[Relevant documents: The First Report from the Social Services Committee, Session 1987–88, on Resourcing the National Health Service: Short term issues, HC 264-I, the Government Response to that Report, Cm. 405 and the Third Report. from the Social Services Committee, Session 1987–88, on Resourcing the National Health Service: Prospects for 1988–89, HC 547.]
I beg to move,
That this House congratulates present and past staff of the National Health Service on forty years service to the public; reaffirms its support for a comprehensive health service, free at the point of use to all citizens and funded out of general taxation, and rejects proposals to end its universal character by subsidising the better off to opt out; welcomes the recent conversion of ministers to the fundamental principles of the National Health Service, and invites them to demonstrate their commitment to it by tackling the serious underfunding confirmed by the latest report of the Social Services Committee (House of Commons Paper No. 547 of Session 1987–88), in order to raise the quality of patient treatment, medical research and community care and to assure development of the best principles and practice of the National Health Service in the future.
Forty years ago today, the National Health Service came into being. With its birth, there was swept away the system of charity hospitals dependent on lotteries and flag days to stay open—a system in which few went to the dentist for preventive care because they were charged even for a dental examination and a system of two-tier health care in which panel patients went round the back to the waiting room while private patients came through the front door to go into the doctor's parlour.
It was a bad health system. It was bad for the nation's health. It was bad for the dignity and self-respect of the individual who could not afford health care treatment. That is why Opposition Members will fight any attempt not to take the NHS forward but to take it back half a century to the divided health system which it replaced.
During the past 40 years, the NHS has served us well. It has provided universal cover, and, because nearly everyone uses it, there is no stigma attached to those who do. It provides comprehensive cover through a network of district general hospitals which have brought nearly every specialty into every neighbourhood in Britain. It has also sustained centres of excellence that can hold their own with the medical schools of any other country, whether it be on quality of training, or research or innovation. It has done that while also supplying a unique system of primary care barely paralleled throughout the western world in which even after nine years of this Government three quarters of all consultations take place within 24 hours of the approach. However, most important of all, the NHS has separated the anxiety of paying the bill from the stress and pain of being ill.
I presume that those points are common ground between Members on the Front Benches, although they may be controversial according to some voices from the Back Benches. I presume that it is common ground between myself and the Secretary of State that the NHS has served us well and made those achievements because I note that, in recent weeks, the Secretary of State has been claiming credit for the Conservatives in having created the NHS.
I was somewhat surprised to be woken up the other morning by the Secretary of State informing us on the radio that it was not Bevan who formed the NHS in 1948 but Churchill in 1944. There is, of course, one inconvenient historical fact in that reconstruction of history, which is that every Conservative Member voted against the creation of the NHS on the Third Reading of the Bill.
The hon. Gentleman has just said that the NHS has served this country well. Did it serve this country well during the period of the last Labour Government when the hospital building programme was cut, nurses' wages were reduced in real terms, there was severe industrial action and waiting lists increased?
If the hon. Gentleman will wait while I go through my speech—I shall respond to his point in a moment—he will see how the present situation compares with that left by the last Labour Government. If he speaks to the nurses from the Royal College of Nursing who have been speaking to many of my hon. Friends and to members of the minority parties and asks them whether they would rather go back to the administration of the NHS in the 1970s or continue with the Government's policies, I have not the slightest doubt about the reply he will receive. If he cares to ask them about pay, they will remind him of something that he has obviously forgotten, that it was not a Conservative Government but a Labour Government who appointed the Clegg commission.
I was recalling to the House the fact that every Conservative Member available voted against the NHS on the Third Reading of the Bill. However, I accept the Secretary of State's assurances that that was just a roundabout way of expressing their support for it. What is at issue is not what they thought about the NHS in 1948, but what they think about it in 1988.
Yesterday the Secretary of State addressed the Centre for Policy Studies, and in the course of his speech he said:
We must tackle the deep-seated tendency within the NHS to self-denigration.
I am sorry, therefore, that the Secretary of State did not take the opportunity to rebut the insulting observation about the NHS in one of the recent submissions from the Centre for Policy Studies to the review. In one of its recent submissions, it wrote:
It is doubtful whether long stay prisoners in maximum security gaols fare much worse than NHS patients.
That is the kind of sentence that leaves one doubtful whether the authors have ever seen inside an NHS ward and absolutely certain that they have never visited a maximum-security gaol. It is unfair to the NHS, half of whose patients are in wards of five or fewer beds. It is even unfair—that is saying something—to the Government's
stewardship of the NHS, and it is grossly unfair to the dedicated, committed nursing staff whom most patients do not remember as gaolers.
The co-author of that sentence was the hon. Member for Wokingham (Mr. Redwood), who I am pleased to see is in his place. Until the last general election, he was head of the Prime Minister's policy unit at No. 10. There is little point in lecturing the NHS on self-denigration when working at No. 10 breeds such prejudice and contempt for the NHS and those who work in it.
That brings me to the review currently being conducted from No. 10, not from the Department of Health and Social Security. I and all my hon. Friends would welcome a review of the NHS, if it were an open review, if it were accessible to those working in the Health Service and if the submissions were being weighed by open and independent minds. We do not have that. Instead, we have review by Cabinet sub-committee. Every member of it is a Minister—the Secretary of State and the Minister of State, Department of Health and Social Security, the Chancellor of the Exchequer and the Chief Secretary, and the Prime Minister. I would not be so provocative as to suggest that there is not an open mind among them, but not one of them works in the NHS. Indeed, not one of them is known to use the NHS. This is not merely a closed review; it is a hermetically sealed review.
My colleagues and I have tabled more than 50 parliamentary questions about the review since it was formed, and we are none the wiser now than when we started. Our attempts to ascertain the remit have been met with the formula that it is wide-ranging and fundamental. Publication of the evidence has been refused on the ground that some of it may have been confidential. It is not said that it was confidential. Instead it is said that it may have been confidential. We have been refused a list of those who submitted evidence on the ground that it is impossible for Ministers to distinguish between those who formally submitted evidence and those who just popped into the post general advice which Ministers found came in handy.
I put to the Secretary of State a request that, if met, will help to persuade us that a genuine review is taking place, not an exercise in party politics.
If the NHS was in the state of crisis that was regularly claimed by Labour Members and the media during the period of hysteria earlier this year, was not that an indictment of all those responsible within the Health Service for managing it, they being unable to make suggestions for reforms to improve it? To invite them to contribute to a meaningful review would be to commit a mistake which has been made before, which is to ask the producers effectively to review their own production.
I am delighted that the hon. Gentleman is in his place for the debate. We look forward to his contribution to it. Only a fortnight ago Worcester district health authority resolved permanently to close 25 beds. I have no doubt that that will be presented to us as not being an example of crisis in the NHS. I remember a succession of Health Service employees who went to Downing street and then to the Secretary of State to voice their constructive views on the future of the Health Service. I remember also that not a blind bit of notice was taken of any of them.
The origins of the review were a constitutional novelty. It was announced by David Dimbleby on television, not in a ministerial statement in this place. But let us look forward to the conclusion of the review. Will the Secretary of State give the House an undertaking that when the sub-committee has ended its labours and has arrived at its prescription for the NHS he will do the House the courtesy of announcing that news first in Parliament and not, as it has been widely suggested, from the rostrum at the Conservative party conference? I warn the right hon. Gentleman that if he chooses the second course he will convince every health worker that the review is part of an exercise to improve the image of the Tory party and not the quality of the NHS.
There has been a remarkable and fascinating shift in ministerial comments on the NHS review over the period of the review. Initially, we were told that the review would lead to a fundamental rethink. The Secretary of State, in addressing that well-known fixture in the medical calendar, the annual dinner of the Aldershot Conservative Association, said:
The impact on the nation's health could be as dramatic as the discovery of penicillin.
He said also that he was looking at any and every idea. How did the ideas tumble out? In a succession of background briefings we heard about opting out, health stamps, vouchers and health maintenance organisations. That was in February. In the past month the Lobby briefings about everything being up for grabs have dried up. Last month, the Secretary of State told us that there will be no big bang in the NHS. The buzz phrase now is that the result of the review will be evolutionary, not revolutionary.
I hate to destroy a good story with the facts. However, has the hon. Gentleman read the public expenditure White Paper, which was published in January 1988, which was after the review was announced and before the various speeches of my right hon. Friend the Secretary of State for Social Services? The White Paper stated:
The Government remain committed to the principle that the NHS should be financed largely from taxation.
The "largely" started to disappear. I shall come to that.
Why has there been a retreat? The retreat is quite easy to explain. The polling data for the review have been telling the members of the review team exactly what they tell anyone else after the public have been consulted, that is, that the British public are overwhelmingly attached to the Health Service. That was admitted the other month by the Secretary of State's most junior Minister, the Under-Secretary of State for Health and Social Security, the hon. Member for Derbyshire, South (Mrs. Currie). The hon. Lady said:
We do seem to have a hang up in Britain that somehow it is wrong to pay for aspects of health care.
The hon. Lady is right: the British public do have that hang up, as she so elegantly expressed it. If I may rephrase what the hon. Lady said, the British people have a deep attachment to the principle that health care should depend on how ill someone is and not on how well off he is. They know that the health care system that best gives effect to that principle is a publicly funded system that is free at the point of use—in other words, the NHS. That is why the Secretary of State is now so anxious to assure us that he fully supports the principle of a universal comprehensive service that is free at the point of use. The Government's amendment deletes those words from the motion, but the Secretary of State keeps assuring us that he supports the meaning of those words.
If the Secretary of State means that, let us hear from him what he proposes to do in the light of his conversion to undo all the measures that he and his predecessors have taken to undermine that principle. Under a Government who are committed to the principle of health care that is free at the point of use, prescription charges have increased by 1,200 per cent. since they took office. It is cheaper now to buy over the counter many of the more common drugs. Under a Government who are committed to a free Health Service, what is happening to eye tests? They are leaving that vital preventive service to be provided at whatever price the market will bear.
There has been privatisation of services in the NHS. The Government, who are committed to a publicly funded and publicly managed Health Service, are punting out to those who measure health care against profits the ancillary services within our hospitals. The Select Committee on Social Services discovered yesterday that 40 per cent. of nurses' time is taken up in performing non-nursing duties because of the shortage of support staff. The Select Committe urged the Government to consider how it might be possible to put more domestic staff into the wards. It would not be necessary for the Government to consider that if they had not shed 70,000 domestic posts in the wards in the process of competitive tendering. Let us hear from the Secretary of State how he squares all the steps to put health care in the market place with a commitment to keeping the NHS out of the market place.
If the members of the sub-committee who are reviewing the NHS have come to the conclusion that the NHS is a fine British institution, let us hear from the Secretary of State how the review will tackle the real challenges of health care in Britain. I ask him, when he speaks, to deal with community care. It is an area of common ground between the occupants of the two Front Benches. There is common ground that the sooner we close the large crumbling institutions that hold the mentally handicapped and the psychiatric ill, the better if will be for those patients.
It is ironic that those who stay the longest in our hospitals are frequently to be found in the oldest buildings, including the old workhouses which were in place a century before the NHS was established. That is why both this Government and the last committed themselves to housing those patients in a more normal environment in the community. However, I must say that, under this Government, care in the community is becoming a cynical deceit, a slogan used to conceal a programme for shedding expenditure on the mentally ill by closing their hospitals and dumping those people on a community that has no facilities to cater for them.
Twenty-five thousand hospital beds for the mentally handicapped have gone under this Government. The appalling truth is that there is no official idea of where those patients are.
No. With great respect to the hon. Member for Suffolk, South (Mr. Yeo), it is open to any hon. Member to cry, "On this point" when they wish to interrupt.
We have an unofficial idea of where those mentally handicapped people have gone.
If I may say so, I regard that as being a most insulting remark to the discharged patients of hospitals for the mentally handicapped. [HON. MEMBERS: "Withdraw".] I echo my hon. Friends' request to the hon. Member to withdraw his remark—not because we are insulted by it but because he insults the patients of the NHS.
I only hope that the relatives of those former patients of hospitals for the mentally handicapped and the people who worked in them will be aware of that exchange and of the contempt that the hon. Member has shown for them, as a butt for his humour, rather than as people who ought to receive health care assistance.
We have an idea of where some of those patients are. They fill our lodging hostels. They can be found sleeping rough in half a dozen places within two miles of this Chamber. They are turning up in our courts. Hon. Members who saw the reports of the disturbances at Risley remand centre will have noted that staff commented that one of the problems was the increasing number of mentally handicapped people being admitted there.
Those local authorities that try to expand their social services to match the need find themselves penalised with rate penalties. Those individuals who give up work to look after a relative find themselves penalised by the latest round of social security cuts, which give no premium to carers. They are now threatened with a poll tax demand for the extra resident in their household.
The Secretary of State is well aware of those problems.
I have clearly said that I shall not give way to the hon. Gentleman. I have already been obliged to give way on four occasions to Conservative Members.
The Secretary of State has seen the problems spelt out in several reports, the latest of which was that of Sir Roy Griffiths, who had the bad taste to point out that community care will work only if we give a much wider role and much greater resources to local authorities. That view was so unpopular in Downing street that Sir Roy's report was smuggled out with no statement being made to the House and with no press conference for the media, and it was published on the day on which Sir Roy was under an anaesthetic in an operating theatre. The Secretary of State may have buried the report, but he cannot bury the issue.
If the Secretary of State takes community care seriously, he must spell out how the Government intend to make a reality of their rhetoric about community care. I am sorry to say that, judging by the leaks trickling out, it does not look as though that is what the review will tackle, but rather that it will fit neatly with the Government's social priorities. Press reports suggest that the only help provided will not be for the poor or for those in need of health care, but will take the form of tax concessions and subsidies in respect of private medical insurance. Not many of the mentally handicapped will pick much out of that.
The Secretary of State, wearing his social security hat, is fond of advising us that an important aspect of Government policy is to target health. Tax concessions are an odd form of targeting. They target help on the wealthy, who will benefit most because of the higher taxes they pay, and on the healthy, because the private insurance companies claim the right to screen and to reject the unhealthy. I saw that principle defended last week by the managing director of WPA, which is Britain's third largest medical insurance company, on the ground that it enables essentially healthy people to avoid being penalised by unhealthy people. That statement at least has the originality of identifying the healthy as the vulnerable group, to be protected against the unreasonable costs of the unhealthy. The truth is that any sum spent on indirectly subsidising private health insurance will achieve a much larger and more immediate impact on health resources than if it is spent directly on the NHS.
That returns us to the origins of the review, because it was not undertaken because the Government are anxious to set about improving the NHS. Only a fortnight before the Secretary of State announced in a letter to me that there would not be a review of the NHS. The review was born out of panic, as the Government reeled from the publicity last winter about the underfunding crisis in our hospitals. That crisis remains.
Last week Bloomsbury district health authority approved a package of cuts that will shed another 80 beds at University College hospital. The Secretary of State will be aware that he has received an internal report from the DHSS pointing out that, in the last three years alone, London has lost acute beds equivalent to six entire district general hospitals.
I shall not give way. I must proceed with my speech. I have been on my feet for 25 minutes and I am anxious to move to a conclusion.
Those closures have not taken place only in deprived inner city areas. Conservative Members know that they are occurring also in their constituencies. This month, Solihull has announced the closure of 37 beds, and Yarmouth proposes to close 60 beds on 17 July unless it receives a cheque in the post by then.
You have invited us to keep our remarks as brief as possible, Mr. Speaker, and I am endeavouring to do so. Plainly it puts me in a difficult position when hon. Members unreasonably interrupt. I have already given way to four Conservative Members.
Gloucester district health authority has gone for the whole fist of closing one hospital, two maternity units and two operating theatres. Most piquant of all are the continuing financial pressures in Barnet, which contains the Finchley constituency. Last April, we were assured that one reason why the Government back-pedalled on housing benefits was that the Prime Minister was also a constituency MP, and as such had been experiencing some difficulty—as had her Back Benchers—in answering awkward letters.
Therefore, I hope that the right hon. Lady read the letter in the Hendon Times from the local obstetric consultant, pointing out that the closure of the Victoria maternity hospital in Barnet had reduced maternity services there to crisis point. He wrote:
It would be unfortunate if the Barnet public were deceived into believing that all is well with the NHS … Only a commitment to health care and a readiness to provide resources at all levels will produce a realistic remedy.
That must be the test of the review. Having quietly buried all the loopy ideas for alternative funding, the Secretary of State is left with no alibi. If there are to be adequate resources, he must supply them. Without them, he will be left presiding over the steady erosion of the NHS.
No, I shall not give way.
I conclude with a striking example of how far that erosion has gone. Today, on the 40th anniversary of the NHS, a pensioner in Birmingham will be entering the Nuffield hospital for a hip operation donated by the magazine Retirement World as part of a promotion drive in which it is paying for an operation to a lucky reader. The company, with no hint of irony over the date, has described the operation as the country's first sponsored surgery.
I have seen too many patients in pain and frustration awaiting a hip operation not to understand the relief, even the gratitude, that that pensioner will feel now that her waiting time is over. But I find it wholly repugnant that she should depend for her operation on a company intent on a sales drive. The fact that a Minister has welcomed that operation makes a mockery of the Government's commitment to a universal Health Service free at the point of use.
I invite all hon. Members, some of whom may be hiding on the Conservative Back Benches, some of whom may well be genuine in their commitment to the principle of a free Health Service, those who share my sense of repugnance at that commercialised operation, to vote with the Opposition tonight to reaffirm those principles on which the NHS was founded and to call for the resources to make it a reality.
I beg to move to leave out from "House" to the end of the Question and to add instead thereof:
'warmly congratulates present and past staff of the National Health Service on forty years service to the public; recognises the achievement of Her Majesty's Government, firmly based on a strong economy, in devoting record resources to the Service to enable both hospitals and community services to provide more care than ever before; and welcomes the current review to ensure that the Service is even better in the years ahead.'
Before I start my main points, I want to illustrate to the House the bizarre nature of the last point that the hon. Member for Livingston (Mr. Cook) has just made. I have never doubted his passion and his commitment, as I have never doubted that on both sides of the House, to patient care. The hon. Gentleman did me the good fortune to use the same illustration in a speech that he made on 28 June. Therefore, it might be useful if I remind the House that, quite apart from the one decent pensioner, to whom he rightly drew attention, who is having a hip joint operation today, there are now 14,000 extra such operations per year—40 per day—compared with when Labour left office, care of the NHS. If Opposition Members are so purblind about their interest in patients that they decide not to welcome additional funds for an additional operation, they are interested only in politics, not patients.
Let me start by saying that the anniversary—[Interruption.] I have used the NHS all my life. I have also, unlike some Opposition Members, found it sensible, since I am lucky enough to have sufficient money as a consequence of the income that I now have, to supplement that health care.
All anniversaries are important, especially the 40th. The 40th anniversary is an unusual opportunity, as those who pass through it know. It is a time not only for congratulation but for reflection. I hope that the House will give a subject as important as the NHS the benefit of the quiet sensible reflection that it merits.
I start—I am sure that the hon. Member for Livingston will join me—by congratulating all the staff, not just those who are currently in the NHS, but those who have served the service for the past 40 years. They have enormous achievements to their credit: achievements that merit congratulation from all of us. Not only have enormous achievements been made, but throughout the joint stewardship of both major parties represented in the House—a stewardship that means that for 26 out of the 40 years a Conservative Government have sought, as the majority partner in that stewardship, to sustain the NHS.—[Interruption.] If interruptions from a sedentary position continue, I shall have to take a little longer, Mr. Speaker, than you would like me to and draw hon. Members' attention to the kind of press coverage that surrounded the 30th anniversary of the NHS in 1978, when the British Medical Association could not even sign a congratulatory note. However, I shall not be trapped into doing that.
In the 40 years that we are talking about there has been a consistent commitment to the initial underlying aim that access should not be dependent on means. I find it bizarre that Opposition Members, including the hon. Member for Livingston, have the temerity constantly to attempt to rewrite history. Therefore, I thought that it might be helpful if I brought before the House again the White Paper presented to the House in February 1944. That was a White Paper of a coalition, not a Conservative, Government. It started with a basic endorsement that has been unchallenged by both major parties in the House—[Interruption.] The hon. Gentleman has obviously not studied the issue as carefully as he might.
Let me remind the House what was said on that occasion. The first paragraph of the White Paper says:
The Government have announced that they intend to establish a comprehensive health service for everybody in this country. They want to ensure that in future every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these"—[Interruption.] It is interesting to note at what point in a serious debate the sans-culottes on the Opposition Benches decide to intervene. I shall try to continue—
shall not depend on whether they can pay for them".
I shall continue by reminding people of the amendment to the motion debated in the House on 30 April 1946 in the name of Mr. Churchill and certain other hon. Members. It started by saying—[Interruption.] It is extraordinary how, as soon as one starts to remind people of the truth, the Opposition simply are not interested. It started by saying:
That this House, while wishing to establish a comprehensive health service"—
what was debated at the time was not the basic aim: that has never been in doubt and is not in doubt—
with access to it free of the ability to pay
that is not in doubt and will not be in doubt while the Government remain in office.
However, the degree to which we can effectively deliver that goal should always be constantly under examination, whatever party is in office.
Before I look at the position today and try to relate the relative records of the Opposition and the Government, I want briefly to review one or two aspects of the past 40 years as it is the 40th anniversary.
I accept, and we all should., that since 1948 there have been major and phenomenal achievements in the health of our country and in what the NHS can offer. Since 1948 there have been extraordinary changes in the kind of diseases that then dominated debates in the House. TB, diptheria and polio, all key issues at the time, have now been virtually wiped out. It is extraordinary to think that in 1948 alone, when the Health Service began, there were 48,000 deaths from TB and only 145 deaths last year. In those years, there were about 18,000 cases of polio a year. Happily, last year there were only three or four cases.
The change in the character of the procedures that the NHS can undertake have been equally radical. In 1948 there were no hip or knee replacements, no coronary artery bypasses and no heart or heart-lung transplants. Yet as recently as 1986, the latest full year for which we have figures, there were 44,000 hip replacements, 12,000 coronary artery bypasses, 243 heart transplants and 72 heart-lung transplants. That illustrates the extraordinary nature of the change that has occurred in the NHS.
I am grateful to the Minister for giving way. In his historic summary he explained to the nation why, at a time of war and a coalition Government, the Conservatives were supporting a National Health Service. Since it is the anniversary of 1948, a year when there were 48,000 deaths from diptheria and 18,000 cases of polio, will he explain why the Conservative party voted against the legislation to establish the National Health Service?
As I have said already, the Conservative party agreed entirely with a comprehensive National Health Service. It tabled a reasoned amendment that disagreed with two features of the then proposal, one of which was utterly changed before 1948—the method of paying salaries to GPs. Opposition Members do not seem to have very much knowledge of their own party's history, let alone that of the Government. There have been an enormous number of changes not only in the character of operations, but in number of patients treated.
The second feature was the way in which it was proposed that the charity and local authority hospitals were to be taken over by the then National Health Service. It was the means that were in debate, not the aim, the thrust or the concept of the National Health Service.
In 1948, 2·8 million patients were treated by the National Health Service. By 1986, that number had increased massively and 6·5 million patients were treated in our hospitals—an astonishing change in 40 years.
As Opposition Members do not appreciate my point, I should stress that I am not claiming that that is a record of this Government or only of previous successive Tory Governments. It is a record of both sides of the House when in office during a 40-year period. I shall illustrate that with some examples of the most significant changes that have occurred in the Health Service under the joint stewardship of the past 40 years.
Which party began the largest ever NHS hospital-building programme in the 1960s? It was not the Labour party. In 1962 the Conservative Government initiated the huge hospital-building programme. Equally, touching on a point made by the hon. Member for Livingston, which party started the critical move away from long-stay institutions to community care? Again, it was not the Labour party; it was the Conservative party in 1961 under the then Minister of Health Mr. Enoch Powell. Which party gave the biggest-ever boost to private hospitals in this country? It was not the Conservative party; it was the Labour party, with its vendetta against NHS pay beds in the 1970s. [HON. MEMBERS: "Nonsense".] I hear suggestions of nonsense from the Opposition. Hon. Members should listen to the answer.
In The Health Service Journal of 30 June, the adviser to three Secretaries of State for Health and Social Security, Professor Brian Abel-Smith, said:
The actual effect was to stimulate the largest growth of private hospitals since the NHS began.
That was a triumph for the Labour party. Which party introduced charges into the NHS? Again, it was not the Conservative party; it was the Labour party in 1951 facing its then spending crisis. As Opposition Members know, the Labour Government did not want to introduce such charges. They did so in the face of their economic crisis, as they did in 1976. That reminds me of the crucial point that brings our debates up to date.
Although I am reticent to involve myself in a dispute between the two major parties, will the Secretary of State tell us of the Government's commitment to the Griffiths report, which is an agenda for action, which has widespread support? Or is there to be a continuation of the development of private nursing homes for the elderly, without adequate training or assessment of the people employed in those homes?
I am grateful to the hon. Lady for raising the same point as the hon. Member for Livingston. We shall discuss that matter another time.
I stress that I found quite distasteful one point which was raised by the hon. Member for Livingston. I would not normally regard his comments in that light, but when Sir Roy Griffiths unfortunately was taken ill I was under enormous pressure, quite properly, from the House and from outside, to publish the Griffiths report as soon as possible. I thought it proper to do so, although Sir Roy was not able to present the initial publication, because I wanted a period of consultation. We shall be considering the report because, as the hon. Lady rightly said, it is extremely important and we shall bring forward our advice when we are ready to do so.
My crucial point is illustrated quite classically by the problems the Labour party faced when in office when it discovered that one cannot fund good causes such as the NHS from tea and sympathy; one cannot fund the NHS on rhetoric. It needs resources. If there is anything that has amazed me about the recent debates, and if there is anything that I find extraordinary, it is the sheer temerity of the Opposition in trying to re-write history in regard to the resources of the National Health Service. I simply cannot believe the nature of this debate. The Labour party's record was one of its more appalling records on any single issue. I accept entirely that the Labour party would not have liked to have been as incompetent as it was when in office and did not wish to make such a radical reduction in the resources which it was able to supply. It is extraordinary that Opposition Members can associate themselves with an issue, when in office they chose to reduce the percentage of GDP they committed to the NHS from 5 per cent. to 4·7 per cent.
Contrast that with our own record. As a consequence of our extraordinary economic success, we have been able massively and rightly to increase the resources to the NHS. These are not things that the Opposition like to hear, but we have been able to increase the resources by 39 per cent. in real terms. More than that, unlike the Labour party which chose to reduce the percentage of expenditure as a percentage of GDP, we have taken it back from 4·7 per cent. to 5·4 per cent. Many may argue that the NHS needs more resources, but the contrast in the two records is unbelievable, and the temerity of the Opposition is extraordinary. Not only have we been able to increase massively the resources, but we have initiated other major changes of great significance in the past decade.
For a major part of his speech the hon. Member for Livingston (Mr. Cook) concentrated on the number of beds lost. He has a strange preoccupation with beds. What about the patients for a change? Will my right hon. Friend tell the House that we have increased the number of patients treated, both in-patients and out-patients—and that is more important than the number of beds.
My hon. Friend is exactly right. I did not wish to delay the House unnecessarily, but I happen to have the figures to hand. It is very interesting, as the political period from 1966 to 1986 covers both parties in office. During that time the beds available declined from 434,000 to 316,000. During the same time the number of in-patients treated rose from 4·5 million to 6·5 million. That clearly demonstrates the point that my hon. Friend the Member for Richmond and Barnes (Mr. Hanley) rightly sought to make.
I was trying to illustrate the fact that enormous additional resources have been put into the NHS, which have allowed us to look after more patients.
There have been many other important changes in the past nine years. Since 1984 we have introduced a much more dynamic management style with a general management system that is recognised and appreciated on both sides of the House. We have introduced an information revolution with Koerner reforms and performance indicators. That has been a spur to much greater efficiency. The cost improvement programme is showing significant additional moneys going into the NHS. Since 1984–85 and by the end of this year we shall have put about £750 million in cash into the NHS. Competitive tendering has sharpened up management and staff and has saved £106 million, which has been used for patient care.
Perhaps the biggest and most welcome of the recent changes are those affecting nurses. The Labour party and others have talked a great deal about nurses. In comparison with the Labour party's cut in real terms in nurses' pay we first created a review body to reflect their professional status and commitment. Secondly—hon. Members on both sides have welcomed this—with the implementation of this year's pay award and its funding we have added over 15 per cent. to the pay bill this year and improved nurses' pay in real terms by 43 per cent. since 1979. We have now put nurses' pay at its highest level ever in real and cash terms. Because of our economic success we have been able to do other things. We have backed management and staff in the introduction of a radical new grading structure to reward extra skills and responsibilities and to help keep staff at the bedside. We have agreed in principle to something that has been dreamed of and debated in the Health Service for generations. We have agreed in principle to the educational reforms in nursing—Project 2000.
Since 1979 all those changes in management, information and nursing have not been easy. We have not shirked them. We have laid the foundations for the future but, as the hon. Member for Livingston said, there is still a lot to do. I have looked briefly at some of the history and at the current position.
Is my right hon. Friend aware that the National Audit Office reported recently that £300 million could be saved by the more efficient use of land and buildings, enough to employ an extra 30,000 nurses? Does that not illustrate the scope that is still available for value for money savings in the NHS?
I was about to come to those points but m y hon. Friend is absolutely right. There is scope for improvement.
The hon. Member for Livingston asked about the future. Further measures will be taken and they will be linked to the outcome of the present review. Unlike the hon. Member for Livingston, I have been interested in what the Financial Times today referred to as the "flood" of papers that have come forward. They are not papers from the think tanks that the hon. Gentleman seems to decry but from all parts of the Health Service. There are papers that have been published and papers that are being seen and debated. There are papers from the Institute of Health Services Management, papers from the National Association of Health Authorities and papers from the King's Fund which will be published this week. They all argue rationally, although with different views, for the need to concentrate on change to improve the system.
I have read with care the hon. Member for Livingston's speech of 28 June. On page 21 I was interested to see that we shall not have the benefit of the Labour party's internal review, which I understand will be published in the autumn. It is an internal review that he suggests will coincide with the Government's. I hope that we shall see that review when it is published, unlike the review on social security, which has never seen the light of day.
The Labour party has made it clear that the one thing it wishes to see for the NHS is more cash. We are back to the same old oft-repeated cry. I genuinely like the hon. Member for Livingston and I can only hope, for my party's prospects in office, that his right hon. Friend the Leader of the Labour party will give as much credence to his views on health as he has to his views on defence. It will be a great help to my party.
On the matter of the Government's review, no decisions have yet been taken. The hon. Member for Livingston knows that. However, the outlines of some of the areas of major interest——
The outlines of the major areas of public interest are becoming clear. The first area, on which I would expect there to be common ground across the Floor of the House, is that we all recognise that we must strengthen consumer power and choice. That will require much more information about the services and offers and, for example, about the choice of doctors.—[interruption.] I can take as much time as the House would like. I would like to continue if possible. There are people outside the House who are interested in this subject and understand, as do one or two Opposition Members, including the hon. Member for Livingston, the seriousness and importance of the debate.
As opposed to the Government's clear view about the need to improve the role of consumers, I was delighted to see that the present deputy leader of the Labour party, as was shown in Glasgow this morning according to the tapes, is following similar lines in his arguments about user-friendly blueprints. It is an area in which we shall be arguing on similar lines. We both want to see much greater emphasis on the quality of care in both the personal and medical sense. We have to pursue the growth of peer review and clinical audit.
We have to look at ways in which we can involve the doctors much more fully in the management process. Alongside their clinical freedom, they must be able to participate in the overall decisions about priority resources.—[Interruption.] The hon. Member for Livingston is nodding because he had the patience to listen to the end of my sentence as well as the beginning. That is obviously difficult for other Opposition Members.
The hon. Member for Livingston and others will be as interested in and as committed to the serious experiments at places such as Guy's hospital in the resource management initiative. We are seeing great improvements in patient care as a consequence of greater involvement in resource management by the doctors.
There may not be such a close agreement about our belief that we need to break down the barriers between private and public provision. There are many examples of that. The National Health Service contracts could be with private hospitals and vice versa. We have to use much more private capital to help fund joint facilities of the bioplan examples. In my diligent reading of the hon. Member for Livingston's speech I was fascinated to see on page 8 that he finds quite acceptable the suggestions of the Institute of Health Services Management about charging for a la carte as opposed to table d'hote. However, he did make other references to that.
Another area in which we are on reasonably common ground, although the semantics of the debate have become difficult, is the belief that we need to create a better mechanism to recognise the efficient and stimulate the inefficient. As the Select Committee on Social Services rightly said, we have a perverse system where the most efficient and the best hospitals in many ways are in difficulty over resources as a consequence. Many words are used to describe that. The quaint phrase used in the Health Service is "cross-boundary flows". The hon. Member for Livingston's speech contained serious references to that.
There are many areas beyond those I have mentioned where, from the review, I expect to see rational and sensible progress made. The 1944 White Paper laid the foundations for the NHS. It said:
Reform in this field is not a matter of making good what is bad, but of making better what is good already".
That was the vision that fired the then Conservative Minister responsible for health, who happened to
represent part of Croydon. It is the same vision that fires the Government today. But we must not confuse ends with means. We must stay true to the fundamental principle of the Health Service while equipping it for the fundamental challenges of the next century. That principle—this is a very critical point—is that access to good quality health care should be determined by medical need and not by ability to pay. This was of crucial significance at the creation of the NHS and I believe that it should and will remain the key to its future. But an institution that fails to adapt to new situations and new demands will never satisfy the hopes placed in it.
We must never forget that it is those on the Opposition Benches who pose the greatest threat to our Health Service. They are a threat because they could not produce the resources; they are a threat because they would not keep faith with the staff; and they are a threat because they would always duck the decisions necessary to ensure that the next 40 years of the NHS are as successful as the first 40 years. They may want to shirk their duty to the people of this country. We shall not. We shall face up to our responsibilities and in doing so enable the Health Service and all who work in it to look to the future with confidence.
I am glad to have the opportunity to speak immediately after the Minister as I believe that I am the only Member who was here when the 1946 debate took place and the 1948 measure was carried into effect.
But before I come to the speech of the right hon. Gentleman—and I certainly want to deal with many of the matters that he has raised—I must congratulate my hon. Friend the Member for Livingston (Mr. Cook) and, indeed, the leader of my party, my right hon. Friend the Member for Islwyn (Mr. Kinnock), because it is they principally, with backing from the whole Labour movement, who have kept the National Health Service at the front of the political debate in this country over many months and years.
During the general election, my right hon. Friend the Member for Islwyn time and again returned to this theme. If he had been heeded then, and if the Government had been prepared to act on the appeals that he and my hon. Friend the Member for Livingston were making, we could have had the kind of debate that the Minister said that we should have. If the Government had provided the £2 billion extra money for the Health Service, I believe that the debate would have been much more profitable and useful, because the immediate strain could have been relieved. At some stage, if the Government are to do their duty, they will have to provide that kind of increase to the present funding of the NHS. That will be conceding what the Labour leadership and the Labour party have been demanding throughout.
I have been on my feet for only a minute or two. I would prefer to get on.
I come now to the Secretary of State. I listened to his speech on the radio the other day about the origins of the National Health Service and I listened even more carefully to him today. He must find some difficulty in pronouncing the name "Aneurin Bevan". Perhaps he has some speech impediment, as Aneurin Bevan himself had, because he finds very great difficulty, when talking about the founding of the NHS, in ever mentioning Aneurin Bevan's name. That seems to me to be a most ungracious way for the right hon. Gentleman to talk, particularly when he gives such a misleading record of what happened.
I was in the House when the Bill was introduced and carried through by Aneurin Bevan in the teeth of opposition from the Conservative party. The Tories voted against the Bill not only on Second Reading—the right hon. Gentleman quoted a part of the motion, but I could quote it all because I have it here—but on Third Reading,which, in those days at least, was a strange thing for a party to do unless it was bitterly and absolutely opposed to the principle of a measure. Then the Conservatives were given a third opportunity by Aneurin Bevan, a few weeks before the introduction of the NHS—when the British Medical Association said that it would not co-operate—to say whether they would give some support to the introduction of the service.
In the face of all that, the Secretary of State should not waste time rewriting history. He should devote himself more to the things for which he has such a gift—presenting us with his half-cooked theories and his cooked figures. He is much better at that than at rewriting history.
When I was writing about these matters I interviewed all the leaders of the profession who had negotiated with Aneurin Bevan at the time of the introduction of the scheme. Not one failed to acknowledge the unique part that Aneurin Bevan played in shaping the service and bringing it into operation. I suggest that the Government should listen to what they had to say. So concerned was I that the credit, honour and glory for having introduced the National Health Service should not be taken away from Aneurin Bevan and the Labour party, which carried it through, that I wrote many years ago that it was possible that somebody would come forward and rewrite history, and that the archives would be ransacked to produce the forgotten name of Sir Henry Willink to mesmerise the House on such an occasion as this. Now we are told that he was the great author of the Health Service.
I prophesied this earlier and perhaps I may be permitted to quote myself. I said:
Future generations may learn that Aneurin Bevan did not make the National Health Service; he inherited it from that much underrated social visionary Sir Henry Willink. After all, did not Jesuit scholars in the nineteenth century teach children in their schools that Napoleon was a general employed by Louis XVII?
The right hon. Gentleman is even more successful in his attempts to erase the name of Aneurin Bevan from the history books, like some Stalinite censor trying to erase the name of Trotsky.
I do not know if I can be of any help at all to the right hon. Gentleman. I respect history. The right hon. Gentleman is quite right; I have sought throughout the past year and in this debate to acknowledge both sides of the issue. I would not for one moment deny the very critical, key role of Nye Bevan in 1946. I left a lot of other names out. I was trying—I know that the right hon. Gentleman will recognise this—to differentiate between the concept of a comprehensive national health service, free at the point of delivery to those who cannot afford to pay, which I ask him to admit was acknowledged by the Opposition at the time, and the method of delivering that dream.
The right hon. Gentleman must be congratulated. I have extracted the name of Aneurin Bevan from him. It seemed to me to be quite a fierce and surgical operation. It is a pity that, having got the name out, he should have spoilt it by referring to what happened in the Churchill Cabinet. I have read quite a lot about these matters too and I can assure the right hon. Gentleman that Churchill had very little interest in the National Health Service. The right hon. Gentleman implied on the radio the other day that everything was decided by Churchill. Perhaps in some Cabinets things do operate like that; perhaps the right hon. Gentleman thought that it must have come from the Prime Minister because that is where these things come from now. That is why we have some qualifications about the committee that he talked about. I am told that the right hon. Gentleman is a member, although I am not quite sure what his qualifications are.
I should be quite happy to quote the amendments which Sir Winston Churchill, leading his party—not all its members willingly—put down against the introduction of the National Health Service. That distortion cannot be permitted. On both Second and Third Reading an amendment was put down saying that the Conservatives would like a national health service but did not want it introduced at that time and would vote against it. If their votes had been effective, we should not be celebrating the introduction of the National Health Service this year. It would not have been introduced in 1948: the whole proposition would have been wrecked. Indeed. many people in the medical profession at the time thought that it should be wrecked. They were prophesying until two or three days before its introduction that it would be wrecked.
Those views were shared by a considerable number of Conservative Members, with Sir Winston Churchill backing them, because Churchill was more interested in wrecking and ruining the career of Aneurin Bevan than in the introduction of the National Health Service. I am sorry to say that attempts by a section of the medical profession to wreck the introduction of the measure were backed by all the raucous Conservative Members. I can remember that, and nobody can contest it because I am the only one who remains.
Now that the Secretary of State can pronounce the name of Aneurin Bevan, perhaps he will be able to learn a little more from him. I wonder that he dares to talk to us about what has happened to the nurses. One of the first things that Aneurin Bevan did—even before he decided on the framework for the Health Service—was to introduce a charter for the nurses. It did not go all that far. It was primitive compared with the legitimate demands of the nurses and the nursing profession today. A matter of months before he had decided on a framework for the National Health Service he had concluded that we needed a much better deal for the nurses. He talked to the nurses and the charter was the product of those discussions.
The Secretary of State talked about his dealings with the nurses and about the acceptance of the RCN's Project 2000. I am glad that he intends to accept it. He must provide all the money for that and for the comparable improvements that need to be made throughout the nursing profession if the job is to be done properly.
If the right hon. Gentleman thinks that the last wage settlement has dealt with all the nurses' problems, he is making a big mistake. I have talked to nurses in my constituency and around Wales, and plenty of them come here in deputations and on lobbies. Morale among the nurses is still very low indeed and much more needs to be done to put it right. If the Secretary of State wants an illustration of what needs to be done, he should read the document that he was applauding only a few minutes ago. It reveals what has really happened in the Health Service, which has so far been concealed by some of the phoney figures that his master, or his mistress, the Prime Minister, flaunts before the House. Many of those figures deserve to be subjected to fierce scrutiny.
The right hon. Gentleman talks about what the last Labour Government did but says nothing about the Halsbury report, which was much the biggest inquiry into the nurses' profession and their wages. The findings of that report were put into effect and backdated by that Government. When it was discovered that the value of the high awards recommended in the Halsbury report was being lost because of the huge inflation, we had to do something about it. The Clegg commission and other arrangements were put in place to ensure that nurses' salaries were increased. They were not increased enough, but they were increased. The present Government try to claim credit.
If the Secretary of State wants a few facts from the nurses——
No. I am dealing with the Secretary of State.
The Secretary of State referred to Project 2000. I hope that he will listen to the words at the end of the briefing which provide the answer to what is happening to nursing training. When nurses come to see me, they often refer to their training. They used to be encouraged to take part in study circles and courses to keep up with their profession. That was a fine aspiration in the National Health Service. Over the past few years, the pressures and the absence of money have prevented nurses from embarking on those study courses as they did in the past. Until the Secretary of State restores such facilities in the Health Service, he had better not boast about what the Government have done.
The contents of a reply given by the Minister for Health about nursing training appear in the nurses' report, which says:
spending on nursing education has gone down in real terms by 18 per cent. since 1979. And over 4 per cent. of nurse teaching posts are now vacant for three months or longer, but no further information is said to be available. Numbers entering nurse training dropped from 33,370 in 1979 to 22,825 in 1987.
Those figures are part of the record of which the Secretary of State boasted. Those are the figures that we rarely hear from the Prime Minister when she parades her statistics at Question Time.
The Secretary of State could take another lesson from Aneurin Bevan—the lesson of talking to those who do the main jobs throughout the service. The right hon. Gentleman ought to be doing that instead of conducting a phoney inquiry from No. 10 Downing street. If he really has the National Health Service at heart, he ought also to talk to some of the people at the top—the presidents of the royal colleges. That is what Aneurin Bevan did. One reason why the Health Service introduced by Aneurin Bevan and the Labour Government was so different from the one that Sir Henry Willink or Sir Winston Churchill favoured was that it introduced the idea of engaging consultants all over the country.
Before 1945, most of the consultants were congregated in the great teaching hospitals in London. The idea of people throughout the country having access to consultants did not exist before 1945. How was it put into effect? If the Secretary of State wants to know the facts, they are all recorded, not only in my books but in the reports of Lord Moran who was the president of the Royal College of Physicians. He carried out some of the main negotiations with Aneurin Bevan. They asked, "How will we spread the consultants throughout the country so that people in Wales and Scotland have access to them, rather than just a few in London?"
They decided that that could be done only by having a nationalised service and by taking all the hospitals into that one service. Lord Moran described how that happened. The Secretary of State does not seem to know anything about that aspect of the National Health Service, which is one of its most important aspects. It is partly because he knows so little about it that he was apparently prepared to offend and insult the presidents of the royal colleges a few months ago. The presidents of the royal colleges wanted to put their case—[Interruption.] The hon. Member for Wycombe (Mr. Whitney) should learn to keep quiet occasionally; it is all part of the way of this House. The Secretary of State should have the courtesy and intelligence to renew those conversations with the presidents of the royal colleges. That is the second thing that the Government should be doing.
There is a third way in which the Secretary of State can learn from what Aneurin Bevan had to say. Aneurin Bevan had to fight the Treasury to get a National Health Service. It was not easy and there were many objections from the Treasury, just as there are now. Aneurin Bevan went to the Treasury and argued his case. He put his case to the House. No one ever believed more strongly in the supremacy of the House. If the Secretary of State had had the intelligence to listen eight and 12 months ago when the case was being put by my right hon. and hon. Friends the Government could have avoided some of the problems.
Ministers should ask Health Service managers how they have been treated by the Government in terms of money. The Government failed to make good the full wage awards one year and said that the money would be taken out of the rest of the finances of the Health Service. They then said that they would not perform that filthy trick next year, but they have not made good the amounts that they took from the Health Service. The Government's refusal to fund wage awards fully has gone on year after year in many parts of the country and is one of the main reasons for the cut in the amounts available for work in the NHS. The Secretary of State should listen to what other people say.
My hon. Friend the Member for Livingston has exposed the shoddy nature of the so-called inquiry. Why should we believe that a secret Cabinet committee presided over by the Prime Minister is the way to deal with these matters? The right hon. Lady will produce an avalanche of statistics, although we have heard most before, in an attempt to suggest that everything is fine, whereas people can see that it is not. That is all that the Prime Minister is capable of doing. She does not have the imagination, or perhaps the courage, to say to the House that she was wrong in denying the Health Service that £2 billion. I do not believe that there is a Minister among those selected to be on the Cabinet committee who has the nerve to stand up to the right hon. Lady.
Why should the House have any faith in such a committee? All the worst Government errors, many of which have had grievous consequences for our people, have been the result of such committees presided over by the Prime Minister. They are remote from any critical attitude that may prevail—it may be optimistic to think that it does prevail—in a full Cabinet discussion. The most recent example, which has appalling consequences for this country's honour, is the way in which tens of thousands of the poorest people are being persecuted through cuts in housing benefits and alterations in their social security benefits. Many of the poorest people have had their lives shattered. They are persecuted because of the Government's pursuit of small amounts of money—this from a Government who, a few months before, gave away billions of pounds to the richest people. I have no doubt that that was all done through a committee presided over by the Prime Minister.
The famous Westland case perhaps involved a one-man, or one-woman, committee, but perhaps we should not inquire too closely lest it implicate others. As for the Falklands, no Cabinet committee ever discussed the evidence that Lord Carrington from the Foreign Office wished to present to the Cabinet. Everything was done by committees presided over by the Prime Minister.
In the light of experience over many years and the deductions that can be drawn from the way in which the Minister looks on the Health Service, no one can have any confidence in the outcome of the new committee. Perhaps the committee will send the Secretary of State along to repeat today's speech. We want the £2 billion to be presented to the Health Service so that it can deal with the immediate problems. Then we should restore the NHS with all the imagination and courage that Aneurin Bevan showed 40 years ago.
Part of the House has enjoyed listening to the right hon. Member for Blaenau Gwent (Mr. Foot). As Aneurin Bevan's biographer, the right hon. Gentleman is entitled to say certain things about the past, but when he diagnoses the present and future his arguments become thinner. We must think about what will happen next.
It was particularly odd that the right hon. Gentleman inveighed against the fact that a Cabinet committee would discuss this matter. He implied that there should be a great royal commission and massive amounts of evidence published. My recollection of history, which may be less good than the right hon. Gentleman's, is that when the Labour Government came to power in 1945 they did not set up a royal commission into the proposed structure of the Health Service. They got on with the job of Government, made up their mind, came forward with their proposals. put them to Parliament and, as it happened, carried them, and ever since we have had the Health Service. I see nothing wrong in the Government's approach. My right hon. Friend the Secretary of State will listen to those who make representations. Today's debate gives Parliament a chance to chip in its pennyworth, and I hope that that is how it will be seen.
My right hon. Friend the Secretary of State was right to table an amendment making it clear that we congratulate the staff of the NHS on their 40 years of work. It has always been a difficult job. It is easy for morale to slip. Whatever our complaints about the Health Service, overall there has been a notable record of achievement. As my right hon. Friend made clear, that achievement has taken place largely under Conservative Governments. It is important to remember that we cannot have a good Health Service unless the morale of those who work in it is high, just as there cannot be a good Army regiment unless the soldiers' morale is high. We should not do anything to undermine the morale of the staff, although we must talk about some of the problems and weaknesses in the NHS.
That is true. There were, however, substantial differences from the Conservative approach, which favoured a closer link with local government and the retention of the voluntary hospitals.
One aspect of the structure adopted by Aneurin Bevan that I would question was the decision to make the whole hospital service have a uniform pattern. That may have seemed right at the time, but there are good arguments for saying that we have inherited a system that is too inflexible.
The Government's amendment refers to the review and the need to think hard about what is going on. Few objective observers would deny the importance of doing that. Obviously, we are not looking for change for change's sake. There is no point in making changes unless one is pretty sure that they will result in an improvement. I suspect that, because my right hon. Friend the Secretary of State has thought about these matters, that message has occurred to him often. We must come to grips with the fundamental issue of funding and the weaknesses of the NHS. To what extent are the weaknesses a result of funding and to what extent do they relate to some other factor?
There is no need to stress what has been familiar from the early days of the Health Service—that the open-ended nature of the demand and high costs of new medical developments impose enormous burdens on the Health Service. Whatever system of funding we choose, we cannot get away from that fact. The system will always be expensive and, to a great extent, the argument is based on whether it is better to produce the necessary money from taxation or constantly to seek new forms of revenue.
Although there has been a substantial improvement, I do not think that the present level of spending will last for all time. To be realistic, before long we shall have to think again about whether there must be an additional injection. The Treasury may not like that, but it will be hard to escape, given the background facts to which I have referred.
The funding problem is only a part of what we must face. There are other weaknesses, too. One is that the structure of the Health Service, in essence, was too monopolistic. That has proved a real weakness. In some ways the service has been too provider-oriented; I apply that to consultants at the higher end of the pile and porters and others at the lower end. For a long time the service was too much in the grip of those who were providing it. As I have stressed, they did many good things, but we must think hard about this aspect. What seems to come across from people who go to hospital—my constituents and friends, for instance—is that too often there is muddle at the point at which one comes into contact with the service, either in the ward or in the way in which a person is received into casualty or hospital reception. It is distressing to hear about people having to sit, apparently forgotten, in waiting rooms. Although much of what happens in hospital is splendid, too often one gets the impression that everything is such a rush that no one knows what is going on. That must be tackled. Fundamentally, it is not a matter of resources.
Of course, it is more difficult now. A greatly increased throughput of patients means that the management of a ward is much more difficult than it was in the days when patients were in for a long time and the process was more leisurely. The administration of drugs is another complication. So there are reasons for the apparently hectic climate, but those who run the service must get to grips with the problem. It is causing much disappointment—or worse.
Patients have responsibilities, too. It is distressing to read of the number of occasions when they fail to turn up for appointments. There was a long fight to achieve appointment services, and rightly so. But the statistics are appalling. I have been worried by a case of which I have heard. In the drive to cut waiting lists, and with the additional money that the Government have provided for that purpose, it has proved remarkably difficult to reduce their length because patients who are allegedly part of the lists somehow vanish into thin air. They do not seem to exist, even though the additional facilities are provided, and I can give chapter and verse on that if necessary.
What should we be doing about the present system in a more fundamental sense? The introduction of general managers has been for the good. The fashon for something called consensus management of a decade or so ago was a disaster. It is not the way to manage any organisation. At the national level, there is not much mileage in the arguments for an independent corporation which are often put forward—the attempt to find a Health Service management board that will operate like an industrial board. That will get nowhere for the simple reason that we in this Chamber do not want it. We shall not allow the job of management to be handed over to a management board in such a way that we cannot take up our constituency cases. We shall insist on defending our cottage hospitals, and so on. We shall insist that my right hon. Friend and his Ministers answer all our questions in debates like this, in Adjournment debates and so on. As long as that is so, it is pie in the sky to believe that we can have the sort of true management that is to be found in industry.
I do not believe that the insurance-based approach will provide the solution, either. It has been discussed for years; it has always been the favoured alternative. It is the alternative that other countries have adopted, and some of them are not doing badly with it, but there are certain substantial problems. One is that insurance inately tends to put up costs. Patient and consultant, knowing that they are part of an insurance scheme, have no incentive to keep costs down. There will, therefore, be upward pressure that will be difficult to control.
Then, as we all know, there is a peculiar problem with insurance. It is that a high proportion of the patients of the Health Service are old people who are almost certainly less well off. There is also the psychiatric and chronic cases—exactly the sort of cases from which the insurance companies shy away as fast as they can. Perhaps they will do a little more to try to support such cases. Perhaps it will be possible in the medical insurance schemes to pay more when young for more benefit when old—but that will not really provide the answers that we want.
At the same time, I do not support the idea that we should give tax rebates to those who opt for private insurance. Whether that would be beneficial from the Treasury's angle is a matter of argument. Some of my hon. Friends have argued that it would, but others will say that the loss of revenue will outweigh anything that is likely to be gained by more people moving into the private sector——
Has my right hon. Friend considered a compromise that is an immediate possibility? Tax relief could be offered in the first place to those of retirement age only, on the basis that not only would that provide a specific target group on which the effect could be assessed, and limit the cost to the Treasury, but, importantly, it would offset the increased cost of health care and insurance for that age group, thereby providing an important balancing factor.
I have thought about that. My hon. Friend is right to raise the point. We are faced with the fact that some old people who are insured with the assistance of tax relief will still suffer incurable long-term illness, for which insurance will not provide the answer. The risks of some form of psychiatric illness will still be present, too. So although I see my hon. Friend's point, I do not think it gives the necessary certainty.
Other ideas have been canvassed. One is to convert the national insurance scheme into a national health insurance scheme and transfer pensions and so on to the tax system. That is worth considering, but it does not contain the answers that we seek. It may create greater transparency for health, but the problem will be transferred directly to the pension system, and I am not sure that people will benefit from that.
Although I may seem to have been negative so far, the one area in which I believe there is real scope for significant change is that first opened up by Professor Enthoven, which is generally called the internal market approach. Enthoven is much the best of all who have studied and written on these problems. I only wish that he was based in the United Kingdom and not the United States. I shall not go into the internal market arguments, as my right hon. Friend the Secretary of State knows them well, but they offer the chance of the sort of choice, variety and a little competition that has been lacking in the monolithic structure of the Health Service until now—but they do so in a way that does not land us with the fundamental difficulties that lie in the adoption of insurance as the overall answer.
Does my right hon. Friend agree that Enthoven made his proposals on the assumption that there was not the political courage in this country to effect significant changes in the structure, so the proposals that he made were within a tight parameter?
There is something in that, but one of Enthoven's merits is that he approached the Health Service in a sympathetic way. He did not say that the whole thing was a shambles and we should tear it apart. He made a good judgment of the realities and feelings of the service, for which I respect him. So I align myself with him. The only other thing inherent in what he has to say is that we should think about whether it is possible to do more to separate the management of the hospitals from the general strategic provision of the service.
I am not particularly persuaded by the health maintenance unit arguments in full, but I think that we might be better off if the health authorities were concerned with co-ordination, planning and ensuring that the provision is there, but the management of hospitals was separated. Perhaps we could see again the existence of voluntary hospitals, private hospitals—as we know them—and National Health hospitals as well. We need more diversification, and a greater spread of accountability and responsibility.
It is a difficult job, but an extremely important one. We will get nowhere if we start from the premise of deciding to tear the whole thing apart: the service is far too important for that. If, on the other hand, we simply say that things are fine, we shall have failed our constituents. I believe that, when the Government come up with their answers, they will be able to put forward proposals that make sense and breathe new life into this distinguished service.
The right hon. Member for Blaenau Gwent (Mr. Foot) was right to remind the House of the true history of the National Health Service, and it would be a calumny not to pay tribute to the immense role that Aneurin Bevan played in its creation. As for the 1944 White Paper, it is worth recalling that Winston Churchill tried to delay its publication, and had to be persuaded to publish it by Lord Woolton, the Minister of Reconstruction, on the basis that most of the compromises had been made by Labour Ministers in the coalition Cabinet.
Of course, many parties and people have contributed to the Health Service over the past 40 years. The genius of Aneurin Bevan, however, was that he understood that it was more than just a sickness service: that it was contributing to the unity of the country and to its values. In "In place of fear", he wrote:
Society becomes more wholesome, more serene and spiritually healthier if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves but also their fellows have access, when ill, to the best that medical skill can provide.
It is that wider dimension of the Health Service, which has crossed party political divides, that has made it impossible for the Government to dismantle the structure, the fabric, the values, the morality and the ethical principles of the NHS. What is important about this debate is that it is not a great ideological discussion about the virtues and deficiencies of the Health Service. We all know that there is now no possibility that the Government will break it up. The danger is that of benign neglect. That is why we must look to the future, and grapple with the problem of the financing of the service.
I am one of those who believe that there is no point in putting money into the Health Service until we are certain that the money will go towards providing a better quality of service, higher standards and, above all, the eradication of the substantial waiting lists, which must be one of the biggest deficiencies of the NHS.
I have no doubt, however, that we are all responsible for a serious underfunding of the service. We are now celebrating its 40th anniversary. Twenty years ago we were spending 4 per cent. of our gross national wealth on it, while the United States was spending a little over 5 per cent. Today, we are spending about 6 per cent., with the recently announced increases in nurses' pay and other expenditure, while the United States is spending well over 11·5 per cent. That discrepancy of investment in health care can be paralleled in most other European countries. We have not kept pace with their investment in health care, which is our most serious problem.
The hon. Gentleman asks, "How much money?" Over a period of three years or so, we should be aiming to increase the percentage of our national wealth that we spend on the Health Service by a full 1 to 1·5 per cent. to 7·5 per cent., which will bring us nearer the average figure for Western industrialised democracies.
Even so, I believe that the NHS gives better value for money than any other health service in the world. The trouble is underinvestment. How can that be dealt with? The more that I have studied the Health Service, particularly over the past six months, the more I have become convinced that people in this country must be made more conscious of how much it costs. There is an extraordinary lack of understanding of how much we spend on it. Not many people realise that this year we will pay from our income tax—excluding the national insurance contribution—14p out of 25p in the pound. I would like the service to be transparent, with everyone knowing how much they paid for it.
The more that I considered the matter, the more I rejected moving towards an insurance scheme, for reasons that have already been cited. The service must be funded from taxation. Yet the more that I thought about it, the more convinced I became that we should have a declared, hypothecated health tax. Furthermore, because income tax is a buoyant tax, it would to some extent keep pace with the ever-increasing demographic and technological demands on health care.
Even more important, a specific health tax would allow the Department to operate a health budget. It is very difficult to run such a massive organisation—the largest single employer in Europe—on the basis of Treasury subventions on a month-to-month basis. Treasurers of district health authorities in February this year were living in total apprehension, unable to know whether what would obviously be a substantial pay increase for nursing staff would be funded fully or only in part by the Government. It is an impossible managerial task to run a health service on such grounds. It has also allowed for a very artificial distinction between capital and revenue, and a grossly undercapitalised hospital building programme—which, to be blunt, all of us at various times have used as a manipulator of the economy, cutting back on the construction industry for wider economic reasons.
I come out decisively in favour of a specific health tax, a specific health fund and a considerable freedom from Treasury controls. But how can we meet the other criteria that I have laid down? If more money is to be invested in the Health Service, how can we ensure that it will be wisely spent, and that it will produce a Health Service based on the demands of the consumer rather than putting money into the hands of the providers?
The first problem with which we must grapple is waiting lists. We must give patients the right to move to another health district if they are faced with a long wait. That right must be exercised in conjunction with their GPs, but preferably in a way that will cause the least possible distortion. I also believe that the cost of not providing for such a patient when the waiting list reaches a certain level should be met by the district health authority in which they live. That would be a useful financial discipline. However, if a private health clinic can provide the necessary treatment or operation at no extra cost to the Health Service other than would be the cost of going to another health district, I believe that the patient should have the right to go to such a clinic. Such measures would provide immensely important financial pressures on Health Service managers and consultants to grapple with the resources available within their districts.
To be effective, the family practitioner must be part of the district health authority. The separation of the family practitioner committees from the budget of the district health authorities is a massive mistake: the two must be brought together. It is impossible to bring about even an embryo health maintenance organization—let alone health maintenance attitudes, which are even more important—until the family doctors see themselves in the same financial basket as the hospital consultant. That is particularly important now that the Government are clearly bent on cash-limiting the family practitioner budget. I understand their reasons, but the day that that is done it will be in the interests of the BMA negotiators to put the family practitioners into the wider pool of the Health Service budget, the hospital budget and family medicine.
The advantage of giving the patient the right to seek treatment elsewhere if there is a long waiting list is that——
The hon. Lady will have an opportunity to make her own speech later. I am trying to keep my speech brief.
The advantage of this system is that it is a most significant initial step towards an internal market. An internal market will take time to develop. I agree with the right hon. Member for Aylesbury (Mr. Raison). Alan Enthoven's writings are by far the most important writings on the Health Service. He took as his remit that it was no good coming in as an American academic and transposing American medicine on to the National Health Service. He had to live with the history, traditions and customs of the Health Service, and the love and affection that many people have for its basis. Therefore, he did not try to challenge the ethos of it. He talked about the districts being like small nationalised industries, so that does not raise ideological issues between the two sides of the House. People may be against the internal market for other reasons, but there is no ideological issue to divide us.
Another matter that causes me great concern is AIDS. We are dealing with a pandemic in this country and in the world. The projections are difficult, but we may be facing as many as 25,000 deaths in the year 1992. Some people say that it may be less, perhaps 20,000, but that is still substantial. What are we doing about it? The answer is, not enough. First, we must face this as a public health issue. We have been down this route before and faced other public health hazards of great epidemic proportions—tuberculosis, syphilis, smallpox, yellow fever, cholera and others. Therefore, we have a corpus of knowledge of how to deal with epidemics.
The first and fundamental point is that what is said to a doctor, and what tests are undertaken by doctors, must be completely confidential. That is the hallmark of the system that we have operated. I find odd this reluctance to face the need for routine testing for the HIV virus. We have never asked people whether their blood should be tested by the Wassermann test for syphilis over many decades. We have got to know more about the HIV virus and to be frank about it. Since October 1985, all blood donations have been routinely tested—over 6 million of them. About 92 HIV-positive people were found and only three were not traced and counselled. We must not be afraid of this knowledge. It is difficult to handle when it happens. Doctors have to be able to advise people confidentially about the situation, but the only way to get control of this epidemic in our midst is to use the tried and tested techniques of public health. It must be made clear that this information is confidential. I can understand why certain groups of people, such as homosexuals, are anxious that this will lead to persecution. It must not, and it will not, because it will help us to control this epidemic.
The Government have not taken the drugs problem and the links between drugs and AIDS seriously enough. This is the bridge into the heterosexual community. In Edinburgh, the problem is immense. I know it is a difficult problem, but I believe that syringes should be provided free to addicts and that there should be a much bigger investment in the drug abuse programme. We have to face the problem of condoms in prisons. Because we pack people into prisons, we must face the fact that there is now a growing epidemic there. These are unpleasant and difficult subjects, and if we are to grapple with this epidemic we have to be braver. The Government led well with their television advertising, but they must go into some of these even more sensitive and difficult questions.
It has at long last been realised that alcohol is a social evil. The Royal College of Physicians wrote a report in 1987 called "A great and growing evil". It had first used those words in 1726. The statistics show that well over 6,000 deaths a year, 62 per cent. of serious head injuries, 66 per cent of suicides, and 50 per cent. of murders are all linked to alcohol. Child abuse, baby battering and wife battering all have their roots in alcoholism. We must do something about it.
We are not taxing alcohol enough, partly because we fear the discrepancy between our VAT levels and those in the rest of the European Community. The way to grapple with that is to have a specific levy put on the drinks industry to help to meet the cost of the treatment of alcohol-related problems within the NHS. I suggest that the Minister for Health uses his existing powers to create a special alcohol service authority, under the Health Service, which will take over all the different alcoholic services, and try to give solving this problem a new dimension and thrust. It would he funded specifically from a new levy on the industry. That levy could allow us safely to reduce VAT, because the burden on the industry would be the same as the present levels of VAT. We must increase this burden as the spending power, particularly of young people, grows. It is clear that hooliganism is related to alcohol and the easy access to alcohol. It is a killer. It is the cause of more misery and violence in our society than anything else. We have been worried about advocating strong action on this for fear of being thought to be killjoys or somehow interfering with people's fundamental freedom. This is a delicate and sensitive issue, but it must be tackled.
I would have liked to talk about many other issues in the NHS. It is not about to collapse. It has many great attributes. It has a strength that goes way beyond what is said or done in the House of Commons. In my judgment, it could never have reached the point that it has reached now, 40 years on, without the dedication of millions of people who contribute to the NHS because they believe in it and think that it is fundamentally a good thing. They are not always looking for extra money or remuneration. They work far longer hours than they are scheduled to work and are paid to work. It is to them that we should be saying, "Thank you for 40 years of service" and it is to them to whom we should look when we assess the future. The Health Service needs change, but it needs change on the basis of a common understanding of all that is good within it. Many of us, in our personal and private lives, owe an immense debt to the Health Service. Let us hope, 40 years on, when the House debates the Health Service again, that people can pay tribute to what will happen between then and now.
I pay a warm tribute to the right hon. Member for Plymouth, Devonport (Dr. Owen) for making one of the best contributions to the on-going discussions on the Health Service that I have heard for a considerable time. I think that I speak for quite a number of my hon. Friends, and a number of my constitutency supporters, when I say that he is welcome on the Conservative Benches any time that he chooses to come over.
This is intended as a birthday celebration for the Health Service. We have, quite rightly, heard a lot about the history of the service, but I see this as a chance also to celebrate the present and look into the future. The Opposition are often keen to tell us about the bad case histories that they have come across, but I believe that almost all of us are aware that in an emergency the NHS is unbeatable.
Earlier this year, my daughter Emily suffered a brain haemorrhage. I cannot imagine any other system—private insurance or any other public health service—that could have worked so smoothly and satisfactorily as the NHS did in her case. I pay tribute to Mr. Robin Illingworth, at the neurosurgical department at Charing Cross hospital, and Dr. Mark Glaser, of the radiotherapy department, and also to the nursing and other staff, especially those in ward 10 south. Without their skill and care, and without the existence of the NHS, I have no doubt that my daughter would not be alive today. Although I have the good fortune to serve in the House, I am sure that there are millions of others who have had the same experience and the same reason to be grateful to the NHS.
Of course, we could examine many matters in this debate, but in the interests of brevity I want to make four suggestions about the subject that I hope the Prime Minister's review will deal with.
First, we need to pay attention to what the Health Service is for. It continually surprises me that there appear to be no clear definitions of the boundaries of Health Service activity. I remember before Christmas that my right hon. Friend the Minister for Health told a meeting that the third most common reason for admission to hospital in one health district was vasectomy. He added that many of the people admitted for that purpose had already had one vasectomy on the NHS, had had it reversed, but had changed their minds and were having their second vasectomy. Although the cost of a vasectomy may be relatively small, when we were being told that—allegedly because of lack of funds—people with life-threatening conditions were unable to obtain urgent treatment, that any taxpayers' money should be spent on providing second vasectomies was utterly absurd.
It is high time that we defined what functions the Health Service will provide at taxpayers' expense and what functions it will not. That argument is also relevant to the debate about the relative responsibilities of local authority social services departments and those of health authorities, where there still appears to be a considerable blurring of the dividing line.
I believe that the presidents of the three royal colleges would be willing to lead the medical profession in contributing to a discussion about where the boundaries should be drawn. In the evidence that they gave to the Social Services Select Committee earlier this year, they appeared to be happy to help my right hon. Friend if he wanted to define the role of the Health Service.
Having decided what the service should do, we should then find a better way of measuring how well it does it. I welcome the fact that some progress has been made towards better measurements of performance. We have progressed a little from the rather sterile, politicol debates that used to take place, with people trading statistics about how much was spent by whom in which year.
No person running a business would think of measuring the success of his business exclusively by reference to its turnover. As long as our arguments were confined to inputs, they told us remarkably little about the success of the service. More urgency needs to be applied to the development of better measurement of outcomes. Too many of the performance indicators that the NHS is developing are just activity measurements.
Obviously a necessary condition of good management is that we should know how much activity takes place in the different sections of the Health Service, but that is not a sufficient condition. We must measure more accurately the health of people who have used the service. Until we do that, it will not be possible to sustain any argument about whether spending is adequate, inadequate or excessive, because we simply do not know how well the existing job is being done. I hope that a major part of the review's conclusions will be about improved measurements of outcome.
Has my hon. Friend seen the work done by Professor Alan Maynard at the university of York health economics unit? Professor Maynard has proposed quality adjusted life years as one way of measuring outcome. Will he suggest to my right hon. Friend that that is a matter that should be progressed?
I have seen that work, and I believe that quality adjusted life years are one way in which we can measure the relative importance of embarking upon one course of treatment as opposed to another. It is worth recognising—it is a fact, which, of course, many practitioners are understandably reluctant to recognise—that whatever the level of funding of the service, and even if present expenditure was doubled, there would still be marginal cases where someone would have to say no. They would have to say that there were insufficient resources to do a particular operation or to offer a particular treatment. It is in such cases that the concept of the quality adjusted life year would be most relevant.
Before leaving the question of performance measurement, we must be aware, as my right hon. Friend the Member for Aylesbury (Mr. Raison) said, that the Health Service has become rather a producer-dominated service, and some providers of health care might be less than enthusiastic about the development of accurate measurements of outcomes.
Having decided what the service is for and how its success should be measured, ways should be found to improve its operation. Many sensible ideas have already been canvassed and, indeed, some have been mentioned in this debate. First, there is the move towards internal markets. I agreed with the right hon. Member for Devonport when he said that the first step towards improving the internal market is to give patients the right—in consultation with their general practitioners—to request treatment in another health district if, within an agreed period, they are unable to obtain treatment in their own district.
Does the hon. Gentleman accept that patients already have that right and GPs already have the right to refer their patients to other health districts? The problem is that all the districts have waiting lists for the same specialties. For example, all of them have waiting lists for general surgery. That is the main obstacle. There is already a cross-boundary flow.
I do not agree with the hon. Lady. It is certainly possible for a general practitioner to negotiate the admission of his patient in a neighbouring district. I do not believe that the principal obstacle is the length of the waiting list. My constituency is relatively well served in health care, but it has a problem with orthopaedic appointments. It takes a long time for someone to obtain an appointment with an orthopaedic surgeon. Other health districts have considerably shorter waiting lists. The problem is the funding of those patients. They do not cross district boundaries with accompanying funding. Therefore, the accepting health district is actually adding to its financial problems when it goes out of its way to solve a patient's problem. We need to ensure that patients cross district boundaries with the appropriate funding, which will open up the internal market.
My second suggestion for improving the way in which the service operates is to implement more whole-heartedly the Griffiths recommendations, many of which are extremely sensible, but have been implemented only in a half-hearted manner. We should start with the appointment of a high profile chief executive. I fear that very few users of the Health Service or, indeed, its employees could name the present chief executive.
On management structures, we should resolve the contradictions between the existence of a management board on one side and a group of regional health authority chairmen on the other, all of whom consider that they have direct access to the Secretary of State. I suggest—and I have reason to believe that this would not be unacceptable to some of the regional health authority chairmen—that those two structures should be consolidated in the management board, provided that the regional health authority chairmen are well represented.
My third suggestion is that we should treat nurses like policemen. In the police force, it has been a source of great satisfaction that many non-policing functions have been civilianised. The police authorities and the Home Office boast that they employ a large number of civilians, thus releasing expensively trained and highly paid policemen to carry out police work. The same should be true of nurses, who also are expensively trained and, at last, becoming better paid. We should make a virtue of ensuring that there are enough ancillary staff in hospitals to enable nurses to spend their time nursing. That would also improve job satisfaction.
My fourth suggestion is that we should consider the treatment of capital much more carefully. There are numerous irrationalities as between capital and revenue in the NHS's financial organisation, but the Health Service should be more careful about the use of its fixed assets. I acknowledge the efforts that have been made to release more surplus land, but many famous institutions in the City have ensured their future financial viability by moving three or four miles east to docklands. Why does St. Bartholomew's hospital not do the same? I dare say that the capital value of the real estate currently occupied by Barts, if sold and reinvested, would be sufficient to cover its revenue costs in perpetuity and that, apart from the consultants, very few people would be inconvenienced by such a move.
I commend to the House most warmly the proposals of Riverside health authority to consolidate its district general hospitals on two sites—one at St. Stephen's, Fulham road, and the other at Charing Cross. It is significant that closure of Westminster hospital has been supported by the consultants. They should be congratulated on that.
Is the hon. Gentleman aware that it is widely thought in the NHS that the three hospitals will be closed and that the land attached to St. Stephen's hospital will be sold for a private hospital? That is not the way in which to consolidate health care in London or to provide cover for the population in the area.
That is not the proposal which has been agreed by the district health authority. I have no doubt that my right hon. Friend the Minister will give his view on that in a few weeks' time.
I have left my final point until last deliberately as it is the least important. It is about money. The most important thing is to decide what the Health Service is for. We must then decide how well it is doing it, and then improve how it does it. Finally, we have the relatively minor matter of how it is financed.
There are many alternatives to the present basis of funding, but I have not seen much evidence to suggest that any of them will do much to improve patient care. The other things which we have discussed will, but I do not think that switching to an insurance-based system would make much difference. The taxpayer would pay less tax if we shifted more of the cost of health care on to the private sector, but my right hon. Friend the Chancellor of the Exchequer is doing pretty well at getting taxes down every year while putting more and more money into the Health Service.
I share the view that there should be a pluralist provision of health care. I want the private sector to grow, flourish and expand. There is every reason for us to support that—it reduces the burden on the taxpayer. I cannot see any great advantage, however, in offering taxation incentives to take out private medical insurance. Many people are already willing to take out such insurance without incentives, and I do not think that we need to promote private medicine in that way. If it is thought sensible to introduce some slight extension of charging, which is already accepted for prescriptions, to cover hotel services for better-off people, that would appear entirely inoffensive.
I hope that the Prime Minister's review will consider the four points that I have mentioned. Irrespective of whether it does, I believe that the message that will go out as a result of this debate is that we have a great deal to celebrate in the NHS, that we undermine its principles at our peril and that it is our job to improve a fundamentally sound structure.
Mr. Speaker has already appealed to the House for short speeches. I repeat that appeal. Unless speeches are shorter, a lot of hon. Members will be very disappointed by 10 o'clock.
There has been a surprising degree of consensus about the basic philosophy which underlies the NHS, and acceptance that there will be little change to it. I am sure that that is gratifying to many Opposition Members and to many people outside who have had considerable doubts about the Government's intention during the past few months. A series of leaks have floated out from the review of the NHS.
Following publication this week of the report by the Social Services Select Committee, I shall be even more delighted if the Minister of State says that he will accept our conclusions. We could then carry the consensus to its logical conclusion. I have some doubt about that happening.
It is also generally agreed that the NHS is largely a sickness service. That is, after all, its role. It is the role which we have defined for it. Its role is to restore people to health if possible and to care for those whose health cannot be restored. It is scarcely surprising that the NHS does what we want it to do. It is also scarcely surprising that it does not do what some people think it ought to do, which is to promote health.
Health promotion is the role of Government, not of the NHS. It depends on many vague and general factors such as poverty, unemployment, damp, cold housing. Over-crowding and environmental deprivation. Those are the true determinants of ill health. The right hon. Member for Plymouth, Devonport (Dr. Owen) mentioned the role of alcohol and said that it is a major cause of suffering, ill health and death. I propose to say no more about that important subject now.
I shall confine myself to two areas of major change in the NHS—the change in organisation and the change in the level of funding supplied to it. I shall not say much about the early organisation of the NHS. It is well known that, like Gaul, it was divided into three parts—the primary care service, hospital services and public health services. They were united in 1974–75. Like most other reorganisations since, that one improved the quality of management in the NHS. It was changed again in England and Wales in 1980 by the withdrawal of one tier of management which, on balance, I think was a good thing. Finally, three or four years ago, Griffiths-style management was introduced.
I agree that, by and large, the change has improved effectiveness and efficiency in the delivery of health care. The service has been constrained, however, by the limitation on resources. There are many reasons for that. They are well documented in reports by the Social Services Select Committee. There is the demographic change about which we all talk and the need for 1 per cent. growth, be it in overall resources, as many of us argue, or in efficiency, as the DHSS tends to argue.
There has also been the increase, which is supposedly inexorable, in medical technology, the increase in Government priorities in certain areas and the growth generated by the increase in efficiency which the Government tried to promote by bringing in Griffiths-style management. That alone is surely the most important reason for the present problems. The NHS is a victim not of its failure, but of its success. We must remedy that if we are to allow it to grow and prosper.
We all agree that most health care in Britain will be provided by the NHS. That is fine, but we must give it the resources that it needs to do the job properly. As a doctor, I do not agree with those who say that demands on health care are infinite in the sense that we must always respond to them. We could produce immeasurable benefits in the health experience of people in this country by a relatively limited injection of additional resources into the NHS. Of course, we must control growth at the margins. That is Government's job and we do it directly through the supply side of that service. We must not constrain the NHS's resources so much that we are presented with the spectacle, as we were last year and as I fear may happen later this year, of effective efficiency units being closed three months before the end of the financial year because there are no resources left to run them properly.
I am interested to know what the Government's review will produce. The leaks about which we have heard, as each scheme that has been touted has been discarded, suggest that the conclusion will be that we should perhaps give some people tax relief for their BUPA subscriptions, although that will scarcely make the earth move for most people in this country.
Many changes in organisation have been proposed for the NHS, as many hon. Members have mentioned. For example, everyone agrees that health maintenance organisations would be much better than the private system of care generally prevalent in the United States, but they would scarcely be a match for the best funded public health service in the world, as we have here. That would not be an improvement. Internal markets are all well and good, but the Minister has pointed to the lack of information, both financial and in respect of quality, required to enable an internal market system to work.
Although, if we take it to its logical conclusion, I can see the possibility of one hospital in central London providing one range of services and another hospital, fairly nearby, producing a different range, it would be a great deal different in the Highlands of Scotland if people had to travel 70 or 80 miles to have their ears examined because the ear, nose and throat department at one hospital had been closed down as it was supposedly less efficient than the one down the coast. I scarcely think that people will be enraptured when they see what the internal market leads to.
I do not believe that the NHS requires any fundamental change in its organisation at this time. We could probably consider some matters. For example, we could consider the role of its management board and its chairman and see how effective and efficient they are in promoting the wellbeing of the service for which they are responsible. We could look at the edifices that they run in London, full of civil servants, and work out how cost-effective they are and what they provide in the way of benefit to the people of this country. We could consider the role of regional authorities and see whether that needs to be changed.
We must certainly bring about the change for which the Select Committee has been asking for years, mentioned again by the right hon. Member for Devonport, to merge family practitioner committees with district health authorities. The only reason for maintaining a separate, parallel tier of management must be if we can prove that it is a more effective way of organising the service, and there is absolutely no evidence that that is the case. Those organisations must, therefore, become part of the same system and generate the savings that can be achieved by streamlining the management.
I do not propose to say anything else this evening other than to mention the fact that, this afternoon, I was given a petition which I intend to present to the House later. It bears over half a million signatures and was collected by the Royal College of Nursing. That is a sign of the true depth of feeling in this country about the NHS. That is one of the reasons why we are debating it today and why we tamper with it at our peril.
The measured contribution of the hon. Member for Kirkcaldy (Dr. Moonie) was in marked and welcome contrast with the hyperbole to which we were treated by the hon. Member for Livingston (Mr. Cook).
I should like to join in the tribute paid by hon. Members on both sides of the House to the dedication and achievement of so many people, past and present, who have served in the National Health Service. However, we must take this 40th anniversary opportunity not only to look back briefly at its origins, but to see the problems that we face and to give what signals we can to my right hon. Friend the Prime Minister and her colleagues in her review, as this is a fundamental juncture in the provision of a truly modern system of health care. Therefore. conscious of your entirely justified injunction, Madam Deputy Speaker, I shall return briefly to the events surrounding the birth of the NHS, to which my right hon. Friend the Secretary of State and the right hon. Member for Blaenau Gwent (Mr. Foot) have already referred.
It is important, so that we can take the issue out of the political dog fight in which it has lain and suffered for so long, to put it firmly on the record that, for very many decades, parties of all persuasions in this country have been, and continue to be, dedicated to a comprehensive, universal system of health care for all our people. The only argument concerns the mechanics of how that can best be delivered. In 1948, there was an argument about the method of delivery. The chief issue of substance was in the phrase they used in those days about whether the hospitals should be "nationalised".
That was not a direct Conservative-Labour fight, as I hope the right hon. Member for Blaenau Gwent will allow. It was largely a fight with the medical profession strongly in the lead. Historically, the contributions of the British Medical Association to medical advance in this country have not been glorious, starting with its opposition to Lloyd George's welcome reforms in 1911. The issue of the so-called nationalisation of hospitals went across the parties in 1945 and 1946. It was the published and authorised policy of the Labour party itself that the hospitals should be locally controlled and it was the firm advocacy of the then Lord President of the Council, Herbert Morrison, against Aneurin Bevan, who insisted that that was the way to go and warned and fought time and again in Labour Cabinets in 1945 and 1946 against the overcentralisation and bureaucracy that would be created by Bevan's structure. Bevan won and said, "No, we shall solve the problem. We shall find mechanisms in the future to cope with those fears."
In 40 years of trying, of Royal Commissions, of reviews, of committees and of changes of organisation, we have not solved those problems. We have not found the solution. That must give us pause, 40 years on, to consider whether there is a solution. The answer is that there is not. However, there is a way through because there is now another option for funding. Herbert Morrison was defeated at the time because no one could think of how to fund hospitals or organisations properly on a local basis.
With the greatest respect, that is a load of rubbish. Herbert Morrison wanted control of London hospitals because he said that he was in total control of local government here and could determine what went on in those hospitals. Many of us never accepted that argument and we pointed out to him that some local authorities were controlled by the Conservative party. That is why he was defeated then, that is why it was right that he was defeated then and the idea that he is still alive and living in Walworth road is a load of rubbish.
I am grateful for the hon. Lady's elegant contribution. I am sorry that she does not know and understand the history of her party. If we go back to the resolution passed by the last Labour party conference before the Second Reading debate in 1946, she will know that the Labour party was in favour of locally funded and organised hospitals.
I return to the question of funding which has bedevilled the Health Service ever since 1948. The right hon. Member for Blaenau Gwent did not bestow on the House another bit of history, the fact that his hero, Bevan, was complaining about the "cascades of medicine pouring down British throats", literally months after the Health Service started. So there have always been financial pressures and constraints on the Health Service. In real terms there has been a fourfold increase in spending over 40 years, but we still have problems. That is a sign that the financial structure as well as the organisational structure was fundamentally flawed when the NHS was established.
I, too, have been reading the records of 40 years ago, including Cabinet minutes of 1948 and 1949. The right hon. Member for Blaenau Gwent (Mr. Foot) did not mention that six months after the establishment of the National Health Service the right hon. Gentleman who preceded him in representing his constituency, Aneurin Bevan, had to ask the Cabinet for another £50 million. On 23 May 1949, the Attlee Cabinet discussed hotel charges for hospital services.
I am grateful to my hon. Friend.
I hope that the House will accept that for 40 years we had had problems that have stemmed from flawed financial and organisational structures. It is only now that we have the opportunity of examining them afresh. I hope that my right hon. Friend the Secretary of State will bring courage and open-mindedness to this challenge.
The resources that are needed for health care are much greater than those that we currently devote to it, and there is a need for significant changes in the delivery system. The right hon. Member for Plymouth, Devonport (Dr. Owen) took up international comparisons, and I suggest that for the moment we forget the United States. It is a convention, when defending the Bevanite structure of the NHS, to say, "If we are not careful, we shall end up like the United States." Let us consider instead our continental neighbours, such as France, Germany, Italy perhaps, and the Netherlands. These are countries with which we tend to compare ourselves. On average, these countries spend about 9 per cent. of their gross domestic product on health care against our 6 per cent. Purchasing power parity is a more effective comparison, and if it is made we find that we are spending not much more than half of that which the Germans and the French spend.
I accept that in some respect the NHS is an efficient structure in terms of using resources effectively, but because of the absence of measurement controls it is most ineffective in many other areas. We cannot get away, however, with spending slightly more than half of what is spent by the French and the Germans and have the sort of standards of treatments that they enjoy. It is a sadness that there has been virtually a conspiracy of silence. Our people do not know what they are missing. As the NHS has become increasingly a political football, the parties when in government have to say, "This is wonderful and we are wonderful." The British people are beginning to learn, however, what they are missing in the delivery of health care and what is available in other countries.
Let us not say that we need to spend as much as the Germans or the French. Let us say instead that we need to go only halfway in closing the gap. That involves additional spending of £10 billion, £11 billion or £12 billion. That would mean spending half as much again. There is no conceivable way in which we could produce that from the public Exchequer, notwithstanding a dedicated health tax or any other scheme that has been suggested by my right hon. and learned Friend the Member for Richmond, Yorks (Mr. Brittan) or by any Opposition Member. No other country has tried to spend that sort of sum through the public Exchequer. No other country would be silly enough to try it. There are ways, however, in which we could proceed.
I was not aware that the hon. Gentleman tried to intervene in my speech.
I refer the hon. Gentleman to the German figures. He is making a comparison with Germany and saying that it would be impossible to increase our expenditure on health care. Why is it that the gap between public spending between the United Kingdom and Germany, in terms of percentage GNP, is precisely the same as the gap between private spending in the United Kingdom and in Germany? Why is he so desperately exercised about private spending and so desperately anxious to deny the case for increasing public expenditure?
Because the funding structure in Germany is different from ours. The employers of those earning up to the equivalent of about £20,000 a year contribute about half of that which is paid to the German health care system. It is clear that the hon. Gentleman does not understand the funding structure in Germany, which is significantly different from that in the United Kingdom.
There is a solution to the dilemmas, but it is not to be found by dividing the nation by introducing public heal! h cover and private health insurance. That is not the way to go, for various reasons, some of which have been referred to already. That approach would not help the Treasury and it would not remove the pressures from the public health structure. It would lead to the significant problems that would result from two nations, which we must avoid.
We need to take up the solution proposed by a committee that was established by the BMA, of all organisations, taking account of my earlier remarks. The committee worked for two and a half years and produced an excellent report. Sadly, the BMA, reverting true to historical form, proceeded to ignore the committee's recommendations and put its report on the shelf. It recommended that there should be a health voucher or health credit system.
We must recognise the wonderful achievements of our Health Service and forget the mistakes which were made. We must learn the positive lessons of foreign experience and apply them to our new structure. We can then provide a system that at last achieves what Herbert Morrison was unable to bring about but which the Labour party of 1945 wanted—autonomous local hospitals. That would enable us to do away with the superstructure of district health authorities, regional health authorities and all the other ineffective paraphernalia. I can assure the House, having been a junior Health Minister, that it is ineffective. Hospitals should become autonomous and funded by a health credit system on an insurance basis. That would put the consumer—the patient—in command with his doctor. The doctor and the patient would immediately have an incentive to turn to preventive medicine. That is what the Americans call wellness management, which is an asset that the NHS has never enjoyed. That would mean a significant change in the funding structure.
That change may seem to be radical, but the reality is that it would take us to what we have always wanted. With a well-funded basic level of health care, anyone who wanted to top up, as it were, for additional services—private rooms or special hospitals, for example—would be able to do so. We would have a truly national Health Service at a local level, and a well funded one. That would fulfil the objectives of the authors of the 1944 White Paper—they came from both parties and all the medical professions—and fulfil also the aspirations for the future.
The explosion of demand that will come is not generally understood. We have an aging population and economic pressures that come from technological advance, but more significant are the rising aspirations of our people—and they are justified in having them. The only way in which we can meet them and avoid the political Passchendaele that the NHS debate has become is to have radical rethinking now.
On the occasion of the National Health Service's 40th anniversary, I start by acknowledging Aneurin Bevan's achievements. At the same time, I pay homage to the well-known liberal, William Beveridge, who first conceived the idea of a National Health Service. His report was presented to Parliament in November 1942, which is perhaps the earliest date we have heard tonight. That report was and remains the cornerstone of the welfare state. Underlying its conclusions were three basic assumptions, of which the second was
a comprehensive health and rehabilitation service for the prevention and cure of disease and restoration of capacity for work available to all members of the community.
On the day that that report was published, 70,000 people queued for a copy of it, but it was not until July 1948 that the National Health Service was introduced. That was made possible because there was universal recognition that the community was responsible for the welfare of its members. There was a pride in national unity and a sense of community, and—if I may dare use the term—a consensus, not only in Government but throughout the country, that the better standard of health and welfare that the individual enjoyed, the more benefit would accrue to the nation.
That sense of community seems to be missing today. The Government's policies are leading us into division and individualism of the worst kind. Survival of the fittest and the richest, obsession with individual responsibility, privatisation, and free market forces override consideration of any other matter. It worries me that, when it comes to our National Health Service, everyone seems to be playing into the Prime Minister's hands. We hear of this book and that book, and of this article and that article—all of them outlining new ways and methods of financing and organising health care in the belief that the country cannot afford a comprehensive National Health Service. That is nonsense. What we can afford is not an absolute; it is a matter of political choice and will. That is the crux of the matter. The Tory regime does not in its heart of hearts believe in an equitable health service, free at the point of delivery, because it has not committed itself to that principle and has not understood or committed itself to the need to fund the service properly.
The evidence is in the underfunding that has gone on throughout the whole of the regions and district health authorities, and I see that happening in my own health authority as well.
The Government's attitude is not the result of ignorance, because we know that they have estimated that the Health Service requires a 2 per cent. per annum increase above NHS price and pay inflation to meet demographic and medical changes. The service's under-funding has been a political decision. The Government have allowed the service to run into crisis—it is the Government's political ideology that poses a threat to a universal health service.
For 40 years, the NHS has served the nation well. Opinion polls show that the majority of the populace want it to continue and are willing to fund its recovery and growth from their taxes. For 40 years, our National Health Service has been the envy of the world. In terms of per unit cost, it is still the best value for money, and we should be building on that success and investing in it rather than considering any major changes.
Even in the present crisis, the hospital service is managing to meet most of the demands made upon it. That is being achieved through the dedication and skill of its staff. I am not denying that there is room for improvement in management, administration and efficiency—as has been mentioned before—or that there is a need for small structural changes. However, those can and should be achieved within the service's present framework and without losing the principle upon which it is based of equal availability at the time of need, free at the point of delivery.
It is that principle which has been threatened by the various schemes that have been thrown into the arena for discussion. I award full marks to the Prime Minister and to the Secretary of State for manipulating the situation and planting in the minds of the nation the seed that the Health Service is in need of massive surgery. We may consider, for example, the proposal to expand the internal market. That is seen as a way of enjoying the perceived advantages of the free market without altering the principle that the major part of funding should come from the public purse. There is already a small ad hoc internal market at work, which has arisen from the need to reduce waiting lists and overcome the poor implementation of the RAWP formula.
Districts that are now below their RAWP targets buy in services that they cannot at present afford to provide. Any expansion of that market would leave such districts at an even worse disadvantage because they would be unable to compete with the better-off districts. The result will be stagnation and deterioration. Needless to say, those areas of the country that will suffer will be the under-privileged, the inner cities and rural communities.
The market ethos that the Secretary of State believes is here to stay will not create freedom of choice for all patients. It will create problems of accessibility for both patients and relatives, in ambulance and transportation services, and in co-ordinating after-care services and referral authorisations. In short, it will be an administrative nightmare.
The internal market also contradicts the idea that a computerised information system will allow the general practitioner and consumer greater choice.
The hon. Gentleman probably sensed my mounting bewilderment and puzzlement as he went on with his script. What is really puzzling me is that I thought that I read a manifesto from one half or the other—or possibly both—of the party that the hon. Gentleman now claims to represent, the content of which was about as different from what he is now saying as it could conceivably have been. It was preaching the internal market in what seemed to me then to be a very ill-considered way. May we know whether this is the SLD's first massive U-turn?
I can answer the Minister's question very clearly. It is not a massive U-turn. The right hon. Gentleman must have been reading The Independent, which obviously got wrong the speeches which have been made lately and in the past. I believe that that is what he has been doing.
An internal market may be some use in the short term in helping to reduce waiting lists, but it should not be considered as the basis of providing a comprehensive health care system for the nation. Such a market would prevent many districts from improving their own situation because the money that they should be investing in building up their own services would be spent on services from another district. That would result in a reduction of local services and uneven distribution of health care throughout the country, and it would add to the hardship and stress suffered by many individual patients.
The RAWP formula was introduced to provide equal opportunity of health care access for people at equal risk. If that scheme had been properly implemented and funded, and if a levelling-up rather than a levelling-down process had taken place, there would not be the need to discuss the internal market on the scale that it is being discussed today.
A number of proposals have been put forward involving various schemes for the use of health care vouchers. Unfortunately, my parliamentary, constituency and local council duties make it virtually impossible for me to digest all of the proposals contained in books and articles that hon. Members and my hon. Friends find the time to write. However, the suggestion is that the individual be given a voucher enabling him or her to contract with an organisation or individual GP to provide the health care required, or at least some of it.
That arrangement raises a number of questions. How often will vouchers be provided? What will be their value? Will they be the same for everybody? How will they be distributed—possibly through the poll tax register? Who will be given vouchers to cover children's health care—mothers or fathers? Will the health organisation, private insurers or the individual GP be compelled to accept a voucher from any individual who approaches them, or will they be allowed to accept only those patients whom they consider to be a good risk, leaving those in most need of health care searching around for someone with whom they may contract?
As far as I can see, all such schemes leave the Government to provide insurance for the chronically sick, and the individual will be allowed to top up his or her voucher. That in itself tells us something about the schemes. The value of the vouchers will be such that organisations will not find it profitable to provide comprehensive cover and the chronically sick, who will have to rely on the Government to insure them, will get a raw deal.
Some of the voucher schemes, along with other proposals, envisage the setting up of some form of health maintenance organisation. In such systems, or those contained in other proposals, our NHS hospitals would be funded by those organisations or would become independent. All hospitals would compete for trade. That would result in hospitals specialising in the treatment that was most profitable. Emergency cases would be in danger of being turned away because the hospital did not have a contract with the patient's organisation—as happens in America—or because the patient was not covered for the treatment required. Health care in the nation would rely on cut-throat competition. A voucher system would seem to be a minefield.
It is reported that the Government are backing down from some of the more radical proposals that have been put to the review body. I can only hope that that is the case. Indeed, in his speech to the Centre for Policy Studies MSD foundation symposium on 17 May 1988, the Secretary of State implied just that. He said:
It means that we will not make access to decent health care dependent on the ability to pay for it. And we want to retain the comprehensive coverage provided by the NHS, so that the old and the sick are relieved from anxiety about obtaining the care and treatment they need.
I should like to believe those words in their entirety, but the recent changes in social security and housing benefit have shown us just how the Government relieve the anxiety of the old and sick.
No. I have given way twice.
The Government usually pull the rug from under the feet of such people. I put it to the Minister that the only way to achieve his stated objectives is to leave the NHS intact and to provide it with adequate funding.
Other less radical options are tax incentives and the choice to opt out of a national health tax to encourage more people to take out private health insurance. I am not opposed to the private sector per se——
I have no wish to deny the freedom of choice to enable those who have the desire and the means to pay separately for private treatment to do so, but that should not reduce the freedom of NHS patients to obtain good health care by reducing the resources available to the service. We are all aware that any expansion of the private sector, which to date does not offer a comprehensive service and tends to take the profitable cases only, will only result in depleted resources to the NHS and a two-tier health system will come into existence.
The private sector has been allowed to expand without consideration of the effect on the NHS. There should be more effective control and current and future plans should be compatible with the services of the district health authorities. The private sector should contribute to the training of health care staff at basic training and postgraduate levels. Perhaps the Minister will tell us more about that. It should be required to participate in studies of epidemics and similar research as required. The private sector should be seen in terms of a partnership with the NHS, not in competition with it, and should not be allowed to dictate the terms or reduce the capacity of the NHS to provide a free and universal health service.
An individual's right to choose private health care should not reduce his or her obligation to the community. People should not be allowed to opt out of their state contribution. Good or bad health is not something over which the individual has complete control. Many illnesses are the result of living in society, or, should I say the community, to prevent confusion on the Prime Minister's part. An individual does not live in isolation. The community as a whole has a duty to provide a health system that is equally available at the time of need, is of acceptable standard to all and free at the point of delivery. I am not suggesting stagnation. Let us look at the NHS to see what minor reforms can be carried out, but let us ensure that those reforms do not result in a depleted second-rate service, but rather in a revitalised, community and patient-oriented service.
In the interests of many hon. Members who wish to speak, I shall be as brief as possible; so I shall not attempt to answer the hon. Member for Southport (Mr. Fearn), although I would be more than capable of doing so.
The hon. Member for Kirkcaldy (Dr. Moonie) is no longer in the Chamber, but he said that many of the problems facing the NHS at the moment arise from its very success. If one looks at the total expenditure, corrects it for inflation and applies it to the population—in other words, the expenditure in real terms per head of population—one will find that it has gone up three times since the foundation of the NHS. Yet most of us members of the Select Committee would say that that is still not enough.
In speech after speech on the Floor of the House, I have pointed out the various factors which lead me to the conclusion that we are going through a period where the increasing demand on the service should be measured in exponential terms. I shall not repeat any of them this evening. But we cannot get away from the fact of increasing demand. There are those representative bodies, such as the BMA, who have asked for a 2 per cent. growth rate, but that, in my opinion, will not be enough. I have stated my position and stick by it.
Let me come to what I believe to be one of the greatest successes of the NHS that has hardly been touched on today—the great advances made in primary health care. We in the Select Committee did our own study of primary health care. We were impressed with what we saw. In our report, we said:
We have been impressed by many examples of good practice and innovative schemes for improving service to particular client groups—for example, children, or elderly, or mentally handicapped people.
We went on later to say:
We doubt whether any major new legislation is called for and hope that the government will not seek to impose blanket plans for changes in services indiscriminately.
We stand by that.
It was interesting, too, that Sir Roy Griffiths, in his report on care in the community, drew attention particularly to the positive role of primary health care. Again, in the interest of everyone else, I shall not read out what he said, but it is all there on the record.
We are getting much better value for public money in primary health care than most people recognise. People do not recognise how good that value is. When, on the Select Committee, my colleagues were good enough to come to my patch in Hampshire to talk to our family practitioner committee, which is the largest in the country serving a population of 1£5 million, we found that the cost per patient of that service last year was £69. The service includes all the necessary drug therapy. I challenge anyone to find any other western country which provides primary health care of that standard at that price.
My advice to my right hon. Friend the Secretary of State is to cherish what we have achieved in primary health care. Indeed, his White Paper led in that direction. Let us build on our success and develop the service further.
That takes us straight to the second aspect of the future of the NHS to which I wish to draw the House's attention, which is likely to be the biggest growth area of all, and that is what we loosely call care in the community. Let me give one illustration from my own Wessex health region. We have been told that during the next nine years the number of people aged 65 or over will increase by 11 per cent. Far more significantly, during the next nine years, the number of people aged over 85 will increase by 50 per cent. In absolute numbers, there will be 21,400 more people over the age of 85.
Let us now consider just one aspect of the aging process. We know that on average the prevalence of senile dementia in the elderly is between 5 per cent. and 10 per cent. in those over the age of 65, and about 20 per cent. in those over the age of 80. We also know that at present no treatment can prevent, arrest or reverse senile dementia.
I use those figures simply to illustrate the caring dimensions of the increasing number of very old people in our nation. There is no way that institutionalised care will be able to cope with that extra burden. It cannot cope with it now, although it makes a very important contribution in handling the more difficult cases. The responsibility in practice rests with families and relatives, supported in part by the community.
The response to how we are to handle more very old people seems clear—care in the community. It is also clear that as a nation we must put more resources into care in the community. I realise that such claims for extra resources have to be made against the background of other urgent claims for extra public expenditure for other equally worthy causes. I am confident that we will get extra expenditure. I am equally confident that whatever increase we get will be insufficient. Such is the nature of our problem.
Ultimately, the deficiencies in public provision will be made up, as they have always been, by individual families and individual people doing their personal best for their own people in need. In other words, the slack will be taken up by the private carers. There are far more private carers than all the professionals added together providing health care to our fellow citizens. There is nothing new about that, it has always been so, but it suggests that we should do more to help those private carers. There are between 1 million and 2 million of us—we do not really know how many. Therefore, services such as home helps, care attendants, meals on wheels and respite care are every bit as important as new acute beds in geriatric wards.
Finally, may I make a brief observation about the structure of the National Health Service. From what I have said it will be clear to the House that I have a preference for the localised rather than the centralised; for small over large and for local services over distant services. It is also clear from the history of the Health Service that its aims could have been fulfilled under a different structure. It is arguable whether a localised model would have worked better. However, it is clear to me that we cannot change basically our structure, for two very simple reasons.
First, as long as 83 per cent. of the income of the National Health Service, and all its capital, comes from the taxpayer through the Treasury, a centralised system of control and accountability inevitably follows. I hate to think what the Public Accounts Committee and the Audit Office would do if my right hon. Friend the Secretary of State and his permanent secretary did not remain in their positions of direct accountability to those great offices. In fact, they would do their nut.
Secondly, as my right hon. Friend the Member for Aylesbury (Mr. Raison) reminded us, we expect the Secretary of State to be personally accountable to the House in detail for the manner in which the National Health Service delivers health care to each of our constituents. So long as that accountability remains, the system must he based on central political control. In my judgment, that is an inescapable political factor. I see the right hon. Member for Blaenau Gwent (Mr. Foot) nodding his assent.
Like every other hon. Member in this debate, I believe that constructive changes should be made in the running of the Health Service. However, I do not think that there is any necessity to pull the National Health Service up by its roots and replant it differently. I would advocate a policy of gradualism based on a programme of persistent improvement. I would caution against a policy of revolution based on a programme of instant convulsions. I have never been keen on the general use of ECT, and certainly not for the NHS. I would remind hon. Members impatient for change of Aesop's famous race between the tortoise and the hare. It was the tortoise and not the yuppy hare who won.
Like other hon. Members, I salute those who have worked in the Health Service and those who currently do so. It is interesting that if one looks at the motion and the amendment—although from listening to the speeches so far it seems that we have not been paying much attention to the Order Paper—one sees that there is a considerable amount of agreement. Indeed, if I had not disgraced myself the other day by voting twice about whether freemasons should have to declare an interest when joining the police, perhaps there would be a case for voting on both sides tonight.
As well as saluting the people who have contributed to the state of the nation's health, let me begin with a personal comment to the Secretary of State. It is the first time that I have been in the House and witnessed him in much better health. I am pleased to see that. I also compliment him on his performance today and on the clever way in which he tried to build a consensus about the evolution of the Health Service during the past 40 years. For once, I disagree with my right hon. Friend the Member for Blaenau Gwent (Mr. Foot). I want that consensus message to go out from the House. Should the Prime Minister's review suggest otherwise, we shall know the changes that have taken place and that it is not part of the pattern to which we are accustomed.
I further compliment the Secretary of State because he has to face my hon. Friend the Member for Livingston (Mr. Cook). I do not think that I do a disservice to my other colleagues on the Front Bench in saying that my hon. Friend the Member for Livingston has emerged as our most powerful spokesman in criticising the Government. It is no easy task for the Secretary of State, certainly when he has not been well, and I am pleased to see him in much better health.
I wish to make only two brief comments. First. I have to confess that when I became Chairman of the Social Services Select Committee I knew next to nothing about health. Therefore, I was fortunate enough to have an open and empty mind. There can be advantages in having an open and empty mind in that sometimes one asks questions that are not asked by those whose minds are cluttered with unnecessary facts. In coming new to the subject, I was struck by what we did not know about the performance of the Health Service. We can consider the national picture—the global GDP figures that hon. Members have rightly mentioned. We can look at our morbidity figures and we can draw the general conclusion that the National Health Service serves us exceptionally well. If we consider particular hospitals and forms of treatment, and we make comparisons between regions arid localities, we would be hard pushed to provide any clear answers other than that we hope that the Health Service is doing us proud.
If we are interested in efficiency, and the Opposition are as keen to have efficiency in public service—or what is left of it—as the Government are, we certainly need information, and currently we do not have that. If this Government, or any other Government in the immediate future, are anxious to increase efficiency they must do it in a crude way and must apply cash ceilings. They hope that by applying those cash ceilings people will scramble about with a bit more efficiency, perform more effectively and that the service will benefit. There is much to point at under the Government's stewardship to show that that has occurred.
To address myself directly to the Secretary of State, there is a danger that if there is only that crude method of controlling expenditure and trying to enforce efficiency, one can get it wrong. I can go further and say that one will inevitably get it wrong by the very nature of the exercise. Therefore, given the crudeness of the method of control, it is incumbent on the Secretary of State and the Government to look carefully at those points in the service that are showing pressure or may become flashpoints.
The Select Committee tried to highlight two of those flashpoints. We complimented the Government in a positive way—unlike some of the responses we receive for our reports—on the nurses' pay award. We also pointed to some of the difficulties in implementing that. If that is not to turn sour, if it looks as if the Government will not be able to fit their regrading reviews within the budget for which they are seeking approval, it will be necessary for them to come back to the House and ask for additional funds. I hope that all hon. Members will support the Government's request for any additional funds they need.
The other immediate flashpoint will be covering the pay award for the non-nursing and medical staff in the NHS. I know the argument well because one has heard it so often. I know that while negotiations are taking place the Government cannot say that they will meet the entire bill—as if the Whitley councils are somehow mysteriously independent of the Government. Surely the message is clear to the Government. When the Whitley councils report, the pay awards must be met in full if the Government are not to face the problems they faced last year where there were cuts in services and ward closures. I put that warning gently to the Government. When operating the crude policy of cash ceilings and trying to enforce efficiency—the only option open to us—the Government must be sensitive and quick on their feet when they see pressure points developing.
I disagree with my hon. Friend the Member for Suffolk, South (Mr. Yeo). I call him my hon. Friend because he is on the Select Committee with me. He said that we do not know whether the service is underfunded. That is partly true; we cannot come up with the exact figures. I know why he put his argument in the way he did. However, we can use our eyes and the evidence to see whether the service is being renewed in the way that we want and whether it has the resources to develop at the beginning of the next 40 years in the same way as it has developed over the past 40 years for which many of us are claiming credit. On that simple basis, it is clear that there is an underfunding.
I will not damn the hon. Gentleman's career by calling him my hon. Friend, although he has probably damned mine. Whether or not we disagree about the evidence that the Health Service is currently underfunded, I hope that he will agree that if new funds are to be put in by the taxpayer, it would be useful to have a better measurement of how much value for money is achieved.
I agree with that. I have not ruined my hon. Friend's career. His independence of mind and ability have finished his promotion chances. There is little I can do to match that. [Laughter.] I did not mean that to be funny. Sad to say, it was a serious point.
Although the Government have many things to say that are to their credit, they have difficulty in reading clearly Select Committee reports. When our committee talked about underfunding and a need for increased resources, we did not ask for money to be thrown at the Health Service. We asked for increases of resources to be specifically linked to certain projects, for those projects to be monitored and for resources to be withdrawn if we found that they were being misused or spent on other items of necessary expenditure. We did not ask the Government to throw money at the problem, although money has a part to play. We talked about four areas.
First, in so much of the debate, both sides seem to be speaking the truth. The Government's record on their hospital building programme is not a bad record to look at. However, the Government's programme on repairs to existing buildings is an area of considerable concern. During the visits that the Select Committee has made people have made their points plain to us. If one can obtain lump sums for large capital programmes, one is all right. However, there is great difficulty in obtaining the necessary capital to undertake a steady programme of repairs. Unless we are extraordinarily lucky, all of us who visit hospitals see that we are building up an enormous backlog in the repairs programme. That is part of the underfunding and we want funds to be specifically targeted to that.
Secondly, there has been mention already of community care. My hon. Friend the Member for Livingston talked about the cruel policy upon which we are embarked of throwing people out of institutions without any back-up because it was thought to be the thing to do. I saw that in my constituency recently where somebody left the Cheshire hospital after 34 years. He has been cut off by his family, except his sister. He sleeps for only an hour and a half at a time, he smokes and drops his cigarettes all over the place. His sister is almost at the point of breakdown. Until that man was returned to hospital, that woman was providing community care. To say that putting such people into bed and breakfast hostels or back on to the street is community care is using language in an obscene way. My hon. Friend the Member for Eastleigh (Sir D. Price) was right to say that the programme of community care is not to cut the bills but to change the direction of spending and probably to increase it. In the long run that is necessary. However, if we are to receive community care only on its current scale, many of us would prefer to see our constituents remain in those dreadful long-term hospitals than have to face life outside.
Thirdly, the Select Committee also made a plea about equipment. We talked about replacements and about taking the technology up market. We asked not for money to be thrown at that, but for areas to be specifically located.
Fourthly, we mentioned information technology. Although I have learnt a lot over the past six months and have been impressed by the skill of Select Committee members and people outside, it was the Secretary of State who made the most interesting point, if the Sunday Times reported him correctly. I am responding to what it said were his comments, which were that it is possible to develop markets that are not governed by profit and are in the public sector. That should be a starting point for the Opposition's debate. For that to be effective, we require a range of information that we do not have at present so that we can build up a public ethos about service, the like of which we already have in the NHS. If we could get the ongoing capital programme to see that the information technology in the NHS is brought up to the standard in some of our businesses, we could approach the next 40 years of the Health Service in better heart than some of us are in at present.
I have tried to be fair to the Government's record but it is interesting to see a Government who have talked about cutting public expenditure cleverly claiming that they spend more on the public sector than we do when in office. All credit to them. The Government have been elected three times on a programme of cuts in the public sector, targeting help, moving away from universal provision in the Health Service and denying the basis of equal citizenship that everybody in Britain looks for from the NHS. So the Government cannot blame us Labour Members if we look sceptically at some of the statements they make.
I hope that in this short contribution I have not strayed into the Select Committee's next report, as have some members of the Committee, but have related our past report, which is mentioned on the Order Paper, to one of the current crises in the Health Service. It is a crisis that we are debating at a time of celebration of the massive success of the Health Service. I hope, too, that I have pointed one or two ways to the future so that, as the right hon. Member for Plymouth, Devonport (Dr. Owen) said in his impressive contribution, we take measures to ensure that hon. Members 40 years hence may have grounds to celebrate the previous 80 years with as much gracefulness and joy as we are celebrating the past 40 years.
The financial memorandum part of the National Health Service Bill 1948—I have a copy of it here which I obtained from the Library—estimated the annual cost of the Health Service at £152 million. In the ensuing debate one hon. Member warned that the cost just might double in 20 years, but this contrasted with the view of various so-called experts, including Lord Beveridge, to whom reference has been made, that the cost per annum would fall. Lord Beveridge thought that as everyone became more and more healthy we would have to spend less and less, so it would be a case of diminishing need. How wrong he and others were.
In 1948 the cost was £152 million per annum; in 1988 it is £23,500 million. It might have shaken even Aneurin Bevan if he had been told that in 40 years it would have gone up that much, although I think that I should remind Opposition Members, because it adds an interesting footnote to some of the things they have accused us of today, that he said in the Second Reading debate:
it has been the firm conclusion of all parties that money ought not to be permitted to stand in the way of obtaining an efficient health service." [Official Report, 30 April 1946; Vol.422, c.43.]
He said "all parties". I would agree with that, but whose money are we talking about? It must be the Exchequer's
and the taxpayers'. Where the sick person has no money. or only some, or wishes to use the Health Service that money must be made available and there must be no doubt in this House or elsewhere that I and my hon. Friends are totally committed to the continuance of the Health Service. Never would we tolerate, for instance, the American system. The one part of the speech of the right hon. Member for Plymouth, Devonport (Dr. Owen) with which I did not agree was where he seemed to praise the American system because they spend more of their gross national product on health care. He did not mention the fact that it was more of their own money and not the American Government's money. That is a rather important point when one is making the comparison.
The truth is that for a lot more money the American health service is not as good as ours. In that country one member of the family can have a motor accident or a long illness which requires many months or even years of care and that family can be bankrupted by the costs to them. No hon. Member could possibly support that sort of system here. So of course there must be continuing care, free for all who need it and cannot pay.
It is fair to say that the situation has completely changed since 1948. We are a far more affluent country. In those days it was quite rare for a family to have one car, and a two-car family was extremely unusual. Now, it is very commonplace indeed. We see families in which the mother has a car, the father has a car and their two or three children each have a car. There is so much evidence of a very greatly increased standard of living. People did not take foreign holidays very often in 1948. Home ownership is now much wider, as is share ownership. One could go on and on. But with greater affluence there can be no real reason why those who can easily afford to do so should not pay a bit more towards their health care, and much more money is undoubtedly needed for the NHS.
I do not believe that we can tackle the situation by further efficiency drives, although I pay a tribute to those. I add my voice to the voices of others who have said that value for money in the Health Service must be ensured. We have very inadequate methods of defining performance in the Health Service. We have 400 performance indicators. They can tell us staff numbers, types of operations performed and the general costs, but not one of them can tell us the cost of an operation in hospital A as compared with the cost in hospital B. We need to know these things.
It is right to say, too, 40 years on that we have a better Health Service than ever before. To those who ramble on about the crumbling Health Service I can only suggest that they look at the facts. The extension of health care today is quite incredible. We have far more sophisticated medical techniques, much cleverer drugs and infinitely more complicated machines, such as lithotriptors and scanners of all kinds. There is vastly more detailed research and people are being treated and cured today who would have been sent home to die only two years ago. My right hon. Friend the Secretary of State referred to the diseases that have been eradicated since 1948. Crumbling Health Service, my foot; it is a wonderful Health Service.
However, the financial implications of all this are incalculable. These much more sophisticated techniques take a lot more money, as do the very much cleverer drugs and the complicated machines. I gather that the cost of these has gone up far in excess of inflation. I believe that the financial implications are almost impossible to put together. And added to those we have the enormous implications of acquired immune deficiency syndrome and the money that we have to spend on drug addicts. I would not add alcoholism, as the right hon. Member for Devonport did, because we spent money on alcoholism in 1948. I am talking about the new sums of money that we are having to find.
Of course it is right to refer to the tremendous amount of money that must go to caring for the elderly, and if it were not for private nursing homes we should be in terrible trouble.
I do not believe those who say that we can solve all the problems by tossing in a further £500 million or £1 billion per annum. It is not possible to say how much it will cost to meet all the needs of all the people as those needs arise. Nevertheless, I say most earnestly to my right hon. Friend the Secretary of State that our aim should be to treat all seriously ill people at the time when they need treatment. That is more important than keeping to a budget. This is the great dilemma. Do we, with all the extra techniques that have been developed, treat the people who can be treated, or do we keep to the budget? There cannot be any answer other than that we treat sick people, and expand the budget. If we have to expand the budget, so be it and we have to accept that lesson. One of the doctors at the Queen Elizabeth hospital in Birmingham said that he could treat all his liver patients now in the renal department if he had not overridden the budget already. We have to expand the budget and that must be recognised.
Such problems are not ours alone. This week, the British Medical Journal referred to the fact that Norway, West Germany, France, the Netherlands and New Zealand are busily reviewing their health systems because of the problems to which I have alluded.
I want to make one or two suggestions. I believe that the public are prepared to pay more money for the Health Service, but they must see that what they pay goes to the Health Service and does not disappear into the maw of the Exchequer. They do not trust the Exchequer and believe that the money will disappear, but they will gladly pay for direct health care. There are many ways to raise money, such as the voucher system and lotteries. I had thought that lotteries made only a small amount of money, but I had evidence recently that £1 billion could be raised each year. It is money that is there to be taken and it is right that we should do it.
There should be charges for hospitals for those who can afford them. It is the right thing to do. It has been estimated that if a charge of only £25 a night was made for those who could afford it—in the old days the almoners could tell us which people could afford it—that would bring in about £2,000 million a year, minus what it would cost to collect. One could not find a hotel for £25 a night. That £2,000 million is an enormous sum and hospital charges should be considered further because people are ready to pay.
Local functions for local hospitals are a very good idea. Those functions may be held for special causes, such as a CAT scanner or for the Birmingham children's hospital. The generosity of local people for every single local cause is undoubted. They will dig deep into their pockets for any call made by the local hospital. We should consider that further. It is difficult for patients to give money to a hospital to thank it, except through the league of friends. They should be able to make a direct contribution to hospital needs.
People who wish to use private hospitals—and can afford to do so—should be encouraged. I disagreed with my hon. Friend the Member for Suffolk, South (Mr. Yeo) when he said that that would not take a burden off the Health Service. It would take a great burden off the Health Service. I have mentioned already what the private sector does for the elderly. There is a lot of co-operation between the public and private sectors, such as the presentation of a lithotriptor. In some areas, the Health Service is being helped a great deal by the private hospitals and that is a very good thing.
We should recognise how unpopular it is with the public that yet more administrators are employed. In Birmingham, we have been threatened with the closure of a women's hospital yet, at the same time as that closure was announced, the authority asked for £40,000 more a year for two extra administrators. It was very unfortunate that a hospital should be closed while two extra administrators were employed. I do not deny that there is a need for administrators, but more time should be spent in explaining to the public why administrators are needed and why they are not necessarily the big bad wolf. Some of them make the hopitals run more efficiently. However, people do not like the fact that we are spending money on administrators and we should recognise that.
We must have balance in all things. Medical secretaries have been underpaid for years and something should be done about that. No consultant could operate properly without his medical secretary. I suppose that they are administrators of a sort.
I should be letting my area down if I did not refer directly to two of our major worries in Birmingham. At the Queen Elizabeth hospital, the great teaching hospital in my constituency of which I am very proud, a quarter of the beds have been closed. Because it is a teaching hospital, there is another worry: one cannot teach medicine to students when there are not enough patients to show them. If something is not done, we face the prospect of an end to all medical teaching at the hospital in October.
Twenty cancer victims a week are being turned down for admission and that worries me deeply. I should explain that they receive examinations; it is treatment that they cannot get. I reiterate the major point that I wanted to make. If it has to be a choice between finding more money and denying desperately sick people treatment, we must find more money.
Like all the other hon. Members who have spoken, I extend my warmest greetings to the National Health Service on its 40th birthday. On behalf of my colleagues in Plaid Cymru and the Scottish National party, I express the warmest wishes that it will enjoy another 40 successful years and thank all those who have worked, and all those who now work, in the Health Service.
We have heard some interesting historical analyses, and I have listened with interest as the debate has moved back and forward across the Chamber and attempts have been made to claim credit for the National Health Service. That has seemed to me in some way to detract from the debate. As someone who has never been a member of the Labour party and who has no intention of becoming a member of the Labour party, I believe that historically credit must go to the post-war Labour Government for the work that was done and for the single-mindedness and dedication of the men and women of that era who ensured that the legislation establishing a National Health Service as we understand the term reached the statute book.
Many hon. Members, myself included, come from the generation of peace babies and we grew up with the National Health Service. Part of the problem that we have faced over the past 40 years is that many of us have tended to take the National Health Service for granted. There has been an element of apathy in the assumption that what we expect of the National Health Service should be readily available.
I have great personal cause to be grateful to the Health Servious because in my early teens I contracted tuberculosis—a disease that would probably have killed me 20 years earlier. I was in hospital for 13 months and I was given expert treatment. As I lay in plaster from my neck to my toes, I had a whole series of very effective modern drugs administered, and here I am now—a fairly healthy specimen, I think. [HON. MEMBERS: "Hear, hear."] My father was a farm worker, and if he had had to pay directly for that treatment it would not have been possible. In considering the National Health Service, we must think of people who are on such low incomes that they cannot possibly afford such essential treatment.
With my colleagues in Plaid Cymru and the SNP, I believe that the allocation of money to the National Health Service is part of the political decision-making process. There are political priorities. We have heard hon. Members suggest new ways in which to fund the National Health Service. The hon. Member for Birmingham, Edgbaston (Dame J. Knight) has just suggested that people would be prepared to pay more for the National Health Service if they knew where their taxes were going. We can take that to its logical conclusion and argue the Government's political priorities. We can ask people how much they are prepared to pay in taxes to ensure that the NHS exists on the level that we want. I believe that they are prepared to pay much more but would say that the Government's priorities are such that they have no guarantee that the taxation revenue will be spent on the NHS. I know where the Government's priorities lie on the funding of the NHS or of Trident or cruise.
Over the past year or so, NHS workers have asked for only £2 billion—a small sum in the context of the Government's overall budget—yet their request has been rejected. Because of the Government's lack of political priorities, they have denied the Health Service the funding that is its right. Central taxation is a method of funding the NHS which we happily endorse. That is the view of people generally and is not unique to the House. Instead of redistributing wealth and ensuring that money was available to cater for the needy, the Government in their Budget gave handouts to the 20 per cent. richest people and denied the NHS access to central taxation.
It is always interesting in debates on the NHS to note what happens when we talk about the Scottish dimension, because of the difference in administration between England and Wales and Scotland. I am pleased to see here the Under-Secretary of State for Scotland—the hon. Member for Stirling (Mr. Forsyth)—and pleased also to see the hon. Member for Mid-Worcestershire (Mr. Forth), because it always seems right when a Scot is speaking to have a Scot basher sitting opposite.
It is usually argued that the Health Service in Scotland has a higher budget than the Health Service in England and Wales. The level of underfunding in Scotland is less acute than in England. According to the British Medical Association, estimates of the difference vary between 9 and 25 per cent. The BMA's survey shows
that the NHS in Scotland is working hard to stand still
and highlights a number of deficiences.
Cash limiting on equipment purchases has resulted in difficulties in replacing worn out and broken equipment.
The BMA refers to
poor building maintenance and consequent deterioration in the fabric of many buildings and difficulties in recruiting and retaining medical secretaries and medical laboratory and scientific officers.
As hon. Members have been keen to talk about value for money, it is worth pointing out how the money spent on the Health Service in Scotland benefits the rest of the community. In Scotland twice as many medical students are taught as in England and Wales; hospital rates bills are almost four times higher. There is less private medicine, hence a greater dependency on the Health Service. There are vast rural areas in Scotland where, obviously, expenditure must be higher to cater for the local communities. If Scotland needs to spend a great deal of additional money on the NHS, it is perhaps because it has high records in terms of unemployment, bad housing, lack of facilities and poor environment—the issues mentioned by the hon. Member for Birkenhead (Mr. Field) as factors creating many of the problems that necessitate having a Health Service. The Health Service in Scotland is effective. We want it to be maintained. We have a commitment to ensure that taxation is raised centrally to ensure its continuance.
We are all worried about care for the elderly. Those of us who have read the Griffiths report recognise that it is one of the most significant documents on this issue produced in recent years. All of us are sons or daughters and have individual responsibilities towards our parents, but collectively we have a responsibility in society to ensure that a service is available to the elderly.
All of us believe in community care, to which much reference has been made. It is not enough to cast people out into the community and hope that they will survive somehow. It is important to ensure that a variety of facilities is available to cater for the individual needs of our constituents. The Voluntary Services agency in Aberdeen, which is an important agency in the Grampian region, has laid down a series of principles of community care. First, there are the client's individual rights. Elderly people should be supported in their homes for as long as possible and should not be forced to move away from their family environment. Secondly, the elderly person should be seen as part of the family, community and environment. Thirdly, there is the principle of service provision—comprehensiveness, accessibility, co-ordination, continuity, promptness of intervention and prevention. I should like to think that the Department will take account of those good principles when it finally gets round to responding to Sir Roy Griffiths' interesting report.
The hon. Member for Edgbaston referred to private homes, many of which are old hotels and buildings that have been taken over by private individuals. I do not want to go into all the principles involved, but my basic concern is that this approach to care for the elderly may result in those homes having staff with no professional training to cater for the needs of the elderly. Catering for the needs of the elderly goes far beyond keeping them dry, warm and fed. It means stimulation, treating them as the individuals they have been all their lives and ensuring that they lead as full a life as possible to the end of their days. I am worried that there is no way of assessing at the point of entry whether individuals receive the correct treatment and no way of monitoring and evaluating the service in them.
I urge the Government to consider the issue carefully and ensure that there are professionally trained people in those homes. If we must have these places, let us ensure that they reach the standards that we would expect for ourselves and our parents. Let us not treat them as "granny farms" but ensure that they genuinely care for the elderly.
These matters highlight some of the problems that face the NHS. I have tried to emphasise that the NHS expects the House to give a clear lead on how funding will develop. I have not heard from Government Members any statement that encourages me to think that the review will be anything other than a cost-cutting exercise. I hope that at the end of the debate we shall hear positive suggestions which will ensure that central funding of the NHS continues in such a way that we can meet the challenges and aspirations presented to us by the people.
We came to the House today to celebrate a birthday. I am sure that those looking in will wonder what sort of birthday party it is. Some hon. Members have denied that they had anything to do with the birth; some want to claim that they had everything to do with it. Some have said they were responsible, others that they were not.
Then there has been the suggestion that we should all go down to the bookmakers and place some bets and, if we win some money, we might be able to clothe and feed the individual who is now 40 years of age. I am sure that as people watch the debate they will realise that we are a close-knit family. Families say wonderful things, make wonderful suggestions and pass wonderful comments.
Although my politics are poles apart from those of the right hon. Member for Blaenau Gwent (Mr. Foot), we are honoured to have with us one who was at the birth. Having been interested in politics for a long time, I have read quite a lot about those days, and I salute and honour the memory of Aneurin Bevan. He was a man who delivered the goods in the end. While there may be much controversy about the how, when and where, there is no doubt that if it had not been for the push, energy and strength of argument that he supplied we would not be celebrating this birth today.
However, when the right hon. Member for Blaenau Gwent chose to quote from one of his own writings he struck a resounding chord in my breast by mentioning the Jesuits.
As an Ulster Member of Parliament, certain matters concern me; and as the only hon. Member representing Ulster who will be able to take part in the debate I want to make the views that I am putting across as broad as possible. I am sorry to see that we are not graced with the presence of the Parliamentary Under-Secretary of State for Northern Ireland, who is in charge of health and social services there. He was in the Chamber a while ago, but he has now gone. Perhaps he will read my contribution.
The Government amendment states that the Government are
devoting record resources to the Service to enable both hospitals and community services to provide more care than ever before".
I just have to open my eyes to see what is happening to the Health Service in my area. But, first, it is only right that I should pay a warm tribute to all the workers in the Health Service in Northern Ireland, who work through great difficulties. I salute the consultants, doctors, nurses, ancillary workers, ambulance drivers and those who do the cleaning for all that they have done. I know that a small minority during the troubles have not co-operated, and when people who had been seriously wounded by bombs and shootings arrived at hospital they would not even wheel them into the operating theatre. But those were a small percentage. The vast majority merit our support, so I pay this tribute to them.
We have four health boards in Northern Ireland—the Eastern, Southern, Western and Northern. The Northern board covers the area that I and other hon. Members represent in the House. It starts at Antrim and goes right up the coast. It takes in part of Londonderry and stretches into the middle of mid-Ulster. In that area acute hospital services have been located in Coleraine, Ballymoney, Ballymena, mid-Ulster, Larne, Whiteabbey and Dalriada in Ballycastle. Now, under the cuts, all but two of these hospitals are to be axed. No hon. Member could be happy about that.
What are we being offered instead? We are being offered phase 1 of a new hospital at Antrim at the southern extremity of the whole Northern area. It will have only 300 beds. In the northern part of the area there will be an extension to the present Coleraine hospital which, when it is all fixed up, will give us possibly 450 acute beds—for a population of 380,000 people. That concerns the consultants, doctors, nurses, and all who are interested in the well-being of the people of the area. I trust that it will not go ahead.
We have tried in every way to stop the machine that dictates that this must happen. We are trying to get a public inquiry, but it has been refused. The Minister told us that even if the health board disagreed with him he would still go ahead with the scheme, which shows two things. First, there is not enough funding for the Health Service, and, secondly, there is terrible cost ineffectiveness. Phase 1 of the new hospital will cost £37 million, but it will cost £65 million to deal with the road works and all the other servicing of the hospital. Such a sum could be more effectively spent. Some of the people going to the hospital will have to travel, not on motorways, but through pointless winding country roads—27 miles of them in some cases—to get there. That is intolerable to the people of my constituency and of the whole board area.
Another point needs emphasising, too. We need home care for our people. We need the meals on wheels and more home helps. Now they are being cut back to such an extent that people who were able before to have a home help for two or three hours a day are being offered one for half an hour in the morning and half an hour in the evening. That is not good enough for elderly people. Like the hon. Member for Moray (Mrs. Ewing), I am worried about the new care centres for the elderly, which do not provide proper care or professional nursing staff. The Government need to examine carefully what is happening.
The Health Service is the envy of the world. Everywhere I have travelled in the world people have asked me about it and what is available through it. It is something that we should boast about and sell to the world. It is unique to our United Kingdom and it is worthy of all our support. I hope that we shall hear encouraging things after the debate, and I hope that we will all back the Health Service.
I was pleased to hear my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) talking about his experiences in the House when the National Health Service was introduced. I remember as a youngster going along to a meeting on the Sunday before the NHS came into being to hear the late Bessie Braddock talking about the change that was about to take place. The leaflet advertising the meeting was headed "The end of the Poor Law … Come to the funeral of the Poor Law."
The House should be reminded that the introduction of the NHS by Aneurin Bevan was partnered with the introduction of other elements of the welfare state, such as the comprehensive national insurance scheme introduced by Jim Griffiths. With that comprehensive system the Poor Law was ended. What makes people fear for the future of the NHS is that the Government have wrought and are wreaking havoc in the welfare state in many other respects. The social fund is in reality the new Poor Law.
I am grateful to the hon. Gentleman, who is a fellow Scouse. I am following his speech with the greatest interest. Does he agree that, on this the 40th birthday of the NHS and in a debate of such importance, it is a tragedy that the sum total of Opposition Members now present is two Front Benchers and three Back Benchers?
I assure the Minister that this debate would not be taking place but for the Labour party. For one thing, this is an Opposition day. The Secretary of State would not raise a debate on the NHS at this time. We would not be having the debate at all had it not been for Clement Attlee, Aneurin Bevan and Jim Griffiths, but we shall have more and more debates about the destruction of the welfare state under the Tory Government.
I got hold of a copy of the Conservative research department brief on the National Health Service and read about all the marvellous achievements that are supposed to have taken place under the Government. Some of those achievements, however, are hardly to be applauded. The hon. Member for Wycombe (Mr. Whitney) did not mention that, at a time when the Chancellor is telling us that we have a buoyant economy and have created marvellous wealth for our country, only three other countries in the European Community—Spain, Portugal and Greece—spend a lower percentage of their gross domestic product on health care, and those countries cannot claim that they have North sea oil. The future of the Health Service depends largely on the strength of the economy, and people fear for it because of our chronic manufacturing trade deficit.
The people of this country have a right to be suspicious of the Tory party. I was pleased today to hear the Secretary of State speak along much more "consensus" lines than we remember in the past. Perhaps the Tory party realises how popular the Health Service is in this country, and is moving away from some of the outrageous statements made in the recent past by the extreme Right wing. But the Prime Minister's promise in April 1979 that there would be no increase in prescription charges, and the promise in 1980 that there would be no charges for the eyesight test, do not infuse Opposition Members with confidence that the Government will not return to some of the hare-brained schemes—I believe that the Minister has called some of them batty—that have come from the Adam Smith Institute and other extreme Right-wing think tanks.
According to the Institute's Omega report of 1984,
At present, many of the resources of the health service are spent on people who are quite able to pay their own way … Charging … for non-essential 'hotel' services would seem a reasonable way of asking the more affluent to take up a greater part of the health care burden.
The Tories often say, "We shall exempt those who are poor and in need," but the institute went on to say:
However, the temptation to exempt too many groups will defeat the whole object of the exercise—for example, some 31 million people are entitled to free prescriptions … Food and other items would have to be found by the patient whether in hospital or not, and it seems reasonable that the service should not cover completely free non-medical services and comfort trimmings.
[HON. MEMBERS: "Yes."] I hear Conservative Members saying that they agree with that. That is why the people of this country know that the Health Service is not safe in the hands of the Conservative party.
I will tell the hon. Gentleman what is wrong with it. The people are already paying through taxation, based, we hope, on a system that involves the rich paying more than the poor.
The question of food provision in hospitals is a question of providing the right diet as part of patients' treatment. It is revealing that many people say that there are splits among the Opposition. I challenge the Minister for Health, when he comes to reply—he is not here a t present, but I assume that the Parliamentary Under-Secretary is not replying to the debate—to take up the point made by his Back Benchers. Does he agree that there should be charges for food and other so-called "trimmings", as suggested by the Right-wing extremists who now control Conservative Central Office?
The hon. Gentleman can make his own speech.
The Adam Smith Institute also talks about charging for ambulances, saying:
Non-urgent ambulance journeys can also be charged for".
Even the Minister for Health, quoted in The Guardian on 22 December 1987, said that
it would not be unreasonable to consider charging for food. Meals alone cost about £3 a patient a day … Quite a lot of people feel that it is not unreasonable to at least contemplate whether expenditure on food for people who are in hospital and not at home should be taken into account".
Interestingly, Dr. Maureen Dixon, director of the Institute of Health Service Management, said that that was facile, and the British Medical Association also pooh-poohed the idea. [HON. MEMBERS: "Hear, hear."] It does not surprise me to hear Tory Members saying, "Hear, hear." A London Weekend Television poll found that
nearly two thirds of Tory MPs are worried about the NHS",
but the poll, carried out by the Harris Research Centre, showed that
63 per cent. of the 135 Tories questioned … believed that NHS patients should pay bed-and-board charges for staying in hospital. Moreover, 56 per cent. favoured a charge for visits to family doctors, with exemptions for the old and needy. Sixty five per cent. wanted tax concessions for private health insurance.
We are not out of the wood yet, because there is the danger that, following the review, the Government will go for private health insurance and will give firms incentives to provide insurance for their employees. Aneurin Bevan put succinctly the argument against any industrial basis for a private insurance scheme. In "In Place of Fear", he said of such schemes:
they are no substitute for a national scheme. An industrial basis is too narrow for the wide range of medical needs which should be met, both for the worker and for his family.
He referred to the experience under the old approved societies. Such a system would mean two types of health insurance provision—that in the expanding industries and that in declining industries.
Under the present regime, we are moving rapidly towards an increasing involvement of the private sector in health provision. It is an unplanned expansion and there is no co-operation between the public and private sectors. More and more private nursing homes are blossoming, and they are being created without any thought of the need to plan properly. In the Mersey region, in two of the hospital areas—Chester and Fazakerley in Liverpool—private nursing homes are being opened. No doubt they will make profits for health care firms, but there will be no real concern for monitoring the provision of these services. In south-central Liverpool, 2,500 elderly people are in private nursing homes, but at what cost to the DHSS?
The NHS has to service these homes, and local doctors have to treat people in them. However, the family practitioner committees have no part in the planning or monitoring of the services provided by these homes. There is no formal complaints procedure and the community health councils have no say in the workings of these private nursing homes. The health authorities do not have the manpower to monitor whether they provide proper catering and accommodation and whether the medical treatment required by elderly patients, such as physiotherapy, is being provided.
I hope that the Minister for Health will look at the issue of proper funding of the ancillary services in hospitals. So far, he has set his face against agreeing that the recommendations of the review bodies on the pay for health staffs will be fully funded by the Government. If they are not, there will be a continuation of the strains on nurses in hospitals. In its report, the Select Committee says that it was told by the Royal College of Nursing that studies in two areas—St. Thomas' hospital in London, and Southampton—showed that nurses spent 40 per cent. of their time on non-nursing duties such as taking patients to and from departments, collecting medical notes, collecting incontinence pads and doing the sort of work that other helpers should be doing. Although it is important, pay is not the only reason for the difficulty in recruiting nurses. A bigger problem is the burden on nurses who have to work long hours, often dealing with difficult patients and doing other people's work.
The low pay of ancillary staffs and all those who are part of the collective health team upon which the treatment of the patient depends should be greatly improved. Over 30 per cent. of the wages bill of the NHS goes on ancillary staff, so it is incumbent on any Government who believe in maintaining standards in the NHS to fund that improvement in full. I hope that the Minister will say something about this.
It is difficult for people with the sort of philosophy that is dominant in the present-day Tory party to consider what is needed in the fight against disease and to help those who are suffering. That involves the philosophy and values not of the yuppie mentality, the "Ioadsamoney" mentality, or the stock exchange, but of something much higher in humanity, which fills those of us who believe in the NHS. I know that, in the words of Aneurin Bevan——
Yes, again. In his "In Place of Fear" he spoke about
the massive contribution the British Health Service makes to the equipment of a civilised society. It has now become a part of the texture of our national life. No political party would survive that tried to destroy it.
That truth may be getting home to the Secretary of State. I hope that, no matter what other destruction is wrought on this country by the most evil Government that we have had this century, they have learnt the lesson from popular opinion that they dare not destroy Britain's Health Service.
It is a pity that the hon. Member for Liverpool, West Derby (Mr. Wareing), having obtained a copy of the Conservative party briefing for this debate, did not read it. Had he done so and contributed to the debate from it, he would have made a rather more constructive speech than the extremely unhelpful and in many respects inaccurate one that he made.
The 40 years of the NHS is a cause for celebration. We have a good story to tell. A debate in the House is the opportunity to tell it and to look to the future. That is exactly what my right hon. Friend the Secretary of State did in an effective and wide-ranging speech. What have we heard from the Opposition? Over the weekend we heard the Leader of the Opposition, and today we heard from the Opposition Front Bench spokesman, the hon. Member for Livingston (Mr. Cook) and the hon. Member for West Derby, each of them with a catalogue of gloom, doom and criticism. Have we heard one word of constructive comment from them?
I shall refer to the hon. Member for Birkenhead (Mr. Field) in a moment.
One wonders whether some Opposition Members have read the Health Service report for 1986–87 and absorbed some of the facts and figures in it. It shows that there has been increased expenditure on hospitals and family practitioner services and that £960 million has gone on capital expenditure. Have the Opposition seen the figures of additional funds released by the sale of surplus land and of cost improvements that have released cash for patient care? Do they not accept that we are now spending £45 million a day on the NHS? It is treating more patients than ever before. There are more doctors, dentists and nurses, and they are better paid. The facts are completely different from the picture that the Opposition seek to draw.
After 40 years, this is a good time to consider the structure, funding and functions of the National Health Service. Many changes have taken place in those 40 years. My hon. Friend the Member for Eastleigh (Sir D. Price) referred to the change in the age composition of the population. There have been enormous changes in the treatment and the methods available. Sophisticated and expensive drugs and surgical techniques that were undreamt of 40 years ago have become available in the past few years.
It is right that the Government should be reviewing the structure, functions and funding of the Health Service. It is also right that the Social Services Select Committee, of which I am a member, should be reviewing it. Is the Labour party reviewing the National Health Service? We look in vain for any new ideas. We have heard none today and there are certainly none in the motion. As is so often the case, it is the Conservatives who are progressive and who are putting forward the new ideas. It is the Labour party that remains conservative. Its only policies are to oppose any new ideas, and simply to demand more money.
I agree that more expenditure is needed, and we have said as much in the Social Services Select Committee. I shall not argue with the Minister for Health or the Secretary of State about how much that should be or how it should be calculated. However, I notice that, although the Secretary of State sometimes disputes the Select Committee's conclusions, he has occasionally made extra funds available. I should like to think that our conclusions are having some influence on him. I certainly argue that the extra funds should be for specific purposes. We will not solve the problems of the Health Service by simply throwing money at it.
I should like briefly to examine four areas. One is information technology to which the hon. Member for Birkenhead referred. The House will have realised how fortunate we are in having the hon. Gentleman as Chairman of our Social Services Select Committee after his well argued and reasoned speech. His was the exception to what I have said hitherto about Opposition Members' speeches. Information technology is now widespread in industry and commerce. The National Health Service is a huge undertaking, yet it is way behind in its use of information technology. It will have to catch up.
I welcome the plans to introduce the family practitioner service's data communications network that will enable GPs to communicate with each other and have access to National Health Service data. I welcome, too, the introduction of resource management trials in various hospitals. They will enable consultants and managers to know the cost of operations and treatment—something that they do not know at the moment. They will give managers the tools of cost control and will also make practicable the operation of the internal market. They will also streamline the way in which consultants can handle patients. For example, they will be able to arrange a series of tests of a patient in one step, simply by pressing a button or two, instead of spending time completing a whole series of forms.
Resource management will benefit the patient and lead to more efficient use of the skilled manpower in the service, but it will be expensive. In one health authority that the Select Committee visited, we were given a figure of £3 million to £4 million. That expenditure will, of necessity, be phased and it must in the long run be to the benefit of the National Health Service and all its users.
Secondly, we must make greater use of the private sector. We have seen examples today of the Opposition's Pavlovian reaction to any reference to the private sector, although it is interesting that many members of the Labour party are happy to use the private sector, and, of course, some 40,000 trade union members are covered by private health insurance.
The Labour party is fond of referring to the proportions of GDP that are spent on health expenditure. It is interesting that, as a country, we spend rather less on health care as a proportion of the GDP than do many others. We should encourage more people, who can afford it, to spend more of their money on private health.
There is ample scope for more co-operation between the private sector and the National Health Service in both directions. There are many examples of where the National Health Service has contracted out to the private sector for operations, such as hip replacement. Similarly, the private sector is using the National Health facilities on a cash basis, obviously to the advantage of the NHS. The problem is that in many parts of the country local political views and political appointees on the health authorities prevent that co-operation from developing.
Thirdly, the pay increases to the nurses have been widely welcomed. We must now study the problem of the ancillaries' pay. For example, I have in mind the MLSOs and medical secretaries, who perform a vital role. Many consultants rely simply on women who produce their notes out of a sense of personal loyalty and dedication to the service—certainly not for the money they receive. They could do far better by going down the road and working in the commercial sector.
I would like to take this opportunity to draw particular attention to the profusionists. Hon. Members may not be familiar with them. There are only 140 in the country. In laymen's terms, their job is to attend to the equipment used for pumping blood around the body during heart surgery. I suppose that, if one has to define them, they are a cross between clinical technicians arid anaesthetists. They form an integral part of a theatre operating team and without them heart surgery would stop, yet they are on the PTBE grade—the lowest grade. A top profusionist earns half the salary of a top radiologist. Like other ancillaries, they are vital to the NHS, and it is important that we should consider their case. I am sorry that the Secretary of State did not feel able to meet a deputation from the profusionists. I hope that after my remarks he will be prepared to reconsider that.
The fourth area is that of preventive medicine. It could be the subject of a speech in itself, but I simply confine myself to welcoming the documents recently produced by the Health Education Authority and its efforts to promote the "look after your heart" campaign.
As chairman of the parliamentary ASH group, I draw attention to the largest avoidable cause of disease and death—smoking. I pay tribute to the work of ASH in trying to promote its cause. I suggest that a modest increase in funds to both those bodies would reduce the demands on the National Health Service, whose 40 years of success we are pleased to celebrate today.
I am pleased to take part in this debate. We are celebrating the 40th anniversary of the Health Service. We must express our appreciation for the work that people in the Health Service do on behalf of patients.
The hon. Member for Chislehurst (Mr. Sims) referred to the Secretary of State's speech and the value of private medicine. I suggest that the right hon. Gentleman is blinkered. He mentioned the history of the service but had to have his attention drawn to the fact that he had not mentioned its architect. Only after provocation did the right hon. Gentleman accept that he had made an error in not referring to Aneurin Bevan.
The hon. Member for Chislehurst is effectively saying that if a person is wealthy he can afford to buy health. My constituency covers three health authority areas, one of which, Wakefield, is going through a traumatic period—and it has been since we had the salmonella poisoning outbreak at Stanley Royd hospital. The oubreak arose as a result of inadequate funding with which to provide a proper kitchen for hospital meals. Nothing has changed very much.
I invite Conservative Members to come and see what is happening in my constituency. They would see how the health authority has been starved of the resources necessary to provide the patient care that everyone screams we should have. If Conservative Members are sincere, I suggest that they visit Wakefield.
On 16 June, I received a letter from the Minister for Health. It was a copy of a letter that he had sent to the chairman of the health authority. I wrote to the Minister asking to meet him because of what he did not say in that letter, but the meeting has not been arranged. It appears that the Minister is afraid to discuss what is happening with Wakefield health authority because of what would be revealed. It would become clear that what the Secretary of State said today is a pack of lies and that nobody can believe what the Tories say about defending the Health Service. What is happening in Wakefield should be revealed.
We asked for an independent inquiry into the area's management, but it has been refused by the Minister. An inquiry is being carried out, but by the regional health authority. That cannot be fair or reasonable because of the authority's interest in the matter. There will be tremendous rancour in my area when the report is published because it is clear that the inquiry's findings will not be in the best interests of the area. There will be tremendous shortfalls in its recommendations.
On the evening of Sunday 26 June, in the cardiac ward at Pinderfield hospital, all the patients were aroused because staff came in saying that they wanted more accommodation. People had to be moved—at 11 pm on a Sunday. The health authority is being reduced to that because it is not being allowed sufficient resources. Unfortunately, a patient died that evening.
A constituent who had suffered a couple of heart attacks suffered another over the Christmas period and was refused admission. That person died shortly afterwards. Imagine how distraught a person's wife and family are when he needs help but cannot receive it. People cannot receive help because the health authority has had to cut the number of beds in the unit to meet budget proposals. That is the kind of Health Service that Conservative Members say they support. Heaven help us if that is how the future develops.
We are told that resources necessary to meet requirements are now available and that people who can afford to go private ought to do so. A constituent came to see me on Saturday. She has wanted treatment and hospital care for some time. In a statement she sent to me she says:
It was the first week in December 1987. My leg had deteriorated rapidly and there was a distinct shortening. Dr. Gaunt gave me no choice of consultants saying only that she would ask Mr. Ghali to see me as he had a very short waiting list and I would be seen before Christmas … She told me I could have physiotherapy on the NHS. I would also be fitted with a heel lift for my rapidly shortening limb. I was grateful for this as I live on a very narrow income with little stretchability to include private treatment of any sort. Alas, that promise was unfulfilled. Towards the end of January I received an appointment to see Mr. Ghali in June!!! I rang his secretary thinking there must be some mistake; I was told that had Dr. Gaunt put 'URGENT' on the request I would have been seen much earlier. Back to Dr. Gaunt … She refused to request an urgent appointment and said the only way I could be seen earlier was by seeing Mr. Ghali privately at Methley Park. I again pointed out the limitations of my income and also my principles which baulked at private treatment. However she refused to enter into any more conversation and unhappily I had to agree to the private consultation. An appointment was then obtained within 48 hours.
The House should remember that she was given an appointment for June in January. The statement continues:
I had a 20 minute consultation with Mr. Ghali and within a couple of days had received his account for £50, he had my cheque by the weekend … He assured me that I was now on the waiting list. I asked whether it would be possible to be transferred to another health authority with a shorter waiting list. I was prepared to go anywhere in the country. Mr. Ghali replied he has the shortest waiting list in the land—from 6–9 months. My leg was then 1½" shorter. Mr. Ghali promised me a heel lift and physiotherapy in the meantime.
We have heard today that that can be done.
My leg now began to deteriorate rapidly, the shortage increasing to 2" at which point I had a heel lift fitted privately, within two weeks I could no longer put my foot to the ground again and the shortening had increased to 3" … I wrote to Mr. Ghali now fearing that my limbs would not be brought into alignment. By this time, it was April and I had previously seen Mr. Ghali in February at Pinderfield under the NHS. He reassured me that my place was safely on the waiting list and again promised a heel lift and physiotherapy … these
promises never took place—hence—my own purchasing of heel lift. Mr. Ghali failed to reply to my letter but within 10 days of my writing him I had an application form from Mercantile Credit for a financial loan, this came unsolicited by mail; one of the 'benefits' outlined was that of private surgery … In my letter to Mr. Ghali, I had included the sentence: 'I do not have the financial resources to seek private treatment"'.
That is the kind of situation that is developing. Patients who admit that they do not have the money to buy private medicine are being canvassed by moneylenders to mortgage their future so that they can have private medical care.
That is Thatcher's Britain of 1988. The Secretary of State buries his head in the political sand. I challenge the Secretary of State, the Minister for Health and the Under-Secretary of State to come to my area. I will introduce them to case after case similar to the one to which I have just referred. When Conservative Members tell me how they see the Health Service, I tell them that they are blinkered and indoctrinated with Tory philosophy. My constituents will receive treatment only if there is an end to Tory doctrine. That is the only way to make the Health Service free at the point of need. Until the Government do that, the Health Service will not be run satisfactorily.
I add my plea to those of my colleagues and of the leader of my party for additional resources. The £2 billion requested last year should be channelled into the Health Service. We had a windfall last year and certain moneys were allocated to the regions. The sum of £4·5 million was allocated to the Yorkshire region. The £230,000 allocated to the Wakefield district health authority was channelled into the cook-chill system, which has caused so much antagonism in my area. The money did not go to patient care. It went to meet the shortfall of a system that is being introduced against the wishes and interests of patients in that area. The money was spent on an idea put forward by the district manager that we should have a cook-chill system in hospitals rather than traditional meals.
Conservative Members should wake up and realise that what is happening in the Health Service is not the rose-coloured development to which the Secretary of State refers. The real world is what the patients are having to suffer. If Conservative Members do not believe that that is the case, I invite them to come to my constituency and witness for themselves what we are having to go through.
The hon. Member for Normanton (Mr. O'Brien) has given us an impassioned and obviously heartfelt criticism of what is wrong with the Health Service. However, in common with the speeches of all his other hon. Friends, except the hon. Member for Birkenhead (Mr. Field), his speech failed to contribute anything new to what might be done about the problems of the Health Service. In such a debate, on the 40th anniversary of the Health Service, when a deep and serious review by the Government is under way, one would have thought that we could have looked to the Opposition for some constructive thoughts and ideas. We do not expect that from the Leader of the Opposition. I do not think that he is given to deep thought on that or other matters.
We expect the catchphrases and shallow polemics that we heard on Sunday. The hon. Lady will get a chance to make her speech in a moment.
The hon. Member for Livingston (Mr. Cook) is one of the intellectual heavyweights in the shadow Cabinet and we might have expected something a little more constructive and heavyweight from him, instead of which we had his usual witty and eloquent speech poking fun at the Government's review. We heard nothing new or constructive. He appeared to echo what now seems to be Labour party policy on the NHS, that the Government should have spent the £2 billion used in tax cuts on the NHS. Hon. Members may believe that, but, if we had a Labour Government, we would not have the £2 billion. That has come from the fact that the economy has grown for the past eight years whereas, with a Labour Government, it would not have done so.
We had some lecturing on history, not least from the right hon. Member for Blaenau Gwent (Mr. Foot), who took us on a nostalgic tour of the late 1940s. Although he describes that period eloquently, I do not believe that he has ever moved out of it. With all the talk about Aneurin Bevan, the 1940s and what the Labour party did to fund the National Health Service, one wonders whether the period from 1974 to 1979 existed. In the rewriting of the history of Socialism, have the Labour Governments of Harold Wilson and Jim Callaghan been obliterated?
Conservative Members take it ill from Opposition Members when they criticise us about underfunding. When the Labour party was responsible for those matters in Government, it cut spending in the Health Service and completely halted the hospital building programme. Lectures from Opposition Members on those matters come very ill and appear extremely hypocritical.
There is no doubt that, whatever is wrong with the Health Service, in the past five years, more doctors and nurses have treated more patients more efficiently than ever before. One may ask oneself how that fact compares with the fact that beds are being closed and the public and many doctors are unhappy about what is happening in the Health Service. I want to make a constructive suggestion about one of the things that the Government might do in their review. The causes of what is going on are a combination of medical advances, an aging population and, quite correctly, higher expectations of people about what the Health Service might deliver to them. The Opposition pretend that it is simply a question of money, but that is not true. In real terms, the Governnent are spending £5 billion more than was being spent in 1979, yet some problems still remain. The idea that another £2 billion or £3 billion will solve that problem is simply incredible.
Potential demand is being fulfilled, but we need some form of rationing, by queue, price or regulation. In the Health Service, we have it by queue and in the private sector we have it by price. I prefer queues to prices in that connection. My right hon. Friends the Prime Minister and the Secretary of State are right at this point to conduct a serious review and I hope that they are considering the objectives of the Health Service. Those are crucial. We must decide what we are trying to do and what we cannot do with the Health. Service and its funding. However. the structure of the NHS is the most important point to which I wish to address my remarks. There is no point in deciding whether we should spend any more money before we have decided whether we have the right structure in place for delivering the service.
I and all my hon. Friends remain thoroughly and wholeheartedly committed to the Health Service, but that does not mean that it must be delivered in the form in which it is presently delivered. I wish to make a plea to my hon. Friend the Minister and to my right hon. Friend the Secretary of State for a move towards the establishment of an internal market. That would get us around some of the difficulties over the present administration of the Health Service which is necessarily bureaucratic and monolithic. There is little or no consumer choice and no competition in pursuit of efficiency. That question of efficiency is crucial to how much money we should spend.
Considerable advances have been made in management, with doctors becoming involved in the costs and choices that face them, but various matters raise considerable doubts in one's mind. For example, bed occupancy varies from 70 per cent. to 90 per cent. between district health authorities. The average length of stay varies from three and a half to 11 days. The recent National Audit Office study of the use of operating theatres came to the amazing conclusion that the average daytime weekly theatre usage is probably in the range of 50 to 60 per cent. We are told that the United States has a substantial overprovision of health services in many areas because of doctors' incentives to sell them, yet they manage to get by on six hospital beds per thousand people, whereas we have eight.
The performance indicators produced recently by the DHSS are perhaps not as reliable as we should like them to be, but I should like to take three of them which illustrate my point that there are enormous discrepancies of cost in different health authorities. If we take the cost per case as a percentage of the average, after having been adjusted for case mix and mobility, in the South-East Thames region there are variations between Camberwell in south-east Kent, at 3 per cent. below the national average, to Dartford and Gravesham, which is 115 per cent. above. That is a 20 per cent. variation in one region and there are similar variations between health authorities across the country.
The cost of providing the hotel service on a per bed, per year basis, varies among regions. In East Anglia, it is just over £1,000 and in north-east Thames it is just over £1,700. That is a variation of 66 per cent. Within the South East Thames region, the lowest is Maidstone with £895. The highest is a health authority which is well known to the hon. Member for Peckham (Ms. Harman) and myself, with £4,487. That is a factor of five. How can it cost five times as much in one authority as it does in another? The statistics to which I have already referred show that the highest costs are not always to be found in inner London. Camberwell is one of the cheapest areas on the basis of cost per case. There must be something radically wrong if one authority can do something for a fifth of the price of another.
I shall take one more example, and that is expenditure on linen, or laundry. There is a variation from £6·50 in Oxford to £10·90 in the South West Thames region. That is a variation of 67 per cent. Within the South East Thames region, the most expensive area is Eastbourne, with £14·80. The cheapest area is Hastings, which is next door, with £4·40. How can it cost three and a half times as much to provide a linen service for a hospital in Eastbourne as it does in Hastings? I suggest that these massive discrepancies should make us ask ourselves whether services are being provided as efficiently as possible.
No. I am sure that the hon. Lady will have the opportunity to make her speech. I wish to be brief.
There are no clinical unit costs available. It would be interesting to know the cost of a hip replacement in one area compared with the cost in another. Those are figures towards which an internal market must work. The old DHSS performance indicators, which were issued in 1982, contained such figures. The cost of a maternity case varied throughout the country from £215 to £690. It would seem that the discrepancies in unit costs are repeated in clinical areas as well. We cannot escape the conclusion that if the best practice were followed, or if the 20 per cent. best practice were followed across the country, we would obtain much more health care for the money that we are spending. That is why I suggest to my hon. Friend the Under-Secretary of State that we move towards introducing an internal market. It would expose cost discrepancies, and competition between the providers of care within the market would encourage best practice. We would have smaller management units. The Health Service is enormous, and the British are terrible at running large organisations. I believe that smaller units would be much better run.
A free service does not necessarily have to be provided by the state. I believe passionately that we should have a free Health Service, but it does not have to be provided by the state. The private sector virtues of competition and the promotion of choice and efficiency can be introduced within a free state service, and that is being done in education. The purpose of some of the reforms that we are introducing in education is to promote diversity, choice and efficiency. That can be done within the Health Service too, while it remains a free service.
In the internal market that I have in mind, the money would follow the patient. The job of district health authorities would be to buy health care, in some instances from public hospitals and in others from private hospitals and charitable hospitals. National Health Service hospitals would become free-standing institutions competing for patients. The district health authority would be able to compare costs and negotiate the costs of what it would obtain from the various hospitals. It could obtain the combination of the best service that it wanted at the lowest price. That is not open to an authority now when budgeting is done on a block basis. I believe that choice would develop as hospitals specialised. The costly duplication that we see now would be eliminated, or at least reduced.
To some extent, that is happening already. It is not a revolutionary idea. I should like to pretend that it is and that I thought of it, but it is not. The NHS buys all its drugs and supplies in the private sector. We do not feel that it is necessary for the NHS to produce those items. Many of the fees for private nursing home treatment for what would otherwise be NHS patients are paid by the DHSS. In Guy's hospital, which is in the district that contains my constituency and that of the hon. Member for Peckham, the private wing never made any money and caused many problems. The management of these wings was handed over to a private hospital, which is now making some money from it. The two hospitals buy and sell services from and to each other. Pathology and X-ray services are sold to the operators of the private wing. It is an arrangement which helps both hospitals. There are many examples of district hospitals buying and selling services to and from one another and from the private sector. In 1985, the last year for which I have figures, 28,000 NHS patients were treated in private hospitals.
One of the most interesting examples is the establishment in Wales of a renal dialysis unit, which was put out to tender to a private company. Tenders were invited on a cost per case basis and the unit cost was reduced from £120 to £80. The unit was built and was running in six months. Any of us who are trying to secure capital improvements for our local district hospitals through the region and the Department know that that process has to be measured in years rather than months.
The practices which I have described should be extended further. The district health authorities should be used as the engines for developing an internal market. This is not something that can be introduced in the form of a big bang, but it should be allowed to grow. It is crucial that district health authorities should be told in their budgeting that they are not to give a block grant of £30 million to one hospital and £22 million to another. Instead, they should be instructed to buy costed and budgeted items of service from the units that are providing the services. The creation of an internal market in health care would promote efficiency and choice, which we all want to see. It would be more likely than the present system to provide patients with what they want. It should deliver more health care for the same amount of money. There would still be rationing and there would be difficult choices to make, but at least we would know that money was being spent to the maximum effect.
I welcome the opportunity of participating in the debate. The day began for me by watching the Under-Secretary of State on television. Like me, the hon. Lady was a member of the previous Select Committee on Social Services, and she criticised the present Committee because it is looking for more money. I assure her and the House that the Select Committee is like its predecessor in that it is determined to examine the issues and report accordingly. If we request more money, it is because the evidence thus far shows that that money is needed.
As I said yesterday during the press conference, the Committee's first report was criticised for producing an arbitrary figure that was plucked out of the air. Since that figure was published, we have discovered that the Minister has graciously pumped quite substantial sums into the Health Service. I said at the press conference that I do not mind what words are used by the Secretary of State as long as his actions speak louder than those words.
As we pay tribute to 40 years of the National Health Service, it is not amiss for any of us to examine in detail what is going on. I have no hesitation in saying on behalf of the people of Northern Ireland that we know the benefits of the Health Service. For 18 years before becoming an hon. Member I ministered in the congregation of which the first Minister of Health under the Health Service, the late William Grant, was a member. He was a Labour Unionist who was concerned to find the best services for the people at the best rates.
During my life I have seen tremendous changes from the days when I was a patient in the old fever hospital. It stood on the City hospital site, where there is now a magnificent tower block to serve the people of south Belfast. I pay tribute to the work that has been done. However, in the NHS, as in Parliament, the Church and every part of society, there will be excellent workers arid the mediocre. There will be dedicated nurses and others who will be looking for Mrs. Brown every half hour of the day. For those who do not know what Mrs. Brown is, may I say that it is a code term for a cup of tea. We pay tribute to what has been achieved but we recognise the disparities that arise.
It is not enough to look back nostalgically and to think of the past as being wonderful because, in my judgment, there was from the very beginning an arbitrary figure snatched from the air for the service's funding, and we have never fully recovered from that.
Accordingly, if I may follow the hon. Member for Lewisham, West (Mr. Maples), the recommendation to which the hon. Member for Eastleigh (Sir D. Price) referred in his reasoned address pinpointed one of the Health Service's great needs, which is for better information technology. Anyone who imagines that the Select Committee was being unreasonable in suggesting that it would take another £1·8 billion to meet the Health Service's current pattern and improve it should remember that subsequent evidence has confirmed that reasoning.
It is exceedingly difficult to know the state of progress in every district, because some districts do not know what state they are in. In addition, judging by some of the answers I receive from the Department in Northern Ireland, which is much smaller than the equivalent Department in England, it also does not know the answers to all the questions. We are told that the best parliamentary question is the one to which one knows the answer before asking it, because time and again we discover that the Departments do not have the answers.
If there is to be an internal market, the district authorities must be supplied with the right tools. Only then will they be able accurately to price their services. I speak from experience. Even in a small community such as we have in Northern Ireland, the services provided by the Eastern board to the Western board are often discounted, because that is easier than going through all the paperwork that is needed to make a charge for them. When we speak of an internal market, we must also bear in mind that aspect.
Reference has been made to variations in the costs of providing linen and other laundry services, but we need more information before reaching an objective conclusion about the reason for such differences. It may be because of privatisation. In the previous Select Committee, we discovered that under privatisation someone had overlooked that redundancy payments might be necessary, and a figure of £15 million was ultimately suggested to us as being the sum required. We also discovered that some people employed in cleaning and laundry services in one district health authority had moved to another without receiving a redundancy payment. When making decisions, we must be careful to consider their consequences.
While we have remarkably good services in Northern Ireland, to which I must pay tribute, they are under pressure. This year, the Eastern board is looking for £7 million out of savings to meet current expenditure, but that will be impossible to achieve without making any cutbacks. The Minister responsible for the Health Service in Northern Ireland said that its health care budget is proportionately about 25 per cent. greater than in England and Wales. However, that must be put in its proper context. No more than three months ago I had the privilege of being treated as a National Health Service patient in the Royal Victoria hospital, which not only has the problem of high numbers of clamouring patients but the tragic security situation and the extra expense that it entails.
For example, I had to be accommodated in a secure unit. As a result of terrorist activity, there has been a tremendous technical advance in treatment, which is undoubtedly one reason why the Eastern board incurs nursing charges for north-west Belfast, in the Royal group of hospitals, that are much higher than for others. They provide intensive nursing treatment. In that context, it is tragic that in the years 1985–86 and 1986–87 there has been a reduction in real terms of about 4·1 per cent. in the budget. If we are to continue making proper provision at the point of need, we dare not curtail those services.
I am grateful for the opportunity to participate in today's important debate, but I hope that the hon. Member for Belfast, South (Rev. Martin Smyth) will forgive me if I do not follow his remarks. I am also sorry to see that the hon. Member for Southport (Mr. Fearn) is not in his place—I see that he is just entering the Chamber. I was mesmerised as he tripped the light fantastic around the SLD's health policies. Last year, I fought a Liberal candidate and thought that I had some view of what the alliance's policies were. However, the swerves and U-turns made this evening have confused and bewildered me. I suspect that that is symptomatic of the SLD as a whole, and that none of my hon. Friends has been enlightened as to its health policy.
The Opposition are to be congratulated on initiating a debate on the 40th anniversary of the National Health Service, as it is singularly appropriate today. I join in agreeing with that part of the motion congratulating present and past staff of the National Health Service on their tireless and unstinting work on behalf of the sick and the elderly. Their dedication and devotion to duty shines as an example we must all seek to emulate.
It was probably Miss Elizabeth Taylor who claimed that life began at 40, but that was not true for the National Health Service. Life began at its birth 40 years ago, and in every year since 1948 it has met the challenges and has improved. It has gone from strength to strength, so that it now provides a wider range of services and health care, meeting the challenges of changes in medical science and technology that were not foreseen or envisaged when Beveridge and Bevan dreamt up and then enacted the National Health Service in the late 1940s.
I unstintingly support the National Health Service and use it exclusively—or inclusively—for my own health care, because I have found that it is excellent in the services that it provides. I have found also that my constituents, who are blessed with two excellent hospitals in the area, are confused and angered by the Opposition's constant attacks and carping purely for political gain.
However, I cannot agree with the majority of the sentiments expressed in the Opposition's motion today. It is not in the interests of the NHS merely to throw money at it willy-nilly. That might result in short-term political gain, or even reach tomorrow's newspaper headlines, but it does not go the heart of the problems that people claim exist in the NHS.
Given the record £23·5 billion that is spent on the Health Service each year, we should consider whether it is as efficient as it should be. I cannot believe that with such a large budget its efficiency is as good as it should be in areas such as drugs, energy and the managing of the hospitals and the consultants. I pay tribute to my hon. Friend the Member for Wokingham (Mr. Redwood), who has produced figures on the effectiveness and efficiency of NHS staff.
If more and more money is thrown at the Health Service without looking at what happens to that money, people will, as in "Oliver Twist", constantly be coming back for more and more without ever tackling any fundamental problems. That is why the Opposition's motion is so depressingly negative. It offers nothing new or positive and, ultimately, nothing realistic for the Health Service's needs in the next 40 years.
Let me deal now with some of the figures that illustrate the wide variations in the service that is being provided in district health authorities which suggest to me that something is wrong with the efficiency of the Health Service and need to be looked at.
One of the greatest complaints, as has been mentioned, is about waiting lists. It is extraordinary that the Health Service does not know the correct figures for waiting lists. They may ay be up to 20 per cent. wrong because people either do not bother to turn up for appointments or they move to another district health authority without informing their previous health authority so that they remain on its waiting list, at the same time joining the waiting list in their new area. That exaggerates the figures and builds up the waiting lists. It is odd that the Health Service cannot even get that right. A private business with little control over, to put it crudely, its stock would be in serious trouble fairly quickly.
The waiting lists remain longer than they should be because there is too little interaction between hospitals and health authorities which may be able to swap and inter-marry their services. One health authority may have a long waiting list for one type of treatment but not for another of which another authority could make use. There could be greater inter-marriage between health authorities and between the NHS and the private sector. The Health Service could use its power as a bulk purchaser to buy services from a private hospital that might not be particularly busy at a given time.
The cost variations throughout the country of different services are a national scandal and should be looked at closely. The number of ancillary staff needed per 1,000 in-patients in Milton Keynes is 5·7 whereas in Halton it is 41·3. The number of administrative and clerical staff per 1,000 in-patients in Scarborough is 8·6 while in Halton it is 46·7. The number of nursing and medical staff per 1,000 in-patients in Scarborough is 39·4 while in Halton it is 160·9. The cost per case for medical records at the West Cheshire hospital is £24 per patient. At the Charing Cross hospital in Hammersmith it is £124. The cost of drugs per patient in Scarborough health authority is £21·50 per patient on average, while in Hampstead it is £153·50 per patient.
Clearly those figures highlight the need for improvements and for cost savings so that the money saved can be targeted towards other parts of the Health Service that need funds to expand their services to meet greater demand without any reduction in health care. That is what we should be looking at, and I am sure that the Department of Health and Social Security, under my right hon. Friend the Secretary of State for Social Services, is doing that.
There are other ways in which savings can be made without any adverse effect on health care, and I trust that the review is considering them. I should like to mention additional funding for the Health Service. I am not talking about the money that the Government provide year in, year out. I mean genuine additional funds from outside the NHS. I believe that a single National Health Service lottery should be introduced to harness the goodwill and the energy of people who already raise money to buy a kidney machine or a CAT scan. Once the scheme is up and running, and as long as the Treasury keeps its paws away from it, in the fourth year of a properly run lottery £1 billion extra could be raised to be spent on equipment that people can identify with. I see nothing wrong with that, and I urge my right hon. Friend to consider it seriously.
The Government have just enacted the Local Government Finance Bill introducing a community charge for financing local government so that every individual knows what local government is costing. I believe that a similar charge should be introduced for the National Health Service. Few people have a clue as to how much they are paying from their taxation. Few people know that the average family pays £32 per week towards the cost of the Health Service compared with £11 in 1979. The average family's weekly contribution has increased by £21, and that shows our commitment to the Health Service. We must bring home to people the cost of the Health Service so that they can decide how they want their money to be spent, and whether they want more money to go to the Health Service rather than to other services. This matter deserves serious consideration.
I shall support the Government's amendment because fundamentally it is more constructive in considering the Health Service than the Opposition motion. I look forward to the announcement of the review that my right hon. Friend the Prime Minister has instigated and is expected to take place later this year. I hope that it produces constructive ways of tackling any unease felt by Opposition Members about the Health Service.
I shall be very brief. Many statistics and case histories have been bandied about during the debate, and I certainly do not intend to repeat them. But I cannot resist reminding the Opposition, since it was their choice of debate, that more is being spent on the Health Service than ever before, more patients are being treated, more professionals are being employed and there are more areas in which this country is leading its counterparts in terms of research and medical performance. All that is accompanied by the largest-ever hospital building programme in the 40-year history of the National Health Service.
I wish that the hon. Member for Wakefield (Mr. Hinchliffe) was present because he offered a challenge to all hon. Members to visit his constituency and see what he described as the crumbling Health Service. I should like to invite him, or any other Opposition Members, to visit my constituency to see the investment of £31 million in the West Norfolk and Wisbech health authority in the past nine years in capital building and the doubling of funds to run the Health Service for my fortunate constituents in south-west Norfolk where the terms "crumbling" and "crisis" would be curiously misapplied.
On the 40th birthday of the NHS what is more important than lists of achievements and of what is being spent is the rather more sophisticated debate about what we want from our Health Service in the next 40 years, how we can measure its success or otherwise, how we can best use the skills of those working in it and how we can achieve those objectives. One positive outcome of the debate that raged around our Health Service throughout the autumn and the winter, and which is mirrored in other western democracies, has been the plethora of ideas about new development and different ways forward. There has been a public realisation that, although there is general satisfaction with the performance of the NHS—we know that 90 per cent. of people are satisfied with it—there are areas that could be improved and other directions that might be explored without threatening the fundamental principle of the NHS. As the Secretary of State said recently, that principle is not and will not be in question. Access to medical care should not be dependent on the ability to pay.
What is certain—the public know this even if the Opposition do not—is that simply to increase the financial input is not the only answer. The Select Committee, of which I am a member, has received a great deal of evidence from experts in every part of the Health Service showing that there is no demonstrable link between levels of spending on health care and a nation's healthiness. That is partly because the Health Service is not the only contributory factor to a nation's health. It has a great deal more to do with the fact that we lack ways of measuring quality and effectiveness in the Health Service.
The amount of money spent by the Americans on health care has been mentioned. It is more or less twice what we spend. Are we to assume that the Americans are twice as healthy or that they have twice as many operations? One needs only one tonsillectomy or appendectomy. Recently I visited Germany to see what could be learned from its system. I did not return with the holy grail but I did learn that there is a great deal about its system that we would be better not to emulate.
The German system is the oldest in Europe and arguably the one on which all others are based. It costs nearly twice what the NHS costs us. It is independent of the state in that more than 1,000 sickness funds, with which the population have to be insured, negotiate terms with local hospitals and practitioners. The service is good for the consumer in that waiting lists are almost unknown. Consumers have a choice. They go straight to the consultant without using the intermediate general practitioner.
However, there is a downside. There are 5,000 surplus doctors looking for jobs and 30,000 surplus beds. There are complaints from employers about the crippling financial contributions they are expected to make and all the by-products of a producer-led system. The average length of hospital stay is twice that in Britain. Patients are routinely, admitted on a Friday for treatment on a Monday. General practitioners ask their patients quite routinely "How long do you want to be ill for?" Also, equally routinely, patients are given a full body scan when they present with an ingrowing toenail.
The overwhelming problem in Germany is one of escalating costs, from 24 billion deutschmarks in 1970 to 113 billion deutschmarks in 1985. That is inevitable in a system where no one authority has the last word and which is producer-led. The German authorities are, quite rightly, worried about the system. It proved to me that we cannot have a system at which more and more money is thrown and where less and less thought is given to the structures, to choice, to care and to efficiency in the delivery of that care.
We have useful lessons to learn on health care from our neighbours. The French pay at the point of delivery. They pay hotel charges when admitted to hospital. That charge was introduced by a Socialist Government and the French officials we met said that at the time of its introduction it caused a brouhaha. It has at least made the French consumer aware of the costs of the health system.
On the 40th birthday of the NHS I wish it a future that more closely defines what we as a nation expect of it. I believe that the Prime Minister's review will achieve that. It is essential that it is given far better information systems by which to measure its performance. The Griffiths reforms, performance indicators and the Körner systems are all helpful steps in the right direction. We must move from a position where, as Dr. Davies of the British Medical Association said,
all we can really measure is the failure of the system rather than the success of it"—
a point amply illustrated by the contributions from the Opposition today.
The NHS needs to make better use of the skills of its work force as well. I am particularly concerned here with doctors. Doctors' decisions determine policies, not just in spending but also in planning. They will need to accept that their desire, which should be welcomed, to enter the funding and management debate must be balanced by an acceptance on their part that in return the public will want a debate about professional accountability and even about clinical judgment. I want to see a Health Service in which the professional skills of the nursing profession are used to the full and in which we have less arcane rules about the way we use our capital assets and the funds from them.
How shall we achieve this? We shall achieve it by being openminded about the next 40 years for the Health Service; by being prepared to build on what is already happening; to accept, as our neighbours in Europe accept, that the proper blend of private and public sector work, the proper blend of consumerism and professional skill, can bring the same sort of success in the next 40 years as the Health Service has had in the last 40.
One of the themes of the debate is the need to recognise that the monolithic National Health Service has given us a relationship between the producers on the one hand and the consumers and patients on the other that has given rise to a lot of the dissatisfaction that has been expressed today. The clue to the nature of that reversed relationship is perhaps to be found in the paradox that we can spend so much taxpayers' money on a monolithic, centralised Health Service and yet find so much claimed or apparent dissatisfaction. This has given rise to a surprising amount of agreement during the debate about where we should go and where we should seek solutions. The agreement has been mostly on this side of the House, if only because on the Opposition side hardly any hon. Gentlemen have been present. At one stage, indeed, there was only one Back-Bench Opposition Member present, and, with the honourable exception of the hon. Member for Birkenhead (Mr. Field), we have heard no positive or constructive suggestions whatsoever from the Opposition.
There is a saying that progress is not about being progressive but about moving forward. The Opposition are interested not in the gimmicks but in supporting the Health Service and in ensuring that it can once again have the confidence of the British people. That means working carefully, slowly and openly in a way that the Government are refusing to do.
That is a catalogue of shibboleths of the kind that we have come to expect from the Opposition, but we have had absolutely nothing in the way of constructive suggestions. What we have heard outlined today are some key ingredients. [Interruption.] I do not know why Opposition Members who have just come in are getting so excited. If they had been here during the debate they would have heard from Conservative Members a number of suggestions, which I will now summarise for their benefit since they have not done us the courtesy of being here.
The first concerns the availability of information. Free patient choice and choice by general practitioners cannot take place without widespread availability of information about the comparative performance of different aspects of the National Health Service. It is widely agreed now that maximum information about the performance and availability of different types of treatment is necessary so that people can make their own decisions as to whether to wait longer for local treatment or travel further for more immediate treatment. That seems self-evident.
Underpinning that is the concept of what has come to be known as the internal market, or competition between providers. It is essential to the use of the information given to the patient and the doctor that they can then go on to make the freest possible choice among competing providers of health care as to which can provide the best care for the patient at the given moment.
There is widespread agreement among Conservative Members that it would be beneficial for different hospitals and districts to provide in competition with one another the best possible health care to the largest number of patients. Those things go together.
Underlying that concept is an obvious concept that is completely absent from the present Health Service—accountability through the provision of real cost information. I do not know how we can possibly hope to provide effective and efficient health care if there is no concept of the cost of money, the amortisation of equipment and the depreciation of buildings. That alone should provide an obvious answer to those of us who ask why we are not getting a proper return on our investment. One reason is that what is normal in the business world is totally lacking in the present world of National Health Service care.
I suggest that we should develop the concept of a patients' charter, for want of a better word. We should guarantee to patients of the Health Service that they will be provided with suitable health care within a given period. If the local district cannot provide that, or if they cannot get it from another district in competition with their own, patients should be entitled to go to the private sector for care and send the bill to their local district. If we did that, patients would know what to expect of their Health Service, and we should achieve accountability in the Health Service through the discipline of such a charter.
There has been no lack of suggestions from Conservative Members about how the Health Service can be improved. Ministers will he able to look through the report of the debate and find a catalogue of suggestions on which there is widespread agreement among Conservative Members. Nothing has come from the Opposition. I have the greatest confidence that when the review is completed Ministers will be able to select from a wide variety of options and make positive and effective suggestions for the future of the Health Service.
I welcome the fact that all hon. Members have said that they fully support the National Health Service. However, my right hon. Friend the Member for Blaenau Gwent (Mr. Foot) was right to warn us to fear the outcome of the Prime Minister's review. The Government have been furtive about the review and the Secretary of State has not enlightened us tonight.
It is clear that those at No. 10 Downing street are keen to hear from anyone who has any ideas about how to beef up the private sector and marginalise the National Health Service. Ministers are in a state of panic, and the date of publication of the review keeps slipping back because most of the proposals canvassed so far by the Right—for example, tax relief for private health care and opting out for those who buy private insurance—have bitten the dust as impracticable.
It looks as though only two proposals are still seriously in the running. The first is the abolition of regional health authorities or the reduction of the number of regions by half, which might be a marginal improvement. The second is the introduction of the market into the National Health Service. Many hon. Members have spoken about the internal market. Those who favour the market argue that it would drive down costs if hospitals had to compete for patients. They argue that surplus capacity would be sold at a profit to the health authority and that districts could shop around for best health buys. The first and most fundamental objection to that is that competition drives down the quality of care.
The hon. Member for Lewisham, West (Mr. Maples) talked in glowing terms about competition in the Health Service. The evidence from America, reported in the New England Journal of Medicine—not just about competition between for-profit hospitals but about competition between not-for-profit hospitals—is revealing. The evidence from America is that the fiercer the competition the higher the mortality rate will be. Put simply, if one is treated in a hospital that has to compete with another hospital for its patients, one is more likely to die.
The reason for the significant correlation between increased mortality rates and competition is that in the competitive environment costs are driven down, corners are cut and the quality of clinical care suffers.
Outcome is the single most important measure of quality in hospital care. The hon. Member for Suffolk, South (Mr. Yeo) was right about that. If one asks people what matters most to them as they enter hospital, they say that they want to get better. They do not want to get worse and they certainly do not want to die. Yet the Government's blanket commitment to markets and their blind belief in competition for everything leads them to ignore that evidence and simply shout no.
The Government have failed to notice the evidence that links competition with mortality rates because they are not interested in the outcome of treatment. They are interested only in the cost of treatment in the Health Service. In health, the Government know the cost of everything and the value of nothing. They talk about the numbers treated but show indifference to whether the result of that treatment is recovery or death.
The Secretary of State has said that performance indicators are a spur to greater efficiency. Only 12 of the 423 performance indicators have anything to do with quality or outcome. All the others measure throughput. The fact that a person is more likely to die in a hospital that is enduring the rigours of the market should, I hope, make most people stop and think—even the right hon. Member for Plymouth, Devonport (Dr. Owen), who is not here at the moment.
Mortality rates are not the only drawback of the internal market. There are other practical problems. My hon. Friend the Member for Kirkcaldy (Dr. Moonie) was right on that point. In theory, a district with spare capacity in one specialty could sell it to a neighbouring authority that has a waiting list and, in turn, that authority could sell its spare capacity in a different specialty. The system could work like that only if neighbouring or nearby authorities had waiting lists or surpluses in different complementary specialties.
If we look at the waiting lists we see that that does not happen. All districts have long waiting lists for general surgery and the only specialty where no district has a waiting list appears to be restorative dentistry. There is no market if all authorities want to buy general surgery and all want to sell restorative dentistry, unless a district sells a specialty in which it already has a waiting list and thereby makes its patients wait even longer. That would happen in practice.
The starting point for the argument in favour of the market is wrong, because it is based on an assumption of spare capacity in the Health Service. My hon. Friend the Member for Normanton (Mr. O'Brien) made it clear that the notion of surplus capacity in the Health Service is laughable. Empty beds, closed wards and unused operating theatres are not symptoms of overcapacity but are caused by underfunding and inadequate nursing policies. It is nonsense to say that there is a surplus when there are people on waiting lists needing services.
Even if there were a scheme for sending patients all over the country, why should they be expected to go? The Government's objective should be to provide services in all districts. We do not want to have a Health Service whereby if it is piles, one must go to Birmingham; if it is varicose veins, it will be Manchester; and if it is a hernia, Newcastle. Our task is to improve the continuity of care. We need to improve the integration of acute and community services within each district and that task would become impossible with patients shuttling between different districts for routine treatment.
Let us be under no illusion that the market is anything to do with patient's choice. It is nothing of the sort. It reduces patient's choice and the GP's ability to give referral advice. Instead, supremacy is given to the manager's decision about where it is cheapest to treat the patient, not where it is most convenient for the patient or where there is the best chance of success.
The terms in which Ministers and other Conservative Members have talked about health care show that they still resolutely ignore the problems generated by commercialised medicine. When we last debated health care I spoke about the United States and since then have visited the States to see for myself. I was struck particularly by the point that, because health care in America is a business—it is not a health care system; indeed there is no system—with a multiplicity of competing hospitals and doctors, there is no coherent base for planning improvements in care, screening or preventive programmes. It is far too fragmented. Our Health Service provides us with a marvellous base for public health planning, and we fragment that at our peril.
Another sad point that struck me was that patients in America do not trust their doctors in the way that we do. Doctors there have a high status because they are very rich, but the profit motive poisons the doctor-patient relationship.
A doctor in Massachusetts general hospital in Boston told me that many newly qualified doctors come out of medical school owing $50,000 in student loans, so they want to start making money as fast as possible. If a woman over 45 goes into a surgery complaining of abdominal pains she will have a hysterectomy, whether she needs it or not. That is $1,200 in the bank for the doctor straightaway, which is why an American woman is four times more likely than a British woman to have her womb removed. The reason why so many Americans get second medical opinions is not that they are luxuriating enthusiastically in consumer choice: it is because they are terrified of being cut open unnecessarily. Overtreatment caused by the profit motive is an epidemic in the United States, which Congressional committees have had to look into. Not only does it put patients at risk of unnecessary tests and treatment, but it pushes up costs.
People will say that this does not happen here. The reason why overtreatment does not take place on the same scale in the private sector here is that medical culture is set in and dominated by the National Health Service. But let the private sector escape from its marginal position and that would soon change. All hon. Members would have fewer parts than we have now. Like my hon. Friends, I am exasperated by the Government's apparent commitment to the idea that the Health Service should be spending less and that we cannot afford it. One of the problems with the service is that we do not spend enough to make a really first-class service. We could afford to spend far more on it if the Government did not choose instead to squander public money on tax cuts for the wealthy and on nuclear weapons. The hon. Member for Moray (Mrs. Ewing) was right on that point.
On this, the 40th anniversary of the Health Service, the Government should be making efforts to improve it. First, that means adequate funding. It also means a number of other measures. The Government should be developing better ways to measure the outcome of treatment. They should be setting objectives for improving the outcome of treatment, and implementing ways of monitoring whether those objectives are being met. They should be developing our medical research programme and ensuring that results are acted on in the planning of the health services. They should develop and monitor standards of care and routinely survey patients' views on comfort and care.
We need peer review of doctors by doctors. In addition to medical audit of outcome, peer review would examine whether consultants turned up on time to see patients and whether they cancelled clinics at the last minute. We need to develop peer review of nurses by nurses. The idea of such review is not merely to weed out bad practice and to spot problems, but to enable health care staff to take part in a constant challenging and stimulating debate about how to improve the services that they provide for their patients. That would apply to all care staff, from consultants to hospital porters.
The professional organisations are keen on these ideas. They have been taken up by the British Medical Association and the Royal College of Nursing, and the Health Service unions are also excited by the prospect. Dozens of different quality initiatives are popping up at local level, but the Government are ignoring them because they are terrified of anything that might involve them in more public investment.
Not only hospitals should be involved in the audit. We need to improve the quality of care and services for patients who suffer from long-term or chronic illness, paying more heed to their concerns and examining how we can expand health care services to people in their own homes. I argue that the Government should set up a quality commission for the Health Service. We already have Her Majesty's inspectorates of prisons, of education and of police. But we have no nationwide, overall supervision of standards in the National Health Service, and we need that. Rather than having a large overall flabby body, we should have a small muscular commission that could develop all the initiatives that are taking place at local level. There are such initiatives, and professional inspections are carried out by the royal colleges for training purposes. From time to time, the Government or a regional authority may set up an inquiry into a part of the service or another region. All that, however, is patchy, haphazard and unco-ordinated.
We need to harness the enthusiasm within the Health Service to improve quality, to identify and iron out problems, and to identify and develop good practice. The NHS has served us well for the past 40 years, but under the Conservative Government's spending restrictions much of the energy and enthusiasm among managers, doctors, nurses and other staff has been dissipated and sidetracked in efforts to protect services from the worst of the cuts.
For the future, the service should be properly funded. That is an essential precondition for the years to come. It should also be reorientated away from service-cutting and penny-pinching. It should be freed from its money worries, and orientated towards pioneering new ways of delivering the highest quality of service to all.
I rather sense that the hon. Member for Peckham (Ms. Harman) had run out of speech as her Benches have run out of speakers, which has been not the least fascinating of today's developments.
In a debate that has at least produced some important common strands, one that certainly unites the House on this day is a spirit of congratulation towards all who have served in the Health Service during the past 40 years on what they have achieved. I wish to make it clear, because of what is sometimes said on the Opposition Benches, that in my congratulations I include not only doctors and nurses, about whom we are accustomed to talk a great deal, but all who do dedicated work behind the scenes to keep the service running.
Perhaps I might say to the right hon. Member for Blaenau Gwent (Mr. Foot) that, in paying tribute to those who have been involved in the Health Service throughout those years, I have no objection to Nye Bevan and the part that he played. I think that all of us will have listened with considerable respect and interest to the right hon. Gentleman, who is probably the only Member in the House who was present at that time. I must also say gently to him that I might have thought even more highly of his speech had he referred not only to being here at the time of the voting on the National Health Service Act 1946, but to the day barely five years later—23 April 1951, with the Labour Government still in office for another six months—when the then right hon. Member for Ebbw Vale resigned because of what the Labour Government had already proposed to cope with the difficulties in the NHS.
I have looked out the Bevan speech of 23 April 1951, when he resigned over the imposition of charges on spectacles and dentures, and it makes interesting reading. The right hon. Member for Blaenau Gwent made some reference to social security, and I hope that, as he managed to do it, I shall be in order if I follow him. Aneurin Bevan said towards the end of his speech that the then Labour Chancellor said that he was
coming to a complicated and technical matter and that if hon. Members wished to they could go to sleep. They did. Whilst they were sleeping he stole £100 million a year from the National Insurance Fund."—[Official Report, 23 April 1951; Vol. 487, c. 40.]
I am sorry that the right hon. Gentleman's report to the House is a little incorrect, but he was not there to hear what happened. Aneurin Bevan was saying that that amount of money had been stolen, and he was reproving Chancellors of the Exchequer who came along and were not sufficiently generous—[HON. MEMBERS: "Labour Chancellors."] Yes, Labour Chancellors. If only the Government would show the devotion to the service that Aneurin Bevan and Hugh Gaitskell showed, we might get on better.
My aim was not to pick a quarrel with the right hon. Gentleman but to underline the important recognition that emerged in most of the speeches made on both sides of the House, including the speech made by my hon. Friend the Member for Wycombe (Mr. Whitney), that the problems of funding the Health Service emerged at an early stage—before the Labour Government had even left office. We must all acknowledge that point in discussing the problems that we face today.
How can the right hon. Gentleman reconcile the statement that he is making with the fact that his Department has denied £40 million for social work training to counteract some of the most devastating problems that society faces?
Simply because that is incorrect. The Government have increased expenditure on social work training and intend to take further steps to improve social work training. We simply thought that the proposals put forward by the Central Council for Education and Training in Social Work in the document to which the hon. Lady referred were not the best way to make progress in that matter.
Secondly, it is clear that we agree on continuing support for the concept of the Health Service as the foundation of health care, and on the desire to see its capacity to serve our people strengthened still further. Thirdly, and perhaps most remarkably, in view of the spirit in which the debate opened, there has been, apart from speeches from the Opposition Front Bench spokesmen and one or two others, considerable agreement about the need to look at the way in which the service works and to see how we can make it work better. The one distasteful feature of the debate was the attempt by the Opposition, at the outset of the debate, to question that consensus about the basis of the service in the future, and to suggest that, somehow, the NHS is a Labour party preserve.
My right hon. Friend the Secretary of State made nonsense of those claims. I shall repeat only two of the relevant figures. One is that expenditure in real terms has risen by well over one third under this Government, and the second is that the percentage share that the NHS takes of Britain's gross domestic product, which fell slightly under the previous Administration, has risen substantially under this. What is just as important as the fact that we have been putting more resources in is that we have been making better use of those resources. What are known, in admittedly not very pleasing jargon, as the cost improvement programmes have the practical meaning that another £600 million has been released for caring for patients. The result is those huge increases in the number of patients treated, and in the proportion of each——
I was trying to make the point that there are more people ill now, and more people need medical care because of the change in demography and the rise in unemployment.
With the greatest possible respect, which is not a great deal in view of what the hon. Lady has just said, I shall just give her the index of the treatment rates per 10,000 population for the over-75s. On an index of treatment rates per 10,000 population, between 1974 and 1979 the figure rose from 100 to 109, and between 1979 and 1985 it rose from 109 to 137. That is a dramatic increase. Those figures have been given to the Select Committee, so the hon. Lady can read them. They can be repeated for almost every part of the population.
Does the right hon. Gentleman know that in Sutton Coldfield, the constituency of the former Secretary of State for Social Services, there are 112 beds for which the regional health authority cannot find funding, and that the opening of a £2 million treatment centre, including a hydrotherapy treatment pool, cannot be opened because the regional health authority says that there is not the money to put the staff—[HON. MEMBERS: "Rubbish."] It is not rubbish; it is true. The regional health authority says that it has not the money to engage staff to treat children and others with rheumatoid arthritis. If everything is so good, why are things so bad in the hospitals serving my constituency?
I hope that the hon. Gentleman will acknowledge that any problems in the Health Service—no one is suggesting that there are none—are very much the problems of a service that is expanding and investing in new equipment and treating more people than ever before. Indeed, the hon. Gentleman's question indicates that self-same point.
It has become a cliché to say that the Health Service is in some sense the victim of its own success. It is true that many of the problems and pressures, which unquestionably are faced, despite the largest capital building programme, for example, in the history of the west midlands region, are caused by continually rising demand. The very fact that we have been so much more successful in keeping alive babies who would have died not so many years ago means that young children need more care than would otherwise have been required. The very fact that life expectancy continues to rise because of the success of the service generates the demands that lead to the increases in treatment rates to which I referred.
Of course, the combination of those demographic trends and our capacity to provide more treatment is reflected in how we have tried to develop the service. We have more than kept pace with the demands, as the treatment rates that I quoted show.
While my right hon. Friend is in this area, will he note that today, in the model health authority of Bury—where there has been a 40 per cent. increase in consultants during the past seven years, and where the number of in-patients treated has risen by 20 per cent. per year since 1978—the keys were handed over on completion of phase 1 of the new £30 million Fairfield general hospital? Is not that another example of our care for the NHS?
I am obviously delighted to know that the 40th anniversary of the NHS has been celebrated in such an appropriate way in my hon. Friend's constituency.
As I was saying, the figures that I gave to the hon. Member for Durham, North-West (Ms. Armstrong) a few moments ago show clearly that we have not merely been keeping pace with, but moving ahead of, rising demands, generated by demography and our capacity to provide more treatment to more people. We also know that however successful we have been in the past——
I shall not give way at the moment.
Nobody can deny the success, bearing in mind the number of patients treated, the number of new treatments introduced and other conceivable measures. However successful we have been in the past 40 years or in the past 10 years though, demand and the desire for new treatments will continue to increase. It is to see how that demand can best be met that we have set in hand the review which has been the focus of much of the debate.
The hon. Member for Kirkcaldy (Dr. Moonie), no doubt anticipating some of the sedentary demands being made by Opposition Members, wanted to hear the conclusions of the review. I am unable to help him tonight, but whatever conclusions the review reaches, it is clear that it will build on a great deal that has already been achived or has been set in hand by the Government during the past eight or nine years.
As the Minister has at last got to the review, may I put to him the question which has lain unanswered throughout the debate and which I posed at the beginning of the day? Will he give the House an assurance that, when the review is completed, the House will receive the courtesy of hearing the results—or is the announcement to be reserved for the Conservative party conference, thus showing the party political nature of the review right from the start?
When we have completed the review, we will decide on the appropriate way in which to make our conclusions known. It is clear that the review's conclusions will make use of a great deal of work that has been set in hand, and which has been announced and is clear to the House.
The first element will be improvement in management in the service, set in train after the first Griffiths report, the beneficial results of which have been mentioned by many of my hon. Friends, and can be seen in health authorities throughout the country. The hon. Member for Birkenhead (Mr. Field), the Chairman of the Social Services Select Committee, made a thoughtful speech. One of the things that we want to do to strengthen the management process—which has been called for by several of my hon. Friends—is to make more targeted use of funds we make available to support good management. The waiting list initiative is a prime example of what can be, and is being, achieved by those means.
There has been unanimity about the need to improve the flow of information to managers, patients, others throughout the service and, indeed, Members of Parliament about how health authorities operate. That information may still not be as good as we would like or as we want to make it, but it is already a great deal better than it was when the Government came to office. It is already being used by health authorities to improve services.
Contrary to what the hon. Member for Peckham said, we want to put more emphasis—as we have already done—on the range of choice available to people and the quality of service they receive. For once, I find myself agreeing with the right hon. Member for Birmingham, Sparkbrook (Mr. Hattersley), who I understand made a speech in Scotland today. I am not sure how what he said fits with what the hon. Lady said in the latter part of her speech, when she seemed to be flatly opposed to what the right hon. Gentleman said. He said that patients should choose their consultants, the day and time of their hospital appointments and have a greater opportunity to change GPs.
It is time that Opposition Members listened a hit.
It is this Government who have set in hand the spreading of better information about where the waiting lists are and what the referral patterns are. It is this Government who have set in hand the improvement of complaints procedures and the possibilities of choice of GPs. It is this Government's policy that patients should be given more information about the general practices and other health facilities in their constituencies, and it is this Government who have launched a quality of service initiative throughout the health authority world.
On the question of patient choice, perhaps the Minister can square his comments with what happened to one of my constituents, Mr. Tom Rossington, who is 93 years old and who, in the autumn of last year, went to his GP and was told that he would have to wait until July of this year to have an examination for his eye cataracts. He ended up seeing the same surgeon in Parkfield hospital in Rotherham a fortnight later for the sum of £70. Is that the choice for 93-year-old people in Britain today?
Our aim and achievement has been dramatically to increase the number of cataract operations that take place in this country.
Finally, we shall seek to build further on what we have done to improve health promotion and the prevention of ill health in this country, for example, by the development of cervical cancer screening and, for the first time in this country, by a full-scale breast cancer screening programme.
The whole House is listening with interest to the way in which the right hon. Gentleman is describing the projections and hopes for the future. Will he tell us whether he accepts the view of the British Medical Association that the NHS still faces a major crisis? What is his view of the need expressed by the BMA and the Select Committee that, this year, it is necessary to have an additional £1 billion to £1·5 billion of expenditure to ensure that there will not be a repetition of this year's crisis?
I shall answer the right hon. Gentleman by going back to the 30th anniversary of the Health Service. On 5 July 1978, when the then Labour
Government were trying to get the BMA to sign a declaration about how marvellous everything was, The Times reported:
In its statement the BMA said that the health service was failing to provide the service that patients had been led to expect and doctors were no longer willing to cover up its deficiencies. The anniversary"—
the Labour party's anniversary—
could not be an occasion for rejoicing, but must be a time far serious appraisal of how to find more resources and boost the morale in all health service workers.
As I said, the Leader of the Opposition always chooses a boomerang and he has chosen an even better one than usual.
Opposition Members will have been expecting me to say something about the winter of discontent, but I am not going to say anything about that. I am going to say something about the summer of discontent that preceded it. I shall refer to one more headline that appeared on 6 June 1978, a month before the 30th anniversary. It reads:
Nurses heckle Mr. Ennals over NHS 'complacency"'.
The nurses jeered him. A month ago the nurses gave my right hon. Friend the Secretary of State a standing ovation.
|Division No. 396]||[10 pm|
|Abbott, Ms Diane||Cox, Tom|
|Adams, Allen (Paisley N)||Crowther, Stan|
|Allen, Graham||Cryer, Bob|
|Alton, David||Cummings, John|
|Anderson, Donald||Cunliffe, Lawrence|
|Archer, Rt Hon Peter||Cunningham, Dr John|
|Armstrong, Hilary||Dalyell, Tarn|
|Ashley, Rt Hon Jack||Davies, Rt Hon Denzil (Llanelli)|
|Ashton, Joe||Davies, Ron (Caerphilly)|
|Banks, Tony (Newham NW)||Davis, Terry (B'ham Hodge H'l)|
|Barnes, Harry (Derbyshire NE)||Dewar, Donald|
|Barnes, Mrs Rosie (Greenwich)||Dixon, Don|
|Barron, Kevin||Dobson, Frank|
|Battle, John||Doran, Frank|
|Beckett, Margaret||Duffy, A. E. P.|
|Beith, A. J.||Dunnachie, Jimmy|
|Bell, Stuart||Dunwoody, Hon Mrs Gwyneth|
|Benn, Rt Hon Tony||Eadie, Alexander|
|Bennett, A. F. (D'nt'n & R'dish)||Evans, John (St Helens N)|
|Bermingham, Gerald||Ewing, Mrs Margaret (Moray)|
|Bidwell, Sydney||Fatchett, Derek|
|Boateng, Paul||Fearn, Ronald|
|Boyes, Roland||Field, Frank (Birkenhead)|
|Bradley, Keith||Fields, Terry (L'pool B G'n)|
|Brown, Gordon (D'mline E)||Flannery, Martin|
|Brown, Nicholas (Newcastle E)||Flynn, Paul|
|Brown, Ron (Edinburgh Leith)||Foot, Rt Hon Michael|
|Buchan, Norman||Foster, Derek|
|Buckley, George J.||Fraser, John|
|Caborn, Richard||Fyfe, Maria|
|Callaghan, Jim||Galbraith, Sam|
|Campbell, Menzies (Fife NE)||Galloway, George|
|Campbell, Ron (Blyth Valley)||Garrett, John (Norwich South)|
|Campbell-Savours, D. N.||Garrett, Ted (Wallsend)|
|Canavan, Dennis||George, Bruce|
|Cartwright, John||Godman, Dr Norman A.|
|Clark, Dr David (S Shields)||Golding, Mrs Llin|
|Clarke, Tom (Monklands W)||Gordon, Mildred|
|Clay, Bob||Graham, Thomas|
|Clelland, David||Grant, Bernie (Tottenham)|
|Clwyd, Mrs Ann||Griffiths, Nigel (Edinburgh S)|
|Cohen, Harry||Grocott, Bruce|
|Coleman, Donald||Hardy, Peter|
|Cook, Robin (Livingston)||Harman, Ms Harriet|
|Corbett, Robin||Haynes, Frank|
|Corbyn, Jeremy||Healey, Rt Hon Denis|
|Cousins, Jim||Heffer, Eric S.|
|Henderson, Doug||Nellist, Dave|
|Hinchliffe, David||Oakes, Rt Hon Gordon|
|Hogg, N. (C'nauld & Kilsyth)||O'Brien, William|
|Holland, Stuart||O'Neill, Martin|
|Home Robertson, John||Orme, Rt Hon Stanley|
|Hood, Jimmy||Owen, Rt Hon Dr David|
|Howarth, George (Knowsley N)||Paisley, Rev Ian|
|Howell, Rt Hon D. (S'heath)||Patchett, Terry|
|Howells, Geraint||Pendry, Tom|
|Hoyle, Doug||Prescott, John|
|Hughes, John (Coventry NE)||Radice, Giles|
|Hughes, Robert (Aberdeen N)||Randall, Stuart|
|Hughes, Roy (Newport E)||Redmond, Martin|
|Hughes, Sean (Knowsley S)||Rees, Rt Hon Merlyn|
|Hughes, Simon (Southwark)||Reid, Dr John|
|Illsley, Eric||Richardson, Jo|
|Ingram, Adam||Roberts, Allan (Bootle)|
|Janner, Greville||Robertson, George|
|John, Brynmor||Robinson, Geoffrey|
|Jones, leuan (Ynys Môn)||Rooker, Jeff|
|Jones, Martyn (Clwyd S W)||Rowlands, Ted|
|Kennedy, Charles||Ruddock, Joan|
|Kinnock, Rt Hon Neil||Salmond, Alex|
|Leadbitter, Ted||Sedgemore, Brian|
|Lestor, Joan (Eccles)||Sheerman, Barry|
|Lewis, Terry||Sheldon, Rt Hon Robert|
|Litherland, Robert||Shore, Rt Hon Peter|
|Livingstone, Ken||Short, Clare|
|Livsey, Richard||Skinner, Dennis|
|Lloyd, Tony (Stretford)||Smith, Andrew (Oxford E)|
|Lofthouse, Geoffrey||Smith, C. (Isl'ton & F'bury)|
|Loyden, Eddie||Smyth, Rev Martin (Belfast S)|
|McAllion, John||Snape, Peter|
|McAvoy, Thomas||Soley, Clive|
|Macdonald, Calum A.||Spearing, Nigel|
|McFall, John||Steinberg, Gerry|
|McGrady, Eddie||Stott, Roger|
|McKay, Allen (Barnsley West)||Strang, Gavin|
|McKelvey, William||Straw, Jack|
|McLeish, Henry||Taylor, Mrs Ann (Dewsbury)|
|Maclennan, Robert||Taylor, Matthew (Truro)|
|McTaggart, Bob||Thomas, Dr Dafydd Elis|
|McWilliam, John||Turner, Dennis|
|Madden, Max||Vaz, Keith|
|Mahon, Mrs Alice||Wall, Pat|
|Marek, Dr John||Wallace, James|
|Marshall, David (Shettleston)||Walley, Joan|
|Marshall, Jim (Leicester S)||Warden, Gareth (Gower)|
|Martin, Michael J. (Springburn)||Wareing, Robert N.|
|Martlew, Eric||Welsh, Andrew (Angus E)|
|Maxton, John||Welsh, Michael (Doncaster N)|
|Meacher, Michael||Wigley, Dafydd|
|Meale, Alan||Williams, Rt Hon Alan|
|Michie, Bill (Sheffield Heeley)||Williams, Alan W. (Carm'then)|
|Millan, Rt Hon Bruce||Wilson, Brian|
|Mitchell, Austin (G'f Grimsby)||Winnick, David|
|Moonie, Dr Lewis||Wise, Mrs Audrey|
|Morgan, Rhodri||Worthington, Tony|
|Morley, Elliott||Wray, Jimmy|
|Morris, Rt Hon A. (W'shawe)|
|Morris, Rt Hon J. (Aberavon)||Tellers for the Ayes:|
|Mowlam, Marjorie||Mr. Alun Micheal and|
|Mullin, Chris||Mr. Ray Powell|
|Adley, Robert||Beaumont-Dark, Anthony|
|Aitken, Jonathan||Bellingham, Henry|
|Alexander, Richard||Bendall, Vivian|
|Allason, Rupert||Bennett, Nicholas (Pembroke)|
|Amess, David||Benyon, W.|
|Amos, Alan||Bevan, David Gilroy|
|Arbuthnot, James||Biffen, Rt Hon John|
|Arnold, Jacques (Gravesham)||Biggs-Davison, Sir John|
|Ashby, David||Blackburn, Dr John G.|
|Atkinson, David||Blaker, Rt Hon Sir Peter|
|Baker, Nicholas (Dorset N)||Body, Sir Richard|
|Baldry, Tony||Bonsor, Sir Nicholas|
|Banks, Robert (Harrogate)||Boscawen, Hon Robert|
|Batiste. Spencer||Boswell, Tim|
|Bottomley, Peter||Greenway, Harry (Ealing N)|
|Bottomley, Mrs Virginia||Greenway, John (Ryedale)|
|Bowden, A (Brighton K'pto'n)||Griffiths, Sir Eldon (Bury St E')|
|Bowden, Gerald (Dulwich)||Griffiths, Peter (Portsmouth N)|
|Bowis, John||Ground, Patrick|
|Boyson, Rt Hon Dr Sir Rhodes||Grylls, Michael|
|Braine, Rt Hon Sir Bernard||Gummer, Rt Hon John Selwyn|
|Brandon-Bravo, Martin||Hamilton, Hon Archie (Epsom)|
|Brazier, Julian||Hamilton, Neil (Tatton)|
|Bright, Graham||Hanley, Jeremy|
|Brooke, Rt Hon Peter||Hannam, John|
|Brown, Michael (Brigg & Cl't's)||Hargreaves, A. (B'ham H'll Gr')|
|Browne, John (Winchester)||Hargreaves, Ken (Hyndburn)|
|Bruce, Ian (Dorset South)||Harris, David|
|Buchanan-Smith, Rt Hon Alick||Haselhurst, Alan|
|Buck, Sir Antony||Hawkins, Christopher|
|Burns, Simon||Hayhoe, Rt Hon Sir Barney|
|Burt, Alistair||Hayward, Robert|
|Butcher, John||Heathcoat-Amory, David|
|Butler, Chris||Heddle, John|
|Butterfill, John||Heseltine, Rt Hon Michael|
|Carlisle, John, (Luton N)||Higgins, Rt Hon Terence L.|
|Carrington, Matthew||Hill, James|
|Carttiss, Michael||Hind, Kenneth|
|Cash, William||Hogg, Hon Douglas (Gr'th'm)|
|Chalker, Rt Hon Mrs Lynda||Holt, Richard|
|Chapman, Sydney||Hordern, Sir Peter|
|Chope, Christopher||Howard, Michael|
|Churchill, Mr||Howarth, Alan (Strat'd-on-A)|
|Clark, Hon Alan (Plym'th S'n)||Howarth, G. (Cannock & B'wd)|
|Clark, Dr Michael (Rochford)||Howe, Rt Hon Sir Geoffrey|
|Clark, Sir W. (Croydon S)||Howell, Rt Hon David (G'dford)|
|Clarke, Rt Hon K. (Rushcliffe)||Howell, Ralph (North Norfolk)|
|Colvin, Michael||Hughes, Robert G. (Harrow W)|
|Conway, Derek||Hunt, David (Wirral W)|
|Coombs, Anthony (Wyre F'rest)||Hunt, John (Ravensbourne)|
|Cope, Rt Hon John||Hunter, Andrew|
|Cormack, Patrick||Hurd, Rt Hon Douglas|
|Couchman, James||Irvine, Michael|
|Cran, James||Irving, Charles|
|Critchley, Julian||Jack, Michael|
|Currie, Mrs Edwina||Janman, Tim|
|Davies, Q. (Stamf'd & Spald'g)||Jessel, Toby|
|Davis, David (Boothferry)||Johnson Smith, Sir Geoffrey|
|Day, Stephen||Jones, Gwilym (Cardiff N)|
|Devlin, Tim||Jones, Robert B (Herts W)|
|Dickens, Geoffrey||Jopling, Rt Hon Michael|
|Dicks, Terry||Kellett-Bowman, Dame Elaine|
|Douglas-Hamilton, Lord James||Key, Robert|
|Dunn, Bob||Kilfedder, James|
|Durant, Tony||Knapman, Roger|
|Dykes, Hugh||Knight, Dame Jill (Edgbaston)|
|Emery, Sir Peter||Lawson, Rt Hon Nigel|
|Evans, David (Welwyn Hatf'd)||Leigh, Edward (Gainsbor'gh)|
|Evennett, David||Lennox-Boyd, Hon Mark|
|Fallon, Michael||Lightbown, David|
|Farr, Sir John||Lloyd, Peter (Fareham)|
|Favell, Tony||Lord, Michael|
|Field, Barry (Isle of Wight)||Macfarlane, Sir Neil|
|Fookes, Miss Janet||Maclean, David|
|Forman, Nigel||Major, Rt Hon John|
|Forsyth, Michael (Stirling)||Malins, Humfrey|
|Forth, Eric||Maples, John|
|Fowler, Rt Hon Norman||Marland, Paul|
|Fox, Sir Marcus||Martin, David (Portsmouth S)|
|Franks, Cecil||Mates, Michael|
|Freeman, Roger||Maude, Hon Francis|
|French, Douglas||Miscampbell, Norman|
|Fry, Peter||Mitchell, Andrew (Gedling)|
|Gale, Roger||Moate, Roger|
|Gardiner, George||Monro, Sir Hector|
|Garel-Jones, Tristan||Moore, Rt Hon John|
|Gill, Christopher||Neale, Gerrard|
|Gilmour, Rt Hon Sir Ian||Needham, Richard|
|Glyn, Dr Alan||Nelson, Anthony|
|Goodson-Wickes, Dr Charles||Neubert, Michael|
|Gorman, Mrs Teresa||Newton, Rt Hon Tony|
|Gorst, John||Nicholls, Patrick|
|Gow, Ian||Nicholson, David (Taunton)|
|Grant, Sir Anthony (CambsSW)||Onslow, Rt Hon Cranley|
|Oppenheim, Phillip||Shepherd, Colin (Hereford)|
|Page, Richard||Shepherd, Richard (Aldridge)|
|Parkinson, Rt Hon Cecil||Shersby, Michael|
|Patnick, Irvine||Sims, Roger|
|Patten, John (Oxford W)||Skeet, Sir Trevor|
|Pattie, Rt Hon Sir Geoffrey||Smith, Sir Dudley (Warwick)|
|Pawsey, James||Smith, Tim (Beaconsfield)|
|Peacock, Mrs Elizabeth||Soames, Hon Nicholas|
|Porter, Barry (Wirral S)||Speller, Tony|
|Porter, David (Waveney)||Spicer, Sir Jim (Dorset W)|
|Portillo, Michael||Spicer, Michael (S Worcs)|
|Powell, William (Corby)||Squire, Robin|
|Price, Sir David||Stanbrook, Ivor|
|Raffan, Keith||Steen, Anthony|
|Raison, Rt Hon Timothy||Stern, Michael|
|Rathbone, Tim||Stewart, Allan (Eastwood)|
|Redwood, John||Stewart, Andy (Sherwood)|
|Renton, Tim||Stewart, Ian (Hertfordshire N)|
|Rhodes James, Robert||Stokes, Sir John|
|Riddick, Graham||Stradling Thomas, Sir John|
|Ridley, Rt Hon Nicholas||Sumberg, David|
|Ridsdale, Sir Julian||Summerson, Hugo|
|Roberts, Wyn (Conwy)||Tapsell, Sir Peter|
|Roe, Mrs Marion||Taylor, Ian (Esher)|
|Rost, Peter||Taylor, John M (Solihull)|
|Rumbold, Mrs Angela||Taylor, Teddy (S'end E)|
|Ryder, Richard||Tebbit, Rt Hon Norman|
|Sackville, Hon Tom||Temple-Morris, Peter|
|Sainsbury, Hon Tim||Thatcher, Rt Hon Margaret|
|Sayeed, Jonathan||Thompson, D. (Calder Valley)|
|Shaw, David (Dover)||Thompson, Patrick (Norwich N)|
|Shaw, Sir Giles (Pudsey)||Thorne, Neil|
|Shaw, Sir Michael (Scarb')||Thornton, Malcolm|
|Shelton, William (Streatham)||Thurnham, Peter|
|Shephard, Mrs G. (Norfolk SW)||Townend, John (Bridlington)|
|Tracey, Richard||Whitney, Ray|
|Tredinnick, David||Widdecombe, Ann|
|Trippier, David||Wiggin, Jerry|
|Trotter, Neville||Wilkinson, John|
|Twinn, Dr Ian||Wilshire, David|
|Viggers, Peter||Winterton, Mrs Ann|
|Waddington, Rt Hon David||Winterton, Nicholas|
|Waldegrave, Hon William||Wood, Timothy|
|Walden, George||Woodcock, Mike|
|Walker, Bill (T'side North)||Yeo, Tim|
|Waller, Gary||Young, Sir George (Acton)|
|Walters, Sir Dennis||Younger, Rt Hon George|
|Wardle, Charles (Bexhill)||Tellers for the Noes:|
|Watts, John||Mr. Kenneth Carlisle and|
|Wells, Bowen||Mr. Stephen Dorrell.|
That this House warmly congratulates present and past staff of the National Health Service on forty years service to the public; recognises the achievements of Her Majesty's Government, firmly based on a strong economy, in devoting resources to the Service to enable both hospitals and community services to provide more care than ever before; and welcomes the current review to ensure that the Health Service is even better in the years ahead.