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Dr. Jenny Tonge (Richmond Park): Does my hon. Friend agree that the private sector should also play a part in the training of nurses and doctors, and contribute financially?

Mr. Harvey: Absolutely. It would be good to see the private sector taking a practical role in training. The idea of private sector contribution to the cost of that is also good in principle, but it is difficult to see how such a charging mechanism would be organised, and we do not know how much it would raise. If a way could be found to make it work, there is no good reason why we should not give it a try.

The Government have established a National Institute for Clinical Excellence to test the clinical effectiveness--and cost-effectiveness--of drugs. That too is a good idea in principle, but we have major misgivings about the remit, especially as it has been changed by means of a statutory instrument. That has brought into play considerations of affordability, which we consider to be properly in the domain of the Secretary of State and the political community. We think that it is for them to decide what the nation can afford.

There is a world of difference between cost- effectiveness and affordability. Something can be extremely cost-effective, but very expensive. It is entirely right to establish a panel of experts to decide what is cost-effective, but affordability must ultimately be a political decision. When it comes to deciding what the nation can afford, the buck must stop with Ministers.

Funding is a major issue that has interested the nation of late. The Government have not been as candid as they should have been about the extra funds that they have invested since coming to office. For the first two years, they stuck to the Conservatives' spending plans. Goodness knows why; I do not for a moment imagine that, in the unlikely event of the Conservatives' having returned to office, they would have stuck to those plans themselves. The Government, however, set themselves an austerity programme, stuck to the Conservatives' targets, and embarked this year on the first of the three years of spending covered by the comprehensive spending review.

If the Government manage to complete those three years and to spend all that has been promised for the NHS, at the end of the full five years they will just about have spent, year on year, more than the Conservative year-on-year increases. If there is a general election after only four years, however, they will not even have achieved that, and their year-on-year increases will not even be as great as those of the Conservatives.

I am glad that, over the last couple of weeks, public attention has turned to the proportion of our national income that we spend on the health service. I am pleased that everyone seems to agree that it should increase. We do not keep up with our European competitors, but, more shockingly, we do not even keep up with America. Many people regard the state-funded health system in America as an emergency back-up, a safety net, a last chance if all else fails. Legion are the stories, probably apocryphal, of people in America who are found at the roadside after accidents and who, unless they have a credit card,

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or insurance policy, will not be taken in and cared for, yet the Americans spend 6.5 per cent. of their gross domestic product on that emergency, last-resort, back-stop system. We are floundering at a figure that is variously estimated at between 5.5 and 5.8 per cent. of our GDP, so we must do better.

Dr. Stoate: I note the hon. Gentleman's point that the Americans spend about 6.5 per cent. of their GDP on their publicly funded system, but does he agree that they get extraordinarily bad value for money in that 45 million Americans have no health care cover of any sort, that one quarter of all bankruptcies in America are due to unpaid health bills and that health outcomes are, in many ways, disappointing, particularly for the richest country in the world?

Mr. Harvey: I agree. The Americans do not get particularly good value out of either their public or private systems. In total, they spend 14 per cent. of their GDP on the health system. At its best, it is very good, but, overall, I am not sure that it is all that remarkable.

What was remarkable was the Prime Minister's pledge yesterday that the Government would get spending up to the EU average in the course of five days--[Interruption.] In five years; I beg the House's pardon. What he promised was remarkable enough. Whether he is any more likely to attain it over five years than over five days, I do not know. Certainly, some of his arithmetic seemed highly dubious. Whether he was supposed to say that, was on message and had been cleared to say it, I do not know. It may have been like his fox-hunting pledge, which he gave when under a bit of pressure at Question Time, but it smacked of a back-of-a-fag-packet calculation.

If the Prime Minister thinks that putting a mere £2 billion a year in over the next five or six years will get us up to the European average, he could not be more wrong, or is he counting these things in the way that the Chancellor of the Exchequer does? The Chancellor would have us believe that, if we put in £3 billion in the first year, another £3 billion in the second year and another £3 billion in the third year, it makes a glorious total of £18 billion.

Mr. Eric Martlew (Carlisle): The hon. Gentleman referred to the Prime Minister's promise. Can we have an assurance that the Liberal Democrats support that promise?

Mr. Harvey: We do. We wish the Prime Minister well in his efforts to achieve that. If it comes to votes to get the funds in place to do it, he can rely on our support. However, I am still sceptical as to whether he will achieve it.

Dr. Peter Brand (Isle of Wight): Did my hon. Friend notice that, towards the end of the Secretary of State's speech, he refused to take interventions? The one matter of substance in his speech was the undertaking to increase spending by 5 per cent.--per cent. of what he did not define. Might it be helpful if my hon. Friend explored what the baseline of the 5 per cent. is and accepted an intervention from the Secretary of State to see whether he could answer that question?

Mr. Harvey: My hon. Friend makes a good point. I was hoping that the Secretary of State might have cast

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a little more light on the Prime Minister's commitment. I think that the Secretary of State said that there would be an increase of 5 per cent. in real terms. Does that mean 5 per cent. over and on top of normal NHS inflation--that is to say, over and on top of anything that we have heard about to date in any comprehensive spending review? Will the comprehensive spending review that we expect in July factor that all in on top?

When the Prime Minister says that he will put in £2 billion a year, does he mean that he will put in £2 billion in the first year, continue that into the second year, adding £4 billion in that year, and continue that into the following year, adding another £2 billion, making £6 billion in that year? If so, he had only to consult the Chancellor, who could have explained that that adds up to £42 billion. If they put in £42 billion, they might begin to get somewhere near the European average in five years.

Dr. Stoate: Will the hon. Gentleman clarify the Liberal Democrat policy? Does he subscribe to the view of the hon. Member for Isle of Wight (Dr. Brand), who said on a television programme on which he appeared with me last week that he would be happy for income tax to rise by anything up to 10p in the pound over the next 10 years to pay for Liberal Democrat promises? Is that Liberal Democrat policy?

Mr. Harvey: The hon. Gentleman misquotes my hon. Friend, who said that, if we were to reach the European average, the necessary investment would be equivalent to that rate. He was not necessarily advocating such an increase or saying that we could reach the average overnight. However, it will take massive investment to reach.

It would not make sense to reach the average at once, as the principal investment that we have to make is in staff and personnel, who take time to train. As the Prime Minister said, it takes three or four years to train a nurse. However, if he had recognised that three years ago and started a drive to recruit more nurses, they would have been coming on stream this summer and in post to help cope with any influenza epidemic that might occur next winter.

Mr. John Burnett (Torridge and West Devon): I am extremely grateful to my hon. Friend and neighbour for giving way. He is making a powerful point: there is great need for staff and personnel. I draw his attention to the case of one of my constituents--Mrs. Hopkins, of Germansweek--who visited my advice surgery last weekend. She is suffering from frequent bouts of fainting and giddiness, for which her general practitioner referred her to a consultant. The Royal Devon and Exeter Healthcare NHS trust has written to her to say that, although she will have an appointment, she will have to wait 140 weeks. Does my hon. Friend agree that such delays are caused by failure properly to fund the NHS and are an utterly unacceptable national disgrace?

Mr. Harvey: I can only agree with my hon. Friend that it is absolutely disgraceful that anyone should have to wait 140 weeks--almost three years--simply to see a consultant. Goodness knows how many weeks after seeing a consultant one would have to wait for any

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operation that the consultant might think necessary. The case that he describes is about the worst that I have heard, and underlines the fact that, whatever progress is being made on in-patient figures is more than counterbalanced by the extra time that people are waiting on out-patient lists. As he says, it is an absolute disgrace.

In recent years, there has been a staggering decrease in the number of nurses working in the NHS. In 1987, there were 514,600 nurses and midwives working in the NHS; today, there are only 373,000. It is incredible that there should have been such a decrease in only 12 or 13 years. Currently, 15,000 nursing vacancies are being advertised, and we are struggling to fill them.

A great deal more will have to be done than yesterday's pay increase--welcome though that was--to turn the nursing profession into something that people are attracted to at the start of their career and will stay with loyally throughout their working lives as they try to build careers. Year after year, many pay increases will be required. Better still, if we are to make necessary progress in recruiting nurses, there should be a complete re-evaluation of our views on the nursing profession and of the value that we place on it both in the NHS and in society overall.

On how pay rises will be paid for, it has been noted that health authorities were given their budgets for the coming year just before Christmas. The Minister has made it clear that the rises will have to be paid for out of those budgets.

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