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Mr. Morgan: Yes, Madam Deputy Speaker. I mentioned that earlier.
Madam Deputy Speaker: The hon. Gentleman was going to withdraw it, but did not do so.
Mr. Morgan: I beg to ask leave to withdraw the amendment. Amendment, by leave, withdrawn.
Mr. Gunnell: I beg to move amendment No. 4, in page 21, line 5, at end insert--
Column 235`5.--(1) No appointment shall be made under paragraph 1(a) or (b) above unless the Secretary of State has first procured and considered independent advice as to the suitability of the respective candidate.
(2) "Independent advice" in subparagraph (1) above means advice from a person or persons with relevant local knowledge or experience, with particular reference to the provision of health services, but who is, or who are, not--
(a) employed in any capacity by, or in any commercial or contractual relationship with, any Health Authority or NHS trust, (b) employed by the Crown,
(c) the holder or holders of any public elected office, or (d) affiliated to, or publicly identified with, any political party or cause.
(3) "Suitability" in subparagraph (1) above means personal qualifications or aptitude, irrespective of political affiliations, for discharging the functions of the post to which the appointment is to be made.'.
It was said earlier that we had been through some issues a number of times, and this is one such issue. We have discussed many times, and at length, the appointment of health authority members. The hon. Member for Milton Keynes, North-East (Mr. Butler) thinks that we have spent an unduly long time on such matters, and I notice that, in support of his plea, the digital clocks have broken down. It is the first time that I have seen them out of action, and it means that we cannot check whether we are talking for too long. However, it is an important issue, and it is necessary to emphasise one or two points in the context of amendment No.4.
The amendment seeks to change the procedure for the appointment of non- executive members and chairmen of health authorities and other health bodies. The Government have already accepted that their record in this respect has been very poor. They have made grossly biased political appointments and because they now feel some guilt in the past month the Secretary of State issued a paper on the appointment of chairmen and non- executive directors to NHS authorities and trusts.
Much of the procedure is contained in the statement but not in the Bill. The Bill gives an outline but not the detail of how the appointments are to be made. The amendment seeks to add that detail to the Bill and to ensure that the system of appointments is more independent than that which the Secretary of State, to judge from her guidance notes, is trying to introduce.
From a statistical point of view, appointments made since the NHS reforms have involved those with affiliations to the Conservative party. Analysis after analysis has made that bias clear. In fact, it is unusual for that bias to be denied, and only in the Standing Committee debating the Bill have I heard vigorous denials that there were political appointments. Even in Committee, evidence was produced to show that appointments were structured to favour Conservative party members. I stress that the barrier to changing the political bias in appointments is in the guidance notes produced by the Secretary of State.
Our experience in Yorkshire shows the political nature of such appointments and, although I raised this matter in Committee, I shall do so again. I was a political appointee, albeit a Labour political one, to Leeds health authority. It might be argued that I was appointed as a member of the council, but I was appointed as a Labour member of a Labour-controlled council. Leeds Health Care, the health
Column 236authority that I joined, is, in many ways, a very good health authority. Four of its six members were clearly political appointees, if I count myself among them.
The chairman, who I believe to be a good and effective chairman, was the chairman of Yorkshire area Conservative group. One member was the ex-leader of the then Conservative-controlled city council and another was a noted Conservative business man who had previously been the chairman of one of the two Leeds health authorities when they were divided. That makes three political appointments out of four, and there were two appointments that I regarded as neutral. A university appointee became vice-chair of Leeds Health Care and a second university appointee was director of the Nuffield centre for health service studies. That meant that there were two people who may have been generally politically neutral.
The health authority made its decisions on the basis of what it considered to be best for health care in the city as a whole. I do not think that decisions were made on a political basis. The appointments were political, but the decisions were, on the whole, sensible. It was intended to reach consensus on the way in which Leeds Health Care worked.
There are still some malfunctions in the way in which our authorities work, as shown by the case concerning long-term care to which I have already referred. The health commissioner found Leeds health authority at fault, yet the case was never reported to health authority members. Although the authority was strongly criticised by the health commissioner, none of the non-executive members of Leeds Health Care--those who were privy only to what went on in board meetings--were aware of the case. I do not think that the chair of the authority was aware of it, either. With a case that gained such notoriety, it was a reflection on the way in which we were organised that a decision that strongly upset the health commissioner was never, either before or after it was seen to be a difficult case, referred to the board. That matter needs to be looked at.
In Yorkshire, although there were a number of Labour appointees, the then chair of the regional health authority made it clear to me that he was regarded as having appointed enough Labour members. When it was suggested that he might appoint another to another authority, he said that he felt that he was already somewhat suspect because most of the authorities in Yorkshire appeared to have a Labour member. As he told me, that was a contrast with what happened in other areas. If we look at the statistics as a whole, we see that the pattern in Yorkshire was not a normal pattern.
What concerns me about the pattern established for the future is that we shall continue to have political appointments despite the fact that the wording suggests otherwise. The position is made clear in the draft guidance, which says:
"The aim of this guidance is to establish a national framework within which Regional Policy Board Members . . . can implement new procedures for the appointment of non-executive directors and chairmen to NHS authorities and trusts."
The guidance continues:
"RPBMs are responsible for the integrity and effectiveness of the arrangements in their region and for making recommendations on appointments to Ministers."
Column 237As we run through the guidance, it is clear, again and again, that the decision rests with the regional policy board member. The guidance says that there will be a sifting process
"conducted by a panel consisting of at least three local chairmen or non- executives . . . The panel may also include an independent member".
When one gets to the end of the section on procedure, it is made clear that the appointment referred to is the appointment of a regional policy board member.
"The RPBM will be able to use this information"--
information about people's performance and information that has come from the independent panel--
"when making his/her decision whether to recommend re-appointment to the Minister. RPBMs will retain the right to over-ride the preferences of any individual board chairmen when making recommendations."
The guidance continues:
"RPBMs should consult with all local MPs on those candidates intended for nominations to Ministers as chairmen."
That is a means of ensuring that the appointments remain in the hands of the Conservative party. The regional policy board members who were appointed under the old appointment procedure--not under the guidance issued by the Secretary of State--were hand-picked members of the Conservative party, whose judgment could safely be relied on. I am sure that the Minister would tell me if he were not absolutely convinced that each appointee was a card-carrying member. Nothing is said, of course, about what the judgment of the regional policy board members will be based on. I have already mentioned a letter that I received from a regional policy board member of the Northern and Yorkshire regional health authority. That board member attempted to consult hon. Members about an appointment to St. James's hospital trust--a critical appointment at a very important hospital. The Minister knows that it was a contentious appointment because the acting chairman, who was a Labour councillor, had extensive experience of the health service.
In telling us about the appointment, Mr. Greetham says:
that is the name of the person appointed, whom I have never met, so I am totally neutral--
"has very wide management experience both in industry and in his distinguished career with the Territorial Army. I am certain that this will place him in a very strong position to lead the Trust through the challenging and changing times ahead, and I hope you will be supportive of this appointment."
We are contrasting a person with distinguished service in the Territorial Army and experience in industry with someone acting as a chair of social services, who played an active role when the widespread issue of child abuse first came to public attention and who has been a member of the health service trust since it was established at St. James's seven years ago. The latter candidate also had experience of being acting chairman for over a year.
Column 238I do not discount experience in industry, but I wonder what the Territorial Army has in common with the national health service. I have no doubt that some of my colleagues would be able to suggest a reason.
Ms Coffey: They all wear uniforms.
Mr. Gunnell: I forgot that. I know that the Territorial Army is pretty hierarchical, too.
We need a process that ensures much more genuine independence. The amendment suggests that independent advice should not be given by people who are holding office in the health authority, who are employed by Her Majesty's Government or who are the holders of any publicly elected office. They should not be political people. [Interruption.] We are suggesting that those people should not be identified with any political party. We are not suggesting that none of the appointees should have political affiliations, but we are suggesting that the independence of advice on suitability of candidates should be more genuinely independent than is suggested in the Bill or in the regulations.
Ms Coffey: I want to add a few comments to those made by my hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell), who gave a fairly comprehensive analysis of the problems. He described how the amendment would achieve some credibility in terms of the public's perception of objective criteria being used in relation to the appointments.
I would be interested to know the size of the new health authorities which will comprise the old health authorities and the FHSAs. Obviously the size of the new authorities will vary according to the existing membership. However, there will have to be a process in some areas whereby existing members will not be reappointed to the new health authorities because there will be too many members when the members of the FHSAs are added to the members of the old health authorities.
As there is no transparent system to show how the members of those authorities were appointed in the first place, I should be interested in the explanation of why some members are not going to be reappointed to the new health authorities.
I was a member of an old district health authority. I did not sit on that authority after 1990 as elected political nominees were thrown off it. Of course, I was not a political appointee, but I was a representative of a political party. That was regarded as positive, because places were reserved for members of political parties. I sat beside other members of the district health authority who were clearly appointed because places were reserved for particular specialities. Others were appointed by mysterious routes. The problem about appointments is not recent; it has existed for some years. The difference between appointments to the old district health authority and the new appointments is that, in those days, no one was paid to be a member of the district health authority. People made a contribution because they were public spirited. They did that work voluntarily. With the new trusts and health authorities, there are executive and non-executive directors. That model is taken directly from private business and all the appointees are paid.
Column 239Some of the members of those authorities do not really know how they came to be appointed. One person told me that he had received a telephone call from someone who said, "You're a local business man. Would you be interested in being on this trust?" That man said, "Yes, " so he knows something about his process of appointment. People who have been appointed in that way have not answered an advertisement. They have simply been approached informally. They know that somehow they have been appointed by the Government because telephone calls from people inquiring whether they wanted to be members of trusts or health authorities clearly came from people who have the power to make such appointments. Ultimately, the appointments are made by the Government, so everyone assumes that they are Government appointments.
The problem for people appointed in that way is that they are not aware of the criteria for what they have to do. They do not know the criteria by which they were appointed. The appointments are short-term contracts. Presumably, members do not know whether they are going to be reappointed. The trouble is that that makes them less than independent. I am sure that some of them must think, "Well, if we create too much trouble, we are not going to be reappointed by this mysterious process which appointed us in the first place. We are not here to be troublemakers."
That attitude impinges on the members' ability to be independent, particularly if they are paid. A voluntary member might think that if he was not reappointed, he could do something else, but when it is a paid occupation, the matter must be given some consideration. That may affect their attitudes and perceptions about what is happening. The Government's view on appointments to trust boards is that trust boards--as the phrase implies--are business organisations. It is clear that they want to encourage people with business interests on to boards because they see the management of trusts essentially as a business enterprise. My hon. Friend the Member for Morley and Leeds, South (Mr. Gunnell) pointed out other difficulties, as there have not just been business appointments. I do not find it acceptable to say that a trust board is a business, and therefore we need people with business experience. But I suppose it is the logical view, if nothing else. A problem is that some appointments have been made for party political reasons.
In Committee I told the Minister that the Conservative Member who lost the Stockport seat in 1992 materialised as the chair of the Tameside trust some months later. The Minister would find it hard to convince me that that man was appointed because of his experience. I think--as do other members of the public--that it was a pay-off to him for having lost his seat. That sort of appointment brings the whole system into disrepute and makes it difficult for us to take seriously the notion of objective criteria.
Appointments to health authorities will be important because the Government cannot argue that those are business enterprises. Health authorities have a clear health commissioning role on behalf of the local population. If the Government's view is that health authorities should be responsive to local people, the people who sit on the authorities will be crucial. My experience in Stockport is that, almost without exception, the trust members came from outside the town. We shall be relying on those members of the health authority in Stockport to justify the idea of a locally responsive health service.
Column 240The attitudes and beliefs of the people who are appointed will be important. As the authority's purchasing role diminishes with the increase in GP fundholding, the strategic role which it performs will be absolutely crucial in the provision of care for the mentally ill, the mentally handicapped, the elderly and other specialities. It is important that the people on the health authority have the experience needed, and are local people. It is more important that they are seen to be appointed by a transparent system in which people can see what the criteria are and what the appointees are being asked to do, and that appointments have been made on the grounds of experience. If we cannot get on to the authority people who can do the best job for the people of Stockport, and who are seen to be the ones who can do that, it will not only bring into disrepute the whole system but will be a great loss to Stockport. That view can be duplicated for all health authorities around the country.
It is not enough for the Minister to say that he believes that appointments should be made among people with the best experience. He should bring forward clear guidelines, and show how those guidelines are to be systematically adhered to and properly monitored. If he does not do that, there will be continual criticism that people get on to health authorities not because of experience, but because of who they know. Ultimately, that is to the good of neither the health authority nor the people it serves.
Mr. Kevin Hughes: Everybody knows that the system is based purely on patronage. The Government have tried to defuse that criticism by changing the procedure for appointments. The new system, however, is also a closed process and the changes represent little more than a sham--a con trick to make people think that things have changed. The Government are not interested in real change or proper accountability and do not want people to see what is happening in the national health service. They do not want to be held accountable for the problems that exist in some parts of the NHS. They want to cover them up and keep them quiet. In short, they would be happy to take the advice of John Maples to have zero media coverage and keep the whole mess under wraps.
The amendment seeks to encourage the Government to introduce a truly independent element into the process, for example, community health councils. The Government's attempt at change--the new guidelines which they announced on 14 February--is no great leap for accountability, openness or democracy. The new sifting panel will consist of chairs of trusts appointed under the old system, and the regional chair will have the final say. Those people, who were all appointed under the old system, will control who enters the national health service and Ministers will still have the final say on chairs of NHS trusts. That is what we in Doncaster call the "Old Pals Act", section 1, paragraph 1.
One reason for our amendment is the fact that local people will have no opportunity to have a say. Five of the eight regional chairs are Tory supporters. A recent survey by The Independent showed that two thirds of the trust chairs examined had links with the Conservative party. That fact speaks for itself. Among them were spouses of Members of Parliament, former Tory politicians and party workers.
Column 241We need a more open and democratic system. Philip Hunt, director of the National Association of Health Authorities and Trusts, recognised that the changes made by the Government will not be enough to restore public confidence in the system. Lord Nolan seems to share that view. The amendment seeks to introduce an independent element into the system and ensure that people who are neither politicians nor civil servants, nor in health quangos, will have a say. The Secretary of State will be forced to seek advice to ensure that the candidate is the best possible person for the job.
Needless to say, when the Government decided to reform the appointments guidelines they missed the opportunity to introduce an independent element. In response to their announcement last week, Lord Nolan pointed out that an independent involvement could give the Government an opportunity
"to dispel the widely held perception that so many are Conservative appointments."
The changes are an admission that the appointments system is neither fair nor open. The fact that the Government have made such a trifling change shows that they are not prepared to open up the system to greater scrutiny and independence, particularly locally. The Government have resisted almost every move to increase both democracy and accountability in the national health service. In Committee, they knocked back amendment after amendment on those issues whenever they arose. They will no doubt do the same with this amendment--I expect little better of them.
The Government have no belief in democracy in the national health service. We have realised that time and time again as they have made their reforms. No doubt the "Old Pals Act" will prevail this evening.
Mr. Malone: I am delighted, as always, to oblige the hon. Member for Doncaster, North (Mr. Hughes) by not rising to any of the invitations that he gives to accept any of the amendments that are tabled. Can I say, Madam Deputy Speaker--
Mr. Malone: Mr. Deputy Speaker. My goodness, one has to be rapid in perception in the House, with the changes that take place. Mr. Deputy Speaker, I hope that it will not be regarded as a serious discourtesy, but I wish to refer to the hon. Member for Cardiff, West (Mr. Morgan), who is not in the Chamber. I must say, in accordance with several admonitions from the Chair this afternoon, that I have not given the hon. Gentleman notice that I intended to refer to him, because I wish to make a fairly friendly comment. When I slipped out earlier, as my hon. Friend the Parliamentary Under-Secretary of State for Wales, the hon. Member for Clwyd, North-West (Mr. Richards), was responsible for an amendment, I did not expect that, when the hon. Member for Cardiff, West had finished, I would return to the Chamber to discover that all the clocks had stopped--but, having listened to him in Committee, I was not entirely surprised.
Column 242I have listened to the debate on amendment No. 4, and several questions occur to me. First, where will that paragon of independence be found? If we took the amendment literally, it is hard to imagine who would be left to take up that important appointment. I assumed that the Opposition tabled the amendment with serious intent, and I considered whether we could accept it. I was tempted by what the hon. Member for Doncaster, North said, and I might well have been tempted to accept the amendment on behalf of the Government, had there not been several problems.
The amendment appeared to rule out anyone employed by the national health service as an independent contractor; so 830,000-odd souls in the country are ruled out by the amendment to start with. The amendment ruled out anyone with any type of contract with the NHS--whatever that means. Perhaps patients have contracts with the NHS--that is 78 per cent. of the public who visit their general practitioner. The amendment appeared to rule out any public sector employee or public office-holder and anyone who was a member of a political party--and presumably is a member of a political party--or identified with a cause. That no doubt also rules out many voluntary organisations.
Amendment No. 4 is the amendment from the planet Mars, because only someone from the planet Mars would qualify to serve as the independent assessor if that amendment were to be passed. On that substantive and important reservation, I suggest that the House should reject the amendment in any event.
My right hon. Friend the Secretary of State published new guidelines for the appointment of chairmen and non-executive directors of NHS authorities and trusts on 14 February 1995. The guidelines, which draw together examples of current best practice and appointment procedures, demonstrate the Government's commitment to a fair and open appointments system based on merit, not patronage. The implementation of those guidelines from 1 April 1996 throughout England will ensure that the NHS continues to benefit from the services of non-executives of the highest calibre.
It is an insult to all those who serve the national health service in a non -executive capacity that the Labour party continues to attack them in a way that is reprehensible and entirely without substance. The new guidelines make it absolutely clear that all new candidates for non-executive appointments will be sifted by a panel of at least three people. Perhaps that meets the independence criterion in the Opposition amendment.
Surely the people best placed to judge whether a candidate is suited to the demands of service as a non-executive director are people already working in that sector. I object to the suggestion in the amendment that people who are meant to be independent should be cut off from the service. I should have thought that the solution to ensuring that proper appointments are made is that people who know the way in which the service works, who can bring some of their knowledge to bear, are far better suited to select people who will serve the health service as chairmen and non-executive directors. That is why the guidelines say that people chosen to serve on the sifting panels should be local health authority or trust chairmen or non-executives.
We recognise the need to avoid possible accusations of bias in the appointments system. We have said in the guidelines that members of the sifting panel must not be drawn from the same NHS health authority or trust board,
Column 243and that the panel may include an independent member. We have suggested, for example, that it might be a member of a local community health council--which no doubt would be welcomed by the Labour party--a local justice of the peace, or someone who is involved in the community. We recognise the value of the view of someone who is detached from the NHS, but who cannot be permanently detached from the NHS as the Labour party suggests in its amendment. The new guidelines establish the flexibility to meet local demands without compromising standards in the appointment process.
On this issue, the Government are adamant that the best people, chosen from the widest cross-section of the population, are serving our national health service. I know that Opposition Members like to mock them, but that does no service to those who have given voluntarily to a substantial and a good cause. I think it is disgraceful that Opposition Members continue to do that.
The amendment constitutes an absurd suggestion to introduce an independence that would detach people from the health service rather than bind them to it. The new guidelines will draw people from an even wider pool of candidates by advertisement, thereby encapsulating what is already well- established best practice. I suggest that the House reject the amendment.
Amendment negatived .
Order for Third Reading read.
The Secretary of State for Health (Mrs. Virginia Bottomley): I beg to move, That the Bill be now read the Third time.
This has been an extremely important debate, and I valued being present for Report as I was not able to serve on the Committee. It takes forward two of the Government's most important objectives for the national health service and it devolves many important responsibilities closer to patients, while ensuring that all parts of the national health service work to common standards upholding its ethos and its values.
The Bill abolishes the regional health authorities and will create a new and more effective local health authority with responsibilities across the broad sweep of health and health care. It will also make a major contribution towards our goal of a primary care-led NHS. The merger of DHAs and family health services authorities is welcomed throughout the House, and I am sure that it will lead to much greater clarity for all of our constituents--the users of the health service. The new authorities will be in a stronger position to take an all-round view of local health needs; they will be able to secure a sensitive balance between prevention and treatment and between primary, community and hospital-based care.
Mr. Heppell: The Secretary of State has talked about the consensus in the House concerning the amalgamation of the FHSAs and the DHAs. We want to see those two authorities merged into one; however, we want it to be done in an efficient and effective way.
This is my only opportunity to ask the Secretary of State how she intends to respond to my hon. Friend the Member for Sherwood (Mr. Tipping), who wrote to her on 31 October to ask about the appointment of a new chief executive of the Health Commission. The former
Column 244chief executive of the FHSA, Mr. Tony Ruffell, was away on gardening leave. The Secretary of State replied then that he was being made redundant and that the matter was being sorted out. Apparently it was not sorted out, and my hon. Friend then asked the Prime Minister on 2 February--
Mr. Deputy Speaker (Mr. Michael Morris): Order. That really is not a Third Reading point. I call the Secretary of State.
Mrs. Bottomley: As you have said, Mr. Deputy Speaker, it is not a Third Reading point. That matter is still being investigated and I think that the individuals concerned are entitled to receive replies before I deal in the House with the issue of people's occupations. I am very pleased that, in Committee, a number of clarifications and improvements were made to the Bill. We have been able to clarify the question of junior hospital doctors, and focus on the importance of education and training and the role of postgraduate deans. Of particular importance is the amendment that the House accepted today which requires new health authorities to secure professional advice from across the whole range of disciplines.
It is that integration of professional advice, rather than the rigid traditional structures, that will be much more effective. That process will include nurses, doctors and other health professionals, and it will give statutory backing to the commitment that I made on Second Reading that professional advice should become professional involvement.
I draw the House's attention to a recent survey carried out among local directors of public health, reported in The Guardian last week. There was much debate in Committee about the role of directors of public health.
The report showed that most of those involved see the NHS health reforms that have taken place over the past five years as having produced clear benefits in terms of improved public health. It revealed that 90 per cent. said that, since the reforms, the needs of the population were either being better met or at least that there had been no change; 91 per cent. saw benefits or at least no change from the purchaser provider system; 85 per cent. said that waiting times for in-patient treatment had improved; 65 per cent. said that hospital surroundings were better; 75 per cent. of local directors of public health thought that fundholding had improved the effectiveness of public health service or at least had led to no change. I hope that all those who feel strongly about the role of the directors of public health will at least take note of their opinions.
I remind the House that, only five years ago, we were debating the Third Reading of the National Health Service and Community Care Act 1990. Then, the Parliamentary Secretary spelled out the key issues as the need to provide better patient care, the need to continue with a NHS funded by the taxpayer, largely free at the point of delivery, the achievement of better value for money, the achievement of better choice for patients and the delegation of authority to NHS staff closer to patients. All those objectives are being achieved, and the improvements in patient care and a more flexible responsive service are at the heart of all our changes.
The Bill marks the end of a period of change and reorganisation to free the NHS better to carry out its vital task for the people of Britain. The role of GPs is vital.
Column 245They, with other members of the primary health care team, have a pivotal role in shaping the provision of services. Advances in practice should not be held back simply because they are not available everywhere at the same time.
Our policy is to level up, not down. I point out to the House--it is a very important point--that under our legislation, for the first time ever, the district director of public health will become a statutory post.
The real point about the directors is that we are devolving important responsibilities to local level, where they properly belong. Regional directors of public health will have a new and important role within the regional offices.
Apart from the clarification of the important nature of the Bill, we have learnt something else about the attitude of the Opposition. They continue to attack managers, but support bureaucracy. In Committee, they sought to amend the Bill to introduce strategic health planning authorities--a bureaucratic nightmare, a waste of money and proof of a Labour party still wedded to centralism not dynamism; to indecision not innovation and to pen pushers not patients.
In contrast, our Bill will save £150 million every year for better patient care. The Labour party's advocacy of regional bureaucracy finds few supporters elsewhere and its enthusiasm for putting councillors in charge of the NHS finds even fewer friends. The BMA has rejected local authority control, and the RCN does not want councillors in charge. Nye Bevan did not want it, and the NHS does not want it. Anyone who has worked under the tyranny of Labour-controlled local authorities knows only too well that our constituents do not wish the health service to be run in same way as Labour -controlled local authorities.
The Bill will create accountable health authorities with a job to do and the means to do it. It will reinforce our policy of allocating money to populations and not to institutions. Accountability will be strengthened through the public having access to a single body. The new authorities will involve the public in decisions about priorities. They must take on more responsibility for explaining the key issues that the health service faces. My hon. Friends were right to focus on the quality, calibre and merit of those involved as non-executives and executives on health authorities as well as trusts.
The Bill is a sensible, timely and effective measure. It will build on the achievement of the new NHS and it will make it an even better place to respond to the changing needs of the patients. It is part of the Government's enduring, unshakeable commitment to the national health service and I commend it to the House.