House of Commons Hansard Debates for 12 Dec 1994

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One way of dealing with the issue might be to require in the statute that each health authority should produce an annual report on the state of public health within its region, so that the public would at least be able to see the authority offering to make itself accountable on public health issues.

Midwifery has been subject to statutory supervision, which has ensured high clinical standards. At present, the regional health authority is the local supervising authority. The Royal College of Midwives has called for supervision to be retained on a statutory basis, and I hope that the Government will support and accept that call.

I suggest that the local supervising authority should be at purchaser level, so as to ensure the effectiveness and directness of supervision. In that context, will the Minister also tell the House whether the Government will retain maternity service liaison committees, which have served midwives and patients well? I shall make a brief, but important, point about student nurses. It is right that nurse training has been improved, and that has been beneficial, but the Royal College of Nursing produced a survey within the last fortnight which showed clearly that many student nurses are simply not able to survive without working elsewhere during their courses. In many areas, it is extremely difficult for student nurses to obtain other work. The result is that student nurses--who work long hours and are gaining more and better professional qualifications--are being forced beneath the breadline. I do not think that we should be training nurses in that atmosphere.

Finally, I wish to mention the future of district general hospitals, and to do so I return to the speech of the hon. Member for Hereford. Hereford is a good example of a city with a district general hospital service--I shall leave the buildings out of it at present--which is extremely good. It does not provide the entire range of medical services, but the broad sweep is catered for by a competent group of clinicians.

The trend now, which one can understand, is towards emphasising centres of excellence, or specialist treatment centres--it does not matter whether they are in the public or the private sector--which provide good-value treatment in particular specialties. Those centres do, of course, have a role to play.

The Welsh Office Minister who is present tonight gave evidence to the Welsh Select Committee recently in connection with specialist treatment centres. In that evidence, he made the point that the percentage of treatment within the given specialty which the treatment centres in Wales provide is still very limited. I accept that that evidence is right, but the centres are a burgeoning trend. There is a feeling in the national health service that the growth of centres of excellence may prove to be a threat to district general hospitals in cities such as Hereford. Ministers must watch closely as the situation develops. If district general hospital services are significantly reduced, we will inevitably see the closure of a large number of district general hospitals and, by that token, a reduction in services to the community. I hope that the Government accept that around every accident and emergency service there exists the need for a wide range of services which are best provided in a district general hospital.

During what I hope has not been too long a speech--I am the only hon. Member speaking for my party in the debate, Madam Deputy Speaker--I have sought to

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highlight six specific points of concern to me and to my colleagues. I have studied both the Bill and the notes on clauses, and not a great deal of light has been shed upon the clauses as a result of that study. Some light may be shed upon those real live doctor- patient issues by the Minister in Committee. Just a little chink of light when the Minister comes to sum up the debate tonight would be much appreciated.

7.28 pm

Mr. Peter Atkinson (Hexham): The lack of passion from Opposition Members during a debate on a matter that I always thought they claimed as their subject has been remarkable. Indeed, if one looks around the House tonight, one can see three Labour Back Benchers and three Opposition Front- Bench Members in their seats. That is extraordinary from a party that always says that it makes the running on health.

The reason for the lack of passion is that the Opposition are concerned where to step, because they know perfectly well that they have no real policy on the subject. They also know that the Labour party is moving slowly, steadily and inexorably towards an acceptance of the Government's health service reforms. It cannot do anything else, because--despite the blustering of one or two Opposition Members--it knows that our health reforms are working and that the health service has improved out of all recognition from when the Labour party was last in office.

Why should not the Opposition accept our recommendations? After all, in recent months they have accepted a great deal of what the Government have done in their period of office. The Opposition appear to have accepted competitive tendering, privatisation and even educational league tables. Some Labour Members even accept the idea of opted-out schools. It is inevitable that the Opposition will slowly move towards an understanding that our reforms have been a success.

On a more serious note, however, if one digs deeper into the Opposition's lack of policy, the makings of a policy can be found. A clue to it can be found in the Opposition amendment, which refers to "regional public health directors" and their document, "Health 2000", published in February, which spoke about a possible regional form of health service.

We know that the Opposition are seeking to break up the United Kingdom. We have heard about a parliament for Scotland and what is called an assembly for Wales.

Madam Deputy Speaker: Order. I am not clear how those points relate to the Second Reading of a Bill.

Mr. Atkinson: If you will bear with me for a moment, Madam Deputy Speaker, I will prove how they do.

Just as the Opposition want regional assemblies for England, so they propose their form of regional health authorities. That proposal would re- politicise the health service, when the Government have successfully de- politicised it. Such a shift is extremely important. I served on a district health authority for some years in the bad old days, when the DHAs were dominated by local councillors or the placemen of local councils. I must admit to being one of those placemen, because a local authority put me on a health authority board.

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At the time, I had scant knowledge about the health service, but I am pleased that it is now run by professionals rather than those who were appointed to DHAs to politicise that service. That politicisation option had been proposed many years ago, but it had been rejected by the then Labour spokesman, Nye Bevan.

The result of the politicisation of the health authorities was quite appalling for patients, especially in regions dominated by the Labour party. Those Labour DHA members had at heart not the best interests of patients, but those of the unions and union members. Labour councils also appointed health workers from one DHA area to sit on the DHA of another. They were not interested in looking after the interests of patients; what mattered to them was looking after the interests of their fellow professionals by adopting a "make work, improve conditions" attitude.

Those DHAs resisted the closure of redundant 19th-century hospitals which should have been closed down years ago. They also opposed root and branch any form of contractorisation or tendering for hospital services. I remember that, when my local DHA eventually succeeded in privatising the cleaning services for one hospital, we were amazed to discover that that hospital worked on a 30 per cent. daily absentee rate. The contracting out of services revealed such arrangements. In those days, we had to work with COHSE, the health service union. A greater misnomer for a union one could not find, because that union continually reduced hospitals and their patients to misery through regular strikes at hospital laundries. That action was one of the union's favourite tactics. That union now represents itself as a new union, Unison, but I am sure that its agenda is the same as that pursued in the old days.

One of the purposes of the RHAs was to sort out the mess caused when local authority boundaries and health authority boundaries were coterminous. That problem arose because of early reforms to the NHS in the 1970s. In those days, patients did not travel within their local authority boundary for treatment but continually crossed to where their doctors wanted to give them treatment, or where those patients wanted to be treated. The RHAs therefore had to have enormous financial departments to sort out the mess caused by such cross-boundary treatment.

All those problems have been resolved through our creation of hospital trusts. That is why it is perfectly timely for the top layer of bureaucracy in the health service to be abolished. I must commend, however, what RHAs have managed to achieve in recent years. If I may be parochial for a moment, I am pleased that the headquarters of the Northern RHA will be relocated in Durham, rather than in Harrogate, as has been argued for today by some hon. Members. Durham

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is the convenient choice, because it is in centre of the region. That RHA has offered an innovative solution to a problem involving my district general hospital.

Mr. Bayley: Without becoming too parochial, is the hon. Gentleman suggesting that Durham is equidistant between Newcastle and Grimsby, which will be within the same RHA?

Mr. Atkinson: Given that the new authority will include Northumberland, Cumberland, Durham and parts of North Yorkshire, I believe that Durham is conveniently close to the centre of that region and has good road links.

My local RHA offered an imaginative solution to the problem posed by Hexham district general hospital. The solution may interest the hon. and learned Member for Montgomery (Mr. Carlile), who might be faced with a similar problem in his constituency.

The small district general hospital at Hexham is rather archaic--it was built as a temporary hospital during the war--but it serves a large rural area, and is loved and appreciated by local people. The difficulty was that the hospital could not provide the wide range of services, expertise and specialties that are available in major teaching hospitals and major city centre hospitals. The RHA's solution was most effective, because it welded Hexham general hospital into a joint trust with the Royal Victoria infirmary of Newcastle, which is one of the leading teaching hospitals. As a result of Government reforms, consultants from the Royal Victoria infirmary are now able to travel out to the district hospital to carry out operations. That change will bring the expertise of that major teaching hospital to the district hospital. I hope that the Under-Secretary of State for Wales, who is on the Front Bench now, will pass on to his colleagues at the Department of Health our optimistic hope that a new district hospital will be built on the existing site in the centre of Hexham.

The RHAs have run their time. They served a necessary and useful purpose, because, in recent years, they have been helpful in establishing the reorganisation of the NHS. The final reform proposed in the Bill will ensure proper independence for the trusts, better financial savings and a better service to patients.

7.36 pm

Mr. Hugh Bayley (York): So far, hon. Members have addressed the issues of bureaucracy and accountability. I accept that they are important and central to the Bill, but the most important issue is whether the abolition of RHAs and the merger of FHSAs and DHAs will improve the health of the people.

The most fundamental principle of the NHS is that of equity--that patients, irrespective of where they live, should be treated on the basis of need and on their ability to benefit from health care. That is the absolute hallmark of a public-sector, tax-based health system--a system into which we all pay and from which we can all draw health care, when we need it, on the basis of need.

Under the Conservative Government, however, evidence has grown of stark, widening inequalities in health, both between different regions in the country and between different social

classes--inequality in terms of access to health care and in terms of people's state of health.

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Evidence of that appeared many years ago in the Black report, which was commissioned by the then Labour Government, but buried after the 1979 election by a Conservative Health Minister. The Select Committee on Health has also taken evidence of health inequalities. For instance, in our recent study of dental services, we learned that five- year-old children in Scotland, Wales and the North Western RHA had twice as many decayed, missing or filled teeth as children in the West Midlands, South West Thames or Wessex RHAs. What is more, the average number of decayed, missing and filled teeth is actually increasing in the poorest regions of the country, whereas it is decreasing in the richest region of the country.

There are disparities not simply between regions, but between social classes. In the Health Select Committee, we were told that adults in social classes IV and V, unskilled and semi-skilled manual workers, when compared with those in social classes I, II and IIIa, white collar workers, had more missing teeth and more than twice as many decayed teeth, but fewer filled teeth, showing a lower level of treatment.

Quite recently, in April 1994, an article by Peter Phillimore and others in the British Medical Journal identified the health inequalities in the Northern region. They found that adults aged less than 65 in the more depressed parts of the region, such as St. Hilda's ward in Middlesbrough or West City ward in Newcastle, were four times more likely to die--they had four times the standardised mortality ratio--than people living in more prosperous parts of the region such as Wylam ward in Tynedale or Whalron ward in Castle Morpeth. In other words, health inequalities are literally a matter of life and death.

The problem of regional inequalities was first tackled in 1976 by the last Labour Government by introducing the resource allocation working party, which funded regional health authorities on the basis of the populations in the regions weighted by death rates in those regions. That basis of funding the national health service has continued ever since.

However, the abolition of regional health authorities as a result of the Bill means that a new funding formula would be needed, because one can no longer fund on the basis of regions. Therefore, last year, the Department of Health commissioned research from a group of health economists at the university of York, to develop a new formula to fund district health authorities.

The researchers found that the current formula underestimates the need for health care in deprived areas, principally in the north of the country and in inner cities, because it takes no account of the health implications of social deprivation. They found that indicators such as unemployment, the proportion of the population who are lone parents, the proportion of elderly people living alone with no carer, and the proportion of ethnic minorities, were good indicators of the amount of health need and the resources required to meet it. The York research team published its findings in the British Medical Journal on 22 October 1994. It estimated that, using its formula, the Northern regional health authority should receive 2.8 per cent. more in relation to acute care to meet the health needs of the population in the Northern region, compared with the health needs of populations elsewhere in the country. By contrast, the

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team found that, as far as acute care is concerned, the Oxford regional health authority received 4.8 per cent. more than its entitlement on a needs-based assessment.

The team also produced a formula for the provision of services for mentally ill people. It found that the North East Thames region received 15.4 per cent. less than its entitlement for psychiatric services, and that the Wessex region received 17.5 per cent. more than its entitlement when the health needs of the population in the region were taken into account.

The day before the researchers published their results--perhaps the timing was co-ordinated--the Department of Health issued a letter to all finance directors in the national health service in England, departmental letter FDL (94)68, which accepted the main thrust of the York researchers' argument and said that it would apply the York formula to the majority of the NHS budget. The Department made some modifications, but it chose the York formula as a basis for the new allocations to health authorities.

It therefore shocked me to find out last week, from a Department of Health press release, that next year's resource allocation to the health service provides exactly the same 4.4 per cent. increase for each regional health authority, irrespective of the health needs of the population in the region. That will perpetuate the health inequalities I mentioned earlier, and will undermine the principle of the NHS as a national health service, meeting the needs of patients equally, whether they live in Newcastle or Bournemouth.

The difference that funding on a straight percentage basis for each regional health authority in the country makes, amounts to very big money. With the help of some of the York health economists, I have calculated over the weekend the target allocations for each regional health authority if the York formula, which the Government have said they will accept, was implemented on the modified basis that the Government laid out in their letter to our health service finance chiefs.

Compared with the actual allocations that the Secretary of State announced last week, the new combined Northern and Yorkshire region will receive £128 million less than its target, according to the formula that the Government say they will apply. The North Thames region will receive £103 million less than its entitlement under the formula that the Government commissioned, and which the Government say that they will introduce.

By contrast, the South and West region will receive £40 million more than its entitlement based on the health needs of the population in that part of the country, and the Anglia and Oxford region will receive a massive £286 million more than its entitlement based on the health needs of the population in that area.

I do not argue for swingeing cuts in the health service in the south. However, if the Government wish to provide a comprehensive health service which provides equal access to treatment for people throughout the country, they should be moving towards the allocation of resources based on health needs. They need a strategy for gradually correcting the imbalance in resource allocation that favours the south at the expense of the north, and this year they had the opportunity to do it.

The press release last week, announcing the Department of Health's allocation for this year, said that the allocation amounts to a 0.85 per cent. increase in

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addition to the rate of inflation. Significant new money is going into the health service, and that new money could and should be targeted on the regions that are underfunded at present.

If one draws a line across the country from the Severn to the Wash, according to the formula that the Government themselves commissioned, north of that line the national health service receives £235 million less than its entitlement based on the population and the needs of a population; and south of that line the NHS receives £235 million more than its entitlement based on the needs of the population. That is unfair; it is unjust. It is unacceptable to meet the health needs of people in the south by cutting the health care budget for people in the north. If we are to continue to have a national health service, health resources must be allocated on the basis of patient need for care, rather than party political geographical allocation, which benefits people living in Conservative parts of the country. 7.48 pm

Mr. Bernard Jenkin (Colchester, North): Following the hon. Member for York (Mr. Bayley), I am intrigued by his discussion of formulae and allocation. I have not studied the York formula, and perhaps he served warning on me, as a representative of a constituency south of the line that he drew from the Severn to the Wash, that I should study it, and with care, but I am bound to say that study of those formulae rarely repays the effort as much as one hopes.

We in the North-East Thames region have, for some considerable time, perhaps been over-provided as a region. The resource allocation working party set up by the last Labour Government in 1975 started to move resources for a fairer allocation across the country. Within the North-East Thames region we have had lengthy arguments about the allocation of resources between the various districts. The most salient point to come out of the discussion about formula is the distorting nature of the regional health authorities. They have not just distorted the allocation of resources across the

country--doubtless that argument will continue--but have distorted the allocation of resources within regional health authorities. They have done so to such an extent that the national formula used by the Government to distribute resources across the regions is discarded by the regions, which use their own formula. That formula is perhaps closer to the York formula, which reflects social deprivation and other such factors. North-east Essex has thereby suffered a double whammy. We are losing money as a result of the resource allocation working party and the trend towards allocating resources out of the London area. We have been losing money again as a result of finances being concentrated in the London parts of the North-East Thames region.

Thankfully, the NHS reforms have, over the years, begun to resolve that problem. There was a wide differential between the amount of funding per head allocated to my constituents in north-east Essex and north Colchester compared with those in south Suffolk. As a result of the NHS reforms, that gap has gradually closed, and we are today much closer to attaining parity.

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It is important that bureaucrats, whether in the districts or in the regions, are having less and less influence over the allocation of resources. As we see the growth of GP fundholders, as fundholders attract resources on the basis of their patient lists and their characteristics, and use that purchasing power--not just within the district where the district purchaser has purchasing power, but anywhere-- we see developing an NHS that allocates resources more intelligently according to the natural signals developing in terms of the internal market. Resources are used more effectively and carefully by the GPs acting as advocates for their patients and allocating resources accordingly.

It is no surprise that the Labour party, for all its modernising tendencies, should oppose the Bill. It has opposed every one of our NHS reforms when we have produced them. We no longer hear the scare stories about NHS trusts leaving the NHS. The Labour party is no longer able to make that charge, because it is ridiculous. No doubt the Labour party will make ridiculous and equally fallacious charges about the Bill. As my hon. Friend the Member for Hexham (Mr. Atkinson) said, perhaps the Labour party will eventually come to the same view on the Bill as it did about education league tables and grant-maintained schools. We expect the argument to continue to advance in our direction.

The achievements in my constituency as a result of the NHS reforms have been considerable. All our provider units, to use the jargon--most people still call them hospitals--have moved towards NHS trust status. As a result, our acute unit has been able to expand and use its resources more efficiently. We have opened a day surgery centre and new surgical wards. It was recently announced that the unit's facilities will be further expanded to include a day surgery. That is not to say that those who work in Essex Rivers Healthcare do not have to work extremely hard, often under adverse conditions. We ensure that the money goes as far as it can. I pay tribute to all who work in Essex Rivers Healthcare and give them my moral support. We must not ceaselessly take advantage of the good will of those who work in the health service.

Perhaps one of the benefits of the continuing devolution of decision-making power in the NHS is that one day we shall get rid of the old Whitley council arrangements for negotiating terms and conditions. We could then apply much more modern terms and conditions, with better pay for those who most deserve it, rather than being hidebound by the existing bureaucratic pay and negotiating structures.

Essex Rivers Healthcare has to cope with discharge policy in the face of what my hon. Friend the Member for Colchester, South and Maldon (Mr. Whittingdale) mentioned--the failure of Essex county council's policy on community care. Despite there having been a 66 per cent. real-terms increase since 1991 in the funding of community care in Essex county council, the Labour party has cocked it up--not to put too fine a point on it.

That just shows that, for all the caring good will--I am sure that those involved are nice people who care--they are incapable of delivering the policies that people expect and on which the most vulnerable in society depend. That inability has a knock-on effect in the NHS, and ultimately places a strain on the good people who work in the Essex Rivers Healthcare who have to make decisions about discharging patients. It is rich for the Opposition endlessly to say that they would look after the health service better

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than we do. That is another example of Labour policies, even in county councils, having a detrimental effect on the NHS.

The mental health services in Essex took on NHS trust status soon after the NHS trusts were first announced. We have a trust called New Possibilities, for people with learning disabilities. All the NHS trusts have become innovative examples of what can be achieved. The New Possibilities trust has started an employment agency specifically for people leaving the old- fashioned system of care under the health service. It moves people into the community and ensures that they find a job. That is an example of innovation that we should surely support.

We also have large numbers of GP fundholding practices that greatly benefit patients in the district. My constituency contains the first single GP fundholder. I urge the Government not to dismiss such innovation. In the initial study, single GP fundholding practices were found not to be cost- effective, but that was because they were given the same start-up funding as multi-GP fundholding practices. Although I am certain that the money may have been put to good use, surely a single GP setting up as a fundholder does not need the same start-up money as a multiple GP practice. That must have had a detrimental effect on the cost-benefit analysis of the study. I urge Ministers to continue to study single practice GP fundholders--a good innovation that works extremely well in my constituency. I wish that we had more of them.

The abolition of the regions is a natural consequence of the NHS reforms. The existing regional structures have done good work over the years, but are part of the old command and control system--the Stalinist system, as my right hon. Friend the Secretary of State called it. That is no longer necessary, as so many decisions on the allocation of resources at local level are now taken at local level. Opposition Members often criticise the rise in bureaucracy in the NHS, but the new policy gets rid of bureaucracy, and it is entirely natural that we should have moved some of the bureaucrats out of the regions and districts and into the hospitals and GP fundholding practices where the decisions are made. It naturally follows that we need to cut out the bureaucracy that has now become obsolete. It is only natural that people sitting behind rows of desks in large office blocks feel that they are doing useful jobs; perhaps they are, but they are not as useful as they used to be, and they are certainly less important now.

I confess that, on my one visit to the headquarters of the North East Thames regional health authority, I was staggered by the size of the building. I lusted after the time when we would have NHS trusts all over Essex taking the decisions, and we would be able to get that distant London -based bureaucracy out of our hair. That has now happened, and we are better off as a result. We do not need regional interference in local policies of the type from which we used to suffer. The job of the regions is obsolete now that we have the trusts.

The development of specialist services is no longer planned by the regions in the way envisaged when the RHAs were first established. The Opposition amendment obliquely mentions cancer services. Decisions about cancer provision and anti-cancer strategy are being made now by the London implementation group, which is

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taking a more keen look at the general provision of cancer services across the regions--a view that a single region could never enjoy on its own. A much more co-ordinated approach is needed. We are moving towards a health service that takes the day-to-day decisions at a level ever closer to the patient; and strategic decisions are planned unashamedly strategically.

Although this may raise bogus fears about accountability, the only accountability that really matters is to the patient, when he or she gets the treatment required. As a party, we are happy to remain accountable to the British people. If they are not satisfied with the service, no doubt they will say something about it at the general election.

All the evidence shows that patient satisfaction has improved. Of course, Opposition Members go on talking up what usually prove to be false fears about the state of the health service, but more patients are being treated and are satisfied with that treatment. If one asks an ordinary person what he thinks about the state of the health service, he will pick up the adverse vibrations sent out to him by--usually--an Opposition Member. If one asks him, however, about his own doctor or hospital, he will say what marvellous treatment he has received at their hands.

Accountability brings me to the membership of health authorities. I am very pleased that, once again, Ministers have made it clear that we are not going back to the argy-bargy political meetings held by the old-fashioned health authorities at a time when people were appointed to them as part of the process of handing out the political spoils of office to councillors. People used to end up arguing about the PLO and many other things that had nothing to do with the health service. The real decisions were not made, and if they were made, they were made far too late.

Mr. Nicholas Brown rose --

Mr. Jenkin: I am not giving way.

The internal market in today's health service provides the information that is needed to make decisions in the service which allocates the resources. This Bill is a natural consequence of the continuing and successful reform of the NHS, and I commend it to the House.

8.3 pm

Mr. John Gunnell (Morley and Leeds, South): I am one of the few Opposition Members to have served as a member of one of the new health authorities. I should like to assure my hon. Friend the Member for Nottingham, East (Mr. Heppell) that I was not appointed because of my support for the Tory party.

My second relevant experience lies in the fact that I, like those who work for the RHAs, was once abolished. I used to be the leader of a metropolitan county council, but then I was abolished, and the father of the hon. Member for Colchester, North (Mr. Jenkin) had a hand in that.

My third relevant experience--the most important one--has come during the past two and a half years of handling queries from constituents. Conservative Members may say that constituents are always complimentary about the nursing care that they receive and so on, but hon. Members are also brought a great many cases of real difficulty. I know of a whole series of such cases, of which perhaps the worst was the one that I

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cited earlier--the person whose operation was stopped after he had been anaesthetised. Such cases lead me to comment on this Bill. I oppose the abolition of the regional health authorities, not from dogma but because I think that abolition will bring to the health service two things that we could do without: centralisation and fragmentation. One result of abolition will be that the strategic planning of the service moves from the region to the centre. My hon. Friend the Member for Nottingham, East pointed to the number of functions that the regional offices will continue to carry out. The difference between the regional offices and RHAs is that the former are accountable upwards, to the NHS executive and to the Secretary of State, but they contain no members who are accountable to other bodies. The current RHAs may have been accountable only in a limited way, but at least there was more downward accountability. That means that strategic decisions will henceforth be taken out of the public eye, because they will be made exclusively in regional offices.

This, too, is very like the abolition of the metropolitan counties. A whole range of decisions previously taken by those democratically elected bodies moved away to regional offices and were taken by regional civil servants.

There will also be less coherence of service within a given region--that is where the fragmentation comes in. At present, RHAs at least consider the context of a region generally. With a series of separate authorities, there will be fragmentation, making it even harder to achieve an equitable distribution around a region. My hon. Friend the Member for York (Mr. Bayley) has already pointed out the inequity of that distribution.

Furthermore, some services will be dumped when the RHAs disappear. They will disappear without trace--another striking parallel with what happened when the metropolitan counties were abolished. Some services, such as the Crown Prosecution Service, were immediately centralised; some remained in a recognisably accountable form. But the powers of such bodies--the joint boards for police, fire and public transport--were gradually whittled away, and smaller, specialised services were lost. That happened not because the powers to promote, say, an archaeology service disappeared, but because the authorities responsible for such services had no money with which to perform them.

The greatest loss, however, was the loss of accountability.

Mr. Michael Trend (Windsor and Maidenhead): The hon. Gentleman has made the rather serious allegation that some services might be dumped as a result of the Bill. Would he care to give us an example?

Mr. Gunnell: I shall shortly be offering a quotation precisely with that in mind.

I should like first to deal with the money that it is claimed will be saved. There is not much evidence that the £150 million savings have been thought through. The abolition of the metropolitan counties was based on the idea that enormous savings would accrue. Research showed that there would be no savings before or after abolition. The savings argument was bogus. We shall be surprised if any savings as a result of abolition go to the care of patients.

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The region is not being entirely discounted. Under the process of accountability each region will be represented by one person, a respected local figure, and he will somehow be responsible for that region. How can one person take that on and be a respected local figure in the whole of the Yorkshire and the northern region? It is facile to say that such appointments will not be political because the eight people who will represent the regions will be on the policy forum at the centre and will inevitably be members of the Conservative party.

My experience of being appointed to an authority as a Labour party member was interesting. I was invited to meet the chief executive of the health authority and he asked whether I would be willing to serve on it. He knew my background and where I stood politically. I had many commitments at the time so I said that I had doubts about serving. I had been asked to serve because I was a member of Leeds city council and I suggested that another member of the council might be willing to serve. I was told that only three members of Leeds city council were acceptable. I am not sure what that made me. One of the three was already on the regional health authority and another was on St. James's hospital trust. That left me and I was told that if I did not take the job there would be no representation from the city council. I discussed it with the leader of the council and we agreed that it would make sense for me to become a member of the health authority and chairman of the social services committee. It was clearly seen as a political appointment, and it is facile to pretend that such appointments are not. That is not to say that they are all political appointments, but the eight people who will be regional bosses will be the ears of the Secretary of State, and those ears will be very sensitive to the policies of the Conservative party.

There are non-political appointments to health authorities. I was one, and it is the job of people on such authorities to make them work. The new health authorities are probably not as bad as we say and not as good as the Government make out. One specific achievement by Leeds health authority which was brought about by the reforms is that before the reforms it was almost impossible to get an abortion in Leeds. As soon as the providers found out that there was income to be had from abortions, they became available in Leeds, and that was a welcome change.

A fellow member of Leeds health care was a non-political appointee. He is David Hunter of the Nuffield Institute for Health at the University of Leeds. In the research paper provided by the Library, Mr. Hunter states what would be lost when the regional health authorities were abolished as:

"arbitrating in local disputes; providing a challenge to local myopia in service development and commissioning; encouraging innovation and new ways of doing things; and promoting health strategy development, community care and priority services, research and development, and health alliances. In theory, purchasers and providers ought to be able to inherit such an agenda. In practice some will but many more won't."

I have two questions about the changes and the merger between Leeds and Yorkshire. Why Durham? No contracts have been let because a site has not yet been chosen. However, £2 million has been spent on the centre in Harrogate to bring it to a high standard. Was that taken into account when the issue was discussed and studied?

Under the Minister's proposals, Quarry house in Leeds will lose 200 employees, which is, I think, 21 per cent. of its staff. A tremendous amount has been spent on Quarry

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house and if 200 staff are going there must be space for 135 from the new regional health authority without having to build anything extra. Have the Government considered the costings and found that it is cheaper to construct a new building in Durham than to use the space that they have created in Leeds by partly emptying Quarry house? The sums do not add up.

We oppose the abolition but look somewhat favourably at the merger of the district health authority and the family health services authority. As the chairman of the social services committee in Leeds I have worked with both authorities and to me it makes a great deal of sense to put responsibility for primary and secondary care together.

Why will fundholders be more directly linked to the regional offices than to the new authority? The authority should be responsible for fundholders as well because if it is not that will perpetuate the current inequity. Conservative Members have not answered our questions on purchasing. As the numbers of fundholders increase, the purchasing role of health authorities will decrease. By acquiring primary care they have obviously increased their purchasing powers a great deal. Will health authorities still have a real role in that context?

8.16 pm

Mr. Michael Trend (Windsor and Maidenhead): I welcome the Bill and the overall progress of the Government's health reforms. I recently had the honour to attend an international conference at one of the royal colleges at which people from health services all over the world were gathered. It was clear that our health reforms were in the international league and that other countries were looking to us with our experience. Not all of them had done what we have done, and the United States was on a completely different tack.

Fundamentally, the reforms are held together internationally by the purchaser-provider split, which was pioneered in this country and has made a real contribution to creating an excellent health service that the country can afford.

The Secretary of State spoke about the OECD report. It states: "The command and control system of the NHS lacks flexibility, incentives for efficiency, financial information and hence accountability and choice of providers of secondary care." The health reforms have been widely praised and I also commend them. We began by addressing the trusts and fundholders. That is evidence of the Government's desire to have a more locally based national health system. Had any Government wished to create a centralised system they would have started by reforming or strengthening the centre. That was not what happened. First, more local systems in hospital and primary care were set up, and that shows the emphasis of the Government's reforms.

While that was going on, some people thought that the purchasing side of the equation was in danger of being left behind. Purchasing is central to the NHS. We have heard much about the so-called centralisation of the NHS through these reforms. Does the Bill centralise? I do not think that it does. It removes a vestige of the command and control system. It is extremely important that we understand that the new NHS will be based, and will be accountable, locally.

What about accountability? The present system is working well in both trusts and fundholding. It is part of the evidence that we need to examine to ensure that

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