House of Commons Hansard Debates for 12 Dec 1994

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accountability is secure. As many of my hon. Friends have already said, we do not want to politicise the NHS, its management or its accountability. We must not forget community health councils, which are the voice of local people. I understand that their position remains unaffected by the Bill.

I am not at all sure about Labour's regional plans. The right hon. Member for Derby, South (Mrs. Beckett) did not clarify its plans for regional health services. I suspect that she is trapped in the difficult logic of Labour's proposed governmental reforms--perhaps having tiers of regional government throughout the country--and she may want some conterminous boundaries between regional government and regional health authorities.

This is a debate about health services in the regions. However, I advise the Labour party to think carefully about its general plans for rearranging local government, or even central Government, on a regional basis. I do not think that the people of England would have any fondness for an end to their traditional national form of Government in favour of the imposition of new regional forms. It is a big can of worms for the Opposition. From the West Lothian question down to the English regions, it will provide a big headache for them in the months and years ahead.

I want to say a few words about the formal relationships outlined in the Bill. First, when the new health authorities come into being, they must respond to what Ministers want in the development of the NHS. There will be a conduit of organisation coming down from Richmond house through Leeds to the new outposts, to trusts and on into the primary system. The means to achieve that must exist. Secondly, the new authorities must be effective. They must be able to do well the job that they have been given to do. They must be efficient and economical and able to direct scarce resources to the areas where they are most needed. Thirdly, they must be responsive to the local environment. It is extremely difficult to legislate for that, so I shall instead comment on the informal relationship that the Bill will establish.

Health authorities have not always been responsive, but that is not the same as saying that they have not been accountable. The lack of responsiveness has arisen out of the old command and control structure. There needs to be a culture shift within health authorities. I shall give an example from my constituency. A distinguished local hospital--the Edward VII--in Windsor belongs, together with two other hospitals, to the local community trust. Last year, satisfactory plans for its future were proposed by the East Berkshire health authority. Shortly after that, the East Berkshire and West Berkshire health authorities amalgamated to make one Berkshire health authority.

The new authority had different priorities and plans for health care provision in my part of the county. The new plans were not nearly as satisfactory as the ones that they replaced. One proposal was to remove the world-famous Prince Charles eye unit from the Windsor hospital. Another proposal was not to proceed with a number of elderly rehabilitation beds, which had formed part of the original plan.

There was a vigorous local campaign. I took part in it, as did the local newspapers. A large petition was presented to Parliament. Doctors, consultants and many other local people raised their voices. The significant factor was that no one appeared to be in favour of the

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health authority's new plans. No voices were raised in its support. The negotiations that took place, which were chiefly between myself and the health authority, were protracted. I was learning as we went along, and I felt that the health authority was also learning. The current position is more satisfactory because the eye unit has been saved and there are to be new and expanded clinical services. However, we have not reached any agreement with the health authority about rehabilitation beds for the elderly and it has now postponed a decision.

My argument with the health authority was not a local argument in the sense that I was saying that we had to have that unit for Windsor, that it must not go anywhere else and that I was sticking up for my people. Of course there was an element of that--there always is. My argument was that the provision of care for the elderly, especially rehabilitation care, would be more appropriately placed in local community hospitals rather than in acute hospitals at some distance--sometimes a great distance--from people who wanted to visit their elderly and frail relations.

We took advice from the King's Fund and others on current thinking and conventional wisdom. However, an impasse was reached because the health authority held one view sincerely and deeply and we held another--based on professional advice, not just narrow local considerations. In such circumstances and where all the local voices are ranged on one side, it is important that a health authority responds sensitively to the concerns of local people.

The new health authorities, whatever they be--regional or district, of whatever type or composition--must listen more to local voices. I thought I heard that message clearly in the opening remarks of my right hon. Friend the Secretary of State. She said that there needed to be more flexibility-- I think that she used the word "visibility". The health authority should be more visible. For example, we heard earlier about the chairman of a health authority who holds local surgeries where he is available for local people to meet him. We also heard today about public meetings on health matters--I have been to some--where almost everyone in the room is a health professional of some sort or another. The health authority calls the meeting and it sends a lot of people to it. Nurses and doctors attend, as do local Members of Parliament and local councillors. However, to get the general public involved, even through the CHC, is extremely difficult. It is only when a specific case arises, such as the Edward VII hospital, that the public have an understanding of the issues involved. Therefore, there must be far more "visibility" by the health authorities. They must work with local people because they are working for local people.

We want a locally based NHS and I believe that the Government are delivering that through their reforms. We want that locally based NHS to be responsive quickly and with the minimum bureaucracy and waste. The Bill will help to bring about that desirable aim. However, if we go too far or too fast and do not take public opinion with us, and if the health authorities are not responsive to local voices, we will risk many of the benefits of our reforms coming undone.

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It is most important that the public's confidence in the national health service is maintained at the highest level. Recent research shows that public confidence in the NHS is higher and growing. The Opposition say, on the one hand, that the health service is falling to pieces, but, on the other, that it is excellent. A constituent of mine, who I suspect is a member of the Labour party, also holds both views at once. He tells me that the health service is falling to bits, there is no care, and people are struggling in the streets and dropping like flies. He then writes to the local paper saying that he has been in hospital for a certain procedure and cannot not speak too highly of the doctors and nurses and the care that he received, and that he felt considerably better. I wrote to him and pointed out that that was excellent news and perhaps he would take a less jaundiced view about the health service in future.

Confidence must be kept high. It is important to ensure that our health authorities in both their formal structure, which makes them locally based, and the informal advice and encouragement which we give them to listen to local voices, are the way forward. None the less, this is a good Bill. It will be good for patients and the national health service, and I hope that it receives a Second Reading tonight.

8.30 pm

Dr. Tony Wright (Cannock and Burntwood): This strange Bill is both short and long. Its substance covers but four pages, while its schedules cover some 50 pages. That shows that it is a framework Bill that takes powers. In this case, it takes powers to the centre where they can then be used in a variety of ways, to be spelled out later in secondary legislation. That is the kind of Bill which the Government favour. If the Bill is a culmination, as we have heard, it is a culmination of a whole way of legislating, in which one takes framework powers in a Bill like this and then backs them up with a battery of further powers in which the meat and substance are filled out.

In some ways, this is a fairly uncontentious and perhaps even sensible Bill. For many years we have discussed whether it is sensible to have regional health authorities, whether their function could be defended or whether the time had come to remove them. It is possible to discuss that sensibly. The problem is that it becomes a more apocalyptic story about a process of health service reforms, of which the Bill is said to be a culmination.

I shall ask three questions about that process of health service reforms. First, will it improve the quality of the service? I understand that that question is fundamental when we sweep aside some of the possible arguments. Secondly, will it improve the accountability of the service? Thirdly and more specifically, although it is important, will it enable people better to complain about the service if things go wrong?

On my first question, I hope that the Bill will improve the quality of the service, because, for a long time, many of us have thought that the way to improve the commissioning--we prefer to use the word "commissioning" than "purchasing"--of health care locally is to amalgamate FHSAs and district health authorities. We felt that the division was artificial and made local health planning much more difficult. The fact that that amalgamation is taking place is, prima facie, an argument for the ability to drive quality upward as a result. However, I put it in terms only of potential rather than achievement because a huge job remains to be done.

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If the Government say that the health agenda is complete in that respect, I argue that it has only just begun. A range of issues to do with the quality of health care are untouched. It is only the precondition for a concerted assault on issues of health quality. I refer particularly to primary care, where FHSAs, or their predecessors, family practitioner committees, have had the sole function of paying cheques to doctors. They have had no effective function in monitoring the quality of primary health care and seeking to drive up its quality.

I hope that a consequence of that amalgamation will be to provide the armoury whereby that can now take place because there is a huge gap in our ability to achieve health quality. For example, in the past year alone an extremely good report has been issued by the director of public health for the South Staffordshire health authority. It identified for my area, Cannock Chase, a number of appalling and worrying developments. It showed that we had the largest number of single-handed practitioners, the longest lists in the district and the highest number of referrals from Gps to hospitals, which usually indicates problems in the quality of primary care.

I took those problems to the Staffordshire FHSA. The analysis was linked to other evidence, which said that the area had the most health needs. As we have more ill people in the area, we have a mismatch: the poorest quality of provision and the worst health. The FHSA is the notional provider of primary health care, so I presented the evidence to it and asked what it could do about it. The answer, essentially, was that it could do nothing. It could have conversations with doctors and watch, but nothing more. That is wholly unacceptable. We must work towards a position where those who pay for or commission primary health care have far more ability to watch, monitor and drive up the quality of that care. That presents a huge agenda, and I hope that it will be grasped.

On the issue of hospitals, the Government must grasp the problem in relation to clinical outcomes, audit and performance, which is a hugely neglected area. Many of the matters to which we have devoted so much energy over the years are of minor significance compared with those hard indicators of the quality of care--not what goes into the system but what comes out of it.

Mr. Malone: I am tempted to invite the hon. Gentleman to come and join us because he is pointing out that the new system can tackle those agendas in a way that the old one could not. It is particularly important that he realises that the ability of GP fundholders to respond instantly to the patient need which he has identified is one of the great benefits of the reforms that are now in place. I am sure that the hon. Gentleman will acknowledge that.

Dr. Wright: I am extremely grateful for the Minister's invitation, which is the best that I have had all day. Nevertheless, he rose a little prematurely, because I was about to add that, if that is common ground, as it should be, what should also be common ground is a serious attempt to look at inequities in health care. If that is not common ground, I simply ask the Minister to look at the evidence presented in last week's British Medical Journal , which brings together much of the contemporary evidence on inequalities in health care.

The professor who wrote the overview referred to the way in which "The Health of the Nation" devoted only one page to variations, not inequalities, in health among socio-economic groups, which are said to be the result of

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complex factors. The British Medical Journal stated that it is inconceivable that changes in the genetic make-up of different socio-economic groups have occurred over the past 15 years to produce the increases and differences in mortality in Britain. That is an appalling and devastating commentary on 15 years of social and economic policies that have produced a massive deterioration in health equality.

We use terms such as "life chances" in a glib and easy way, but here we are literally talking about life chances, which have deteriorated in the past 15 years as the result of a so-called trickle-down policy that was supposed to make everything come good. It not only failed to come good but came bad in a big way. Surely we could at least agree on health policy aims to reduce inequalities in health, then apply our minds to achieving those aims. Instead, we have failed to agree and the position has grown substantially worse. There is a huge agenda to tackle.

Will accountability be improved? Is the Bill a decentralist or a centralist measure? Regional health authorities play a role in protecting and sponsoring health authorities and now trusts. They perform a variety of useful functions, and one must question what will happen to some of those roles when regions are abolished. Only last week, almost all the consultants at the Foundation Mental Health Trust in Stafford passed a vote of no confidence in its chief executive. That was a fairly dramatic occurrence and, by implication, a vote of no confidence in a rather ineffectual trust board. Those consultants were immediately able to seek the advice and guidance of the region, which acts as a buffer between the centre and the localities. When regional offices are no longer statutory offices with a status and integrity of their own but simply regional outposts, the relationship will change and roles will alter.

Reference was made to problems in relation to the regional director of public health. The service needs every independent voice that it can get, and the Bill will reduce rather than increase independence. As the former chairman of a community health council, I regret that CHC statutory rights in relation to proposed trusts are removed by the Bill. We should strengthen the role of CHCs, users and consumers--not weaken them further. Every time that I hear the statistical arguments that were made earlier, the more I become convinced that the NHS desperately needs an independent inspectorate that can produce reliable information of a kind that does not exist at present.

The most crucial aspect of accountability is the composition of the new health authorities. I return to the nature of the Bill, with its few clauses and vast number of schedules. It is extraordinary that a Health Authorities Bill should fail to answer the fundamental question of who will serve on the new authorities. Schedule 1 on page 19 of the Bill states only that there will be new health authorities, whose members will be appointed by the Secretary of State. Earlier, the Secretary of State told the House that they will be the best people. I have evidence of the best people who have been appointed to such bodies in the past, but Conservative Members might find it embarrassing if I presented it now.

The new bodies will be the key commissioning organisations for health care in local communities, but the Bill does not say who will serve on them. Recently, the House considered the composition of police authorities.

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It would not dream of allowing those authorities to be established by a Bill without any indication of their composition, yet it is doing so in respect of this legislation.

Recently, the chairman of the Conservative party said that one could not have serving on health bodies people who were not in favour of the Government's reforms. That is preposterous. One wants people who are committed to the health service. It seems that to be passionately in favour of or passionately against reforms is cause for disqualification. One wants people with an acute sense of public interest, who will defend it and the NHS at all costs. The Conservative party chairman has stumbled into a miasma of patronage, without thinking of the implications of his remarks.

There is now a test of whether the Government are prepared to roll back their public appointments process. Of course we need an open system and a commission publicly to advertise such appointments so that anyone who has something to contribute can apply, and normal civil service criteria could be used for selection. Such appointments must be taken out of the orbit of ministerial patronage and put in the arena of public interest. No wonder that Professor Chris Ham and Professor Hunter in Leeds both concluded that the Bill looks more like a centralising than a decentralising measure.

The complaints issue, which surfaced briefly in the debate, is dealt with by the Bill only in terms of transitional arrangements, yet it is the Bill's biggest lacuna. On any reckoning, the present complaints system is a total mess. Sir Alan Wilson and his committee were asked to investigate that aspect as a matter of urgency a year ago. The committee reported in May and consultation ended in August. We were promised speedy action, but Professor Wilson is now expressing regret and disappointment that there has been none.

Mr. Malone: There will be action. We shall bring forward proposals once we have considered what must be done.

Dr. Wright: That is good to know, but I can only go on the present delay. There was a clear expectation that there would be such legislation as was required in the present Session. The present complaints system has been called chaotic by everyone who examines it--the health service ombudsman, Sir Alan Wilson, the National Consumer Council and the National Association of Health Authorities and Trusts. A report on the matter was welcomed and broadly endorsed by every relevant party.

The present complaints system undermines the most fundamental principles of the citizens charter in terms of speed, effectiveness and independence. It cries out for reform. This is a health Bill, but one that signally fails to take up the one option that would bring direct and immediate benefit to users of the service.

There is now a certain ambivalence in people's attitude to the health service, as hon. Members--including the hon. Member for Windsor and Maidenhead (Mr. Trend)--have pointed out. Why do they feel passionately well disposed towards the service, yet passionately ill disposed towards aspects of the way in which it is run? I believe--this is meant, in a way, to be helpful to the Government--that something approaching a crisis of legitimacy is currently evident.

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My theory--it is no more than that--is that the recent explosion of complaints about the service is not simply due to the fact that there is more to complain about; that is an easy point to make. I think that at one time people were not inclined to complain, because they felt that it was "their service"--or rather, "our service". Now they feel that it has truly become "their" service. A real test of legitimacy must be applied to the Government's proposals, and I do not think that the Bill meets it.

8.50 pm

Lady Olga Maitland (Sutton and Cheam): Throughout the debate, Opposition Members have carped and jeered at the NHS. I entirely endorse what my hon. Friend the Member for Colchester, North (Mr. Jenkin) said about people's responses to his questions about their experience of the services. I receive the same responses on doorsteps in my constituency. People tell me that they are worried about the health service, but when I ask them about their personal experiences, they always express gratitude for the care and support that they have received. When I ask, "Then why do you feel as you do?", they reply, "It is what they say on television; it is what those Labour party politicians say."

I am sick and tired of hearing a litany of disaster. I thought that it might be helpful if I quoted from the response to a questionnaire sent out by a GP fundholders' practice in my constituency, the Cheam family practice. That response is very revealing: 111 patients responded, 97 per cent. of whom said, interestingly, that they were entirely satisfied with the care that they had received. That is completely at variance with what the Opposition are trying to tell us.

Mr. Morgan: We surrender.

Lady Olga Maitland: I am delighted to hear it. I could take up hon. Members' time by going through the rest of the questionnaire, which contains many points that you now beg me to mention. [Hon. Members:-- "No."] You do not want to hear the truth.

Mr. Deputy Speaker (Mr. Geoffrey Lofthouse): Order. The hon. Lady must not keep using the word "you"; the Chair has nothing to do with this discussion.

Lady Olga Maitland: I stand corrected, Mr. Deputy Speaker, but there are times when I feel somewhat goaded.

It might be beneficial and educational for Opposition Members to hear a little more about the questionnaire, although originally I did not intend to impose it on the House. To the question

"On entering the ward were you made to feel welcome?", 86 per cent. of patients replied, "Absolutely." When asked, "Were your family/friends made to feel welcome?",

98 per cent. said yes. When asked,

"Did staff respond quickly to requests for assistance?", 82 per cent. said yes. When asked, "Were you given privacy?", 100 per cent. said yes. Again, 100 per cent. said yes to the question, "Was your linen clean?". There must be some sense of reality about the kind of patient care that is actually being delivered. I welcome the Bill. At first sight, it might strike many patients as no more than an accountancy exercise; but many patients will benefit from it. Any GP's eyes will

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light up when he sees how his practice will benefit. Let me focus for a few minutes on how the Bill will affect patients in my constituency. I see them as the VIPs who are at centre stage in the whole scenario; the Bill, after all, is designed to improve facilities in their daily lives.

My regional health authority, South Thames, is scheduled to disappear as a result of the reforms. I shed no tears, because my constituents will be better served without it. The RHA's staffing level will drop from 400 to 135: that number will form the NHS local executive branch. It does not take much imagination to see how local medicine could benefit from the value of 375 salaries.

Moreover, it is plain common sense to merge Sutton, Merton and Wandsworth district health authority with the family health services authority. It strikes me as perfectly normal for GPs to work in ever closer partnership with the district health authority, and from the same building. In this instance all parties will operate from Wilson's hospital in Merton: as a result they will be not a telephone call or fax away from each other, but literally just a step from each other's offices. Daily, regular contact to discuss mutual problems--particularly when the GP is playing an increasingly important role in managing patient care--can only benefit all of us. In short, we shall have a one-stop shop.

The new chief executive of the combined health authority will be Mr. George Gibson. He is enthusiastic about making the GP the key link in the whole health-care system--the gatekeeper, as it were, who will determine who gets what and where. His input will ensure personal involvement as well. In his health authority alone, as a result of the Bill, Mr. Gibson will have the means to allocate £1.5 million more resources to front-line patient care--for instance, X-rays for lung cancer, tests for breast and cervical cancer, the delivery of effective drug rehabilitation care, health promotion such as anti-smoking campaigns, especially among schoolchildren, and more community health centres, especially on low-income housing estates. Indeed, why should there not be more district nurses?

In the same mode, Mr. Gibson wants to provide more mental health care to help families who must care for relatives suffering from schizophrenia, Alzheimer's disease or deep depression. All those conditions impose great strain on carers, who badly need psychiatric nurses to be on hand. I hope that his "wish list" will bring on stream child and adolescent psychiatric services: such services, sadly, are needed more than ever as children suffer from the pressures of broken families and drugs.

GPs, in turn, would have more resources to earmark for primary care. There would be help for children with special educational needs, crucial speech therapy and more physiotherapists. Surely he should have the power to employ a full-time carer or nurse if that means keeping a patient at home rather than in hospital, which is costly and not always necessary.

I cite the example of a local case involving four people suffering from sickle cell anaemia, which is a painful and miserable illness. Between them they were in and out of hospital 800 days a year, and pain management was the main problem. It was common sense to employ a full-time nurse to look after them and to help them cope with the pain and provide the support that they needed. They were able to stay at home in familiar surroundings and hospital

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beds were released for expensive acute care for others. I trust that the Bill will mean that more resources are made available to expand such services.

It must be right that a GP should have a direct say in all aspects of patient care. More important, he should be encouraged to take a more proactive role, even if that means attending refresher courses. He should also be coaxed into offering more services in his surgery and given the necessary resources to be able to do so. That should apply whether or not he is a fundholder, but, clearly, the GP who is a fundholder will have more say in how his patients receive the appropriate care and, in addition, will receive the benefit of the extra resources made available as a result of the Bill.

There are a number of enthusiastic GP fundholders in Sutton. However, there is anxiety to ensure that resources earmarked for primary care are ring fenced. That would certainly introduce the necessary discipline, especially where there is a temptation for a district health authority to become so immersed in its own spending plans that, despite the well-aired aims, GPs end up being sidelined. My fundholding GP told me what the extra resources would mean to him. He would like to improve his premises so that he can deliver more surgical care. It is nonsense to suggest that patients should have to put up with what I experienced years ago when I had to attend out- patients at Bart's to have a boil lanced on my thumb. It should have been done by my GP in proper surroundings. In future, a GP should be able to deal with all manner of minor surgery from skin lumps and bumps and the removal of cysts to joint injections. I know a GP fundholder who is also a fellow of the Royal College of Surgeons. Once a week he carries out a minor surgery list which could include the treatment of hernias. Much routine work could be delegated in this way. With the extra resources, a fundholder should be able to employ physiotherapists, dieticians and counsellors and social workers should be brought in to work closely with patients who need extra care and support.

If we were to stretch a point, we could follow the example of the general practice in Aviemore in Scotland which was visited by a GP whom I know and his teenage daughter. She had broken her arm while walking on the moors, but the fundholding practice had a 24-hour casualty service. The girl was X -rayed and made comfortable and only then allowed to go to a hospital in Inverness for an operation. Had she had a clean break, all the services would have been available in the plaster room for her to have been fixed up without having to go elsewhere. Would it not be marvellous if resources released for primary health care as a result of the Bill could provide such services? I have no doubt that rural areas in particular would benefit.

GP fundholders should have the power to insist that their patients are placed in single-sex wards in general hospitals if that has been requested. I welcome the written reply that I received today from the Minister in this regard, but I am not certain that the patients charter standards to be issued next year, which will require hospitals to inform patients in advance when they will be accommodated on a mixed ward for non-urgent treatment, will be entirely satisfactory. The reply does not make it clear what patients can do if they find the arrangements unacceptable.

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Is the onus on the health service to comply with the patient's requirements if a single-sex ward is not available immediately? I hope that, when establishing their contract with local hospitals, fundholding GPs will make it a condition that patients's concerns will be top priority and that they will not be exposed to embarrassment and forced on to a mixed-sex ward. There has already been some publicity about the issue, but it is not only women who are worried--I am told that men, too, are not always keen to be on a mixed ward.

I heartily welcome the Bill. It may not hit the headlines, but the result will be that patients, at their most vulnerable, will benefit most. It is disappointing that the Opposition cannot bring themselves to support it wholeheartedly. The Labour party's proposals will rebuild overloaded bureaucratic structures, and pressure groups will have their say at patients' expense. Throughout the debate Labour Members have demonstrated their obsession with political appointments. Under a Labour Government, the health service would go back to the bad old days.

I am delighted that the Bill deals with the real world. It will become law and provide improved services which patients need so badly, while Opposition Members bicker about how they will increase NHS bureaucracy. I doubt that patients will thank the Labour party for putting jobs for the boys first.

9.5 pm

Mr. Kevin Hughes (Doncaster, North): Contrary to what the Secretary of State for Health and her colleagues have said in the debate, the Health Authorities Bill represents yet another blow against accountability, which has been attacked consistently throughout the Government's reform of the health service. Accountability must play a part in the provision of health services. However, with this Bill the Government are running away from accountability yet again and making the system less responsive to people's needs.

Accountability is essential because it is the only way to ensure that patients' interests come first. As a result of the internal market process, emphasis on cost cutting is defining priorities far more than the wishes of patients. Services are being planned by accountants and business managers whose priorities are financial and have nothing to do with the caring professions or with patients. Under the Tories, business has taken over from service in the national health service. Patients have become "consultant episodes" rather than people. Applications for new equipment have become "business cases" to be negotiated with the private sector. In meetings, local health service managers talk about "strategic directions", "over-performance", "under-performance", "outturns" and "contract monitoring". They have figures and tables for everything--although most of them are designed so that no one, apart from the author and a chosen few insiders, can understand them. Bureaucracy has gone mad under the Tory Government.

In the current dispute over local pay, doctors are putting in about an extra 14 hours per week performing management tasks, including preparing invoices on patient charges, drawing up contracts, assessing prices and talking to managers. The public can ask legitimately: why are doctors not treating patients in that extra time?

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Yes, patients are suffering. Last week, one of my constituents was told that he would have to wait for months just to obtain a consultant's appointment. He was also told that he would have to wait about two years to have a very painful cyst removed, even though the doctors knew that the man's employers had threatened to sack him if he did not receive treatment, because he could not continue to do his job in his present state. However, my constituent was told that if he could pay for the consultation--if he could find £50--he would be seen by the same consultant almost immediately. That is privatisation by the back door, and the Government know it.

The Bill further undermines the role of doctors and nurses in the decision- making process. It drops the duty to recognise local advisory committees of clinicians. It gives no details of any seats on health authorities that will be designated for medical staff. How will their expertise become part of the decision-making and oversight process? I know from my experience in social services that finding out about the practical problems and taking a practical approach to their resolution is essential if management are to be effective in securing improvements in services at the point of delivery. Staff are a part of the accountability equation. Some months ago, a report by the health advisory service on mental health services in Doncaster was published. One of the problems clearly identified was the lack of consultation of staff and the lack of weight given to their opinions by management. If there are no clear lines of accountability in the NHS, that situation will be duplicated throughout it, with the inevitable consequences for planning, for the efficient use of resources and for patient care which flow from such failures. The report also found that a number of service users and their groups felt that the consultation was superficial. Clearly, people who matter are being excluded from the decision-making process.

The Bill is yet another example of how the Tories treat the NHS as just another business venture. Maples was right. The Tories will never win on the NHS because they will never learn that co-operative, collective action works and that people are central to success. They can only understand competition, selfishness and market forces. They do not understand that the NHS is staffed by people, that the services are delivered by people and that the patients who are treated are people. We are not dealing with machines making goods. We are dealing with people treating people and with the need to get the very best from the highly trained and skilled people in the NHS. The Government's approach, which undermines the rights of staff and patients, will not achieve that.

The Secretary of State says that a light touch is needed. That can only mean limited co-ordination and a lack of accountability which will prove damaging in the long term. The new regional executive offices should not be centralising bodies which consider themselves to be responsible to the centre. If that happens, there will be a lack of oversight and the loss of a strategic, regional, co-ordinated approach. We shall be left with an even more fragmented health service than we have now. The Government have put in place a system of mini-health businesses which are run by their sycophants at local level. Locally negotiated pay will take us further down

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that road. As the Government move to complete their reforms with the Bill, fragmentation of the service and privatisation by the back door will continue.

The Government now propose that the health care function of the Department of Health should be run by the NHS executive, which will take full responsibility for the NHS. The executive will thoughtfully help Ministers with parliamentary accountability. Presumably the executive will give them their lines to read at the Dispatch Box, as usual.

Another aspect of the proposals which suggests that someone in the Department of Health has a healthy sense of irony is the announcement that the Bill will reduce the costs of management in the NHS, a view parroted by the Secretary of State today. Surely that is a joke too far. Since the introduction of the reforms, in Doncaster alone administration costs have risen from £4 million to £6 million, a rise of 48 per cent.--[ Laughter. ] Conservative Members may think that that is funny; I certainly do not. Patients are entitled to know why that money is being spent on administration in Doncaster. That figure is completely separate from the 300 per cent. rise in managerial costs locally. Yet the Government expect £150 million to be released for patient care as a result of the changes. They are living in cloud cuckoo land. How can the Secretary of State, who has presided over such a massive explosion in NHS bureaucracy, tell the House with a straight face about the merits of reducing costs to plough money back into patient care?

The Government do not--and, I suspect, dare not--say how they arrived at that £150 million, which is perhaps why they seem confused about how much, if anything, will be saved. If the changes follow in the tradition of the remainder of the Government's reforms, we can expect a vast increase in costs and bureaucracy. We shall find that health authorities have to take on some of the region's functions, but they will do so less effectively because of their lack of expertise. There will be local duplication of some of the work previously done by regional health authorities, and costs will undoubtedly increase as a result.

Frankly, I do not believe the Government's claims about the national health service. They perversely attacked it for inefficiency and waste, but then created a new system which put incredible bureaucracy and waste in its place. Their claims about bureaucracy are not credible, just as their claims about waiting lists are not credible and were exposed earlier in the debate.

The Government's business-oriented and competitive approach to the national health service is fundamentally flawed because their ideology is wrong. I look forward to kicking them out of Government so that we can build a national health service based on socialist principles, which mean that people come first.

9.15 pm

Mr. Nicholas Brown (Newcastle upon Tyne, East): The Bill was presented to the House as bringing to a natural conclusion the Government's health care reform agenda. The end result is supposed to represent the Conservative party's vision of a national health service safe in their hands. In opening the debate, the Secretary of State described it as the "final building block" in a national health service that will survive while the Prime Minister lives and breathes.

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The Bill is not an impressive conclusion or summation of Mrs. Thatcher's vision when first embarking on the project. What started--indeed, what swept in--in the mid-1980s like Boadicea's chariot, and caused almost as much chaos, is ending in farce and confusion, as if Boadicea had been replaced by Mr. Bean. Heralded as a streamlining measure, it attracts bureaucracy and leaves unanswered more questions than it deals with.

Perhaps I may put this question to the Minister: if the Bill is supposed to save money, why is it followed by a money resolution? I suppose that the Minister will answer that it will save money later but may require expenditure of funds immediately. It certainly looks that way.

There is, and always was, a case for merging district health authorities and family health services authorities in England and Wales, but it follows logically that the opportunity should have been taken to provide the national health service with coherent boundaries at local level, to parallel the well understood community boundaries used by local government. There is no case for a separate, geographically incoherent map solely for the national health service, which continues to be disfigured by demarcation disputes with local authorities about community care provision. The Bill could have dealt with that structural issue, but it did not, and the present situation will be allowed to continue. Whatever else the Bill may be, it cannot be described as the completed reform agenda of which the Government boast.

The Government's second and more controversial structural reform is to convert the eight remaining regional health authorities in England to eight regional outposts of the NHS executive. The claim for that agenda is that it will abolish a layer of bureaucracy. As my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell) and others correctly pointed out, the Bill does nothing of the sort; it merely transfers the regional tier from the national health service to the civil service. The new structure makes the regional tier directly responsible to the Secretary of State.

As civil servants, staff will be subject to the terms of the Official Secrets Act 1911 and their first duty will be not to the NHS or to patients but to care for the Secretary of State in the community. It is perfectly possible--

Mr. Jenkin rose --

Mr. Brown: I would have given way, but I am beginning to share the Prime Minister's opinion of the hon. Gentleman, who did not give way to me, so I will not give way now.

It is perfectly possible that the agenda will increase rather than decrease the number of administrators needed. With the new joint arrangements between the different health authorities, it is quite possible that we shall put in place a new tier of administration, and do so in an ad hoc manner.

In any event, the changes must be set in the context of the rest of the Government's health care reforms. Before doing that, I should refer to the first-rate speech by my hon. Friend the Member for York (Mr. Bayley), who spoke of the injustices of the Government's current method of allocating resources, with specific reference to the absolute nonsense of merging the Yorkshire and Northern regions. The Northern region alone is the size of Wales, and the entire new region of Yorkshire and the North is the same size as Scotland; yet we are told that the resources

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allocated to its regional office will be broadly similar to those allocated to smaller regions. It is difficult to conclude that that is anything other than a political decision. The Government are advantaging areas where there are Conservative seats at the expense of areas where there are predominantly Labour seats.

The broader context is well known, but it will not hurt to remind the House of it. Since 1988, the number of NHS managers has increased by an astonishing 1,538.3 per cent. In 1993 alone, the number of managers employed by the NHS increased by 13.5 per cent.--this from a Government who claim to be committed to cutting bureaucracy. Since 1987, total costs throughout the NHS have risen from £1.44 billion to £3.02 billion, with an increase of 110 per cent. in administration costs alone.

The proportion of the total NHS budget spent on administration, clerical and management costs rose from 8.77 per cent. in 1987-1988 to 10.8 per cent. in 1992-1993. It used to be a source of pride that administrative costs in the NHS were lower than elsewhere in the developed world, but the Government have thrown that advantage away with their new structure without demonstrating the corresponding benefits from the new system.

We shall want to examine in more detail in Committee the allocation of responsibilities and functions between the health authorities and regional offices, but a number of important questions ought to be raised now. Who will hold the contracts of junior doctors? Who will maintain and monitor cancer screening services? That question was put directly to the Secretary of State, who responded by praising the services. I join her wholeheartedly in so doing--that is not an issue of contention between the parties--but she did not say who will maintain and monitor the cancer screening services.

Who will be responsible for the vocational training of general practitioners? What provision has been made for a national overview of nurses' training? How will day-to-day responsibility for GP fundholders be managed, given that that responsibility is now passing directly to the Secretary of State even though the resources are to come from the local health authorities? It is a bit much for the Secretary of State to say that an incoming Labour Government would be centralising and totalitarian--she refers to us as Stalinist--when she is centralising significant powers theoretically in her own hands. When she said that a Labour Government would have authoritarian powers, she was perhaps referring to the structures that she will hand over to the incoming Labour Government.

The training of nurses is an important matter. Training is being devolved, as I understand it--I am willing to be corrected if I am wrong--to local consortia of NHS trusts. As I have said, those consortia--they have yet to come into being--could create a whole new tier of administration. The structure is bound to make the planning of nurses' training more problematic, and it may result increasingly in shortages of trained nursing staff.

The failure to address obvious long-term planning issues has been accompanied by a failure to invest in nursing training and the long-term future of the NHS. The Secretary of State seemed to recognise that problem, because, in what I took to be an effective adjustment of the contents of the Bill, she said that regional directors

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would be invited to take a special interest in that matter. That suggests that the case for a regional tier is almost being rebuilt as the details of the Bill are examined by the House.

My hon. Friend the Member for Nottingham, East (Mr. Heppell) rightly pointed out that public confidence in the proposed arrangements has been further undermined by the lack of any democratic accountability. The public interest will be represented on those new structures by the usual Conservative business men or close relatives or friends of Conservative Members. The public find that quangosity wholly unconvincing and they are fed up with it. A legitimate debate may be held about exactly where and how the lay interest of health service consumers should be represented in the NHS. I do not believe that there is any one absolutely correct method of representing local public interest, but it should surely be represented by people chosen by the public and it should specifically not be undertaken by those whom the Secretary of State has chosen--especially since they all seem to be drawn from the ranks of the supporters of the right hon. Lady's party and their relatives. [Interruption.] I am happy to give way to the right hon. Lady, who is muttering; perhaps she has thought of someone whom the public would accept.

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