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Mr. Brown: The Secretary of State offers me one name that she has managed to find from the great list of placemen--one person who she considers I might think reputable. I accept that one name, but we are looking for more than that.
Mrs. Bottomley: If the hon. Gentleman would like a great list of names, I would be prepared to discuss them with him. He should bear in mind, however, that a great many people in the Labour party are becoming progressively more embarrassed by the need to identify them. They wish that the Opposition would turn round and say that they support trusts and the progress made in health authorities and stopped putting the frighteners on their own people.
Mr. Brown: We have always made it perfectly clear that we do not support the trusts that the Secretary of State has established, but we want to participate in the democratic mechanisms of the NHS. A statement--now several years old--from the national executive of the Labour party authorised members of the party to become members of a trust if invited to do so. It is a lie spread by Conservative Members that members of my party would be under some disciplinary injunction if they participated in the work of a trust. That is wrong and untrue.
I suspect that the reason why there are not more Labour party members on trusts is that they are not chosen by the Secretary of State and those who advise her. In fairness to the chairman of the Conservative party, he made it
Column 703perfectly clear that he wants to choose people who support the Conservative party to work on trusts and not supporters of its political opponents.
I took what the Secretary of State said to be an invitation for more Labour names to be proposed to try to give some respectability to institutions of whose very structures the Labour party is deeply critical. It would be easier to put such names forward were it not for the fact that the exact composition of health authority boards is unclear. It is astounding that we are having this debate when we do not know from precisely which areas those who are to serve on the new committees will be drawn.
We understand that the chairs will be appointed by the Secretary of State. As my hon. Friends have already said, in practice that will undoubtedly mean that those people will be political appointees of the Conservative party. The Secretary of State implies that I might be surprised. I am ready to be surprised, but I do not think that I shall be. The remaining five executive members and the five non-executive members will be left for the regulations to determine. I have to say to the Minister for Health, who is presumably to steer the Bill through Committee, that we shall expect to have the details before the Bill leaves Committee. The Secretary of State has said that there will be a role for senior figures from the world of public health, that there will be a role for the medical dean or equivalent figure from the world of dentistry, and that for the other posts she will seek in her appointments--for they are indeed her appointments--people with health backgrounds, a full range of health professionals. What that will mean in practice remains to be spelt out in regulations; it is not obvious from the structure of the Bill. The House is entitled to a full explanation of what it is expected to be legislating for before we legislate, not afterwards.
The abolition of the regional health authorities removes the statutory position of universities and medical schools under the National Health Service and Community Care Act 1990. As I am sure the Minister recalls, that enables them to participate in regional planning and decision making. It is not obvious what arrangements will now be in place for their participation in strategic decision making, and the Bill does not guarantee a role for health care user groups in the decision-making process of health authorities. As the Secretary of State contended in her introduction to the debate, one way of proving that everyone is content with everything is not to provide a unified system for processing complaints. My hon. Friend the Member for Cannock and Burntwood (Dr. Wright) referred to the work of Professor Alan Wilson, vice-chancellor of the university of Leeds, who chaired a committee to consider that subject and made some important recommendations, which the Secretary of State appears to have ignored. He recommended a single system, with similar features, for handling all complaints about NHS care and services. I took careful note of the Minister's intervention to my hon. Friend, but an intervention promising action in future is not the same as tackling the issue where it should be tackled: in a Bill that is intended to be the final building block in the Government's health care reform, although according to the Minister some cement is still to come--we shall see.
Column 704I should be happier if we were able to discuss Professor Wilson's recommendations in Committee. He recommended that the complaints procedure should be separate from the disciplinary systems. He recommended a three-level complaints procedure, including an independent panel chaired by a lay person and with a lay majority; he did not say anything about the Secretary of State appointing them all. He also made recommendations to widen the role of the Health Service Commissioner-- another subject on which the Secretary of State has been silent. The Bill is intended to complete the Government's health reform agenda; yet the subject of complaints is not tackled. Although the Bill sets out to draw several new boundaries, the one boundary that has been overlooked appears to be the most glaring omission--the case for a strategic authority for London. Health care in London has a range of problems; yet they are all tackled in an episodic and piecemeal way. There is no London wide health authority or health care strategy and no London wide review of the condition of accident and emergency services. There is chronic underfunding of London health care. High levels of special need, caused by social deprivation in London, remain unmet. Indeed, there is a specific threat to units such as the North Thames region ethnic minorities unit because the passage of the Bill may leave no one to finance it. It is right to consider the other serious problems caused by earlier Government health care reforms which remain unsolved by the Bill: massive hospital in-patient waiting lists; a two-tier system of health care, of which the Conservatives are so proud, with GP fundholders able to fast-track their patients; hospital trusts which act like independent businesses and are almost impossible to call to account; and competition between hospitals resulting from the internal market and leading to inefficient duplication in some sectors and neglect of others.
Local variations in service provision seem to many to be politically driven. There are continuing bed and ward closure programmes. In 1993 alone, the service lost 10,637 beds. There has been a relentless encroachment on public services by private medical interests and an astonishing growth in maladministration and even corruption, as identified by the recent reports of the Public Accounts Committee. Now there is an absurd, expensive and inefficient row about performance-related pay and local rather than national pay bargaining.
We are told that all of this is the final, triumphant conclusion to the Government's health care reform agenda and the Government confidently ask the British people to judge them on the result. On that, we can all agree: I, too, hope that the British people will judge the present Government on what they have done to the national health service.
The Minister for Health (Mr. Gerald Malone): We have now heard from the hon. Member for Newcastle upon Tyne, East (Mr. Brown) that he and his party are against trusts. That is not quite what the right hon. Member for Derby, South (Mrs. Beckett) said earlier. I am pleased that we have at last managed to get the admission from them.
Column 705repeatedly been told by the Opposition that we are of course against the existence of national health service trusts. Had we come to power in 1992, we would have got rid of them. There are so many of them that all the individual hospitals are likely to be trusts. We are looking for a new way to re-knit individual health businesses into a co -ordinated structure. The fact that we are against health service trusts has never been in doubt, and it never will be, because they are destroying the national health service.
Mr. Malone: The right hon. Lady has now adopted an even more interesting position--I hope that she has cleared it with her shadow Cabinet colleagues. She is against trusts which are destroying the health service, but her party is going to do nothing about it as there are too many of them and they have succeeded--that is an extraordinary position. In fact, the pass was sold by the hon. Member for Wakefield (Mr. Hinchliffe) at the beginning of the debate when he helpfully said, from a sedentary position, that he and his party were the first ones to think of the reforms contained in the Bill, which were an extremely good idea.
Mr. Hinchliffe rose --
Mr. Hinchliffe: I do not think that the Minister was around in 1989 when what became the National Health Service and Community Care Act 1990 was going through Standing Committee. The Secretary of State was, and she will recall that the Labour position was that we would bring together the district health authorities and the family health services authorities, which is now the Government's position. Why have the Government taken so long to come round to Labour's policies?
Mr. Malone: As the hon. Gentleman said, I was temporarily displaced at that time, but I continued to take a great interest in the affairs of the House. I am delighted that the hon. Gentleman has intervened in the debate and confirmed that he thinks that the Bill's principles are sensible. I am sure that that view is shared by his Front-Bench colleagues and by others.
The right hon. Member for Derby, South did not know whether she was coming or going when she opened the debate. At one moment she argued that the Bill would ensure that the service was fragmented, split up and spread around the country so that there was, ultimately, no NHS, which would be the end of life as we know it. We then heard her say that she objected to the Bill because it would centralise everything. According to her, it is a centralising Bill and a fragmenting Bill at the same time, as well as being a privatising Bill. I am not sure which of the strands she intended to follow, but her arguments were entirely contradictory.
What the Bill does, and what my right hon. Friend the Secretary of State set out to say that it does, is to put the final touches to a structure that is now firmly in place. It is a logical and reasonable Bill to conclude that process and is widely accepted by the country. At heart, the point of it is recognised by Opposition Members who,
Column 706throughout the debate, have argued and given their views on the health service, but have not done much to criticise the essence of the Bill.
The right hon. Member for Derby, South said that the executive was being floated off by the Secretary of State. Nothing could be further from the truth. The NHS executive is part of the organisation, accountable to Ministers just like the rest of the Department of Health, and it will remain so. It is informed by internal market guidance, just as the whole service will be. There are clear and practical ground rules for judging the balance between local purchasers and national responsibilities. Local freedoms and responsibilities must be kept in balance, and there is a simple set of principles further to improve the efficiency and quality of responsiveness of the service to the needs of patients. That is what the internal market guidance is for, and it largely answers the points raised by the right hon. Lady.
The right hon. Lady also made the point that consultation on trusts would no longer be compulsory. I assure the House that there is no intention of abolishing consultation, which will be carried out by the Secretary of State or by the trusts themselves. It makes sense to cover the range of possible circumstances when consultation will be needed in regulations, so that we may adjust as necessary. That is better than rigid provisions that would entail primary legislation when circumstances changed. It is surely right to build in such flexibility.
The right hon. Lady also discussed the abolition of professional advisory committees. Frankly, I do not believe that they were much loved. They were widely criticised and were ineffective. We shall be looking to health authorities to demonstrate that professional input is far more integrated in their work--input not just by the professions but across the professions. The integration of such advice is important; there are many models in the best health authorities of nurses and doctors either in executive posts or being consulted in other ways. They participate in constructive discussions between clinicians, purchasers and trusts, and the help of outside experts is also called upon. This puts the consultation process well beyond the formality that it sometimes became. It was often ignored and left on the sidelines: we are giving it real life.
The right hon. Member for Derby, South also mentioned the independence of public health officials. District public health officers will report on the health of their local populations and will be free to comment on it. The regional role will become different under the new structure. It will be to carry out functions on behalf of the executive. No longer will there be a regional report on the health of a region's population. The experience of the whole service has been that, as care has devolved ever closer to the patient, it has become more important to identify local need. That is why public health functions, when devolved to district level, will be more effective at identifying trends and putting in place policies to deal with them.
A couple of ancillary, and sedentary, points were raised at the start of the debate in connection with the Northern and Yorkshire regional office site appraisal. Of course the Public Accounts Committee can call for full documentation. Some Members of Parliament, including one who raised the issue, have already asked for, and received, a summary of what has been proposed. The only details left out are estimates of prices, which must be left
Column 707out as the district health authorities still hope to obtain better prices than have thus far been submitted. The whole process has been effected according to Treasury rules. There is nothing to hide; indeed, I am surprised that hon. Members brought up the subject at all.
My hon. Friend the Member for Hereford (Mr. Shepherd) made a powerful constituency speech. I can reassure him that we have no preconceptions about the size of the authorities, about the organisation of the services that they will provide, or about whether local authority boundaries should coincide. I assure my hon. Friend that there will be consultation as the process continues, when provisional recommendations are drawn up by the regions. His powerful points of today will certainly be borne in mind. We adopted the same approach to the new regional health authorities, but that did not stop us changing boundaries in response to compelling local representations.
My hon. Friend also made a couple of points about the provision of services. Of course the Secretary of State has a duty, clearly set out in primary legislation, to provide the whole population in England with a comprehensive health service. I hope that he will understand that, when authorities of whatever sort are shaping their services, they will have to bear that in mind.
The hon. Member for Nottingham, East (Mr. Heppell) spoke about joint executives of district health authorities and family health services authorities. He underpinned the fact that those authorities are beginning to coalesce naturally and sensibly. I hope that he welcomes that. It has happened in my constituency and it has been very effective. The legislation recognises the coming together of structures.
Mr. Heppell rose --
My hon. Friend the Member for Colchester, North (Mr. Jenkin) was courteous enough to tell me that he could not be in his place for my winding-up speech because he has a constituency engagement. He spoke about weighted capitation, as did other hon. Members. Work is in hand to develop a new approach to resource allocation. It is a complex issue which needs a great deal of careful thought, but the Government remain committed to allocation by a formula which will demonstrate a clear need to devolve spending according to local need. That demonstrates our clear commitment to the principle of access to health care within and between regions in a properly informed way. My hon. Friend the Member for Colchester, North also spoke about health authorities competing with general practice fundholders. They are in partnership, not competition. The GP fundholding accountability framework, which has been published for consultation, should help to clarify that relationship in the best possible way. I hope that my hon. Friend understands that.
The hon. Member for York (Mr. Bayley) spoke at length about inequalities and resource allocation. I wholly refute his allegation that the north has been treated unfairly in resource allocations for 1995-96. Allocations to regional health authorities are not the real issue. The real issue is the allocation to district health authorities. Regional health authorities will take into account the
Column 708directions in the new calculations when they make next year's allocations to DHAs. There is no sense in making major changes to regional health authority allocations for the final year when there is only one year to run.
Regional health authorities can be expected to manage changes to the DHA allocations at a sensible pace. I was glad to hear the hon. Gentleman acknowledge that it would be pointless if it caused substantial dislocation. As we move towards a new formula and its total implementation, we must move evenly so that dislocations do not occur.
Mr. Bayley rose --
Mr. Malone: I apologise to the hon. Gentleman. I said earlier that I did not intend to give way and my usual bonhomie in giving way must not be demonstrated now, as there are many matters to which I must respond.
The hon. and learned Member for Montgomery (Mr. Carlile) spoke about the public health function and the future of services. His fear that public health doctors will be gagged is entirely unfounded. Health authorities will be required to have medical directors of public health and to publish annual reports. That, not the regional level, is the right level for such reports. They will be crucial in determining the future of local services, and it will be for health authorities to decide which services are needed locally and which will be needed in specialist units.
The hon. and learned Gentleman asked what voices would be heard on the new authorities. I reiterate what my right hon. Friend the Secretary of State said in her speech--that it is important that the boards comprise the best people locally to provide the balance of skills that are needed. We expect that a growing number of members in executive or non-executive positions will have backgrounds in nursing or medicine or in other professions. That is a growing trend throughout the health service and I welcome it.
The hon. and learned Gentleman asked about consultation with community health councils. He will be glad to know that there will be no change in the requirement on health authorities to consult CHCs, nor is there is any intention of changing their number. He spoke about the local accountability of health authorities. I entirely agree that new health authorities should be clearly accountable to local populations. That can be done in a number of ways--for example, by establishing a single local body. The Bill simplifies local accountability arrangements, and that means that, demonstrably, the public will be able to know who is providing the service and who is purchasing it on their behalf and they will have a far clearer input to it. Health authorities will continue to be required to transact all important business in public, to publish accounts, reports and strategic plans and to consult widely on all key proposals. The hon. and learned Gentleman's final point was about the supervision of midwifery. The responsibly for that will shift from regional health authorities to the new health authorities. That is as the hon. and learned Gentleman wishes it to be, so I hope that he is reassured.
The hon. Member for Morley and Leeds, South (Mr. Gunnell) asked why the Northern and Yorkshire regional office is to be located in Durham. The decision on relocation follows an extensive appraisal of a wide range of options. My right hon. Friend the Secretary of State has authorised the regional health authority to pursue locations in Durham, subject to a strict cost calculation.
Column 709The hon. Gentleman also raised a point about policy board members not being representative of regions. We are not suggesting that they should formally represent regions. The argument goes to the core of what Labour Members think--that throughout the health service people should be representatives of sectional interests. That is not the way that we see it. We want them to represent the interests of the service and of the patients. We want them to be drawn from the widest possible constituency.
The hon. Member for Cannock and Burntwood (Dr. Wright) made an interesting speech, with which I obviously agreed at exactly the right moment because he then went on to disagree with everything that the Government are doing. He said that the Bill centralises too much, but he was one of the centralisers. He also said that the Bill gives too many regulation-making powers to the Secretary of State. I find it difficult to recognise the Bill that the hon. Gentleman described. It is always sensible to put in regulations the detailed provisions that may need to be adjusted from time to time. The majority of the enabling powers in the Bill already exist in relation to district health authorities--for example, provisions on membership and on joint working between authorities. There are already matters for secondary legislation. The hon. Gentleman may think that it would be far better to have a 700-clause Bill on these issues, but I do not. The future of the NHS is much better served by a flexible structural framework.
Mr. Nicholas Brown: I understand what the Minister means when he says that some matters are better dealt with in regulations than in primary legislation, and on that point of principle there is no quarrel. However, on some of the key issues, we want to see what will be in the regulations before we let the Bill come out of Committee.
Mr. Malone: The hon. Gentleman makes a Committee point, which he and I can explore some time in the new year. My point is sensible and straightforward. The issues that will be subject to regulation are no different from those that have been subject to regulation in the past. Throughout the debate, the Opposition have suggested that something novel is involved-- [Interruption.] If the hon. Member for Cardiff, West (Mr. Morgan) would remain silent for a second, his hon. Friend the Member for Newcastle upon Tyne, East might hear what I am saying. There is nothing novel in dealing with arrangements by regulation. Of course the Committee will explore the Government's intentions. I shall be glad to do so.
The hon. Member for Cannock and Burntwood asked about the remaining statutory right for community health councils to be consulted. I have dealt with that point, but I repeat that we remain committed to consultation. They will be among the bodies specified in the regulations to be consulted on the establishment of new trusts. The hon. Gentleman also said that membership should be specified in the Bill. As I said, it would not be sensible to do that. It is far better to have wide powers and the ability to seek talent where we can and in the widest possible way than to follow the representative route wanted by Labour Members.
Column 710My hon. Friend the Member for Windsor and Maidenhead (Mr. Trend) made a constituency speech and raised a specific point about the Edward VII hospital. He asked what we could do about appropriate accommodation for the elderly. Suitable accommodation for elderly people is already available within a reasonable distance of the hospital. I have heard what he said and hope that he will take the opportunity either to write to me on that issue or to come and meet me, when I shall be happy to discuss the matter with him further. The Bill is the last building block of the reforms that we introduced in 1990. I am sorry that, yet again during the debate, we have heard from Opposition Members, including the right hon. Member for Derby, South, appalling slurs against all those who serve on trust boards and health authority boards, in terms of their selection and interest. I challenge the right hon. Lady to give a single instance of misconduct. If Opposition Members have evidence that they have acted against the interests of the trust boards on which they serve, I invite them, with the protection of the House, to give a few instances instead of those vague slurs against people who give voluntary service in the best tradition of British public life.
Mr. Malone: The right hon. Lady and her hon. Friends forever talk about Tory placemen on boards. Nothing of the sort exists. If one wishes to discuss the position of people on authorities, one need look no further than the Labour party to see what instructions are given. I was fascinated by an Opposition Member's Freudian slip when he said that, at some point, the Labour party had "authorised" its members to serve on those boards. They get the authority from Walworth road, but it goes beyond simple authority. Not only is their appointment to boards authorised but they are given instructions. I quote from the "Guidance on participation" issued by the Labour party's national executive committee.
The "Guidance on participation" says:
"Labour party members may take up places on non-elected authorities and use them as a platform for our campaigning". Labour Members are not in the least interested in serving the board--they are interested only in serving their party. That is not all. The guidance goes on:
"Party members who are appointed to non-elected boards must discuss ways of reporting back to their local constituencies and other constituencies . . . Consideration should be given to ways of liaising with Labour Party representatives in other capacities . . .Members accepting appointments of this kind should inform Walworth Road so that the relevant Shadow spokespeople and Head Office policy officers can maintain a network of contacts".
The instructions given by the Labour party to its representatives on boards are more detailed than those the KGB ever gave Richard Gott of The Guardian . I do not know how they are delivered--whether it is by dead letter boxes in Islington or tete-a-tetes in the Gay Hussar--but instructions are clearly given to make it absolutely certain that Labour members turn to party interests when they are meant to be serving on boards in the public interest.
Column 711The Bill puts in place important reforms at the end of a series of reforms that now deliver better health care at a better cost than ever before. The health service is now recognised for its excellence not only in this country but abroad. Opposition Members should look at the OECD report and British attitude surveys that are now being published on the excellence which people now consider the health service delivers. As I asked the right hon. Member for Derby, South to do, I ask them to look at the figures on this matter. They should look at the number of operations, the treatment that is given and the services which the NHS can deliver in primary health care, which it was unable to deliver before.
That improvement across a system that is delivering better health care, better value for the taxpayer and increased volume of health care is something of which we can be proud. The Opposition have not made their case against the Bill. They tabled a token reasoned amendment but did not speak to it. I have every confidence in supporting the Bill before the House tonight, and I invite my right hon. and hon. Friends and Opposition Members who support the reforms to join me in the Lobby.
Question put, That the amendment be made:--
The House divided : Ayes 267, Noes 308.
Division No. 18] [22.00 pm
Column 711Abbott, Ms Diane
Adams, Mrs Irene
Ainsworth, Robert (Cov'try NE)
Anderson, Donald (Swansea E)
Anderson, Ms Janet (Ros'dale)
Ashdown, Rt Hon Paddy
Banks, Tony (Newham NW)
Beckett, Rt Hon Margaret
Beith, Rt Hon A J
Benn, Rt Hon Tony
Bennett, Andrew F
Bray, Dr Jeremy
Brown, Gordon (Dunfermline E)
Brown, N (N'c'tle upon Tyne E)
Bruce, Malcolm (Gordon)
Campbell, Menzies (Fife NE)
Campbell, Mrs Anne (C'bridge)
Campbell, Ronnie (Blyth V)
Campbell-Savours, D N
Carlile, Alexander (Montgomry)