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National Health Service

Volume 124: debated on Tuesday 8 December 1987

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3.25 am

I cannot help feeling that to address the House at 3·25 in the morning on the question of health is a contradiction in terms. I owe an apology to my hon. Friend the Parliamentary Under-Secretary of State for Health and Social Security as this is the second time in a comparatively short period that I have kept her out of bed to answer a debate that I have been lucky enough to start. I should extend my apology to the hon. Member for Peckham (Ms. Harman) who was also here on the last occasion that I performed this dreadful rite.

The debate is about the National Health Service. It is a fine achievement. It is treating more patients and delivering a better service than ever before. For example, stillbirths fell by 49.4 per cent. between 1974 and 1986. The NHS is spending more money and building more hospitals than ever before, but it is also undoubtedly under short-term stress.

My purpose is to debate the long-term future of the National Health Service, but I shall take a quick look in passing at some of the short-term pressures affecting my constituency. First, there is the way in which the district health authorities have to play into constantly moving goalposts. When Maidstone hospital was being built, new hospitals got commissioning money. Lo and behold, when Maidstone hospital was finished, the rules changed and we received none. Under the RAWP formula, Maidstone made its plans, but ACORN came along and hundreds of thousands of pounds were taken away.

Everywhere else in the country, students coming to a district for their placements bring with them SIFT money; but not, for some reason, when they come to Medway. As I see my hon. Friend the Member for Maidstone (Miss Widdecombe) in her place, I shall say nothing further about the discouragement of good practice, as I know that it is a subject close to her heart.

A second level of debate concerns how to organise the Health Service better, to enable it to deliver its services. At this level of debate, such questions are evoked as, should we persevere with national wage scales? Should not the whole giant structure be broken down into manageable portions? I see no reason to brag that the National Health Service is the largest employer in western Europe, because that means it is 15 years or more behind successful national and multinational firms in creating devolved cost centres. National salaries and wages do not work any more. In Maidstone, agency nurses cost the authority at least 20 per cent. more than elsewhere, and in 1986 the district health authority spent almost £500,000 on agency nurses, not to mention cooks and medical secretaries. District health authorities should be free to strike their own bargains with staff according to local conditions.

The second question is, do we need a regional tier? I accept the need to equalise resources; no one who represents Medway could fail to do so. But is the regional tier as it is organised at present the best mechanism for doing this?

I cite three examples from my own region. The first concerns the capital valuation of a district health authority's capital assets. One of my district health authorities was asked to carry out a valuation of its capital assets, which it did with enormous care and the best professional advice available, only to find that the region proceeded almost at once to do exactly the same thing at great expense.

The second example concerns the creakiness of some of the machinery. In theory, regional control allows for easy movement of staff from declining areas of work to growing ones. Tell that to the district authorities that are finding it almost impossible to obtain additional staff from declining units in the region.

Thirdly, there is extraordinary slowness on the part of the regions to adjust to changing demography. Why do we continue to pay twice as much at St. Thomas's for patients who could be treated in Maidstone or Medway? Of course I accept the value of having centres of excellence, but the M25, the M20 and the M2 have all appeared since St. Thomas's was built and have radically altered the centre of gravity in the south-east of England, and the opportunities for specialist and teaching provision. It is no longer necessary to have 18 teaching hospitals within a horse-drawn carriage's distance of Harley street. What is more, the Government circular of May this year—DA (87)18 — which severely limits the redevelopment potential of green belt hospital sites, adds a huge premium to the redevelopment value of inner-city hospital sites.

My chief concern tonight, however, is to ask some of the philosophical questions that underlie all the management questions to which dismayingly little attention is paid by the public, unless or until some crisis raises a part of one of them. Let us start by being clear about two things. First, health care provision marches roughly in line with national wealth. It is therefore sentimental and muddle-headed hypocrisy to try to cut health off from other centres of the economy. The reason why the hospital building programme has surged ahead under the Conservatives, in contrast to the savage cuts that it sustained under Labour, is that the economy as a whole has been effectively improved.

Secondly, health care provision creates demand in excess of supply, and it always will. So there will always be rationing. Do the public understand that? Do we, as Members of Parliament, do enough to help them understand it? Rationing means that there will always be patients capable of life who will die for lack of treatment. That is not in question. What is in question is: which patients, and who should make the decision? At present, it seems to be made by consultants—at least, it is until the money runs out. Then it is made in the crudest possible way by the district health authorities, which seem to have no more effective financial control to hand than to close beds, wards and even hospitals. As a long, or even medium-term solution, that is unacceptable.

Perhaps we trust consultants to choose for us who shall live and who shall die. We may also want them to be free to choose whether the operations that they perform are cheap or costly. If so, we cannot for ever expect the district health authorities, which do not even employ them, to carry the can for their decisions. Still less can we expect district health authorities to endure being attacked on television by the consultants, whose actions are often so influential in determining the rate at which resources are expended. The principal argument for attaching a consultant's contract to the region is that that permits him or her to work in more than one district. Has the time come for alternative solutions to this problem to be tried? I believe that it has.

Rationing also means that not everyone can have a transplant or a hip replacement. It is irresponsible to argue, as so many Opposition Members frequently do, as if people could. Who is to miss out? Should everyone expect two replacement hips in a lifetime, or is there to be some cut-off age?

Health care can be patient-led and technology-led. Where it is technology-led, the best is often the enemy of the good. Just because the latest X-ray machine will be obsolescent in four years does not mean that it should automatically be replaced at three times the cost or that its use should be denigrated by staff and patients. Scanning procedures are expensive and it is often more cost-effective to use one on three patients than three on one patient. Such choices are often made on haphazard and capricious grounds, rather than as part of a rational use of rationed resources.

We also need to open up the humanitarian argument. In recent years we have blindly followed the line that because we can, we must. The time has come to examine the costs of that and to ask where it has led us. Because we can extend life, we do extend it. As a result, the number of people surviving into extreme old age increases rapidly. By 1996 we think that there will be 1·3 million more people over the age of 75 than there were in 1976, and double the number of the age of 85. This costs money. In 1983–84, the National Health Service spent on average £185 per head, but over-75s cost £875 per head in hospital and community services.

There are other costs besides money and it is time to begin the argument about quality of life. Some of our old people are slaves to a tyrannical technology that will not let them depart in peace. When my father died of emphysema, angina and allied ills, his spirit, as is so often the case, rallied on his final day and he greatly enjoyed happy, peaceful hours with his wife. Then he died. At that point the duty of the hospital forced him for hours into hideously undignified procedures in a vain attempt to resuscitate him in the certain knowledge that if they had succeeded he would never have been the same again.

Hon. Members should think of the cost in humane terms and in nursing and medical terms and ask whether we have balanced the debate. There is much else to be said about the long-term future of the National Health Service, and if we do not know what we want of it, we shall create only an uncertain future.

I should like to raise just two more matters, the first of which is funding. The National Health Service should normally be free at the point of receipt. Private insurance schemes will never provide a sufficient basis for health care, even of the rich. It has to exclude known conditions and must run heavy overheads in order to process its accounts. It could never carry the burden of catering for the nation's health, but, clearly it has a role to play.

It has been well said that if people wish to pay for additional amenities or for something to which they attach value, such as privacy in a single ward, we should aim at providing such facilities for everyone who wants them. Who am Ito argue with Aneurin Bevan? There is so much confusion about the word "private" in health care that we should probably cease using it. Firms should be encouraged to expand the health education, screening and other facilities that many firms offer to their staffs. We should also address the ways in which we needlessly damage ourselves.

I agree that there should be more workplace-based screening. Does the hon. Gentleman agree that it is regrettable that a proposal to have cervical cancer screening for the many female employees of the House and nearby offices was turned down by the Services Committee? Does he further agree that this would be a good time to reopen the question whether there should be on-site cervical screening for people who work the odd hours that being employed here entails?

There is great merit in providing screening facilities. There are difficulties in doing that here because many of those who work in the House are not employees of the House but of individual Members. But I agree that the facilities should be available and that, possibly, lion. Members should contribute to the cost of enabling their staff to take advantage of those facilities. For those employed by the House, they should be available.

I was saying that we should address the ways in which we needlessly damage ourselves. Every poll puts health at the top of people's preferences, but when people vote for health they deceive themselves; they would rather spend their increasing disposable incomes on drinking, smoking, over-eating and dangerous pastimes, including driving much too fast.

In 1986, there were 4,895 fatal accidents on our roads, 58,187 serious accidents and 184,762 slight accidents. The cost of those was estimated to have been £2·8 billion. In addition, there were 1,478,000 damage-only accidents, which cost a further £964 million.

Adjustments must be made in the balance between expecting taxpayers, be they never so temperate, to pay for the excesses of those of us who choose consistently to damage ourselves and others. Random breath testing may prove as helpful to the NHS finances as an increase in Government funding. I see no reason why those who belong to clubs which indulge in sports with above-average accident levels should not pay a modest health insurance along with their club subscription. There is plenty to be done in health promotion and prevention of disease, as the Minister passionately believes and preaches.

Huge changes are occurring in the Health Service. Men and women are entering it with one vision of what the life is about, only to find that new techniques have changed it utterly. That is stressful, and people react to that stress either by leaving the job or by seeking to hang on to their older version of it.

Much of the hierarchy in the Health Service is obsolete, and many of the job definitions with it. Many professionals have been effectively deskilled by their machines, while new professions have achieved a level of proficiency which allows them to diagnose, treat and evaluate treatment to an extent which leaves them independent of the medical profession. Yet neither in salary nor status does the service recognise the new position. These anomalies need to be addressed.

There is a further peril overhanging the future, and that is the growing trend to take cases of malpractice or mistake to the courts, where enormous damages are exacted. If we go too far down that route, we shall undoubtedly find that doctors and other professions will become increasingly unwilling to act without having the most expensive machinery, two or three alternative opinions and everything else available to them. That is a difficult area, because nobody wants to see patients left with no recourse.

The National Health Service is very much alive. It has its problems and it always will have problems. It could do with some more resources in the short-term, but in the long-term its future depends on all of us becoming involved in the debate. I hope that I have outlined some of the points of that debate tonight.

3.44 am

Any mild displeasure that I might have felt about the hour of night at which the debate was to be conducted has been entirely dispelled by listening to the very eloquent and forceful speech of my hon. Friend the Member for Mid-Kent (Mr. Rowe). I am particularly grateful to him for securing the debate tonight and giving me an opportunity to draw to the attention of the House the problems of my constituents and the National Health Service crisis in Maidstone. I am also grateful to my hon. Friend for mentioning Maidstone and for drawing attention to some of its problems. Although Maidstone general hospital is in my constituency, it serves many of the constituents of my hon. Friend the Member for Mid-Kent and of my right hon. Friend the Member for Tonbridge and Mailing (Mr. Stanley).

As I examine the problems of the NHS tonight, I want to consider one particular aspect—what I would call the "efficiency paradox". The Government's policy has always been that resources should be directed towards patient care; that the emphasis should be at the sharp end of the Health Service; we should minimise expenditure on "hotel" services, such as catering and laundry, by achieving the most effective value for money for those services; that we should try to increase activity to as high a level as is compatible with facilities; that we should aim at fast throughputs of patients and for the lowest possible cost per patient compatible with providing an adequate, proper and satisfactory service. However, because of the way in which the Health Service is funded, and the interaction of the various tiers within the Health Service, the fact remains that the efficient are penalised and the inefficient have no particular incentive to mend their ways or to improve their performance.

Regional health authorities allocate money given to them by the Government. I must state at the outset that I have no quarrel with the amount of money that the Government are putting into the NHS or that they have been making available to my regional health authority—the South-East Thames regional health authority. However, what happens beyond that does matter, and that it what has had such a catastrophic effect on my constituents.

The regions allocate money on the basis of expected levels of activity. They try to match the amount of money required with the activity expected from individual district health authorities. That is like looking into a crystal ball once a year and allocating money to the images that form there. Instead, the allocation should be achieved through the day-to-day calculations of the slide-rule.

I have examined the DHSS performance indicators throughout the South-East Thames regional health authority for the past two years for which figures are available. There are very few instances where expected and actual activity converge on the graph. On the whole, there are large fluctuations, with some hospitals underperforming against their expected levels of activity and others, such as Maidstone general, which well and truly over-perform and return a very high level of patient care against what is expected.

Those DHSS performance indicators clearly show that Maidstone general hospital is the most efficient hospital not only in the South-East Thames region but in the country. I draw the attention of my hon. Friend the Minister to that, and take the opportunity to say that my hon. Friend the Member for Mid-Kent, my right hon. Friend the Member for Tonbridge and Mailing and I are grateful to the Minister for having taken on board our recent urgent representations that, because of the difference between actual and projected activity, Maidstone is no longer able to provide the services that are expected.

When regional decisions adversely affect the resources of district health authorities — my hon. Friend the Member for Mid-Kent outlined several adverse decisions —an inefficient authority can react, because it can make cost improvements on hotel services, cut waste or take initiatives to improve efficiency and thus save money. An efficient authority, such as Maidstone district health authority, is not able to react because it has already made all the savings it can reasonably have been expected to make and did so well in advance of any Government guidelines on the subject. It has always put emphasis on patient care and has pared down and cut out anything beyond that.

The efficient authorities are effectively penalised for being efficent and the inefficient have no incentive to mend their ways, because, if their activity is less than expected and for which they have been allocated money, there is no incentive to make savings and try to close the gap, which is what faces efficient authorities. I urge the Minister to draw up firm guidelines, if not regulations, so that the two most important factors for deciding the annual allocation of money to regional health authorities should be efficiency and activity.

I do not altogether blame the South-East Thames regional health authority for wrong forecasts, particularly as it has had to make them on thoroughly out-of-date statistics. I strongly urge the Minister to revise the statistics on which allocations are made, so that data can be brought up to date and authorities do not have to use data that pertained four years ago, which in my region has redounded greatly to the disadvantage of my constituents.

Further nonsenses develop from penalising efficient authorities for their efficiency. Maidstone has a brand new general hospital, which is a very tangible demonstration of the Government's commitment to the National Health Service. It was built in 1983, having been needed for several decades before that. It is a grand, modern, well-equipped hospital, a large capital asset, but some of the main wards cannot be opened, or, to put it the other way, some main wards are now being closed. Trying to make savings by closing wards in modern hospitals is rather like trying to make savings on the railways by digging up the railway lines. Such a practice is not efficient or a proper use of capital. Therefore, we have penalised efficiency and that has led to even greater inefficiency.

If money were always used to the greatest possible advantage, more could be squeezed at regional and district level. I deplore the fact that South-East Thames regional health authority is currently spending £600,000 in rent on empty, administrative headquarters that it left two years ago. If that regional authority would kindly hand over a similar sum to Maidstone for direct patient care we could reopen the closed wards. I ask the Minister to consider drawing to the attention of that regional health authority the vast, rambling empty premises on which it is spending precious resources and the greatly under-used wards that could relieve the suffering and sickness of my constituents.

Perhaps it is all to do with the fact that the regional health authority chose to place itself out at Bexhill-on-Sea. Perhaps, because it is such a difficult place to reach and involves so much travelling time and administrative expense, that authority is not as familiar as it should be with the actual minutiae and the day-to-day effects of some of its terrible decisions.

Nevertheless, even if it is true that South-East Thames regional authority has not been as effective as it might have been in the distribution of resources, and even though it is possible to say that that regional authority has wasted fairly large sums, the fact remains that if one spends the housekeeping on the horses one still faces the problem of feeding the family. It is unfair to blame the person who supplies the housekeeping in the first place, and, therefore, it is totally unfair for us to blame the problems of the authority on the Government who supplied the money. However, we are still left with the problem of feeding the family or, in this case, caring for the sick.

I ask the Minister to intervene in what is happening in Maidstone and throughout the regional authority. Although no blame can be attached to the Government for the present situation, surely blame must accrue if no remedy is speedily found. I am not suggesting for one moment that we should he handed a crock of gold, but my constituents need an urgent, desperate remedy from the Government for the ills that they are suffering. In the great, modern brand-new showpiece hospital in Maidstone we are dealing with nothing except malignancies and emergencies. No routine surgery of any sort is carried out in that hospital.

I know that the Minister is already considering various possibilities of help, but while that is taking place the queues are getting longer and our patients remain untreated. I urge sensible haste. In the immediate future not the long-term future about which my hon. Friend the Member for Mid-Kent spoke—I hope that there will be a greater accent on efficiency in regional allocations.

3.58 am

It is a particular pleasure to take part in this debate, which has been introduced by my hon. Friend the Member for Mid-Kent (Mr. Rowe). In a previous incarnation, I was a teacher in my hon. Friend's constituency and I well remember occasions when I took pupils who had injured themselves down to the local hospitals. It was interesting to listen to my hon. Friend's graphic description of the Maidstone health authority's problems and the way in which those problems have been tackled. I was also pleased to listen to my hon. Friend the Member for Maidstone (Miss Widdecombe) because before I taught at Chatham I taught at Aylesford, which is just outside her constituency, and I well remember the occasions when I had to take pupils to West Kent general hospital, which pre-dated the modern hospital that she has described.

This debate is an opportunity to discuss in a rational, less polemic manner than in recent weeks the problems that face the Health Service. One of the most frustrating aspects of the National Health Service has been that, although the present Government have devoted far more to it than any previous Government in terms of resources and manpower, there continue to be undoubted problems in health care provision. As a Conservative Member, I care as strongly about our health services as any member of the Opposition. I should like tonight to examine some of the problems, and the ways in which we might tackle them, in a dispassionate and positive way.

Let me begin by paying tribute to the work of my health authority, the Pembrokeshire health authority, which was established in 1982. Under the leadership of its chairman —Captain Bill Phillips, ably supported by the general manager, Brian Davies, and his team of administrators, nurses, doctors and other staff— the authority has led the way in Wales in obtaining maximum value for the money that it has spent. The Withybush hospital, opened some 10 years ago, continues to expand — with new wards, an additional operating theatre, and a purpose-built psychiatric day care facility — and the South Pembrokeshire hospital in Pembroke Dock has been modernised. These are just some examples of the progress made by the health authority.

Considerable savings have been achieved through putting services out to tender, and Pembrokeshire leads the way among Welsh district health authorities. All this has been achieved in spite of a 4 per cent., or £800,000, under-funding in 1986–87, on the Welsh Office's own formula. I shall be looking to my right hon. Friend the Secretary of State for Wales for continuing moves towards ensuring that Pembrokeshire receives equal funding on that formula with other health authorities throughout Wales.

It is not only the health authority that has been working strongly for health provision in Pembrokeshire. The people of Pembrokeshire are fiercely independent, and maintain a strong tradition of support for what was the county hospital and is now the district health authority's main hospital. Indeed, the establishment of the Pembrokeshire health authority in 1982 was as a result of that independence — the wish for a separate identity, rather than being merely a part of the wider county of Dyfed.

The strong support shown by the people of 4Pembrokeshire for their local health service has meant that the gamma camera appeal has now raised £100,000 towards the £120,000 cost of the camera. That is the equivalent of £1 for every man, woman and child in Pembrokeshire, and is an excellent example of what voluntary contributions and help do for our Health Service.

However, I do not wish to speak only about the achievements of Pembrokeshire. I should like also to mention a major problem, on which I hope that the Government will show some flexibility in the near future. That is recruitment. Because of the location of Pembrokeshire in the west of Wales, some distance from Cardiff and the major centres of population, there are difficulties in recruiting nurses and doctors to work in the health authority. There is no establishment problem; the authority cannot recruit staff up to the establishment that it is allowed. That means that, in the current year, the health authority has already had to spend nearly £200,000 on agency staff salaries. I hope that the Government will make rapid moves to get rid of the national pay negotiating system and introduce pay negotiations on a district level, so that it is possible to take account of the vast variations in the supply of staff for different health authorities.

Let me now leave the problems and achievements of Pembrokeshire health authority and make some positive suggestions on how we can help to improve the Health Service. We must, start with the basic principle that health provision must be available nationally to all, regardless of income and at all times. That is not questioned by Conservative Members any more than it is by Labour Members. However, it should not blind us to basic questions about the Health Service and how it is operated. It is important that we ask a number of questions for the Minister to examine with her civil servants—although naturally I do not expect a detailed answer tonight—and see whether solutions are possible.

We should start with aims and objectives. I believe that the first aim of the Health Service must be the prevention of ill health, the second the maintenance of good health, the third the cure of illness, and the fourth the relief of pain. If we can put the emphasis, as we have done in our recent White Paper, on the prevention of ill health, that will be the key to improving health. It is far better to have prevention rather than having to seek cures when we have failed to prevent the illnesses in the first place.

It is rather ironic that every time we talk about the Health Service and issue the statistics—we are all guilty of it — we talk about the number of in-patients, the number of out-patients, the number of operations, the amount of treatment that is given. If the Health Service were to be properly judged, we ought to be talking about fewer in-patients, fewer out-patients, fewer operations, because we had prevented the illnesses in the first place. It can be argued that the more illness and the more in and out-patients, the greater the sign that the Health Service is perhaps not doing its proper job. I particularly welcome, therefore, the recent White Paper on primary health care, with its accent on prevention. Primary health care also, generally speaking, is a far more efficient and cost-effective system than hospital-based treatment.

I want, however, to direct most of my remarks to the 'hospital side of the National Health Service, because this is where the majority of the expenditure is to be found and the biggest percentage of staff employed. I should like to start by looking at the management structure. My hon. Friend the Member for Maidstone talked about the regional health authority; I think that the time has now come for us to ask whether we need this tier of management. In Wales we are happy to do without it. District health athorities are responsible directly to the Secretary of State. There is great merit in the argument that we could perhaps get rid of regional health authorities and go for a system which allocated the money to the districts rather than to the regions.

Secondly, we must ask ourselves whether we have gone too far in diversifying individual services to individual hospitals and whether we ought now to go back to having a number of major centres of excellence round the country, which will perhaps take back some of the burden put on the district hospitals.

Thirdly, we must look at the outcome measurements and the statistics in the Health Service. I recently asked a series of parliamentary questions on child intensive care units and their costs, and the cost of abortions, in each district health authority. In neither case was the information available. We need to ask the Department of Health and Social Security to request regional and district health authorities to break down the figures on relative costs of treatments within each hospital and each service. It is essential that we have performance indicators to measure the success and failure of competing demands and treatments. The time has now come when we must start asking the difficult questions on finance.

For many years, services such as education, social services, police and health repelled any question about financial accountability through measures like cost-benefit analysis by the argument that they were qualitative services and not susceptible to measurement by crude quantitative yardsticks. The Griffiths inquiry into the management of the National Health Service in 1983, for example, reported:
"We have been told that the National Health Service is different from business in management terms, not least because the NHS is not concerned with the profit motive and must be judged by wider social standards which cannot be measured."
The report found that these differences could be greatly overstated. Academics like Alan Maynard in 1983 and A. L. Cochrane in 1972 looked at the lack of evaluation of health care systems and concluded:
"the majority of medical therapies in use today have not been evaluated in a scientific manner … the link between health care inputs and outputs unclear".
We must also provide more information about the behaviour of health care systems:
"It will be a poor investment in scarce resources unless managers can be induced to use this information and change the behaviour of decision makers for the better".
Again, the Griffiths inquiry, reporting in 1983, said that the National Health Service management of the time lacked
"any real, continuous evaluation of its performance criteria".
and that the National Health Service is about
"delivering services to people. It is not about organising systems for their own 'sake'. The accountability review process … should start with a unit performance review based on management budgets which involve clinicians at hospital level."
After noting that many hospitals
"do not yet have budgets",
the report recommended that
"each unit of management has a total budget and that procedures should be established for the development of the budget and monitoring performance against them, rules for virement between unit budgets and individual budgets within the unit, authorisation limits and the flexible use of total resources; and the financial relationship between unit budgets and any district-wide budgets for functional services on which the unit may call."
There are signs that people in the Health Service are considering the cost of provision. In another article, in 1986, Alan Maynard argued that over the past few decades the way of financing the service had changed only marginally. In a fascinating article entitled "Balancing the budget and maintaining standards of care", he suggested that the Health Service should consider "Quality adjusted life years", or QALYs. That is something that the Department should consider carefully. It involves health care inputs, such as expenditure on hospital beds, drugs, doctors, nurses and ancillary staff, the health care activities or processes involved in the measurement of throughput, such as the number of GP consultations, the number of out-patient visits, the number of in-patient stays and the length of stay.

Those matters in turn affect health status outcomes, which are the measures of impact, both positive and negative, of inputs and activities on the patient's health status, or the amount of life that he will continue to have as a result of the treatment. We must consider those matters if we are to measure the effectiveness of the treatment.

My hon. Friend the Member for Mid-Kent talked about consultants, which is a sector that we must tackle and challenge. At the moment, rational decision-making is often being thrown out of the window by one or two consultants who spend their time waving shrouds and arguing not on the basis of rational decisions but on the basis of what they consider politically expedient at the time.

I regret that in debates on the Health Service we are often subject to emotional outcries — rightly in many cases—but we do not dispassionately ask how we spend money and why we got into the position in the first place. Sometimes, consultants have a lot to answer for in the way that they make decisions on hospital expenditure.

Many of my friends are nurses, and what comes through from their experiences is that the present shift system in the Health Service is in need of radical overhaul. On the afternoon shift, there is often an overlap of three or four hours between different shifts, but that is the only time of the day that it occurs. It often means that nurses are standing around with little to do, instead of being properly utilised.

We must consider the work that nurses are asked to undertake. All too often we ask people who are highly trained, and who have joined the Health Service well motivated and ready to help with patient care, to be no more than ward orderlies. We must examine the role of ancillary staff and ensure that the trained staff are used properly for nursing.

I am most concerned about the proposals in Project 2000. The idea that we should turn nursing from a practical on-the-job profession into some sort of quasi-academic skill, where nurses rarely see a patient and spend most of their time in colleges of further education being taught in a classroom, is not the best way of utilising skilled and motivated young people.

My hon. Friend may be interested to know that several years ago when I was working in Scotland for the Department of Health a study was done that showed that people went into nursing or medicine as a career because they longed to help patients. At that time, the medical profession's training meant that they did not see a patient for two years, which was changed.

That is an extremely valuable point, and it backs up what I am saying. We must ensure that those who have a vocation and desire to help patients do not have that desire stifled by being thrust into a classroom away from the people whom they want to help.

It is unrealistic to believe that we can have an all-graduate nursing profession. Insufficient people are interested in working in nursing to supply the necessary number of graduates. I do not think that it is necessary to have people educated to degree level to work in nursing. The evidence we have about the present nursing force shows that we get very good nurses who come in with five 0-levels or a couple of A-levels. That seems to be about the sort of academic standard that we should be demanding. The idea that we should go all the way up to degree level will put off a large number of able young men and women who want to come into nursing now.

We have to look at the appointments system in hospitals. I was interested to read in the debate on the Health Service a few weeks ago that one of my hon. Friends referred to the fact that many hospitals call up 40 people at the same time for an appointment. I understand why they do that—because many people do not turn up at the time for which they have been called and the hospital wants to ensure that there are sufficient patients to be seen by the doctors at a certain time. However, there is another side to the argument. When 40 people are called at the same time, people know that there is no point in coming at 9.30 am; if they are not seen until 2.30 pm, there is a natural reluctance to turn up. I believe that hospitals have to look again at the appointments system to see whether they can work out a far more rational way of calling people for such appointments.

Friends of mine who work in the hospital service and in accident and emergency wards and casualty departments tell me that another area to be looked at is the number of people who come into casualty departments who should not be there. I am told that up to 75 per cent. of people who come to accident and emergency units at local hospitals should have gone to their general practitioner. They come to the hospital at all times of the day and night because they do not want to wait in a doctor's surgery. That is a dreadful misuse of the trained, skilled staff in the accident and emergency units. I welcome the experiments that I understand are being carried out at Oldchurch hospital in Romford to ensure that the accident and emergency department is used by those for whom it is intended.

I suspect that some doctors shuffle off their more irritating patients to the local hospital or send them along for an X-ray or whatever in order to get them off their hands. Doctors should be aware of how much an individual patient costs every time they are sent to the hospital for some form of treatment. Therefore, I also welcome the proposals in the White Paper on primary health care, which will enable doctors to do much of what is currently done by hospitals.

I believe that the main aim of the Health Service must be to be responsive to patients. At the moment, there is little connection between the needs of patients, the cost of the service and the provision offered. We need a reexamination of the financing of the Health Service to ensure that we get far more competition into it and that private money is used more widely. We need to look at the way in which we fund the Health Service, at the insurance system and the role of private health insurance and private health care schemes. If we do that, we will perhaps get better value for money from the £21 billion we are spending. Conservative Members as well as Opposition Members are frustrated by the fact that that money does not seem to be spent as wisely as it could be.

4.18 am

I thank the hon. Member for Mid-Kent (Mr. Rowe) for once again bringing before the House an important topic for discussion. It is important that he should have raised the issue of "because we can we must" and whether we should continue with treatment simply because we have the medical knowledge and technology to do so. It is right to consider what have now been called quality adjusted life years. However, one of the problems of discussing that issue in the current climate is the fear that it is being raised not through concern about the patient and relatives but about the Exchequer and public spending. It is difficult to disentangle the two.

The starting point when discussing whether treatment should be engaged in or intervention in relation to someone who may be dying should be proceeded with must be the well-being of the patient and considerations for the family rather than whether it will cost too much. There is a great deal of suspicion that the sinister ulterior motive behind these issues being brought forward now is the desire to save money.

The hon. Member for Pembroke (Mr. Bennett) talked about people unjustifiably clogging up casualty departments. In London and many other large cities people go to casualty departments because of a breakdown in the primary health care system, particularly at night. People cannot get their GP to come out to see them. They know from experience that, under the deputising service, it will take hours for the doctor to arrive, that, as they are paid according to the number of visits they make, they will stay only a few minutes and be exhausted from overwork. Such people are therefore worried about the quality of service when the doctor does finally turn up — and they are voting with their feet. They end up getting a cab, or borrowing a friend's car or taking their own, to the casualty department.

We should not blame the victim and complain that people have not been prepared to sit in a GP's surgery. If GPs provided a good service, day and night, people would go to them first. When people go to casualty departments, they inevitably face a long wait to see a doctor who they do not know and who is not familiar with their case, but the alternative is worse.

There is a great deal of truth in what the hon. Lady says, but a friend, who is a nurse in an accident and emergency department in a major London teaching hospital, told me that people are going during the day with headaches and cut fingers — things that it would not occur to most people to go the doctor with. I admit that those are extreme cases, but we must deter people from turning up at accident departments for trivial reasons.

The hon. Gentleman is doing a blame-the-victim number. He must understand that people sometimes turn up during the day because they have telephoned their doctor for an appointment and been told that they cannot go for two weeks because the doctor is so busy. Of course doctors and nurses are frustrated, when there are real accident emergencies to deal with, by receiving people who should be dealt with by the primary health care system.

It is important, however, that we do not blame the victim of the primary health care system. Rather, we must ensure that people are able to go to their family doctor and receive a good service day and night. The hon. Member for Pembroke said that he is concerned that we are not getting good value for money and that we are spending too much money—

The hon. Gentleman said that we are not getting good value for money. We must remind ourselves that the British Health Service is run on a shoestring compared with other European countries and the United States. Yet, despite the comparatively low level of funding, the quality of service is still high. Therefore, rather than asking whether the Health Service is inefficient, we should be recognising that, despite all the constraints on it, it is still efficient.

The hon. Gentleman asked whether we should be considering more insurance-based schemes and private funding. We have only to look to America, where such schemes are operating, to see the price that is paid if that is the path that is trodden. The United States spends roughly twice as much of its national wealth on its health service as we do on ours, but it does not get such a good system. Moreover, because the United States has a multiplicity of insurance-based schemes, it spends a great deal on the administrative costs of constantly sending out bills to insurance companies or assessments and bills to individuals. The system becomes overloaded, and that is a disadvantage that we do not have.

In a system that is a mixture of private funding, insurance-based funding and the public sector, it is difficult to plan for developments in health care, whether in the primary or hospital sectors. It is clear that the individual patient gets a much better deal from a system if it is planned in advance and developed sensibly. In the United States it is impossible to plan sensibly and to have a strategic approach to health care because it is such a jumble of a number of different systems. Therefore, not only is it very expensive, but it does not give the individual patient a good deal at the end of the day. It would be wrong to assume that the poor get a bad deal in the United States, but that it is all right for the rich.

When a health care system involves a large element of profit, whether it be insurance-based schemes or straight payment over the counter, those techniques or treatments that are most profitable tend to be developed most strongly. All sorts of medical interventions and treatments are developed for the patient, not necessary—ily in response to the patient's condition but because the system has developed the the habit of overtreating so that more bills can be sent to the insurance company and thus more money is made. That is a real distortion in the development of medical care in the United States because of the involvement of commercial medicine and insurance-based schemes to which Britain has not, as yet, fallen victim, for which I am thankful.

My sister had two children in an NHS hospital in London and had twins in the United States. She was astonished at the level of intervention after the children were born. Every test was performed on them every half hour from head to toe, logged up and charged to the insurance company. I am well aware that some of those tests are engaged in because everybody is trying to cover his back so that he will not be sued if anything goes wrong. The legal system has a part to play in this, but that is not the whole story. The more treatment a patient receives, the more the service is paid, so a great deal is done.

It is ironic that there seems to be a growing recognition that the Health Service is under-funded, simply to provide a platform from which people can launch themselves with suggestions for alternative funding. I would argue that the recognition that the Health Service is under-funded should lead to pressure for more funds to be put into the Health Service and not necessarily to demands to change the system by which the Health Service is funded. Wherever the funds come from, they will be part of the national wealth that is being put into the Health Service. We might as well build on a system that uses resources efficiently —that is, their use by the public sector—rather than put those resources into the private sector which would still take resources from the national wealth but result in a much more expensive health care system that could not provide such a good deal.

I turn now to waiting lists. The hon. Member for Pembroke mentioned "shroud waving". It is unfortunate that if consultants, who after all are trained to treat patients, save lives and ease suffering—that is why they went into the Health Service and chose that type of work — speak out because they are concerned about the deterioration in patient care and their inability to do their job properly because of spending restrictions, they should be accused of shroud waving. It is absolutely unacceptable to challenge their good faith in that respect.

I spoke the other day to a heart surgeon from Guy's hospital who told me of the heartbreak and frustration that he feels because he has been told that he must reduce the number of patients on whom he operates although the theatre is available, as are the nurses. Indeed, the whole system is geared to provide coronary bypass operations, for which there is a large waiting list. Despite those facts, that surgeon has been told to reduce the number of operations that he performs in order to save money.

He told me that, when explaining to a patient why he or she needs an operation, he may have to say that if they do not have the operation they could die. Obviously, the risks must be explained. When a patient is told that he can have an operation that will save his life, the consultant is immediately asked, "When can I have the operation, doctor?" The consultant replies, "Six months, if you are lucky." So, having explained to the patient that he or she needs that operation and that he advises it because the patient might die without it, he must then explain that the operation cannot take place for at least six months. Of course, the patient knows that during that time there is a chance that he or she could die or become more ill and less able to recover when the operation does take place.

The consultant said that the next question is often, "If I go private, when could I have the operation?" The consultant is able to reply, "If you go private, you can have the operation next week." We are getting into an invidious situation if people then feel that they must borrow money from the bank, take out a loan or borrow from their relatives because for about £4,000 that possible death sentence of a six-month wait can be lifted.

When consultants bring such issues into the public arena, it is a travesty to be told that they are shroud waving. Those consultants are raising an important matter for debate. Indeed, it is their public duty, and I welcome the fact that they do so. To accuse them of shroud waving is to try to stifle the debate because the Government are trying to avoid criticism.

Some consultants do shroud wave. There is no question about it. Some consultants play on the emotions of the public over cases which, it is true, are very sad. However, that is often done by consultants who, for one reason or another, have chosen to play very little part in the administration or responsibilities of the unit in which they operate. Although there are plenty of good consultants who raise perfectly responsible points, there are far too many of the other kind as well.

Incidentally, the surgeon from Guy's hospital, to whom I spoke the other day, has actually taken on the management of his unit as well as doing all his surgical work. However, he is still told by the district authority that he must cut down the number of operations that he has to carry out.

Conservative Members talk with disdain about emotional cases, as though they are somehow unpleasant. Of course, the fact that last year 24 premature babies died after being denied intensive care cots is emotional. There is something wrong with people who do not think that that issue is emotional and deserves an answer. It is certainly an emotional issue for parents who see the chance of life for a premature baby being denied because of a lack of intensive care cots. We must recognise their feelings and respond to and be concerned about them, rather than condemn them as emotional and, therefore, not something that should be part of the debate, or regard consultants as shroud waving. It is worrying that waiting lists remain high.

I saw the junior Minister's comments about going private reported in the newspapers yesterday. We can clearly see that private insurance companies are issuing leaflets stating, "Can you afford to wait so long on the waiting list? By the time you get your treatment, you might just be inoperable or will have lost your job. You had better go private." At the same time, the Government are failing to attack the long wait for treatment that many people have. We also see the junior Minister urging the well-off—those on over £18,000 a year—to go private. That is shameful. The point about a taxed-based system is that the more one earns, the more one pays. One is entitled to use that system, whether one pays nothing—because one does not pay any tax because one is not earning—or whether one pays a great deal. We should not develop the arguments that somehow people who are not paying taxes are scroungers and should not be entitled to use the system, or that people who have paid an awful lot should not be entitled to use the system because they are too well off. We should recognise the benefits of a comprehensive national health care system and build on that base. The Health Service is a tremendous asset. We should build on it rather than try to chop it off piecemeal and allow it to disintegrate.

Talking about things disappearing piecemeal, I wish to get some answers from the Minister on family planning. District health authorities, faced as they are with real difficulty in balancing their budgets, are looking around for services that they can cut and from which people will not die as a result. Clearly, many general managers have lit upon family planning. They think to themselves, "Well, we can cut the odd session here and the odd clinic there and nobody will die as a result." Or they may think, "Well, people can go to their GPs and get family planning advice." What is the Minister's view about the dire threat that hangs over the district authority provision of family planning facilities? We should try to improve contraceptive advice and reduce the number of unplanned pregnancies. We should not allow family planning to go into retreat. It is not an answer for people to see their general practitioners for advice. It would reduce women's choice. Women might choose not to go to their GPs for contraceptive advice. They might particularly want to have a woman doctor giving them contraceptive advice but have a male GP, or their husbands might have had vasectomies and they may feel embarrassed about asking their GPs for contraceptive advice. There might be a whole load of reasons.

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

In that case, they would not need contraceptive advice.

Indeed, they might need contraceptive advice, even if their husbands have had vasectomies. That is precisely why they might not want to go to their GP.

The other reason why it is not a good idea in current circumstances for people to be forced to go to their GP for contraceptive advice without the opportunity to go to a clinic is that most GPs are not trained to provide contraceptive advice. I am sure that nobody here would relish the idea of being fitted with an intra-uterine device or a cap by a doctor who was not trained to do so. Many GPs who are not trained to fit IUDs or caps do not relish the idea either, so when people ask for contraceptive advice they are dished out with the pill. That distorts the sort of contraceptive prescription they are given. They might be given what the GP is able to provide rather than what might be best for them in their circumstances.

I should like to have a very firm reassurance from the Minister tonight that she regards family planning services as a central part of mainstream National Health Service provision and that it will not be abdicated to the charitable sector. That sector has done much to move the Health Service sensibly into this sphere, but it does not wish to take a step backwards and be left carrying the can. Will she assure us that we will not be left with untrained GPs and no choice in the provision of contraception? I hope that she will show the House tonight her recognition of the dire situation facing family planning services in district health authorities and tell us what she is going to do to ensure that they do not carry on down that path.

I know that the Government issued a circular recently to district health authorities about terminal care. I very much welcome the recognition that the Health Service must be caring and that the Government value the work it can do for patients who will not recover as well as for those who will. We have a long way to go in this respect, and a path has been well charted for us in the Health Service by voluntary and charitable organisations which have been working in this sphere for a long time. They, like me, want to see the Health Service assimilate and take up the experience and expertise gained within the voluntary and charitable sectors. However it does not make sense for the Minister to issue circulars to district health authorities saying that there should be more concern for the terminally ill when DHAs are hardly able to maintain their level of services for those with some chance of recovery.

The Minister ought to be honest enough to recognise that the hopes kindled when she talked about the importance of terminal care have been dashed in practice. As someone said, it is like rearranging the furniture on the Titanic; if the ship is not safe as a whole, it is difficult to develop services and add to them.

I hope that the Minister will be honest enough to recognise the situation that nurses are in at present. Far from being able to go on training courses to learn how to deal with terminally ill patients and find the time to look after them when they come back to work, that is just not happening.

I should like to finish by saying something about agency nurses. They are not just more expensive than directly-employed nurses, although it is an important feature that a health authority pays much more for agency nurses than for its own employees; there will not be such good quality of care.

Agency nurses are less likely to know where things are and whom to contact, because they are not part of a team. So they do not work as well as part of a team and they cannot nurse as well as people who are part of a mainstream team. Ideally, a ward will have nurses who know where everything is, know whom to call when they need someone, and know the people with whom they are working. They should have a continuous relationship with patients who have been in the ward for some time and they should know their way around. That does not happen with agency nurses.

Another point about agency nurses that has not been sufficiently highlighted is that when they have done a full week's work in the National Health Service and are working at the weekend, they are likely to be exhausted and unable to provide a good quality of care.

I hope that the Minister will say something tonight about the recruitment freeze, which is already affecting nurses. District health authorities are imposing such a freeze on nurses in a vain attempt to meet their budgets, and the freeze is threatened to continue next year. It should be recognised, too, that we cannot enhance the grading structure and improve pay at the top of the scale by taking from poorly paid nurses at the bottom of it. I hope that the Minister will take time to answer some of the points that I have raised.

4.46 am

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

In the few minutes that the hon. Member for Peckham (Ms. Harman) has left me — she made a 27-minute speech — I shall endeavour to do just what she has asked.

I congratulate my hon. Friend the Member for Mid-Kent (Mr. Rowe) on once again having got me up in the middle of the night to talk about an important subject. I hope that he will win the ballot next time, too, but be kind enough to choose a subject such as the arts in Manchester. I shall work through the questions in my hon. Friend's important and valuable speech.

My hon. Friend asked whether we could have local bargaining for pay. If that was agreed, pay rates would rise in the home counties. If my hon. Friend the Member for Pembroke (Mr. Bennett) is right, they would rise in rural Wales, too. Unless funding followed, the problems of balancing income and expenditure would make things worse, so we should be wary, because that is perhaps a slightly simplistic approach. We rely heavily on recruiting young women—and, increasingly, young men—into the Health Service. One problem is that the number of school leavers is dropping sharply. We shall have difficulty in recruiting staff whatever the pay rates, now or in the future.

My hon. Friend asked, as did my hon. Friend the Member for Pembroke, whether we needed regions. I tend to feel that restructuring is the last resort of those who have no idea of what to do next. I am reluctant to have another reorganisation of the Health Service, having gone through more than one in my time in it. The last reorganisation had a strong element of everyone swapping around on musical chairs, getting paid £3,000 a year for doing the same job. Meanwhile, the old lady with the hip operation or the old gentleman with the heart attack were still waiting outside the door for treatment. So I am not sure that reorganisation solves problems—sometimes it creates them.

My hon. Friend asked about the slowness in moving patients and money out of London. I do not know whether he has had a chance to read the Official Report of the Adjournment debate that took place on 27 November about St. Thomas's, in which we aired some of these difficulties. The hon. Member for Vauxhall (Mr. Holland), who raised that issue—his constituency is in London—felt strongly that the money should stay in London. My hon. Friend the Member for Pembroke (Mr. Bennett) suggested in an equally interesting and well thought out speech that we put the burden back on the major centres and stopped taking the money out of them. So my two highly intellectual hon. Friends have demonstrated the problem of choosing which solution is right.

It has been said several times tonight that primary care reform should help, partly by scrutiny of the referral rate of GPs, and partly by GPs doing more themselves. My hon. Friend the Member for Pembroke was right to talk about the pressures on casualty departments. He forgot to say that about one third of the patients who roll into casualty departments are drunk, and many of the problems are caused by alcohol. Therefore, whatever we do about GPs or hospitals, we have a distinct problem.

My hon. Friend the Member for Mid-Kent asked about who should hold consultant contracts and whether it was appropriate for them to be held by the regional health authority. I used to be the chairman of a teaching district and I held the consultant contracts. I can assure my hon. Friend that we had exactly the same problems. It is a question not of who holds the contract, but of who can enforce the contract and who can persuade, preferably, the consultants concerned that we all have an obligation to keep within our budget. Indeed, we all have an obligation to have budgets and it is an important part of health care to know what it is costing every time one does an intervention of some kind.

My hon. Friend asked about the cost of technology. I intervened to suggest that one might have more than two hip operations in one's lifetime. I was quite serious about that. The early operations lasted about a decade. If I get my first hip replacement in my fifties and, God willing, I live to be in my nineties, I might expect to have several renewals; I know of constituents who have had several. That puts the matter in context.

Most admissions to acute hospitals—about 60 per cent. — are elderly people. We are pleased about that and they are substantial recipients and the demanders of health care. Life expectancy is rising at about two years per decade.

My hon. Friend asked about caring for the terminally ill. The hon. Member for Peckham spoke about the circular that I issued earlier this year. I agree with my hon. Friend and with other hon. Members about the terminally ill. We do not care nearly well enough for our terminally ill. Frequently, we do not care for them at all. People should die with dignity — and, indeed, most deaths in Britain occur at home.

One of the most distressing aspects of some of the recent discussions has been that the shroud waving is done with people who are dying. To have patients who are terminally ill with cancer rolled up before me as if it is my fault that they will not survive is wicked. It is a cruel way of trying to wring money out of the Health Service, often for quite inappropriate purposes, because often it would be much better if the patient were able to go home to his or her family to receive appropriate home and palliative care to meet the end with some peace. I feel strongly about that.

My hon. Friend the Member for Mid-Kent asked about prevention. He was right to do that and I am glad that he did. I say to the hon. Member for Peckham that if we just continue putting more money into surgery and fail to tackle prevention, then we fail those people who are heart patients. The number of people needing care and treatment, particularly for heart disease which is our major killer, is not under control and is among the highest in the world. We fail not only the people who wait for care, but their families, sons and daughters, as well because there seems to be a family proneness to heart disease. Unless the nation tackles the matter of the prevention of preventable diseases, especially heart disease and cancer, all that we will continue to do is to build more and more hospitals and cut up more and more veins and arteries but not improve the quality of life for our people as a whole.

I am afraid that I shall not have time to deal with all the points made in the debate. My hon. Friend the Member for Maidstone made an eloquent speech arid spoke about the highly efficient hospital in her constituency which, as she knows, I visited last year. Historically, Maidstone has had a surprisingly low level of locally provided hospital health care. The nucleus-designed Maidstone hospital was opened in 1983 and replaced two and a half old hospitals. Things began to improve, took off at a rate of knots, and activity has risen phenomenally since the hospital opened. Overall, activity is about 30 per cent. up.

Some types of day case work has gone up by over 200 per cent. The key point is that last year alone in-patient treatments rose by 13 per cent. Nobody could plan for that level of increase in demand or for that level of increase in expenditure— 13 per cent. in 12 months. I know that the hospital is well in the forefront of cost improvement programmes and I know about all the things that it is doing. I have before me a note which the chairman prepared for my hon. Friend the Minister for Health, who will appreciate the kind remarks of my hon. Friend the Member for Maidstone. The chairman says that they are re-examining all possible cost improvement ideas, exploring all legal and soon-to-be-legal income-generating ideas, and that they would welcome more insurance-based patients. She says that they note that their two local private hospitals are running well below capacity. They are reviewing all existing services with a view to paring the low priority areas, and even recognising that there would be some concern about those.

I am able to help my hon. Friend with one problem about the storm damage. We hope to make announcements shortly about some financial help being given to those regions that have suffered particularly from storm damage. I cannot tell my hon. Friend tonight how much it will be—it will be given to the regions and they will decide but it will be substantial. We hope that that will assist with solving the problems of districts such as Maidstone, especially their immediate short-term problems.

Any reading of debates on health care, going back to the time when the whole thing was founded 40 years ago, leads one to the conclusion that all Ministers who stand at this Dispatch Box have had exactly the same problem: the money goes up, and the demand goes up even faster. It is never likely that the demand will decrease and, under a Conservative Government, I suspect it is unlikely that the funding will decrease either. It will carry on going up, but it will never be enough.