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Consultation On National Health Service Trusts

Volume 169: debated on Tuesday 13 March 1990

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(1) Before making an Order under section 5 of this Act the Secretary of State shall lay before Parliament a report.

(2) A report under subsection (1) above shall state:

  • (a) The results of a ballot of staff at the hospital or service applying for Trust status.
  • (b) In any case where a majority of the patients of the hospital or service reside in a single borough or district council, the result of a ballot of electors registered in that local authority area.
  • (c) The views of any relevant District Health Authority or health board in Scotland.
  • (d) The views of any relevant Community Health Council.
  • (3) The Secretary of State shall not approve application for a National Health Trust until a report under this section is approved by both Houses.'— (Mr. Robin Cook.]

    Brought up, and read the First time.

    I beg to move, That the clause be read a Second time.

    We now come to the heart of the Bill and of the Government's proposals. The new clause relates to the proposal that the Government were good enough to refer to as one of their key propositions—the creation of self-governing trusts. That matter has given rise to strong views both for and against, and I am therefore happy to assure the House that this is not an occasion on which it is necessary for me to strike a non-partisan note. I have strong views on this matter. I believe that self-governing trusts will result in the fragmentation of the Health Service, that the competition on which they are based will introduce a commercial ethos into the Health Service, and that they are patently designed to pave the way for the privatisation of the Health Service.

    I am aware that Conservative Members take a different view. Some take the view that this will be an excellent change for the Health Service. The Secretary of State's predecessor proposed that the changes would be the greatest breakthrough in medicine since the discovery of penicillin, but I doubt whether many hon. Members would wish to go that far.

    Whichever view hon. Members take on whether self-governing trusts are desirable, there can be agreement on both sides that that step is a major decision for the local Health Service. The contention of new clause 4 is that that decision should be taken by local people. I am happy to say that the Secretary of State seems to agree with that proposition. At an early stage during the debate on the White Paper, he made a speech on self-governing hospitals which was videoed and included on the staff communications video. These are the words of the right hon. and learned Gentleman in that message which was so expensively prepared for the staff of hospitals contemplating self-governing status:
    "I believe the best decisions on local services are the ones made by doctors, nurses and managers who have first-hand knowledge of the needs of local people."
    That is a sensible basis on which to proceed.

    However, I am sorry to report that, ever since we took the Secretary of State at his word, he has been desperately inventing arguments about why this local decision could not be left to local people. The Bill makes it perfectly clear who is intended to take that "local" decision. Clause 5 opens with the deathless line:
    "The Secretary of State may by order establish bodies, to be known as National Health Service trusts".
    It also states that the Secretary of State shall also appoint the board of directors of the trust, and
    "The functions specified in an order…shall include such functions as the Secretary of State considers appropriate…
    The Secretary of State may by regulations make general provision with respect to—
  • (a) the qualifications for and the tenure of office of the chairman and directors of an NHS trust…
  • (b) the persons by whom the directors and any of the officers are to be appointed and the manner of their appointment
  • (c) the maximum and minimum numbers of the directors;
  • (d) the proceedings of the trust; and
  • (e) the appointment, constitution and exercise of functions by committees and sub-committees of the trust".
  • All those things will be established in regulations that are to be decided by the Secretary of State. It is perfectly clear that it will not be left to the local people to decide whether they shall have an NHS trust, nor even what that NHS trust shall do. There is nothing in the Bill to oblige the Secretary of State, when deciding whether to create an NHS trust, to produce a single scrap of evidence that it is supported by the people who work in that hospital or those who use it.

    That is why I have tabled a new clause 4, which would oblige the Secretary of State to report to the House before approving an order for an NHS trust on the views of three seperate groups that are most closely affected—all of them local people. The first of the three groups comprises the patients of the hospital. They come from the population of the catchment area of the hospital or unit concerned. I am conscious that the formula that I have proposed in the new clause will not fit every case on the list that is proposed for self-governing status. However, it will fit the majority—a point which I shall develop later.

    Why should patients worry about the creation of National Health Service trusts? Why should they seek the right to ballot on the creation of a trust? The first reason is that trusts will be obliged to trade on their own account. Working paper No. I on self-governing hospitals is refreshingly candid on that point. On page 8 we find in paragraph 2.2 the following candid statement on how various hospitals or units are expected to balance their books:
    "The main source of revenue will be from contracts with health authorities to provide their residents with specified NHS services to a given level and quality of service. Other contracts may come from general practitioner practices or private patients"
    —a point to which I shall return. The moment that a hospital or unit finds that it is dependent for income on trading on contracts, it has entered into a commercial environment in which the directors who run the hospital will be obliged and have a duty to secure its financial viability before medical needs can be fulfilled.

    5 am

    I am following the hon. Gentleman with great care. The passage that he quoted would apply to every hospital in the NHS, whether self-governing or directly managed. I am not sure why the quote from working paper No. 1 gives a key reason why self-governing status should be the subject of the ballot that he proposes.

    I welcome that intervention, which I anticipated. The Secretary of State has just confirmed that not only self-governing trust hospitals will enter into a commercial ethos, but every hospital in th Health Service will find itself in a competitive and commercial environment.

    The reason why I believe that patients in a catchment area where there is a proposal to create a trust should be anxious is that the moment that the hospital becomes self-governing it will be outwith the scope of the district health authority. It will no longer be directly managed by the district health authority. In the case of several district health authorities, to which I shall refer later, hospitals will have acquired self-governing status in defiance of the wishes of the district health authority. Hospitals may find that the district health authority does not have the loyalty and commitment to making it a success that it has to those which it directly manages.

    If hon. Members have any doubts about how swiftly and dramatically the new environment would encourage a commercial ethos within the hospital sector, they need only glimpse the documents currently being prepared by hospitals contemplating forming an NHS trust. I have found it depressing how quickly the language of public service has been replaced by the patter of the salesman. The most remarkable is the document produced by Yorkshire region. It advises management on what it will need to do once the hospital is a self-governing trust. It contains the immortal advice that managers should keep changing the product lines. I presume by that they mean the specialties of the hospital.

    The dilemma of such hospitals has been well expressed by the director of one of the private hospitals in London, the Lister hospital. He was invited to write an article outlining what he saw as the challenges to the management of a self-governing trust. He said:
    "The opted out hospitals will need to make firm decisions as to which services to promote and which are uncompetitive. Some specialities may have to go. The problem of unsuccessful specialities will be a real one. For how long could one carry a loss-making speciality?"
    I invite my hon. Friends to notice what happened between the second last and last sentences of that paragraph. There was a reference to "unsuccessful specialities". How is an unsuccessful speciality redefined? Not as a speciality which failed to cure the patients, nor as one which was not needed by the patients, but as a loss-making specialty. The population of the catchment area of the hospital and its patients may seek the right to cast their vote on the question: what if they are the loss-making patient?

    It is not difficult for them to work out what specialties are at risk of being loss-making. We can identify them easily by running our finger down the list of specialties not provided by the present private sector. They are chronic care and long-term care with no immediate prospect of cure and involving heavy expense, for example, geriatric care, renal dialysis and chemotherapy. All are lacking from the private sector and are likely to be under pressure once the Secretary of State has created commercial pressures within the public service and the NHS.

    The hon. Gentleman is being most courteous in giving way. I am waiting for him to come up with one coherent argument for his proposed ballots. Perhaps because of the time of morning, he has so far not produced one. The manager of the Lister hospital has nothing to do with our proposals. All hospitals will depend on these contracts for finance. There is no distinction between NHS trusts and the rest. That means that they will be financed to the extent that they attract NHS patients. When they attract patients, whether for advanced surgery or basic community care, they will recover the full costs of treatment. They will not make a profit or a loss. If they are unsuccessful it will be because they are not attracting the patients of the GPs who would otherwise refer to that unit. We spent a long time on this in Committee, in which the hon. Gentleman appeared from time to time and took some part, so he knows that that is the position. I do not see the slightest relevance of his remarks to that position.

    The Secretary of State has made an interesting observation which, if he means it, will requir.t him to go back and redraft many of the notes of guidance and circulars which have been going around the district and regional health authorities for the past six months. He has just said that hospitals will recover the full cost of treatment of patients. That is not what his Department is saying to health authorities. It is saying that they must price a contract for a number of treatments with other district health authorities, their district health authorities or GPs, and deliver the required number of treatments within the price on the contract. That is the meaning of the whole contract system. The hospitals are not guaranteed the cost. If they get it wrong they will have difficulty in making ends meet. If that is not the case, it is utterly impossible to conceive what the function of creating the new system is, because at present we offer the hospitals their costs. It is that historic basis of pricing and paying the Health Service that we understand the Secretary of State is putting behind him.

    If the Secretary of State is going to tell us that the director of the Lister hospital, as a director of a private hospital, has no insights to offer us about the future of the NHS, let me share with him the comments of the management of Trent region. It is within the NHS, although it seems to have every possible intention to get out as fast as possible. It produced an extremely interesting document marked "Strictly confidential" which provides advice to the personnel managers of hospitals seeking self-governing trust status. I shall return to the document later.

    I think that the hon. Gentleman has said something that, on reflection, he would not have meant to say. He stated that the people of the Trent region are working as hard as they can to get out of the National Health Service. The whole point about the hospitals—or units—is that they will remain part of the service.

    That is an opinion which the hon. Gentleman is perfectly entitled to hold, but it is strongly disputed by many Opposition Members, and I shall develop that argument during my speech. If it is argued that those self-governing trusts will remain within the National Health Service, the hon. Gentleman has so redefined the meaning of that service as to put it beyond the recognition of anything that people would have previously contemplated.

    I anticipate that the Secretary of State will not say that the management of the Trent region are irrelevant to our debate. Their document opens with some assumptions about self-governing trusts:
    "a. in the short term there will be an initial period of stability and no immediate crisis"—
    that is refreshing and reassuring, I am sure—and
    "b. in the medium term, there will be rationalisation and contraction of services".
    That is the assumption of the management of Trent region. That brings us back to the anxieties of patients in the catchment area, to whom I referred earlier. There is now a risk that specialties may be squeezed on commercial and financial grounds, but those patients require them.

    Once upon a time, we were promised safeguards against contraction and rationalisation. Working paper No. 1 on page 3 promised those safeguards. The opening paragraph of the working paper on self-governing hospitals said:
    "There will be safeguards to ensure that essential local services continue to be provided locally."
    Those safeguards were going to be the core services.

    One question that patients would want to ask themselves when considering voting in a ballot on the issue is what happened to core services. It was a pretty short list, which did not at any stage include paediatrics or maternity services. The Nottingham Post had an entertaining quotation from a spokesperson for the Department of Health, who, when asked why maternity was not in the list of core services, replied that it was because Ministers forgot to put it in. However, it does not really matter whether paediatrics, maternity or anything else was omitted from the list, because there is not a word anywhere in the 60 clauses of the Bill about core services.

    In Committee the Under-Secretary, who I suspect must be on the afternoon shift of these proceedings, advised us that he regretted that Ministers had got the name wrong. They should not have called them core services, because the use of those words encouraged us to have the wrong expectations. As it turns out, core services are no more than matters for negotiation between the district health authority and any hospital in the district that is contemplating forming a self-governing trust. There is nothing to prevent those trusts from deciding, during the negotiations, that they need a rate of return on renal dialysis or geriatrics that prices it beyond the reach of the district health authority, and nothing to stop the district health authority from deciding, during the negotiations, that the price offered is too expensive. Bang—between them, in the process of negotiation, it is gone; it is priced out.

    I suggest that that is one of the key reasons why patients need a voice in whether their local hospital leaves the management of the local district health authority. They will lose the choice if a specialty goes and they may even lose the choice if the hospital retains the specialty that they need, because, as the Secretary of State fairly said in his intervention, patients will get into hospital only if there is a contract with the hospital for someone to pay for them to have speciality treatment—whether it is the district health authority or their GP.

    That brings me to the last reason why patients in that catchment area should be anxious about their hospital becoming a self-governing hospital.

    How can we be certain that patient needs will be defined? The scheme has been likened to going to a garage for a particular type of car repair. Is it not the experience of us all that we require treatment in hospital for a variety of reasons that involve different techniques? How will that practical problem be addressed?

    5.15 am

    I intend to deal later with that point. However, I believe that it is a travesty to describe the White Paper and Bill as proposals for the National Health Service. They regard people's experience of the NHS, particularly of hospitals, as episodic and completely unrelated to the continuity of care that they receive. The Government's proposals therefore threaten a break in the continuity of care that is represented by the present integrated service.

    I was about to remind hon. Members of the contents of paragraph 2.2 of working paper No. 1. It refers to contracts with private patients or their insurance companies, with private hospitals and employers generally. We have only reached paragraph 2.2, but already we are into private provision. Let us suppose that a self-governing trust discovers that the mark-up for private patients is higher than the mark-up for district health authority patients. Let us also suppose that the private insurance companies with which it is supposed to negotiate says, "You will get our patients only if our patients get preference and shorter working times than NHS patients." That would be the perfectly normal reaction of private insurance companies. Would NHS patients then find that they had been disadvantaged?

    The prospectuses that have been published by hospitals that are contemplating self-governing status are full of commitments to expand private practice. The nearest hospital to this Chamber that is contemplating self-governing status is St. Thomas's hospital. It has published a lengthy document which contains the following statement:
    "There will be an expansion of private patient services, including a range of choice of accommodation.
    Where is the expansion to come from? Where is the new range of choice of accommodation to come from? During the last two years that hospital has become notorious for removing NHS beds. Its expansion and new accommodation will not be a fresh site. The expansion in the number of private patient beds and new accommodation for private patients will be at the expense of the present NHS provision and of present NHS patients, who therefore are entitled to express their views in a ballot before such a step is taken.

    Would it be the policy of the Labour party, should it ever come to power, to refuse to allow any National Health Service hospital under any circumstances to take private sector patients? Does the hon. Gentleman know how much income would therefore be denied to the NHS?

    It is easy to answer the hon. Gentleman's second point: at present National Health Service hospitals are not permitted to take in private patients at a profit. It is only as a result of the Government's Health and Medicines Act 1988 that it is possible for them to seek to make a profit out of private practice. It is no part of the function of a free public service that is committed to meeting need, rather than to responding to market demand, to seek to make a profit out of the sale of medical services.

    The hon. Gentleman has taken me wide of the new clause. I am anxious to confine my remarks to the scope of the new clause. I want to return to the new clause.

    I am terribly sorry to disappoint the hon. Gentleman, but I have to say that I responded to his point. [AN HON. MEMBER: "What about the charity out of which he has had a good living for years?"] That is a very fair point.

    As I do not want the hon. Gentleman to be disadvantaged in any way, I shall try again to answer his point. He may intervene again if he wishes to do so.

    Will it be Labour policy, should that party ever come to power, to allow National Health Service hospitals to take any patients from the private sector? Will the hon. Gentleman please answer yes or no?

    Our policy on that matter has been set out fully on a number of occasions. The answer to the hon. Gentleman's question is that we have no intention of legislating to prevent hospitals from taking private patients. None of our policy statements contains anything to suggest that we so propose. It is our policy, however, that no patient should be brought in on a trading basis—for profit.

    Secondly—and much more important—the function of National Health Service hospitals is to treat NHS patients and to meet the needs of the people in their catchment areas. If the National Health Service were successful in meeting that objective, the private sector's market would vanish. If the hon. Gentleman ever looks at BUPA's recruitment leaflets, he will see that the organisation's one selling point is the waiting lists for NHS hospital treatment.

    All of this indicates precisely why we worry about a Government so patently committed to the expansion of private provision. One does not stimulate the private sector, one does not push the demand for private medicine, by subsidising it. Tax relief for the elderly patient is at the margin. If the hon. Gentleman asks, the private sector will tell him that such relief is peripheral. The way to increase the demand for private provision is to run down the public sector to such an extent that it cannot make proper provision. That is why one is suspicious of an Administration committed to expansion of private practice. Such an Administration cannot be committed to excellence within the NHS.

    I was tempted wide of my remarks just as I was about to turn to the second group who, under new clause 4, would be provided with a right of consultation—the staff of the hospitals or groups proposed for self-governing status. The main anxiety about the proposals for self-governing status is the anxiety about what they will mean for patients. Staff do have legitimate concerns. Indeed, those concerns came up during exchanges in Committee on this point. The only protection for staff is provided in clause 6. It provides protection, but only at the point of transfer to the self-governing trust. At that point, staff will transfer with the pay and conditions to which they were entitled on the previous day. Thereafter, they will be on their own. They will have no right to be included in national negotiations. A self-governing trust hires and fires its staff; it sets its own wage rates; it chooses whether or not to follow a national award. Here we are considering not just Whitley council staff. What about those people who fall within the pay review body network? A self-governing trust will not be obliged to follow a pay review body award.

    What about the thousands—tens of thousands—of nurses who are still awaiting a decision following the clinical grading review? What will happen if their hospital decides to form a self-governing trust? What will be done about appeals? To whom, for that matter, would they appeal?

    Not only do the staff find themselves outwith national negotiating systems, but they find that they have no absolute right to collective bargaining. A self-governing trust has no obligation to recognise even the existing health unions. [Interruption.] Iam grateful for that confirmation. A self-governing trust need not confer the right to organise in a union, although the staff transferred to it will be members of a union. There is no obligation, even on a self-governing trust, to recognise any system of collective bargaining, whether through trade unions or for any other purpose. Both those points—the exclusion from national negotiations and the loss of the right to collective bargaining through recognised existing Health Service unions—are surely sufficient to warrant the staff being asked whether they wish the hospital or unit for which they work to make such a dramatic change.

    There is an even more pressing reason why the staff should be given the option of voting on this question. They are not even to be asked whether they are willing to transfer. Clause 6 does not give the staff the option not to transfer with the self-governing trust. They are not to be allowed to say, "I am sorry, I do not want to transfer to a self-governing trust. I want to stick with my present employer and hold my present employer to my present contract of employment." Clause 6 makes it clear that that option does not exist. Subsection (5) states that the preceding subsections
    "are without prejudice"—
    that is rather nice—
    "to any right of an employee to terminate his contract of employment"—
    it is unfortunate that we are obliged to use the legal fiction that everyone is male, especially in the context of the Health Service, where most of the employees are women—
    "if a substantial change is made to his detriment in his working conditions"
    That does not confer any additional right on an employee, because he or she has that right whether or not it is stated in the clause. I invite my hon. Friends to mark well what comes next:
    "but no such right shall arise by reason only of the change in employer effected by this section."
    In other words, that employee has no right to terminate his or her employment because of the transfer from the district health authority to a self-governing trust. As my hon. Friends know, were employees so determined to terminate their employment, and were they to turn up at the unemployment benefit office, they would be told that they became voluntarily unemployed and did not qualify for benefit for six months.

    In Committee, Conservative Members rejected Labour amendments to give staff the right to say, "No, we wish to stick with the district health authority." All right, if it has to be a compulsory transfer and staff are not to be given the individual right to say no, surely they must be given the collective right to ballot on whether their hospital should form a self-governing trust. Conservative Members have strongly insisted over the past decade on ballots of union members for every conceivable purpose. I concede that over that period unions have got in a lot of practice in balloting. I admit that some have become quite attached to the idea of ballots, but the Government will leave those members of health unions in a strange position. They have a statutory right to elect their general secretary but they will have no ballot on a change in employment that could result in that general secretary not being able to protect them or negotiate for them with the employer to which they had been transferred.

    Lest any hon. Member thinks that these anxieties are fanciful, I shall deal at some length with the document produced by Trent region called "Patients before Profits". It was essentially about the personnel function of the new hospitals that are to form the self-governing trusts. Let me share with the House some passages. This is a passage from page 6 of the document:
    "Suppose people in key positions manifest a lack of commitment to organisational goals, ideals and values? What about renegades, subversives and opposers of what is being attempted? There will be a nettle to be grasped in terms of recruiting, keeping and getting rid of people in key positions right through the self-governing trust."
    I note that my hon. Friend the Member for Halifax (Mrs. Mahon) is here. I suspect that if my hon. Friend had been an employee on such an occasion—and she was an employee of the Health Service—she would quickly be indentified as a renegade subversive and opposer. I suspect that my hon. Friend would be rather insulted is she were not swiftly so identified.

    5.30 am

    Page 9 of the document contains the following statement on trade unions.
    "A self-governing trust will need to take decisions at an early stage as to whether it wishes to recognise any staff-side organisation for collective bargaining. It may be an appropriate tactic from the first day not to confer recognition on any organisation in order that the self-governing trust can pick the perfect time and opportunity to begin to enter into discussions for recognition of collective bargaining."
    We should note the passage:
    "to begin to enter into discussions for recognition of collective bargaining."
    On page 10 there is the suggestion that even collective bargaining may not be conceded:
    "A self-governing trust will have a choice. It may choose not to enter into collective bargaining arrangements. It may choose to continue to adopt the Whitley pay strategy or, alternatively, it may seek to impose pay deals. The trust will also need to have a clear view of its pay strategy and whether it chooses to move totally to individual remuneration packages."
    I finally want to share with the House a passage from page 13. It says in the discussion on pay:
    "Where the issue is one of lack of competitiveness, buying out a staff group may not be a viable option as this would merely increase costs when the defined problem was that the costs"—
    I remind my hon. Friends that "costs" means pay—
    "were already too high. The options here appear to be either to red circle existing work posts and offer different rates to new starters or to move into competitive tendering."
    In that passage, the problem identified is that NHS staff are paid too much.

    What emerges from the document is a picture of a management already manoeuvring to clear out those of independent mind and to remove the right to belong to a union that is recognised by the management. It is a management prepared to contemplate not even honouring existing pay agreements to new staff.

    Will my hon. Friend also accept that the Bradford Health Service trust has already said that staff who do not like the terms and conditions on offer will be subject to instant dismissal without any right of redress and that all night sisters in Bradford have been told that the night sister posts are to be abolished under the trust? They have been told that they may be redeployed, but they fear that it would be to lower nursing grades. They are also fearful that in cases where such vacancies are not available, they will be made redundant.

    My hon. Friend strengthens the case for new clause 4. If those are likely to be the changes that will flow from transfer to a self-governing trust, how can one in all conscience deny those night sisters a say in whether that step is taken? Is it any wonder that they should worry in those circumstances? Is it any surprise that they want the right to be consulted on such a dramatic change in their employment?

    So far, my remarks on staff have been directed mainly, but not solely, to the waged staff. There are also grounds for concern for the professional staff. There are the minority professions, by which I mean not professions that are marginal, but those that are small in number. My hon. Friend the Member for Newcastle upon Tyne, Central (Mr. Cousins) highlighted their position in a speech in Committee. There are only 900 medical physicists in Britain, and only 1,200 clinical biochemists. What are the implications, for small professions of that type, of the fragmentation of employers, possibly following different pay, different conditions and perhaps even the issue of different qualifications, because working paper No. I says:
    "These hospitals will be free to hire whomsoever they please."
    What will happen to the regional spread of such professions? What will happen to issues such as training and co-operation among professions that are so small in numbers that to be effective they require a high degree of collaboration on new techniques? Those are all questions of legitimate concern to those professions, the members of which should also have the right to cast their votes in ballots about what should happen to their hospitals.

    Then there is the much larger medical profession, where, I concede, there may be a different result in respect of pay compared with what I anticipate will be the result in terms of pay and conditions for waged workers. It is possible that the members of the medical profession may be able to exploit the new arrangements to their financial advantage. The NHS is the monopoly purchaser of medical staff. It has immense bargaining strength. I suspect that that explains why other European countries have to pay more for their doctors. For reasons that appear dubious to me, the Secretary of State proposes to throw away that bargaining strength that he has in relation to the medical profession.

    In creating self-governing trusts, the Secretary of State is creating competitors with himself for the best qualified doctors, and the most likely result is that he will have to pay doctors more. The Trent document anticipates that in some respects and says:
    "There is a danger that they"—
    self-governing trusts—
    "may overheat the market place and create an inflationary spiral in respect of certain groups of staff whereby each of the self-governing trusts are bidding up terms for scarce staff or are recycling a chronic staff shortage."
    In other words, those self-governing trusts will find that they are bidding up the salaries of doctors.

    The Secretary of State's views on the financial motivation of doctors is well known, since he gave birth to an unfortunate phrase which identifies their motivation with their wallets. It is to the credit of the medical profession that its response to the proposal of those self-governing trusts has not been to recognise them as an opportunity for personal financial gain. Doctors weighing up the pros and cons of self-governing trusts have given their impact on patient care very careful consideration.

    But there are narrower professional issues with which we must be concerned and which have already dominated the votes that have occurred, on an unofficial basis, among consultants in hospitals contemplating self-governing status. Most of those issues have been concerned with their contract. At present, consultants hold a contract with the regional health authority. In future, they will hold it with the self-governing trusts. To all intents and purposes, they will hold their contract with the unit general manager.

    The past two years in hospitals throughout the country have been marked by a struggle between consultants and unit general managers in which the latter have been cast in the role of people trying not to get more work out of their consultants but to stop the consultants from treating more patients—from going over budget—and there is foreboding among consultants about a situation in which, by contract, their general managers will be able to order consultants to stop carrying out treatments that they believe the patient population requires.

    The next issue of concern to consultants is their freedom to speak out. They were promised that freedom by Nye Bevan at the time of the founding of the NHS. That promise has been respected until now by every Government. Sometimes it has embarrassed Governments. It has certainly been exercised by consultants, who have had no regard to whether they were embarrassing Governments or their managements. A self-governing trust is unlikely to respect the freedom of consultants to speak openly and freely to the public whom they serve about the standard of service in their hospital, and the pressure on them to restrict that standard in the interests of the budget.

    I understand the hon. Gentleman's need to pay heed to his union paymasters, and to make a determined plea to protect the power of Health Service unions. Does he believe, however, that the Secretary of State should have centralised powers to dictate to every unit in the country—however small—the qualifications for the staff that that unit wishes to hire and the work, salary, hours, terms and conditions of every employee?

    As far as I am aware, none of my hon. Friends is sponsored by the British Medical Association, or, for that matter, by the National Health Service consultants' association. I should be slightly surprised to find that we had formed that link without its being brought to my notice at some stage, as I am a member of Labour's national executive committee.

    The hon. Gentleman does not need to tell me the names of the Health Service unions. Of course there are links between them and my party, and I make no apology for those links: they are one of the reasons for our being able to keep abreast of developments in the Health Service, despite the cloak of secrecy with which the Government have tried to veil them. I happen to believe that the work force has legitimate rights which must be legitimately expressed. As I said earlier, our main cause for concern is the effect on patient care, but we should not dismiss the feelings of staff.

    The hon. Gentleman asked whether the Secretary of State should have the power of direction. He does not at present: most of the qualifications are set by recognised professional bodies. Certainly I am not in favour of leaving it to individual self-governing trusts to decide what are the appropriate professional qualifications and what is the appropriate training; the House has a duty to the public to ensure that national standards are adequate.

    I am sure that my hon. Friend would agree that professional qualifications have been developed not only by the unions but by the professional organisations, over many years. Are Conservative Members saying that what applies to accountants and lawyers should not apply to the Health Service? Surely professional qualifications are particularly important—indeed, essential—when life and death depend on them.

    I have some sympathy with my hon. Friend's point, although it often strikes me as curious that we insist on professional qualifications for every profession except our own.

    Consultants may be willing to forgo their right to speak out publicly, but it is a democratic right none the less. It was given to them by means of a parliamentary assurance, and they should be asked to give it up only on the basis of a democratic vote in which they are able to participate.

    Consultants have other worries. What will happen to research programmes, for instance? Much of the most successful medical research is based not on actual sponsored work, but on the meticulous recording of patient notes over the years, and on investigations that, while not immediately necessary, are important to the consistency of the research programme. It is based on a case mix that is not necessarily consistent with the highest throughput or the greatest volume. All that may come under pressure from a board of directors looking for rapid turnover and high throughput. It may also conflict with the needs of medical training which requires that spread of case mix.

    Those are all important considerations which give sound reasons why the medical profession may wish to have a vote on whether their unit forms a self-governing trust. I should like to think that the Secretary of State would not wish to deny consultants that ballot. That may be a rash presumption, but he has committed himself to that proposition. On page 22 of working paper No. 1, he says:
    senior professional staff, especially consultants, must be involved in the management of the hospital…Any successful proposal would need to demonstrate that it carried the substantial commitment of those likely to be involved in the new management."
    What better evidence could there be of that substantial commitment than a vote by the consultants on whether their hospital should form a self-governing trust?

    5.45 am

    I am not keen on a ballot confined to consultants. Other members of staff also form part of the same health team. Hospitals do not need just doctors and nurses to function; they also need ambulance staff, medical secretaries, porters, cooks, physiotherapists and laboratory staff.

    If the Secretary of State is prepared only to recognise consultants, I am prepared to make the giant compromise and say that we will settle for a ballot on a consistent and official basis for consultants.

    What worries me, and may worry other hon. Members, watching how the Secretary of State has gone about gathering in the applications for self-governing trusts, is that I know how he will go about getting that evidence of substantial commitment. He will find a few pliable consultants who sit around in committees putting their name to prospectuses to give the cover of consent for that hospital.

    That approach is already causing tension. In Guy's hospital the consultants became so fed up with the fake consultation offered to them by management that they called in the Electoral Reform Society to carry out a ballot. Another hospital approached the BMA to hold a ballot because
    "the in-fighting is poisoning the business of care at the hospital."
    The problem is that the Secretary of State is playing with rubber rules. The problem with rubber rules is that they create friction. If he really wants to demonstrate that the consultants' commitment is clear and above board, if he wants to get the self-governing trusts off to a start that all consultants can accept as fair and open, he should give all consultants a vote in a ballot.

    I have addressed my mind to why patients and staff should wish a ballot. But another group is identified in my new clause as requiring consultation before a step is taken to form a self-governing trust. That other group is the relevant district health authority. At first sight, it may seem eccentric even to state that the views of the district health authority should be obtained. After all, the hospital that is forming the self-governing trust happens to belong to the district health authority. It owns the buildings and hires and pays the staff. Its buildings and staff are going. Yet a number of major hospitals within district health authorities have submitted proposals for self-governing status against the express vote of those district health authorities. I know of four. They are Newcastle, where the Freeman hospital and the mental health services unit have been nominated for self-governing status; Doncaster, where, as my hon. Friend the Member for Barnsley, West and Penistone (Mr. McKay) will know, the Doncaster Royal infirmary and the Montague hospital are seeking self-governing status; North Tyneside, where we have the particularly rich paradox that North Tyneside district health authority has come out against self-governing status, and the entire services of North Tyneside are seeking self-governing status, leaving the district health authority with nothing directly to manage; and West Lambeth district health authority has come out against self-governing status and there remains an application on the table from St. Thomas's—not just one of the largest hospitals in central London, but the hospital of West Lambeth district health authority.

    I can think of no more striking example of the way in which district health authorities are being bypassed by a new line of heirarchy—running from Richmond terrace, through regional management, to district management and down to unit management—than the way in which the Secretary of State has been able to call forth up that line of management accountability proposals for self-governing status that bypass the very health authority affected by the application.

    There are reasons why the district health authority should be concerned, and why it may wish to have its views recorded before the House in the way that I propose in new clause 4. This brings me back to the intervention of my hon. Friend the Member for Newham, South (Mr. Spearing). There is the fragmentation of the service. The district health authority's strength is that it brings together in one comprehensive management both the hospital and community services. In Scotland we have achieved an even greater integration because the health boards also include the primary care function.

    I always thought that the way forward in England was to achieve greater integration of the health services in England, instead of which the Secretary of State has chosen to go for fragmentation. That begs a number of questions. What is the meaning of continuity of care when the hospital is managed by a self-governing trust and the community services are managed by the district health authority?

    The best patient care and management results from close contact and common management between consultant and district nurse or occupational therapist. Already that relationship is stretched by the increasing pressure on community services from the fast turnover in hospital beds. As a result, patients who have not fully convalesced are being sent home, placing an extra burden on community services. Effectively, hospitals are achieving greater efficiency at the expense of greater cost to part of community services.

    If this happens now, how much more will it happen once the district hospital and community services have separate budgets and separate managements? Will not the self-governing trust be tempted to externalise its costs by passing as much as possible on to the community services still managed by the district health authority? That appears to be a matter of legitimate anxiety to the district health authority, which should have the right to record its views to the House. An essential reason for that anxiety is that the Government's new structure deals with hospital treatment as an episodic, isolated event, limited in time.

    The hon. Member for Pembroke (Mr. Bennett) who, unfortunately, is not with us——

    I am glad that I carry my hon. Friend with me on that point.

    The hon. Member for Pembroke, unfortunately, was with us throughout that Committee proceedings, as my hon. Friend will recall. During one of the Committee sittings, he said that organisations that claimed to represent patients were bogus because patients' experience of the Health Service was limited to two weeks at a time. That would come as a novel insight to the Asthma Society or the Epilepsy Society which, by definition, represent people who are lifelong patients. It is a revealing glimpse into the way in which the package of measures before the House is dominated by the concept of short bouts of illness, and rapid cure and turnover. That is an experience limited to only a minority of patients. For the majority of patients, the episode in hospital is part of a continuous experience in which continuity of care is marked by transfer from primary care to hospital, and from hospital back into the community service. That is an issue about which any district health authority, or health board in Scotland, might wish to express views to the House.

    I am grateful for my hon. Friend's exposition of the point that I raised earlier—the disintegration inherent in the Government's proposals. Is he aware that I understand that St. Thomas's hospital stated specifically to those whom it wished to recruit that it would be handy and near to the proposed Channel tunnel terminal at Waterloo? At the moment, the district hospital in Newham is not contemplating opting out. However, should—by some chance—the Channel tunnel railway come to Stratford, according to the Government's proposals the hospital could opt out without any vote or any concern for the district health authority. Is not that the precise point that my hon. Friend is making?

    I well remember my reference to that. I said that St. Thomas's claims that one of the advantages of opting out would be that, because of the proximity to the Channel tunnel terminal, it could attract overseas referrals. St. Thomas's will have to do some rethinking in the light of what has happened with the Channel tunnel, but the idea existed that it might receive overseas referrals—presumably treated as part of its expansion of private patients' facilities, in the new range of accommodation for private patients at the expense of NHS provision.

    It would be only a marginal extension of the practice of St. Thomas's hospital if it went across the Channel for patients. It has been trawling for patients around the Medway towns and the rest of Kent for many years, at the great expense of the Medway towns, in order to keep alive one of the many hospitals in London for which there is no longer any serious need.

    Without necessarily taking a view on whether the hon. Gentleman is correct, his contention goes to the heart of my new clause. He said that St. Thomas's meets no real need in the local population. That contention would be bitterly disputed by the West Lambeth district health authority. The new clause seeks to give that authority—which is opposed to St. Thomas's seeking self-governing status—the statutory right to have its views recorded in a report to the House. It would be proper for the hon. Gentleman in those circumstances, should he choose, to vote down that report and the views of the authority. If he is to bandy around such wild statements, we should confer on the health authority the right to express its views to the House and to protect the people whom it serves, who also strongly feel that they still require those services. I expect that the hon. Gentleman will soon recall the words of the Under-Secretary in Committee—not all of my hon. Friends will be aware of them—when he said, with characteristic candour, that as a result of the operation of capital charges—which would penalise the centre-of-London hospitals—some patients from those hospitals were being redirected to peripheral areas where capital charges were less costly, possibly Mid-Kent and thereabouts.

    On the issue of new clause 4, I wish to focus on the anxiety of a district health authority rather larger than West Lambeth—for example, Leicester—or a health board—for example, Lothian—that has more than one major hospital. It may well have developed those hospital services not to compete with each other as the Bill supposes, but to complement each other. I shall cite the example of Edinburgh, a place I know well. It has two major hospitals—the Western general and the royal infirmary. They have been developed so that the rarer specialties are allocated between them to provide a complementary balance, not on the basis of a competitive scramble for the patient. The health board chose and planned that strategy because it is cost effective, and cuts out competitive duplication in expensive equipment and rare and expensive skills. It avoids the waste of the American system in which every commercial hospital has to have its own latest piece of technical gadgetry to retain an image necessary to succeed in competition.

    A health authority with more than one hospital may wish to record its anxiety to the House about what would happen if one of the hospitals were to opt out. What changes would that cause in the other hospital that remained directly managed? How would it adjust to meet the competition? What new expenditure would be necessary? What new staff would it need? What new specialties might it have to consider adopting in order to meet the competition? Those are all considerations that the Minister may miss as he mulls over the questions in Richmond terrace. Those are considerations which the health authority has a right to have recorded in the House.

    6 am

    There is one even greater ground for anxiety among health authorities. Let me introduce this passage by reminding the House that the hospitals and the units setting out on the self-governing path are being invited to push the boat out into the new competitive sea. On the basis of the statements that I have seen by managements who are peddling self-governing trusts, there is an intriguing feature common to all the prospectuses and statements.

    Every management seeking to encourage its staff to go out into the competitive sea says that it will succeed in the competition between hospitals. Logically, they cannot all be right. Some may succeed, but competition implies that there must also be losers. A district health authority is surely entitled to express its view as it answers the question, "What will happen if our district general hospital is the loser in the new competitive environment?" What if the hospital fails? It is not a fanciful question. It is a feature of the commercial market that there is constant contraction and expansion of competing firms.

    In America, where competition between hospitals is commonplace, 90 acute hospitals have closed in every year of the decade. Will the same logic apply to these hospitals? Apparently, yes. The previous Minister of State, before his rapid and unexpected departure, went on record as saying that it was no part of the new NHS to subsidise hospitals that could not compete efficiently. Translated into the local context, that means that if a district general hospital has gone into a self-governing trust and is unable to make itself financially viable, the district health authority will see it closed because it is no part of the new NHS to subsidise hospitals that cannot compete efficiently.

    Is there a safety net? If not, surely the district health authority is entitled to express its view on whether it wishes to see its general hospital take that competitive risk. That is undoubtedly also of concern to the staff and to the unions of the Health Service. After all, they are very much in the boat that is being pushed out in the competitive sea. They may want to ask, "Will it sink?" That is another reason why they should have a ballot. It is certainly the consideration which should weigh uppermost with the district health authority in expressing its opinion.

    Until a year ago no NHS hospital had been required to price a single contract or a course of treatment to its district health authority. It is now being invited to enter the new competitive market in which it will have to do precisely that. The original theory put forward by the Secretary of State when he launched the White Paper was that by April of next year each candidate for self-governing status in the first wave would have cracked the problem of how to price contracts, would be able to price a contract on every treatment and could also guarantee that the aggregate of each contract balanced the total expenditure of the hospital and of the unit. I concede that there has been much hedging and settling for second best as the sheer impossibility of the task became clear, but in essence those hospitals and units contemplating self-governing status are still left with the challenge of how to negotiate contracts that result in revenue matching expenditure. How will they do that? That question will surely exercise minds in many district health authorities and the staff at the hospitals. After all, the staff have witnessed at close hand the financial skills of unit general managers over the past two to five years. They have not always been impressed by the financial acumen of those general managers. Indeed, over the past year the Secretary of State has been constantly blaming those general managers for weak local management which has resulted in the financial crisis in the health authorities. However, the Secretary of State is now putting the charge for the financial viability of hospitals on those general managers. The tools that he is providing for them are pretty rough and ready.

    When the White Paper was launched a year ago it was suggested that the pricing of contracts could be achieved by adapting the computer system for the resource management initiative. That computer system has not yet been evaluated and it was developed for a purpose entirely different from costing and pricing contracts. The district health authorities and the staff representing the hospitals within the resource management initiative quickly decided that they would need more time before they could price a contract.

    There are only six hospitals in the resource management initiative and five of them made it clear from the outset that they could not carry out that function in the timetable required.

    About six weeks ago I wrote to my local hospital about a patient who was seriously ill with gallstone trouble. I received a reply from the unit manager, not from the consultant. The answer was revealing and shows that that hospital is already carrying out the kind of exercise described by my hon. Friend.

    The unit manager stated that although the consultant said that the patient was of the highest priority, the hospital had exceeded patient numbers for this financial year and therefore the operation could not take place. I received that letter on 12 March from Miss Waterhouse, the unit general manager for Wigan hospital on behalf of her consultant urologist.

    My hon. Friend illustrates the other side of the contract. Not only will hospitals have to get the costs right, because every penny coming to the hospital will come by way of contracts, but patients will get into the hospital only if there is still room in the contract for additional patients.

    I was stating that five of the six hospitals in the resource management initiative decided that they needed more time before they could price a contract before April 1991. The one exception was Arrowe Park hospital in the Wirral. It expressed polite interest in the concept and was on the first list of hospitals listed as having an interest in self-governing status. That hospital has dropped out of the first division of that list. None of the hospitals that have experienced the resource management initiative computer system now want to opt out. All the hospitals that are seeking to opt out have no experience of that computer system.

    Therefore the Secretary of State has produced a fall-back system. He has three pilot projects for a computer system known, appropriately, as HIS—hospital information systems. All those pilot projects are in deep trouble. I notice from the latest issue of Computer Weeklythat two companies that were bidding for the system have now withdrawn. Many of the firms that did not bid, such as ICL and Istel, claim that the plans were overambitious with too short time scales between tendering and supply.

    I have been glued to my seat for some time as I have listened to the hon. Gentleman through error after error, with misstatement after misstatement, describing the new process that he is seeking to attack. Does he accept that we have now reached the positon where all hospitals—not just self-governing hospitals—will have to provide all their services under contracts, such as he is describing, not only for acute services, but for community services also? All hospitals and all community units will be working under contracts.

    Does the hon. Gentleman also accept that this issue about contracts has nothing to do with his new clause, and that the pricing of those contracts, the stipulation of quality and everything else that is required, will not depend on the resource management initiative or on HIS? We have made all that absolutely clear. Therefore, before the hon. Gentleman wanders off down this latest byway, perhaps he will return to the point raised by his hon. Friend the Member for Makerfield (Mr. McCartney) who was describing a situation which has arisen under the old National Health Service—the pre-contract National Health Service. No doubt that health authority was behaving as health authorities sometimes have to behave in response to the cash limit within which all health authorities operate. I remind the hon. Gentleman that the Labour Government introduced the system of cash limits. The position that the hon. Gentleman has described has been occurring in the NHS for as long as I can remember——

    No, I am sorry. This is an intervention. I am replying to the hon. Member for Livingston (Mr. Cook) who has kindly allowed me to intervene.

    Given that the hon. Member for Livingston accepts the system of cash limits that was introduced by his own Government, how does he propose that the Wigan health authority should cope if it does not price what it is doing, if it does not have any budgeting or information systems or any matching of work with resources? What is his answer to his hon. Friend who has complained about the unreformed NHS, which he appears to defend? In the past, the hon. Gentleman has talked about activity budgeting. Will he explain what that means, as it appears to be his answer to the things that his hon. Friend mentioned?

    On a point of order, Mr. Deputy Speaker. It is not fair that the Secretary of State should make such a long intervention when he will have the opportunity of making his own comments at the Dispatch Box to try to sell what he is trying to sell. It is appalling——

    I can reassure the hon. Gentleman that I shall make my speech as soon as I am enabled to do so after this third-rate filibuster to which the Opposition have now reduced our proceedings——

    On a point of order, Mr. Deputy Speaker. Could you tell the House whether my hon. Friend the Member for Livingston (Mr. Cook) has breached any of the Standing Orders during his excellent outline of the new clause?

    I think that we had better get on with the debate. I call Mr. Cook.

    Indeed, we had, Mr. Deputy Speaker. However, first I require your guidance. My hon. Friend the Member for Bradford, South (Mr. Cryer) has been good enough to point out that you have not intervened at any point to draw me to order. If, when responding to the Secretary of State, who has tempted me to discuss the general financial environment of hospitals and to respond to some of the statements that he made, I stray out of order, could you guide me, Mr. Deputy Speaker?

    Since the Secretary of State has raised this point, let me respond to it. The right hon. and learned Gentleman said that cash limits were introduced by the last Labour Government, to which I can make two responses. First, I pray in aid my hon. Friend the Member for Makerfield (Mr. McCartney) and invite him—[Interruption.] I am terribly sorry if I have misplaced my hon. Friend, who is unusual among Scotsmen for having a detailed knowledge of Lancashire geography which is denied to many of his compatriots. I pray in aid my hon. Friend who has a knowledge of his area that stretches back to the days of the last Labour Government. Can he recall a like case that arose during the period of the Labour Government?

    My second response to the Secretary of State is that although the last Labour Government introduced cash limits, they were subject to supplementary estimates. Throughout the period of office of that last Labour Government, the cash limits were automatically raised to reflect every staff and pay increase. It is the loss of that automatic uprating in line with the award to staff which has created the squeeze of the hospital sector under this Government.

    I put it to the Secretary of State, since he asked the question, that I and my right hon. Friend the Leader of the Opposition have stated our commitments clearly. The next Labour Government will do two things in the hospital sector. First, they will restore to the hospital sector that sum by which the health authorities estimate that they have been shortchanged by this Government since 1984. Secondly, we shall fully fund pay awards that are made thereafter. I notice you shifting uneasily, Mr. Deputy Speaker. I am conscious that it is perhaps time that we returned to the new clause.

    6.15 am

    I wish to respond to one point in the Secretary of State's lengthy intervention—which I believe was in order. He made a comment about computer systems. I was not objecting to computer systems. It would be a good thing if more computer systems were developed within the Health Service. The point that I queried and which has been queried by Computer Weekly and by most reputable computer companies is whether it can possibly be done in the time scale on which the Secretary of State insists. He is shoving hospitals and health authorities down a path at a pace that is likely to guarantee chaos.

    Just as the staff who work in hospitals should have a vote and patients should have the right to a ballot, the district health authority should have the right to record its views before the House. I have dealt with each of those three groups separately. But it is worth recording that they all have reasons in common to worry about the self-governing proposals. Each has a right to wish to express its view before self-governing status is acquired

    I stress to the House that if it does not accept new clause 4, it will leave each of the three groups with no statutory right to express a view on the proposal for self-governing status. That is because the Bill makes little provision for any consultation before, during or after the creation of self-governing trusts.

    If new clause 4 is not accepted, there will he no consultation before self-governing trusts are set up. There is no proposal in the Bill for consultation. Ironically and rather eccentrically, it proposes that there should be consultation before a self-governing trust is wound up, but not before it is created. It is one of the rare flashes in the Bill that suggest that the Secretary of State may have a sense of humour.

    Staff, patients and health authorities will be excluded from the choice of directors. Just as the Secretary of State will decide whether to set up the self-governing trust, he will appoint the directors. There are only two constraints on his choice. First, in appointing the non-executive directors, he must consult the chairman. Who appoints the chairman? The Secretary of State. Secondly, the two non-executive directors drawn from the local community will be appointed by the regional authority. Who appoints the regional health authority? The Secretary of State. There is a seamless web stretching back to Richmond terrace.

    Staff will have no right to nomination, community health councils will have no right to consultation, and patients will have no right to representation. Most breathtaking of all, the district health authority will have no right to nomination. The Secretary of State's choice of the regional health authority as the body which nominates the local community representatives is particularly eccentric.

    As the College of Health has observed,
    "A board of 10 directors with a Chairman appointed by the Secretary of State and including at least two community directors appointed by the regional health authority does not sound like local people running their own hospitals."
    I may be wrong. Perhaps the non-executive directors will be excellent people who are so much in touch with the local community and staff that there is no need for the new clause. Possibly, the need for new clause 4 will vanish at the announcement of their names. The simplest way to put that thesis to the test is to name them. It appears that the non-executive directors have already been appointed.

    I have with me the minutes of the conferences of project managers held in December, January and February, all in large central London hotels. There is something perverse about decisions on local hospitals being taken in central London hotels behind closed doors.

    Certainly not cheap hotels. I concede the point to my hon. Friend.

    I draw attention to paragraph 7 of the minutes of the December conference which was held in one such hotel. I cannot name which one, but most were held either in St. Ermin's or the Grosvenor. The heading reads, "Non-executive helpers" and continues:
    "Original chairmen have been commissioned by the Secretary of State to provide names of non-executive helpers by the end of the year."
    That is the end of last year. It becomes patent that the phrase non-executive helpers is a transparent way of referring to non-executive directors whose names were provided to the Secretary of State by the end of last year.

    I brush over the fact that we are still debating the Bill which creates those self-governing trusts. I overlook the fact that the Secretary of State has at present no power to appoint non-executive directors of a self-governing trust anywhere. I leave aside that constitutional nicety. I seize on the possible convenience of that to our debate.

    If those non-executive helpers are the right people, perhaps we do not need the right of consultation through a ballot. This may be an opportunity for the Secretary of State to cut short the debate. Will he name these non-executive helpers whose names he received by the end of the last year, and share them with the House?

    I would not wish the Secretary of State to remain so glued to his seat that he cannot intervene. His silence on this occasion speaks more eloquently than his intervention on the last occasion.

    These non-executive helpers are remarkably coy. The rest of the paragraph states:
    "Project managers have reported that in some cases such helpers are not prepared to be named publicly, at least until a firm decision to submit an application has been made. Some argue that public identification of such a helper may not be acceptable to clinicians at this stage."
    It emerges from that minute that these are not people who represent the local community; these are people who are terrified of the reaction of the local community to their names becoming public. That reticence to go public is another good reason why staff and patients should have the right to a ballot before a hospital is handed over to these coy missing names.

    May I share with the hon. Gentleman the reason for my diffidence and that of some non-executive helpers? My guess is that they are rather loath to be drawn into the daft debate that we have had for the past hour about self-governing hospitals. The hon. Gentleman has misdescribed, deliberately in many cases and sometimes accidentally, just about every feature of the self-governing hospital proposal. I have not the first idea how he would describe the role of these individuals if they were named. No doubt he would cast them in some Mephistophelian guise. If we get outside people with business experience to help those contemplating the possibility of a self-governing trust in their locality, they should not be exposed to this sort of nonsense, even if hon Members must.

    We can answer that succinctly. The Bill provides for £10 million to be paid to members of the new health authorities. [Interruption.] I think that the Secretary of State is in danger of misleading the House by saying that they will not be paid at all. Payment to the directors is a matter for the self-governing trusts to resolve.

    Given that smearing everybody's interest has been a feature of our debates from time to time, I took the intervention of the hon. Member for Bradford, West (Mr. Madden) to mean that non-executive helpers have been paid in some way for their present role. They most certainly are not.

    I understand from that intervention that the Secretary of State is confirming my statement that the directors will be paid by the self-governing trusts once they are established.

    I found two points in the Secretary of State's penultimate intervention particularly interesting. First, when he referred to the qualifications and background of the non-executive helpers, he named only one consideration—business experience. Not community representation, not medical qualifications but business experience. Secondly, the reason he gave for the helpers' coyness about being named was that they were not willing to enter into debate. I understand why people may not wish to enter into democratic debates and may not wish to mix with politics and I do not mind that. They are perfectly entitled to get on with their business and private lives as they wish. However, they are not entitled to seek to run major public services such as the Health Service because people who purport to run those services have to be prepared to enter into debate with Members of Parliament and with Opposition spokesmen on health.

    There has been a revealing exchange between the two Front Benches about self-governing helpers and the direction in which self-governing trusts are going. The last area in which staff, patients and district health authorities are likely to find themselves excluded from having a say is in the future of the self-governing trusts. Working paper No. 1 on page 14 promises:
    "In general, the Government looks for as much openness as possible in the management of the NHS hospital trusts. As a minimum, each Trust should hold an annual meeting open to the public, at which a report on the previous year's performance, the accounts, and the business plan would be formally adopted"—
    not by the public, but by the trust.

    I put it to the Secretary of State that an annual meeting at which annual reports are adopted by the trust in front of the public is scarcely
    "as much openness as possible."
    It is pretty mininal openness.

    Three paragraphs in the working paper are headed "accountability". They are all concerned with financial accountability; none of them is about democratic accountability. As has been said, accountability of an annual meeting adopting annual reports is no more open to the public than the board of Unilever or Harrods is open to the public. Before the boardroom doors are closed and self-governing trusts are established, staff and patients must be given the right to express their views.

    The last reason for staff and patients to be given a vote, under the terms of the new clause, is that there have been a number of such ballots already, on an unofficial basis. We have debated a number of them in Committee. Wherever those ballots have been held they have come down crashingly against self-governing status.

    In Aberdeen, where there was a ballot of consultants, 251 votes were cast and 80 per cent. of them were against self-governing trusts. In the Borders general hospital in Scotland in a staff ballot, 831 votes were cast and 80 per cent. were against. In towns in the north-west of the country there have been a number of ballots open to both the community and the staff. The total number of votes cast was 30,920, with 620 in favour and 30,300 against. In the east Midlands more than 7,000 people were polled in various locations. The vote for self-governing hospitals was 446 and the vote against was 6,500. In a ballot of 800 consultants in Wessex, there was a clear majority against any hospital seeking self-governing status. The pattern is unmistakable. Across Britain—from Aberdeen to Cornwall and from Blackpool to Lincoln—there is the same message. Given half a chance to take a local decision, local people do not want local hospitals to leave the management of the local health authority.

    The real reason why the Secretary of State does not want ballots to take place is that he knows that whenever there is a ballot there is bound to be an overwhelming majority against opting out. If he thought otherwise, he would not be against ballots. The figures that my hon. Friend has given well illustrate that fact.

    My hon. Friend's helpful intervention leads me to my next point.

    Where ballots have taken place there may not have been a specific proposal to opt out. Where there has been a specific proposal by hospitals to opt out, we find exactly the message that my hon. Friend suggested. There is only one major hospital in Scotland that has expressed an interest in forming a self-governing trust: the Royal Scottish National hospital at Larbert.

    6.30 am

    My hon. Friend referred to a hospital that has expressed an interest in opting out. He is falling into the trap of accepting, unconsciously and unintentionally, the definition of a hospital that is implicit in the legislation: that the hospital is not the staff, or the patients, or the local community but simply the general management. I ask my hon. Friend to make it clear that he rejects that definition of a hospital. If he uses shorthand, such as "a hospital has applied to opt out", may we take it, nevertheless, that he rejects that definition of a hospital?

    I am justly rebuked by my hon. Friend. She is absolutely correct. It is a phrase that I have slipped into using because of its frequent repetition by Conservative Members. A hospital cannot express an interest; it is a building. There are some remarkable examples of that in the original list of hospitals that expressed an interest in opting out. One of those hospitals was the new district general hospital at Gravesham, which at present is a collection of fields. There were pleasant television pictures of cows grazing peacefully in a field that had expressed an interest in opting out.

    It is not always the unit management that expresses an interest in opting out. In some cases, individual members of the public have expressed such an interest. Gateshead mental services unit found that it had been nominated by an unknown member of the public for opting out. A hospital in East Grinstead found that it had been nominated by a concerned member of the public. I am happy to say that those hospitals have disappeared from the list. The original list of 178 has been reduced to fewer than half that original number. My hon. Friend is right to point out that the decision to opt out is not a corporate decision. The point of my new clause is to ensure a ballot that would result in a genuine corporate decision by those who are involved with the hospital.

    The Royal Scottish National hospital was nominated by the unit general manager and by nobody else. That hospital is unusual and distinctive. It caters solely for severely mentally handicapped patients. They have made their home for decades in that hospital. I find it tasteless that the hospital for those patients, who cannot write letters to The Scotsmanand cannot join protest marches through Glasgow, should be chosen as the pilot project for Scotland. The staff were balloted; 802 members of staff were opposed to self-governing status while 34 were in favour of it.

    In Leeds, East there are two major hospitals. One of the largest hospitals in Europe expressed an interest in opting out. The two community health councils conducted a postal ballot of 1 per cent. of the electorate in 10 wards of Leeds, East. They found that 76 per cent. of those balloted were opposed to opting out and that 24 per cent. were in favour. The Secretary of State has just appointed as community representative and chair of the Leeds, East district health authority the chairwoman of the Yorkshire Conservative association. I have already said that the district health authority in Doncaster opposes the formation of a self-governing trust there. As hon. Members will know, an opinion poll in Doncaster found that 71 per cent. of electors and patients oppose self-governing status, whereas only 13 per cent. support it.

    In West Norfolk, where the acute services have expressed an interest in opting out, there was a ballot of consultants. Of those, 33 came out against, and seven were in favour. How that can be regarded as evidence of senior staff being committed to self-governing status I do not know, yet the proposal there is going ahead. North Middlesex is nominated for self-governing status. In Haringey, 2,000 staff of the district health authority voted, and self-governing status was opposed by 96 per cent. of those. In Plymouth, there was a ballot of consultants. Ninety were opposed to self-governing status, and six were in favour.

    The West Midlands regional health authority carried out the most comprehensive exercise. In a referendum open to every elector in Redditch borough, 32,000 votes were cast. That represented a 57 per cent. turnout—quite respectable for a local election. The people there were asked whether the local Alexandra hospital should press ahead with its proposal to opt out and form a self-governing trust. Of those people casting votes, 81 per cent. were against a self-governing trust. So there was massive opposition in that important test of local opinion.

    Of course, my hon. Friend the Member for Walsall, North (Mr. Winnick) is right when he says that the Government are opposed to referendum because they produce these results. My hon. Friend was not a member of the Standing Committee, where we heard objections tumbling out of a number of hon. Members. They were at pains to point out why all these results were unreliable. One of the reasons, apparently, was that the people taking part in the exercises had got hold of the wrong leaflets, which contained misleading information. Other reasons given were that people misunderstood the proposition and that they had been misled by me and by my hon. Friend the Member for Peckham (Ms. Harman).

    In a winding-up speech in Committee the Minister said that the issue was too complex to be put to a mass vote. It is quite clear how the hon. Members on Standing Committee E would have voted on the Reform Act had they been here in 1832: they would have been against it. It would have been too complex an issue for the masses to vote on; or people are too prone to being misled by Opposition spokesmen; or they might get misleading leaflets.

    At every general election in which I have stood, my opponents have circulated misleading leaflets. That is in the nature of democracy. One has to trust the electorate to be able to see through misleading leaflets. I am happy to say that, in my case, that is what has happened. This is the rough and ready nature of the British electoral system.

    I come now to my concluding piece of evidence. We now have—I concede to the Secretary of State that we did not have it previously—ballot evidence that cannot be subjected to many of these criticisms. I refer to the ballot that was carried out by the district health authority in West Lambeth—the first official ballot formally organised by a health authority within the Health Service. Every member of the staff of West Lambeth district health authority was balloted. The people were presented with the issues. They were given information. The leaflets cannot have been misleading, as they were produced by the health authority.

    What was the result? The result of a ballot with proper information and proper leaflets, and with not a single speech from my hon. Friend the Member for Peckham or myself, was that 2,449 people were against self-governing status, whereas 550 were in favour. I note from the press that the chair of the West Lambeth district health authority has undertaken to write to the Secretary of State to draw his attention to the result. Of course, the chair of that authority has more direct and immediate access to Richmond terrace: his daughter is the Minister for Health. I understand that, after that result, he indicated that he wishes to withdraw the community services from the bid for self-governing status. The major part of the bid—the application for St. Thomas's hospital to be given self-governing status—still applies.

    Given that we were promised that such applications must show staff commitment and given that a properly organised, officially conducted ballot was held which showed that staff resistance, I regard it as an affront to democracy that the authority should persist with that application. It would be an insult to Parliament if the Secretary of State were allowed by the rules to let the unit general manager to get his way and opt St. Thomas's out so that it becomes a self-governing trust without even reporting that data to Parliament. That vote makes the case for new clause 4, the case for staff to have a right to ballot and for Parliament to have a right to know the results. On that ballot, I rest my case.

    I have said enough to open up the debate. In Committee in debates on NHS trusts, we repeatedly heard how good they would be. We were told that they would release enterprise and initiative to find new cures for cancer. If the Government believe that self-governing trusts will be so good, let them put that case to the people and let them judge. I ask the Secretary of State to have faith in his case and to believe that it will not be blown apart by a misleading leaflet or a speech by me. If he really believes in local choice, he should give the local people a choice.

    I give this warning: if the Government refuse to give that choice and turn down new clause 4, we will make sure that those ballots are organised for the Government. Throughout the country, we will expose not just how damaging self-governing trusts will be to the Health Service, as a public service committed to continuity of free care, but the fact that the Conservative party knows that the proposals are so deeply unpopular that it is terrified to let the people vote.

    When we began our proceedings on the Bill, I did not imagine that we would not embark on a discussion of the proposed reforms of the English National Health Service until more than 12 hours had gone by. At last, we have the opportunity of entering a debate. I apologise to certain Members for my getting up second, but I cannot be accused of getting up too early in terms of the time spent on debating new clause 4.

    I have found the process of parliamentary debate on the Bill intriguing from beginning to end. I concede that we had a reasonably civilised discussion in Standing Committee. We completed our clause-by-clause analysis of the entire Bill—the National Health Service reforms and the care in the community clauses—within a reasonably fast time, without having to have any late-night sittings or a timetable and, for much of the time, without excessive controversy—[HON. MEMBERS: "No."] That allowed us to complete that stage of the proceedings. Obviously, there was a difference between us. The hon. Member for Livingstone (Mr. Cook) would expect me not to have been overwhelmingly impressed by all his arguments. The point was underlined to me that the deph of opposition in the Labour party to many of our proposals was not quite as great as one might have thought, given the froth outside.

    After a pretty easy ride in Committee, in terms of the qualitative arguments and the length of time that they took, when we have come to the Floor of the House, we have suddenly turned to a long filibuster on the first NHS clause. [HON. MEMBERS: "No."] I have made long speeches in my time when in Opposition. I do not recall making one of nearly two hours, as the hon. Member for Livingston has just done. On a new clause that in essence covered ground that we covered several times in Committee, for two hours the hon. Gentleman produced a snippet of this and a bit of that and familiar arguments which I have heard many times before. The hon. Gentleman was entitled to return to them. Mr. Speaker selected the new clause and, of course, we must debate the amendments in order. I am glad to respond to the hon. Gentleman's arguments. As I said, having failed to mount a serious challenge to our proposals in Committee, the Opposition are in danger of reducing the Report stage to a third-rate filibuster.

    6.45 am

    The Secretary of State owes it to the House and to others who are interested to make it clear that many of us were not members of the Committee and did not have the opportunity to hear the details of the argument. Aside from the poll tax, the Bill has been the single most important issue on which we have received correspondence for the past year. It is, therefore, important that we know the details of the argument on Report.

    It is important that everyone knows the details of the argument about any parliamentary proceeding at every stage. I merely said that we had gone by the most peculiar fits and starts in our debates. The opportunity for the hon. Member for Leeds, West (Mr. Battle) to participate in a full debate on each provision in the Bill will plainly be jeopardised if the Opposition spokesman, the hon. Member for Livingston, suddenly switches from the tactics of reasonably short speeches in Committee to two-hour introductions of new clauses once the Bill is debated on the Floor of the House. I need not detain the House for anything like the length of time that the hon. Gentleman did.

    Apart from the fact that I submit to the right hon. and learned Gentleman that he is giving the House a distortion of events in Committee, does not he consider that in his first speech after the Government's defeat, he might offer a little bit more modesty than he has done so far?

    I think that I should be out of order if I went back to earlier new clauses, tempted though I am. I have given my description of events. An analysis of the length of the speeches of the hon. Member for Livingston will confirm what I have said. I shall give way as often as hon. Members wish. I anticipate that, given their current chosen tactics, they will interrupt me frequently. They obviously wish to spin out the proceedings.

    I shall give way if hon. Members insist. If it is the desire of the Opposition merely to stop serious debate proceeding, I shall concede that. Otherwise, I shall begin to address myself to some of the hon. Gentleman's remarks.

    Most of the hon. Gentleman's points, as I sought to make clear in my interventions, were not remotely relevant to self-governing hospitals, although he said that they were. I shall try to sweep together a group of the hon. Gentleman's arguments—the theme to which he recurred frequently. The theme that he often uses when talking about the reforms is that we are "commercialising" the National Health Service and that in future, we shall concentrate on what is profitable, not what is loss making. He believes that that is a threat to the future of the Health Service. Most of those points relate to the contractual basis on which health services in the acute sector and the community sector will be financed when our reforms are implemented.

    As I sought to make clear in an early intervention, the NHS trusts, the self-governing hospitals and the self-governing units to which the new clause relates will not be the only parts of the Health Service engaged on this contractual basis. It will be true of the directly managed units as much as of the self-governing units that they will enter into agreements with the district health authorities and with the GPs who wish to refer patients to them, either in a block or individually, to provide the services to those patients. In that agreement, they will set out the quality and quantity of service to be aspired to. They will also set out the nature of the service, and whether it requires continuity of care and a combination of the acute and community services, or even the management of a condition, such as diabetes. That will be stipulated in the contract and will apply to every unit, whether self-governing or directly managed.

    There may be later amendments when we can discuss in greater detail the nature of the contracts. I suggest to the House that the most relevant amendments will be those later on quality. It is important to bear it in mind that when people make their choice, which they are entitled to do, about how they would prefer to be treated in the National Health Service, quality is probably the most important factor that they have in mind. So the way in which those contracts stipulate quality and the way in which we decide what quality of care the district health authorities, GPs and patients should be looking for, are probably the most important features of the contract.

    In any event, contracts generally will apply to all hospitals. That is not a separate feature of NHS trusts, which can be the subject of any of the ballots to which the new clause is devoted. When we deal later with contracts, we shall make it clear that there is no such thing, and there never will be such a thing, as a profit-making or loss-making contract in the NHS. So the analogies on that basis are all false.

    The hon. Member for Livingston argued that self-governing hospitals should be examined because if a hospital went self-governing, that somehow posed a threat to the delivery of essential local services. He went on to call services designated services. They are not set out in the Bill in those terms because it does not require a change in legislation to put into the reforms that we are proposing the concept of designated services, a subject that we explored repeatedly in Committee, when I tried to explain the position to Opposition Members.

    When an application for self-governing status is made—and it is allowed, so that there is an NHS trust—and one then discovers that the trust is providing a service, which must be provided at that locality for a particular section of patients served by a district health authority, we have repeatedly made it clear that that will not be determined by ballot. The DHA will be able to require the NHS trust to carry on delivering that service. There will be no question, despite what the hon. Member for Livingston appeared to imply, of people being denied it because it will be priced out. They will be entitled to look to the Secretary of State to require that service to continue to be provided, and the Secretary of State will settle the price if that becomes a difficulty between the trust and the DHA. Again, that is not remotely connected to the question of ballots.

    The right hon. and learned Gentleman appreciated that the debate on the new clause involves important principles, which my hon. Friend the Member for Livingston (Mr. Cook) adequately expressed. Is the Minister saying that where there is a difference of opinion—where there is a difference of interest between a district health authority and any contracting hospital, which may be a hospital of the type that we are discussing—the judgment of what is reasonable, or a similar form of judicial responsibility, will be placed on the Secretary of State? If so—and the right hon. and learned Gentleman said that it was so—is not that centralisation of the sort that his party is against in principle, as well as putting on a central authority, at the Elephant and Castle or anywhere else, a duty to make a judgment of clinical and medical matters for which such an authority is hardly suited?

    It is true that in those cases, which I believe will be comparatively rare, where there is disagreement between, say, a district health authority and a self-governing unit about whether a service should be designated as a service that must be provided by that trust at that location for a particular group of patients, in the end the Secretary of State will have to decide.

    The hon. Member for Newham, South (Mr. Spearing), who is familiar with the NHS, will realise that every time a major change in the pattern of service is proposed by a DHA that gives rise to local controversy, in the end that is determined by the Secretary of State. In practice, such matters are usually delegated by every Secretary of State—including those for whom I have worked—to the Minister of State. I take the view that I have made enough decisions about closing hospitals and major changes of service to have had my fill, so I get involved now only with the exceptional ones. A large proportion of the workload of the Minister for Health, under any Government, involves making just those judgments about proposed major changes of service, although the number of those that will arise in this conext will, I believe, be somewhat reduced.

    What criteria will the Secretary of State use to adjudicate between a purchaser and a provider in relation to the provision of a core service in a given area? I do not think that that has been dealt with, although business plans are being prepared.

    I think that that has been spelt out, so I shall give an unscripted answer. The criteria will relate to whether the district has a reasonable alternative to the service to be provided from the location of the NHS trust. What is reasonable will depend on accessibility and geography, and also on whether any service of equivalent standard is available.

    The circumstances will vary. Someone with a rare heart complaint, for instance, will be unlikely to find a designated service at his local hospital: people can travel hundreds of miles for such treatment. By definition, however, a high proportion of community services will be provided locally, in particular localities and by a particular part of the Health Service, and many will be designated. It will depend on the local circumstances of each case. That is why we have not spelt out the details of maternity provision. The maternity service varies throughout the country; it is also a service in which people particularly want choice. Indeed, we all want mothers to be given choice, rather than a single place being designated for all patients from a particular location.

    Can the Secretary of State give us his definition of "local"? The definition in Bristol, where three district health authorities converge, may be very different from the definition in Cornwall.

    I agree that that could vary from place to place, but it refers to what is reasonably accessible to the population—given the geography—and to the service or specialty involved. We are not specifying a three-mile radius, for example, because, whatever a patient's condition, whether it is essential and reasonable that the service be provided locally varies from one area to another, as do the distances involved. The main test will be whether there is any reasonable alternative.

    I questioned the Secretary of State closely last year about whether DHAs such as mine would keep their accident and emergency services, and he gave me a couple of answers. I asked the same questions in Committee. According to the answers, the trust or the DHA will decide what is local. Will the Secretary of State give me a guarantee that Calderdale will keep its accident and emergency service?

    I do not give such guarantees about any accident and emergency services, and never have: I have closed one or two in my time, as have my predecessors, both Labour and Conservative.

    A major change in the service, such as the closure of an accident and emergency service, would be approved by the Secretary of State only if it were part of some improvement in the service: indeed, it would normally be proposed only in such circumstances. We do close accident and emergency services. I remember closing some in London, where they used to be extremely close to each other. There can be advantages in having one good centre, rather than a lot of underequipped ones scattered around a small area.

    Before the hon. Lady decides that I am speculating about Calderdale, let me say that I cannot remember the configuration of accident and emergency services there, off the cuff; nor can I say whether anyone is remotely contemplating any change of any sort there. Under the new arrangements as under the old, however, the NHS would consider closing an accident and emergency unit only as part of an improvement in service.

    Considerable pressure is being imposed on us by the Royal College of Surgeons to examine all our trauma services. It has made some extremely interesting propositions. Many surgeons think that it might be a good idea to concentrate more of our major accident work on fewer sites, and build up expertise and a range of specialties on those sites.

    There is often a conflict between medical and public opinion. The average member of the public, including most hon. Members, probably thinks that accident and emergency departments should ideally be a couple of minutes away from wherever one happens to be knocked down. That is not something which would worry many doctors. They would want to know what was in the accident and emergency department to which someone would be taken. In particular, for a head injury, they would want to know whether there were the necessary specialists in the place to which the person was to be taken.

    Those are the only sort of criteria that will go into such judgments in future, as under the old arrangements. As I have repeatedly made clear, it is nonsense to keep raising fanciful claims that an accident and emergency department would be closed because it was unprofitable or because people would go roaring off into doing private work at the expense of NHS work.

    7 am

    The decline in NHS work is dealt with in the Bill. It would have been nice if, in moving new clause 4, the hon. Member for Livingston had reminded himself of clause 5(6), which makes it clear that anybody engaging in private

    sector work must not do so at the expense of NHS contracts into which he has entered. The idea that he put forward, en passant, wandering off into his red herrings with a particular flourish, that such people might take in private patients who could be put ahead of NHS patients in the waiting lists is complete nonsense, as the hon. Gentleman knows. We have repeatedly committed ourselves to the six principles that are accepted by both sides of the House that govern the treatment of private patients in NHS hospitals. One is that they should be treated according to clinical priority and we, like the Labour party, are against the idea of private patients queue-jumping. That will apply within the NHS within which there will be self-governing trusts in future.

    The only change on private practice that the hon. Member for Livingston was proposing, as far as I could see, was that he would reduce the price charged to private hospitals. Apparently, he thinks that it is wrong that the NHS should make a profit out of private medicine. But he will not stop private hospitals engaging in private medicine on NHS premises. That is an extremely quixotic gesture. He will deprive the NHS of income by reducing the prices that it charges to the private sector. What a strange insight into the alternative policy of the Labour party on the NHS.

    Is not the inevitable logic of a system, whereby the district purchases and chooses on the basis of cost between different offering hospitals that it will go for the cheapest option? As a result, there will be competitive activity between the providers, the hospitals, with, certainly in London—more obviously in London than elsewhere—the resultant forcing out of some of the services that would be regarded as core services simply because cheaper ones will be available, which districts will be obliged to contract to purchase. Is not that the inevitable consequence of a system that will become more competitive and that requires districts always to be seeking to save money, irrespective of quality, which is another criterion altogether?

    I am genuinely grateful to the hon. Gentleman because his intervention goes to the heart of a genuine controversy about our new proposals. It is simply not correct to say that districts will choose to place their services according to cost and cost alone. Many reputable critics of my proposals base their whole case on the proposition that somehow districts and GPs will feel obliged always to go for the cheapest option. I think that we all agree that there can be no more foolish approach to the obtaining of medical care than to believe that the cheapest option is always the one we should go for. Not one hon. Member would remotely want our health care to be decided on that basis. However, I would also guard everybody against the simple assumption that is often made, not least by hon. Members, that the most expensive is necessarily the best. That underlies many of the arguments that I face. The range of costs in the Health Service, under the present system, varies amazingly between one district and another. It by no means follows that the districts with the most expensive services are the best.

    In making all those decisions, people will make a judgment, based on the combination of quality and the use of resources, as they should be doing now. All health judgments tend to be like that. Most people engaged in health care, be they professionals, clinicians or managers, constantly have to make difficult judgments on what is the best quality of care that they can obtain or provide for their patients within the resources available. Under the new system, that process will be undertaken in a more rational and open fashion, and people will see to what type of care and what quality the resources are being committed.

    I am grateful and I understand that. Let us take a specific example. My local health authority of Lewisham and North Southwark has options. It might go for what it regards as perfectly good orthopaedic treatment, to, for example, Guy's, King's College, or Maidstone hospitals. The qualitative judgment will be similar. Therefore, it will be bound to make its decision on the basis of the financial judgment. It will have many other needs to meet, and if it is looking to provide all those other needs for the populace of Lewisham and North Southwark, it will inevitably choose—if there is not much to choose on quality—the cheaper option. Eventually, that process will drive out alternatives because the market will have taken over from a National Health Service providing corporate care.

    If there is not much to choose from on quality that might happen. The first judgment that the authority makes will be based on quality, as I have said. However, in using all the resources, it will have to do what it does now—to make decisions about how to get a comprehensive service so that everything, not just orthopaedics, is financed. It will want to get the best quality across the spectrum, using the resources that it has.

    It may be that in some areas the de luxe quality is so expensive that the authority will decide that it cannot spend that much on orthopaedics and has to go for a cheaper option, either because it has to get the volume to get its waiting lists down or because it wants to invest more money in its mental illness or mental handicap sectors.

    Those sound difficult choices, and they are. But they are exactly those that the Health Service has always made. The odd-sounding events described by the hon. Member for Makerfield (Mr. McCartney) related to a specific example, about which I know nothing. However, we all know the sort of difficulties that health authorities currently get into when they have to make just such judgments.

    The trouble is that, at present, authorities do not know exactly how much they are spending on their orthopaedics or their community services. Nobody measures the quality. We are introducing quality control through clinical audit. The authorities do not know whether the services that they are receiving are better than those at the place down the road. When a district discovers that it is spending spectacularly more on a part of the service than is the next-door district health authority, it is often a revelation to those in the district. When they look to see what they are getting for the extra money, they may find that it is nothing, in which case the contract system will enable them to rationalise.

    I do not object to auditing and ensuring that money is spent wisely. However, the Secretary of State must appreciate that the difference between the system that he proposes and the present system is that, at present, the same patients in the same health authority, for example, Lewisham and North Southwark, look to their local hospital to provide all those services. The difference will be that when the quality judgments work out equally and the cost judgments are different, instead of all the services being available locally, some of them will no longer be available locally. People will be sent away for those services because the district will have no other choice, so gradually there will be a contraction of the wide range of local health services provided in the local community by the local hospital. Gradually, that will whittle away choice, as people will not have the choice to go to their local hospital for the range of services because they will not be there any more.

    We shall not agree on that and we are in danger of repeating ourselves. Lewisham and North Southwark will want to respond to the local population, who may want to be treated locally. I accept that in most urban areas the population want to have the bulk of their medical care from the nearest hospital, where their relatives can easily visit them. They sometimes find that the planners, who are defended vigorously by opponents of my reforms, are closing down the little local hospitals.

    The districts will be under a duty to respond to the wishes of their general practitioners who, under our new contract, will be driven by their patients' wishes. The districts will put in place a series of contracts to provide local services. They might find that their local services are spectacularly more expensive than the alternative, but they could still continue to place their contracts locally——

    They may be doing that at the moment, but the costs are inordinately high. When they discover that—and I do not know whether Lewisham and North Southwark ever will—they have to ask themselves whether that is consumer friendly and whether the fact that it is local is sufficient reason to justify the increase in costs. They will put great pressure on the local hospitals because all the money will go in high costs, which will inhibit their ability to develop their services.

    Does the Minister realise that the reason why costs will be spectacularly high in London will not be luxury or quality, but capital charges which, for the first time, will have to be paid by NHS and opted-out hospitals? Therefore, the cost of treatment in Maidstone or Brighton will be very much cheaper. For certain surgery and for ordinary district general hospital services, patients from London will be bussed out to outlying hospitals where the land charges are much cheaper. Given that local accessibility is a key factor in quality, does not that mean that there will be an undermining of the quality of those services for people in London.

    Health care in London is high-cost health care, and always has been. Capital costs are a key feature of health care costs in London. That will be exposed by our capital charging system, and why not? We must face up to that truth. The Government did not invent the position. The fact is that it costs more to treat people in hospitals in London. That is why a permanent problem for about the past 120 years in the British health care system has been the concentration of so much of our hi-tech teaching health care system on practically the most expensive site in Europe—all in the middle of London and within a stone's throw of each other.

    We are doing nothing other than what should be done in any sensible, businesslike organisation—exposing where the costs lie, including the capital costs in London. If the Labour party does not want to face up to those costs in a system that it aspires to run, it is simply burying its head in the sand.

    Of course, there is the danger of a sudden exodus if the Labour party did nothing about the problem. However, I do not think that it would be patients in Lewisham, Peckham or Lambeth who would stop having their treatment in London. They would say to their GPs and the DHAs, "We want to go to the local hospitals. In fact, we want more access to them. There is too much fancy stuff coming in from outside."

    The inhabitants of Hertfordshire, Kent, Bedfordshire and Essex may well ask their DHAs, "Why are we having to wait such a long time to go to those expensive hospitals in London when, with the same money, you could treat us a great deal quicker in the place where we want to be treated, which is the district general hospital?" We must face that reality. I know that two Kentish hon. Friends here will want to make that point, and if any of my hon. Friends from Hertfordshire were here, they would also be getting steamed up about that. We must ensure that there is not a sudden cutting off and a disruption of the service.

    That is why, in the new system of allocating moneys to the regions, we have built in for all time—until somebody changes it—a system of added allocations; we are still building in 3 per cent. extra for the Thames regions to reflect the inescapable extra costs of providing services in London. There are other in-built advantages in the way in which the money is distributed.

    7.15 am

    In the new contracting system we shall also distribute to the districts that use London services a bigger allocation of money, because we realise that we have to compensate them for the costs of seeking to place so much of their service in London. All those things have to be addressed and they will be sorted out. We are taking steps to avoid dramatic consequences and the sudden threat to the London hospitals and their standards described by the hon. Member for Peckham (Ms. Harman).

    Of course, the London hospitals are very strongly placed because they include some of our finest hospitals. They cannot compete on costs. If it is a battle between Bart's and a hospital in Maidstone or in the middle of Kent, Bart's cannot get down to the costs of Maidstone. What Bart's has to offer is a world standard of excellence in the best of its services, although we should not assume that they are all marvellous. The patients and those who act on their behalf—districts, GPs and so on—will make the judgments about quality, cost and best use of resources that I described as part of the contract system.

    The dominant competition will be in quality. The Opposition are so fearful of the word "competition" that the idea of different clinical units aspiring to demonstrate that they treat their patients better than others is inimical to them. They prefer a planned system, which does not allow such nasty comparisons to be made and in which people do not vie with each other on the excellence of the service that they can offer to patients.

    I am relying on the Opposition rather than my hon. Friends to induce me into filibustering.

    I am not asking my right hon. and learned Friend to filibuster, but the fact is that the Opposition resist the proposition that there is any form of competition in the National Health Service at the moment. That is a total myth. Anyone with any idea of the bitterness and arguments between health authorities about the allocation of resources knows well that competition is alive. Furthermore, many of the London-based Opposition Members seem to believe that Londoners are incapable of travelling for treatment while people from Kent are expected to do so.

    I agree with my hon. Friend on both points, which he made passionately. The descriptions by the hon. Member for Livingston of contracts for self-governing hospitals were for the most part mere fiction. My hon. Friend has intervened to show that his descriptions of the present service were pretty rum too.

    There has been reference to the professional standards required in the National Health Service. It is not the case that self-governing trusts will be allowed to set their own qualifications and professional standards—a serious point made by the hon. Member for Livingston. He did not attend all the proceedings in Committee—[Interruption.] I did not either, but the hon. Gentleman may not have reached schedule 6(2), which provides, in relation to NHS trusts, that the Secretary of State shall stipulate what the professional qualifications will be of people in the National Health Service. The trusts will not be allowed to set their own professional criteria for staff. They will be obliged to go by NHS standards.

    The Minister used the word "battle" when referring to competition between hospitals. Can he tell us what will happen to the hospitals that lose the battle?

    The word "competition" is used frequently—perjoratively on one side and in praise on the other. In the Health Service it is used in terms of quality. There will be competition to attract patients into a unit. Under our arrangements, for the first time, as long as patients continue to be referred to the unit and are treated, the resources that that unit requires will come with the patients and allow that unit to be financed. If the unit is ambitious, the people working there will want to demonstrate the excellence of their work and try to get more patients and more resources.

    Under the new arrangements if a unit is not doing so well, obviously patients who used to be referred there are now being referred to another unit—the district health authority, the GPs and the patients obviously prefer to go to the other unit. The DHAs are under instructions to follow the wishes of GPs. The GPs will retain the freedom to refer their patients wherever they want and they will respond to their patients and to the new contracts that were fought so bitterly by the Opposition and some sections of the medical profession. Those contracts will make GPs more responsive to their patients than ever before.

    There have always been closures in the Health Service. One of the qualities of the National Health Service is that under both Labour and Conservative Governments, the NHS has closed its redundant facilities and has developed better and newer facilities elsewhere. There are health systems abroad that are so arthritic that they cannot do that.

    We have a careful process of consultation, including the approval of the Secretary of State. My Labour predecessors closed redundant hospitals at about the brisk pace that Conservatives close them. I believe that David Ennals was somewhat quicker in that respect than we have been.

    Much of the controversy now, as hon. Members will realise, is based on great arguments about planning, the policy of the DHAs and resources. Many hon. Members challenge those issues like mad because they are all open to argument.

    Under the proposal in the new clause, a unit might get into difficulties. Perhaps the service is being rationalised and the unit should go. That might happen because the GPs and DHAs prefer to use another part of the system. If another part of the system achieves better quality, that is one of the better reasons for contemplating a change in the pattern of services. Of course, I hope that the less successful sections will be provoked by competition into asking why they are losing referrals. They might then use the system of clinical audit to raise their standards, and to recapture referrals.

    Will all hospitals be on an equal footing or will we have the old long-standing distinction between so-called teaching hospitals that are predominantly concentrated in London and non-teaching hospitals elsewhere? All patients seem to want to be referred to teaching hospitals, even if their local hospital is just as good.

    My hon. Friend's constituency is further north than mine, but I am about as provincial as most people in the House. I cannot forbear adding Nottingham, Leicester and Sheffield to Leeds.

    There is a problem with the teaching hospitals, We must ensure that the contract system does not damage the provision of undergraduate medical training, postgraduate training for doctors and continuous education for consultants. We must also ensure that the system does not damage research. That is why extensive discussions are continuing with the various interests to ensure that in attracting contracts for their services, the teaching hospitals are not put at a disadvantage because they have to carry extra costs on the contracts for teaching and research.

    However, I also share the concern expressed by my hon. Friend the Member for Stockton, South (Mr. Devlin) that we must ensure that, in meeting their legitimate expectations to have education and research protected, the teaching hospitals are not placed at an unfair advantage. I do not want money put into the teaching hospitals under the excuse of protecting postgraduate education and research if that enables those hospitals, together with the cachet surrounding their names, to continue to attract patients who could perfectly well be treated in a good district general hospital close to their homes.

    I actually heard the hon. Member for—I cannot remember the name of his constituency——

    That is safer than it used to be. I heard the hon. Member for Bradford, South (Mr. Cryer) muttering, "Level playing field" under his breath earlier. That is a good Tory slogan that has even got to Bradford, South. We are seeking to ensure a level playing field between the teaching hospitals and the rest.

    Will the Secretary of State face up to the fact that the bogus link in his argument and the reason why competition will be that of cost and not of quality, as he has asserted, is that the decision about where patients will go for treatment will not be made, as now, by the general practitioner, but under the NHS contract system? The decision will be made by the managers of the district health authority, who are not trained or recruited to know anything about quality and outcome, but who are trained and recruited to know everything about cost.

    I totally refute that and I shall seek to persuade the hon. Lady that that is not an accurate description of the contract system when we reach that new clause and when the contract system is more relevant to the debate.

    The DHAs will place the contracts. It will not only be the managers who decide that. The DHAs will place the bulk of the contracts, first according to the advice from their own public health adviser and other medical advice. Following our instruction that they should put in place contracts for the preferred referral patterns of their own GPs, unless there are compelling reasons to the contrary, the managers will not simply place the contracts where the DHA wants, but will place them as the GPs want. We have also made it clear that there must be a contingency fund so that any GP who wishes to refer an individual patient to a particular place outside the DHA's block of contracts will remain free to do so.

    Under those arrangements, the DHAs will be much more responsive to GPs. I am sure that my reforms are building up the role and influence of general practitioners in the NHS like never before. When we ask the DHAs to take on this task, we are discovering that they are having to get to know their GPs for the first time. Many DHAs do not know their GPs—[Interruption.] They do not. It is no good laughing. This is the system that the hon. Member for Halifax (Mrs. Mahon) is defending. When I reveal some of the things that the NHS has done, the hon. Lady is dying in the last ditch to try to keep it that way.

    For the first time, the DHAs, which currently manage our hospitals, are having to discover the referral patterns of their local GPs; why they refer in that way and what they are seeking for their patients in those services. That is what they will have to reflect in the contracts. That has not happened before.

    General practice budget holders will be able to bypass the DHA and directly handle large sums of money that they can invest in the local Health Service, where it matters——

    Well, I am not sure on what parliamentary day I shall now be able to answer the hon. Gentleman's written question. A lot of nonsense is talked about the opposition of doctors and, as soon as we proceed and I am able to answer that question, I shall reveal to the hon. Gentleman that the vast majority of GPs who are eligible to be fund holders and to have a practice budget have expressed an interest in doing so, because GPs see what I see—that they will have a much more influential role in placing contracts than British general practitioners have ever had before—[Interruption.] No, I hate to have to tell the hon. Member for Peckham that the figures will prove that doctors are not taking seriously any of the nonsense that is being put out by her, or parts of the BMA, about the practice budget scheme. They are on the wrong side of the argument. They should have thought of it first.

    Does the Secretary of State accept that GPs are putting themselves forward to become fund-holding practices because they fear the straitjacket of their loss of clinical freedom to refer under the NHS contract system? Their applications are not a vote of confidence in fund-holding status but a vote of fear about remaining in the system when the NHS contract system bites.

    7.30 am

    That was a good try. The hon. Lady has been telling us for the past 12 months that fund-holding practice budgets are the greatest threat to general practice. So has the BMA. The hon. Lady was led into error by people who should have known better and who, in my opinion, should have invented practice budgets. The BMA has pumped its message out through the medical profession for as long as I can remember. The moment that we put out our explanation and a form and asked those who were interested to come forward, the majority applied—as I have said for ages that they would. We all meet GPs. I was in no doubt that the majority would apply. The vast majority have applied and not for the reasons given by the hon. Lady.

    I wish to move on. We shall have contracts and GP practice budgets only if we can get on with the Bill. I have tried to explain why none of what took up most of the speech of the hon. Member for Livingston had anything to do with self-governing hospitals and ballots. When we got on to what had something to do with NHS trust status we reached a point about pay and conditions, trade unionism and so on when the hon. Gentleman became lyrical. Pay and conditions represent a high proportion of what is getting up the Labour party's nose about self-governing hospitals. Labour Members are desperately anxious to maintain national bargaining for pay and terms and conditions for all staff. They are anxious to retain the present strange and archaic methods of collective bargaining in the NHS. They are completely in the pockets of NUPE, COHSE, NALGO and GMBATU, the TGWU and all the people who have run fancy polls up and down the country.

    I know that there is a fairly reputable and legitimate case to be made in favour of collective bargaining, national bargaining and so on. But I must correct some of the coloured phrases used by the hon. Member for Livingston to describe what faces people. NHS trusts will indeed be free to set their own pay, terms and conditions, if they wish. But they will have to negotiate them. They will not wish to do it on a dramatic scale, certainly in the early stages, not least because they will have to fit in with the contracting system of the directly managed hospitals.

    Staff will transfer into an NHS trust with their current contracts of employment. Any changes would have to be negotiated and, presumably, discussed and made attractive to the staff. The clause that was objected to—the hon. Gentleman said that people would be fired if they did not like the change—merely means that staff will not be entitled to walk out on their job simply because the hospital or unit has become a trust. They will not be able to rely on that as the basis for a claim for wrongful dismissal. The change of employer alone would not be regarded as a change to their detriment. Staff will carry all their rights under their contract, including their right to redundancy and so on. If they are treated in some of the ways that the hon. Gentleman described, they can bring a claim for wrongful dismissal under their contract.

    The Secretary of State said that people will transfer from the National Health Service to the NHS hospital trusts and that they will not lose their employment rights. Staff may take with them the piece of paper called their contract of employment, but it was made clear in Committee that they will not take with them their right to have their union recognised. When they become the employee of an NHS trust, although they will have their piece of paper called a contract of employment, they will not have the right to have their union protect them when that NHS self-governing trust tries to renegotiate individually the terms and conditions in the contract. If the Secretary of State says that existing trade union members will take with them the right to have their union recognised we will accept that there is no detriment. But if they are to be stripped of that right, he must accept that there is a severe detriment on transfer from the NHS to self-governing trust status.

    The hon. Lady knows that I will not give guaranteed rights of recognition. Every employer will have to consider what trade unions are recognised. It would be foolish to say that all the unions recognised for every category of staff should be recognised in every self-governing hospital, not least because some unions will undoubtedly not have any members in those hospitals.

    This is not the time for me to launch into the Whitley council procedure, although it is relevant because NHS trusts will no longer be bound by its terms and conditions. The distribution of voting rights on Whitley councils bears no relation to the membership of the trade unions. At times it is even laughable. I am not complaining. I am extremely pleased about the satisfactory outcome to all sides of the ambulance dispute, resolved finally by the staff side voting yesterday. My guess about the ambulance officers—they will never tell the Secretary of State—is that the vast majority are represented by NALGO. When I deal with the unions my belief is that it must have the majority of ambulance officers. They are outvoted on the Whitley council by the other trade unions.

    At the start of the dispute the ambulance men's Whitley council consisted of NUPE, which I am sure has more members than any other union, with COHSE, the TGWU, GMBATU and NALGO. The distribution of the voting rights is quaint. I am not making an issue of this and I will withdraw it if I am proved wrong, but although GMBATU does not have many ambulance men, it has quite a lot of votes. What would be appropriate as a trade union for particular groups of staff at a particular place is different from those that have recognition now.

    Does that mean that if a particular group of staff has one member of a union recognised nationally that member is entitled to say that his union must be recognised the monent they achieve self-governing status?

    I realise that the moment I get into trade union rights and recognition I am likely to rouse Labour Members. I shall try to calm them down by saying again that it is fanciful to suppose that this will give rise to huge disputes in most NHS trusts, although it will give rise to a great deal of campaigning in the proposed ballots.

    May I take the Secretary of State back to my hon. Friend's point about the possible clear-out of dissident staff in health authorities that opt out and propose the formation of a trust? Is it not a fact that that clear-out is already taking place? He is aware of the sacking of the treasurer of Wakefield district health authority in questionable circumstances. He stood up and opposed the expenditure of large sums of public money on wining and dining in connection with the opting-out process—he has been backed by consultants in the authority—at a time when nurse staffing levels in the wards are dangerously low. Has not the clear-out already begun? Is that not what happened to Mr. Corner in Wakefield? It will happen elsewhere.

    The hon. Member for Livingston spoke for two hours and promptly vanished. He has not been here for the past three quarters of an hour.

    There may be some good reason for that which I shall hear in a minute. The hon. Gentleman made extensive use of the Trent regional health authority document which I have never seen. There is no way in which anybody can be dismissed from the NHS without having all the usual rights of a contract of employment, unless he is in breach of it. The document has not been drafted by me or anyone in my Department so far as I am aware. I have heard only the partial quotations from it in Committee and again today. One cannot sack anybody for dissent, without having a claim against one for unlawful dismissal. One must be able to demonstrate that the person has turned that dissidence into a refusal to obey proper instructions.

    I am. not going to get drawn into the management disputes in Wakefield district health authority. It is an area which produces lively disputes about management. The district health authority's case is that the treasurer in question was dismissed for failing to obey a reasonable instruction. I understand that that is now being argued about and will no doubt be sorted out in the normal way.

    In my reforms I am in favour of devolving the maximum amount of responsibility at local level, and arguments between the district health authority in Wakefield and the district treasurer should be sorted out locally in the usual way. The treasurer has the usual forms of redress if he does not think that he was dismissed on satisfactory grounds.

    The Secretary of State made a comment about the absence of my hon. Friend the Member for Livingston. My hon. Friend is explaining to the country at large, through radio and television, our profound opposition to the Bill and our concern about the way that the Government refused last night to accept the will of the House to protect elderly people from eviction from private homes. Many members of the public in Conservative Members' constituencies are bewildered about the reasons why some of their constituents face eviction.

    What a ridiculous parliamentary performance. The hon. Member for Livingston gave us an easy time in Committee—both in terms of the quality and length of his arguments. As soon as we begin to discuss the Health Service on the Floor of the House he speaks for more than two hours—he was deliberately filibustering. Then he does not wait to hear a word of the reply but goes dashing off to appear on television, having apparently lost all interest in parliamentary proceedings for the time being. The hon. Member for Peckham is pointing to the clock. I should sit down soon, and perhaps you will make me, Mr. Speaker, but it is obvious that the Opposition are determined to interrupt me frequently. I have taken part in filibusters before. The moment that we get to the subject of the NHS in England, the Opposition abandon any serious discussion. They did not discuss it much in Committee, and now they are just spinning it out. They can feel free to intervene on my speech to spin it out, but I regard this as an abuse of Parliament. The idea that the hon. Member for Livingston is out there appearing on television now, boasting about his pathetic performance——

    On a point of order, Mr. Speaker. It is a matter of public record that the Opposition fought this Bill every inch of the way. I served on the Committee and I did not miss a sitting apart from an hour and a half on one occasion, which was unavoidable.

    It is on record——

    On a point of order, Mr. Speaker. You will confirm that we have now been debating the Bill for about 15 hours and that a number of Opposition Members, including myself, have not intervened although, unlike most Conservative Members, we have been present for those 15 hours. You can also confirm, Mr. Speaker, that the only contributions on the new clause, on which I have been waiting to speak for 15 hours, have been those by my hon. Friend the Member for Livingston (Mr. Cook) and by the Secretary of State. Will you also confirm, Mr. Speaker——

    Order. Yes, I can confirm that easily because I have a note of the timings. The hon. Member for Livingston (Mr. Cook) spoke for nearly two hours and the Secretary of State has spoken for an hour. We should move on to the Back-Benchers.

    Further to that point of order, Mr. Speaker. I assure the hon. Member for Bradford, West (Mr. Madden) that, unlike the hon. Member for Livingston, I will stay to listen to his speech, if he is lucky enough to catch your eye. Secondly, I shall stop giving way to interventions, which are lengthening my speech and I shall conclude——

    I shall give way one last time—to the hon. Gentleman and then I shall conclude my speech as rapidly as I can.

    On a point of order, Mr. Speaker. The Secretary of State has alleged on several occasions that Labour Members are filibustering. I would like you to confirm that you and your Deputies, throughout the 15 hours that we have been debating the Bill, have not found any hon. Member out of order. If any Member was committing a fillibuster, you and your Deputies would have called him to order. As that has not happened, the Secretary of State is clearly wrong in his assertions.

    It is within my knowledge that no occupant of the Chair has ruled any hon. Member out of order for filibustering. However, the Front-Bench speakers have made long speeches. The House will wish to hear the speeches of Back Benchers.

    I am grateful to the Secretary of State. Will he reflect on two points? First, his Cabinet colleagues who hope to get other Bills through the House this Session may not thank him for his absurd account of the Committee proceedings. Secondly, it is not unreasonable, especially after last night, that the British people should hear what the Secretary of State for Health in the forthcoming Labour Government wants to say.

    7.45 am

    I hear what the hon. Gentleman says. The Secretary of State for Health in the forthcoming Labour Government, if there is one, will have to demonstrate rather better knowledge of the NHS reforms after they are implemented than he demonstrated in his speech.

    The hon. Member for Livingston implied throughout his speech that self-governing hospitals have something to do with the acute sector only. That is complete nonsense. Many applications have been from a combination of hospital and community services; quite a lot of them have been from community services alone. That part of the hon. Gentleman's speech was irrelevant.

    The hon. Gentleman said that our reform is based on an episodic approach to patients rather than on continuity of care. I forebore to ask him what on earth his evidence was for making such a claim. He frequently makes that claim. However, as the contract system shows, and as we develop the specimen contract, it will be obvious that we are not dealing with each patient incident as though it was isolated.

    I must refer finally to what purports to be the point of new clause 4: everything being handed over to ballots of staff and electors and the views of district health authorities. I do not believe that management changes of the type that we are discussing, imperfectly understood as they are, even by the hon. Member for Livingston, can be turned over to local referendums for a final decision. When the National Health Service was created in 1948 it was not subjected to a ballot of staff and local electors. When a hospital is closed we do not ballot the staff and the electors. No major change in the pattern of services has ever been subjected to any process that is remotely like that, either by a Labour Government or a Conservative Government, during the past 40 years.

    The staff will remain National Health Service employees. The hospitals will remain NHS hospitals. A previous Labour Government changed the employment conditions of private enterprise employees when private sector companies were turned into nationalised industries. I do not recall that the Labour Government canvassed the idea that the judgment on whether to nationalise an industry should be left to a staff ballot, or to a ballot of the local population, or anyone else. These management changes are akin to the 1972 changes. Nobody said that they should be subjected to a ballot. The Labour party and the trade unions are enjoying themselves. They are conducting opinion polls throughout the country and they are trying to give legitimacy to that course of action.

    I give an undertaking to the House for the umpteenth time that when we receive formal applications for NHS trust status we shall submit them to the fullest process of public consultation. They will have to include business plans, plans for the development of patient services and the names of those who are proposed as directors or chairman of the NHS trust. Then there will be consultations on the basis of reasonable information. Those consultations will be taken into account in the way that Ministers of all Governments are used to doing, after which the Secretary of State will make his decision on whether to allow a particular unit to attain NHS trust status.

    I have made it clear that I shall go in for the fullest consultation and, in the light of that consultation, shall base my final decision in each case on one key criterion above all others: is this application for NHS trust status in the interests of the National Health Service, of the people who work for it, and of the patients who will be served by the unit in question? I repeat that that key judgment will be made after the fullest process of consultation.

    As I have said, the Opposition are trying to give legitimacy to these ballots all over the place which were discussed interminably in Committee. I do not propose to base any decisions on such straw polls. The Labour party and the trade unions are organising these on their own terms; they are using their own propaganda, and people do not have any actual proposition before them. I have a look at opinion polls occasionally. Not all of them get published. Let me give the Opposition a word of warning lest they put too much faith in all these remarkable opinion polls. One whose results I have seen shows clearly that, on the basis of almost any kind of polling, one can get different answers depending on what questions one asks. We all know that. It is why so many polls are producing damned silly answers to damned silly questions.

    The response that one gets from the public about whether they approve of NHS trusts depends crucially upon whether they are told that the NHS trusts will remain in the Health Service. Some of our critics have had great mileage out of the totally false claim that these trusts will opt out of the service. The public do nor want hospitals to leave the National Health Service; nor do I. It is a deeply unpopular proposition. I have seen results that show that if the questions that are asked make it clear that NHS trusts will remain part of the Health Service a majority of the public in most localities think that local management is a good thing. When the NHS trusts are in place—at the moment there are 79 in the first wave—people will see from experience that they will provide the much better National Health Service that we are seeking to create.

    I had better start where the Secretary of State left off. He referred to private polls whose results, he says, indicate that the public really believe that the NHS trusts are acceptable. It would be helpful if those results were published. If I may give the Secretary of State a little advice, it is that, so far, there is, I believe, grave suspicion of the Government's scheme. That view is based on an objective examination of the situation.

    The starting perception seemed to be that hospitals would be separated from their local health districts—that they would be on their way out of the Health Service. I know, and the Secretary of State will know, that many people have been at pains to make it clear that that is not the case. Certainly people can make mischief by pretending that the local hospital will opt out of the Health Service.

    If there is evidence that proper, objective polling has indicated that people are happy that self-governing trust hospitals should be set up, that evidence ought to be produced. I have here a large, colourful document I am sorry that I do not have a smaller copy, but, after all, it is breakfast time. The document reproduces this question:
    "Under the Government's proposals for the NHS would you be in favour of Guy's, Lewisham and the mental illness service seeking to become a self-governing trust?"
    That question is reasonable; it is not loaded, as I hope the Secretary of State will agree. He can see the figure: 90·5 per cent. said no. This was a staff-side exercise. It is the first known ballot of Health Service employees in Lewisham and North Southwark. The Minister knows, too, of the narrow decision by the district health authority that there should be a ballot of all its employees. That ballot will take place. We expect the result within the next month. In Lewisham and North Southwark we have had three ballots so far. It was agreed that when the proposals have been worked out finally, the 220-plus consultants will be balloted. When there is a ratio of more than 9:1 against the Government's proposals in that reasonably put question, the staff must start by feeling some suspicion. I have referred to the view of people who work in the Health Service. The Government have cause for concern.

    Although I did not serve on the Standing Committee—perhaps I am grateful for being spared that—I should like to refer to what remain the crucial issues in the debate. The questions and answers mentioned during the Secretary of State's speech go to the heart of the subject. Without being personal, I must say that it is a bit much for the chief spokesman and then the second spokesman for the Opposition to come in and go out of the same debate. In the debate about hospital trusts, there were three changes of Opposition Front-Bench staff. That is not satisfactory in terms of meeting one's duty to take responsibility for a debate.

    I shall discuss the area that I know best because it provides a good example—the hospital which first looked as thought it would lead the way to opting out, Guy's hospital. My first question relates to the options put in the ballot. The Secretary of State said that there had never been, under either a Tory or a Labour Government, any ballot to decide on a change of management like this. I accept that that is the case in the Health Service. I accept that one can argue that it is merely a change in the management structure and that the hospital will stay within the Health Service so a ballot may not be necessary. Under the Prime Minister's premiership, the Government have introduced and argued for ballots when there has been a change of management—not a complete and fundamental change—in two different sectors.

    Both examples occurred in my constituency, so I know them well. In the education system, parents have taken part in ballots to decide whether schools should opt out of the control of the local education authoity to become grant maintained. The London Nautical school, which is just up the road and is on the Lambeth-Southwark boundary, did that.

    Provision was made also for ballots of tenants when someone wants to take over their property or, more importantly, when there has been a change of management, not from the public to the private sector, but from one part of the public sector to another—from the local authority to a housing action trust. As the Secretary of State will remember, at the end of the debate on the Housing Bill, the then Housing Minister decided that housing action trust sites would come into operation only if there were a ballot of tenants. There are therefore precedents for consulting, by ballot, the people affected when a change of management occurs.

    I should like to explain why the Secretary of State should consider even now the validity of ballots. The Health Service needs the confidence and commitment of the people who work in it. It is abundantly clear that certain parts risk not having the staff that will be needed in years to come. Nursing is an obvious example, because of demographic trends. If changes are to take place with the confidence of the Health Service—I am talking not so much about the confidence of the doctors outside the hospitals as about the confidence of the doctors, nurses and other staff in the hospitals—is not it important that they should be persuaded of the merits of the case?

    After informed debate, those staff should be able to judge the merits of the case. We will have had the White Paper, the Bill will have been considered for a year in both Houses and consultation will have taken place—the Secretary of State said that there will be further consultation—so surely at the end of that series of exercises there is no reason why all the people concerned should not have the full information and the ability to decide between the options. The Secretary of State would be wiser, in the interests of the Health Service, to allow people to pass that judgment.

    It is not as if there will be self-governing hospital trusts in every health authority; clearly, there will not. There will be an option between places that will have a self-governing trust and others that will not. The Secretary of State has confirmed that some of the hospitals that were originally in line for going to self-governing status are no longer regarded as being in the first wave. There will be an option. Under the scheme of the Secretary of State, in two to six years' time there will still be hospitals that are integral parts of the local health service with their local health authorities. They will not be separated in the way on which the debate has been concentrating. If that is the case, the option between having and not having self-government is realistic and should be available to all. It is important to take account of the views of those concerned.

    There is—and I say this with real feeling—an enormous public demand to participate in the decision. If we are to keep the public involved in the Health Service and to ensure that they feel that it is their Health Service, the last thing we want to do is to make it look as if decisions are made by a handful of people, let alone one.

    8 am

    Paragraph (2)(b) of the new clause says,

    "In any case where a majority of the patients of the hospital or service reside in a single borough or district council".
    Forty-nine per cent. of those coming to Royal Lancaster infirmary come from all over Cumbria. What happens to them? That figure applies only to one specialty. It is a massive problem in all specialties and the new clause would give the 51 per cent. an enormous power over the 49 per cent. How does one define a constituency for that sort of situation?

    That is a proper and important question. I want to link it to the key question. In the interchanges in the speech of the Secretary of State, we did not get to that question and I should be grateful if I could attract the attention of the Secretary of State to this crucial point. The hon. Member for Lancaster (Dame E. Kellett-Bowman) asked how one finds a proper constituency for a ballot of the public.

    I understand that. The hon. Lady will appreciate that my London constituency contains a teaching hospital. In her constituency and mine, enormous numbers of those who use the hospital come from outside the local health authority. The only proper constituency is the area of the health authority at the moment. That brings us to the last questions in the interventions in the Secretary of State's speech. His arguments seemed to be quite plausible arguments for cross-charging and for saying that if people come from outside a health authority to use its services, such as in Lancaster or my constituency, they should bring their fees with them, quite compatible with saying that that will encourage good standards and good practice because it means that if Lancaster royal general hospital——

    If the Royal Lancaster infirmary or Guy's hospital is doing a good job and attracting people, they are getting paid for the work that they do, which is proper. However, it is not necessary for the consequence to be that they separate the local hospital from being the automatic provider of hospital care for the community with which it is geographically and traditionally associated.

    I support the idea that the hon. Lady's health authority should be able to charge the authorities that send patients to it for the proper cost of their care. If a hospital did a good job, therefore, it would stand a chance of having more income and being able to develop its services. If it did not do a good job, people from outside the hon. Lady's district health authority would go elsewhere. People from outside my district health authority might also go elsewhere.

    The Secretary of State did not give a word of explanation of why that requires separation of hospital from health authority. There are still grave reservations not about the principle that hospitals should be paid for what they do and that good practice should be thereby encouraged, but about the principle of separating health authority and hospital. If Guy's hospital opts out, how can that be compatible with tradition, general interest and proper democratic procedures? In the context of tradition, Guy's hospital, like some others, was set up by a 1725 Act of Parliament. It was founded with the money of Thomas Guy, a Southwark man, and its duties were set out by that statute, which made it clear for whose benefit the hospital should be provided. It said in the will of the benefactor, provided for in the Act, that the hospital should be
    "for those who are thought capable of relief by physical surgery; several species and kinds of sick persons deemed or called incurables; and … the time of continuing them in hospital to the discretion and pleasure of the trustees."
    Although that was stated in 18th century English, the purpose of the hospital—which was set up to deal with those for whom St. Thomas's in those days could not deal—was to care for the long-term sick, people in need of convalescence and the poor. All the evidence that I have been able to accumulate makes it clear that the motive for founding Guy's hospital was not simply to provide acute services but to provide long-term services. There is ample evidence concerning the purpose of the hospital.

    The 1990 version of that is a hospital which must meet the range of services—from the most difficult internationally reputed specialities and operations for which people come to Guy's from all over the world to see consultants who are world famous—and be a local district general hospital, providing services which, by any definition, are not cost efficient or profitable, such as geriatric care and so on.

    The great concern—in saying this I hope that I do not misrepresent the views of the local community—is that all those services that are not so high tech, high cost, high turnover, high quality and high profit could be at risk because they may not come within the obligatorily provided services.

    The bulk of people in my constituency—there must be some also in the Secretary of State's area—rely on the local hospital because they are at the bottom end of the income scale and have worse health than many people in the country. They suffer from bronchitic, arthritic, chest, lung and other disorders and they need to be assured that they will have a local health service. They fear that they will not, because it will not be compatible with the cost criteria for the local hospital to continue to provide everything. They fear that the least cost-beneficial services will have to go.

    I had better intervene now in this mini Adjournment debate, as it were, on Guy's, and Lewisham and North Southwark, because I may not have a chance to do so later. What the hon. Gentleman is saying is relevant because it provides a good vehicle for discussing self-governing NHS trusts.

    What the hon. Gentleman says is true of all the London teaching hospitals. They are crowded together because originally they were put here to serve the poor of the teeming London slums. They provided free treatment to the residents of those poor districts in exchange for the residents allowing themselves to be used for medical teaching, training and research.

    Now, a high proportion of that population in most of London has gone away from the area of the hospitals, so we have extremely up-market, high-tech centres of excellence, with international-quality surgery being done in the teaching hospitals which were established for another purpose. I accept the hon. Gentleman's underlying point. I am not attracted by the idea, any more than he is, of some of the London teaching hospitals becoming high-tech centres of international excellence that give up their contact with local services. They will not do that because it is more profitable; as I tried to make clear earlier, the geriatric services will enter into contracts with the NHS that will cover the cost.

    I understand that those who favour self-governing status at Guy's are contemplating a merger with the Lewisham hospital, although I do not know how that affects the community services associated with those hospitals. Contrary to popular belief, we are leaving it to the local people. However, I have encouraged those in favour of self-government to look at configurations that will ensure that Guy's stays tied in with what I recognise as one of its fundamental objects: serving the local population in Southwark and Lewisham. I shall certainly use that criterion to judge any application that is made, and it will virtually swamp the public consultation to which I committed myself a few moments ago.

    Although what the Secretary of State has said may apply most acutely to the London teaching hospitals, I am sure that the same sentiments are felt throughout the country. I was born in the north-west. in Stockport; no doubt those who use Stockport royal infirmary will feel the same. I was brought up in south Wales, and no doubt those who use Cardiff royal infirmary will feel the same, too. There may be a difference in the degree of feeling, but not in the principle. People want their local hospital to be able to provide the range of services that it provides now, with no prejudice to the least glamorous aspects.

    Indeed, it is not a Guy's issue or a London issue. The people of Burnley certainly want to be treated at Burnley general hospital. They feel that they are entitled to the best possible treatment locally, unless they need recourse to a specialty for which they know that they must go elsewhere.

    I am sure that the Secretary of State recognises the feeling on both sides of the House—and I am sure that his friends in Kent and Hertfordshire agree—that, if possible, those who wish to receive treatment locally should be able to.

    The system for deciding which hospitals should become self-governing is regarded with great suspicion. I have considerable respect and some affection for—and many dealings with—some of the senior people involved in the Guy's proposal, and I know that they have the interests of the Health Service at heart. I believe that, at the time of the debate on the Health Service in the 1980s, they would have opted for a system of district cross-charging rather than for the Secretary of State's proposals. That would have been a much better idea.

    Lord McColl of Dulwich and all the other protagonists—in general terms, that is—have accepted what they see as the second-best option, encouraged by a fairly self-evident "carrot": if Guy's goes first it will be looked after. They are clearly attracted by the finance that they would secure for their hospital and teaching facilities as a result of its being the apple of the Government's eye.

    What worries ordinary people, however, is that the decision will eventually be made by the Secretary of State, after he has been approached by a mere handful of advisers. We all know that tradition removes Secretaries of State from the direct sentiment of local people. I do not criticise the Secretary of State personally; he must know that any Minister who runs a Department that spends such huge sums finds it impossible—with the best civil servants in the world—to be as much in touch with local feeling as he would like, as any ordinary Member of Parliament is with the community.

    The problem is that the Government will want the scheme to succeed, and will want hospitals to opt out to show that it can succeed, even if there is mass opposition from all but the handful of people whom the system empowers to put the idea on the Secretary of State's desk. That is what is wrong with not testing the argument and allowing the whole community to decide through a ballot.

    During the past year we have been unable to discover from the Government exactly who would make those decisions. Members of Parliament from Sheffield had meetings with the health authority and about two months ago, more by way of a slip, it admitted that it was a group of consultants. In the meantime, outside the Northern general hospital, a group of local people set up a table with a petition on it against the proposal. People in the hospital got out of bed, put their clothes on and went outside, down the drive, to sign the petition. People passing and going into the hospital signed the petition and none was in favour of the decision.

    8.15 am

    I think that that is right. The Secretary of State must know. I have met no one in favour of the scheme. That is not because they have misunderstood it. I am talking about many well-informed people in the Health Service and outside it. New clause 4 allows the Secretary of State to put his argument that there is a better way to run the Health Service to each local community so that it can judge.

    I am not here to defend the technical drafting of the new clause and say whether the electorate is correctly defined. I know that there are problems about that. However, the best electorate are not the people who work in the Health Service, but the people who use the Health Service. I have never understood the argument that it is more important to ballot those who work for that employer because, clearly, they have a self-interest and they are traditionally conservative. We all are about our own professions, and I have the same profession as the Secretary of State.

    When a hospital closes, which is far more serious than a hospital taking self-governing status, there is no ballot. The proper way of focusing public opinion is through community health councils. Another point that I am sure has been raised many times in the early hours of this morning——

    I have not been to bed yet. I have been here listening carefully. I may go to bed in a minute, but let me return to the point that I was trying to make.

    How on earth does one determine, in a place like Guy's or Bart's, who has to be balloted? Those hospitals have enormous numbers of people from an enormous area across all sorts of boundaries. It would be administratively impossible. Is not that the real difficulty about the Opposition's proposal?

    If the hon. Gentleman had been here earlier he would have heard me answer that point in reply to the hon. Member for Lancaster. One cannot have ballots for closing hospitals, because that is a decision for which one needs less resource. This is not the same situation. This is a decision about whether to change the nature of the relationship between the local hospital and the local health authority. That is perfectly susceptible of a ballot in a way that closing hospitals would never be, because one would never get the assent of a community. No such parallel can be drawn.

    The Secretary of State said that he is aware of private polls that show that a majority of people are in favour of the scheme. The rest of us have not seen those polls. I have seen no public polls to that effect. One poll last week showed that 71 per cent. disapproved of the Government's scheme, 58 per cent. disapproved of their hospital becoming a self-governing trust and 37 per cent. of those who said that they were Tory voters said that the electorate should be the local community.

    I should have hoped that the new clause would have more appeal after a second glance. It does not say that the ballot is determinative, and it could be criticised for that. It says that there must be ballots, reports of which must be presented to Parliament. The hospital can be allowed to be a self-governing hospital trust only if that report is approved.

    If, on reflection and having seen the difficulty that this part of his scheme has given him, the Secretary of State believes that it is worth ruining the chance to improve the Health Service by staying firmly with this proposal, he is committing a grave error of judgment. I hope that he will realise that this proposal is probably provoking the greatest difficulty for him among the public at large.

    I hope that the Secretary of State will realise that if he is determined to offer the opportunity of separating a hospital from a district, a way forward is to say, "I am prepared, as my colleagues in other Departments did, to accept that the public must have a say." If the public have a say, his Health Service reforms may begin to get more widespread approval. If the public are excluded, people will not believe that the reforms are in the interests of the Health Service and the public, and are just more separation according to Tory dogma and a development of the Health Service from one based on care to one based on cost. That is not what any of the public want.

    The Secretary of State mentioned consultation. Is it consultation as a PR exercise or meaningful consultation? Given the track record of Conservative Governments since 1979, I believe that when they say "consultation" it is merely a PR exercise. They intend to take no notice of what the people and various groups are suggesting. A recent example of that occurred over their education and student loans policy. The talk of consultation is a charade. I wonder whether the Conservative Government are aware that a vast number of people in this country place a big question mark over what the Government say? When the Prime Minister and the Secretary of State say that the NHS is "safe in our hands", no one believes them or anyone who tries to kid the public.

    I passionately believe in the National Health Service and fully support it, as do the vast majority of the public. There is no doubt that, given the option, the public would contribute a little more in taxes or another form, to ensure that they have a viable, efficient Health Service that meets their needs. Regrettably, Tory dogma stops that happening.

    For the Government, opting out is not one step but one of a series of steps towards the privatisation of the Health Service. I will oppose it in every possible way because the public certainly want a Health Service, and the House has a duty to provide it.

    There is another aspect of the opting-out proposition in relation to hospitals. A new hospital is being built in my constituency; the Secretary of State is coming to lay the foundation stone next week. I shall not comment on what my constituents say that they should do with the stone. I suspect that the new hospital will not get the chance to opt in, but will be opting out from the very day it opens. We can look forward to a future of new hospitals being built that will always be opting out and never opting in.

    There is no need for me to comment because my hon. Friend's point is self-explanatory and well put.

    When the Secretary of State lays the foundation stone, perhaps consideration should be given to putting him in a time capsule. He is unique and will be worth a bob or two in years to come.

    When I was a Labour member of Doncaster council I served on the Doncaster health authority, and became its vice-chairman. The chairperson was Celia Wilson. She left no one in doubt that she was a Conservative, but her brand of Conservatism was vastly different from the Government's. Tony Dale was the secretary—again, not a Labour supporter—but he was a first-class administrator and was committed to the Health Service. David Eaves, the treasurer, was also committed to the Health Service.

    The Government talk about value for money and an efficient Health Service. David Eaves and Tony Dale helped to provide the foundation, the core services and the efficiency of Doncaster health authority. It has one of the lowest administration costs in the country. The major part of its funding is used to ensure that nurses can provide the necessary care for patients. The administration costs are kept down.

    Doncaster is a jewel in the provision of health care. But because it has been so efficient the Secretary of State cannot kid me that he is not making a decision on that authority until later in the year. He has already made his decision about Montagu hospital because of political dogma. It is a tragedy and it makes a mockery of his statement.

    I am not a gambling man, but I will bet the Conservative Whip £l—[Interruption.] I am not sure whether I am allowed to do that in the Chamber, so I shall make my wager outside. I am convinced that the Secretary of State has already made the decision about the published list. He referred to the Whitley council. I served on that council, and I carefully studied the various disputes—especially the ambulance dispute. The blame——

    I accept that, Mr. Speaker, but the Secretary of State mentioned the benefits of the Whitley council in relation to wage negotiations. Having sat on a Whitley council I am aware of the manipulation by the Secretary of State for Health. It is kidding people to say that the Whitley council can make its own judgment. It cannot.

    8.30 am

    The Bill is one of a series of steps towards the privatisation of the Health Service. Everyone is convinced of that. That is one reason why the Government are opposed to the new clause.

    On a point of order, Mr. Speaker. It is a very serious matter. I have just returned from St. Stephen's entrance where I saw the shadow Health Secretary in a seated position, with electrodes on his head and surrounded by men in white coats. That may confirm some of the suspicions many of us have had for a long time. Might it be appropriate for the hon. Gentleman to make a personal statement?

    If the hon. Member for Harlow (Mr. Hayes) had been in the Chamber as long as we have, he would have heard the explanation. It shows that he was not in the Chamber for the whole debate, which is unfortunate.

    I said that the Bill is one of a series of steps towards privatisation. Since 1979 various Secretaries of State have shifted every health authority chairman who has voiced opposition or even raised a question about Government proposals. They have been replaced by the nodding brigade. How can people believe the Conservative Government when they fill the health authorities with people who will not say that enough is enough?

    Doncaster health authority has a fair mix from the community. The chairman, who was appointed recently, supports the Conservative party. That was no surprise; we expected it. There is a Conservative majority built into the authority. One problem for the Government is that occasionally the consultants say, "Stop." When the health authority discussed opting out, the two consultants decided that they wanted nowt to do with it, and the health authority decided not to support the opting out of Doncaster royal infirmary and the Montagu hospital.

    One reason why the people do not trust the Government is that since 1979 there has been a regrettable lowering of standards, despite what the Prime Minister says at the Dispatch Box about more money, more nurses and more of everything. I wish people would go into wards and open their eyes instead of looking through blue-tinted glasses. Since I finished with the health authority, when I became leader of Doncaster council, my sister has had three major operations, my brother has become a diabetic and my brother-in-law has had two strokes which have left him blind. Unfortunately, I am at that age when many of my friends and colleagues are falling ill and requiring treatment at Doncaster royal infirmary, the Montagu hospital or even at Hull and Sheffield hospitals. Standards are lower.

    No one would praise nursing staff more than I. However, I do not want to single the nurses out. They are part of a team including ancillary workers, from the porters to the people who type and send the notifications of appointments. If one visited a ward now, one should not see a highly qualified nurse dashing round serving cups of tea to the patients. That should be someone else's job. We should not train nurses to perform skills and then employ them as charladies. That is really disgusting. I am convinced that we should ensure that nurses are paid for nursing and not for mashing cups of tea and serving lunches and dinners from a trolley.

    My hon. Friend is making an important point. However, with due respect, we are talking about the control of hospitals, not the services within them. In relation to the points about the Government systematically changing chairmen, does my hon. Friend suggest that the Government are practising a form of nepotism in that they are securing positions to control the hospitals so that their clandestine actions in relation to privatisation will meet no resistance? Are the Government doing that systematically as a step towards the privatisation programme for which they have no mandate?

    Order. I remind the House that we are considering National Health Service trusts.

    My hon. Friend the Member for Hemsworth (Mr. Buckley) is absolutely right. The Government could guarantee the Conservative supporters.

    Doncaster royal infirmary and the Montagu hospital have expressed an interest in the trusts. The two unit managers—Nicholson and Turner—covertly or in some other way, decided together with a small clique to write to Trent health authority and to the Secretary of State. Since then they have spent a fair amount of time—which is money—and a fair amount of real money as well, pursuing an issue that I believe was outside their terms of contract. They are employed by Doncaster health authority, not by Trent health authority or by the Government. However, they connived with one or two other people in the authority to express an interest.

    When we tried to discover the names of the people who had expressed an interest on behalf of the people of Doncaster, the Secretary of State informed us that he did not know who had expressed that interest. There is a saying—which is not racist—"They kid niggers in Africa." That is what the Secretary of State is trying to do. He is trying to kid us. He knows the names that were submitted from Doncaster.

    When the Secretary of State was pushed because we wanted to know the facts and started to apply pressure, we were told that the unit managers had expressed an interest, that the consultants had carried out a ballot among themselves and that they supported the expression of interest. However, it turned out that the chairman of the consultants—of the medical panel—had done his own thing and consulted one or two cronies. Having consulted a minority, he decided that he would follow the example of the Secretary of State and allow the minority to dictate to the majority. Although there were no proper consultation, the proposals went ahead.

    My hon. Friend the Member for Livingston (Mr. Cook) referred to Doncaster council, which paid for a MORI poll to ascertain the opinion of the people of Doncaster. A survey was carried out, in which MORI, not the council, posed the questions. MORI decided, "That is the problem; these are the questions." When asked, the overwhelming majority of the people decided that they wanted nothing to do with the Secretary of State's proposals on opting out. The community health council also decided that it would not go along with that expression of interest. I have already said that Doncaster health authority has decided not to support the two unit district managers.

    Montagu hospital had been earmarked years previously for a geriatric hospital. It was said that the accident and emergency unit would close, that the operating theatre would be lost and that it would become a geriatric unit. Regretfully—for the Government and Trent—the local people fought like blazes and reversed that decision. We now have some fine operating theatres and good improvements, although we still have some way to go. If we had listened to the pundits and to the whiz kids all that time ago, Montagu hospital would simply have been a geriatric unit, but now it provides the services that I have mentioned. It is one of the hospitals that will opt out. Does the House think that the people of Mexborough and the Don valley will stand idly by?

    Against that background, I hope that the House will reject the Government's proposals. I have said that I am totally committed to the NHS. I am a blood donor, but hate to think that some of my blood might go to a hospital that has opted out. New clause 4 should be accepted, as should the idea of ballots and referendums—whatever one likes to call them. I hope that the House will support new clause 4.

    The Select Committee on Social Services made a recommendation on balloting, which is the subject of new clause 4. The paragraph with which I am concerned in our eighth report, which was issued in July, begins with some sentences that were agreed by the whole Committee:

    "The proposal for self-governing hospitals within the NHS is controversial. The Government is pressing ahead very fast with its plans, despite the fact that the basic cost accounting systems … needed to provide the foundation for the establishment of trading in the NHS generally, and of self-governing hospitals in particular, have not yet been fully developed. Unnecessary haste with one aspect of the planned changes may make it impossible for others, including the planned budgets experiment, to work."
    That was accepted without any attempt to amend it. The paragraph continues, and this was the subject of an unsuccessful amendment to delete the passage:
    "If self governing hospitals are to be implemented, they should be phased-in like GP budgets. If this is to be a consumer-oriented revolution, as the Secretary of State claims, the first such hospitals should be set up in districts where there is only one district general hospital serving that area and where customers in the district, i.e. the local population, have indicated through a ballot that they support the hospital becoming self-governing."
    That is the very point at issue in new clause 4. The recommendation was approved by a majority of the Select Committee. It was not done on the spur of the moment. The Select Committee devoted two full sessions to examining the resourcing and structure of the NHS.

    8.45 am

    When the vote was taken, those who supported the recommendation were not all Labour Members. They were two Labour Members, two Conservative Members and an Ulster Unionist Member. The House will agree that that was a fair spread. Three Conservative Members opposed the recommendation. Of those three, only one had served on the Select Committee during the whole of the inquiry. If we take away the vote of another member of the Select Committee who was not present during the whole inquiry, and my vote on the grounds that I am Labour so I would vote that way, the remaining members, all Conservative, supported the recommendation by three to one. Conservative Members of the Committee who took part in the whole inquiry, supported the idea of a ballot by three to one.

    Did the Select Committee refer to the position that arises when an entire district health authority prepares to opt out as is the case with the Bristol and Weston health authority? The authority seeks to take all hospitals out.

    Some anxiety was expressed on that point from time to time, but most of us thought that it would be improbable. Although we want to retain an integrated service, that method of remaining integrated would, I think, not meet with much favour on the Select Committee.

    I have compared the provisions of the new clause with the recommendation of the Select Committee. The new clause is both more cautious and more comprehensive than the Select Committee's recommendation. It is more cautious because it does not give the last word to the ballot of the population. It gives the last word to the two Houses of Parliament.

    The new clause is more comprehensive in ways which have merit. It accepts the notion of a ballot of the population. That is crucial. I hope that my hon. Friends on the Front Bench have been influenced by the deliberations and recommendations of the Select Committee. But my hon. Friends have gone further. They have met the Government's argument that perhaps the electorate would lack expertise. The new clause remedies that by making sure that there would be a ballot of the staff. That provides expertise from clinicians and those working daily in the hospital concerned, which is a valuable addition.

    My hon. Friend the Member for Livingston (Mr. Cook) explained in detail how the new clause takes account of the district health authorities' views also, and requires that they be made known to the House. That point would not necessarily have commended itself to me immediately, but my hon. Friend was convincing. The new clause draws in administrative expertise. Because his speech was rather too short, my hon. Friend did not explain that the new clause also brings in the views of any relevant CHCs. The Government have not paid attention to that. Indeed, it has scarcely been touched on. Perhaps the Government do not want CHCs' views to be made known because the Association of Community Health Councils has already made clear its strong reservation on the whole matter.

    Does my hon. Friend agree that clearly, whoever is balloted, the Government believe profoundly that they will be defeated in every single aspect of democracy? Therefore, to subvert that, they must have recourse to diktat. Diktat is now the order of the clay because they have smelt defeat if they engage in democracy.

    I fear that my hon. Friend is right.

    My hon. Friend the Member for Livingston referred to various ballots which have taken place. I shall quote from evidence to the Select Committee, particularly choosing bodies for the range of interests that they represent. They are not trade unions. There was considerable unanimity on this point across a wide range of organisations.

    The Maternity Alliance is a broad organisation devoted to the needs and wishes of pregnant women. It pointed out:
    "Within many hospitals' obstretric units women are now getting more choice about how they give birth but choice about where they do so has been restricted by closures, usually of smaller units. This has meant that many women now have to travel further for their maternity care. The Maternity Alliance is concerned that, under the new proposals, the economics of competition and the creation of self-govermng hospitals will further concentrate services."
    It points out how that would be a drawback for women:
    "A more patchwork service would mean more trawl."
    It expands on that point, but I shall not detain the House. I recommend the evidence to the House.

    In Committee I moved an amendment to include maternity services in core services. As my hon. Friend the Member for Livingston rightly said. core services have disappeared from the Bill. The Government refused to include them. That shows their lack of commitment to a comprehensive Health Service.

    My hon. Friend makes a good point. Undoubtedly not only the Maternity Alliance but bodies such as the Royal College of Midwives have expressed grave reservations about the fragmentation likely to result from these proposals.

    Even allowing for our wholly disproportionate reliance on hospitals for childbirth, pregnancy and childbirth necessarily involve the community, then the hospital and then the community again. Fragmentation would be extremely dangerous—and I use that word advisedly—for the care of expectant mothers.

    My hon. Friend rightly mentioned that women now have to travel considerable distances for their children to be born, because of communication difficulties, and that is a real problem in the south Wales valleys and particularly in the Rhondda valley.

    I am glad that we have been joined by the shadow Secretary of State for Wales and the shadow Health Minister for Wales, because I hope that they will be able to correct that situation when they come to power. One of the greatest things that can happen to a person in Wales is to be born in the Rhondda. That is not only considered to be a distinction; it is a distinction. However, women in East Glamorgan have to travel to be delivered of their children; due to Government cutbacks children cannot be born there. In a tribal area such as the south Wales valleys such an issue is of considerable importance. I know that the shadow Secretary of State for Wales will put this issue high on the agenda when we win the election next year.

    The Medical Women's Federation said:

    "Implementing change without consulting those on whom the burden will fall flies in the face of good management practice and demonstrates a discrepancy between this Government's self image and its behaviour."
    The federation went on to make even less complimentary references to the Government, but in deference to the fact that they are having a hard time today, I shall not quote any more.

    The Royal College of General Practitioners, speaking about independent hospital trusts, said:
    "The College feels that the proposals for independent hospital trusts will seriously affect the level of services for patients and training. The creation of self-governing hospitals will de-stabilise future community care and may lead to a fragmentation of services."
    Perhaps that is the sort of evidence that has led the Government to believe that it would be highly dangerous for medical opinion to be consulted and to be laid before the House; the Government think that they will lose.

    The Health Visitors Association is concerned about another aspect that has been somewhat neglected. Community services as well as hospitals can opt out of control by the community through the district health authorities and that is an extraordinary proposition.

    The Health Visitors Association is deeply worried about that because, by definition, health visitors are in the community. It said:
    "A possibility not touched on in the White Paper and Working Papers (except implicitly in the references to health authorities being empowered to buy services from the private sector) is that a private company could bid for the contract to provide all or part of the community nursing services. While the Government's stated intention is for careful regulation and monitoring of contracts and their performance, the Association believes that specific safeguards are needed to prevent vested interests from developing services in directions detrimental to the interests of clients. An infant formula manufacturer, for example, should not be able, by any act or omission, to create conditions within the health visiting service which would adversely affect the quality of unbiased information and advice about infant feeding."
    That is a matter of great concern, which the Government have not referred to at all. They are not privatising the NHS—I will concede that—but they are blurring the edges and the interface between it and the private sector, which will result in a most peculiar and uncontrollable hybrid.

    The Health Visitors Association has proven knowledge of and a proven interest in the matter. It would welcome the opportunity to ensure by means of a device such as new clause 4 that its concerns were put directly to the House.

    The association also referred to the integrated nature of the service. It said:
    "Integrated child services ensure close links between the nursing and medical staff, in and out of hospital, concerned with a range of provision for children with special needs, and in relation to child protection. Where these aspects of hospital and community services were no longer to be managed by the same agent, the Association fears that these links could be jeopardised, particularly if they added to the hospital's costs."
    The last phrase—
    "particularly if they added to the hospital's costs"—
    contains a considerable sting. It will determine what a hospital does. I agree with the association that the kind of services to which it refers, which are so important to children, would be jeopardised.

    The Division of Social Responsibility of the Methodist church also submitted evidence. I accept that the term "social responsibility" might invalidate the Methodist church's evidence in the eyes of Conservative Members, but that will not apply to the public. The Methodist church's response to the Select Committee's report was:
    "NHS Hospitals may opt out of Health Authority control. They will be managed by business-oriented Trusts, which may trade with other institutions, private and public, hiring their own staff at their own rates."
    9 am

    The Secretary of State compared this reorganisation with the 1972 reorganisation—again by a Conservative Government. I was not predisposed towards that reorganisation, but it bore no relationship to these proposals. The Secretary of State relies on people not having read the documents relating to his proposals. The Methodist church referred to the relationship with the private sector and said:
    "There is no reason to welcome the expansion of the private sector; countries with a larger proportion of health care provided privately do not always enjoy better health care than does Britain. The White Paper envisages the NHS working much more closely with the private sector. In view of the proposals to bring senior clinicians more closely into management, this implies a very serious conflict of interest. Consultants are likely to have a fairly dominant role under the new proposals, and would be chiefly responsible for buying services from the private sector, that is, from their own medical businesses. This is seen as corrupt when it occurs in the Local Authority context, and will place a heavy policing burden on the Audit Commission and on Health Authorities.
    The deep suspicion arises, however, that the plans for hospital trusts are designed to make large-scale privatisation possible."
    That is not a Labour party document; it is a document from the Methodist church's Division of Social Responsibility.

    I am very impressed by my hon. Friend's remarks. Does she agree that, as all this is about cost, there will be a temptation to put pharmacy, laboratory services, and so on, out to the private sector and that, as a result, we shall have an inferior, less efficient service that could put lives at risk?

    I agree entirely. As the point that my hon. Friend has made is self-explanatory, I shall not elaborate on it.

    As I have shown, the Select Committee took evidence from a very wide range of organisations. It took evidence also from the research team for elderly people at St. David's hospital, Cardiff, which added its voice to the expression of worries and anxieties about the likely consequences of the Government's proposals. No doubt, those people would like a chance to be consulted. The research team told us:
    "The interface between community and hospitals, including flexible respite care, is also critical for older people. It is hard to envisage hospitals which become autonomous seeing such work as a priority unless they perceive that such an approach will reduce the readmissions of chronic cases. What evidence exists suggests that elderly people who get into trouble after discharge are not regularly reassessed. There will be no financial incentive for a hospital to ensure that good follow-up and rehabilitation facilities exist. The tendency will be even greater if such reassessment is likely to lead to readmission, thus incurring heavy financial disadvantages. Unless the auditing system extends to surveillance of the community, these failures are unlikely to be recognised."
    I suggest that the people who would recognise these failures, and indeed would be in a position even to anticipate them, are elderly people themselves. Thus, those who care for them clinically and those who carry out research on the subject should have the ear of the House, as should the elderly people themselves, by way of the proposed ballots.

    The case for a ballot has been made not so much by Opposition Members as by all these outside organisations with their expertise and their interest—and that cannot be said to be simply self-interest; the range is far too wide for that. I could have quoted many more instances. As it is, I have quoted a very wide range of people with an excellent reputation and with expertise.

    I believe that the new clause, because it would give the final say to both Houses of Parliament, is cautious. It is also comprehensive, in that it brings in clinicians and other staff, district health authorities and community health councils, as well as the local population, and ensures that the Secretary of State is obliged to include their views in any report on proposals to opt out. He would not dare proceed against the weight of the opinion that would be disclosed. That is why the new clause is being resisted so fiercely by Government Members.

    The Secretary of State complained at the beginning of his speech that my hon. Friend the Member for Livingston (Mr. Cook) had spoken for a long time in moving the motion on the new clause. The Secretary of State spoke for one hour and 11 minutes and did not get to the point of the new clause until he had spoken for one hour and six minutes. By contrast, like my Back-Bench colleagues, I shall devote all my remarks to the purpose of the new clause, which is to ensure that there is a consultative ballot of local people about the future of their local hospital.

    The Secretary of State is not in the Chamber. He told the House that he intended to make a special point of being present for speeches by Back Benchers. He left the Chamber almost as soon as they started to make their speeches. His absence is particularly unfortunate because I intend to take him to task for his remarks about the ballots held in some parts of the country.

    I speak for the west midlands. The Secretary of State announced in a press release that five "units"—the Government's word—have expressed an intention to opt out of local health authority control and become self-governing trusts. I was interested to note that the first of the units on the list promulgated by the right hon. and learned Gentleman is the Alexandra hospital in Redditch. It is first because the list is in alphabetical order. The Alexandra hospital is in the area of the Bromsgrove and Redditch health authority, where I lived for many years and which I briefly represented in the House.

    A hospital was desperately needed in that new town, and the people of Redditch campaigned for nearly 20 years to get one. Everything else was provided—housing, schools, shops and roads—but the hospital was at the end of the list. A marvellous hospital was eventually constructed a few years ago. Although it does not operate to capacity because of underfunding, it is a tremendous boon to the people of Redditch. However, they have learnt that someone—I believe that it may be the health authority—has expressed interest in the idea of the hospital opting out and becoming a self-governing trust.

    My hon. Friend referred to five such hospitals in the west midlands. Is he aware that the opt-out proposal for a district general hospital in my borough has been opposed by the local community health council, which made it clear in a letter to the Secretary of State that there was no justification for opting out and which echoed all the fears that I expressed in an Adjournment debate on this subject last July? Is not it a fact that there has been no sign of any public support or support from the staff at those five hospitals for the proposal?

    I am grateful to my hon. Friend. He has saved me from making some remarks about Walsall. I thought that he might want to represent the interests of his constituents.

    I shall concentrate at this stage on the Alexandra hospital in Redditch, where a ballot has been held. The Secretary of State referred to what he called fancy polls up and down the country and talked about the Labour party and the trade union movement enjoying themselves organising straw polls to oppose self-governing trusts for NHS hospitals. The people of Redditch will take grave exception to his remarks, because the Redditch ballot was organised not by the Labour party, the trade union or some fancy people but by the local council. It is true that there is a majority of Labour councillors on Redditch district council, but the ballot was supported by all parties, including Conservative councillors who, to their credit, believed that the people of Redditch should be consulted about the future of their local hospital, for which all parties had campaigned for many years. Those councillors went so far as to invite the Secretary of State for Health to launch the ballot. He declined and refused to send a representative. The leaflets distributed by the local council could not be described as propaganda. They set out the arguments for and against a self-governing trust.

    When I read the leaflet, I wondered what the result would be, because it gave the Government's alleged advantages of opting out. The ballot was organised by the council officers on behalf of all the council and it was done fairly. There was no bias in either the questions or the explanatory leaflet. Even the Secretary of State would have to concede that point if he took the trouble to look at the leaflet.

    9.15 am

    The ballot had a tremendous result. There was great interest in the town of Redditch, and 57 per cent. of the people took part. There was no way in which the ballot boxes could have been stuffed. The ballot was conducted by council officers who visited people's homes to collect the forms, so there can be no allegations of rigging. Thirty-two thousand people took part in the ballot which was organised by all parties on the district council in Redditch. Of those, 3,210 or 10 per cent., having read the arguments for and against, could not make up their minds on whether the hospital should opt out, and 5,262, which is 17 per cent., were clearly in favour of the hospital opting out. The other 22,869 people said that they were against their hospital opting out. That is 73 per cent. of the many people who took part in the ballot and represents 81 per cent. of those who had an opinion, as my hon. Friend the Member for Livingston said. They said that they were against their hospital opting out.

    The hospital serves not only Redditch, but the Bromsgrove district. I know that district well because I used to live there. It includes a rural area as well as the town of Bromsgrove and is a large district. It was only right that the people of Bromsgrove should be consulted as well as the people of Redditch, because the hospital serves

    both districts. Unfortunately, Bromsgrove district council, which is Conservative controlled, refused to conduct a ballot, so it was left to the Labour party to consult the people of Bromsgrove. Bromsgrove Labour party, to its credit, put a great deal of effort into organising a ballot, which it tried to make as fair as possible. It received a tremendous response, too. There were 20,000 ballot papers and 35 per cent. of the people in Bromsgrove responded to the opportunity to be consulted about the future of their hospital, which is the Alexandra hospital. That is more people than participate in many local elections, as hon. Members of all parties will accept. Having thought about the issue, 238 people said that they were in favour of the hospital opting out and becoming a self-governing trust, whereas 6,812 people said that they were against opting out. Of 20,000 ballot papers, the response was 7,050, which is 35 per cent. Ninety-seven per cent. were opposed to the Alexandra hospital being allowed to opt out.

    Another ballot was held, not by the Labour party or by the council, but by the staff for the staff at the Alexandra hospital. It was not restricted to staff who happened to be members of trade unions, but was for all staff. It recognised the right of everybody who worked at the hospital to express an opinion about the future of their place of work. Eighty-three per cent. of the staff took part in that ballot, and the result was similar to the results of the ballots of those living in the catchment area of the hospital. Thirty-one members of staff were in favour of a self-governing trust, whereas 795 voted against. That is 96 per cent. against a self-governing trust and only 4 per cent. in favour. There is no question about the overwhelming opinion of the staff at the hospital, of the people living in Redditch and of the people living in Bromsgrove about the future of their hospital.

    What was even more significant in the context of this debate about new clause 4, about whether people should be consulted and whether people should have an opportunity to express their opinion, was the result of the other question that people in Redditch were asked. Redditch council asked the local people whether they thought that they should be consulted. There were differences of opinion about whether the hospital should opt out, 81 per cent. of those who expressed an opinion being against—although the crude voting figures showed that 73 per cent., three out of four, were against opting out, with 17 per cent. in favour and 10 per cent. not knowing.

    But when the people were asked whether they should have an opportunity to be consulted, the response was even more impressive. Only 3 per cent. did not have a view about that; 10 per cent. had not formed an opinion; only 7 per cent. were against being consulted; but 90 per cent., including a large number of those who were in favour of opting out, said they should have an opportunity to express an opinion. They were talking about being consulted, not about determining the future of the hospital. That is the purpose of the new clause—to ensure that people are consulted—and experience among the people in the Bromsgrove and district health authority area clearly shows that the public want to be consulted. The Government are resisting the new clause and are thereby saying that people should not even be permitted to give their view.

    We are not saying that the local people should determine the future or that the ballot should be binding. The Conservatives are in favour of compulsory and binding ballots when it suits them. Let the people be consulted and express a view, and let us be told the result. The Government's supporters, Tory councillors and even those who are in favour of the hospital opting out want them to agree to the principle of the new clause.

    Five units are now being considered. In other words, in five places an intention to opt out and become a self-governing trust has been expressed. My hon. Friend the Member for Walsall, North (Mr. Winnick) said that the Walsall acute services hospital was one of the five. I have spoken in detail about the Alexandra hospital. It has been suggested that a hospital in Rugby should become a self-governing trust, but unfortunately we do not have an hon. Member among us to say what the people of Warwickshire think about that.

    Two other units are outstanding. In those, an intention to become self-governing trusts has been expressed. It so happens that the people served by those two units will be consulted in the most effective way. They will have not just the opportunity but the right to be consulted about the Government's plans, not only for their hospitals but on a wide range of other issues. Those two units are the Mid-Staffordshire mental health hospital and the Mid-Staffordshire community hospital. The people of Mid-Staffordshire will have their say on 22 March. I am confident about the view that they will express, and the Government will be obliged to listen.

    I need not apologise for intervening in the debate because first, I have been waiting for 16 hours to speak to the new clause and, secondly, I am anxious to report why many people in the city of Bradford strongly believe that the public and staff concerned should be consulted about the Government's proposals for self-governing trusts.

    We in Bradford are told that there is to be a trust which will incorporate Bradford royal infirmary, St. Luke's hospital and Woodlands hospital. If that is true, it means that 85 per cent. of all Bradford's hospital services will be included in the trust. There are rumours that a fourth hospital will also be included, although it has not been identified.

    Many people in Bradford, and throughout the rest of the country, are concerned about the extensive preparatory work undertaken over the past 12 months to establish trusts, before any parliamentary approval has been given to the Bill that provides for them. Dr. Mark Baker, Bradford's district general manager, has spearheaded the intense preparations for the Bradford trust. He has secured a very unusual agreement with Bradford health authority: he has been seconded to Yorkshire regional health authority for two years, after which he is free to return to his Bradford post if he so wishes.

    That unusual agreement underlines the suspicion that the Government see the Bradford trust as the flagship of their proposals to dismantle the NHS there. There is also some significance in the allegation that the Government have allocated £400,000 extra to the Bradford health authority this year: that is clearly intended to facilitate and finance the preparatory work that has been under way during the past year.

    Many other worries felt by Bradford people reinforce the need for ballots to be held before NHS trusts become a reality, there and elsewhere in the country. The Bradford trust, unlike the health authority, is not observing an equal-opportunity recruitment policy. Top jobs are being filled not through open competition—they are not being advertised—but under the old pals act, which many people both inside and outside the NHS find entirely unacceptable.

    Furthermore, neither the public nor the press will have the right to attend the meetings at which the trust will determine its overall policy on patients and other important matters. That, too, is causing widespread concern. Officers who intend to become directors and officers of the trust have been drawing up their own trust contracts, and dealing similarly with other matters in which they have a direct financial interest. Some have received large bonuses to speed the development work. It is feared that after April 1991, when the authority takes on its new contracting status, it will be left with a rump of officers unable to compete with the much more powerful sole supplier of core services—the trust, whose directors will know the health authority inside out. That is no way in which to operate a contractor-contractee relationship.

    This year, the health authority's budget of £80 million has had to be cut by £3 million. Chronic services for the elderly, psychiatric patients, disabled and handicapped people, and the community services, have been cut by £1·2 million, whereas acute services, have been cut by only £300,000. That has occurred against a background of continuous concern about underspending of the chronic services budget and overspending of the acute services budget.

    9.30 am

    We know that the acting unit general manager for chronic services is planning to go to the trust as Dr. Baker's deputy. That man is in charge of the cuts programme in chronic services, cuts which protect acute services and make the trust more financially viable, and which are thereby of direct future financial interest to himself and in conflict with his present responsibilities to do the best that he can for the chronic and community services. It has been freely admitted that part of the cuts will entail job losses in the geriatric and school nurse services.

    There is serious anxiety about the trust's employment policies. On 13 February 1990, Mr. Charles Vize, a senior consultant for the ear, nose, throat and eye unit, who is to become the clinical director of the Bradford trust for those specialties, met nursing staff at Bradford royal infirmary and told them that the Whitley council's terms and conditions of service, at present recognised by the Bradford area health authority, would not be recognised should Bradford become a self-governing trust. They were also told that flexible working patterns are to be introduced in the ear, nose, throat and eye unit in the near future with or without members of staff approving them, and that members of staff would be liable to summary dismissal and would lose the right of redress.

    As I have already said, night sisters in Bradford have been told that under the trust those posts will be abondoned. A night sister working in Bradford wrote to me saying:
    "I am now told that I am no longer necessary and I am very worried and concerned for my patients and my staff. Who will help and support my staff, some of whom are newly qualified … At the end of the day it is the patients who will suffer … I feel angry, hurt and let down that after all these years my services are no longer required. I worked for many years on a low salary but because we were classed as dedicated this was acceptable. Now when I am receiving a decent salary I am classed as an expensive commodity and out I go. Do the public realise that there will be no Health Service as we know it if the White Paper is passed through Parliament? I would appreciate any help that you can give me."
    That comes about because I understand that under the trust there is to be rotating 24-hour staff cover and night sisters will not be part of that. There will be only day sisters; night sisters' posts will be abolished. They are worried about whether alternative vacancies will be offered to them and whether those posts will be on a comparable grade, and there are real fears that a number of night sisters now doing dedicated and caring work in Bradford are likely to be made redundant in the near future.

    I have also received letters from junior doctors in Bradford. They have recently formed the Bradford junior doctors committee and they are campaigning about their excessive hours of work which range from 90 to 120 hours a week. They write:
    "We feel that now is the time for action. Bradford Area Health Authority have expressed an interest in "opting out" and are putting a lot of behind-the-scenes effort into this, but none into improving our working conditions. Things will only get worse if opting out becomes a reality."
    In the view of many of my constituents and the majority of people of Bradford, the Bradford trust and the aura that is being created around it, is producing an unacceptable atmosphere of secrecy, sleaze and self-interest. Instead of health care, there is talk about business plans. Instead of talk of patients there is talk of customers. The principle of the National Health Service was put to the people of this country at a general election and the Labour Government in 1945 received a massive mandate for it. The proposals fundamentally to dismantle the National Health Service should, in turn, be put to the people of this country at a general election. Therefore, the Government should call an immediate halt to the preparation for National Health Service trusts throughout the country. We are told that 16 will be announced this October, and another 40 or 50 next year.

    It is wholly unacceptable, and possibly unlawful, that preparatory work for those trusts has gone on in Bradford and elsewhere during the past 12 months—months and months in advance of parliamentary approval. If the Government are not prepared to accept the recommendations in the new clause that extensive and thorough consultations with staff and the public should be undertaken in properly supervised ballots, they have no alternative but to withdraw the proposals, call a halt and allow the people of this country to show clearly at a general election whether or not they support the fundamental dismantling of their National Health Service.

    I am grateful to be called after 16 hours of detailed debate of the Bill to look at new clause 4 in the light of a hospital in my constituency, Christie hospital, a famous national centre of excellence. I wish to show by this case study the process that has been going on over the past 12 months and why the clause is so important. I shall concentrate on subsection (2)(a) of the new clause, which refers to a ballot of staff at a hospital. I specify that part of the new clause because, although I fully support and commend the Opposition calls for wider consultation and ballots among the local community, I accept that, in the case of Christie, patients come from all over the country to use its facilities and there could be an argument—I say no more than that—why the electorate would have to be narrowed down in this ballot.

    The people of south Manchester are proud of Christie hospital. They do a lot of work to raise money to ensure that it continues to operate. Without that support from local people many of the services that still exist at Christie hospital certainly would not have continued. With that reservation, I shall limit my remarks to a ballot of the staff.

    I shall first make a general comment about the context of Christie hospital. It is in South Manchester health authority. In Committee, the Secretary of State for Health, on one of his rare appearances in the Committee, said that he was fed up hearing about the problems of South Manchester health authority. He is going to hear a bit more about them today.

    The chaos of financial crisis in south Manchester continues. It has come to such a point that not only has the chair of the health authority resigned and will not be reappointed from 1 April, but the general manager leaves tomorrow. Three months of consultations have just been completed on a document containing plain supposedly to rationalise services between Withington and Wythenshawe hospitals, has been rewritten and a new document was to be presented to a health authority meeting this Thursday. At 11.30 pm yesterday I learned that that meeting has been cancelled and no meeting to discuss the consultation document will be held before the chairman of the health authority and the general manager leave. Therefore, the financial crisis and chaos in south Manchester continue. We must consider the proposals for Christie to opt out in that overall context.

    It has been clear from the start that any expression of interest by the consultants and staff at Christie hospital to opt out of South Manchester health authority control has been based exclusively on the lack of resources within South Manchester to provide the amount of care that the hospital wants to give. There was an Adjournment debate on that very subject in 1986. If those resources had been made available to Christie hospital, recognising it from that point as a centre of excellence, there would have been no expression of interest in opting out. It is the last resort to gain some extra resources; a cynical attempt to grab what money may be available to prop up a failing service.

    Even that expression of interest was not unanimous. A ballot was held among the consultants and, by only a narrow majority, they decided to express an interest. However, it was made quite clear that that was only so that they could receive more information about opting out. There was a clear understanding that no decision had been taken about opting out, that the information from the Department would be studied, and a decision then made.

    However, based on that expression of interest, the whole bandwagon got under way at the hospital. The general manager, Mr. Fry, wanted to push ahead as fast as possible and to retain the hospital's position on the short list for being one of the first to opt out. He was egged on by a few consultants, and the whole process moved on.

    Hon. Members have already mentioned the amount of work done in hospitals even before the Bill has completed its stages. Already a draft document is ready to be presented to the Secretary of State. A great deal of management time and expenditure went into that which should have been spent on health care for South Manchester. It is a scandal and the Secretary of State should be here to try to defend that.

    What is the process of consultation to discover whether that vague expression of interest has any validity among the staff of the hospital? The Labour party has been accused of trying to influence public opinion on opting out by putting out misleading information. What did the management of south Manchester do? It regularly produces a good-news newspaper for the health authority called "Health Call". That is distributed to all the people in South Manchester. Throughout the financial crisis in South Manchester, when wards and even whole units have been closed and waiting lists have grown, with consultants saying that people are dying because they cannot be admitted to hospital, did the newspaper mention those facts? Not a word—it is all good news. It contains articles such as
    "Why Christie's may opt for self-government"
    with a nice picture of a smiling general manager exploding the so-called myths of what is happening.

    Follow-up propaganda—a nice, glossy magazine—was also produced at the health authority's expense to explain why the hospital should opt out. It is probably only a coincidence that it is on blue-headed paper. It gives the management's position and then devotes a whole page to
    "Some myths associated with self-governing status."
    The general manager, in his unbiased presentation of information for the staff on how to reach a decision, quotes the supposed myth:
    "When health authorities or GP budget holders run low on funds, patients will be denied treatment."
    He then asserts:
    "Not true. The Department of Health has stated many times that … no patient will be denied treatment solely on the grounds of lack of cash."
    However, when we tabled an amendment in Committee to ensure that no patient would be denied treatment because of lack of funds, the Government refused to support it and voted it down. Therefore, the "not true" assertion of the general manager of Christie hospital has exploded in his face. It is party-political propaganda to try to kid the staff that it will be in their best interests to opt for self-governing status. That flies in the face of the Government trying to accuse the Labour party of undertaking such propaganda exercises.

    9.45 am

    What is the process that Christie will undertake? The whole basis of the expression of interest has been on that one vote among the consultants. They have continued down the path. Now there is to be a series of consultative meetings with staff in the hospital. When the general manager was asked to have another ballot to see whether the expression of interest had been firmed up, he said that it was not possible to have a ballot because he could not identify which population should be balloted. When it was accepted that the ballot should take place only for staff in the hospital, he wondered whether all the staff should take part, or whether part-time staff should be allowed only half a vote. He refused a ballot and said that he would arrive at a consensus which would emerge from the consultative meetings. When he was asked how it would emerge, he replied that he would gauge the mood of the staff meetings.

    The position is reflected in a copy of a letter that I received from a consultant who is happy to be named. Mr. Martin Harris wrote to the general manager:
    "I have read the Draft Application for Self-Governing status for the Christie Hospital, and I do not believe that it sets out a convincing case that the Hospital is likely to be financially viable as a Trust. Furthermore, I feel that the application is misleading in a number of ways".
    He identifies why it is misleading. In the light of the new clause I shall read just the first one:
    "I object to the implication made at several points that the Application has the support of staff in the hospital. Perhaps it does, but this has not been ascertained by a ballot."
    He wanted a ballot and he thought that the votes cast for and against should be identified in the application. The general manager has said that a consensus of support is emerging. Mr. Harris carried out a ballot of his staff and the consultants in pathology and medical oncology. Every consultant was against the proposal, as well as 15 out of 27 staff; 60 per cent. were against the proposal.

    Here we have a general manager expressing a view based on no new information from the Department of Health. He has refused a ballot and said that he can gauge the consensus. Yet the evidence is clear that if there were a ballot, the majority would vote against the proposal.

    As my hon. Friend the Member for Livingston (Mr. Cook) said, we will not allow the management of hospitals to opt out without a ballot. We will ensure that the staff in Christie hospital have the right to ballot. We will ensure that that is included in any further document and that the people of South Manchester, who care passionately about the future of the hospital, understand that the Government are ignoring the wishes of the staff and of the general public, and are ploughing ahead. That is democracy to the Tory party. We will ensure that democracy is seen to be done.

    The hon. Member for Harlow (Mr. Hayes), who is back in his place, raised a point of order earlier. He drew the attention of the House to the presence of some men in white coats. My hon. Friend the Member for Livingston (Mr. Cook) is still here. Until a few seconds ago, the hon. Member for Harlow was missing. I cannot see the Secretary of State. I wonder whether that was the reason for the presence of the men in white coats.

    The Secretary of State owes an explanation to the House. Having criticised my hon. Friend the Member for Livingston, who had been present for much longer than he had been, he said that he would listen to contributions from Back-Bench Members. So far as I could see, he did not listen to any. But that is par for the course for him.

    New clause 4 is clear, logical and reasonable. I believe that it invites the support of the House and I have no doubt that it has the support of public opinion. The new clause is headed "consultation" and it deals with the essential principle that the Government have adopted of opting out and the formation of NHS trusts. If we still claim to be a democracy, it must be reasonable that patients, workers in the Health Service and communities should have a say in the Health Service in their areas.

    I was disappointed that the hon. Member for Southwark and Bermondsey (Mr. Hughes) saw a difference between those who work in the NHS and the patients. I do not believe that the patients see it that way. They accept that they owe a great debt to NHS workers and they would respect the views of the people who maintain the Health Service, of which we have been proud and of which we will be proud under the next Labour Government.

    The Secretary of State opposes the principle in the new, clause. However, as we saw in Committee, he does not oppose it on the basis of logic or by embracing democracy. He does not oppose it because he thinks that it will not improve the Health Service or because the Government are being consistent—and we must remember that we are talking about a Government who imposed ballots on the trade unions, and introduced the same principle to education and housing, but who have now decided that the principle is not practical for health because they know that in every test of public opinion the Government's view would not prevail. The reason for the Government's stand on this clause, as on others, is that we face nothing but dogma, and that dogma is utterly repugnant to the British people.

    My hon. Friend the Member for Livingston and my other hon. Friends who have contributed to the debate, including my hon. Friend the Member for Preston (Mrs. Wise) who referred to the view of the Select Committee on Social Services, have made an unanswerable case. The case is so unanswerable that I will conclude by asking the House to take the only reasonable view, which is to support the new clause. If the Government still resist it, I invite the House to divide on it.

    I will endeavour to answer some of the questions that have been raised and if other hon. Members—

    On a point of order, Madam Deputy Speaker—and I am not being unreasonable in raising this point of order.

    I understood that my hon. Friend the Member for Monklands, West (Mr. Clarke) rose to ensure that a closure would not preclude a speech being made by a Scottish Member on this important matter. If the Minister is taking this opportunity to reply, can we presume that we will not be excluded from the debate? My hon. Friend the Member for Monklands, West was protecting himself—

    Order. That is a very convoluted point of order. Thee hon. Member for Monklands, West (Mr. Clarke) rose and it was my duty to call him as he speaks for the Opposition.

    Obviously if the hon. Member for Monklands, West (Mr. Clarke) tries to intervene, I will try to answer any questions that that he may ask.

    The hon. Member for Monklands, West made the main point of his attack the fact that we were approaching the establishment of NHS trusts as a matter of dogma. I cannot agree with that. I believe that there is sound common sense behind our proposals, because we are not taking anything away from the NHS. We are not taking anything away from the people of Manchester, Withington, of Birmingham, Hodge Hill or of Bradford, West.

    Through the delegation of greater responsibility to hospitals, mental health services, ambulance services and districtwide services—there are many different types and models of NHS trusts—I hope that we shall restore more local pride and responsibility in the management of the NHS. I am somewhat surprised at the hon. Gentleman's comment and disagree with him that we are approaching the issue as a matter of blind dogma. I honestly believe that it is sound common sense and later this year when the House sees initiative covers a relatively modest number of hospitals and other units, hon. Members will recognise that it is a sound and sensible initiative——

    I apologise for interrupting the Minister so early in his speech, but he said that a relatively small number of hospitals and units were involved. The South-West regional health authority contains 11 district health authorities. Currently his Department is planning for eight of those DHAs to be removed to trust in their entirety. That is not modest; that is not a small number; it is almost all the NHS provision in the South-West region in its current form.

    I do not believe that the hon. Lady has got her statistics right for two reasons——

    First, we listed 79 potential NHS trusts several months ago, ranging across the board from services within an entire district, to an acute hospital, to an ambulance service and a mental health unit. There were many different examples. I hope that I have made it clear to the hon. Lady that when my right hon. and learned Friend the Secretary of State launches the initiative once the Bill becomes law, we shall be dealing with a relatively modest number. There are 260 major acute hospitals in England of which a relatively modest number will join the initiative.

    The main thrust of the earlier remarks of the hon. Member for Bradford, West (Mr. Madden) was that he questioned the validity or the constitutional propriety of such preparatory work. I do not think that he used the word "illegal". He knows that this matter has recently been tested in the courts and that a clear judgment was reached, ruling that the preparatory work undertaken so far was legal. I assure him—as did my right hon. and learned Friend—that no definitive steps will be taken until Parliament has given the Department of Health the necessary authority. The preparatory work is prudent and modest. Whatever Government were in power and planning any change in the NHS, for whatever reason, I believe that they would have sought to take such steps.

    The hon. Member for Birmingham, Hodge Hill (Mr. Davis) said that the public would not be consulted. I think that that fairly reflects the hon. Gentleman's concluding remarks. I am sure that he did not mean that we would not go through the regular consultation procedure involving the community health councils when the Bill is enacted. Through the community health councils of those districts where NHS trusts are recognised as potential candidates, there will be a process of proper consultation lasting several months which will involve the community health councils offering their opinion, ascertaining the views of the public through media advertisements and doubtless through the canvassing of the hospital staff, both medical and non-medical. All those views will be sought and, I am sure, expressed. We are not proposing in any way to change the existing procedure by which the community health councils can express their opinions on what will be a significant change of a delegation of authority within their districts.

    We believe strongly that a formal ballot is unnecessary because we are talking about the delegation of authority. We are not taking anything away; we are not removing a hospital from the Health Service. The units will remain within the service. We are delegating authority and therefore we believe that a ballot is unnecessary.

    We are delegating——

    In all the consultations that have been guaranteed and taken place in the past, whether involving a hospital or ward closure, the overwhelming evidence from the public, staff and patients has suggested that the place should stay open. Yet after that consultation, the opposite has happened. The results of the consultation have been completely ignored. Therefore, there is frustration. It is fine to have the consultation, but unless the powers-that-be take notice of it and act upon it, it is a complete waste of time. A ballot shows the number of people who believe that such a place should stay open or should not opt out. The evidence is public and should be recognised. Consultation is a con. If we could have some sort of ballot, action could be taken.

    It is not fair to say that the community health council consultation procedure—certainly in my experience—has been a con or a sham. It is statistically true that few hospital or ward closure decisions, perhaps as part of rationalisation, are reversed or stopped in their tracks. But the nature of the changes is often altered as a result of representations from the CHC. The qualifications placed on what may happen may be changed.

    10 am

    I have listened carefully to the Minister. He may recall the occasion not long ago when people from the St. Helens area came to see him about the geriatric units there. Everyone, from the community health councils to doctors and everyone else involved agreed that they should not close. The Minister listened to the area health authority and ignored the populace at large. What guarantee is there in what he says?

    When decisions do not go in the general or specific direction that hon. Members and their delegations want, they believe that the Minister has listened to the health authority. Any Minister from any Government has to listen to the facts of the case. He has to operate within certain guidelines. The guidelines are the resources available to the region and the district. The consultation procedure is not a sham.

    A balloting system—[Interruption.] I keep my remarks brief, logical and to the point. A balloting procedure is unnecessary because responsibility is being delegated.

    We are delegating responsibility for hiring staff, except junior doctors. We must maintain control over the pyramid career structure for all doctors. We must control the number of junior doctors. We want to give NHS trusts the power to hire staff in the numbers and range of qualifications that they need and to pay them the right rate for the job in the local circumstances. That does not mean——

    Certainly I shall give way, but I wish to finish my sentence first. It does not mean that NHS trusts will be able to pay the limit and therefore bid staff away from directly managed units for the simple reason that money is not being printed. NHS trusts will have to win, through contracts, sufficient revenue to balance their books. They will be subject to the same constraints as directly managed hospitals.

    Will the Minister clarify two points? I do not know whether he was in for all the Secretary of State's speech. The Secretary of State said that some unions might be under-represented in the new trust hospitals. If so, will unions be recognised? Secondly, did I understand from the Minister's latter remark that, far from paying the going rate, trusts might pay a lower rate? If so, how will they retain staff?

    I was here for the great majority of the Secretary of State's speech although, like many other hon. Members, I sought a brief rest during the night. I heard most of his remarks. He said that there would be no automatic guarantees of union representation in NHS trusts. That would be a matter for the trust. He answered that point fairly and squarely.

    The NHS trusts must ensure that they provide a range of services through the contracts that they have won. They must pitch their labour rates for clerical staff and support staff in the hospital at the right level to attract the right number of staff of the right quality.

    Mr. Freeman