team, senior board members found themselves unable to raise the finance necessary to run the business of Government. No private company worth its salt would survive in the marketplace after such a debacle. I suppose that, if the Government were not a public undertaking-- if they had been privatised--we would expect them to do what Mr. Cedric Brown did recently and choose the moment of the lowest public esteem to award themselves a 75 per cent. pay increase, or at least something substantial.

The Secretary of State says that the Bill will complete the reforms that were begun in 1990. The phrase has a neat, tidy and finished feel, as though she were a ship's steward, conscientiously dashing about, reordering and rearranging the deckchairs on--no, not the Titanic on this occasion, but perhaps the Achille Lauro. The impression created by the Secretary of State's public statement, which she sought to reinforce in her intervention a few moments ago, is that soon everything will be satisfactorily completed and after her spate of demented and feverish

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activity she will be able to sit back and relax in her deckchair as the national health service liner continues on its voyage. The reality, of course, is quite different. Like the Achille Lauro, the national health service has sunk--and public confidence in the Secretary of State's captaincy at the Department of Health has gone down with it, just as public confidence in the Government has descended to the depths. Contrary to the cheery picture that the Secretary of State tries to paint of the tidy, scrubbed deck of a floating national health service, all that we see are survivors trying to cope in the 485 separate leaky lifeboats of the individual health businesses that are the real result of the Secretary of State's reforms.

The Secretary of State asked why we were criticising the performance of the health service under her administration, and talked about all the improvements that she detects and the figures that she gives for specific operations. One of the reasons why we take what the Secretary of State says not with a pinch but with a bag of salt is that scarcely a day goes by without an NHS survivor contacting my office and the offices of my Opposition colleagues, alerting us to yet further deterioration in the service as they experience it.

Mr. Tim Smith: "It wasn't like that under the last Labour Government."

Mrs. Beckett: The hon. Gentleman is exactly right. That is exactly what they say on every occasion--"The health service is nothing like it was. Our health service is disappearing before our very eyes and we bitterly resent the speeches of Conservative Members who do not seem to understand what is happening in our health service." That is what they all say.

Mr. Smith: My experience is that complaints about the NHS were never greater than in 1976, 1977 and 1978, when the Labour Government cut capital expenditure on hospital buildings by 20 per cent. In comparison, there are very few complaints today.

Mrs. Beckett: I can only tell the hon. Gentleman that none of the people who have telephoned my office so far have been aged less than 18. They are all people who experienced the national health service and were treated by the national health service in the days that the hon. Gentleman is talking about. They all say what everyone except the Conservative party says--that the NHS is worse than it used to be, and that they are deeply upset and worried about the way that it is disappearing before their eyes.

Mr. Campbell-Savours: As my right hon. Friend knows, I have been in hospital for some fairly long periods in the past couple of years, and it is interesting that, every time that I have been in hospital--sometimes for as long as three weeks--nurses, doctors, consultants and administrators have always come to my bed when they learned that I was a Member of Parliament, to tell me how worried they were about developments in the national health service. How can the Government possibly deny it?

Mrs. Beckett: My hon. Friend is entirely right, and he knows that his experience is shared by every Opposition Member. I find it extremely difficult to believe that people avoid saying the things to Conservative Members that they say to every Opposition Member.

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I will give some further examples of reasons why we express anxiety--to which the Secretary of State seems to take such exception--about the service that is provided. Three thousand seven hundred operations were cancelled on or after the day of admission in the three months between July and September in London and the south-east alone. Recently, the surgical directorate at Whittington hospital in London decided to cancel all--yes, all--non-urgent surgery except for patients of GP fundholders. In Staffordshire last week, eight out of 11 consultants cast a vote of no confidence in the chief executive at the Foundation trust. A study carried out in Britain, France, Canada and the United States showed that British doctors were the most overworked, half of them wanted to practise abroad and one third wished that they had chosen another career.

Senior hospital doctors recently made a statement about the "disintegration" of the health service--their word, not mine--and drew attention to what they saw as the distortion of clinical priorities. They said that, although patients should, as the public expect, be treated on the grounds of clinical need and priorities and their sickness, rather than the finances of the trust, that was ceasing to happen. They alleged that patients of fundholders were being treated preferentially and that non- urgent patients were taken from long waiting lists at the expense of urgent patients, who then had to wait longer. That was all being done for financial reasons--to keep hospitals solvent--rather than for reasons of medical priority. In addition, it was being done at the direction of managers because of financial concerns rather than on the basis of clinical decisions made by the medical profession.

Mr. John Gunnell (Morley and Leeds, South): I thank my right hon. Friend for giving way. I will illustrate the point that she has just made. One of my constituents had his operation stopped after he had received the anaesthetic and was waiting outside the theatre. It turned out that the operation had been stopped on the direction of the hospital administration because of the overtime that would be involved if it were completed.

Mrs. Beckett: I just do not believe that no Conservative Members are told similar stories or are aware of similar concerns. Lady Olga Maitland (Sutton and Cheam) rose --

Mrs. Beckett: I admit that I might well believe it of the hon. Lady.

Lady Olga Maitland: Surely it is time to balance the debate. Is the right hon. Lady aware that whenever I meet constituents they tell me how much they appreciate the treatment that they receive in our local NHS hospital trust of St. Helier? They say how much they appreciate the dedication of the doctors and nurses, and the speed of delivery of treatment. Does the right hon. Lady agree that, as a result of health service reforms, 3,000 more patients a day are treated than before? Surely that is something of which to be proud.

Mrs. Beckett: First, that is not the result of the health service reforms. Secondly, as the hon. Lady must be well aware, those figures are nonsense. We are talking about finished consultant episodes, not people. All that the British public care about is when people are treated, the length of time that they have to wait and how their concerns are handled. Of course we are well aware of the

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dedication of national health service staff. In the hope of preventing questions such as those asked by the hon. Lady, I went out of my way at the outset to make it plain that we do not question that dedication.

I was speaking about the concern of senior hospital doctors at some of the changes they see. I am sure that the Government and Conservative Members must be well aware that it is not only those doctors who are concerned, but every patient who uses the health service and who objects to the outcome of care being determined not by the medical profession on grounds of clinical need, but as a result of Government policies. As well as the more general reports of what is happening, my office is contacted daily by people expressing fear and anxiety as a result of their personal experience of how the health service works today.

The Minister for Health (Mr. Gerald Malone): My right hon. Friend the Secretary of State is the only person in the debate so far to have given statistics about what is happening in the service and improved patient care. The right hon. Member for Derby, South (Mrs. Beckett) has relied on nothing other than anecdote. When will she provide facts? When will she make anything other than general assertions that the facts that we are providing about the health service and improved care are wrong? When will she say, in detail, why they are wrong, rather than simply making allegations? It would be extremely helpful to the debate if we could have no more anecdotes and a few facts.

Mrs. Beckett: I do not know what all that was about. The Secretary of State gives statistics about details of operations. What is the Minister of State asking for--alternative statistics? He knows perfectly well that there is widespread concern about the validity of the Government's statistics--everyone knows that. At the last Department of Health Question Time a Minister admitted that the Government's figures do not count people, but episodes of treatment.

Mr. Malone: We all know that.

Mrs. Beckett: The Minister of State says that we all know that. I rest my case and propose to go on with my speech.

Mr. Malone: There is no point in the right hon. Lady trying to be astonished about things that are well known facts. Of course such statistics are counted in completed consultant episodes--that has been the basis on which treatments have been considered for some time. On that basis, it has been shown that treatments have increased by a record number. The right hon. Lady cannot get away with trying to say that that is an astonishing revelation--it is well known.

Mrs. Beckett: I am delighted that the Minister of State has put that even more firmly on the record. It is certainly the Opposition's understanding that for a considerable time Ministers have sought to cloud the issue. When the hon. Member for Sutton and Cheam (Lady Olga Maitland) spoke a few moments ago, she talked of people being treated and said that the number of people who had been treated had increased. But the figures that she was quoting did not relate to people, but to finished consultant episodes. We are pleased to have it on record that those

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are well known facts. I hope that Ministers will not trot out such statistics as proof of how many people have been treated in future. The Minister of State mentioned levels of throughput. We are seeing changes in the method of delivery of health care, including new technology--everyone recognises that. But not one jot or tittle of the credit for any of that belongs to the Conservatives. It belongs to staff in the national health service and developments in medical technology. The attempts of Conservative Members to take the credit for it offends not only the Opposition but the general public. The conflict between managers and clinicians is growing. There are increasingly regular reports of clinicians declaring their lack of confidence in the chief executive of their trust. Nothing in the Bill changes those concerns. On the contrary, it further centralises bureaucracy in the health service and further concentrates power in the hands of the Secretary of State. Waiting lists are still at record levels. Hospital in-patient waiting lists still stand at more than 1 million. We all know--I hope that this, too, will soon become an uncontested fact--about the many people who are not on waiting lists as they are yet to have their first out-patient appointment, but who are none the less waiting for treatment. Nothing in the Bill will assist them in their plight. Instead, the Bill's effect will be to withhold still further information from the public as regional staff become civil servants, bound by the Official Secrets Act and responsible only to the Secretary of State.

There is nothing in the Bill to address the number of complaints about the NHS. The Minister of State asked how we could raise certain issues without giving statistics, so I will give him this one: complaints about the health service rose by 57 per cent. between 1991 and 1993--so much for the Conservative party's contention that everyone is perfectly content with the progress of the service. The Bill does not respond to any of the issues. It responds to a different set of demands and a different agenda. We have seen the commercialisation and fragmentation of the health service and are now seeing the drive to introduce competition at all costs when it is co- operation in the provision of a public service that the public and staff wish to see.

There was an interesting report in the Health Service Journal at the end of last week suggesting that guidelines to be issued soon by the NHS executive would take a harder line. It said Ministers would take a harder line on the internal market and seek to

"clamp down on `anti-competitive developments' such as hospital mergers."

The article continued:

"Contrary to the softer official line adopted in recent months, the guidelines reassert the efficiency gains which can be generated by competition".

In fairness, the article also stated that

"Minimum intervention to protect the interests of patients" might occur from time to time. But the public want co-operation in the provision of health care.

It seems that the ultimate agenda is the privatisation of the national health service in so far as it can be said that that has not already taken place. We are seeing its removal as a public service, and we are not the only ones to say that: the chairman of the British Medical Association also

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did so when he spoke on behalf of that organisation at its conference. He expressed surprise at the Prime Minister's lack of understanding of the fact that the health service is already being privatised. We are witnessing the virtual floating off of the national health service executive from the Department of Health. If the changes contained in this Bill are laid alongside the structural changes taking place in the Department, it seems to me that the provision of health care is slowly being transferred to a quango. The NHS executive has been given responsibility for policy development in health care, a responsibility that surely ought to rest with Ministers and the Department. If they are not paid to set policy, what are they paid for? By further detaching functions from the Department and placing them under the NHS executive, the Secretary of State is in effect floating a separate arm of the health care business.

The danger, we believe, is that the same loss of parliamentary and public accountability will occur as occurred with the other Government Departments from which major functions were devolved. As a result of the creation of the Benefits Agency, hon. Members now have to take up queries and complaints not with the Secretary of State, who takes no responsibility for the service as it is provided, but with the chief executive of the agency.

One of the knock-on effects of that change was that information that had been given in parliamentary answers and published in Hansard --and thus been available to all hon. Members and the public, not just the person raising the query--was, for a long time, given only by letter to the hon. Member making the complaint or raising the query. It took a long campaign by my hon. Friend the Member for Newport, West (Mr. Flynn) before Parliament and public again gained access to this valuable information.

What the Secretary of State is doing by means of this Bill cannot be reconciled with what has been said here today. She is not devolving power. Far from it: she is just shifting the centre of power, floating service delivery off into separate businesses and thereby creating opportunities for privatisation. Shifting the centre of power in this way serves the second item on the Secretary of State's agenda. Rendering power and responsibility more diffuse shifts blame and disperses responsibility. There is nothing the Secretary of State would like better than to shift blame and responsibility elsewhere, so that they do not rest with Ministers. Today the Secretary of State argued that organisational changes, particularly incorporating regional health authorities in her Department as offices of the NHS executive, would lead to more effective streamlining, to greater efficiency in the treatment of patients and to greater savings. She has tried to convince us that she is abolishing one tier of bureaucracy. All she is doing, however, is replacing one statutory tier of bureaucracy by another, more centralised bureaucracy. She is not even abolishing an entire tier. The Bill reveals that mental health review tribunals are to stay, on the basis of the existing regions. That is just one example of the fact that some regional functions are to continue, although it is not altogether clear how they will be managed, or what will happen to some of the other functions.

The substitution of the existing tier by another will create a bureaucracy that is to be more secretive. Staff will now be bound by the Official Secrets Act. They will be more tied to the Secretary of State's patronage and thus

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more tightly controlled by the centre. In other words, under the powers granted by the Bill, far from removing bureaucracy the Secretary of State is giving herself the opportunity, through patronage, to create a more pliant and amenable bureaucracy--all of which ties in with the Maples memorandum which issued instructions to stop up the leaks and silence any criticism of the service. While the Secretary of State increases centralised control over the allocation of resources direct to health authorities, through a new formula, there will be top slicing of money for strategic development, research and development, and education and training. It is not clear what the new formula will be; it is not clear what the degree of top slicing will be. All those decisions rest in the hands of the Secretary of State, who is taking substantial enabling powers in clause after clause.

There are references in the Bill to the orders that the Secretary of State will lay. We shall want to explore and debate the possible contents of each order very carefully.

There is a real question as to whether this recycled organisational tier-- recycled, not abolished--will do what the Secretary of State promises and will slim down the burgeoning bureaucracy of the health service. There is a growing belief, which I am coming to share, that there may be an increase in bureaucracy at the lower levels of the health service, because regionally based services will now have to be run by smaller units. The British Medical Association has argued that removing the strategic planning tier will mean that hundreds of trusts and authorities will have to acquire the skills to agree on regional specialties, public health policy and a host of other issues previously dealt with by the regions.

Local authorities will have to do this with a loss of economies of scale, and will have to combine with the contracting process inherent in the internal market. We believe that that too is bound to generate more bureaucracy. That would be entirely in line with current trends under the reforms, which show that the number of senior and general managers in England has shot up since 1986, from 5,000 to more than 20,000; and that total bureaucratic costs since 1987-88 have more than doubled.

Despite these unhelpful precedents, the Secretary of State said today that there will be savings. None of them were properly costed here today, and we have some doubts about them--partly because of the context of the overall effects of the Secretary of State's reforms, which have cost the British taxpayer will over £1 billion. We also doubt them because there is a planned reduction of staff of about 1, 500, and we doubt whether the savings that have been identified could come just from those staff reductions.

We also doubt the savings because of the Secretary of State's remark--or so I thought--and the idea in the Bill that possibly as much as £150 million could be saved. A press release issued after the publication of the Bill contained a revised figure of nearer £60 million. The notes on clauses and the Bill itself actually make it clear that provision has been made for an increase in the short term in the money spent by Parliament as these changes are made. It is just over two years since hundreds of civil servants were moved at considerable cost, not to mention disruption to them and their families, to Leeds. Now 200 of them are to be made redundant, thereby creating a great deal more cost and difficulties for their families. How can it be that only two years ago these people were so needed

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by the NHS that it was prepared to go to great lengths and considerable cost to move them all to Leeds, yet now, out of the blue, they are no longer needed? It is either gross incompetence or part of a different agenda.

Will the end result be that regional functions--for instance, advice on information technology, currently carried out a regional level--that will still be necessary will be contracted out? Is that the Government's secret agenda? If the functions cannot be performed owing to staff losses, will that be an opportunity for contracts in the private sector? There is certainly a widening circle of waste of public money--public money spent to take staff to Leeds, then spent to make them redundant and then, almost certainly, spent on the contracted out functions that could have been performed by those staff had they not been made redundant.

We question why the Government have proceeded with the changes in this Bill. Is it just that a further fragmentation of the health service will make it easier to privatise, as well as making it easier to bring private companies into the operations of the service? Certainly, if the Secretary of State's record is anything to go by, it is neither to slim down the bureaucracy nor to save money. She has been catastrophically bad at both.

We expect the changes in the Bill to lead to growth in bureaucracy at the expense of patients and of clinical care, but there are also wider concerns. We shall be looking closely at the allocation of responsibilities and functions as between health authorities and the regional offices. The Bill abolishes the local advisory committees, and any replacement will be dealt with by regulations. Here and elsewhere in the Bill it seems ever more clear that what the Government have in mind is dispensing with much of the expert advice that they currently receive. We do not believe that clinicians should be given excessive power to veto changes and improvements in the health service, but we do not believe either that it is advisable for management on the ground to do without the advice of experts in health policy and practice.

Who, under the terms of the Bill, will hold the contracts of junior doctors? Who will monitor the cancer screening service? Who will oversee the vocational training of GPs? Who will deal with complaints about trusts? It seems to be suggested that functions such as the oversight of communicable diseases and the handling of national confidential inquiries will mostly, or perhaps completely, be dealt with by the new, more local health authorities. However, there is deep disquiet as to whether that is the right place for them to be handled and whether such authorities will be able to or should deal with such matters.

There is alarm at what seems to be the loss of independence of the regional director of public health. The Secretary of State expressed surprise that we had drawn attention to that in our motion, although I notice that she did not go so far as to suggest that what we said was incorrect. It is an honourable part of the history and tradition of Britain that the holders of posts such as that of director of public health are whistleblowers in the interests of the general public. But in this new regional structure anybody at that level who blows a whistle will find himself on the street. There is widespread concern not only about what that will mean for the structure of the public health service below the level of regional director, but about to what extent the public will get the degree of oversight to which they have become accustomed.

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As I said earlier, throughout the Bill the approach seems to be to discard in-house expertise whose impartial advice should be needed when judging the quality of information or advice which might be bought in from outside. That is only one example of ways in which long-standing and successful partnerships seem to be at risk. Despite what she said, the Secretary of State must know that the deeply held view of those in medical education, whether at undergraduate or postgraduate level, is that the combination of academic and clinical roles is an essential prerequisite of the training that has been provided hitherto. That view is held by the universities and by the health service.

Despite what the Secretary of State said about the consultations that have been held, she must be aware that that structure is perceived by people, including the Committee of Vice-Chancellors and Principals, to be put at risk by the changes. She must also be aware that there is real anxiety about the nature and scale of future medical education not only in the medical profession but in ancillary professions. Despite the impression given by the Secretary of State, that anxiety has not been dispelled.

The most professionally anarchic proposal of all is the Government's aim to devolve pay to local level. If anything will lead to increased costs and bureaucracy, it is that ill-thought-out policy. The time of managers will be used up in lengthy local negotiations on pay and conditions. Doctors, nurses and other staff will find themselves neglecting patients because they will be expected to attend to their own pay negotiations. The National Association of Health Authorities and Trusts has already said that the administration of local pay schemes alone will cost an extra £40 million.

The Secretary of State talked about people wanting to reduce matters to the lowest common denominator. No Opposition Member wants to do that, but that is what local pay is all about and that is what the Government are trying to achieve. They are trying to create a scenario in which pay and conditions can be cut, although where scarce skills are needed competition between trusts to attract and retain professional staff seems likely to lead to options for those specialties in which more than 480 different bargaining units will have to engage in competitive bids.

We do not intend to let the Government or the public forget what is already occurring in the structure for which the Government make such claims. An example of such an occurrence is to be found, I believe, at the Royal Marsden hospital, where a circulated memorandum suggested that someone should be hired not merely because he was the best in his clinical field but because removing him from another hospital would destabilise a competitor. Competition rather than co-operation will be further enhanced by local pay, which will also distort clinical priorities.

Skilled clinicians will no longer move from hospital to hospital for professional development reasons alone. Hospitals with research teams and research facilities will no longer seek to attract people primarily because they are innovators at the frontiers of scientific development: they will also depend on the pay that the chief executive can offer.

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Some trusts will not be able to enter that competition. The director of personnel at the Havering Trust has already announced that he has to save £3 million in the next three years. How will that trust be able to attract or retain scarce skills during that period with the anarchy of purely local pay bargaining? How will patient care be delivered in that locality in those circumstances? The Secretary of State expressed surprise that we wished to move a reasoned amendment rather than simply supporting the Bill. As we have made plain, we did so because we oppose the abolition of the NHS regions in their present form, although we welcome some of the Bill's other proposals.

Mr. Tim Smith: Ah!

Mrs. Beckett: I do not know why the hon. Gentleman says that; I made our position clear at the outset, but perhaps he was not here at that time.

Above all, oppose the way in which the functions of the regions will be dispersed and broken up. We oppose further fragmentation of the health service and we believe that behind the Bill lies the hidden agenda of breaking up and floating off different NHS functions and making them ripe for picking by commercial interests. As Mr. Maples advised, the intention is to silence the staff while that is happening.

At best, the Bill fails to address the real problems of health care in Britain. At worst, it exacerbates the problems that Government reorganisation has created. The Secretary of State repeated phrases that she has used in every speech that I have so far heard and read. There is the suggestion that under what she calls the old NHS there was a command and control structure, which she attacked. A command and control structure of a kind that no previous Secretary of State has enjoyed is precisely what the Bill introduces to the health service. For the sake of our national health service, that process, like the Government, must soon be brought to a halt.

6.6 pm

Mr. Colin Shepherd (Hereford): I am pleased to be called to speak so early in the debate. Those of us who take an interest across the spectrum of activities in our constituencies have to address the issue of health service delivery against the background and the experience of our constituencies. The changes that have been made in Herefordshire over the past few years, and especially the change in the make-up of the county's health authority and the bringing in of executives with particular expertise, have been beneficial. Therefore, the Bill is a logical next step and I have no quarrel with it in principle. I shall certainly support it in the Lobby.

I support the Bill's concept of endorsing local decision making in the NHS. That is very much at the core of the admittedly constituency interest that I wish to put before the Secretary of State and the Minister of State. We are greatly worried about how health services in Herefordshire could be affected if there is unsympathetic implementation of the Bill's proposed changes. I emphasise that the reforms must make sense to people if they are to be supported and understood.

My worries are about the imminent decisions that will be made by West Midlands regional health authority in its dying days. That authority has been charged with the

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responsibility of predicating the shape and number of health authorities in what is currently the west midlands region. My Herefordshire health authority--I take the proprietorial "my" on behalf of my constituents--is already the smallest in the country, with the exception of that for the Isle of Wight. It is working fairly well and is consistently meeting all the national targets. It is financially sound, it is at the top of the efficiency index in the west midlands, its management costs are well below the average for equivalent-sized authorities, and it has taken more steps to identify further reductions in those costs. This year, it knocked £200,000 from its management costs.

What is worrying is that, on this coming Thursday, 15 December, the regional health authority will decide its policy for the counties of Hereford and Worcester. It is anticipated that the recommendation will be that there should be just one new health authority covering the two counties.

The authority has arrived at its recommendation--although I think that "decision" would be nearer the mark--without very much consultation, and certainly not without its own walls. Its own statement says that consultation is

"limited at this stage primarily to Health Authorities". I inquired where the consultation had taken place and discovered that there had been little in Herefordshire. Indeed, I am not entirely sure who has been consulted.

The two county Members of Parliament--myself and my hon. Friend the Member for Leominster (Mr. Temple-Morris)--had a meeting with the health authority chairman and the director of performance management, at our request. It was certainly not a consultation because we were making representations. I understand that the chairmen of the health authorities were not even consulted. The general managers of the four health authorities concerned were summoned to the regional chief executive and told what was to be the case.

What the matter boils down to is that, without much consultation, the regional management executive has determined what is to be the case and, presumably, will go out to consultation. What will be the value of that consultation if, as I perceive, decisions have already been made and written on tablets of stone?

I am not alone in feeling great hostility towards the proposed move. Everything in me shrieks against it. I do not believe that it is necessarily in the best interests of my constituents in Herefordshire. I am not alone in that view--the general practitioners and their council in Herefordshire are unanimous in their opposition to that particular shape for the health service. The clinicians, the consultants, the joint operation of clinicians and general practitioners, the Hereford medical forum and everybody else involved in the medical sector are unanimous in their opposition.

The foundation for that opposition comes from 20 years of local government experience. It shows that where Herefordshire has been linked to the larger population base of Worcestershire there has been an inexorable suction effect away from Herefordshire and into the heavier weight of Worcestershire. A classic example of that is the eight years of the Hereford and Worcester area health authority between 1974 and 1983. It was like trying

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to get hold of a cotton wool cloud. We could not get hold of the authority; it simply was not there in tangible form--it was too busy sitting in committees.

I am told that circumstances have changed and we have moved on, that I must not lock myself into 1974-type thinking and that I must adjust myself to today. However, our experience over the past 20 years is that, whenever small Herefordshire has been linked to large Worcestershire, because the demographic weight of population is to the east of the county, we have not benefited.

We actually made progress from 1983 onwards when we were given our own health authority. It was identifiable and small. At the time, we were told that it would be too small, but we said, "Let it run." It has been very successful and it has made progress. From my point of view as a Member of Parliament dealing with constituents and the health authority, I have found the lines of communication both short and effective. There have been good results in sorting out problems and unscrambling messes when they have occurred.

In Wolverhampton on 26 October, my right hon. Friend the Secretary of State told the chairmen of health authorities and trusts in the west midlands region that the new health authorities would be the stewards of the local community. The question being asked in my part of the world is: how local is local? The west midlands--Birmingham--is light years away. I must inform my right hon. and hon. Friends that Worcester is also light years away. That might seem very parochial, but our area is sparse and large distances are involved. There is a range of hills in between. We are not the same. Over the years, we have tried to work in many different forums on a Hereford and Worcester basis, but none has been effective in its operation. Where is the sensitivity to local needs? We need reassurance on that point from my hon. Friend the Minister. Herefordshire has a high elderly population, a low ethnic population and an old town. Redditch, on the other side of the joint county arrangement, has a high young population and a new town. Worcester has an old town and a high ethnic population. If the weight of population is to the east, how will sensitivity to the west be recognised?

In terms of finance, we are worried that the loss of sensitivity to the Herefordshire population profile will leave us at a disadvantage. We are very worried about the potential lack of sensitivity to the more rural parts of Herefordshire and beyond. My hon. Friend the Minister with responsibility for health matters in Wales knows full well how far into Wales runs the catchment area for Hereford, which is looked to as the centre for the provision of acute hospital care. I am aware that my right hon. Friend said that we must not look for sectional interests on the area health authority, but unless there are people who come from the Herefordshire side of the hills there cannot be a recognition of what Herefordshire needs. I am not making sectional interest pleading; I am asking how Herefordshire's needs will be understood. It is not all number crunching. It might look very tidy from the inside looking out, but from the outside looking in it is not quite so tidy and comfortable.

All our experience suggests a shift of services to the centre of gravity of the combined area. Our worry is that that would be detrimental to the range of hospital facilities

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