House of Commons Hansard Debates for 20 Jul 1999 (pt 16)

Mr. Simon Hughes: It may be easier for the right hon. and learned Gentleman to answer my question now that he is in opposition than it would have been when he was in office. Does he agree that it is now sensible that we should move away from such appointments being entirely the responsibility of the Secretary of State of the day? They should be dealt with by a cross-party or all-party process and should be much less political appointments--as Neill has recommended for other public offices.

Mr. Clarke: I am a straightforward chap and I think that it is a pity that Secretaries of State cannot handle those matters. I fear that appointment-making will be taken over by quangos of the great and the good. I am not sure whether all the rules that have been introduced on public appointments have improved the quality of those appointments--all that results is a great paper chase and some curious appraisal methods. With great respect to the officials, more people tend to be appointed whom the officials know and less people whom the Ministers know. That is not an automatic advance. If it is any consolation to the hon. Member for Southwark, North and Bermondsey, when I was at the Home Office, I once made a senior appointment of a Social Democrat who had lost his seat. It should be possible to have clear guidance and the Secretary of State should be held to account. We try to hold him to account, but he offers us a rather unconvincing explanation of the ridiculous total of Labour party activists that he has appointed all over the place.

Even more serious are the bureaucracy, the constraints and the changes that are being imposed on the ground, largely to satisfy the Government's claims that they are reversing the Conservative reforms. I believe that those changes will inhibit the delivery of the service, and the aspect about which I feel most strongly is fundholding. I totally reject the slogan used by the hon. Member for Wakefield that the NHS was made a two-tier service. The whole idea of fundholding was to give incentives to GPs, who act as gatekeepers to the service, to raise the quality of service that they provide to their patients. We discovered that some could do that better than others, but it is no good turning around and saying that the whole system is unfair because some people cannot manage it and make a mess of it, so everything has to return to the level it was before.

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I come now to what I trust will be the most eloquent part of my speech, in which I quote a letter I received from a doctor. The letter was entirely unsolicited, although I have expressed strong views on fundholding. I shall not name the doctor, who is a GP in my constituency; I have no idea what his political allegiance is. By chance, he summed up in his letter my fears about fundholding. He writes:

"It is clear that the end of fundholding means that our patients must return to the unacceptably, and in my view, dangerously long waiting times for both inpatient and outpatient appointments. So much for the 'levelling up' process proposed by the government.

In addition to the above concerns, it is not at all clear that the Practice based services such as Physiotherapy, counselling and venepuncturist will be available in the future. Despite strenuous efforts on our part, Nottingham Health can not or will not give us any idea what the future holds for these services. I suspect that through a process of vacillation and procrastination they will wither on the vine . . .

The innovation and local flexibility that fundholding brought to General Practice is being stifled by the plethora of administrative structures, PCGs, TCPs, Trusts etc. The only result of all this reorganisation has been to introduce yet more bureaucratic layers, costing money which could be available for patient care.

You might be interested to discover that the approximate cost of each PCG"--

primary care group--

"of which there are six in Nottingham, is £250,000--not a penny of which has been spent on patient care--and the complaint was that fundholding was expensive!"

I could go on and give other details of the threats to his practice that that doctor fears. Almost every doctor in my constituency was in a fundholding practice by the time the Conservatives left office. Many of them fought the system fiercely when it was first proposed, but discovered the benefits of it and now regret its loss.

One of the great strengths of the NHS is the primary care service, provided by the family doctor who knows at first hand the needs of his patients. The duty of the family doctor is to act as a gatekeeper to access to NHS services, such as hospital care and community care services in his locality, and to get his patients the best possible access for the public money available for their care. That is being threatened by the crisis in local services. I could give a plethora of examples from the rising number of submissions made to me--that the number is rising may be chance, but I think not--of people whom the service fails when they find they want it.

The hospital service is also breaking down. The waiting list initiative is being used shamelessly to distort the length of waiting lists. People are removed from waiting lists for reasons that are administrative and have nothing to do with their clinical need. I have examples of people who need a hip replacement being told that they will have to wait 16 months before they can have a first interview with a consultant, because they only go on to the waiting list figures after the first interview and their waiting time thereafter is thus shortened. I have also found that our health authority has stopped allowing GPs to refer out of area because waiting times are shorter elsewhere, which is one of the flexibilities that the previous system

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permitted. All that tells of a steady deterioration in what can be done on the ground, and the prospect of a stream of public announcements and initiatives is no substitute.

Dr. Stoate: Will the right hon. and learned Gentleman give way?

Mr. Clarke: No, because I shall answer the point the hon. Gentleman made about what should now be done.

Fortunately, the Government have not reversed the previous NHS reforms. They have kept the purchaser- provider divide. The NHS now has management information that was not at the disposal of anyone before the reforms were made. I used to compare the old unreformed national health service with the Indian state railways: no one was apparently in charge of anything and the system worked only because everyone knew that they had to do roughly what they had done the year before, while hoping that they did not run out of money before the year's end. We now have an altogether better system which is capable of being controlled.

We must release from the centre the great bulk of unallocated money and stop introducing central initiatives. The walk-in health centres sound like a good idea--although they will probably stimulate extra demand, which is a great misfortune. However, they are not a first priority when we consider the strains on the service and they run the risk of diverting resources from other areas. Local priorities will differ somewhat from place to place; that is why we have a postal list variation. Sometimes variations are inevitable and sometimes they should be addressed--especially when big items, such as beta interferon treatment for multiple sclerosis, are involved. People should be allowed to say that, because waiting times are quite good in their region, they want to tackle other areas of the health service.