Wednesday 7 March 2007
[Mr. Martyn Jones in the Chair]
Democratic Republic of the Congo
Motion made, and Question proposed, That the sitting be now adjourned.—[Tony Cunningham.]
I thank Mr. Speaker for granting this debate on UK Government assistance to the post-election Democratic Republic of the Congo. It is now more than three months since Joseph Kabila was sworn in as the first democratically elected President of the country since Congolese independence. Those elections have been described by some as the most important in Africa since the election of Nelson Mandela.
The registration of 25 million voters and the smooth running of a national election in a country that has only 300 miles of paved roads but is nearly the size of western Europe, was a major achievement. Those of us who were privileged to act as election monitors can testify to the basic fairness of the process. The verdict of the international and national observers on the presidential and national elections was that there were some hiccups, but that the process was basically fair, although there have been some questions since on how some of the provincial governorships have worked their way through.
I salute the bravery, maturity and determination of the Congolese people, who have suffered so much and who we saw behave with the most extraordinary dignity in those elections. They would walk miles and miles to the polling stations to cast their votes and queue overnight to play their part in the process. Now, of course, they are filled with expectations for the future, which we cannot afford to betray.
I am also proud of our Government’s role in recognising the vital strategic importance of the DRC by moving to become the largest European bilateral donor and by giving major support to the elections. I am proud of the personal commitment to the country shown by our Secretary of State for International Development.
The DRC is in the heart of Africa and is emerging from a civil war that has been called Africa’s world war, involving six neighbouring countries and leaving 4 million dead from conflict, disease and starvation, and more than 3 million people displaced. Rebel groups from other countries have rampaged over its land and continue to do so; members of the Lord’s Resistance Army have been camping out there. That has been a continuing problem.
All that follows a century and more of the exploitation and plundering of the DRC’s resources and longer still of its people being taken into slavery overseas, a fact that I am sure will be highlighted this year as we celebrate the ending of slavery, although it has continued in a modern form. The DRC is rich in resources. It has huge potential, but also huge difficulties. It is astonishing that it has not been given more prominence in our national and foreign affairs debates. If we could bring stability and development to the DRC, the effect on the rest of Africa and international security would be immense.
Like other hon. Members who visited the DRC for the elections or to look at the problem of street children or more general issues of international development, I have been profoundly affected and moved by the experience. I hope that the debate gives us the chance to focus on the future of the Congo and its people, and on the role of our Government and the international community.
As Mr. Speaker knows well, I have been seeking this debate ever since the elections; I put in for it on a number of occasions and have only just managed to secure it. I have three main reasons for raising the subject. First, the DRC has emerged from the peace process, the transitional Government and the elections, as a country that remains politically fragile and very volatile. It could hardly be otherwise, given its history. Between the two rounds of elections and since, we have seen sporadic violence break out, and the country could always disintegrate into violence again. I have been concerned about the recent violence in Bas-Congo and how it was brutally dealt with, and about the disturbances that continue in the east of the country. It is a very fragile country. Of all times, now is when it most needs support. The international community cannot afford to let its focus on the Democratic Republic of the Congo slip.
We need to reassert the statement made in June last year by the Secretary of State in evidence to the Select Committee on International Development’s inquiry on post-conflict reconstruction. He said clearly that we are in the DRC for the long term. We need to reassert that. The DRC has not been afforded the priority that it should have been in our public debates, although we have recently done better in raising questions in Parliament. However, we need to reassert that serious commitment and to maintain it in the long term.
As the International Crisis Group sets out graphically, there is no point in going somewhere and feeling that we have done our job because the election has happened. The danger time is during the next couple of years. During the election, the focus was on all the work going on around it. In the following period, it will be very easy to fall back into the conflict that we seek to avoid if people feel that nothing has been achieved.
The Secretary of State put the problem well in his evidence to the Select Committee, when he said:
“If this goes wrong again in the DRC, then the knock-on consequence for the whole of the Great Lakes region really does not bear thinking about. Given the scale of the loss of life there has been because of violence and disease, a very good question is why did not more people do more about it earlier.”
I would like to hear it reasserted—I know that the Secretary of State has made this assertion already—that our Government are committed to keeping their eye on the ball and being in the DRC for the long term, and that we will not be diverted by the next most high-profile issue in the news, important though things in other parts of the world and the continent are. My most important point is to reassert our country’s commitment and our involvement in trying to engage other countries in their commitment to the DRC.
My second reason for raising the debate is that we have to commit ourselves to helping and supporting the DRC on the hugely difficult issues that confront it. I would like to get a sense of where we are on some of those, although I cannot possibly cover them all. No doubt other hon. Members will want to raise other matters. There is a huge range of complex issues that we should assist and persuade the politicians of the DRC, civil society and others to tackle: governance and democracy; the role of civil society; corruption and what happens to revenues that are spirited away; natural resource extraction and the role of companies and mining contracts; development generally; the provision of basic services; and security. The agenda is massive. The Government have helped on some of those, but we have to keep our eye on the ball.
My third reason for being concerned is that I feel a very personal debt to Christian Aid, which sponsored my visit and that of my hon. Friend the Member for Islington, North (Jeremy Corbyn) and of Stephen Carter, the co-ordinator of our group. I am also indebted to the civil society organisations that hosted us.
On the banks of the Congo itself, we were read a wonderful declaration by the organisation Dynamique Interactive de la Société Civile du Bas-Congo et du Maniema. You may wonder how civil society in Bas-Congo and Maniema managed to come up with a wonderful joint declaration, given that they are several provinces apart. The declaration came out of the discussions that we had during the two rounds as monitors in those two provinces. The first round was in Bas-Congo, where Jean-Pierre Bemba’s support was strong, while the second was in Maniema, where Joseph Kabila’s support was strong. We felt able to speak with some authority about the fairness or otherwise of the elections and we saw what people were thinking in two contrasting parts of the country.
The declaration was developed, and I should like to pass it to the Secretary of State. It sets out a number of concerns. For example, it starts by describing the DRC as a “country belonging to others”—a good description. It talks about how, given the history—the explorations of Stanley and Livingstone, the colonisation, the dictatorship, the moving into the form of a UN protectorate and how the country had been plundered by others—it would be difficult to claim that the country had ever belonged to Congolese citizens. The organisation is concerned that that should not be the case in future, when the country should belong to its citizens. However, it also pointed out ways in which the British Government had made a great contribution, and it gave a plea for continuing attention to the various issues that it raised, including the development of civil society as an essential part of the democratic process.
I warmly congratulate the hon. Lady on securing the debate. She mentioned the challenge of good governance, an important part of which is accepting responsibility for protecting human rights. Recently Marie-Thérèse Nlandu, a former presidential candidate with close links to Jean-Pierre Bemba, was arrested in circumstances that many would regard as highly dubious, to put it mildly. Does she agree that it is important that when we talk about being “in there” we should be in there not only financially but morally, and that it is important to encourage respect for good practice, which is to be a lynchpin of the effective governance of the country long into the future?
I agree absolutely, and I shall return to that. The prisoner in the case that the hon. Gentleman mentions has been adopted as an Amnesty prisoner of conscience and an early-day motion has been tabled by my hon. Friend the Member for Islington, North, which has been signed by a number of us. We certainly hope that the Government will take up her case. I do not want us to try to run the DRC as it has been run by foreigners and others over the centuries, but at the same time we have a huge responsibility to keep on the backs of the elected politicians and to try to make them behave in a way that enables the processes to go forward. If we are to invest a great deal in the DRC, as we do—it is expected that a substantial proportion of its revenue will continue to come from international donors—those politicians have a responsibility to adopt good governance and human rights. Our Government have an important role to play in that.
The declaration said that
“democratisation is a long process in which elections represent only a single step”,
and that is absolutely right. The declaration is wonderful. It was read out in ringing French, and it does not read nearly so well when it is translated into English; the whole thing was rather magnificent. One of the speakers said that
“derailing the process of democratisation is untenable, it could disintegrate in to a situation where the country is ungovernable. It could be catastrophic.”
A number of issues were raised, from resource extraction to how food is dumped on the DRC, the international trade rules and what has happened to the agricultural industry, as well as a number of other issues that the group wanted us to promote. That was an important reason why I wanted the debate to promote the subject.
My first question concerns the Government’s commitment to the DRC and my wish to ensure that we reassert the commitment to working in the Congo and with other countries around us. To illustrate some of the difficult issues, I want to talk about one of the most moving parts of our work. I talked about the Congo, that mighty river that has woven its way through the tragic history of the country. We are told that it could provide electricity for the electrification and industrialisation of the whole of Africa and also export some through a southern Mediterranean connector to southern Europe. We do not know what that will do for development and the environment of the Congo, but we do know that a large part of the population does not have access to safe drinking water or electricity. Those are the sort of contradictions that we face.
Does my hon. Friend recall when we stood with others in a small village in Bas-Congo that had no electricity and no water, and the only thing that we could see were huge pylons above us taking electricity over the villages? Nobody could afford to connect to that supply; it is simply a crazy situation.
I remember that. I remember, too, that in the last polling station that I visited in Maniema, my most useful job as a monitor was to hand over my torch to the people who were trying to count the votes. They had one lamp, which they could hardly read by. That is an illustration of the issues. It shows the contradiction in the fact that there is an amazing river, which could provide all that electricity, when the people do not have electricity or even safe water.
We decided to go over to the other side of the river, as other monitors would not be doing that, and to go right down to visit polling stations in Maniema. We perilously, and rather nervously, took the Christian Aid jeep across on two boats made from hollowed-out tree trunks tied together with bits of rope. I must admit that Stephen and I sat on the edge, watching the process and waiting for the jeep to fall in, before we got into the boats without it.
We successfully reached the other side, and we then went up the one road or track, calling at about 10 polling stations. On our way, we called on a Christian Aid project that revealed a number of the difficult issues that we need to tackle. We had to go on motorbikes on a track off the main road miles from anywhere to go and visit the project.
We arrived and were greeted rather beautifully by 40 women singing to us in Swahili. They pointed out to us that they were concerned about education, as it was difficult for their children even to get to school until they were old enough to be able to walk the distances. They had been displaced by one of the rebel groups, the Mai-Mai; their houses had been burnt out, and they had been subjected to the sexual conflict that so bedevils the Congo. A practical issue in trying to develop our commitment to education is dealing with the distances that the children would have to travel. They asked whether it would be possible to get somebody out to the project to educate them. Of the 40-odd women, only five had been to school. That was a practical difficulty in education.
We have made a welcome commitment to immunisation through the international finance programme for immunisation against the five killer diseases around the world. I am proud of that; it is a wonderful commitment. How easy does the Secretary of State think it would be to bring that programme into a country such as the DRC? Of every 1,000 live births, 205 die before the age of five. We asked whether anyone at the project knew of children who had died before the age of five, and they immediately said, “Oh, that woman’s child died two days ago.” That is common. According to UNICEF, more children die each year in the DRC than in the whole of China, which is 23 times bigger. That is a massive problem.
We went to one Department for International Development-supported Merlin hospital, which was unusual. I was amazed to find a child with meningitis who was clearly going to live. Children in my constituency have died from meningitis because they did not get to hospital in time, so that case was rather remarkable given the distances. It brings home how difficult it is to engage in such programmes. I would welcome hearing what we can do through our education and health programmes.
I am aware that another early-day motion has been tabled about the way in which resources go into conflict-afflicted zones. The statistics from Save the Children show that a smaller proportion of our resources go into non-conflict zones than into conflict zones. I understand that an international donor day on education is coming up, and I hope that we will express the importance of getting education into conflict zones and post-conflict zones, because that is difficult. The early-day motion supports Save the Children’s request that 50 per cent. of our international education resources should be put into conflict and post-conflict zones. Obviously, that is a difficult area, but I would appreciate some comments from the Secretary of State about our education programmes.
I realise that I have not thanked all the people whom I should have thanked. I thanked Christian Aid, and I should thank the other organisations that were involved with the various projects that we saw. Andy Sparkes, who is our ambassador, and Phil Marker, who is head of DFID in the DRC, were both extremely helpful to those of us who went out to the elections, and they have been helpful since—particularly when I have phoned the ambassador to ask what is going on in the DRC, when I have been asked to do radio programmes and have not wanted to land him in it by saying the wrong things about the situation. They have been helpful and play an important role. I also thank our support staff on the all-party group on the great lakes region and genocide prevention—Stephen Carter and Hazel Rogers—for all the assistance that they give us, without which we would not be able to do our work.
I wish to touch on three main issues before I hand over to other hon. Members, who, I am sure, will go into some of them in greater detail. The first issue is security sector reform. Without security, nothing else can happen. We know only too well that the security situation continues to be difficult. Integrating the forces and forming a national army that does not have a large presidential guard under the control of the President clearly is a major issue. It is generally agreed that some overall co-ordination of the international contribution is needed. It has been suggested that MONUC—the United Nations mission in the DRC—may be able to take on a short-term training role, but several observers have said that the overall co-ordinating role should be given to EUSEC, the European Union security sector reform mission in the DRC. I would appreciate comments from the Secretary of State on the matter.
I congratulate my hon. Friend on initiating this debate. I went to the DRC some four years ago. One of the key issues then was the command structure. MONUC has had some problems with sexual abuse by some of its forces, and it will function properly only if an appropriate command structure is in place. Obviously, that is a key requirement. We saw British officers there, and it would be good to hear from the Secretary of State what we intend to do to maintain our role. On that issue, could my hon. Friend say something about what she saw when she was in the DRC?
The matter needs to be taken up, and there is also an issue about not winding MONUC down too quickly. If there were views that we should move our resources elsewhere, it would be a real tragedy if the MONUC role were diminished before stability had been brought back to the country. There have been criticisms of MONUC’s behaviour, but we saw it giving political support. Uruguayans from MONUC turned up on MONUC transport with the printers that were needed for the compilation centre in Bas-Congo. The printers had failed to turn up from Kinshasa, but suddenly soldiers turned up bearing two. Without them, the election could not have proceeded.
MONUC has a valuable role, but further co-ordination of security reform is required, and it is also necessary to deal with all the children who were co-opted as child soldiers. They still have not been integrated back into society.
The second issue has already been referred to by the hon. Member for Buckingham (John Bercow). Good governance is critical. Prime Minister Gizenga has made several extremely positive statements about commitments to deal with security, to tackle corruption—he said that it would be a no-go area in the future—and to develop a positive programme for the country, but that will not work unless there is good governance.
Several concerns have been highlighted by organisations and by people who have visited us from the DRC or who are part of the Congolese diaspora in this country. When someone says that the election was not fair—that it was stolen from them—I think of what I heard the Secretary of State say: we all think that when we lose elections. I believe that the national election produced a fair result, although there are some doubts about the way in which provincial governorships seem to have gone so substantially to the ruling party.
There are also issues about proper opposition, which is essential. It seems that the Opposition are being kept out of posts in Parliament that one might expect them to be able to have. The danger is that if the Opposition are not allowed a proper role, they will be tempted to say, “This does not work. We will go back to our old ways. We will go back to conflict and get out the arms and soldiers again.” That is a serious issue, and we and other countries must play a major role in keeping the pressure on.
I would also like to know more about what we are doing about governance and education. I know that education work is going on in relation to the Parliament, and there may be a role for some members of the all-party group to go out there and do some work on that.
Rwanda now has the highest proportion of women in Parliament of any country in the world. That has also happened in some other post-conflict situations, but it has not happened in the DRC. That is a great shame, because if women are engaged, they are more likely to deal with the whole range of issues that need tackling.
The hon. Lady has been generous in giving way. She mentioned education. There is the sensitive but challenging matter of rampant allegations of child witchcraft—an issue that other hon. Members and I encountered when we were in the DRC. Does she agree that we must keep that within our sights and do what we can to try to demythologise the subject? However sincere the believers in child witchcraft are, sometimes the effect of their belief is to trample on the human rights and stability of the children in their care.
I agree. We heard from children and talked to pastors about tragic cases of children who had been accused of witchcraft. The subject has been dealt with by other hon. Members in the past.
I shall be brief, because I know that other people wish to speak, but I just want to make a few more points. Without the development of civil society organisations and their role in education, how will the people know that they have the right to call to account those whom they have elected? That is crucial, and I am concerned about any suggestion that resources to civil society might be diminished in a DFID restructuring. It is a subject of some concern, and it has been engaging some of the organisations in the DRC that have been asked to get involved. It would be a real tragedy if we were to cut back on that in any way.
Similarly—this may be a point that the Secretary of State would wish to hear—it would be a huge mistake if DFID staffing were to be cut because of financial pressures. In a fragile post-conflict situation, the best people are needed to deal with the issues, to give support, to assist in the process and to give the right advice to our Government and to other Governments.
My final question is whether we will ensure that there will be a post-CIAT mechanism for donor countries. CIAT is the committee in support of transition in the DRC. President Kabila may not like it—he would like to have the aid without the pressure—but even though we do not wish to interfere in how the country is run or carry on in an imperialist way, if we are putting in money, resources and assistance, we have a responsibility to ensure proper governance, and that requires some mechanism for donor countries to be able to work with the country, the institutions and civil society.
There are huge problems and difficulties but also huge potential. If we let this opportunity go by, the country will move back into a conflict that could engulf the whole of that part of Africa. It would not be good for our security, for Africa or for the people who we enjoyed meeting so much when we were in the DRC and who we seek to help in the future.
Thank you for calling me, Mr. Jones. I shall ensure that I finish on time so that my colleagues may also speak.
I start by congratulating my Friend the Member for Amber Valley (Judy Mallaber) on securing the debate. I know that she has tried very hard to get it for some weeks, so well done her. This proves that persistence has its reward. I echo everything that she said about all the people who supported the delegations of monitors and observers for the presidential election in the Congo, of whom I was one. I was sponsored by Christian Aid, and I give a big thank you to that organisation and all the other non-governmental organisations for the help and support that they gave during our visit. I also thank Stephen Carter of our all-party group.
I believe that I am the only Member who will contribute today who has a substantial Congolese community in his constituency. This is a long-standing community that goes back to the 1960s, following the death of Patrice Lumumba—some of his family came to live in the area. A great deal of support is given to the community on asylum and immigration matters, and social and pastoral support is provided by the local Catholic church, St. Mellitus. I pay tribute to those who are involved, and to Father David Ardagh-Walter for the support that he gives to the community.
I could say a great deal, but I want to be brief and ensure that we get points across for the Secretary of State to respond to. One needs to understand the sense of tragedy in the history of the Congo, going back to the times of colonial intervention, slave traders, Belgian rule under King Leopold and then under the Belgian Administration themselves, and finally the process of independence in 1960. It is salutary to recall that this week we celebrate 50 years of Ghana’s independence. Congo became independent slightly later, and although no African country has had an easy ride since gaining independence, the tragedy of the people of the Congo must stand in a league of its own. The number of deaths caused by civil conflict in the Congo has been astronomical, even by the standards of African wars of the last few years, during which several million people have died.
We should also recognise that during that period a great deal of mineral wealth was extracted from the Congo, from which a great deal of money was made by people all around the world. There is something deeply sad about the appalling lack of facilities for the people of the Congo, and enormous challenges lie ahead for the new Government. I pay tribute to the Secretary of State and the Government for the support that they have given the Congo, particularly with the electoral process and the building of institutions.
I shall concentrate first on the importance of supporting a democratic process and an accountable form of government in the Congo. The last genuine election was probably that of 1960. Since then, during the period of dictatorship, a series of rather strange referendums and other such things were held, followed by last year’s elections. However, an election results only in the election of individuals—either to state governorships, Parliament or the presidency. It is not the beginning and end of the political process. That process must be ongoing. That is why any support that can be given to civic education and civic rights for the entire population and to the development of the education system as a whole is so important.
I hope that the Secretary of State can help us in that respect by indicating the priority that the Government give to education as a whole, but particularly to the development of civic institutions and accountable forms of government. That, it seems to me, is the key to the future.
Enormous pressure must be applied to ensure total transparency in mineral dealings. Localised civil wars have been going on in the east of the Congo, which the trite reporting of some of the western media puts down as merely “tribal” conflict. In reality, they are wars by proxy, funded by mineral interests that make a great deal of money out of them. The tragedy that that has caused is simply appalling.
My second point has to be the development of education and public services. We have rightly signed up to the development goals, which we all support. We want all children to receive primary school education and a reduction in illiteracy in Africa as a whole, but particularly in the Congo.
Any dispassionate observer of the situation in the Congo would conclude that the rate of illiteracy is probably rising, not falling. The population is increasing fast and public education barely exists in most parts of the country. Teachers are not paid, so they have to charge their pupils or the families—if they can afford to pay. Church schools, insofar as they operate, do their best, but there are not many of them.
There is a large number of private schools, and parents spend as much as they can on securing an education for their children, but the quality of those schools varies enormously and what education those children receive is often limited. The priority must be the development of free primary education for all children in the Congo. That has to be the start. Otherwise, the waste of natural and human resources will remain massive.
Thirdly, the health care situation in the Congo is unquestionably bad. My Friend the Member for Amber Valley mentioned her visit to a hospital, but it is unusual for anyone in the Congo to get anywhere near a hospital. The death rate from wholly preventable conditions, such as malaria, and occasionally from cholera and other water-borne diseases is basically a product of poor standards of public health and poor sanitation. Clearing out the ditches around Kinshasa would save an awful lot of lives. It would be of enormous benefit and not be particularly costly. Such small-scale things are often very important.
Fourthly, I have tabled an early-day motion concerning the post-election situation of Marie-Thérèse Nlandu. It is important that the House recognise the importance of supporting an open, legal and democratic structure in the Congo. By any stretch of the imagination, her arrest and detention are extremely unfortunate. We should be supportive of her right to her day in court if charges are to be laid against her, but no one should condone arbitrary arrest and detention, which is effectively what has happened in her case. I hope that the Government feel able to support the points that my colleagues and I make in that motion.
My last point concerns the role of women in society in the Congo and the crucial part that they play in the development process. Last week, I had an interesting meeting with a delegation of Congolese women who came to the House of Commons. We spent an hour and a half discussing the situation in the Congo and they gave me a substantial memorandum. The advice and support that they gave were first rate and the memorandum is excellent; I shall pass a copy to the Secretary of State.
I know that the Secretary of State is very busy and under a lot of pressure, but I would be grateful if he was prepared to meet a delegation from that broad-based women’s coalition in the United Kingdom, many of whom have recently come from the Congo or have travelled there recently. They give enormous support to women’s organisations in the Congo. It would be extremely helpful if he met them, and he would probably benefit a great deal from such a meeting.
I shall refer briefly to a number of points included in the memorandum. First, it states:
“The United Nations office of gender affairs in the D.R.Congo claims that the role of women in the Congolese society has gone from full participation in the pre-colonial period, to marginalisation during the colonial period to a complete exclusion during the post-colonial period.”
The situation facing many women in the Congo is extremely serious. Rates of illiteracy are even higher among girls than among boys, and the physical abuse, domestic violence, sexual attacks and general discrimination against women in the Congo are also very serious.
I hope that the Government are prepared to do a number of things. First, I ask that they support the creation of a women’s commission office based in Kinshasa, which could give some focus to women’s rights and activities, as well as their role in civil society. Secondly, we need to work for the collection of accurate statistics on how women are denied, in many ways, participation in economic activity. I also ask the Government to support that monitoring work and, when possible, to support projects that will help with women’s education.
I support the point made by my Friend the Member for Amber Valley that we need to encourage the Government of the DRC to do far more to recognise women’s role and rights in society. For instance, there were many women candidates in the elections for the National Assembly and for other posts in the Congo, but only a small number were elected. Far more women are involved in Parliaments in Europe and in most other African countries than in the Parliament in the Congo. A great deal more needs to be achieved.
The Congo represents all the horrors of European colonialism that we meted out on Africa. The death rates, the poverty and the misery are ever present. The election has provided a watershed and an opportunity, but it is not the end of the story. Those wonderful natural resources need to be harnessed for the benefit of the people of the Congo, and the human resources of the Congo need to be liberated so that the development of the country and a high standard of living, which are eminently possible, can be achieved.
It has been enormously interesting and a pleasure to be a member of the all-party great lakes group and to have visited the Congo to observe the elections. It is up to us to do all that we can to support what ought to be a simple act of human solidarity with people who are up against it.
I thank my hon. Friend the Member for Amber Valley (Judy Mallaber) for securing the debate. I am co-chair of the all-party group on street children and managed to secure a debate soon after applying for it, so I congratulate her on her magnificent effort in securing this one. I want to put on the record my thanks to War Child, which enabled myself and the hon. Member for Gainsborough (Mr. Leigh) to visit the Democratic Republic of the Congo towards the end of last year.
I will concentrate on a couple of issues and pick up on what my hon. Friend said about security problems. An issue closely linked to security problems is the lacklustre disarmament, demobilisation and reintegration process. The programme appears to be winding down and so far it has had mixed results. CONADER—the Congolese body for the DDR—is renowned for widespread corruption. Its director of information says:
“disarmament was suspended at the end of 2006 due to lack of funds, and there are 150,000 people waiting to be demobilized”.
There is some dispute about whether that figure is in fact 30,000, but whatever it is, a significant number of people are still awaiting demobilisation.
There are concerns about the verification of disarmament and the quality of weapons that have been surrendered. There is an urgent need for improved vetting to prevent those guilty of serious abuses from joining the new army. Former fighters who opt for demobilisation often have difficulty supporting themselves even after reintegration programmes. One former fighter, Peter Ucan, told Amnesty:
“We are incapable of feeding our families and cannot even pay the rent. The solution is for these people to give us our weapons back.”
Frankly, frustrated as those people may be, the solution is not to give them their weapons back.
The programme has failed to deal adequately with the thousands of children in the armed forces. An estimated 11,000 are still to be demobilised, including thousands of under-age girls who are used as camp wives, servants and kept as virtual slaves. Little follow-up support has been given to those who have been demobilised into communities, which often reject them, and more funding is needed to ensure durable integration. Without a long-term commitment, the most vulnerable children can easily gravitate back to armed groups or crime. Will the Secretary of State for International Development say what plans our Government have to support the continuation of the DDR programme and the reform of CONADER? In addition, what plans are there to improve the reintegration of children and girls back into society?
The report of the all-party parliamentary group on street children said:
“It is vital that education reform and development for women is linked to livelihood support. In this respect, education must incorporate functional literacy, practical skills training and access to enterprise nurseries as a platform upon which women will empower themselves and secure the rights of their children. We strongly recommend, therefore, that the UK Government consults closely with civil society, especially local and international NGOs and churches, the Government of the DRC, other international partners and local business networks in the development of a national strategy that will support the establishment of micro-enterprise nurseries, training and practical income-generating initiatives for women—linked to access to education—across acutely vulnerable communities.”
That is vital, particularly for children. The report goes on to state:
“This will provide the architecture through which local and international NGOs as well as other development partners of DRC can invest resources in a focused, coherent and co-ordinated way.”
Anti-corruption and impunity must be matters of concern for all of us. The DRC urgently needs a specific, visible and proactive agency involving Government, the judiciary, civil society, the international community and, particularly, the media. Above all, such an agency should involve and be led by the community and the public, as the all-party group on street children recognised.
I will quickly mention some of the key points that I believe are relevant. One of the main causes of the suffering endured by former child soldiers and street children in the DRC is corruption. There is a contempt for children’s rights on the part of politicians, officials, the police and the military, and children are regularly subjected to extortion, beatings and worse. Round-ups of street children by officials are extremely violent. Our Government are committed to action on corruption, but they now need to ensure that the relevant institution is created and action is taken. They must give greater priority to tackling not only corruption, but impunity—particularly now that the DRC has a new Government. That should be at the top of the list for our Government and for the international community, and should go hand in hand with security sector reform and a widening of the democratic space. We cannot afford to leave that process until afterwards because, frankly, nothing can succeed without it.
Targeted sanctions need to be imposed against individuals and organisations that abuse the rights of marginalised children in the DRC. Some of those sanctions could include visa restrictions or the freezing of assets, including at European level.
Our Government have a valuable role to fulfil in the DRC and internationally. We should push for a clear strategy to be adopted at all levels and mobilise support for a cross-sectoral body, involving the state, civil society and the media. We can use our influence to secure funding, and I hope that the Secretary of State will do so.
I want to raise one or two issues in relation to vulnerable women and marginalised children. My hon. Friend the Member for Islington, North (Jeremy Corbyn) mentioned education. When the all-party group considered that, it recognised that a no-fee schooling system would not necessarily reach all children because they often look after younger children or even work to support their families. Adolescent street children are often perceived negatively by teachers and are excluded from school. They are sometimes not happy in schools that have much younger children. However, education is vital for such children and, combined with livelihood development, it is key to providing an escape from living on the street. In the DRC, education is also crucial to combating the belief in witchcraft, which the hon. Member for Buckingham (John Bercow) mentioned. Witchcraft is the source of much trouble for many children.
I round off by saying to the Secretary of State that in the DRC and internationally our Government can play a valuable role in raising some of the issues that I have mentioned. It is important to push for the development of a strategy that can be delivered in the DRC and we should raise that with the World Bank and other agencies, particularly those involved in the reform and development of education in the DRC. We should use our influence in the DRC and internationally to secure more funding, which is vital for future developments. We should also ensure that NGOs and marginalised groups, particularly children and women, are fully involved in the delivery and monitoring of the developments that we and the people of the DRC wish to see. I hope that he will take some of those issues on board and respond to them.
I congratulate my hon. Friend the Member for Amber Valley (Judy Mallaber) on securing the debate. I had the good fortune to travel with her in July to the DRC to observe the first round of the presidential election and the National Assembly elections. It is hard to overstate the importance of the DRC to Africa’s development. I think that, geographically, it is the second biggest country in Africa; it is certainly huge. It is situated at the heart of Africa, has a population of 60 million people and is strategically important: it is surrounded by eight other countries, and the conflict in the past decade in the DRC spilled over into many of them. Its neighbours’ borders stretch to the Red sea in the case of Sudan, to the Indian ocean in the case of Tanzania and to the Atlantic ocean in the case of Congo-Brazzaville and Angola—although, of course, the DRC has a very short Atlantic coastline all of its own.
The DRC is mineral rich, but it has virtually no infrastructure—no roads. It has poor schools, and few schools in rural areas. It has poor health services. It suffered 40 years of corrupt kleptocratic government and a decade of conflict, which, as my hon. Friend reminded us, cost 4 million lives.
The UK has been right to take the initiative of making the DRC a key partner for development assistance, despite the fact that we do not have historical links with the DRC. Despite Henry Morton Stanley’s exploration, we have not, as a colonial power, had the historical relationship with the DRC that we have with many other parts of Africa. Our Government are right to concentrate on peace building and the disarmament, demobilisation and reintegration of the former fighters from the conflict, because without peace there can be no progress on democracy or development.
The UK has invested heavily in supporting institutions necessary for effective governance. We have supported the transitional Parliament, for instance. When the Select Committee on International Development visited the DRC in May of last year, the speaker of the National Assembly, Monsieur Luhaka, paid a comprehensive tribute to the UK and thanked the UK for helping the transitional Assembly to draft a new constitution and to work effectively. That was a challenge, because none of its members had ever been in a Parliament or an elected institution in their lives—not that they were elected; they were appointed to the transitional assembly. The big difference and change that the elections brought was just that—people were elected.
The UK is a major donor, a major development assistance partner, for the DRC. The latest DFID statistics, which record bilateral aid for 2004, show that the DRC was our second largest recipient of aid in that year, mainly because of large debt write-offs by the UK. Last year, we contributed £63 million. Like my hon. Friend the Member for Amber Valley, I pay tribute to our ambassador to the DRC, Andy Sparkes, and to Phil Marker, the head of the DFID office there. We talk in London about the assistance that we give to countries that are on the path from dictatorship to democracy and going through the process of economic development, but the work on the ground is done by very small teams of Brits, who work often in very difficult circumstances—the ambassador showed me a bullet hole in the wall of his residence. The difference that those people make to the quality of life for people in the countries where they work is enormous, and we owe them a debt of thanks.
The elections were a huge logistical achievement. About $500 million in foreign aid went into organising them, registering voters—which was a major UK exercise and achievement—training election observers and so on, although the greatest congratulations should of course go to the Congolese people, who did not have a tradition of elections. The elections last year were the first multi-party elections that they had had for 40 years, yet they rose to the occasion. They knew what was required of them; they did it, and they successfully elected a president, National Assembly and regional government. That is a huge achievement, helped by aid from donor countries, but we must not rest on our laurels and allow the DRC to slide back into chaos and conflict, not only because that would be a huge waste of the money and resources that we have put in over recent years, but because it would condemn 60 million people to a life that, frankly, is hardly worth living and that we, as fellow human beings, should not tolerate.
The Congo’s future, however, does not depend on aid alone. Fundamentally, it depends on the leadership of the Congolese people and the contribution of the people themselves. Economically, it depends on the growing of a private sector. A viable economy in the Congo will never be created through aid, but if livelihoods are successfully to be provided for the ordinary people—the mass of the people, the poor of the Congo—business has to break with the traditions of the past. It must not be corrupt and must operate transparently. The extractive industries and the forestry industry have to operate in environmentally sensitive ways.
Does my hon. Friend agree that, as time passes and we see, I hope, a degree of economic development in the Congo in the coming years, it will remain very important to recognise the fact that about 70 per cent. of people living in the DRC depend in some way on the rain forest, that the land rights of those people must be respected and that the work of DFID and the round table on alternatives to logging, which has begun but has more work to do, is continued and stressed as the months and years pass?
My hon. Friend is absolutely right. That is why business, especially multinational business, must observe international standards when it becomes involved in the DRC, which it is increasingly doing because of the stability that the electoral process has created. I am thinking of standards such as those set by the Forest Stewardship Council. Newspapers report that more and more companies—for instance, Rio Tinto Zinc and Anglo American—are moving back or considering moving back into the DRC.
Today, at a breakfast meeting organised by the Royal African Society, Sir Mark Moody-Stuart posed the question: is it possible for a multinational company to thrive in a corrupt environment? I think that The Economist argues that it is, so long as the company itself does not engage in bribery and pays the taxes that are due, but Sir Mark said that it is not. He told us that corruption prevents businesses from operating efficiently, because it means that they are operating in an environment of poor infrastructure, low skills and unreliable services. He also said that, in a corrupt environment, companies will be blamed for the poor state of affairs, whether or not they contribute to it, and that is bad for their reputation. Finally, he said, very bluntly, “If you are a business leader and you bribe somebody, these days you can end up in prison,” and he cited the case of a senior western executive from an oil company who is serving a prison term.
I say to my right hon. Friend the Secretary of State, who is the co-ordinator of the Government’s anti-corruption programme, that we need carrots—such as the Forest Stewardship Council, the extractive industries transparency initiative and the Kimberley process—but we also need sticks. The Serious Fraud Office is investigating a number of cases of alleged transnational bribery by British companies or British citizens, and we need to start bringing those cases to court, as has been done for many years in the United States and as is done in France. Three years ago, the Government brought a draft anti-corruption Bill to Parliament—a new Bill needs to be brought back.
The Congo is at an important crossroads. Fragile democracy is more vulnerable than dictatorship or mature democracy to destabilisation through violent civil disorder. We need to give further attention to the electoral system and to support the new institutions, including the National Assembly. Aid is needed for the political parties, because a weak party system makes it much easier for the Government to divide the Opposition and marginalise Parliament. Jean-Pierre Bemba needs a real role as the leader of the Opposition. He lost the presidential election, but secured 42 per cent. of the vote, which entitles him to be seen as the elected leader of the Opposition.
I warmly congratulate the hon. Member for Amber Valley (Judy Mallaber) on securing such an important debate. The elections in 2006 were indeed a great step forward, but as everyone here has said, they were only a first step—the start, rather than the conclusion of a process—and they cannot, in themselves, achieve the social outcomes that are needed. The job now is to ensure that the positive momentum continues so that the democratic process and developmental change can take place in the DRC.
Time is short, so I shall concentrate on just two key issues, which other hon. Members have raised. Education lays the foundation for lasting peace and development by providing a whole generation with the skills that they need to build their country. Post-conflict, education offers people the skills that they need to rebuild their lives, but if it has been missing for years or for generations, as happened in some cases, the skills and capacity needed to establish civil society and economic prosperity simply will not be there.
At the last International Development Question Time, the hon. Member for Wakefield (Mary Creagh) asked what investment the Government are making in the DRC to ensure that every child has access to the education that they deserve, and I recently had a reply to a written question on the issue. However, the answers to those questions were vague and suggested that there was no direct bilateral aid for 2005-06. Although the Government have undoubtedly given the DRC a great deal through other forms of aid, it is hard to understand what portion of the aid used by multilaterals or for budget support goes on projects to support children in education.
Save the Children and others have reported that the primary victims of the years of civil war are the children of the DRC. Recent figures revealed that more than 5 million children of primary school age are out of school, and the number of children in the DRC who are out of school is among the highest in the world. Given that the country is so fragile post-conflict, there is an ideal opportunity to introduce an initiative to demonstrate a commitment to children in post-conflict states. The Government are committed to education in the developing world, and I congratulate them on that, but less aid goes to conflict-affected and post-conflict states. We could use the issue to provide a shining example of the difference that such investment may make, as the DRC stabilises and, I hope, moves into a proper, democratic and stable environment in the years to come.
The other issue that I wish to address is the country’s wealth and natural resources. The DRC is blessed with huge potential wealth and vast natural resources, but as hon. Members have said, the need to reduce corruption is paramount if people are to have real confidence in the institutions that exist to serve them. In the recent war, fighting was fuelled by the country’s vast mineral wealth, and post-conflict a continuing cause of problems remains the desire of countries and groups to get their hands on the country’s rich natural resources—diamonds, gold, other rare metals and, in particular, coltan, which is used in mobile phones.
The challenge for the country’s Government is to ensure that those natural resources bring real benefits to all the people of the DRC, not simply to those who are corrupt. I would be grateful, therefore, if the Secretary of State outlined what the British Government are doing to address the illegal exploitation of natural resources in the country. Have they considered the link between exploitation and the continuation of the conflict?
The United Nations report issued in April 2001 noted that foreign armies were used in the conflict as an excuse to continue exploiting resources. It concluded that the illegal exploitation of mineral and forest resources was taking place “at an alarming rate”. In 2003, my hon. Friend the Member for North Norfolk (Norman Lamb) posed several questions on the issue to the Government. I shall pose his questions again, because I would like to know how much progress has been made.
My hon. Friend stated:
“For future action, the UN report recommends, among other things, travel bans on individuals identified in the report.”
How far has that gone? He continued:
“It also recommends freezing their assets and imposing banking restrictions.”
What progress has been made on that in the DRC? He went on:
“Given the extensive business connections with this country”—
“that is an important question, and the Government must deal with that. What action are the Government taking to follow those recommendations about individuals closely connected to the UK, and what is the time scale for that action?
How do the Government respond overall to the report’s recommendations, specifically in considering how the actions of the countries involved in the conflict in the Congo will affect future grants of development assistance? Will those grants be conditional upon proper conduct regarding the DRC? On 13 November 2002, the chairman of the panel of experts, Ambassador Kassem, recommended a five to six-month grace period to allow individuals and companies to change their working practices. What is the Government’s assessment of the position three or four months on from that recommendation?”—[Official Report, Westminster Hall, 5 March 2003; Vol. 400, c. 287WH.]
It is now years since those recommendations were made in the UN report, and I would be grateful if the Secretary of State said whether the Government have taken any steps to implement them.
Recently, thanks to the film “Blood Diamond”, we have all become more aware of the Kimberley process. Are there any plans to extend that process to other extractive industries?
To reiterate, I have highlighted those areas of concern because both are vital to the DRC’s long-term prospects. Often, the long-term vision on aid and development is swept aside by pressing short-term needs. Ironically, however, those short-term needs will never be met unless long-term strategies on issues such as education and tackling corruption are implemented.
I join others in congratulating the hon. Member for Amber Valley (Judy Mallaber) on securing the debate and on her determination. Her remarks were excellent; she covered a big issue and summarised it extremely well.
The hon. Lady was right to highlight the part played by the Congolese people, as well as their determination, and right to link that to their aspirations and hopes for the future, particularly in the context of their country’s appalling past. She was also right to raise the dangers of regression and the fragile nature of democracy in the DRC and to highlight the fact that those involved have taken only the first, important step towards rebuilding the country. Furthermore, she was correct to mention the importance of the UK’s continuing commitment to assisting with the immense and numerous challenges that the DRC faces. She summarised many of those challenges in a particularly articulate way.
MONUC—United Nations Mission in the Democratic Republic of the Congo—also needs to be congratulated on its impact in creating the atmosphere that enabled the first elections for 40 years to take place, because it played a major role in achieving stability. It would be helpful if the Secretary of State stated the UK position on the future of MONUC. There is pressure, particularly from the United States, to wind down the MONUC force, but it still has a significant role to play, especially as there are still significant forces from other countries—in particular, Rwanda and Uganda—on Congolese soil, as well as people in displaced persons camps who require disarming and repatriation. MONUC also has a significant role to play in reforming the Congolese armed forces.
The two main presidential candidates should be congratulated. There were difficulties, but to a great extent they managed to control and limit the violence that took place during the electoral process and that has taken place since. Despite the enormous challenges and issues faced by the country, the elected Government have made some limited progress and taken some steps, including moving to liberalise the economy, freeing up the currency, lifting foreign exchange restrictions and increasing Government revenues. The Government have been successful, for example, in controlling inflation. They have also signed up to the extractive industries transparency initiative and the Kimberley process with a view to overseeing control—far better control than in the past—of the critical mining and diamond industries.
The scale of the challenges is enormous and it is worth mentioning one or two stark statistics: 80 per cent. of the population live on less than 30 cents a day; 80 per cent. have no access to safe water; 70 per cent. have no access to any form of health care. Those are enormous challenges, not just for the new Government of the DRC, but for the country’s political make-up and for the international donor community. The UK, and DFID in particular, have made a significant contribution to the electoral success in the DRC and the progress made on trying to reconstruct the country.
I want to focus on two or three issues to try to extract from the Secretary of State the UK Government’s current position. The first is security sector reform, without which it will be very difficult for the democratically elected Government to make significant progress. The army needs to be apolitical and to draw recruits from all ethnic groups. That should be a priority for President Kabila. Unfortunately, there are signs that things seem to be moving in the other direction and 80 per cent. of the human rights abuses against civilians are committed by the DRC army. That is particularly a result of irregular army pay and poor living conditions, which often make it impossible to survive without extracting additional income. That is often expropriated from local people, and the situation urgently needs to be addressed.
Funding for the security forces also needs to be tackled. It has recently been estimated that up to half the army payroll is embezzled in corruption. President Kabila retains a presidential guard of between 10,000 and 15,000, which is significantly better paid than other army units and ethnically based. Reform is needed to create an ethnic balance and financial parity, which would reduce distrust and division in the DRC.
Many informed commentators, including the International Institute for Conflict Prevention and Resolution, have suggested that the only way to tackle the problem effectively is to allocate one donor or international institution to take overall control and responsibility for the reform. What discussions have the Secretary of State or his officials had to try to progress that idea?
The hon. Member for Dumfries and Galloway (Mr. Brown) rightly highlighted the issue of child soldiers, which remains a significant problem, and mentioned the figure of 11,000. Very little progress has been made by CONADER, the body charged with reintegrating child soldiers. I reiterate the hon. Gentleman’s question about what changes the Secretary of State and the Department are making to CONADER, what reforms are being put in place and how quickly the reintegration can happen to ensure not just that the children are reintegrated in civil society, but that that is done sustainably, so that they can maintain livelihoods for themselves and their future families.
Sadly, like much of sub-Saharan Africa, the DRC is significantly adrift from the millennium development goals. I gave some statistics earlier, but there are terrible health problems, including 1 million people infected with HIV. The hon. Member for Islington, North (Jeremy Corbyn) rightly highlighted the prevalence of malaria, which accounts for 45 per cent. of deaths among children. The DRC has the highest child mortality rate in the world.
What work is the Secretary of State doing with other donor parties, both bilaterally and multilaterally, to ensure that there is significant harmonisation with the newly elected Government to get the maximum and fastest possible impact for the benefit of the people of the DRC? I think I am right in saying that there is no DFID country assistance plan for the DRC. Perhaps the Secretary of State will say whether one is being written and, if it is, when it will be finished. It is essential that the people of the DRC who went out of their way to participate in the democratic elections—the first for 40 years—should see some benefit from those elections as fast as possible. Quick impact projects are therefore important.
The hon. Member for City of York (Hugh Bayley) was right to highlight the importance of the private sector and the development of a sustainable economy. That will provide jobs and create the wealth needed to generate revenue for the Exchequer of the DRC, enabling it to become less dependent on aid and donations from the international community. That, of course, depends absolutely on the lessening—and, I hope, the eradication—of corruption, which, sadly, is deeply entrenched at every level of society. It has been estimated that up to 80 per cent. of the customs revenue was embezzled. A quarter of the national budget was not accounted for and millions of dollars were misappropriated in the army. An important part of resolving that problem is the creation of accountability and transparency, and ensuring that the judiciary is independent, with the resources to allow it to investigate significant allegations.
As to natural resource extraction, the hon. Member for Islington, North rightly highlighted the importance of transparency of contracts, and the hon. Member for City of York was also right to point out the growing and renewed interest from the national and international mining corporations. Transparency is obviously needed in that context so that the revenue raised by the export of those raw materials benefits the Congolese people in a way that is accountable.
However, in addition to accepting the importance of those issues, the Secretary of State should encourage other types of business—not just the export of raw materials. Infrastructure is very limited in the DRC and needs to grow significantly. Assistance is needed for the building of structures to ensure that revenue is generated. I know that there is very limited road infrastructure, but electrification of rural areas is needed, as is, where that is not possible, the installation of new technology such as solar-powered systems that will enable communities to avoid dependence on national grid structures.
There has been significant concern from some NGOs that DFID may reduce its support for civil society after the elections. I hope that the Secretary of State will confirm that that is not the case.
The elections were a significant step forward in the DRC’s history. The DRC has potential not just because of its natural resources, but because of the dynamic nature of its people and their aspirations for the future—given a chance. There is an enormous agenda to be discussed, including issues that we have not had a chance to talk about today, such as the President’s decentralisation agenda, legal reform and state reconstruction, the role of the United Nations Peacebuilding Commission and the possible establishment of a country-specific committee. Also, regional, pan-African and international trade are important ways to promote economic growth in the DRC.
Britain must play its role in encouraging political and economic stability, as well as the all-important rule of law, to encourage inward direct investment alongside an ongoing commitment, via DFID, to the DRC. We shall support that.
I congratulate my hon. Friend the Member for Amber Valley (Judy Mallaber) on securing the debate, and I congratulate her and other hon. Members on their interest in the Congo. I pay tribute to the all-party groups on the great lakes region and genocide prevention and on street children.
Fifteen or 20 years ago, the House of Commons probably would not have had a debate on the Congo. Britain certainly did not have a development programme there then. Those changes are testament to the fact that people have begun to understand the scale of the disaster that has affected that country, as well as its need for support and the importance of providing that support.
We heard from my hon. Friends the Members for Islington, North (Jeremy Corbyn), for Dumfries and Galloway (Mr. Brown) and for City of York (Hugh Bayley), and from the Opposition spokespeople, the hon. Members for Hornsey and Wood Green (Lynne Featherstone) and for Boston and Skegness (Mark Simmonds), that the challenges facing the Democratic Republic of the Congo are enormous—almost beyond belief. The country has been shattered by decades of misrule and two devastating wars, in which 4 million people died.
My hon. Friend the Member for Amber Valley asked for clear reassurance about the degree of our commitment and whether we are there for the long term. I am happy to give that reassurance, and I point to the evidence. The first time I visited the Congo, the Department for International Development had three staff. We now have 34, and that number will rise to 35. The development programme budget has also risen from about £3.5 million to £4 million at that time to £67 million this year. It will be £70 million next year, and is one of our largest programmes in Africa. If that is not evidence of commitment, I do not know what is.
I agree with all hon. Members who talked about the hunger for peace that the people of the DRC expressed by voting in very large numbers in those two extraordinary election rounds. I pay tribute to hon. Members who went out there on behalf of the international community to help to oversee that process. I am also proud of Britain’s role in that process as the largest funder. The real challenge for President Kabila and Prime Minister Antoine Gizenga is whether they will be able to respond to the incredibly high expectations that the people have after casting their votes in large numbers. The Government have only just come into being because Ministers got to work only last week, following their appointments.
The new Government programme that was adopted by the National Assembly on 24 February is a reasonable start and says the right things. It states:
“The fundamental principle for the action of the Government is good governance. This is characterised by participation, transparency, accountability, respect for rights, efficiency and equality”.
In the end, they will, like all Governments, be judged on what they do, and not so much on what they say.
The really difficult problem is that everything needs to be done there, so the Government face hard choices and need to prioritise, as does DFID. As a significant donor—we are shortly to become the largest bilateral donor—we must work with other partners and bilateral donors, the international community, the World Bank, the United Nations, the European Commission and others to divvy up the contribution that we can make to help the Government meet those priorities.
I agree that we need a mechanism to replace CIAT, which has come to an end because there is now a sovereign elected Government. It is important that we find a way to ensure that the conversation with, and support for, the elected Government from the international community and donors continues.
I shall respond to the points that have been raised and set out our future thinking. Clearly, a Government’s first priority is to ensure the safety of their people, but, for reasons that we understand, that is not yet the case in the DRC. Its Government have to make army integration happen. We have supported EUSEC in trying to deal with the problem of money going astray to pay ghost soldiers. We have also made funding available to provide some incentive to the military forces to go through the integration process, so that they have shelter, clothing and support when they come out. However, the Government of the DRC need to take the lead. The World Bank is leading the current DDR programme on the donor side, and we are working with UNICEF to treat child soldiers as an urgent and special case to be dealt with through the multi-country DDR programme. We have contributed an additional £5 million to that project. I hope that that answers the points raised by my hon. Friend the Member for Dumfries and Galloway and the hon. Member for Boston and Skegness. The second priority is to have a police service that provides security, and the third is to have a credible justice system. It is likely that DFID will focus on reforming both of those systems.
The hon. Member for Boston and Skegness and others spoke about MONUC. I join them in paying tribute to MONUC and to Bill Swing. As I told him when he came to see me last week, it has done an extraordinary job in very challenging circumstances. I want to make absolutely clear the Government’s position that MONUC should maintain its current troop levels for the time being, because there is a continuing need for it to oversee security. Any draw-down over time should be based on improvements in security.
While I am talking about security, I shall briefly address the case of Marie-Thérèse Nlandu. Andy Sparkes has raised that case several times with a number of people in the Government, including, most recently, President Kabila.
Another priority is to strengthen accountability, because elections alone do not make a democracy. We want to support the new independent electoral commission, Parliament and the provincial assemblies. I agree with the comments that have been made about the need to reach out to the Opposition in the DRC.
DFID’s funding for civil society and non-governmental organisations will go up, not down. It will focus increasingly on working with NGOs to provide services so that people begin to see a democratic dividend. I agree with my hon. Friend the Member for Islington, North about the role of women. As ever, I am happy to meet a delegation if he wants to bring them to see me.
What matters now for people in the Congo is that they see some change as a result of the votes that they have cast. The hon. Member for Hornsey and Wood Green asked about education. I am happy to write to her with more detail, but we are currently supporting, through the humanitarian pool fund, 50,000 vulnerable children so that they receive education. We are working with Catholic Relief Services on that. We are planning a major programme, with the World Bank, to help to reduce school fees, which she will know are a major obstacle to children going to school. We are also planning a community-driven reconstruction programme to help to rebuild local infrastructure, which will include schools in rural areas.
On health care, we will be doing more on water and sanitation. In the past two weeks, one in five children in the Congo will have had diarrhoea because of the lack of clean water. One of the programmes that we will be working on will provide clean water to 500,000 people in Mbuji-Mayi. We are also working with UNICEF to extend access to clean water to a larger number of people across the country.
I was asked specifically about education in fragile states. Our spending on that has trebled in the past three years. In the White Paper, we made a commitment to do more in such states, but we need their Governments, including in the DRC, to come up with plans to improve education, so that they can be supported. We are also investing in roads, because they will help with economic development.
The DRC is blessed with great natural resources that have been raped and pillaged, and from which the people have not benefited. The hon. Lady, in particular, asked what we are going to do about that. We are going to work with USAID on a programme to encourage better corporate governance in the minerals sector, and we will support the Government of the DRC in implementing the extractive industries transparency initiative. We are also contributing to the multi-donor trust fund on forestry, and we support a continuing moratorium.
On sanctions, we have played an important role in sanctioning particular individuals, through the UN Security Council, who have violated the arms embargo. We are pushing to extend the list of those who are subject to sanctions, and the UK national contact point has made statements about three of the companies that were highlighted by the UN panel.
We will continue to offer a lot of humanitarian assistance in the Congo. This is the most important opportunity that the country has had for almost half a century to achieve something better. As we heard, it is clear that people have a burning hope for a better future. We must help them to achieve that.
I requested the debate because in the city of Norwich there are two eating disorders associations. There is first the Norfolk Eating Disorders Association, which spends a lot of time consulting and counselling people in its open surgeries. It is full not only of patients and people who are suffering but of carers, who have a major problem as well. Families and friends come independently and get advice and so on from the association, which is fanning out into Yarmouth and other parts of the county.
The other major eating disorders association is the national one, which represents those with problems across the country and has a phone line system, counselling and so on. It has recently changed its name from the Eating Disorders Association to “beat”. I remember the meeting in which we said, “Stop being negative about disorders. Let’s get after it and do something about it.” That is why I am here—to urge the Minister to consider the problem and what we can do about it.
Some harrowing pictures have been produced of individuals who have lost weight and had problems with eating. I do not want to discuss them too much, because the problem is not just about the physical body. There are also mental problems for individuals who use food as a comfort in trying to tackle their daily problems. It controls one aspect of their lives if they use food to try to cope with the emotional difficulties that they are going through. There may be several causes of eating disorders—we just do not know. One thing written in the National Institute for Health and Clinical Excellence guidelines, which I will discuss, is that more research needs to be done. I hope that the Government will respond to that.
Eating disorders primarily affect young women aged 18 to 25, but of course not always. They also affect older women, and an increasing number of men are afflicted by anorexia nervosa or bulimia nervosa. There are cross-governmental issues that we need to consider to get a whole-society approach to the problem. Low esteem among our young people is often a problem, and reports from various organisations and UNICEF studies have put Britain at the bottom of league tables. We can argue about the figures until the cows come home, but we know that they can be better. That is the message that we have all received. There are a lot of unhappy young people out there—as well as old people in here—and for many of them that sadly leads to the problems in question.
We must link the issue with balanced school meals and sport activities so that young people can get some esteem and pride in what they are doing. There is nothing like running around and getting a few endomorphines in the body to feel better and healthy instead of continually having to worry about weight.
The media have a lot to answer for. The problems came into the public radar in the ‘90s when Kate Moss and co. introduced to the wider media the phenomenon of “heroin chic”. Today we have Posh Spice and Nicole Richie, who my researchers tell me is Lionel Richie’s daughter—I cannot keep up with it myself. She evidently sells the “size zero” phenomenon, and the debate arises from such celebrities. Magazines are filled with pictures of skinny bodies, and they are on the bottom shelves. One does not have to go very far down the road from here, to Westminster station, to see magazines such as Zoo and Nuts, which hit esteem on two important levels. They treat women as objects, with no worth, and they feature page after page of unrealistic bodies, semi-naked—so I am told; I do not know myself, of course. We know the type of imagery that is used. There are also lads’ mags and papers with similar content. The media influence how people feel they should look.
There is increasing incidence of eating disorders among men. Men can and, I am told, should, look good, live up to the Adonis-style body image—I do not mean the Minister of that name—purchase beauty products and so on. We must ensure that the resources and treatments that we get for tackling eating disorders are relevant to both male and female patients. Family upheavals also play a part in developing low esteem and affecting a person’s state of mind.
Eating disorders are serious illnesses and need to be treated as such. To take patients and put them in psychiatric wards, as happens to some young people, is the worst thing that can happen. I had a meeting on Saturday in the Forest of Arden with cancer consultants and asked them, “What would you do? Would you know what to look at?” They said, “Well, not really, we are cancer experts, but we think that the worst thing in the world would be to stick young people with this problem into a psychiatric ward.” Sadly there are a lot of a cases in which that happens. The people affected need special psychological treatment, help and support, so we must stop the habit of dumping the problem somewhere else. The NICE guidelines reflect that and are highly praised by the charities to which I have spoken. They cover getting help early, getting good information about the illness to the patient and their family, giving access to counsellors and self-help groups, including for families, and recognising that patients may be ambivalent towards their treatment but that they persevere anyway and should be encouraged to do so.
Psychological interventions such as group therapy and cognitive behavioural therapy should be made available, as well as dietary counselling and an annual physical and mental health review. Pharmacological interventions are helpful only for morbid conditions, which are rare. The physical aspects of illness must be managed, including by reducing the laxatives that people tend to take and gradually increasing their calorie intake. There must be regular dental checks and dental hygiene advice—people who vomit, for example, need that care and attention. The problem is deep-seated and needs the involvement of a large number of people in repairing it.
We need to screen vulnerable groups by assessing their body mass index and asking them to consider their relationship with food. We must be honest about it. Such things need to happen in schools, too, and people need to know that they are happening. We do not need celebrities to tell us how our bodies should look, although Princess Diana did a good job by reflecting openly on her problems with bulimia, bringing it higher up the agenda.
The guidelines are not being implemented sure-footedly across the country, and not all GPs are aware of them. They do not all diagnose eating disorders when they should. We need to do something to inform GPs, and I shall make a suggestion about that. Health professionals might not know the symptoms or what to look for, and they may not have an understanding with the patient.
A particular case in my constituency has hit the media waves. A young woman, Catherine Scott, died. She weighed six stone and it was recorded on her death certificate that she died of a liver-related disease. The implication was that she was drinking and that that was the cause. She had been under the care of her local GP for several years. Her family complained about her treatment and, after advice, the death certificate was changed to show that she had died from bulimia. It is interesting that they had to fight to get that put on the death certificate.
The family, of course, were very hurt. They have been down here, and they met the Minister at a reception. They have carried on fighting, through the Healthcare Commission, and they have now gone to the ombudsman. They feel that the GP should have picked up the problem much earlier, but instead the young woman died. That cannot be right. The worst thing, which a newspaper picked up on, is that the GP has now fallen out with the family and taken them off the surgery’s list. That is severe. I understand that some patients, and some constituents, can be difficult, but trying to get rid of the problem in that way is an overreaction. Parents and carers need a lot of support and help. I hope the Minister will look into the case of my constituent, Catherine Scott.
Many people with eating disorders can be treated as out-patients, as long as the illness is recognised early. Although in-patient treatment is rare, it does happen, but a psychiatric ward is the worst place for treatment. The places where I have seen the best treatment are outside hospitals in private areas in nursing homes and so on, funded and supported by the NHS. Young people who receive the necessary care and attention in such places seem to recover.
Eating disorders are recognised, and the Government are beginning to move on that front. There is good work on that, but more remains to be done because many young people are slipping through the net and not receiving counselling or therapy. We need a crusade to ensure that that does not happen. The problem of eating disorders must be addressed because they can be treated and eliminated. No one should die because of misdiagnosis, but I am sure that there have been other cases of misdiagnosis.
The problem is not just about weight; it is about the emotions that young people go through. There may be problems at school or in the family that need intense understanding by the counselling service. The local health community must review its practice to ensure that every surgery has a doctor who knows something about the disorder. We could start with one or two specialists in every GP area, as happens with diabetes. One member of staff should have some expertise to enable the problem to be picked up early. When patients have finished treatment, they must be monitored and not just dropped back into society. Some young people go through an unhappy phase when they are under pressure, and they should be followed up to ensure that there is no relapse or recurrence.
We should get busy on this. We could score highly, because we know what to do. The NICE report said that we need more research and some money. We have good guidelines, and it would not cost much to put those into operation in every GP practice and prevent the sadness, illness, break-up of families and the continual remaining problems when someone, sadly, dies.
I congratulate my hon. Friend the Member for Norwich, North (Dr. Gibson) on securing this debate on an extremely important issue. This is a good opportunity to raise in Parliament the issue of eating disorders. We must raise awareness, not only among the public but, as he rightly said, among NHS staff.
I thank my hon. Friend for his work on behalf of “beat”, which is the working name of the Eating Disorders Association. The organisation wants to raise awareness and provide support for those with the condition and their families. He talked eloquently about the problems that can arise, and highlighted a case from his constituency. I am sure he will be aware that it is difficult for me to comment on individual cases, but I know from my constituency work the distress that can be caused. We often concentrate on younger people, but there can be issues with older people, particularly the elderly and frail, when recognising an eating disorder may be problematic. I was pleased to attend the “beat” campaign launch and to be able to congratulate it on pointing out that people can survive and recover from eating disorders. Getting out those positive messages is extremely important.
My hon. Friend referred to the media. It is absolutely right to recognise that some media images of excessive thinness must play a large part in encouraging young people to aim for an unrealistic body weight and to run the risk of becoming anorexic. The media have a role to play in addressing some of the issues. It would not be helpful to debate whether the media cause eating disorders, but I hope that they will, in conjunction with organisations such as “beat”, print positive stories covering the reality of eating disorders, the people who have recovered, how people must be able to talk about the problem and how to reduce the stigma of eating disorders, as well as providing good advice for those who need to look for the symptoms, whether families or teachers, to ensure that people are aware of the problem. The media have an important part to play.
It was interesting to see in the publication that “beat” produced on the day of the renaming launch that GPs and nurses are the most likely people to be confided in, and I was sad to learn that parents and teachers are not. A big question is how can we get over that and make sure that people feel able to confide in parents and teachers. We know that the sooner people come forward, the sooner treatment can start and the better the outcome.
As my hon. Friend said, there is a lot that we do not know about eating disorders and how they manifest themselves. I am happy to confirm that we are considering whether we can undertake further research, and I hope to make an announcement in the not-too-distant future.
I am pleased to hear that. I did not know about it. It is not often that an hon. Member leaves a debate feeling that something will happen. I thank the Minister on behalf of everyone concerned. If we can help in any way to make that happen quicker, I hope that we can work together. Many people will be happy that something is being done at last.
Thanks to the work of organisations, such as “beat”, and my hon. Friend awareness has been pushed up the agenda. The Government want to respond to public concern.
My hon. Friend was right to say that we must consider what GPs can do to identify signs of an eating disorder and to be able to offer the right treatment as early as possible. He made an interesting point about GPs in every practice having such training. We are always looking for ways of increasing awareness, but we must be aware of some of the practical difficulties—for example, in single-handed practices. We must ensure that good systems are available in primary care and that there is awareness of symptoms among health care professionals.
I thank my hon. Friend for pointing us in that direction.
The Government have assisted practitioners in choosing the most appropriate treatments. As my hon. Friend said, we asked NICE to produce guidance on the management of eating disorders, which was published in January 2004. In fact, “beat” was involved in drawing up those guidelines, and we are again very grateful to it for its assistance. The guidelines make clear recommendations about the available treatment and set out a structured pathway of care.
NICE has also published information for the public, explaining the guidelines and setting out what people with eating disorders can expect from the national health service. That is the other side of the story. As my hon. Friend said, such people may have low self-esteem and self-confidence, so they may find it difficult to share their circumstances. If they are unaware of the available services, they may wonder what is the point in going along to a meeting. We therefore wanted a two-track approach that involves being clear with health care professionals about the available treatments and the pathway to care, as well as ensuring that the public know about those treatments and that something can be done to help.
My hon. Friend talked about the different options that are available, including on psychiatric wards and so on. People with severe and intractable eating disorders might require referral to highly specialised services when local services cannot meet their needs, and specialised services have been developed in recent years. That indicates the various care settings that are now available.
When I visited a community mental health team recently, I was impressed because they had a eating disorders specialist. Previously, the practice had always been to refer people to in-patient care, but now consideration is being given to helping people at home and in the community through specialised services.
There are various ways of providing services, and there is some very good in-patient care. We must consider the individual to determine the most appropriate care. Sometimes in-patient care will be most appropriate, but it is important for commissioners to consider closely what can be offered in the community. As the role of PCTs changes and they clearly examine the needs of the local health population in the community and closely consider the services that they commission, it is important that they assess whether they have the right balance between in-patient care and the care that is available to people in their own homes—particularly at a highly specialised level—to help individuals with eating disorders.
The new role that PCTs will play in considering their own commissioning will help to identify and examine whether services are appropriate. They will often work with local organisations, such as “beat”, and those that my hon. Friend mentioned from his constituency, to determine whether there are occasions when they ought to commission services jointly, because voluntary organisations are sometimes more effective than statutory services at reaching out to people.
Although I agree with that point, does the Minister agree that young people with cancer do not like being on wards with adults? She will know about that from her work in the cancer field. Young people talk a different language, play loud music and have a different culture and style. It would also be dangerous to place them in a mental hospital where adults are on the same ward; that would distract them, and it might hold back their recovery.
My hon. Friend makes an important point. It is always vital, however, that we allow clinicians to exercise their judgment about what is most appropriate for individual patients, and it is important to examine closely the balance between in-patient care and the care that can be provided effectively in the community. For some people, it is better to provide services in the community; for others, in-patient care is the right approach. However, my hon. Friend is absolutely right that in-patient care must be appropriate to the needs of the individual.
The important point is that, in recent years, there have been massive increases funding for the NHS in general and in funding for mental health services. The issue is about examining how the funding is used to establish whether it is being used as effectively as possible to provide the personal services that we want—for example, the individualised and tailored services for people with eating disorders.
My hon. Friend also mentioned counselling. We made a manifesto commitment to increase the number of counselling services, because there are not enough of them. In 2001, we published guidelines on treatment choice in psychological therapies and counselling, which covered eating disorders, among a range of other conditions. In 2004, we published guidance called “Organising and Delivering Psychological Therapies” to help local services to understand best practice and how to organise local services to support access. Last year, we also started our demonstration sites in Doncaster and Newham to examine how we could provide psychological therapies for people with mild to moderate depression.
Some of those initiatives will tackle the very real points that my hon. Friend made about low self-esteem and lack of confidence. We want to increase support so that we can reach people as early as possible. We all agree that it is important to achieve early access and to ensure proper in-patient support, community support and general access to psychological therapies, because we can then provide treatment quickly.
The Government fund several voluntary sector organisations in the field, including Weight Concern and “beat”, and we are funding a three-year pathways to recovery project, which is about providing a buddy network of people who have had eating disorders. At the “beat” reception, I met some people who are very much involved in showing what has happened to them. It is so important to encourage people to share their experiences. We have done many things already, and we can do many more, to ensure that society takes on the challenge and that people work together to prevent more tragedies and blighted lives.
Sitting suspended until half-past Two o’clock.
NHS and the Private Sector
It is a pleasure to speak under your chairmanship, Mr. Jones, and a pleasure to see two such affable hon. Members in the seats of power. I got to know the Minister well on the Select Committee on Health way back in 2001-02, when we were both very new and just out of the egg. I shared an office with the shadow Minister, the hon. Member for Billericay (Mr. Baron), during the first few weeks after our arrival in 2001.
This is not meant to be a confrontational debate. Sitting bang in the middle, as I do, I hope that I am able to speak from the point of view of patients and staff of the national health service, and put forward strongly their views on what is right and what is wrong with the involvement of the private sector. I have no political message; I am just exploring the issues, asking a mass of questions and hoping for some answers.
Briefly, I shall deal with the very successful public-private partnerships that have existed for years. The traditional partnerships were laid out in the first part of the Health Committee’s report on the role of the private sector in the NHS in 2001-02, and we listed many of the successful partnerships at that time relating to voluntary hospices, psychiatric beds, brain injury rehabilitation, treatment for eating disorders, drug abuse and, of course, care homes. We must not forget the vital contribution of the independent community pharmacies and the vast pharmaceutical industry.
In the Health Committee report on the influence of the pharmaceutical industry in 2004-05, we were careful to recognise its importance for the NHS. In paragraph 43, we said:
“A flourishing UK pharmaceutical industry is of great importance for healthcare as well as having economic benefits. To achieve this, it is most important for the industry to be able to undertake research effectively.”
“The industry’s ability to compete internationally requires a legislative and organisational framework for research that protects the interests of all stakeholders—patients, researchers and pharmaceutical companies.”
It is a very important partnership, which has been drawn into optimistic relief recently. Last Saturday, The Independent reported that the company Sanofi Aventis has come together with Médecins sans Frontières to produce, for 50p a day, a combined anti-malarial drug that is required to be taken for three days only. Moreover, it waived its right to seek a patent for it. The company’s vice-president for access said:
“This was not a love wedding, it was a reasonable wedding…But reasonableness is often more important for a long marriage. They’ve seen we are not nasty people working against poor countries and seeking only profits.”
That is a very good sign for the future, and perhaps in other fields we shall see the large pharmaceutical industries coming down on that side.
There have been newer developments in the field of private-public partnerships. The out-patient renal dialysis unit in my hospital is one such development. I am not going to talk about GPs. Everyone knows that they are independent providers who very much relish that role, but I know very few who concentrate on private practice, so I shall not talk about them.
Before I examine the Government’s use of the private sector as health service provider, I want to explain what I see as two conflicting views of privatisation. My impression of the Government’s position is that they feel we have an NHS regardless of who provides the service as long as the patient does not pay. That does not reflect my views, or those of most NHS staff and a lot of patients. They believe that to have a true NHS, most services—particularly if we are talking about acute hospital services—must be provided by the NHS. It was Bevan’s revolution, as long ago as 1948, that meant that all NHS staff were paid on the same scales at a stroke, whether they were top teaching hospital consultants, lowly consultants in district general hospitals, matrons in huge hospitals or those in cottage hospitals. The unity of the quality of staff throughout the country was crucial. When I was looking for a consultant job, pay was not an issue; it was a question of the sort of work one wanted to do and the place one wanted to go. The fear is that a multiplicity of providers may lead to a loss of this strong influence of unity.
I want to examine in detail three aspects of health care provision: first, the treatment centres and services for investigations; secondly, clinical assessment, treatment and support services; and, thirdly, the private finance initiative. I intend to conclude with some terribly worrying warnings that have been expressed in some quarters about the future.
On treatment centres, there is no doubt that it is correct to separate elective work from emergency work. That means that we do not have cancellations and we can usually accommodate all the patients on the lists. An organisation called NHS Elect was set up to study that process in four or five centres, of which Kidderminster was one. Only eight months after setting the organisation up, instead of waiting to see what would happen, the Government produced phase 1 of the independent sector treatment initiative.
The Minister contributed to the Health Committee report of 2001-02. There were bits about which we both agreed, although there was one bit on which we did not.
I am grateful to my hon. Friend and namesake for giving way.
People are concerned that independent sector treatment centres do not necessarily provide value for money, although they may improve waiting times for elective surgery. They do not necessarily augment NHS capacity, but can have a damaging effect on the hospital where they are located. Queen’s hospital at Burton upon Trent is an example of that. Finally, they do not have any responsibility for the provision of undergraduate or postgraduate medical training and the integration of research. Those three areas are crucial, but the private sector is able to walk away, with its half-empty beds, while damaging the general hospital next door or just up the road.
I shall cover all those points, so I shall continue and hope that I do so before the hon. Gentleman has to leave.
One of the conclusions of the report on the role of the private sector was:
“It remains to be demonstrated that greater use of the capacity of the independent sector poses no direct threat to resources in the public sector.”
The Government, in their response, said:
“The Government agrees with the Committee that it is important that new capacity is genuinely additional, and does not simply mean moving capacity from one place to another. This is true of the development of new capacity within NHS, as it is of the use of capacity in the independent sector.”
The first question is whether the capacity produced in the independent sector treatment centres is genuinely additional.
The Health Committee inquiry into independent sector treatment centres received a considerable amount of evidence that showed that the local capacity analysis was not full or accurate. Indeed, the private cataract unit in Oxford was imposed on the local NHS, rather against its wishes. Our report said:
“If there had been a severe shortage of capacity, the ISTC programme should have had little effect on capacity utilisation of NHS facilities. This has not been the case; according to NHS Elect, the introduction of ISTCs has led to under-utilisation of NHS Treatment Centres (because of the ‘take or pay’ contract).”
The hon. Gentleman makes a good and strong case, although I hope that I am not anticipating a point that he wishes to make later. He has certainly identified problems with independent treatment centres, but there are also private bodies that operate within NHS hospitals, as they do in my constituency. Clinicians who work for the NHS are at the same time in the market for providing services in the private sector, which clearly compromises their commitment to the NHS. Does he agree that those relationships need to be separated? Clinicians must make a decision: are they in the NHS or in the private sector?
I shall touch on that point peripherally. Briefly, where NHS consultants are involved in independent sector treatment centres, it is clear that that should be part of their NHS contracts and not paid at extra rates. I shall come to that, although I agree that the long-term permission for consultants to do private work as well as NHS work must be carefully defined and monitored.
The Department of Health has perpetuated the myth that ISTCs have had a dramatic effect on waiting lists. The best evidence against that comes in the ophthalmic field. For example, at a time when more than 300,000 cataract operations were being done in the NHS, precisely 20,000 were being done in independent sector treatment centres. Waiting lists were falling because of hard NHS graft before the ISTCs came into operation. Ministers and civil servants acknowledged that in our inquiry. One of our conclusions was:
“ISTCs have not made a major direct contribution to increasing capacity, as the Department of Health has admitted. It is far from obvious that the capacity provided by the ISTCs was needed in all the areas where Phase 1 ISTCs have been built, despite claims by the Department that capacity needs were assessed locally.”
I shall digress briefly and discuss clinical investigation facilities. They fell outside the remit of our ISTC inquiry, but they are relevant to the notice taken by the Government of local capacity issues. I received a letter out of the blue from a former houseman who is now a professor of clinical magnetic resonance imaging in one of the major universities, and therefore in charge of MRI scanning for a prestigious university hospital. He was not aware of any attempt to see whether extra capacity was needed in wave 1 of the ISTCs. It was not as if existing facilities in the NHS were underused; rather, they were underused only because of lack of resources. If the money had been put into those facilities, they could have done everything that the independent sector was going to do.
There was no consultation on wave 1, and even though that doctor’s trust turned wave 1 down because it did not need it, it was forced on it. If only the Government money had gone to the trust, it would have achieved exactly the same results. If primary care trusts are offered free centrally funded MRI scans, it is not very hard for them to choose those rather than the NHS ones, for which they would have to pay. There is no level playing field. The Health Service Journal recently surveyed 97 NHS chief executives, who were asked a series of questions. When asked about the playing field on which the private and public sectors competed, 97 per cent. said that it was unfair.
Is the hon. Gentleman saying that the centres that were set up received special compensation deals from the Department? Is there any evidence that money was being filtered in to encourage them to set up, to reduce their capital costs and to guarantee their futures?
From the point of view of MRI scanning, the money was provided directly from the Department rather than going through the trusts. The independent sector treatment centres in the first wave were paid a premium. The answer to the questions that we have asked about that is that the premium was necessary because the ISTCs had to set up the services. I am not sure that I bought that argument, but perhaps the Minister will say something more about it.
What really bothered the Health Committee when we considered ISTCs was that there was no hard evidence on clinical outcomes. We heard alarming anecdotes about disasters, such as revisions of joint replacements and so on, but we could not get hard evidence either way because it did not exist. We therefore welcome the chief medical officer’s request to the Healthcare Commission to review the quality of care in independent sector treatment centres. The Government response to that inquiry gave the terms of reference, although to be honest we all thought that they were rather woolly. For instance, the current key performance indicators are a measure of process rather than of quality. The Healthcare Commission’s remit appeared to concentrate on process rather than outcomes. We were told that the inquiry was due in March 2007—this very month—so I wonder whether the Minister has any information about when it will arrive. Also, I understand that the Royal College of Surgeons is willing to set up another inquiry, into real outcomes, and I wonder whether he has any information about that.
Other concerns about ISTCs include their integration with the NHS. During the Health Committee inquiry we visited several independent sector treatment centres. Those that were working closely with the NHS, swapping staff, were working extremely well. Those centres that were working entirely separately were working in competition. The independent sector treatment centre for orthopaedics in my area is exactly like that. It is in competition. The local NHS orthopods can see no good coming out of it, and have had no chance to get into it and try to improve it. There is also a weird clause of additionality, which goes against integration, but it is funny that it has been applied in some places and not others. There has been a report about the independent sector treatment centre at Queen’s hospital in Burton upon Trent, which is obviously one that works with NHS consultants. If that centre can do that, why cannot others?
Orthopaedics is a shortage specialty, so I understand that the additionality rule will not be lifted for the phase 2 ISTCs, which will be very sad. Integration will equate the standards and answer the other great criticism mentioned by the hon. Member for North-West Leicestershire (David Taylor): the lack of teaching in ISTCs. Worries have been expressed about the quality of the doctors who work in ISTCs; if they come from continental Europe, they will not necessarily have undergone the same stringent accreditation processes as we have in this country. Will they be adequately qualified to provide teaching in ISTCs?
Are ISTCs a threat to NHS services? The Health Committee could not come up with hard evidence on that, but we made two comments:
“The Phase 1 contracts, including the ‘take or pay’ elements, give ISTCs a significant advantage over NHS Treatment Centres and other NHS facilities. This is one of the reasons that several NHS Treatment Centres have spare capacity. In the longer term, there are good reasons for thinking that ISTCs could have a more significant effect on finances of NHS hospitals.”
We concluded the ISTC report with the following words:
“We are not convinced that ISTCs provide better value for money than other options such as NHS Treatment Centres, greater use of NHS facilities out-of-hours or partnership arrangements such as those at Redwood.”
Recently—in Hospital Doctor, I think—there were reports of the south-west London elective orthopaedic centre, a joint venture between four NHS trusts: Kingston Hospital NHS Trust, St. George’s Healthcare NHS Trust, Mayday Healthcare NHS Trust and Epsom and St. Helier NHS Trust. The centre provides NHS elective orthopaedic surgery, and is working very successfully. It treats more than 3,000 patients a year, and needs 300 a month to break even. However, staff there are terrified that new independent sector treatment centres proposed for the area could pose a threat.
I hope that, before the hon. Gentleman moves on, he will ask questions about an important issue—perhaps it is the worrying trend that he rather coyly mentioned in his opening remarks. We have been assured that the European Union is not interested in policies on nation-state issues such as health. However, it has become clear that the EU and the European Court is looking at the opening of the Pandora’s box of providing for the private sector in the NHS in the manner that he has described. They consider that, if the market is being opened up, the Government need to play by market rules; the Pandora’s box has been opened and cannot be closed. That is of great and deep concern to many right hon. and hon. Members.
The hon. Gentleman is a mind reader; I shall come to exactly that point at the end. It is the potential bombshell.
I move on to CATS—or clinical assessment, treatment and support services—which are being consulted on in Cumbria and Lancashire. I am not sure whether the part of Lancashire represented by the Minister is involved, or whether it is the northern part of that county. I should like to draw attention to the consultation document, which is an absolute example of consultation pointing in one direction only. Its very title is, “Improving our Patients’ Experience of Healthcare in Cumbria and Lancashire”. It is highly significant that the introduction and welcome pages are signed by six PCT chief executives and one chair. The latter happens to chair the independent sector commissioning board, and one of the chief executives is the lead chief executive of the same board. Surely, that is a conflict of interest. Furthermore, not a single clinician is mentioned in the introduction—nor, as far as I can see, in the whole consultation document. There is certainly no mention of patients forum involvement or anything like that.
The hon. Gentleman referred to a state of affairs in my constituency. He may be aware that the CATS consultation came about only after extreme pressure; it is really only about how, rather than whether, CATS is imposed. Perhaps he will note that many clinicians in my constituency are concerned about the impact of CATS on local hospitals—particularly my local one, Westmorland General hospital. It is estimated that between 60 and 80 per cent. of current out-patient demand will disappear if the CATS centres arrive, therefore undermining the potential viability of my local hospital.
I am aware of a lot of the things going on, but not the details of Westmorland and Lonsdale.
One has only to look at the contents of the consultation document to see which way it pushes people:
“CATS adds to existing health services…CATS is designed around the patient…CATS is intended to help reduce waiting times, simplify patients’ experience and add services closer to patients’ homes…We are designing CATS to meet the needs of patients…We intend to introduce eight CATS centres across Cumbria and Lancashire…The preferred bidder for CATS services is Netcare UK”.
There is a section entitled “What will the changes mean for my local hospital?”, and it is fairly dismissive. The most striking early sentence is about having a negative effect on hospitals not being
“the intention of introducing CATS.”
However, it says lower down that
“CATS will mean changes for hospitals”.
I am very bothered that continuity of care seems to be swept aside, but the document says that the huge advantage to local PCTs is that the introduction of CATS services is all free and that there is £23 million in additional money to fund it. The consultation’s response form, which has to be returned by 9 March, has no question allowing someone to disapprove of the proposal as a whole. I am still puzzled at why there is no contribution from medical or nursing staff to the document.
It is true; there are six specialties. The ones about which I know most are rheumatology, gynaecology and orthopaedics, because they are the ones that people have spoken to me about.
I shall speak briefly about rheumatology; I do not think that the people who designed CATS know what specialist rheumatology hospital doctors do. They can cope with anything from painful shoulders and backache to the really crippling inflammatory arthritises and the very rare, life-threatening rheumatological diseases. There is no detail about who Netcare’s doctors will be—are they accredited rheumatologists, do they have experience as physicians? A great thing in rheumatology is the multi-professional team so essential to modern care.
The hon. Gentleman is very generous in giving way. I shall be brief. Is he aware that rheumatology—which is indeed one of the specialisms in which CAT centres, in south Cumbria at least, are likely to specialise—has no waiting list to speak of whatever at the moment? Given that the official explanation for introducing and imposing CATS is the 18-week waiting time, it all seems completely off the mark and as if there has been no consultation.
I am aware of that. The British Society for Rheumatology has been on to me. Rheumatology is a speciality that will be able to reach 18-week waiting lists across the whole region without a problem. If referrals to the NHS drop by 50 per cent., for example, the area will be able to afford only 7.5 whole-time equivalent rheumatologists across the region whereas at the moment 17 cover 16 hospital sites. On the gynaecology side, a gynaecologist expects the fallout from CATS to affect all trusts. He tells me that trust managers and local MPs are worried, to say nothing of the clinicians. The great problem with gynaecology is that the problems in different trusts are different. Some can do it; some cannot. The same goes for the other specialties.
A catch-all solution across the area does not seem to be necessary. The gynaecologist who has spoken to me says that the answer is better management by clinicians and managers of the existing NHS services and that, if the money that will go to CATS could go to them, they are sure that they could improve the services to get down towards the waiting time targets. There are many concerns about the CATS.
Let me say a few words about the private finance initiative. I want to take the Minister back to our first inquiry in 2001-02, when we were both new to the House of Commons and to the Health Committee. We did not agree on the main issue, but he agreed with many of the recommendations, and I want to ask him what has happened to some of those with the recent approvals for PFI hospitals. In particular, we asked for more transparency, stating that
“there has to be more transparency, openness and accountability.”
The Government response stated:
“The Government welcomes the call for a more rational and objective debate about the Private Finance Initiative...and accepts the Government’s role in this.”
A later section dealt with the management of risk. I am sure that the Minister will remember that we concluded that the evaluation of risk was as much of an art as a science. We wanted more realism about the public sector comparator. We wanted more expertise in negotiating bodies from the health service point of view. My PFI was one of the early ones, and it is blamed for £7 million of the trust’s overspend. I do not know whether the following provision was worked into all the early PFI contracts, but if the bed occupancy goes above 90 per cent., which it regularly does, there is an extra fee to pay. Over the past few days, I have seen newspaper reports that new borrowing regimes are coming in for trusts from 1 April. The trust in Plymouth has decided to abandon its plans for a PFI, because it thinks that it can get its money from the public sector under those borrowing arrangements.
I shall begin to draw to a conclusion, as I am aware that I have been speaking for a long time already. In the rush to open the provision of hospital services to private providers, we must be sure that that is appropriate, that it is wanted by patients and that it will not lead to the downfall of the NHS as we knew it. There was an article in the British Medical Journal last September headed “Where are the medical voices raised in protest?” It bemoaned the fact that, whereas in the 1980s medical voices were raised strongly against the Thatcher Government’s changes, things appear to have changed, stating:
“In the past six years we have seen reform on a scale never before attempted in the NHS. The prime minister continues to say he wants to increase the pace of reform; however, it is not just the sheer speed of reform that makes it distinctive, but also its breadth and depth.”
The article includes a nice photo of Aneurin Bevan admiring a new hospital back in 1948, with two very posh gents with winged collars—we do not see many of those around—on either side of him. The photo is captioned, “Would Aneurin Bevan recognise today’s NHS?” The article went on:
“These reforms seem more radical than commentators in this journal dared imagine…If we add in the vagaries resulting from the PFI process, then we have a reform agenda that seems to sweep away Bevan’s NHS across the board, blurring the boundary between public and private not only in financing the service but also in the provision of care”.
Medical voices are raised and have been all the time—in particular those of the NHS Consultants’ Association, the “Keep Our NHS Public” organisation and the well-known Professor Allyson Pollock—although they have tended to be disregarded, but stronger voices are emerging. The royal colleges are beginning to speak out—in particular, the Royal College of Surgeons. There was a good report about Bernard Ribeiro of the Royal College of Surgeons in the Health Service Journal only last week, which said that he is determined to have a say in the political aspects of the NHS.
I have been drawn to voice my medical protest now as loudly as I can by the fact alluded to by the hon. Member for St. Ives (Andrew George). The best report on that, I think, was in the February edition of the British Journal of Health Care Management by Nicholas Timmins, the highly respected public policy editor of the Financial Times, who is not prone to raising groundless alarms. He quotes Ken Anderson, who was recently the Government’s commercial director:
“‘My personal conviction,’ he told the Financial Times, ‘is that once you open it’”—
“‘up to competition, the ability to shut it down or call it back in passes out of your hands. At some point European law will take over and prevail, and that is not something that can be rolled back. In my opinion we are at that stage now.”
Mr. Timmins went on to report that the Department of Health has taken legal advice, which states that for various reasons, health services are exempt from compulsory tendering under EU law. However, other legal advice runs contrary to that, and he quotes reports that the European Court has decided that
“if a national health system embraces competition, then competition law will apply”.
I fully accept that the Government are committed to maintaining a health service that is free at the point of delivery, but if we continue to encourage the increasing provision of health services by private providers, we will not end up with a national service. It risks being fragmented across the country. The Guardian published a brief letter last September, when the NHS Logistics Authority was privatised. It stated:
“The sale of NHS Logistics means privatising, at the stroke of a Hewitt pen, a 20th of the NHS. It is yet another huge step away from Bevan’s integrated, public NHS in which everyone was on the same team.”
Surely, we can all resist the rush to unquestioned involvement of the private sector in NHS provision before it is too late. The Minister is a free-thinker and he has been given a certain amount of leeway to think for himself. I very much admire the way in which he went out immediately after his appointment to work in the NHS and I hope that he was able to talk to some of the staff without managers and civil servants present. I therefore make an appeal to him. Abraham Lincoln once said:
“My paramount object in the struggle is to save the Union”.
Could the Minister study all the pros and cons? If he agrees with many of us about the threat to the NHS, could he make dealing with it his paramount object?
One day at Horton general hospital in Banbury, we suddenly discovered that we were going to have a new independent treatment centre. I am sure that Capio does a wonderful job as an orthopaedic treatment centre, but no one asked for it—we certainly did not. All that it seems to have done is undermine the excellent, world-leading Nuffield orthopaedic centre in Oxford, which provided an excellent orthopaedic service for years.
My concern, to follow on from the excellent speech by the hon. Member for Wyre Forest (Dr. Taylor), is that there seems to be no coherent philosophy or steer from the Government as to what they expect the NHS to achieve, and I think that the Minister recognises that. I hope that he has not been misquoted—indeed, I think he has been quoted correctly—but I understand that he wrote to the Secretary of State, saying:
“The irony is that the process of change necessary to secure long-term public support for the NHS risks driving a wedge between the coalition of its strongest supporters…There is a feeling of nervousness among NHS staff about being on a journey without knowing where the end point is…Some are concerned that the values of the NHS are in some way up for grabs.”
Most of us believe that the NHS should be a comprehensive service that is free at the point of use and provided according to need, not ability to pay, but we are becoming increasingly confused.
What we have seen is a circular reorganisation of the NHS: it started in 1997, and we are now back where we began. We have seen PCTs come and go. At one stage, we had five PCTs in Oxfordshire, but we are now back to a single Oxfordshire PCT, which looks very much like the old Oxfordshire district health authority. There is also no indication of what local voice there now is in the NHS. All the non-executive members of trust boards are appointed by the Secretary of State and clearly believe that they are beholden to her. When we had concerns about the reconfiguration of services at the Horton general hospital, I wrote to all the non-executive directors of the Oxford Radcliffe Hospitals NHS Trust, but none of them responded. I think not that they were being discourteous, but that they felt entirely beholden to the Secretary of State. There is now no local voice, and without a strong steer from the Secretary of State and Ministers as to what they expect from the NHS, everyone else is completely adrift.
There is an incremental movement towards acute super-hospitals, and the Horton has been told that that is because there is a shortage of middle-grade doctors in disciplines such as paediatrics and, possibly, maternity. We are then told, however, that 30,000 middle-grade doctors are looking for 20,000 posts. I cannot believe that there are no middle-grade paediatricians among the 8,000 who will not get a post under the new system—the Government have announced that they will review it—but who could come to the Horton to ensure that we maintain a paediatric service. That service was set up as a consequence of a Government review that Barbara Castle initiated as Secretary of State for Health after a child died in Banbury.
As we come to the 60th anniversary of the NHS, the Government seem to have no coherent philosophy, other than bandying around the word “reform”, as if doing so is, in itself, a good thing. I am a child of the NHS and I was born shortly after it came into being. Both my parents spent their whole working lives in the NHS—my mother as a theatre assistant and my father as a doctor. I seemed to spend every Christmas day until I was 18 somewhere on my father’s wards and I spent most of my university vacations working as a hospital porter.
As an integrated entity, the NHS worked, and there was a clear philosophy about how it worked. Of course improvements can be made to how GPs commission services and so forth, but the permanent revolution in the NHS is incredibly demoralising and confusing. Unless the Minister can give some rational public policy explanation for why the Nuffield is being undermined and a treatment centre is being put in Banbury, Ministers will need to stand back and say that it is perhaps time to stop trying to reorganise the NHS and to start giving clinicians and communities a chance to get on with delivering services in the way that they want to. If Ministers do that, they will be surprised to find that those services are often delivered very well.
Ministers must avoid being contemptuous of public concerns about what is happening in the NHS. Last autumn, 15,000 people in my constituency and throughout Oxfordshire signed a public petition expressing concerns about how NHS resources are allocated. As I am sure the right hon. Member for Oxford, East (Mr. Smith) will explain to the Minister, we in Oxfordshire are paranoid—some more than others—about the allocation of resources. Although I readily accept that I am paranoid, whether about resources for the police or the NHS, there was a petition, and I presented it to the House in the usual way. Yesterday, the Clerk of Public Petitions, who had referred the petition to the Department in the usual way, sent me a note:
“I have now been told that no government observations will be issued on the petition.”
It is a disgrace that Ministers cannot even bestir themselves to draft a two-paragraph response to a public petition signed by 15,000 concerned NHS staff, patients and members of the general public.
The petition was organised in part by George Parish, who is a Labour district councillor in my constituency —the “Keep the Horton General” campaign is a cross-party community campaign. The fact that Ministers cannot even be bothered to respond to a public petition illustrates the confusion they have got into.
As we come to the 60th anniversary of the NHS, I hope that the Government can understand and get back to where the NHS started—as a public national service free at the point of delivery and available to all. I hope that we shall not have all this reform for reform’s sake, because it is causing confusion, consternation and division in the service.
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing this important debate. I shall try to be brief; indeed, I have already made a couple of my points, because he kindly let me intervene.
Like the hon. Gentleman, I do not speak from a position of outright ideological opposition to private sector involvement. However, I have a concern about my constituency in south Cumbria, where a rather rushed and belated consultation on clinical assessment, treatment and support centres is under way. As I said, the consultation is about how rather than whether CATS is delivered, and we are concerned that the arrangements are being imposed in ignorance of the local situation.
As I also said, we have no waiting times for rheumatology, and it appears that many local consultants in a range of disciplines have not been consulted. The stated aim of the CATS centres is to reduce waiting times, but it appears that waiting times are not an issue in many disciplines, at least in my area. We should be grateful that they are not—indeed, the Government should claim credit for that, rather than trying to make us change local operating circumstances to deal with a problem that perhaps does not exist.
We also have a concern about the preferred bidder, Netcare. Local trusts were of course not given the opportunity to bid to provide the CATS centre services because the bid is entirely national. That is a matter of concern because of the impact that we believe CATS may have on local hospitals. We are told that there will be three CATS centres in Cumbria: one in Ulverston, one in, I think, Whitehaven, and one in Penrith. None of them, certainly not in south Cumbria, is on the site of, or even close to, an existing hospital. For a relatively small general hospital such as Westmorland general, the prospect of losing perhaps 60 to 80 per cent. of the demand for out-patient services because of the CATS centre undermines the hospital’s very existence—it could take away demand and staffing. We already face the possibility of losing acute services at Westmorland general because of another consultation—and incidentally, 26,000 people signed a petition opposing those cuts, but the trusts ignored it.
If we are forced to have a CATS centre in our area, we shall have to make the best of a bad job. I am concerned that we should ensure that the centres are situated close to hospitals, so that resources can be shared, rather than existing services being undermined. I am concerned also that the proposed removal of acute wards at Westmorland general coincides with the introduction of surgical provision from the independent provider Capio. My fear is the same as that of many of my constituents—that Westmorland general will cease entirely to provide emergency services and become simply a surgical centre. That is clearly not the vision for our hospital that local people, including local clinicians, share.
I would be grateful, incidentally, if the Minister looked into and responded fully to talk—some of it, I believe, informed—of Netcare, the provider of CATS services, being owned by the same venture capital company that owns Capio. As there is a possibility that the CATS centres will refer people on to surgical services provided by Capio, there is a clear potential conflict of interest. I am willing to be told that that is nonsense, but I would be interested to find out about any current links—or historical links, which are also important—between Capio and Netcare.
As there are problems with retention and recruitment in the NHS in Westmorland, a question that people will want me to ask is where the staff for Netcare and CATS service provision are to come from. Also, although it is clear from answers to written questions that the staffing of the CATS centres will have to comply with minimum standards, we are told that the employers do not need to comply with NHS terms and conditions. Two possibilities thus arise: Netcare’s terms and conditions could be better than those of the NHS, which would give rise to the risk of losing staff to the private sector, or they could be worse, in which case, whatever the minimum standards might say, we would run the risk of lower-quality provision.
My final comment is about value for money. The Government’s major case, apart from the 18-week waiting times—I think that that can be undermined, because of the local situation—is that what is happening is all about value for money. As a general point, money may go from NHS primary care trusts into acute hospital trusts, but under the arrangements involving independent sector providers, money from the PCT will go at least in part into the pockets of shareholders. That is not an ideological objection; it is just an objection to wasting money—to money leaving the NHS, which is clearly inefficient and something to avoid.
The argument for involving the private sector in public sector contracts is often that it is somehow good at taking risks and using its private sector fleet-footedness. However, the NHS is taking the risk in this case, not the private sector provider. Netcare is being given a minimum income guarantee of £4 million a year, irrespective of whether it does any work. That is not an incentive. We take the risk and it appears that Netcare takes the profit.
Why are the Government doing this? I do not know. I do not believe that the Minister is ideologically driven on the point. I share the admiration for him that the hon. Member for Wyre Forest voiced, and I believe that he is a free thinker, committed to the NHS. Perhaps the Government are panicked about the apparent lack of return on their investment in the NHS, which has been considerable. However, if we want to increase capacity, why not build it in the NHS to provide the services in question? If the Government were to do that, they would find that they had much more support.
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. He covered a vast terrain and in the limited time remaining I can focus on only one aspect of his contribution. He said that there has been a long and successful partnership between independent, private, voluntary and charitable provision and the NHS. So there has, but as plurality of provision develops it becomes all the more important that the terms of the interaction between the different parties—particularly with reference to the impact of innovations such as independent sector treatment centres—are fair.
I want to concentrate on specialist orthopaedic centres. The Nuffield Orthopaedic Centre NHS Trust in my constituency is affected by the issues that I shall outline, and so are the Robert Jones and Agnes Hunt Orthopaedic and District Hospital NHS Trust in Oswestry, the Royal National Orthopaedic Hospital NHS Trust, the Royal Orthopaedic Hospital NHS Foundation Trust in Birmingham and the Wrightington, Wigan and Leigh NHS Trust. The essence of the problem is that all those trusts are affected in varying degrees by the inability to date of the Department of Health to arrive at a national tariff that adequately recompenses them for the costs of carrying out complex orthopaedic treatments. Of course, as more of the routine work has gone to the ISTCs, the problem has been brought more into focus.
It should be stressed that the orthopaedic specialist centres have co-operated with the ISTCs and have not sought to block the arrangement. They went along with it on the understanding that talks would resolve the question of fair recompense for the work that they undertake. So far that has not been achieved. As was mentioned, the hospitals do important training work as well as much needed specialist and complex operations. Often treatment is expensive. The operation to save the limb of a patient with bone cancer might cost £7,600 but attract a payment of only £1,700, whereas, interestingly, the alternative of amputation, which I understand might cost £8,500, is adequately reimbursed under the tariff. There is a danger of perverse incentives. More importantly, the hospitals need to do the work—the patients need it—yet there is financial pressure.
There has been a system of additional payments to offer some protection to the specialist trusts, but there is a fear that if and when that is removed they will be exposed to severe financial pressures. The arrangement also works very unfairly in that it undermines the ability of those hospitals—my own included—to gain foundation status. In the case of Nuffield, that was merely because of questions about its medium-term financial viability, which was solely the result of the problem I have described. There were no doubts about its expertise or the international renown of the quality of the work done there.
Talks on this issue have been going on for a long time. The Secretary of State for Work and Pensions was Minister of State for Health when I first took a delegation to the Department about this problem. I am looking to the Minister today to provide some assurances, including to the Specialist Orthopaedic Alliance, about when the problem will be resolved. I ask in particular for reassurance with respect to a suspicion that exists of a danger that hospitals will be pressured into mergers—in some cases, not altogether well considered mergers—which will not resolve the problem, but merely hide it. The problem of fairly reimbursing the specialist centres for those highly complex operations is the nettle that must be grasped. The possibility of a merger with the John Radcliffe hospital has been floated in my area, but another tranche of specialist underfunded work that would have to be cross-subsidised out of other services is something the JR needs like a hole in the head.
I am speaking up for internationally outstanding centres of excellence in this country and I urge the Minister to assure us that early progress will now be made to ensure that those centres that have co-operated with the ISTCs will be fairly and properly reimbursed, as they should be.
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on securing the debate. I certainly accept the principle, particularly in respect of emergency and core NHS services, that a service is bound to be compromised if at the same time the provider is seeking to maximise shareholder profit.
I acknowledge that the private sector has a role to play in the NHS. I am not ideologically opposed to that, because it has a role in the provision of bricks and bedpans, but I am, to use that polysyllabic word, ideologically opposed to its involvement in core services, because that compromises them.
I said that clinicians who work for the NHS and are in the market for private work at the same time clearly compromise themselves and the efficiency of the service. A survey that I undertook in Cornwall in 1999 showed that the specialties with the longest waiting times were, coincidentally, the same specialties in which the greatest amount of private work was done by clinicians who also worked in the NHS.
I question whether that situation is efficient. It creates more bureaucracy. One of the clinicians in my constituency, Alistair Paterson, has complained to the Secretary of State through me that his previous booking system has had to be replaced by a waiting system, and, as a result of the new independent sector treatment centres, referral management centres now intervene in the process of GP referrals. A new raft of bureaucrats tries to redirect patients away from the NHS to ISTCs, because otherwise the income that the ISTCs will inevitably receive will be wasted.
The key issue is the one that the hon. Member for Wyre Forest finished with, and I hope that the Minister will address it. At the time, perhaps because of a surplus of NHS policy development officers in the Department—I am not sure why this happened—a decision was made that privatisation was a jolly, whizz-bang idea and that we should give it a whirl. The problem is that Pandora’s box has been opened, as the hon. Gentleman said. Now the NHS has to play by market rules, and it is open to the same competition rules as other sectors. In fact, the situation is rather worse than that. The advice that I have seen implies that the Secretary of State herself will be constrained from intervening and bailing out services in the way that under previous regimes she could have done.
I am grateful to my hon. Friend the Member for Southport (Dr. Pugh) for having given me a small amount of his time to make those points.
I congratulate the hon. Member for Wyre Forest (Dr. Taylor) on introducing this important debate. I too had the privilege of sharing a room with him during our early period in Parliament, which makes this occasion quite incestuous. I hope that the Minister is in a good mood today, particularly after the excellent Champions league results last night. As an Evertonian, I am sure that he is as pleased by that as I am.
It is nonsense to suppose that public service can exist in isolation from private enterprise. The NHS, like any public service, has always been a big purchaser of supplies and, indeed, of services from the private sector. But, by and large, it has not bought direct services for patients from private enterprise until recently. Nowadays, however, it is almost an orthodoxy to say that it should, provided that neither the quality nor the cost to the patient is in any way affected—provided that the service remains free at the point of delivery. That mimics the great saying of Deng Xiaoping, the founder of modern China, who said, “Who cares whether the cat is black or white so long as it catches mice?” Thus we have seen under this Government private profit-making enterprises take on many of the medical duties that formerly were done exclusively by NHS bodies and employees.
Ministers sometimes argue, with a degree of sophistry, that the NHS has always been, de facto, a confederation of small businesses. They argue that GPs have always been self-employed. However, the goal of private business, as we must acknowledge, is profit-making, but the goal of GPs is not and never has been profit-making. No genuine private enterprise would encumber itself with anything like the Hippocratic oath or subordinate its business practices to a constitutional framework such as that imposed on all the people who work for the NHS. In fact, the British Medical Association made that point specifically when it wrote:
“Although GPs are ‘independent contractors’ they are steeped in the ethos of the NHS and put the interests of their patients at the heart of their work. In many ways GPs’ independent contractor status is simply a reflection of the way they are paid rather than any suggestion that they not an integral part of the NHS.”
It may be impossible to serve God and mammon, and it has always proved tricky to serve the NHS and shareholders at the same time.
It certainly is the case that some bodies private and profit-making, or independent and charitable, are capable of taking on medical work done by the NHS. It is often suggested nowadays that there should be no animus against their doing so, especially as it appears at first sight that patients will be looked after as quickly and as well.
There are presumptions for and, equally, against using the private sector. It can reasonably be suggested that involvement of the private sector adds an additional cost: the profit margin of the entrepreneur, as mentioned by my hon. Friend the Member for Westmorland and Lonsdale (Tim Farron). As the hon. Member for Wyre Forest said, it puts at risk the co-ordination and smooth operation of health system provision and complicates the patient’s path to care when they are passed between the public and the private sector.
Using the private sector certainly reduces transparency in the operation of the whole system. There have been a couple of debates in this place on the deficiencies of out-of-hours services. Many people who have looked into the situation to get details about what is actually happening have had to use freedom of information legislation to prise from private contractors information that they would normally have had from the local NHS.
I believe that the Minister would acknowledge that using the private sector introduces needless legal complexity and a lesser degree of accountability. One cannot impose a statutory duty on a private contractor. If a private contractor fails to deliver, people normally complain to the commissioner, not to the contractor. That creates a genuine difficulty. Legislation going through Parliament at present will introduce local involvement networks—LINKs—to lobby on behalf of patients. If they want to take up issues, they must go to the commissioner first and only indirectly to the provider.
The major presumption against private sector involvement—it is a presumption that runs from Beveridge to Bevan right through to Wanless—is that a publicly delivered, publicly financed system of health care is an equitable, efficient and good model. In fact, I hesitate to call that a presumption—it is a fact.
To be fair, presumptions are made on the other side in favour of contracting out delivery to private contractors. It can be suggested that they are more motivated to control costs. It might be assumed that there is a plethora of competing interests out there just waiting to vie competitively for NHS custom, and that using them can defray capital costs and reduce the public sector borrowing requirement. It may be suggested that they are more flexible, and more ready to embrace innovation or bring in experience from other health systems. The big presumption running through all of that is that a competitive market will always deliver better outcomes than monopoly provision, even if the goal is to deliver health entitlements.
My views are clear: I am with Beveridge, Bevan and Wanless. The Government, though, have a problem. The Labour heart and soul are with Bevan but the brain has been captured by centre-right policy units. The Government endeavour to solve the problem by claiming to adopt a stance of even-handed Deng Xiaoping-type pragmatism, but the practice is quite different, and that has been well exemplified in this debate.
The private sector is not just chosen. It is encouraged, featherbedded and guaranteed payment regardless of work actually done. It is introduced into areas where its presence creates problems not only for NHS providers but for patients’ pathways of care. That is not just my view. The Healthcare Commission complains about clinical data from independent sector treatment centres being of extremely poor quality. The National Audit Office in its recent report on clinical governance mentioned poor management and audit of the independent sector by the PCTs that commission them. The Health Select Committee complained about the lack of robust data. The BMA bemoans the absence of a level playing field, and cherry-picking by the private sector. The Royal College of Surgeons reports itself as being unhappy about outcomes, and even the Conservatives suggested in a recent survey that poor value for money is produced by such arrangements.
If we go back to Deng Xiaoping’s metaphor, using the private sector is like force-feeding the black cat with food taken off the white one and not expecting it to catch any more mice in the process. At times, it approaches an improper attempt to use public resources not to benefit from a market but to create one in the belief that marketisation is the panacea for all public service woes. The Minister, I think, is on the verge of producing for Parliament a solution and a way of allaying those fears—the new NHS constitution. That will clarify all those issues and leave many of us quietly at rest.
I start by congratulating the hon. Member for Wyre Forest (Dr. Taylor) on his thoughtful and kind contribution. I congratulate him also on his positioning in the Chamber, which is truly independent.
The Opposition support the involvement of the private sector in the NHS if it can deliver benefits for patients. Private sector involvement is nothing new and nothing to fear. For instance, GPs, opticians and dentists are, essentially, private providers. Our central concern is that the way the Government are trying to embrace the private sector is highly inefficient. By trying to micro-manage where the extra capacity is being placed in the NHS, they are doing patients down and causing harm. We believe that if the Government were to create a right to supply the NHS and then allow patients a choice of where independent providers should be engaged, that would make for a much more efficient allocation of resources. The problems caused by the Government’s heavy-handed approach can be seen clearly in their policy towards independent sector treatment centres, as the hon. Member for Wyre Forest and others pointed out.
I start with the question of capacity. The process of engaging the private sector has been managed from Whitehall, so the ISTC programme has resulted in capacity being misplaced. New providers have been imposed on areas where NHS organisations are already meeting waiting time targets. That is happening because of a lack of consultation. Last year, in the Health Committee, the hon. Member for Wyre Forest made that very point. Indeed, the report stated:
“ISTCs were not established in accordance with the local capacity plans…In Oxfordshire, independent provision was imposed on local NHS providers against their wishes…since it would involve the transfer of work away from an NHS facility with an excellent reputation”.
That, I suggest, does not make for good and efficient allocation of resources. Patients are suffering as a result.
Just as worrying, however, is the Government’s model for engaging the private sector. Patient choice and GP-led commissioning have been sacrificed to divert referrals away from NHS providers and towards the ISTCs to make them viable. In other words, the decision has been made at the centre to restrict choice and to force patients down the ISTC route. That has to be wrong, but it is precisely what is happening through referral management centres, which sometimes have the power to overrule referrals made by GPs. What is more, some PCTs have told GPs that they must opt in favour of the new independent providers. That forces some patients into the private sector against their wishes.
I put it to the Minister that if the Government firmly believe in the value of the independent provision that they have commissioned, they should put that belief to the test by forcing ISTCs to compete fairly with the local NHS trusts. Patients and GPs would judge which was best.
As other hon. Members have suggested, another concern regarding the forced introduction of ISTCs is training. The impact of the policy on existing NHS services can be—and, I suggest, is—disastrous. The private sector has effectively been allowed to cherry-pick straightforward operations. That point was made by the right hon. Member for Oxford, East (Mr. Smith). A real concern is that specialist services are suffering because of the withdrawal of cross-subsidy from the profits generated by those routine procedures. The training of the next generation of NHS employees will suffer as a result, as trusts have to cut back on their teaching responsibilities. That point has been reinforced by the British Medical Association. We therefore risk problems being stored up for the future.
Another concern is the nature of the ISTCs’ contracts with trusts. The reason is that errors in forecasting patient numbers could result in trusts paying for operations that do not occur—in other words, paying for capacity that it not used. That will result in money leaving the NHS, but the NHS gaining nothing for it. The Minister may say that that is fanciful thinking, but answers to recent parliamentary questions reveal that utilisation rates, measured on the basis of value rather than activity, averaged only 77 per cent. in the 12 months to May 2006. That means that nearly a quarter of the capacity purchased from ISTCs has not been used. It is as simple as that. The NHS is paying for a service but not receiving it.
In addition, the ISTC programme is delivering procedures at a price that is above what they would cost the NHS. The figure is about 11 per cent. Again, that is hardly good value for money, and patients are suffering as a result. That is why the Opposition say that the private sector should supply to the NHS only if it can meet the standards and the price. However, the Government are keen to shy away from genuine competition to favour the private sector. Why? That is clearly the impression being gained in the front line of NHS service.
I offer an example of the negative impact that ISTCs are having on local NHS providers, and I have only to look within my own patch and to Basildon hospital. I realise that the Minister has had meetings with the hospital management and the Under-Secretary of State for Communities and Local Government, the hon. Member for Basildon (Angela E. Smith), but the Government are trying to force an ISTC on the hospital without due consultation. That will harm local patients.
According to the hospital, imposing a new private sector provider on the hospital could, in a worse-case scenario, result in £11 million of income being diverted to the ISTC. That will cause real problems. It is not me saying that; the hospital management are raising those concerns on a cross-party basis.
In addition, I am concerned that Basildon hospital will be forced to pay for operations that did not occur because errors will have been made in forecasting patient numbers. I mentioned some figures given in answer to recent parliamentary questions and said that nearly a quarter of capacity purchased from ISTCs is not being utilised. If we really want an efficient NHS, I suggest that only those treatments received by patients should be paid for by the NHS. Basildon hospital management’s concern is that that will not happen, particularly because patient number forecasts have yet to be finalised, although here we have an ISTC being forced on the hospital.
Imposing an ISTC on Basildon hospital will harm the training of staff there—a point made at a recent meeting of the hospital management. We know that ISTCs like cherry-picking the straightforward operations, but that will harm the specialist services in the local hospital, as well as across the NHS. I therefore ask the Minister to assure me that he will re-examine that decision, because its effects apply not only in my patch, but throughout the country.
I am conscious that time is drawing on, Mr. Jones, and I want to give the Minister time to answer our questions. I shall conclude with another direct question. Since December, he and his Department have been consulting everyone who provides care to NHS patients on 10 core principles. I believe that that is part of plans for an NHS constitution. The principles suggested bear a remarkable similarity to the 10 principles set out in the NHS plan. In fact, the only principle from the NHS plan that does not appear in the new draft almost word for word, or in spirit, is the seventh principle, which states:
“Public funds for healthcare will be devoted solely to NHS patients”.
The other principles are all there, including shaping services around the needs of individuals, supporting NHS staff and respecting patient confidentiality. But the seventh principle has been dropped, which leaves the possibility open for public funds to be used for patients to go private.
My party has dropped the concept of a patient passport. Are the Government about to pick it up? If not, why has the seventh principle of the NHS plan been dropped?
I am grateful to the hon. Member for Wyre Forest (Dr. Taylor), a fellow member of the Health Committee when I served on it, for the generous spirit in which he made his comments. As always, I respect his opinions on these matters and I agreed with much of his speech. However, there is a genuine point of difference and I will explain that before dealing with his specific questions. I am not sure that I will be able to answer everything in the 10 minutes that I have left, but I will do my best and will write to hon. Members with more specific answers, in particular to the hon. Member for Westmorland and Lonsdale (Tim Farron).
The hon. Member for Wyre Forest asked whether Aneurin Bevan would recognise today’s NHS. I am pleased to say that he would and that he would be proud of it. Since Labour has been in government, the state of the NHS has improved immeasurably—that is not spin; it is fact. That is what has happened on the ground and in constituencies up and down the country. There are not just considerably more staff in the public employment of the NHS—he knows the statistics and I do not think that he wants me to reel them off again—but the bricks and mortar on the ground in many of our communities are of a standard far superior to those in 1997. The very fabric of the NHS has been renewed. That is the progress that we have made.
The size of the public side of the NHS is considerably larger today, but I would be the first to say that it does not have a monopoly on good ideas or on how to deliver health care. I have described the changes that we have made, but our ambitions do not stop there. The hon. Gentleman knows that our ambition is to deliver a maximum 18-week wait by the end of 2008. In reality, for the vast majority of patients that will mean a wait of eight to 10 weeks. I would describe that situation as providing an end to waiting and waiting lists. People will begin their patient journey and will not simply be put on to lists to be managed. That represents the end to a process that the Government set in train.
Why is that important? I listened carefully to the hon. Member for Banbury (Tony Baldry), who made some valid points. However, to me his remarks portrayed reform as an intrinsic attack on the NHS. He read out a letter that I had sent and I stand by every word of it. Essentially, he put forward the idea that reform was a form of attack. If we, as a Government, had not taken steps to ensure that the NHS is responsive and delivers quick, high-quality care to patients, the arguments of those who call for alternatives to the NHS—those on the Opposition’s side of the political argument—would have been far louder.
There has not been a disagreement about whether the NHS is the right model for the future health care needs of the country. I am hugely proud that we have made the case for a universal health care service that provides care on the basis of people’s needs, not their ability to pay. That is increasingly accepted as not just the right way, but the fair way and the way in which we can continue to provide health care efficiently to the whole population. I do not accept that anyone from the Opposition can say that they have always believed in that. It is this Government who have shown their commitment to the NHS, stuck their colours to the mast and been a true friend to the NHS. A true friend would ensure that the NHS moves with the times and that it can deliver care of the quality and convenience that people expect today and will expect in the future.
Dare I say that I am probably the youngest contributor to the debate—or perhaps not. People of the hon. Gentleman’s generation, my generation and younger will have extremely different expectations of the national health service as they get older and become more regular users of health care services. If the NHS is not ready to provide the level of service that they expect, we will not in the long term be in a position to support its value. That is why we are taking forward a programme of reform—so we can shore up and maintain solid levels of public support for the NHS.
I remember the conversations that the Health Committee had during our inquiry into the role of the NHS. There was opposition to the concordat with the private sector that was signed shortly after the general election and to private finance initiatives. Such opposition is not heard from the patients and the communities that are benefiting from those initiatives, and that is why I fundamentally disagree with opposition to such schemes.
I will pick up on some more of points made by the hon. Member for Wyre Forest, as they were important. He asked whether the capacity is genuinely additional. Absolutely it is. In many ways, he contradicted himself in his next point because he went on to say that the additionality clause in some of the wave 1 contracts was a wired clause that worked against the interests of the NHS. Wave 1 ISTCs were commissioned to provide genuine additional capacity to that provided by the NHS. That was the reason for the clause that he went on to describe as detrimental to the interests of the NHS.
I do not have a great deal of time to deal with anything else. I will push on and perhaps we can pick up on that point in future.
The hon. Gentleman raised the issue of value and questioned how private sector involvement can be the right thing. As a long-standing clinician, he will know that NHS spot purchases from the private sector are not new and have taken place for many years. Across the full period of wave 1 ISTC contracts, the average percentage costs above the NHS equivalent costs for all wave 1 ISTCs is currently 11.2 per cent. That compares favourably with the historical costs to the NHS of spot purchasing from the independent sector. That is because it has been done in a planned way and in a way in which economies can be generated. That is driving good value through the NHS. Let me quote Laing and Buisson’s 2005-06 health care sector report, which says:
“The emergence of a new raft of ISTC providers able to quote at, or fairly close to, NHS reference costs made it clear that the days of NHS spot purchasing from the ‘incumbents’ at 30-40 per cent. over reference costs were over, and that they would have to reduce costs and prices if they wished to be involved in any significant way in servicing the NHS market.”
Hon. Members have failed to recognise that point, which is extremely important. There is a powerful value-for-money argument as well as benefits to patients who will be offered treatment more quickly than they could otherwise have secured it.
A question was asked about capacity planning when schemes are taken forward. I assure all hon. Members that there is a robust process in place to ensure that there is local support and capacity need for each ISTC scheme introduced. That is guaranteed.
The hon. Gentleman asked about training, which is another important issue. Training is a requirement for all phase 2 providers and is contractual. However, it is the choice of local training local organisations—the deaneries—whether the training capacity is used. Such an approach has been agreed with the Postgraduate Medical Education and Training Board. I hope that he welcomes the progress that has been made on that.
My right hon. Friend the Member for Oxford, East (Mr. Smith) mentioned specialist orthopaedic trusts and quoted my local trust, Wrightington, Wiggin and Leigh. I understand the situation in which those providers find themselves and the argument that they make about the costs of providing specialist orthopaedic work not being adequately reimbursed through the tariff. I understand that point. The process of payment-by-results will refine and improve as we progress so that there can be a further differentiation of high-value work and work that can be provided at a lower cost. I recognise the need for a sustainable solution.
My right hon. Friend has raised issues in relation to the Royal National Orthopaedic Hospital NHS Trust before. The trust needs clarification on such questions to take forward plans in relation to its estate or to realise its ambitions to be a foundation trust hospital. There is a need for a sustainable solution, and I and the Secretary of State met the trusts concerned not long ago. I assure my right hon. Friend the Member for Oxford, East that we will work towards finding a solution.
Autistic Children (Education)
I am delighted to have secured this debate on education provision for autistic children. Estimates of the number of people with autistic spectrum disorders total 587,900, and of those 133,500 are under 18 years of age. In the past few years, numbers have risen in my own constituency. According to UK researchers, autism may affect up to one in 100 children. Autism impairs social interaction, communication and imagination, and the spectrum also covers Asperser’s syndrome.
The debate was inspired in part by my constituents Ivan and Charika Corea of Buckhurst Hill in Essex. They have a son, Charin, who is 11 and has ASD. To the Corea family and anyone who has met him, as I have on a number of occasions, Charin is a God-given blessing. He is a special child, with the most wonderful loving, caring nature. He has inspired the family to campaign long and hard, with no funding, because, in Ivan’s words,
“There are thousands of Charins who are suffering without public services in education, health, specialist speech therapy and respite care.”
Charin goes to Buckhurst Hill primary school, where an autism unit has been built, and Hatton school.
The Corea family launched their autism awareness campaign in the United Kingdom in 2000. A small acorn of an idea turned into a substantial movement with the launch of autism awareness year in 2002, supported by the British Institute for Brain Injured Children, the Disabilities Trust, the National Autistic Society and more than 800 other UK organisations.
Ivan has met and lobbied the Prime Minister and my right hon. Friend the Leader of the Opposition. Last Saturday, Ivan met the Secretary of State for Education and Skills. The Corea family have shared the serious concerns that they have, as parents and carers, with parliamentarians of all parties. They and many other families affected are calling on the Government to launch a 10-year programme of building and staffing specialist autism schools and the construction of autism units in mainstream schools. They are urging the Department for Education and Skills to address the failure of some secondary schools to come up with education strategies to deal with autistic students.
I am sure that I speak for everyone in the Chamber when I congratulate the hon. Gentleman on securing the debate and on the passion and commitment that he brings to the subject. He has referred to a 10-year plan. He will be aware that, 10 years ago, not remotely the same number of children were identified as being on the autistic spectrum as now, and 10 years before that there were hardly any. What does he assume that the figures will be in 10 years’ time? Does he envisage the situation worsening and numbers increasing, or does he feel that we have plateaued and that all the children on that spectrum have been identified?
I add my congratulations to my hon. Friend on securing this important debate. Does he agree that there are real challenges—particularly for secondary schools, which perhaps, despite the guidance provided by the Government, feel that an obligation is being thrown back on them to deal with these concerns? I have found that in my own constituency. Looking to the future, there are also issues about the lack of support for adults who are encountering autism. That is a real concern.
I thank my hon. Friend for that intervention. Yes, he is perfectly right. I hope to cover a number of the points that he has raised.
Another concern relates to the bullying of autistic children as well as the lack of recreational activities and further and higher education opportunities for young people with autism. On the health front, children with autism desperately need osteopathy on the NHS and parents are calling for answers on what causes autism, although I do not intend to go into that today.
Carers need respite as dealing with autism is a 24-hour-a-day job. Many of my constituents have spoken to me about marriages breaking down, people having nervous breakdowns and the stress and pressure that is put on people who are carers 24 hours a day. I am sure that other hon. Members on both sides of the House have encountered similar cases.
In 1978, the Warnock report argued passionately in its conclusions for the inclusion of children with special needs in mainstream schools, and that view has influenced education policy ever since. Recently, however, Baroness Warnock called on the Government to set up another commission to review the policy of inclusion. She concluded that there is an urgent need to reconsider the concept of inclusion.
We need a level-headed and rational assessment of the situation as it is, not as we would like it to be. The dogmatic approach of placing all pupils with special needs in mainstream schools has frequently benefited neither them nor the children whom they are educated alongside. A far more pragmatic approach, offering parents and special needs pupils a real choice between mainstream and special education, must be adopted. All too often, with the postcode lottery of special educational needs provision, the choice is, “Take it or leave it.”
In my area, Redbridge, we are fortunate in having Hatton school and Little Heath school, both of which provide a first-rate service to children with special educational needs. I pay tribute to the teaching staff and everyone else involved with those schools. We are also lucky in having a very active group called STAAR—Supporting Together Autism and Asperger’s in Redbridge—which works tirelessly in support of autistic children and their families.
I would also like to draw attention to Kisharon day school in Finchley, which does excellent work with children from the Jewish community who have special educational needs. A religious element in education should be recognised as a legitimate choice for parents.
I commend the work of TreeHouse, which is a national charity for autism education. Its vision is to transform through education the lives of children with autism and those of their families. Established in 1997 by a group of parents, TreeHouse runs a school for children and young people with autism, and campaigns for better autism education nationally.
More needs to be done to identify at an early stage children with autism. More detailed information about how to recognise the condition needs to be made available to parents, doctors and teachers. Getting that right will bring the educational support that the children need to progress in structured learning.
Since 1997, more than 90 special schools have closed and those remaining have fewer pupils, despite a steep rise in the number of children diagnosed as having special educational needs. Ministers state, “Inclusion is not an agenda to close special schools,” so we need to ensure that we prevent special schools from closing, recognise the poor provision in many areas of the country and record the fact that there is increasing demand for those places.
My hon. Friend referred to the Government saying that their policy is not to close special needs schools. I remember initiating a debate on this issue three or four years ago. I pointed out at the time, and it is worth pointing out again, that the problem with stated Government policy and the way they approached it back in 1997, 1998 and 1999 was that they gave an opportunity and an excuse to local authorities to use the rationale of inclusion to get rid of special needs schools, selling the land for housing to make short-term money, very little of which was ploughed back into the system. A very casual statement such as the one that we have heard about does not deal with the truth of the matter.
May I follow on from the intervention made by my right hon. Friend the Member for Chingford and Woodford Green (Mr. Duncan Smith)? The situation has become worse. I raised it in the main Chamber earlier today and the Prime Minister’s response was disappointing. The issue is not only local authorities closing special schools, but local authorities not taking cognisance of the need for out-of-borough placements. Of course, the Prime Minister was right to say that the decision is a local one, but 75 per cent. of local government funding comes from central Government, and unless central Government will the means, local government cannot take that on board. That is a particularly important point.
I thank my hon. Friend for that comment and I am sorry for what I am about to say. It would be easy to turn the debate into a political Punch and Judy show and blame the Government for all the ills in education provision for autistic children, but that would not be totally deserved and would not take the discussion in the right direction. I recognise exactly what my colleagues have said, but I want to look forward to how to resolve problems.
Baroness Warnock is right to say that inclusion
“springs from hearts in the right place”.
Many of us have at some time been seduced by the theory of inclusion, which seems so nice and reasonable and politically correct, but there is clear evidence that it does not work for every autistic child. Many parents know that inclusion is not appropriate and that that policy is failing their child. We need to make available to every autistic child the form of education that will give them the most effective learning environment. We should support inclusion, but only where it is in the best interests of the child and is the parents’ choice.
I draw attention to the National Autistic Society’s superb efforts to assist people in the UK with autism. In May 2006, it launched its first ever education campaign, “Make School Make Sense”. Its research found varied outcomes for children with autism, such as 20 per cent. of them being excluded from school and 67 per cent. of those excluded children being excluded more than once. It also found that only 30 per cent. of parents are satisfied with the understanding of autism in their children’s school and that 66 per cent. of parents believe that their choices have been constrained by lack of provision. There is difficulty in accessing professionals such as speech and language therapists even when such support is identified in a statement as being needed. The results of the research led the NAS to call for three things: the right school for every child, the right training for every teacher and the right approach for every school.
The hon. Gentleman has touched on an extremely important point about the broad range of the autism spectrum—what is appropriate for one child often is not appropriate for another. Does he think that there is a role for external agents such as educational psychologists to take decisions, given that parents are understandably sometimes incapable of objectively regarding their sons and daughters?
The autism spectrum is so long and wide that a child’s behaviour can sometimes be identified under another heading such as attention deficit hyperactivity disorder or as a behavioural problem. Does the hon. Gentleman think that an objective external body could take such decisions? If so, what would its role be? I am thinking particularly of educational psychologists who are employed in local education authorities.
Of course, there has to be a role for an external body, but I emphasise that parents are with their children on every day of every week—it can be hard to be objective in those circumstances. There must be professional help, but in unison with the parents, not ordained from on high.
There should be a statutory duty on local authorities to secure a range of SEN provision centrally and it should be properly funded. NAS research found that more than 50 per cent. of such children are not in the kind of school that their parents believe would best support them. That recommendation was endorsed by the Education and Skills Committee report on SEN last July. It is not unreasonable for a parent or child to expect some form of SEN provision in their area, whether it is a special school, specialist support or a resource base in a mainstream school. Where provision is absent, long journeys to school can have adverse consequences on a child’s ability to concentrate and on the time spent with their family. In some cases, the sheer cost of travel can be a problem.
It makes sense for local authorities to work together to assess and plan provision for children with autism and all forms of SEN. Similar suggestions were made in the autism spectrum disorder good practice guidance produced by the Department for Education and Skills. What is the Minister going to do to encourage co-operation between local authorities and others to develop the range of provision for children with autism?
Given that autism is thought to affect one child in 100, every teacher should expect at some stage to teach a child with autism. There have been welcome recent developments on teacher training. For example, SEN co-ordinators must receive SEN training and must be qualified teachers, and there are autism resource packs for every teacher. There is also an inclusion development programme that includes autism.
The need for improvements in teacher training was made all the more clear by a recent survey by the National Union of Teachers, which found that 44 per cent. of teachers are not confident in teaching children with ASD and that 39 per cent. are not confident in identifying children with ASD. Some 76 per cent. said that the lack of professional development in this area is a barrier to teaching children with ASD. All mainstream schools must be autism friendly so that as many children with autism as possible can be educated in mainstream schools.
NAS campaign research found that children with autism often miss out. Almost half the parents of such children in mainstream schools say that the school is not adequately accessible. Almost half such parents say that their child has not been able to take part in activities before or after school, where they are provided. I must add, however, that in many areas there is no such provision. The NAS “Make School Make Sense” campaign encourages schools and local authorities to make improvements for children with autism. What works for children with autism tends to work for all children. Examples of good practice include providing quiet space, having peer support such as a buddy system or circle of friends, and having visual timetables.
I think we agree that more needs to be done to help to secure a better education for children with autism, and I hope that this debate will help to move matters in that direction. I have met many families in my constituency who rightly want to do what is best for their children, and I am sure that all hon. Members have similar experience. Let us start to help them.
I genuinely welcome this debate and the efforts that the hon. Member for Ilford, North (Mr. Scott) has made to bring these important issues to the public’s attention. As a constituency MP, I have dealt with these matters on behalf of parents, and I know how challenging it can be to deal with a child who has special educational needs, particularly one with autism. I recognise the hon. Gentleman’s commitment to this issue, and that of other hon. Members. The hon. Gentleman is particularly concerned for his constituents, but I cannot comment in detail on the individual cases that he discussed, as I did not have advance notice of them.
The significance of this issue has been highlighted by the NAS “Make School Make Sense” campaign. The Under-Secretary of State for Education and Skills, my hon. Friend the Member for Gloucester (Mr. Dhanda), was pleased to speak at the parliamentary launch of that campaign back in May. Other hon. Members spoke forcefully at the launch about the pressures that having a child with autism can put on families. Like many MPs, I know from my constituency work how desperate parents can feel when trying to ensure that their children get what they believe to be the right provision. We acted to help parents under our early support programme by publishing our popular guidance for the parents of autistic children. However, more needs to be done.
Before I go any further on the issue of autistic children, I shall respond to some of the points that the hon. Member for Ilford, North raised and make some general comments about SEN. For the record, this Government have never had a policy of closing special schools, per se. Indeed, local authority expenditure on SEN has increased from about £2.8 billion to £4.5 billion over a period of five years. Since 2001, the percentage of children with statements who are educated in special schools has increased by 1 per cent., and local authority expenditure by school shows a 50:50 split between special schools and mainstream schools. I welcome the fact that the hon. Gentleman encouraged his colleagues not to start a party political battle on this, especially given that many more special schools were closed under the Conservative Government than under this Government.
The hon. Gentleman talked about the construction of schools. Clearly, the opening of new schools is a matter for local authorities and for voluntary and independent providers, but we will—this directly addresses one of his points—produce guidance on the reorganisation of SEN provision. That will rightly promote a range of provision, including special provision.
The hon. Gentleman also raised the crucial issue of equipping teachers and teaching assistants with the skills and experience to deal with children with special needs. That is a key part of the programme that the Department is developing.
I entirely concur with the points that the Minister has just made, as I am sure everyone will. What does he have to say about training people in mainstream education to assist with early identification? I constantly come across cases in which teachers have concerns but do not have sufficient training to identify them in a manner that would be recognised by professionals in the field. Is there any generalist training?
My hon. Friend’s point is exceedingly important. We are prioritising training for teachers in respect of children with special needs, and we are also prioritising the role of special educational needs co-ordinators so that they can work within a school. Early identification is crucial so that children get the direction and support that they need.
As hon. Members will know, autism is a spectrum condition. We talk about autistic spectrum disorders because people with the condition range from those with severe learning disabilities and challenging behaviour to intelligent people with Asperger’s syndrome. Individuals on that spectrum have a unique profile of need. For example, a young person with Asperger’s may also have behavioural or mental health difficulties. That spectrum of difficulties, which requires input from a number of agencies, makes autism an exemplar condition.
As autism is a spectrum condition, children on the spectrum need different types of provision—in mainstream schools, in units attached to them or in special and autism-specialist schools. It is crucial that we make it clear that that variety is available, which is precisely why our policy is to encourage a spectrum of provision to meet that spectrum of needs. Indeed, the good practice guidance on autistic spectrum disorders, which we published in 2002, promoted that spectrum of provision. We know that schools, local authorities and the regional partnerships that we fund have used that guidance to help deliver and develop that provision. We continue to support that policy for both children with autism and those with special educational needs in general.
That guidance is extremely helpful to schools but, from the figures that my hon. Friend the Member for Ilford, North (Mr. Scott) postulated earlier and the response that I have had from secondary schools in my area, it seems that there is a tremendous lack of confidence that schools can deal with pupils with the condition. Is the problem a lack of confidence or a lack of qualification and ability on the part of teachers to provide the best support?
I shall come later to the specific issue of parental views on what is happening in the system. Although I would be the first to recognise and acknowledge that there are real challenges for some parents and some young children, the overall figures show that there is much greater confidence in and support for the system than is sometimes suggested. I certainly acknowledge that we need to do more.
It is not only encouraging that there is a spectrum of provision for a spectrum of needs, which is the right approach; it also fits in with what parents want. The report for the “Make School Make Sense” campaign noted that, taking parents’ views as a whole,
“the answer is not mainstream or special, but both. When given a theoretical choice, parents are fairly evenly split between mainstream schools, special schools and resource bases in mainstream schools as the best option for their child.”
Often, quite rightly, it is parents who do not get the option that they want from whom we hear, but there is a wider variety of views in existence.
Although there is still a way to go, the range of provision that we want is developing. For example, based on visits to 150 English local authorities, the Department’s team of SEN national advisers has reported that many authorities are developing specialist resourced provision in mainstream schools and that most of that new provision is for pupils with autism or behavioural, social and emotional difficulties.
Hon. Members may be aware that Ofsted has reported that additionally resourced provision is particularly successful in achieving high outcomes for pupils academically, socially and personally. For example, there is a successful autism unit at Beal high school in the constituency of the hon. Member for Ilford, North. It is featured in the online version of our good practice guidance, as is Hatton special school, also in his constituency.
It is not just in the maintained sector that provision is expanding. In the past few years, new autism-specialist provision has opened in the voluntary and independent sectors and is part of a spectrum to which local authorities can give parents access. We encourage local authorities to work co-operatively with those providers, as they can sometimes provide the solution.
Do such welcome developments mean that there are no problems with educational provision for children? Clearly not, and a number of the difficulties that the hon. Gentleman highlighted underline that fact. It is true that the parents of children with autism, like those of other children with SEN, do not always get the school that they want, and it is a concern that the number of appeals registered in 2005-06 at the special educational needs and disability tribunal was higher for children with autistic spectrum disorders than for those with any other type of SEN. Most worrying of all is the finding of the Office for National Statistics that 27 per cent. of autistic children have been excluded at some point and that most of those—23 per cent. overall—have been excluded more than once. That is a concern.
Worrying though those findings are, it is not possible to argue that we have a general crisis in provision for children with autism, although we do need to deal with the problems. It is always helpful to hear about individual cases of the system not working which are identified by MPs, but we need to see the wider picture. As of January 2006, some 39,000 children with autistic spectrum disorders were being supported at schools in England, and of those the great majority—almost 30,000—had SEN statements. That means that they have resources available for their education over and above what is normally available in mainstream schools, and that their parents have a better chance of getting the school that they want for their children. As I have said, not all parents get the school that they want, but local authorities, for example, can and do fund provision in autism-specialist voluntary or independent schools. A recent report by the Audit Commission found that the majority of children placed in non-maintained or independent special schools with fees paid by local authorities had autism or behavioural, emotional and social difficulties.
Of the 760 appeals relating to autism cases that SENDIST dealt with in 2005-06, 318 were withdrawn and 155 conceded. Of the 287 decided, 162 involved appeals about the school that the child should go to. Appeals to the tribunal are not the only barometer of parental satisfaction but, when compared with the 39,000 children being supported by schools, such figures do not suggest that children are routinely not receiving the educational provision that they need. When that is the case it is right that we focus on it, and one issue that we consider is parental support and parental advocacy to local authorities. However, we are not facing a picture that uniformly shows a system that is not delivering.
What I have said does not mean that we are in any way complacent. Previous reports have suggested that about 70 per cent. of parents of autistic children are satisfied with the education that their children are receiving, although one report from Brunel university in 2005 pointed out that that is only after some parents have fought for the provision that they want. As both an Education Minister and a constituency MP I know that there are concerns about the degree to which parents have to fight, through schools and local authorities, and we need more help and support through better training and better recognition of the spectrum of disorders.
Of course, if 70 per cent. of parents are satisfied, 30 per cent. are not. Frankly, that is not good enough and we know that there need to be improvements. As I said to my hon. Friend the Member for Ealing, North (Stephen Pound), improving teachers’ skills to provide for children with autism is important, which is why autism will be one matter on which we will focus in our inclusion development programme, which is aimed at providing practical help for teachers in the classroom. It is also why our autism working group is taking up a recommendation from the NAS and developing an autism pack for schools.
We also recognise the importance of supporting parents in contributing to the education and development of their autistic children. That is why, through the Department’s children, young people and families grant programme, we are supporting the TreeHouse Trust to work with parents’ groups campaigning for improved autism services. We are also supporting the NAS to extend its “help!” programme, which assists parents with such things as guidance on educational rights and accessing services and benefits.
We know that much good is being done and that there is much good provision across the country meeting the special educational needs of children with autism. We also know that more needs to be done to ensure that all autistic children get the provision that they need. We will continue to work with our partners in schools, local authorities and the voluntary sector to meet that important and significant objective.
North Yorkshire and York PCT
This year, North Yorkshire and York primary care trust received a 9.5 per cent. increase in funding—an additional £69 million—taking the total NHS budget for the county to £870 million. The NHS in North Yorkshire has never been better financed, yet the PCT is predicting that it will end the year with a £35 million deficit, and York Hospitals NHS Trust anticipates a £2 million or £3 million deficit.
We face a paradox. NHS patients are being treated better and more quickly than ever before, but a small number of patients—250 so far, according to York’s local evening paper today—with non-urgent conditions have been refused treatment. It is not necessary to remind the Minister that the 250 patients who have been refused treatment, not the hundreds of thousands of patients who received treatment, hit the newspaper headlines. I do not deny that the Government must reduce the deficit, but they must not deny patients necessary treatment while doing so.
My first point is that my constituents in York pay the same taxes and national insurance as everyone else, and they are entitled to the same access to NHS care. On my birthday on 9 January, I asked the Minister:
“The national health service is based on the principle that care is provided on the basis of patients’ clinical needs, not their ability to pay, so will the Minister reassure the House that the rights of patients in north Yorkshire will be protected, despite the PCT’s deficit, and that they will retain access to the same range of NHS treatments, and experience the same waiting times, as NHS patients from other parts of Yorkshire and the Humber.”
I was pleased to hear the Minister’s reply. He said:
“I agree with my hon. Friend and I congratulate him on adopting a constructive approach towards the difficult financial circumstances that his PCT faces.”—[Official Report, 9 January 2007; Vol. 455, c. 143.]
I expect the Government to honour that commitment, under which the PCT must change some of its current policies. In December, I met the chief executives of the Yorkshire and the Humber strategic health authority, Margaret Edwards, the North Yorkshire and York PCT, Janet Soo Chung, and the York Hospitals NHS Trust, Jim Easton in my office in York. My hon. Friend the Member for Selby (Mr. Grogan) also came to the meeting.
During that meeting, I asked the strategic health authority to produce regular information for each PCT in the region showing patients’ access to NHS services in those PCT areas. The chief executive wrote to me in February saying that she had discussed the matter with the NHS information centre and asked it to develop some meaningful indicators. I call on the Government to ensure that that work goes ahead and that the indicators are published soon and regularly. They will reassure MPs and, most importantly, the public in areas with deficits that NHS standards in those areas are not falling below the standards in other parts of the country.
In the meantime, Margaret Edwards, the chief executive of the SHA has provided information devised by her own staff. Interestingly, it shows that waiting times for in-patient treatment in North Yorkshire have fallen by 13.6 per cent., while waiting times in the region as a whole have fallen by only 3.6 per cent over the same period. There is a 10 per cent. faster fall in waiting times in North Yorkshire. The national average has fallen by 1.1 per cent. That leaves fewer people in North Yorkshire on waiting lists for in-patient treatment—13.2 people per thousand in North Yorkshire compared with 15.2 per thousand in Yorkshire and the Humber, and 15.5 per thousand nationally. Also fewer people in North Yorkshire are waiting for out-patient appointments: 11.1 per thousand in north Yorkshire; 17.8 per thousand in Yorkshire and the Humber; and 20.4 per thousand nationally.
Such information should be published regularly. I regret, but expect that waiting times in North Yorkshire will increase as the PCT’s overspend is cut. If the number of people on waiting lists increased to the same level as in other parts of Yorkshire, I could not honestly complain, because I believe passionately in the equity principle that people in all parts of Britain should have the same access to NHS services, depending only on their clinical needs. However, if Yorkshire’s waiting lists became longer than regional or national ones, I would raise hell. I would be back in this Chamber pressing the Minister to adjust his policies.
My second point is that access to health care has always been rationed, although politicians do not like to admit that. In private systems, such as in the United States, care is rationed by price. Thankfully, we got rid of that in this country when the post-war Attlee Labour Government created the national health service. Care in the NHS is rationed by waiting lists and by doctors, particularly by general practitioners who traditionally act as the gatekeepers to NHS services. As waiting times have fallen sharply as a result of this Labour Government’s policies, the pressure on doctors to ration demand—to ensure that patients are treated according to their clinical needs—has increased.
I regret to say that relations between GPs and the four former PCTs in North Yorkshire were never good. Forming a close, trusting and co-operative partnership between GPs and the new North Yorkshire and York PCT is essential if the problems caused by the deficit are to be overcome. After the new PCT was established, a prior approval panel was introduced for certain procedures without consultation with the GPs through their local medical committee. The procedures included arthroscopies, grommets, vasectomies and diagnostic scans. That policy provoked strong opposition from GPs in North Yorkshire and York, and I met their local medical committee to discuss it. The committee sent me copies of letters that GPs from around the county had sent to the PCT expressing their concern on behalf of their patients.
It was because of that concern, and GPs’ inability to sit down in a room and sort out the difficulties with the PCT, that I asked the Prime Minister in the House on 31 January to broker a meeting between the PCT and the LMC. I am pleased that that happened the following week. The relationship between the new PCT and the GPs is improving, many of the differences are being resolved and mutual respect and trust are returning. That is happening not because sweet words have been said, but because some of the PCT’s policies will change. Many of the interventions that the PCT decided would require prior approval will be changed at the end of the month and before the start of the new financial year.
I ask the Government not to put pressure on the PCT to deliver quick cost reductions to overcome the deficit because, if they do, it will end up with inappropriate measures, such as some of those that have been introduced in recent months, and undermine the trust of the public in the local NHS and of GPs, whose support is absolutely necessary in partnership with the PCT. I hope that practice-based commissioning will be introduced in all parts of North Yorkshire and York shortly, so GPs’ co-operation is essential.
The York Hospitals NHS Trust has worked with North Yorkshire and York PCT. I pay tribute to both chief executives—Jim Easton at the trust and Janet Soo-Chung at the PCT—who have worked openly and constructively, and I thank them for the way in which they have kept me and other MPs from the county in the picture. However, the NHS trust has had to freeze a significant number of vacant posts and to close some beds to respond to the PCT’s funding difficulties and to reduce its deficit. The PCT may have reduced its deficit, because if it is £35 million, it will be £10 million less than was predicted a short time ago.
The trust has also had to accept that the PCT will not be able to pay York hospital for some of the patients that the hospital has treated. For the first time, therefore, the hospital will enter an end-of-year deficit—a fairly small deficit—of £2 million or £3 million. In effect, part of the PCT’s deficit will have been transferred to the local hospital.
Negotiations for next year’s service level agreement between the PCT and the NHS trust have been extremely tough. It is anticipated that, because more patients will be treated in the community in the coming year, there will be fewer admissions than in the past year and further job reductions. I ask the Government again not to push the pace of the PCT’s deficit reduction to the point at which necessary services to patients are cut.
Let me provide one example. Next year, York hospital will be paid for fewer emergency admissions than it had and was paid for this year. GPs will be brought to the forefront of the accident and emergency department’s work and NHS walk-in centre staff will also co-operate, along with hospital consultants, to try to reduce the number of admissions. However, if on any particular day or week, there are more patients from York needing an emergency admission to hospital, I ask the Minister to guarantee that they will be admitted and that the hospital will be paid for those excess admissions. If we do not have that guarantee, we will return to the dreadful situation that we experienced under the Conservatives and patients needing an emergency admission to hospital will rattle about in the back of an ambulance looking for a hospital with the capacity to take them.
It would be a tragedy if, after the Government have trebled the NHS budget, we were to return to that situation. I do not think that it is necessary, anyway, because next year the Government will increase the budget of North Yorkshire and York PCT by a further £77 million—an almost 10 per cent. uplift in expenditure and an increase in funding that is significantly greater than the rate of inflation.
Will the Department of Health reconsider some of its policies that, unwittingly, make dealing with the deficit in North Yorkshire rather harder? There is still huge variation in the productivity of consultants throughout the country. If one considers the case-mix adjusted work rate of consultants, some are dealing with twice as many patients in a single operating session—in the case of surgeons—than others. In some cases, that can be explained by complications with a particular individual, but if the case-mix adjusted work rates of consultants differ consistently over time and without a clear explanation, that ought to be built into doctors’ remuneration. It is a serious issue that the royal colleges must address, and I hope that the Government will prompt them to do so and to return with a revision of the consultants’ contract.
NHS services in York are now provided in part by the privately owned Clifton NHS treatment centre, which is run by Capio UK. Doctors in York have expressed concerns to me that, despite being paid to treat a certain number of patients, the centre has not treated those numbers. I do not know whether that is true, but I tabled a written question that was answered by the Minister of State, Department of Health, my hon. Friend the Member for Leigh (Andy Burnham). I asked,
“how many procedures for NHS patients will be (a) paid for and (b) provided by the York Capio Centre in 2006-07”.
The Minister gave me some background information about the NHS, but ended his answer by saying that
“payments for services and operational costs of Capio UK is commercially sensitive.”—[Official Report, 25 January 2007; Vol. 455, c. 2052-54W.]
The centre provides an NHS service that is paid for with public money for NHS patients from my constituency and from that of my hon. Friend the Member for Selby. The Government must be publicly accountable for those services in the same way that they are publicly accountable for NHS services provided by NHS doctors—as it happens, the self-same people who operate in the Capio centre—at York Hospitals NHS Trust.
Parliament cannot properly scrutinise the NHS budget unless that information is made public. I have written to the Comptroller and Auditor General about that, and I hope that the Government will revise their policy and publish as full a body of information about activity in privately run NHS treatment centres as they do about the NHS’s own hospital trusts.
There is some inconsistency between the tight limits on funding, which will be imposed on the NHS trust in its new service level agreement and the Government’s choose-and-book arrangements. If there is to be a cap on the number of patients that the trust is funded to treat, how will choose and book operate? If patients were to choose to be treated at York hospital and the funding were not made available for treatment, how could the system operate?
Finally, I asked the Library statisticians to examine the geographical distribution of NHS deficits. I was told that of the PCTs in deficit in February—the time at which the Library undertook its work—12, or 44 per cent., of those trusts were in areas that are classified as predominantly rural; 11, or 41 per cent., were in other urban or mixed urban-rural areas; and just four, or 15 per cent., were in areas that are considered as major or large urban areas.
The Library statistician told me that such distribution could not be explained just by poor management. He referred me to work done in June 2006 by BioMed Central Health Services Research, which concluded that PCTs with deficits tended to be in relatively affluent and rural areas and that poor management alone was unlikely to be the cause of the deficits.
I appreciate that there are PCTS in many predominantly rural areas that do not have deficits, but independent bodies have expressed enough concern, which the Select Committee on Health has repeated and underlined, to persuade the Government to set up a review of the resources allocation working party—RAWP—health service funding formula. I hope that the Minister will confirm that the review is taking place, and that among other things, it will analyse the cost of providing health services in predominantly rural areas and ensure that the costs are properly funded.
It has been suggested by GPs in my area that, if only North Yorkshire and York had the same health service funding per capita as Hull, there would be no deficit, and of course that is the case. One has to accept, however, that the distribution of funding for health care will vary from area to area according to the burden of ill health. Hull clearly has a higher burden of ill health. There is much lower life expectancy and higher death rates from cancer, heart disease and so on than in North Yorkshire; it has more demand for health care. I would not expect the Government to equalise funding across—
Thank you very much, Mr. Jones—not for interrupting my colleague, I hasten to add.
I begin by paying tribute to my hon. Friend the Member for City of York (Hugh Bayley) for securing this debate and for handling the situation in a responsible and balanced way. He did not attempt to mislead his constituents into thinking that this was an easy situation, but equally he has championed, publicly and privately, their right to have access to high-quality, responsive NHS services, despite the financial challenges faced by his local health economy. His constituents are entitled to know that he has been strident in putting the case for their interests, while making it clear that he believes that there is no future for an NHS that does not insist on financial discipline. Most hon. Members accept that financial discipline is ultimately the route to a stable NHS that can take maximum advantage of the incredible, unprecedented sustained investment that the Government have made available in recent years. As my hon. Friend said, by next year, that investment will have nearly tripled.
I pay tribute to my hon. Friend the Member for Selby (Mr. Grogan), who has also made consistent representations on behalf of his constituents, both publicly and privately, and expressed concerns about the consequences of the current financial situation with regard to their access to health care.
This is not an easy situation for anybody. The Government have decided that for the first time, arguably, in the history of the NHS, we are going to look it in the eye and say, “Like any other public sector organisation, or any household in this country, you have a finite budget and the expectation—the norm—will be that you manage within that budget.” As my hon. Friend the Member for City of York said during his excellent contribution, that is unquestionably the case. If hon. Members, or residents of York and the surrounding area, were to consider the year-on-year increases that their local health economy has received, irrespective of any global or national figures, they would find it hard to dispute that the increases have run considerably ahead of inflation, and will continue to do so next year. The Government cannot and will not apologise for asking the NHS in every locality to achieve that balance.
My hon. Friend has been incredibly active—including submitting a question to the Prime Minister—in making the case for the centrality of an integrated working relationship based on mutual trust and respect between the primary care trust and local general practitioners, and also the three-way relationship between the PCT, GPs and the acute hospital trust, to ensure that the locality takes a holistic view of the resources available to secure health care. He has played a major part in rebuilding bridges, which hon. Members would admit, if they were frank, were severely damaged by the historical relationships between GPs and the former PCTs. In the end, that situation undoubtedly got in the way of patients having access to the quality care that they deserved, and got in the way of the best use of resources.
It is always difficult to strike a balance between the responsibilities given to managers and leaders, and the professional judgment and leadership provided by practitioners, whether they are doctors, nurses or others. In York and elsewhere, it is crucial that those different professional responsibilities in the NHS do not get in the way of an acceptance of the common cause of ensuring equal access for patients to high-quality, responsive services.
As my hon. Friend said, the history of the coming together of four primary care trusts is difficult because each of the four had a deficit at the point of merger. Therefore, it was never going to be an easy management task for the leadership of the new PCT. I am pleased that he praised the leadership of the PCT and the hospital trust for the way they are working to get through those difficulties together.
It is important to be honest about the inevitability of redirecting resources within the NHS from acute NHS care to community-based health care, and beyond that, to social care. Medical advances, patient expectation and the desire of people to receive treatment closer to home so that they can remain in the community instead of being hospitalised unnecessarily are all factors, and many such decisions and choices are the right ones for the NHS, irrespective of financial difficulties. We must disentangle, where we can, good practice from what should be happening anyway with regard to the redirection of resources and the appropriate balance between primary and acute care. Some changes should be happening anyway, irrespective of the financial pressures.
I shall respond to some of my hon. Friend’s specific points. He talked about accident and emergency. Ministers will always add caveats to statements in such debates by saying that we no longer run the NHS from offices in Westminster and Whitehall. However, as he said, we are accountable to hon. Members for ensuring that patients have equal access to NHS care in their constituencies. It is a difficult balance to strike with regard to where the responsibility lies. I shall try to address the points that my hon. Friend made in that context.
On access to accident and emergency, we need to have a sensible, mature approach that deals with the relationship between the hospital and primary care. It should mean that in all circumstances other than the most exceptional cases, nobody is turned away who genuinely needs emergency care and admission to hospital. The problem with that statement is that there are exceptional cases sometimes where an individual believes they should be admitted to hospital, but the genuine view of the clinicians is that that is not appropriate. Some of us, indeed, have our own personal experience of that over the years.
My hon. Friend asked about Capio and the question of commercially sensitive information. I am not at liberty to undermine the Government’s entire policy on this matter—that is probably a little above my pay grade—but one way round it might be to encourage Capio, in the interests of transparency, to be clearer about its facility in York, with regard to how much it has been paid and how much capacity has been utilised as a result of those payments. That does not totally address my hon. Friend’s point, but it seems reasonable to approach Capio directly—at the end of the day, it is not doing anything wrong, as far as we can see—and ask it to share its funding situation and outcomes with hon. Members.
I agree with my hon. Friend about consultant productivity. Variability should be addressed, and the royal colleges and the professional bodies should take responsibility. It is not just a matter for Government, but a question of being a true professional, and what that means in terms of productivity. I understand his point about the choose and book process. We want patients to have the maximum choice possible when choosing a hospital, and despite the financial challenges that we see at the moment, I hope that the vast majority of patients in York will continue to have that authentic and genuine choice.
It being Five o’clock, the motion for the Adjournment of the sitting lapsed, without Question put.