House of Commons Hansard Debates for 31 Jan 1995

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attack the charter and the league tables. For them, accountability is something that one talks about at Islington dinner parties, and power is what one gives to the trade unions. We well understand that.

I want to say a little more about primary care, which is, sadly, too often neglected in our debates. Every year, about eight out of 10 people visit their family doctors. General practitioners carry out, on average, nearly three consultations a year for each patient on their list. Even with list sizes nearly 10 per cent. smaller than a decade ago, that means a lot of patients and a lot of GP time. Our family doctors deserve recognition and support. The Government are giving them that, not only in the form of improved premises, additional staff and an attack on paperwork, but in what is perhaps the most important area of advance, GP fundholding, so rightly mentioned by my hon. Friend the Member for Lancaster (Dame E. Kellett- Bowman).

My hon. Friends and, I suspect, in their hearts, many Opposition Members as well, will know of hundreds of examples of how patients have benefited from GP fundholding. News has even reached the BMA which, in a recent document, stated:

"It could be argued that fundholding, because of the size of the population served, is a good model for achieving consumer accountability in the NHS."

GP fundholding has brought about the most decisive shift in power in favour of family doctors and their patients in the history of the health service. It is at the heart of making the NHS more responsive to patients, more respectful of their choices and better at meeting their needs. That is why we are working to extend the benefits of fundholding to all patients.

Nowhere is the true nature of the so-called new Labour party better revealed than in its spiteful pledge to abolish fundholding. That is socialism in action--the envious grudge against success, the distrust of innovation, the ideological urge to reduce everyone and everything to the level of the slowest and the worst.

Mrs. Beckett: Is the Secretary of State aware of a survey conducted by "Pulse" among general practitioners which showed that more than 75 per cent. of general practitioners would like to see fundholding abolished?

Mrs. Bottomley: Fundholding has been commended not only by the Organisation for Economic Co-operation and Development and the London School of Economics, but even by the National Audit Office as a way of delivering more flexible and better care to patients. GP fundholders throughout the country are proud of their success. I do not believe for one moment that they would welcome the right hon. Lady's commitment to vandalise one of the most exciting and important innovations in primary care. Throughout the country, fundholders are outraged by her stance and, as my hon. Friend the Member for Lancaster said, their patients will be outraged when they discover that she plans to rob them of all those advances.

Mr. John Gunnell (Morley and Leeds, South): If the Secretary of State envisages 100 per cent. fundholding, what will be the purchasing role of her new health authorities?

Mrs. Bottomley: The health authority, much discussed on Second Reading of the Health Authorities Bill and in

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Committee, will continue to have a strategic role in monitoring, supporting and encouraging. Fundholding is a voluntary initiative. I do not anticipate that we will have 100 per cent. GP fundholders in the foreseeable future. But those GPs who wish to take that step do so in the interests of their patients.

The hon. Gentleman may also not be fully aware of the fact that few fundholders will be purchasing all the services that their patients need. I announced last week a doubling of the number of full fundholder projects and an evaluation scheme to consider carefully how they work. However, doubling the number takes us to only 50, so health authorities will continue to have an important role in the foreseeable future.

One of our great successes in recent years, but rarely debated because there is such agreement about it, is "The Health of the Nation" strategy, the delivery of which is through the local health authority, partly so that it can collaborate with other agencies in order to ensure that they play a direct role in improving the health of the local community.

Throughout the country, change is under way. Change is difficult for the people involved, but it is necessary in order to build a better and more responsive service, to have top-quality centres of excellence and to have accident and emergency departments with 24-hour consultant cover, as at the Royal London hospital, which was the first to have such cover.

The Labour party, by resisting every closure and undermining change, something for which it was attacked only the other day in the much-quoted article in The Guardian , would store up trouble for itself. It would be failing to recognise the success of the changes and the importance of what is being achieved.

Above all, we now hear with growing alarm about all the socialist hangers- on, all the different organisations, beating a path to the right hon. Lady's door to protect the interests of the

purchaser-provider divide. The Socialist Health Association and Unison, when the right hon. Lady embarked on her vindictive attack on managers and the right hon. Member for Sedgefield (Mr. Blair) pledged to sack 8,000 health service managers--never have I known such a vindictive attack on a group of health workers--

Mrs. Beckett: I do not know where the right hon. Lady got that from, but there is not a word of truth in it, as I am sure she must know. I know that it was in the Daily Mail , but that is no recommendation.

Mrs. Bottomley: The fact that the Socialist Health Association and Unison have already made urgent representations to the right hon. Lady and the right hon. Member for Sedgefield that such an unprecedented attack on managers is not in their interest shows the extent of their power over the words that are uttered by Opposition Members.

We have heard a huge amount about what a villainous lot NHS managers are. I am pleased that there was an improvement in that regard today and I imagine that that is simply because of the representations made by the Socialist Health Association and others. The Opposition are totally cynical. The right hon. Member for Sedgefield has pledged to turn back the clock on the NHS reforms. That brings back memories to Conservative Members. He has made a cynical deal with the unions. They give him a new clause IV, he gives them

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the NHS. It is not as if the trade unions do not already have enough power over the Labour party's health policy. The right hon. Lady is their greatest friend in the shadow Cabinet. All her team are sponsored by the unions. We have already talked about the cosy sweeteners to help them on their way.

The chairman of the home policy committee is a union apparatchik, deciding on Labour party health policy and other policies that it would pursue, such as the minimum wage and the abolition of competitive tendering, which we heard about again today. The unions will be pleased. The end of pay beds is proposed--another tick in the box of what has been asked for. That is all for the unions. It will cost patients £1 billion every year simply to pay the paymasters and to keep them quiet. Given Barbara Castle's experience, I am not sure that even that will keep them quiet.

Even The Guardian , much quoted, has told the Labour party that it is talking nonsense and that it would be

"disastrous for the NHS if Labour only looked back".

That is right. The Labour party undermines trusts, described by the right hon. Lady in our previous debate as an abomination, and would rob GPs and their patients of fundholding status. Instead, she promises more power for the unions and less for the patients. The Health Authorities Bill will abolish the regions and sweep away an entire tier of bureaucracy. She proposes an amendment that would place a duty on the Secretary of State

"to establish Strategic Health Planning Authorities".

Oh dear. Strategic health planning authorities? I think we all know what that means. It is clear from his famous memorandum that Leo McKinstry knows what it means. Mr. McKinstry, a former adviser to a Labour health spokesman, wrote:

"That's what Labour is good at: creating bureaucracy. Establishing a new body is one of the few solutions a Labour policy-maker can ever propose when confronted with a problem." I think that my hon. Friend the Minister for Health remembers that from the Committee stage of the Health Authorities Bill. It is the only thing to emerge from the interminable consultations organised by the right hon. Member for Derby, South.

The right hon. Lady wants to create a new tier of unnecessary interference and a new group of bureaucrats to second-guess the bureaucrats down the line; she wants to give more power to the planners, and take power away from doctors and nurses. Oh dear. But she does not just want to put the bureaucrats back in charge: she and her party want to break up the national health service and hand it over in little pieces to the so-called regional assemblies, described by Mr. McKinstry as

"irrelevant and unwanted talking shops".

I agree with him.

The right hon. Lady wants to take the ability to make decisions away from staff of trusts, who know what patients want, and give it to her friends in local government. Again, the McKinstry memorandum spells out what that means.

Mr. Eddie Loyden (Liverpool, Garston): Is the right hon. Lady aware that, under the present structure, it is virtually impossible to gain access to information? Trusts are failing to respond to local needs and local advice, or to deal with any of the problems that, as Liverpool people know, are damaging their health service. When will the trusts and the Secretary of State listen to the voice of those

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who use the health service--the consumers? At present, the trusts are a closed shop from the point of view of the people of Liverpool.

Mrs. Bottomley: I imagine that the people of Liverpool rejoice every day of the week that Sir Donald Wilson rather than Derek Hatton has been leading the health service. If Labour had its way, however, the Derek Hattons of this world would be in the driving seat. The hon. Member for Liverpool, Garston (Mr. Loyden) says that there is a problem with information. I wonder where he has been all these years. What did he ever know about the number of patients treated, about outcomes and about waiting times? The trusts must hold annual meetings and produce annual reports; they must publish their accounts. There is a whole process of scrutiny, evaluation and provision of information. When the Labour party was in power, all that the hon. Gentleman could collect were statistics on deaths and discharges. There was no competitive or comparative information--which was a wonderfully cosy arrangement for those who worked in the health service, because there was no way of keeping them on their toes and ensuring that they all aspired to the level of the best.

I think that we have dealt with Mr. McKinstry and the appalling picture that he paints of Labour's plans. He called Labour councils "a mean minded cocktail of political correctness, bureaucracy, intervention and abuse of public money . . . massive procedural delays and rumours of corruption."

As I have said, Mr. McKinstry advised one of the most recent Labour health spokesmen; I am very pleased that he is so well informed. Mr. Rhodri Morgan (Cardiff, West) rose --

Mrs. Bottomley: That is the nightmare that the Labour party is lining up for us.

Mr. Morgan rose --

Mr. Deputy Speaker: Order. Is the hon. Gentleman deaf? He should obey the Chair. The Secretary of State is not giving way, and I hope that he can see that she is not. There should be proper decorum in the Chamber, and we will have it.

Mrs. Bottomley: I am grateful to you, Mr. Deputy Speaker. I have given way to Labour Members an excessive number of times--many more times than the right hon. Member for Derby, South, as the hon. Member for Cardiff, West (Mr. Morgan) will doubtless find when he reads the record.

Mr. Harry Barnes (Derbyshire, North-East): The Secretary of State should get a gold star.

Mrs. Bottomley: I hope that I shall.

The Labour party paints a picture of a fragmented, bureaucratic health service, hobbling from crisis to crisis with neither vision nor direction: a pen-pusher's dream, and a shop steward's idea of Christmas. Labour's policies would result in chaos, upheaval, confusion and waste. They are rejected by the British Medical Association, which describes the "major organisational upheaval" that would result from local authority control of the health service; people do not want that. They are also rejected by the Royal College of Nursing, which believes that the very principle of equity would be lost. They are rejected

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by the doctors and nurses in trusts and fundholding practices, who are not prepared to see their precious freedoms wrenched away and given to the Labour party's friends; and they are, and will be, rejected by the public and by patients.

The right hon. Member for Derby, South used a phrase that Opposition Members always seem to find irresistible. Referring to scientists leaving the country, she spoke of a "brain drain". She should think again, and recognise the enormous brain gain from which the country benefits. Only the other day, I met a team of scientists who had come from America, Australia, New Zealand and other countries all around the world to work in Britain, because of the advantages of working in this country and with our national health service. Moreover, under the director of research and development we have developed a new strategy, providing extra funds so that we can build on our excellent medical research and ensure that its results are properly considered throughout the service.

What the Labour party calls the market mechanism is actually a process whereby purchasing authorities and GP fundholders can measure outcomes and effectiveness. They want to know whether they are getting value for money; they want to scrutinise and to question. At last we have a knowledge-based, evidence-based national health service, fed by our research strategy and feeding into further and profound improvements in patient care throughout the country. That is possible because of the changes in the health service. It is possible because, by being more effective and efficient, we have secured additional resources to put into the service. What Labour has offered does nothing to encourage researchers, doctors, nurses and managers, and certainly does nothing to encourage patients. Our policies, by contrast, are creating a coherent and stable framework for a strong and modern service.

The national health service has always embodied the finest values and the strongest ethos; there can be no doubt about that. But in its old rigid, centralised form it was decaying; it was falling behind the pace of change that is necessary for evolving medicine, and demanded by the growing needs of patients. Thanks to our reforms, the service has been invigorated with new, local freedoms. We have established the right balance between central direction and local flexibility. Many of the recommendations of today's Select Committee report can be implemented more effectively because of the new structure that we have put in place.

We have a national health strategy; we have national as well as local accountability; we have ensured that national policies can be, and are, delivered more effectively through local action. What Labour derides as "the market" is, in fact, the power of health authorities and fundholders to challenge the system, to question and scrutinise, and to insist on benefits for patients. That is their aim and aspiration: to demand the answers to questions that would not even have been asked when Labour was in power.

Of course there is more to do. There is more to do for mental health, for junior hospital doctors and for a whole range of services. But by acting as good stewards for the health service, and improving efficiency and the number of patients treated, we have put ourselves in a better position to go even further forward. Let me make it clear that we are proud of the changes that we have set in hand.

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We are proud of the extra money that we have put into the national health service, and we are proud of the achievements of staff. It is simply not good enough to utter populist gibes from the sidelines: the NHS deserves better.

Conservative Members want to protect trusts and fundholders. We want further progress in primary care, and even more improvements in the health of the nation. We will not stand by while Labour seeks to destroy all that has been achieved to meet the outdated, grasping demands of the unions. We will not let the clock turn back to nods and winks, and post-dated blank cheques. If anyone can speak as the guardian of the national health service, it is the Conservative party, which has run it for twice as long as the Labour party.

The Government need no lessons from the Labour party on our commitment to a comprehensive and coherent health service. We have taken the action necessary to equip it for the future. We have acted while the Labour party has ducked, dithered, plotted and fudged. I suspect that it will be a long time yet before the Labour party has the nerve to come to this place, without a policy to its name, simply to threaten upheaval and turmoil. It is under a Conservative Government, and only under a Conservative Government, that the NHS can look forward to a strong, secure and exciting future.

5.29 pm

Mr. Sam Galbraith (Strathkelvin and Bearsden): Listening to the Secretary of State for Health and to her expose on the health service, I had a certain feeling of de ja vu. Once again, she made what a number of hon. Members have come to regard as slightly distasteful comments in claiming responsibility for almost every medical development in the health service. She spoke again of the development of artificial hearts. Such hearts have been developed elsewhere for many years, and it is no thanks to the Government that such developments have taken place.

I recall that when a former Under-Secretary of State for Health wanted to attract lots of publicity she used to make various claims for key-hole surgery, organ transplantation and other treatments, as though she had pioneered them herself. The fact that more patients are treated is due not to the Government but to the nurses and doctors who work in the service. The sooner the Government stop making false claims, the better.

Mr. Couchman: The hon. Gentleman rightly praises the excellence of national health service staff. Does he agree, however, that when things go wrong in the NHS, it is often down to a member of staff?

Mr. Galbraith: That truism has no particular relevance to what we are discussing. I did not understand the point of that intervention. There is no 10-minute limit on speeches, although I shall definitely try to--

Mr. Deputy Speaker: Order. There is no 10-minute limit, but hon. Members should not feel that they have to fill the whole time.

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Mr. Galbraith: You, Mr. Deputy Speaker, can be assured of that. I just wondered how many interventions I should take on this matter.

Mr. Peter Bottomley (Eltham): Four.

Mr. Galbraith: That is more than I usually take, so there should be no problem.

I want to concentrate on rationing in the national health service. Debate on the subject is increasing in health service journals, including in the British Medical Journal . I consider it to be a serious and sinister matter, which we should knock on the head at this stage. The reasons for that debate are secondary to what has been done to the health service under the Government. Their policies have led to the starvation of resources and to a market mechanism in the health service. To camouflage that and to enhance the changes, we get discussions about rationing health care.

It is said that rationing is necessary. We should not accept that argument and that, somehow, we cannot fund the service properly, and that some needs cannot be met. We should object to and resist that argument. We should not agree that the health service must accept rationing.

A definition of the rationing of health care is important. Rationing of health care is the denial of treatment that would benefit the patient, that the patient wishes to have and that the service wishes to give him. That is the correct definition. Within that definition, I do not include unnecessary treatment of patients. Many antibiotics exist for upper respiratory and viral infections. Stopping such problems is good medical care and a proper use of resources, but it is not rationing. We must remember that rationing is the denial of treatment that would benefit patients.

An important criterion of rationing is that no exit from the system is possible. There is only one true form of rationing in this country: transplantation. There is no equilibrium between the need for and provision of transplantation services; need exceeds provision because of limits on the service. The important thing, which is true rationing, is that there is no exit from that system: one cannot have a transplant in the private sector. The problem is that we are talking about rationing not of other provision but of NHS provision. People who have money immediately exit and are treated in the private sector. The private sector is growing under the creeping, growing, sinister, behind-the-scenes privatisation of the NHS, which has been going on for many years.

Mr. Peter Bottomley rose --

Mr. Galbraith: I give way to the hon. Gentleman because I know that there is no 10-minute limit.

Mr. Bottomley: This is almost the same point that the hon. Gentleman is making, and I put it in a non-partisan way. If the number of cataract, hip and heart operations has significantly increased, is that because doctors are more able to carry out such operations, because people could not receive them before or because of some form of rationing? Is there another explanation? It is certainly

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true that more major treatments, which are of great advantage to elderly people in particular, are being offered. Is that an end to rationing or an increase in it?

Mr. Galbraith: If the hon. Gentleman will let me continue, I shall develop my argument and raise a number of other related issues, and I hope that, in doing so, I shall answer the questions.

One of the other justifications for rationing that we must dispense with is that, somehow, health care is a bottomless pit and that, therefore, need will never be met. That is not so. It may be true of a demand-led service, with unnecessary treatments and demand generated by the private sector and popular consent, but not of a needs-based service, which the NHS should be.

We know how many people require hip replacements--not everyone does, so demand is not bottomless. We know how many people require hernia operations, and demand is not bottomless. All we have to do is establish the extent of such need, after which it is a question of having the political will to meet it. Let us hear no more justification for rationing on the basis that need is a bottomless pit. That argument is fallacious and we should dispense with it. Another argument for rationing that is often advanced is that everyone is doing it so we are no different from them. Again, that is not quite true. Many health care systems are concerned about cutting resources, but that is not necessarily the same as rationing care. The United States of America is not rationing health care; it is trying to stop unnecessary investigation and treatment, which is a different matter. In this country, the culture of medicine and all its ramifications are based on clinical judgment rather than on clinical independence, which is different. We should try to enhance that culture, which is threatened under the market system. It is said that we already have some rationing in the NHS and that it is achieved through waiting lists. That is not true. Waiting lists are a system not of rationing health care but of delaying it, which is different. It is an unfair, arbitrary system that, again, allows people to exit from it to receive their treatment. It does not ration treatment but delays it.

The other system involves the general practitioner as the gatekeeper: the GP sees bigger waiting lists and, therefore, does not add to them. Again, that is not true. If a GP thinks that a patient needs health care, he sends him for it. The system allows the GP to use his or her clinical judgment and it reinforces the need not to get involved in unnecessary investigation and treatment. That is the system here, unlike in the United States. Someone who goes to see his GP with a headache does not need a CT scan or elaborate investigations. Instead, the GP uses his clinical judgment, which is what happens under the gatekeeper system. It is not a rationing system if it is based on clinical judgment.

Mrs. Virginia Bottomley: I support much of what the hon. Gentleman is saying. His point shows why GP fundholding is so successful and effective.

Mr. Galbraith: The Secretary of State is completely wrong. That system works only if the patient has a trust relationship with his or her doctor. [An Hon. Member:-- "What does that mean?"] That question reveals the ignorance of the hon. Member for Milton Keynes, North-East (Mr. Butler), who listened to my right hon. Friend the Member for Derby, South (Mrs. Beckett) while

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laughing and giggling about the health service. The trust relationship between patient and doctor means that they trust one another, which is in the best interests of the patients. The way to destroy that system is to introduce a GP fundholding practice, which will introduce a financial element into the decision-making process, as happens in the United States, where the doctor and his patient wonder whether the financial element will come between them. The Secretary of State is completely wrong and will ruin the trust mechanism. The loss of that trust mechanism leads to secondary defensive mechanisms and increased costs.

The hon. Member for Eltham (Mr. Bottomley) mentioned rationing. There has been, and there still is, a form of rationing in the sense that some sections of the population have low expectations. The rates for operations such as cataract removal, prostatectomy and others vary across the country and across the social classes--there are higher rates in the higher social classes and lower rates in the lower social classes. It might mean that the higher social classes have a few unnecessary operations, but I doubt that. However, it does mean that the lower classes have lower expectations. I hope that that deals with the hon. Gentleman's point. That form of rationing has persisted for some time but we should be seeking to eliminate it.

Mr. Peter Bottomley: The hon. and caring Gentleman speaks from experience. Most of us would accept that people need to have higher expectations and the royal colleges can help by carrying out studies in their various fields of expertise into what would happen if there were equitable treatment for all. However, does the hon. Gentleman accept that a significant increase in the number of heart, cataract or hip operations must be a reflection of extra resources or better organisation, but certainly of meeting higher ambitions, which is something for which we should all be aiming?

Mr. Galbraith: The hon. Gentleman has identified rationing as it used to exist. Renal dialysis is a case in point. That treatment was introduced when I was but a lad in medical school. It was limited for quasi -medical reasons but there was a form of rationing. However, there is a difference between that form of rationing and that proposed today. Under the previous systems, rationing of new developments was recognised but the aim was to eliminate it and expand the service. We are now going the other way by reducing and denying treatment.

I conclude by cautioning against two systems that have been suggested for use in this country. The first is the Oregon system, which the Secretary of State said was flawed. For those who may not be aware of it, it is a system used in Oregon to try to ration health care. It involves condition treatment for pairs of patients in a ranking system based on utility and disability. It is not an effective system for rationing care and should not be introduced here. I trust that health managers will not attempt to use it. It is not a true rationing system because it is concerned only with rationing Medicaid, which is only one part of the care available for the indigenous population. There was public consultation but it was a sham because it involved only middle-class people and not those affected. The major flaw is that it does not deal with an individual patient's needs.

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The second system that is occasionally advocated is "qualys", or the quality adjusted life years system. It is quasi-scientific involving given numbers but its reputation has no basis. I have tried to use qualys from time to time along with other systems of practically no value in dealing with individual patients. Such a system is nothing more than a useful research tool. The main reason why qualys and similar systems are useless is that they do not deal with the individual patient on whom we should be concentrating. The problem is that we often end up talking about categories, as the Government tend to do.

We must deal with the different factors affecting individual patients. Rationing systems have no part to play. Practices may have to be varied because someone wants extra time to see his grandchild, son or daughter graduate but, at the end of the day, someone has to sit on the bed, look the patient straight in the eye and say, "Yes, the treatment would be of benefit to you but because the Government have told me to ration it, I'm afraid you can't have it." I am in favour of the elegant muddle through, whereby pressures are adjusted according to individuals and patients are consulted under the trust relationship that exists between them and their doctor. That relationship is being threatened by the Government's underfunding and the introduction of market mechanisms into the system.

5.46 pm

Mr. Peter Brooke (City of London and Westminster, South): It is a pleasure to follow the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith). He is a classic example of how much the House gains by having among its number those who have had an expert career outside--an issue that I hope the Nolan committee is considering. I express appreciation, too, for the right hon. Member for Derby, South (Mrs. Beckett), who, if imitation is flattery, paid me the great compliment of imitating an anecdotal technique that I developed in national health service debates as a novice Back Bencher between 1977 and 1979 when she was a Minister elsewhere. My one salient regret about her speech was that she left her mission statement so late that she did not allow herself adequate opportunity to develop the strategies that would have given that mission statement meaning. It was a little more than three months ago that a debate on the national health service in London afforded me a maiden recent opportunity to speak about Bart's and its merger with the Royal London and the London chest hospitals. I am grateful to the Opposition for affording me a further opportunity today. I said at the time that Bart's had entered into the merger negotiations with good will and in good faith but that I was disturbed by the spirit in which progress was being made, given the fact that for the merger to bear fruit it was essential that the parts of Bart's that might transfer to the Royal London should feel that what was emerging was an institution greater than the sum of the parts. I choose my words carefully about the shape of the merger because of the current consultation about the trust's proposals.

I should like to be able to tell the House that my anxieties have been allayed by the developments since our previous debate. Since then, the consultation has been initiated, which is as it should be. I am confident that on such a serious issue responses to the consultation document will be comprehensive and well informed. Of course, the consultation period still has some time to go.

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I am more uneasy, however, with the spirit underlying the merger, which is critical to the process. Since conspiracy theory was already rife at St. Bartholomew's, to which I shall return, it is unfortunate that conspiracy theory should have emerged at the Royal London hospital as well. I refer to the recent press conference on the shape of the future hospital, at which allegations about Bart's and its behaviour leached into the national press. It seems to a bystander careless, on so sensitive a subject, that it was not arranged for anyone to be present to represent Bart's at that press conference, when the participation of Bart's representatives is critical to the future and the future merger.

That is what I mean by saying that the spirit of the merger process seems to have gone unnecessarily sour, when the trust is asking Bart's to make the principal emotional sacrifices. The unfortunate consequence has been an overwhelming vote of no confidence in the trust's management and leadership by the medical council at Bart's, at precisely the moment when maximum confidence would be desirable for the future success of the enterprise.

I implied earlier that conspiracy theory had been present at Bart's. That followed the health authority's decision to recommend the closure of Bart's accident and emergency department, barely days after the consultation period had ended and when there had been a massive numerical majority of representations in favour of its retention. That was followed a year later by the trust adopting a one-site solution with what seemed unexpected speed against the grain of the earlier debate.

One of the consequences--it is a bad consequence--is an imbued conviction among some at Bart's that the current consultation is all over bar the shouting. I have total confidence that the authority and my right hon. Friend the Secretary of State will measure most judiciously the evidence laid before them. If they were in any doubt previously, I hope that recent events have brought home to them how essential it is that the decisions reached on the consultation's evidence are seen to have been evaluated with exceptional--indeed, preternatural--fairness. They have a delicate and highly frangible vessel in their hands.

I am not seeking to revive the controversy over Bart's A and E unit. I pay tribute to the way in which the national health service elements are working with the City of London corporation to examine plans for an expansion of the minor injuries unit at Bart's, to ensure that residents of the City, south Islington and south Hackney--a cohort of about 30,000 people in all--are not disadvantaged by developments at Smithfield, whatever in future they may precisely be.

My right hon. and hon. Friends have not, however, laid to rest the fears of the wider City about how well prepared they are for an emergency in the City on the scale of the five in recent years involving the railways and terrorism. It is understood that the paramedic provision is a response to individual heart attacks. That is accepted, but very serious evidence was given to the consultation on the Bart's A and E unit by the City of London police about traffic patterns in the area--notably after the anti-terrorist traffic restraints were imposed on the perimeter of the City. That evidence has never been properly countered or those fears assuaged in the context of a major emergency.

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I hope that in his winding-up speech my hon. Friend the Minister will comment on the scale of paramedic provision available against the known statistics of past emergencies. I mean no unkindness to my hon. Friend or others on the Front Bench when I say that it is not enough for them to believe that all will be right on the night. The public and the police have to believe that it will all be right on the night, too.

All that said, there is no reason why good cannot come of change--a proposition that, paradoxically, is more widely recognised by Conservative Members than by Opposition Members. The South Westminster health clinic, which was promised for the aftermath of Westminster hospital, has trodden cautiously, but, in so doing, has secured and enjoys the increasing confidence of consultants and local residents alike. It is a friendly, welcoming and effective facility. With some tactical differences, the similar new clinic in Soho promises well, after years of my Soho constituents raising their voices to heaven to say, "How long, O Lord, how long?"

There is no reason why the national health service cannot meet rising expectations, even in inner-city communities, with e lan and efficiency. What is so depressing about the stance of Her Majesty's Opposition is the sterility of their thinking and their motion today in the face of problems that the NHS will face in the next century, and which the Government's reforms were admirably and timeously designed to address. It is no good the Opposition thinking that the problems presented by demography on one hand and the advance of medical science on the other will go away, yet there is no evidence of what their solutions would be.

When the hon. Member for Livingston (Mr. Cook) was health spokesman for the Opposition in the previous Parliament, there were glimmerings of recognition that the national health service's future problems were stark and that neither the status quo nor a suspiciously flexible amount of extra public expenditure in billions of pounds would solve them.

The fatwa of the hon. Member for Dunfermline, East (Mr. Brown) against public expenditure commitments has inevitably exposed the bareness, not to say the barrenness, of the intellectual policy cupboard of the right hon. Member for Derby, South. Of course, we understand the defensive mantra that states in response to any problem that it would be inappropriate and imprudent of any Opposition spokesman to say anything at all about their future policies until they take office. There are still some highly specific decisions that I acknowledge could not be taken until one knew the price of eggs on the night, but that does not apply to strategic thinking about the national health service. A repeal of the reforms of this Government would take one back to the status quo ante and, even among the most atavistic on the Opposition Benches, there cannot be many who think that that would do as an adequate posture. So we are confronted by a wall of moth-balled, first world war E-boats, with their weaponry masked; a generation of naval architecture on a chronological par with clause IV. Whoever replies for the Opposition will have to do better than the right hon. Member for Derby, South if the Opposition want to claim that what they have initiated today can properly be called a debate.

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Mr. Alex Carlile (Montgomery): It is always a pleasure to follow such an exemplary parliamentarian as the right hon. Member for City of London and Westminster, South (Mr. Brooke). He treated us to a piece of English at least, which will be well worth re-reading tomorrow. I also agree with much of what he said about Bart's. I know that my hon. Friend the Member for Southwark and Bermondsey (Mr. Hughes) would have wished to be here this afternoon to comment on that issue.

During the first hour and three quarters of this debate--it seemed at times a good deal longer--reference was made to a number of surveys. Of course, most of them had been carried out after treatment had been completed and on questions asked of patients. The tribute which those surveys pay is not to the organisation of our national health service but to the doctors, nurses and other staff who serve in that service. The issue in this debate is the conditions in which those servants of the public give their service.

I suspect that many Conservative Members read The Daily Telegraph , so they will know what I am talking about when I refer to the "Bottomley ward". The "Bottomley ward" was described in an article by Martyn Harris in The Daily Telegraph on Monday. It is that overflow ward, now common, made up of trolleys in the hospital corridor--the place where, literally, patients are allowed to fall off their trolley and are sometimes not noticed until it is too late. That is one of the adversities that staff face, and it makes calls on all their resources of humour and determination; but I suspect that those staff would take a very different view from the complacency offered by the Secretary of State.

Mine is a rather different approach from that of the right hon. Member for Derby, South (Mrs. Beckett). She believes that the Government want to wrap up and privatise the national health service. I do not think that that is right at all. In a sense, it is worse than that. The Government do not want to wrap up the national health service, but they are doing so without trying. It is not privatisation by stealth; it is failure by bungling.

The Government's reforms of the NHS have reached crisis point--at least that is what we are told day after day by the people working in it. It is a crisis in which the reality of trolleys in the corridor is but one small, overt sign. The concern of patients and staff has turned to dismay and despair as they feel the brunt of the Government's market-driven policy stick. Indeed, political obsession with the market is coming before health issues, and it is time that the Government realised that that is happening.

Now a new sophistication has been added--one might call it the Bottomley lobotomy. It is a very simple, non-invasive procedure. It involves taking the truth, debriding it, dressing it in healthy-sounding platitudes, and then plastering it with statistics. For example, I refer to waiting list statistics. Some people are waiting to wait to go on the waiting list. Waiting list statistics that allege that nobody has to wait more than two years are simply not true. It is time that the Government recognised, accepted and confessed that what they say about waiting times, if not waiting lists, is simply untrue.

In an attempt to back the Department's campaign of what must be called deceit about what is happening in the NHS, the NHS trusts have tried to gag those who know

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