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Column 661that will be available in Hereford--not immediately, as these things take time--and that over the years there will be a migration of services as people rationalise and strategic decisions are taken about what is done where and how. In 10 years' time we could find ourselves not with the present acute hospital unit providing a broad range of clinical services, but with a hospital providing an accident and emergency service and the ancillaries that go with that. That worry must be laid to rest.
I am glad to see my hon. Friend the Under-Secretary in his place. When I explained my fears to him, I am afraid that his reply merely underlined them. My fears reflect those expressed to me by my constituents. I very much hope that my hon. Friend will be able to reassure us.
The regional health authority will put a paper before the meeting on Thursday. The reasons given in that paper for its decision seem to me to be self-justificatory bull.
Mr. Shepherd: Definitely not Herefordshire bull--Birmingham bull. It appears to me that the authority's attitude is that a decision has been taken, so it must make everything fit it. I am told that the new authority will operate best against
"a sensibly sized strategic canvas"--
"Local sensitivity will be assured by Primary Care-led purchasing, and the extensive development of GP Fundholding"
covering 87 per cent. of the population. I wonder what the sensibly sized strategic canvas will be. I was told that Hereford is too small to support both a strategically focused health authority and an extended range of GP- focused purchasing. When I met the regional health authority chairman and his colleague, I was told about the "theology of numbers" for a successful operation, which is somewhere between 300,000 and 500,000 residents.
When the Herefordshire health authority started, we were told that the population was too small at 140,000. I pleaded with the then Minister and he accepted my arguments, and we have a successful health authority as a consequence. It covers 160,000 people, and the mid-Wales dimension takes the figure to 250,000--not far short of the bottom limit of the theology of numbers. However, having pursued that matter with my hon. Friend the Minister, I understand that there is no bottom limit but that it is a matter of what makes sense. The regional health authority seems to be making rules to suit itself. What is the foundation for that theology of numbers?
It is suggested that a single health authority would attract high-quality staff and administrative savings of £1.5 million, which would be available, if it materialised, for reinvestment in local health services. I understand that the Price Waterhouse report is distinctly suspect and that if there were a single commissioning authority or health authority for Worcestershire and one for Herefordshire, the savings would be not £1.5 million but £500,000. I am worried about the numbers that will be put before the regional health authority on Thursday. The regional chief executive's report dated 21 July stated that the situation in Hereford and Worcester is much more complex and that local ownership and accountability within any arrangement is more important than financial considerations. That is intriguing, because it implies two lines of thought.
Column 662We have marvellous clinicians in Hereford. They like working there and do not wish to leave, and there is no reason for them to do so. The quality of life in Herefordshire is darn good, and they do a good job.
The third argument is a wonderful piece of jargon. It is that NHS providers in particular will find it easier to shape their future against a clearer purchasing and commissioning strategy. That is true whether the authority is large or small. The argument is also made that the functional clinical links developing between providers across the county make a clear purchasing view all the more important and urgent. Those links will be made whether there are one or two authorities because they make sense. That is not a reason but a reflection of something that will happen as a matter of logic. It is said that the business cases for the Hereford and Worcester hospitals are nearing completion, and that the Hereford scheme in particular should have its outline case approved by the regional office by the end of December.
I have been pursuing the establishment of a hospital since 1974. Hereford has three clapped-out building sites, one of which has finally been identified as a site for redevelopment. It is expensive, maintenance is bad, and it is difficult to see how services could logically be provided. In addition, the site is dangerous. A cardiac arrest on the operating theatre in the general hospital would necessitate an ambulance run to the county hospital's intensive care unit, which is unacceptable. I urge my hon. Friend the Minister to press for the completion of that hospital at the earliest possible moment.
Although the business case was presented in Birmingham today, I received from Mr. Brian Baker, chairman of the regional health authority, a note saying, "Hold on a second. We cannot go now on the shape of the Hereford hospital--not until such time as we know what is to happen in Worcester." That emphasises my worst fears. The two are interdependent, but decisions are being taken before we are ready. I support the Bill's principles because they are right, but I urge my hon. Friends on the Front Bench to make a sensible arrangement for my part of the world, because it is different by virtue of its geography and demography. The reforms must make sense for people if they are to secure support.
What message are the Government sending my constituents? At 9.30 am on Thursday morning, the Local Government Commission will make an announcement, which I would bet heavy money will say that there should be a unitary authority for Herefordshire. It will recognise that the connection with Worcestershire over the past 20 years has not been to Hereford's advantage, and that its people think that they can do better. At 10.30 am, the regional health authority will say, "We are taking away Hereford's independence and will tag it on to Worcester to make a big merged health authority."
Although Hereford's health authority is small, it is good. It could be nicely merged with a family health services authority to form a new authority that is responsive to the needs of the people and understands them. The logical way for my hon. Friend the Minister to progress is to say, "I hear you, Herefordshire, and your worries. You will have a health authority in your own right." He can enter the caveat that, if that does not work, he will exercise the Bill's inbuilt powers to put Hereford together with another health authority, possibly
Column 663Worcester. He can do that if, in the light of experience, shortcomings are identified, and the individual authority is perceived not to make sense. I urge my hon. Friends on the Front Bench, as I support them tonight, to listen to us in Herefordshire. 6.28 pm
Mr. John Heppell (Nottingham, East): The Secretary of State said that the Bill exists to take account of Government reforms, but all those made so far have been utter failures. I see no reason why the Bill should not also be a complete failure.
The Secretary of State asked for facts and statistics. Government health reforms so far have cost £1.2 billion, which has meant that the cost of NHS bureaucracy has risen from £1.44 billion to £3.02 billion- -an increase of 110 per cent. or £1.5 billion, which could have been spent on patients rather than on administration. The right hon. Lady spoke about streamlining management. In 1986-87, the national health service had 500 managers. In 1989, it had 4,600 and by 1993, it had 20,010. That is an increase of 1,800 per cent.--not quite as large as the increase in prescription charges, but almost. In 1987, management costs were £25.7 million. Today, they are £49.8 million. That is what the Government's reforms have meant; those are the statistics for which my right hon. Friend the Member for Derby, South (Mrs. Beckett) was asked.
The Government say that they want to introduce further reforms that will save more money and make the NHS more efficient and effective. Does any Conservative Member seriously believe that we seriously believe what the Government say? They say that they plan to remove a tier of the health service, but when we examine the small print we find that they do not really mean that. They plan to remove regional health authorities--the section of the service that secures accountability at regional level.
It is no use for the Secretary of State, and other Conservative Members, to talk about the way in which people are appointed to trusts or regional health authorities. Every hon. Member--and, I suspect, everyone in the country--now knows that one overriding criterion ensures appointment to trusts, district health authorities and regional health authorities: allegiance to the Conservative party. More than half the 240 health authority chairs come from businesses, consultancies or financial institutions. They are directors and employers in firms that donate money to the Conservative party. Only 15 of those 240 have any medical background, but more than 120 have financial backgrounds.
If the appointees are not directors or other members of firms that give money to the Conservative party, they are members of the party. I know from experience--as, I am sure, do other hon. Members--that prominent members of Conservative associations are repeatedly appointed to trusts and health authorities. The same applies to Conservative candidates, both national and local. They are usually failed candidates, but what does that matter now? If a candidate cannot persuade the country to let him put his ideas across by means of the ballot box--if he cannot secure the changes that he wants democratically--it does not matter. As long as he has an allegiance to the Tory party, the Government will appoint him to a quango, such as a trust or health authority.
Column 664Not only those people themselves but their wives, brothers and brothers-in-law may be appointed. They have this in common: they are all yes-men, or yes-women, in relation to what the Tories want to do. In fact, regional health authorities do not pose much of a threat to the Government; they produce little opposition to the Government's proposed changes. Every now and again, however--not very often --we see a bit of independence and initiative, and hear a few murmurs of discontent and disagreement. For that reason, RHAs will have to go. The Bill is not about removing a tier of the NHS; it is about removing accountability.
Are the Secretary of State, the Minister and other Conservative Members trying to tell me that nothing needs to be done at regional level any more? I have taken time to read research paper 94/124, produced by the Library. A section beginning on page 11 asks: "Who will do what in the new NHS?"
I have highlighted the instances in which it is still necessary for the region to act, and almost every part of the section has been highlighted as a result.
The regional officers will still set the local research agenda within a national research and development strategy developed by headquarters, and will manage research and development projects. When the revenue allocations are made directly to health authorities, surely the NHS executive will use its regional tier to establish what those allocations should be. When the responsibility for public health functions goes to local health authorities, regional offices will ensure
"that effective arrangements have been put in place".
When the professional advisory machinery is at local or multi-district level, the current sub-committees--the specialty sub-committees--at regional level will retain their responsibilities:
"regional offices will be responsible for performance management of health authorities and for monitoring Trusts".
After that, they will have new responsibilities for GP fundholding. The regional tier will still have to do a great deal of work. I find it hard to accept that the changes at regional level will save £150 million. How can 1,500 jobs disappear when all that work will still have to be done-- unless, as my right hon. Friend the Member for Derby, South suggested, the plan is to contract the work out to private companies which are probably making large donations to the Conservative party? In any event, why are the RHAs being targeted in connection with bureaucracy? Bureaucracy has not increased in the RHAs.
Between 1992 and 1993, regional staff numbers fell from 7,845 to 3, 905--a massive drop, as everyone would surely agree. Moreover, in the following year the numbers fell to 2,613. Meanwhile, bureaucracy has increased in the trusts, in the FHSAs and at district level, but predominantly in the trusts. If bureaucracy is to be tackled, they should be tackled. It is nonsense to abolish the tier in which bureaucracy has been slimmed down-- the tier that has been made lean and mean--and preserve organisations in which bureaucracy continues to flourish.
A limit of 135 staff has been set for each region. Can anyone tell me how that number was arrived at? Is there no difference in the size of the regions? Is not the regional authority represented by the hon. Member for Hereford (Mr. Shepherd) smaller than some others? If the size indeed varies, will not differing staff numbers be required?
Column 665The truth is that the figure was plucked out of the air--and, even if it is met in the short term, I am certain that it will not stay the same in the medium and long term. As I have said, the work that needs to be done at regional level will continue. I guarantee that no future assessment of the number of staff required will produce a figure of 135, if it is done correctly.
Although I agree in principle with the amalgamation of the district health authorities and the family health service authorities, I have very strong reservations about whether the Government will carry it out efficiently and effectively. I have evidence that in some areas it is not being carried out efficiently and effectively.
Mr. Malone: It would be a little presumptuous if it were being carried out wholesale while the Bill has not yet received a Second Reading. There are a number of co-operative arrangements in place, which is very different from sorting out the amalgamation once the House has sanctioned the Bill. Surely the hon. Gentleman understands that.
Mr. Heppell: I understand it, but it seems that the Secretary of State does not. My hon. Friend the Member for Sherwood (Mr. Tipping) wrote to her pointing out that the Nottinghamshire FHSA and the Nottinghamshire health authority had combined--informally--to form a health commission and had proceeded to pick a new chief executive who is already in post and being paid. The chief executive of the Nottinghamshire FHSA has been sent home on what is described as "gardening leave". That person is on a salary of perhaps £50,000 or £60,000 but has been sent home before Parliament has even debated the necessary legislation because someone else has been given the job of taking over the new amalgamated health authority, which the Minister says should not yet be in place.
Perhaps the Minister will tell me that he proposes to take action against members of the health authority or the FHSA or against the chief executives of both bodies for proceeding without parliamentary approval. The Minister shakes his head. He clearly accepts that inefficiency has been engendered by the attempted amalgamation of two bodies without there first being in place a proper structure and without there first being a proper debate with the medical profession and members of other services involved. I am sure that the Minister will therefore accept that I am bound to have some reservations about the Government carrying out the reforms and achieving the savings they seek.
The Bill will be a failure because of what is not in the Bill as much as for what is in it. It does not tackle the real problems in the NHS. It does not deal with the fact that there are now 1 million people on the waiting list and that there is a secondary list of 1 million people waiting for out -patient appointments. The Bill does not tackle the fact that, since 1979, 147,790 beds have disappeared from the health service and that some people are now finding it impossible to get a bed.
The Bill does not deal with the fact that, in 1993 alone, 10,637 beds disappeared from the health service or that since 1979, 538 hospitals--or one in five--have closed. It does not deal with the patients charter. We learned only this week that the charter's targets are not being met. Nor
Column 666does the Bill tackle the problems of increased prescription or dental charges or the cost of eye tests. It does not tackle the fact that we now have fewer nurses than ever--in 1989, there were 397,650 nurses but by 1992 the number had dropped to 361,460.
The Bill does not solve the problem of perks going to the most well paid people in the NHS or the excessive pay rises that some people award themselves. Last year, the average pay claim by chief executives was 8.5 per cent. although some awarded themselves 33 per cent. even while the Government were telling public sector workers that their pay should not rise by more than 1.5 per cent. How can the Government in all honesty say that to ordinary NHS workers while some chief executives award themselves 33 per cent.?
The Bill does not deal with complaints which have increased by 57 per cent. to 58,000 a year and nor does it tackle staff morale. My right hon. Friend the Member for Derby, South mentioned the fact that the Government were trying to introduce locally negotiated pay. Only today I had a visit from a member of the British Medical Association, Dr. Gill, who is on the local negotiating committee. I am sure that he will not mind my mentioning that he told me that locally negotiated pay would be disastrous. It would mean that, in addition to their management and administration duties, hundreds if not thousands of doctors would have to attend one or two meetings a week to negotiate pay, whereas, at the moment, it is negotiated nationally and effectively and no one has complained.
The Bill gives the impression that it will cut bureaucracy but it will not; it gives the impression that this is the end of the NHS reforms but it is not; and it gives the impression that it will help the NHS but in reality it is a collection of bogus measures which are, if anything, simply a public relations exercise for the Government. The Bill's provisions are a smokescreen for the NHS reforms that have already taken place, and for the Government's betrayal of the service.
Mr. John Whittingdale (Colchester, South and Maldon): I hope that the hon. Member for Nottingham, East (Mr. Heppell) will forgive me if I do not agree with him entirely. I find extraordinary the Opposition's constant desire to denigrate dedicated individuals who are trying to improve health care in their communities and especially strange is the idea that anyone who has had any association with Conservative politics--or who happens to be related to anyone in Conservative politics--should not be allowed to serve on a regional or district health board.
I shall not take up too much of the House's time because, despite the speeches that have been made so far, I do not think that the Bill is especially controversial. It is quite narrowly defined and technical, although that might not be immediately apparent--I note that schedule 1 will require 45 Acts to be amended, including the Polish Resettlement Act 1947, the Dartford-Thurrock Crossing Act 1988 and the House of Commons Disqualification Act 1975. Despite the wide-ranging nature of the Bill, I do not think that it is controversial, and it has received wide support, especially outside the House.
Column 667I agree entirely with my right hon. Friend the Secretary of State that the Bill is the logical consequence of our national health service reforms which were undoubtedly the most radical change to the structure of the NHS since it was created. Much of the attention since then has been given to the establishment of NHS trusts, and I was pleased to hear my right hon. Friend announce today that the coverage of the trusts is to be extended further to take in, I believe, 98 per cent. of patients. Attention has also been given to GP fundholders whose numbers have been growing steadily, but the biggest NHS reform was the creation of the internal market and the separation of purchasers and providers.
The Bill reforms the structure of the purchasing side of the national health service, which I have always believed is at the core of the NHS. I do not take the ideological, rigid view that the NHS should use only publicly owned providers. I am happy to see it use privately or publicly owned providers, as long as they deliver the best possible treatment to patients. The core of the NHS is its purchasing function, and the Bill concentrates upon that. Three and a half years on, we can now begin to make a judgment about the results of the NHS reforms. Despite what the right hon. Member for Derby, South (Mrs. Beckett) said in her speech, I have absolutely no doubt that the reforms have worked. NHS trusts have been an unqualified success. General practitioner fundholders are providing better care to patients and, as a result, the number of patients being treated has increased and the quality of care has improved.
A couple of weeks ago, The Guardian stated that the NHS reforms had achieved "considerable success" in helping to restore confidence in the NHS. I take it that that was not written by the KGB. Inevitably, when reforms as great as the NHS reforms are introduced there will be some problems. I accept that one such problem is the number of layers of management created and the amount of money spent on administration. I do not accept the more simplistic charge that the reforms have simply created layers of management. An organisation the size of the NHS must have strong management. It spends the equivalent of a small country's gross national product, and it must have properly qualified, good managers to ensure that we receive maximum value for money.
One of the reforms' main intentions was to devolve responsibility downwards --to give real decision-making power to those who are involved in running hospitals and to the GPs who have chosen to become fundholders. Devolution of responsibility has led NHS trusts, quite correctly, to recruit more management staff. The problem is that that increase has not been matched by a corresponding reduction in the number of administrative staff employed elsewhere within the NHS. The recruitment of more managers in NHS trusts should mean that many managers are no longer needed at the upper level of the health service. The Bill is designed to address that problem.
The disappearance of regional health authorities will require one or two of their tasks to be performed elsewhere. A traditional responsibility of the regions was the allocation of funds within a region using a weighted capitation formula.
Column 668The House has heard me talk previously about the consequences of that funding allocation in the North Thames region. I do not wish to go over familiar ground in detail, but I repeat that there has been a problem. Although there is a national formula to distribute funds between regions, when a region such as mine adopts a different formula for the allocation of resources within a region it leads to unfairness, particularly in my district of North Essex.
Because the national formula does not take full account of the social deprivation factors which the region uses to distribute funds within North Thames, North Essex has been doubly penalised. I have raised the problem with the Minister previously, so I do not wish to spend too much time on it tonight. However, as a result of the changes introduced by the Bill, I hope that the Department will implement a single national formula to allocate funds between districts. That will remove the present unfairness and ensure that all districts are treated equally.
The regional monitoring role must continue to be performed. It has been suggested that part of the role can be performed by the new health authorities-- in particular, that they will be responsible for monitoring GP fundholders. As the British Medical Association has pointed out, the new authorities will also be competing purchasers. It concerns me that they will be not only competing with GP fundholders, but given responsibility for them. Will the Minister explain how the system is intended to operate?
At district level, I believe it must make sense for a single body to be responsible for ensuring that patients receive the proper degree of health care. The division between primary and secondary care has always been pretty artificial; it is now breaking down even further.
More and more treatments can be performed in a GP's surgery and no longer require a visit to hospital. When hospital treatment is needed, it is often performed on a day-case basis and no longer requires an overnight stay. In some cases, GPs will come into hospitals and use their facilities to treat patients and, as a result, consultants and registrars do not need to be involved.
These changes--many the result of technological change within the health service--will inevitably alter the profile of the health service. In future many people will not need to go anywhere near hospitals; their local GPs' surgeries will become mini-hospitals. Judging the performance of the health service, as the hon. Member for Nottingham, East did, on the basis of the number of beds available or the number of operations performed will become increasingly irrelevant.
I congratulate the Secretary of State on the speech that she made earlier this year--I think it was to the National Association of Health Authorities and Trusts conference--in which she drew attention to the changes that will take place in the health service. She highlighted the report by the United Kingdom chief nursing officers, who predicted that in future 60 per cent. of operations are likely to be performed on a day-case basis, 40 per cent. of specialist consultations will take place outside hospital and, as a result, 40 per cent. fewer beds will be needed.
The figures caused great uproar when they were first published, but it is an inevitable consequence of the technological change which is taking place in health
Column 669care. It is important that we should recognise it and debate now the consequences for the shape of the health service in the future. Separation of the body responsible for the purchase of secondary care--in other words, the district health authority--from the body responsible for primary care is becoming increasingly daft. Many areas have recognised that already: commissioning agencies have been formed, with close co-operation between the two bodies.
In North Essex relations between the family health services authorities and the two DHAs are very good. Following my right hon. Friend's statement earlier in the year, the FHSA and the two DHAs talked about the structure of future health provision in the county. Clearly, the main question was whether future health authorities should be divided into two or three different bodies, or whether a single body should have jurisdiction over the whole county. As well as engaging in wide consultation, the FHSA and the DHAs commissioned the King's Fund to investigate and make recommendations on that point. I was sorry to hear about the experience of my hon. Friend the Member for Hereford (Mr. Shepherd), who did not feel that sufficient consultation had taken place in his constituency. Very wide consultation has taken place in Essex and, as a result, there is almost universal agreement that the most sensible structure is to divide the county along existing district health authority boundaries and to have two health authorities in future. I congratulate the three chairmen--Major- General Robert Wall of the FHSA, Alec Sexton of the North Essex health authority, and David Micklem of the South Essex health authority--on the way in which they conducted the investigations into future health provision in Essex. I think that their recommendations will enjoy widespread support and prove a great success.
I will touch upon one or two concerns that have been raised already in the debate. The first concerns accountability within the health service. I agree entirely that it is essential that the public have confidence and feel that they are fully involved in decisions affecting patient health care. The Bill is not entirely clear about the membership of the new health authorities--although I welcome the Secretary of State's clarification in her speech. I hope that members of the future health authorities' boards will be widely drawn from within the local community.
Clearly, the membership should include medical professionals. I especially welcome the announcement that the director of public health will be a mandatory executive on the health board, but I believe that a wide range of individuals who have specific skills to bring to bear should also be involved. I especially hope that there will be full involvement of the primary care sector. It is important that the new authorities should not be based mainly on the existing DHAs and that they should properly reflect the responsibilities of both the DHAs and the FHSAs.
As I have said, it is essential to try to increase public involvement in the provision of health care. North Essex health authority has been extremely good at trying to involve the public. I cite the public consultation
Column 670exercises that the authority has carried out on the provision of cancer services in the county which has recently led to the recommendation that there should be a new cancer centre in my town of Colchester. I also cite the consultation exercise on the provision of orthopaedic services. The original proposals for orthopaedic services to be centred on a single site in Broomfield were dropped as a result of the consultation exercise and new proposals have now been introduced for two centres, one in Chelmsford and one in Colchester. I also cite the exercise in determining public priorities for medical treatment within the county. Many consultative documents were issued by the health authority, but, unfortunately, there was a lack of response to the documentation. I know that the director of public health was rather disappointed by the number of responses he received. One parish council in my constituency complained about the number of consultative documents it received and said that it was unreasonable for it to spend so much time answering them. That is a problem. I hope that consultation exercises will be phrased in simple language so that they will generate a proper response from those who wish to participate.
One of the interesting results of the recent visit by members of the Select Committee on Health to Oregon, where a wide-ranging consultation exercise has been carried out, was the discovery that the people who came along to the public meetings were not members of the public at all. They were health professionals. There must be the danger that a limited response to a public consultation exercise may not properly reflect public opinion in the locality.
I commend the fairly novel approach of Alec Sexton, who is the chairman of North Essex, one of the health authorities. He has started to hold public surgeries and he invites members of the public to raise with him any concerns they have about the provision of health care. That is an extremely welcome innovation and I hope that his example can be followed widely by the new health authorities. Another problem has arisen in my area which the new authorities will need to consider--the growing number of patients who are being removed from GP lists. In Essex, there has been a slow but steady rise in the number of removals, from 977 in 1991 to 1,154 in 1993. I entirely accept that the figure still represents only seven out of every 10,000 patients, but I believe that it is a cause for concern. It has been claimed that the increase is the result of fundholding practices seeking to remove patients who will be costly to their budgets. There is no evidence to support that claim. Indeed, the evidence in Essex proves precisely the reverse. In my mid-Essex area, there are fewer removals by fundholders than by non-fundholding practices. I accept that a doctor must have the right not to have on his list a patient with whom his relationship has broken down, but it is not acceptable for a doctor arbitrarily to remove a patient from his list, especially if no proper explanation is given to that patient. In rural areas such as mine, real problems can be created if the nearest alternative practice is many miles away. I should like there to be a requirement for doctors to justify the removal of a patient from their list and,
Column 671perhaps, for an arbitration scheme to be established to try to prevent the problem where possible. I hope that my hon. Friend the Minister will consider that point.
I now turn to the responsibility of the new health authorities for long- term care. As the House is aware, lead responsibility for the provision of community care rests with the local authorities. However, the availability of social care is, obviously, a paramount consideration in determining whether a patient is to be discharged from hospital. If adequate social care does not exist, patients will have to be kept in hospital, thereby putting additional strain on the health authority's budget and occupying badly needed beds. Essex county council, in common with a number of other Labour and Liberal Democrat-controlled authorities, has announced that its community care budget is close to exhaustion. That will cause real difficulties for the health authority.
It has been claimed that, in Essex, community care has been inadequately funded. That simply is not true. The amount available to spend on social services this year stands at £175 million, which is an increase of 22 per cent. on last year's figure and 7 per cent. more than the national average. The change in the distribution of the special transitional grant, which some local authority social services departments claim has penalised them, has benefited Essex by a further £21 million. The principal reasons why Essex county council social services department is now in that position are simply mismanagement and the council's failure properly to plan its budget in advance.
Mr. Hinchliffe: I have listened with interest to the hon. Gentleman's comments about community care. The subject does not have a great deal to do with the Bill, but it is important to make one point. Does the hon. Gentleman recall, that in the first year of the care changes, the Association of County Councils made the point that community care was underfunded? At that time, the association was controlled by the Conservative party.
Mr. Whittingdale: I simply do not accept that community care has been underfunded. The hon. Gentleman will find that this area of local government responsibility has received better funding than almost any other and that the funding has been steadily increased since the changes were introduced. There is no justification for local authorities to claim that their budgets have been exhausted. Such claims have aroused fears among some of the most vulnerable people in society, which is a disgrace.
Essex county council's reserves stand at about £25 million. The council should simply transfer some of that money to make up any shortfall and it should take immediate action to ensure that such a situation cannot be repeated. I can see that you are looking at me, Madam Deputy Speaker; I am conscious that I have strayed a little from the Bill. I thank you for your indulgence.
I have no doubt that the Bill will result in a more efficient and streamlined structure for the NHS. It will consequently result in real benefits for patients.
Several hon. Members rose --
Column 672must point out that, so far, no Back-Bench speaker has managed to make a speech in less than 20 minutes. If that trend continues, there will be some disappointed Members who will not have made a speech at all. I hope that I make the point clear.
Mr. Alex Carlile (Montgomery): I cannot resist starting with a reference to the strong plea that the hon. Member for Hereford (Mr. Shepherd) made on behalf of the Herefordshire health authority. I have a lawyerly connection with Hereford and, as a Member of Parliament for mid- Wales, I am well aware of the number of patients, especially from the south of the county of Powys, who go to Hereford for the very good hospital treatment in that ancient city. The hon. Gentleman's argument was sound and not merely on a local basis relating to his constituency, although that stands too.
I am glad to see the Under-Secretary of State for Wales, the hon. Member for Clwyd, North-West (Mr. Richards), in his place. In his presence, I ask the Government to ensure that, during the reorganisation, close attention is paid to ensuring that patients who seek treatment, or are sent for it, across the Welsh border will continue to be able to receive it efficiently.
The consideration that the hon. Member for Hereford mentioned applies equally to constituents in Brecon and Radnor; and to my constituents, who go to Shrewsbury for much of their treatment. Indeed, it applies in particular to the Minister's constituents in Clwyd, many of whom gravitate towards Chester for treatment. Cross-border availability is an important issue. There has certainly been a feeling in my constituency that the Shropshire health authority has tended to look east, to the neglect of the western part of its catchment area. The reorganisation should not allow that trend to continue.
I have a feeling that, while drafting the Bill, the parliamentary draftsman was reading the Maples memorandum. We have four pages of Bill and 50 pages of schedules. I suspect that the instructions might have been to make it so dull that it would introduce legislative anaesthesia and possibly euthanasia of the Standing Committee--Oregon was mentioned a few minutes ago--so that the politics of the Bill, or indeed the whole Bill, would be forgotten.
Beneath that textual exactitude, which the draftsman so skilfully incorporated--especially in schedule 1--lies a breathtaking transfer of power. Breathtaking powers are to be placed in the hands of the Secretary of State and of unelected and extremely large public bodies. Of course no one objects to reorganisation if it improves the quality of service, unless one takes a dogmatic view as to whether all health care should be provided by the public or the private sector, which I do not. I hope that we will gain an assurance from the Minister in his reply, especially in answer to the hon. Member for Hereford, that it is improving the quality of service that drives this reform and not some organisational ethos, which is what crept into that remarkable jargon that the hon. Member for Hereford read to us earlier.
Reorganisation is unacceptable if the quality of service is not improved. We must bear in mind the fact that those extraordinarily large and totally unelected public bodies will take decisions that will affect the fundament of people's lives. They are the organisations that will decide--as some have decided not to--whether to pay for
Column 673extra coronary operations, above the number of operative treatments for which they have contracted. Like the existing Powys health authority, which is responsible for my constituents, they are the authorities that will produce proposals that may mean emergency ambulances only in a large and sparse rural area. No one could imagine a decision--based on financial stringencies, of course--that could be less calculated to serve the large, local, elderly population.
Those are the authorities that make arbitrary judgments--again like Powys-- such as the decision that, as a matter of policy which I believe to be unlawful and capable of judicial review, childless couples will in no circumstances be able to gain fertility treatment on the national health service. Such decisions should never be taken, but the lack of any sort of democratic accountability, whether in the old or the new authorities, renders them more likely.
Beyond those general considerations, I must deal briefly with six specific issues. The first has already been mentioned--predictably so--and concerns how members of the authorities will be appointed. Will there be yet more epidemic and centralised patronage? I want to be fair. The Labour Government's record on epidemic patronage before 1979 was every bit as bad as that of Conservative Governments since. There is no reason for it to be so. For example, why will the Department of Health and the Welsh Office not advertise for possible non-executive members of the authorities? Why trawl among the great and the good and those with whom they happen to go to cocktail parties, rather than advertising every one of the posts in the regional press, so that the trawl can be made from the widest range of possibilities?
The Parliamentary Under-Secretary of State for Wales (Mr. Rod Richards): May I enlighten the hon. and learned Gentleman by tellinhim unequivocally that my right hon. Friend the Secretary of State for Wales will soon be advertising the posts of chairmen of the new health authorities in Wales?
Mr. Carlile: I will give way in a moment. I seem to be drawing a chorus. Like two choirboys, singing seasonally, the Ministers come to their feet. Perhaps the Minister of State will tell us why every non-executive post on those health authorities should not be advertised.
Mr. Malone: The hon. and learned Gentleman should be aware that that is increasingly the practice. The availability of posts is advertised. The widest possible representation is sought among applicants, to enable the appointments to be made. That already happens in some
Column 674regions, especially in the south and the west, which I represent. It is an excellent practice, it is being encouraged and it will be expanded.
Mr. Carlile: I feel a little like a swordsman rather successfully drawing blood. Perhaps I should keep on this tack and in another 10 minutes we might have an announcement that all the posts will be advertised.
Mr. Bernard Jenkin (Colchester, North) rose --
Will the Minister of State assure us in his reply that each authority will have representatives of the executive and medical, nursing and midwifery staff on its board, as well as consumer representatives, who might best be drawn from the community health councils that have been serving the public so well?
On consultation, will the Minister of State be able to assure the House that the authorities will be statutorily required to consult with community health councils? We face the threat of some health councils being taken out of existence as a result of the changes. The Bill requires at least one community health council for every health authority area. One suspects that that may mean that, in some areas, there will be only one community health council for that health authority area. I hope that community health councils will be consulted, and that we can expect to see very few reductions in the number of community health councils.
I was encouraged to hear what the Secretary of State had to say about universities. Eloquent representations have been made by the vice- chancellors, and in particular by the principal of St. George's medical school, Sir William Asscher. He has made the point that the regional authorities will, in effect, be replaced by regional outposts, which could mean that the influence of the universities will be reduced. All the research which universities do and the facilities they provide at the clinical frontier may also be reduced.
I hope that the Minister will be able to confirm that we will not simply have a token university representative in each enlarged region, but that the proportion of university representatives will be maintained in the new structure so that the extremely valuable quantum of their influence is not lost.
The next point I wish to make briefly relates to public health. Representations were made on that issue by Labour Members earlier in the debate, particularly by the right hon. Member for Derby, South (Mrs. Beckett). Public health doctors are concerned at the way in which the independence and discretion of members of the medical profession will be affected by the changes. Will they be able to speak freely on public health issues within the range of their responsibility, or will they always have to seek authority from the region--or possibly even from the Department of Health--before they speak on public health issues?
It is extremely important that consultants in public health medicine should have the liberty to express their medical opinion. There is a danger otherwise that the Government may naturally wish to play down a particular issue because of its political consequences, whereas public health specialists might wish to speak out to make the public aware of the medical consequences.