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Steve Webb: I must be fair to the right hon. Gentleman. I checked the Division list while he was
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speaking and he is not guilty. He was obviously otherwise engaged at the time. I have some sympathy with the point that he makes. Simply because the Chancellor labels something does not automatically mean that it is so. I am very much of that view, but if we did not have the 1p on national insurance, which we supported and which we warned before the 2001general election would be required but which Labour never quite got round to mentioning, we would have £8 billion less of total Government revenue. We can argue about where that would come from, but clearly it is ring-fenced and earmarked for the NHS by statute, and that is the right place for it.

Mr. Lansley: As my right hon. Friend the Member for Charnwood (Mr. Dorrell) rightly points out, it is a fiction that the change in national insurance directly determined the level of NHS expenditure. If the hon. Gentleman looks at the accounts for last year, as I am sure he has done, since he is a professor, he will find that national insurance provided £1.5 billion less to the national health service than it was expected to provide. Did that change the amount spent by the NHS? That is separately determined in public expenditure through the vote. The point that we were making in 2002 related to the economic consequences of the way in which the Chancellor would raise the money. That is why, at the subsequent election, we committed ourselves to maintain that level of expenditure, but of course my right hon. Friend might have chosen to raise the money in a different way.

Steve Webb: I am interested in the hon. Gentleman’s claim that the Conservatives would maintain the expenditure. If the patients’ passport that his leader wrote into the manifesto had been implemented, money would have had to be found to subsidise people to buy their way out of the NHS. Where would that money have come from?

Chris Ruane (Vale of Clwyd) (Lab): I thank the hon. Gentleman for raising the crucial issue of financing the NHS. The hon. Member for Peterborough (Mr. Jackson) referred to the period between 1979 to 1997, when expenditure under the Tories went up by 60 per cent. May I remind the House that from 1997 to 2008, under Labour, the budget will be going up by 300 per cent.?

Steve Webb: Nobody could dispute that the rate of increase in spending under the present Administration since 1997 has been substantially in excess of what the Conservatives did or would have done, had they been in office. I am glad the hon. Gentleman mentions 1997. Part of the reason why I am addressing the House now is the record of the Tories on the NHS. In 1997, I had people coming to see me at my surgery with letters from their hospital stating that it would be two years before they could see an orthopaedic consultant to be put on the waiting list.

The reason Conservative Members object to my raising that and think we should be attacking solely the Government is that the Conservatives are portraying themselves now as the friends of the NHS. I find that laughable. They have form. They have form in cuts in their final year in office, they have form in voting against money for the NHS, they have form in the
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patients’ passport, and only last month the Conservative leader took out from the first draft of his speech a line that pledged to match Labour’s spending on the NHS. What was that about? If the hon. Member for South Cambridgeshire (Mr. Lansley) wants to reinsert that pledge on the record, I will give way to him.

Mr. Lansley: It is clear that we were all elected on the basis that we would match Labour’s planned spending to 2008-09. We have no idea what Labour’s planned spending is after 2008-09.

Steve Webb: So the hon. Gentleman does not rule out spending less than Labour on the NHS.

The hon. Gentleman said at the start that the debate was not principally about finance. One of the reasons why there are 90 per cent. unemployment rates among physiotherapists when they graduate, and one of the reasons that we are seeing redundancies, including of front-line medical staff, is the Government’s mismanagement of the finances of the NHS.

A recurrent problem throughout the debate is the issue of reconfiguration and who should decide when health services need changing for greater efficiency. At Prime Minister’s questions earlier today, the hon. Member for Hastings and Rye (Michael Jabez Foster) said that, if we do not like what is to happen to our accident and emergency department, whom do we ask? What do we do about it? There is only one person who has been anywhere near a ballot box whom people can ask, and she is sitting on the Government Front Bench. [Interruption.] The Secretary of State says overview and scrutiny. The local authority can scrutinise. What does it have the power to do? It has the power to go and ask her, and if she wishes and deigns to do so, she can refer the matter to an independent body.

My overview and scrutiny committee asked the Secretary of State to review the closure of Frenshay hospital in my constituency. Guess what? She refused. All three parties on the council, not just the Liberal Democrats, wanted a referral. I want a referral. Anyone who had ever been elected in the area wants a referral, but the Secretary of State blocks it, so she is the one who controls these matters centrally. How is that a democratic and accountable national health service?

Simon Hughes (North Southwark and Bermondsey) (LD): Does my hon. Friend accept—the Secretary of State may anticipate this—that that must be right because, two nights ago, I went with four Labour colleagues to see her and the Minister of State Lord Warner to ask her to reinstate some of the cuts in south London for the most vulnerable this year and to look again at some of the prospective cuts for those with mental illness? The Secretary of State very reasonably said that she would reconsider because she believed that the formula that had been arrived at in London was unfair and she would seek to have it recast to reinstate some of the funding. We hope that that will be successful. We would not have gone to see her if it were not the case that the Secretary of State for Health is able to decide what happens. In the end, she calls the shots.

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Steve Webb: Indeed, except when there is bad news. When there is bad news, it is a local decision. The right hon. Lady is the Secretary of State for good news in the health service. Whenever a community hospital opens, it is because of a Government promise. Whenever a community hospital closes, it is because of local decision making.

Ms Hewitt: Does the hon. Gentleman accept that I have been assiduous in going round the country to talk to staff in hospitals and local areas that are facing extremely difficult decisions, including Nottingham, about which we heard recently, and that I meet those staff privately to discuss the difficulties that they are facing? I do not go only to areas where everything is excellent. In the real world, most areas have to make difficult decisions to achieve the best use of their resources. Rather than continuing to sit on the fence, the hon. Gentleman must decide whether he is in favour of difficult decisions being made to get the best value, to take advantage of modern medicine and to get the best care for patients, even when that means, in his constituency or elsewhere, difficult changes.

Steve Webb: At the risk of being parochial, there is the strange coincidence that the hospital in my Liberal Democrat-held constituency closed so that a new one could be built in the neighbouring Labour-controlled constituency. We need to know that the difficult decisions that have to be made are being made on clinical grounds. All too often, it seems blindingly obvious that other factors, shall we say, come into play.

The Government and the health service must treat the public as adults and give them the necessary information and the opportunity not to be consulted and ignored, but consulted and listened to and for their views to be acted upon. I have discovered a new word in the English language—it is sham-consultation. We cannot have the word “consultation” any more without the adjective “sham” in front of it. Throughout the country when I, like the Secretary of State, visit local people, they say, “Yes, we went to endless consultation meetings, we had engagement, then consultation, then review, and then all the rest, but in the end they did what they were always going to do.”

If people are making decisions against the will of the local people, they should be people whom local people can get rid of. How can it be right that decisions affecting hon. Members’ health services are made by people whom they never elected, whom they can never get rid of, and whose only right of appeal is to the Secretary of State—who has total discretion to ignore the appeal and, if she hears the appeal, can refer it to a quango, which we also did not elect? Where is the democratic accountability in that?

I have some sympathy with the idea of getting rid of centralised meddling, so to that extent I am with the Conservatives on the idea of independence, but it falls down because there is no democratic accountability, particularly at the local level. Local communities are frustrated because they feel that the decisions are being made for them, rather than with them. Lots of meetings take place, but how often do they change anything? That is one of the things in the health service that must be changed.

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The Secretary of State met the press this morning. She is anticipating whatever the Healthcare Commission might find tomorrow about the health service’s performance. She said that we need action plans. In other words, where PCTs are found to be weak we urgently need action plans to start within a month. That typifies the Government’s mismanagement of the NHS. She does not say that we need long-term strategic thinking for efficiency over a period of years or that we need deep-seated financial problems sorted out in the medium term, but that we anticipate a bad headline tomorrow, so we need an action plan and we have a month—a month—to do things that presumably have not been done for the last nine years. Is that a month to put long-term plans in place; a month to consult and listen and refine? No, just a month to get them out of the mess they are in this month.

What is happening with NHS finances is that problems that have built up over years, decades in some cases, have to be sorted out by Wednesday week. How can that be a rational way to run the health service? We have huge financial instability. The Secretary of State complained that the Tories wanted to spend taxpayers’ money subsidising the private sector. The words “pot”, “kettle” and “black” spring to mind. Independent sector treatment centres are being given better prices than the NHS, guaranteed volumes of delivery, the chance to cherry-pick the easy hips, cataracts and scans, but at the expense of what? She mentioned the ISCT at Shepton Mallet, but that has resulted in job cuts at the Royal United hospital in Bath just up the road. Frenshay hospital will virtually close and the chances are that an ISTC will be built on the site, so the same people will be having the same procedures on the same site but done by the private sector instead of the public sector, probably at greater cost—and that is not privatising the NHS? I wonder what would be.

Sandra Gidley: My hon. Friend has probably also seen the predictions that many of the ISTCs will not fulfil their full contracts, so they make more money. Does he share my concern that, for example, in Southampton we are faced with a treatment centre that will take cataract operations out of the system and threaten the viability of the extremely good and useful eye unit that we have?

Steve Webb: My hon. Friend’s experience is absolutely typical. It is hard to see what was wrong with the eye unit at her local hospital, yet because the Government are obsessed with marketisation, with trying to create a fake market and with trying to shake up the NHS by subsidised private competition, good quality NHS facilities are being undermined throughout the country.

Mr. Edward Vaizey (Wantage) (Con): Will the hon. Gentleman therefore confirm that it is Liberal Democrat policy to close the existing ISTCs and not to open any more, or is it their policy to fund them in a different way?

Steve Webb: I can give a straight answer to that—it is Liberal Democrat policy not to subsidise ISTCs, which is what has been happening. One question that I would ask the hon. Gentleman is where is the value-added
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coming from? As my hon. Friend the Member for Romsey (Sandra Gidley) said, some of the ISTCs have block contracts, so they are paid for work that they do not do. The hon. Gentleman’s party complains about low productivity in the NHS, whereas here the private sector is creaming it at the expense of the NHS.

Meg Hillier (Hackney, South and Shoreditch) (Lab/Co-op): Most patients go to their GP, in the vast majority of cases a private partnership, are given a prescription that they take to their local high street pharmacy, a private business, and are then given a drug from a private drug company. That is accessed free at the point of delivery, funded by the public purse, but provided by a range of providers—so I am not quite sure what his argument is.

Steve Webb: The origin of the cheers says it all. The GPs are not providing services to make a profit, although the drug companies might be trying to do that. The critical point is why should the private sector have to be subsidised and bribed in order to bring it in. Does the hon. Lady support that? Does she really believe that the private sector should get more than the NHS for providing the same treatment? That is Government policy.

Andrew George: Is my hon. Friend aware that in Cornwall at the moment, despite the fact that GPs refer patients to NHS consultants, who have to operate with one arm tied behind their back, constrained by minimum waiting times, NHS managers intervene with unsolicited phone calls to offer the possibility of those patients being seen earlier in the private sector?

Steve Webb: My hon. Friend raises some very strange matters that are occurring in the NHS. I assume that the Secretary of State knows what is happening. We are supposed to have patient choice. The patient is supposed to see the GP, go through a list on the screen, pick one, and then a booking is made—except that someone is tapping the phone line. Someone intercepts the call, second-guessing the GP’s referral, and in some cases saying, “Are you sure you want to do that? Let’s try to refer them somewhere else.” How that squares with patient choice I am not sure. If the GP and patient jointly decide one course of action and that is second-guessed, I do not see how that is patient choice.

My hon. Friend referred to minimum—not maximum—waiting times. We have examples all over the country—my hon. Friend the Member for Twickenham (Dr. Cable) has raised the matter with me—of people being told that they have to wait longer because there is no target at the bottom end. The people right up against the target will have priority, even if the others could be treated sooner because there is no target. Those are the sort of distortions that the Government’s obsession with targets are creating in the NHS.

Dr. Stoate: I have great sympathy with what the hon. Gentleman says, but he is in danger of confusing one or two issues. I work part-time as a GP and I refer people on the choose-and-book system. I bring up the list of possibilities on the screen for the patient, given his condition, and the patient then chooses the hospital
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and makes the appointment to suit themselves. Waiting times on choose and book are very good indeed. On occasion, a patient may choose a private sector deliverer if there is one on the list within the NHS tariff, but in my area nine times out of 10 the patient will choose a local general hospital that they have had contact with before. I do not quite understand where he sees the confusion.

Steve Webb: Perhaps the hon. Gentleman does not have referral managers in his PCT. Those are people who come between him and his referral to the consultant and suggest sending the patient somewhere cheaper. That is what happens.

Susan Kramer (Richmond Park) (LD): Just to confirm the cases that have been brought up by my hon. Friend the Member for Twickenham (Dr. Cable), about a week ago my local GP complained to me that, having called up various consultants for treatment of his patients and been told that they and the operating theatre were available, when he tried to book in the patients he was told that there must be a 10-week delay until they are right up against the target barrier. That, presumably, is a mechanism for pushing costs, certainly within the London area, into the next financial year by delaying treatment as long as possible. My GP is very concerned about the deteriorating condition of his patients. I am now asking patients if they are willing to give me their names so that we can bring those cases forward.

Steve Webb: My hon. Friend has illustrated the consequences of the financial squeeze in the NHS. Ministers seem to think that they are running a different health service in which such things do not take place, and, as my hon. Friend has said, sometimes they do not seem in touch with what is happening on the ground.

The focus of today’s debate is the work force, and the Council of Heads of Medical Schools has rightly criticised what is going on:

It is talking about the Government’s failure to ensure proper work force planning. Whenever I have asked written questions about that matter, I have been told, “That is the responsibility of trusts or health authorities.” I sometimes think that this Government are the “Not me, guv” Government, because they always say that it is someone else’s problem.

Where things need to be done strategically and nationally, the Government should be planning—I know that “planning” is a dirty word in new Labour—so that people who commit their lives to the NHS by undertaking three, five or seven years of training have a good prospect of obtaining a job when they complete their training. The Secretary of State has no answer to why 90 per cent. of recently graduated physiotherapists are unemployed. Is that acceptable? Has the right hon. Lady got anything to say on the subject? All she has said is, “We are trying to help. We will do what we can.” The situation is totally
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unacceptable; it is the result of mismanagement; and the buck must stop on the Government Front Bench.

Some things in the NHS must be done nationally, strategically and with accountability to Parliament. However, as much as possible should be done locally by local people, who should be engaged early in the decision-making process to allow them to face the difficult choices, to express their priorities and to have those priorities respected, which is not happening in the NHS at the moment.

One important issue that has arisen in the debate is that of switching money from people with longer life expectancy to people with shorter life expectancy. There is the question whether enough money is going into the system in the south and whether too much money is going into the system in the north. How can the Conservative party run a “no cuts” campaign without promising to spend any extra money? It is difficult to work that one out, until one realises that, with one or two exceptions, it does not intend to win any seats north of the Watford gap. Conservative candidates in seats south of the Watford gap will say, “We will spend more money in this area.” If, however, we were to have a parliamentary by-election north of the Watford gap, the Conservative candidate would not mention spending less in that area.

Mr. Graham Stuart: Does the hon. Gentleman accept that the economics of the issue and health outputs both involve using the money wisely and both concern productivity, which lies at the root of the Government’s failure? By reducing centralising bureaucracy and, as he has wisely pointed out, distortions caused by target setting, it would be possible to use the existing money to deliver more care. As the Labour party used to say before it got into power, which it has wasted, it is not only about money.

Steve Webb: The hon. Gentleman represents a seat north of the Watford gap, and he is right that we need to spend every penny wisely. Every incoming Government say, “Vote for us and we will spend the money more wisely”, but the issue goes deeper than that. The Conservative party is saying that it would spend more money in the south of England without ever saying that it would spend less in the north. The shadow Secretary of State has said that the Conservative party should regard public health money as one pot and money for illness as another pot. Those two areas are clearly separate, but the total will not change—if one area gets more, another area must get less.

Chris Mole (Ipswich) (Lab): Will the hon. Gentleman clarify that the Liberal Democrats would not change the national distribution formula for the NHS one iota, which would help to rebut local Liberal Democrats who say, “We will get back the 10 per cent. that Labour has sent to the north”?

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