Rt Hon Lord Lilley

    Mr. Peter Lilley (Hitchin and Harpenden): Thank you, Mr. Deputy Speaker, for the opportunity to address the question that this debate enables us all to respond to. It is the question that the public are putting to all parties, and to every Member of the House. The public want to know how this country can have world-class public services. They are puzzled as to why, despite the claimed–and in some cases, real–injections of additional money by the Government, those services appear to be getting worse in many sectors.

    The public are puzzled, and they want a thoughtful, reasoned answer from people in the House. They will be profoundly disappointed by the response from the Secretary of State today. They will not be pleased that his reply consisted only of negative, bad-tempered, partisan attempts to blame everything that is happening now on the past and on his predecessors. They have a right to expect something more reasoned, thoughtful and forward-looking from a Secretary of State, particularly as he has vouchsafed to the media outside the House his thoughts and inklings of his plans, which he failed to mention here today.

    I want to try to address some of those issues. I hope that I can claim some respect across the House for being not exactly partisan on this matter. My departure from the Front Bench and from the deputy leadership of my party was precipitated by a speech that I made on the importance of focusing on and improving public services, and the limited role that private enterprise would have to play in that process. That evoked anger and horror in The Times and other organs of extremism that now relish reflections of what I said when they are uttered by the Secretary of State for Health.

    Like my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), I seek consensus, but I shall begin by spelling out a few facts as they appear to my constituents, based on their experience of public services in Hertfordshire. I shall focus on health in due course, but I shall start with education, and with the size of classes and the pupil-teacher ratio in maintained secondary schools in my constituency.

    I was worried about what appeared to be happening, which seemed to contrast with what I was hearing from the Government, so I tabled a question asking what had happened to the pupil-teacher ratio since I was first elected in 1983. The answer showed that the pupil-teacher ratio improved during the period in which the Conservatives were in office, but in the secondary schools of Hertfordshire it has deteriorated every year since the Government were elected.

    Class sizes have got bigger. A Government who told us that their top three priorities would be education have given us bigger classes, bigger classes, bigger classes. That may be partly because of the difficulty of recruiting teachers. Hertfordshire is a high-cost area and, despite the fact that our schools are attractive places in which teachers would generally like to teach, we have recruitment difficulties.

    I therefore tabled another question asking how many teacher vacancies there were in Hertfordshire. The Minister for School Standards came back with the figures, on the central definition that he used, and said that there were just 50 unfilled vacancies in Hertfordshire. I issued a press release to that effect and, to my embarrassment, the local newspapers came back asking, “What do you mean by this? There are far more than that.” Indeed, the county council figures show that the actual number of vacancies is more than four times as high as that revealed by central Government. [Interruption.] The figure recorded and collected by officials at Hertfordshire county hall is 209, not 50, and they believe that that understates the position because it does not include temporary cover in certain circumstances.

    On transport–

    Mrs. Shephard: Before my right hon. Friend leaves the subject, can he throw any light on the reasons for such a discrepancy? He was enjoined by Labour Members to give facts, and he seems to be in possession of two kinds.

    Mr. Lilley: It could be that the Government‘s rhetoric is not accurate.

    Several hon. Members rose–

    Mr. Lilley: This causes such horror among the loyalists anxious for promotion that I must give them their chance.

    Mr. Rammell: Totally fortuitously, I happen to have information on teacher vacancies in Hertfordshire in my possession, because some months ago I was making a comparison between Hertfordshire and Essex, where my constituency is based. The definition of a vacancy has not changed. The figure for Hertfordshire in 2000 was 17, whereas in 1990 it was 216. Can we have some credibility and frankness on this issue?

    Mr. Lilley: I am sorry, but the hon. Gentleman‘s figures are as unreliable as, and rather similar to, those deployed by the Government.

    Mr. Rammell: They are from the House of Commons Library.

    Mr. Lilley: I am comparing figures given by Ministers with those given by county hall officials. I have got hold of the questionnaire used by the Government, and it applies a more restrictive definition than that used by county hall officials, which explains how it is possible to get the figures that the hon. Gentleman is deploying. The head of teacher recruitment came to Hertfordshire for a one-day think-tank seminar on how to recruit extra teachers, and he acknowledged that the figures used by Government generally across the country are only a third of the number reported to local education authorities. I am grateful to the hon. Gentleman for enabling me to elaborate a little on that point.

    David Taylor: Will the right hon. Gentleman give way?

    Mr. Lilley: No. I now wish to move on to transport.

    We were told that Thameslink 2000 would produce more train services and thus ease some of the problems on the already overcrowded line from Hitchin to Kings Cross and from Harpenden down the existing Thameslink line. The cost of the project has risen from ?250 million when it was first proposed to an estimated ?2 billion now, yet the Strategic Rail Authority, a Government-created body, which made this proposal, now admits that the ?2 billion will not, as formerly believed, result in any extra services. There will not be a single extra train at peak hours down either line. It will allow those trains to go further through London, and that is welcomed. It will also make the service more attractive, but there is no point in attracting more passengers if there is not room for them on the trains because there are no extra trains to carry them.

    Although those facts have emerged during the public inquiry, the effective renationalisation of Railtrack has so bemused and paralysed management that they have been unable to respond to it or to produce alternatives, which would have given us a little extra capacity for the ?2 billion worth of public finance that it is proposed to put into this project.

    As I said, I want to focus above all on health, so let me give a few facts about the situation affecting the NHS in my constituency. In 1997, we were told that it would take just 24 hours to save the NHS. Since then, I am afraid that in some material respects, things have got worse in Hertfordshire. There are now 60 vacancies for GPs in the county, and that figure has risen twentyfold in a year. The shortage of nurses has become so worrying that it has been necessary to close not just the special care baby unit but the maternity unit and the children‘s unit at Hemel Hempstead and transfer them all to Watford. We are awaiting the outcome of an inquiry, which may have reported to the Minister today, on whether that move will go ahead and, if so, whether it is likely to become permanent. If so, we fear that it may precipitate the undermining of Hemel Hempstead as a viable general hospital with its own acute and accident and emergency units.

    That problem springs from the current shortage of nurses and the difficulty of recruiting staff.

    and doctors, surely those problems were created by the previous Conservative Administration and can be nothing to do with the current Administration.

    Mr. Lilley: The Government have been in power for more than four years. More importantly, there is in this country a substantial number of nurses who are qualified but not working in the NHS. There is therefore a vast pool of nurses from which recruitment could be made. However, rather than doing that, the Government have often recruited from the Philippines, as has been done for units elsewhere in Hertfordshire.

    Andy Burnham: Will the right hon. Gentleman give way again?

    Mr. Lilley: I have already given way once. The hon. Gentleman has done his duty by his Whips.

    We then have the issue of waiting times. In 1997, the national figure for the proportion of patients waiting for more than a year was just over 2 per cent. Now in Hertfordshire, it is three times that proportion. Although improvements have been made in some areas during the 50 years in which the health service has been in existence, on a number of key issues things have got worse. The broad move forward that we were promised has not happened in the NHS and people are worried about what is happening.

    The Government‘s response is to promise more money, and then to go on promising more money in the future. They have set a target that this country should raise spending on health as a proportion of national income to the European average. That is an absurd target to set. Surely one should set a target–I hope that my hon. Friends will agree that this is their ambition–to match or surpass the standard of care achieved by comparable countries, not simply to spend as much money. Anybody can spend money without necessarily achieving improvements or higher standards.

    Mr. Dawson: Will the right hon. Gentleman give way?

    Mr. Lilley: I shall give way in a moment.

    When my right hon. Friend the leader of the Conservative party illustrated that point, the Prime Minister had no response to it. My right hon. Friend said that Scotland, Wales and Northern Ireland already spend a higher proportion of GDP on health than the continent spends, which is the target that the Government want to attain. Does anyone pretend that the quality of care, of health outcomes, in Scotland, Wales and Northern Ireland is one that we should seek to emulate and universalise across England? Does any Labour Member say that his or her ambition is to make the English health service as good as the Scottish health service and no better? None of them does, but that is the Prime Minister‘s ambition. That is why we believe that the answer does not lie just in spending targets.

    The problem with the NHS, now and in the past, is that it is too centralised; Labour has made it even more centralised. Again, in my area, one sees that. The Government have taken away the right of the patient and GP to choose which hospital to go to. My area is surrounded by five general hospitals. We used to be able to choose which hospital to attend, despite some obstacles, but we can no longer do so.

    Instead, the Government gave that responsibility to primary care groups. They then merged primary care groups into bigger primary care trusts. They merged the four health authorities in Hertfordshire in twos, so that there were just two. Those were merged into a single one for Hertfordshire. Now that is to merge with Bedfordshire. There is constant merger and increase in size. Across the country, about 95 health authorities are to be merged into 28 big ones.

    Dr. Stoate: May I inform the right hon. Gentleman that it was his Government who got rid of the freedom of GPs to refer someone to whichever hospital they liked? Following the 1990 health reforms introduced by the right hon. and learned Member for Rushcliffe (Mr. Clarke), I phoned up Guy‘s hospital because I had a patient with a very rare type of leukaemia. The specialist said, “Have you got a contract with this hospital? If not, we cannot help you.” It was the only hospital in the area that could help. In the end, I won my case but it was the Conservative Government who ended the right of GPs to refer patients to where those patients wanted to go.

    Mr. Lilley: That is not the case. [Interruption.] I am sorry. What ended that practice was the circular that I have in my hand: circular 177 from 1999, which abolished extra-contractual referrals. The hon. Gentleman said that he achieved his aim in 1991–an extra-contractual referral.

    Dr. Stoate: In fact, I had to argue my case. A very kind consultant from Guy‘s said, “I will bend the rules for you.” I had lost the automatic right to refer a patient with a very rare form of leukaemia automatically to the hospital of my choice. I had to move through a very circuitous route before I was able to win. I had to persuade the consultant to accept my case.

    Mr. Lilley: The hon. Gentleman cannot say that we abolished that right and he none the less achieved it. It may not have been as easy as he would like or as I will propose, but the practice was certainly abolished as a right by the circular issued in 1999. Since then, my constituents have not been able to choose which of the five surrounding general hospitals to go to.

    I have had deputations of surgeons and specialists saying that the problem of specialist care has been intensified and exacerbated by that policy change. That was repeated by the president of the Royal College of Surgeons, who said that it had seriously undermined the provision of specialist care of the kind that the hon. Member for Dartford (Dr. Stoate) mentioned.

    Centralisation has been going on in the health service under this Government, at least up to now. It has culminated in central Government specifying in micro-detail what hospitals and parts of the local health service will do. My local hospitals are set about 248 targets. That is an archetypal sign of Stalinist centralisation: the belief of the people at the top that they can micromanage by laying down directives from on high, which all hospitals have to meet.

    Nowhere in the modern world attempts to manage large organisations such as that. The lesson from most large organisations is that, increasingly, one should take the opportunity to delegate responsibility locally, to give much greater autonomy, to make much more use of flatter, leaner management structures and of the opportunities that modern management methods and information technology make possible. However, that has not happened under this Government.

    That is partly because the mind-set of the left is to centralise; it believes in central planning and control. That perhaps explains to some degree what has been going on, but it does not explain why new Labour Ministers who thought that they had shed the centralising tendency, or at least who were open enough to recognise that it had been a fault in the past and who declared themselves to be free of it in the present, have been involved in centralisation: the attempt to control everything from the centre. It is partly because of that other aspect of new Labour Ministers: they are initiators. They demand an initiative a day or a week to get the headlines.

    The simple way to get a headline is to launch an initiative from the centre, which inevitably involves some central decision imposed on the people at the sharp end of the service. That is why all those ring-fenced funds have been established, all those targets have been set, all those central directives have been laid down–so that new Labour news managers can get cheap and initially favourable headlines at the expense of a much more centralised, rigid and inefficient health service. That is what has happened in the health service.

    I have been advocating a move in the opposite direction. I published a document, which is already going through its nth print run, called “Patient Power”. I recommend it particularly to the hon. Member for Dartford, who did not remember the history accurately of how these things have come about.

    I have advocated that we return power, decision making and choice to patients and to the GP who advises them. That is the most important direction in which power should move. We should restore the right of the patient to choose which hospital to use, certainly for all normal operations; for more specialist procedures the choice will inevitably be limited.

    As I say, from 1999, that choice was removed by circular 177. It has meant that, instead of the individual patient making a choice, the local health bureaucracy, the primary care trust in most cases, enters into contracts with hospitals, and patients follow the money rather than the money following the patient.

    It is important to enter into the history and to acknowledge that the problems have not always been recognised, even by my own party. Choice existed in the NHS prior to its establishment and was perpetuated when it was established. It was recognised that patients could choose whichever hospital they wanted, although normally they went to the local one, which was right and proper.

    However, patients should have the right, if they want, to go to a hospital with a shorter waiting list and to which the journey is shorter. They should have the freedom to go to a hospital that is nearer relatives should they want that. If they want to go to a hospital that specialises in the operation that they want, or has a particularly good record in it, they should have the right to choose that hospital, even if it means a longer wait than if they went to the local hospital. If they want to go to a hospital that they know has wonderful standards of cleanliness and care, they should have the right to opt for that. They may want one that does not have mixed-sex wards. For all those reasons patients may want to exercise choice, as they were historically allowed to do.

    Then problems began to arise with tighter budgeting in the 1970s and 1980s. All too often, patients chose, naturally, the most popular hospital. Therefore, the most popular hospitals ran through their budget before the end of the year, and it was the most popular wards and most popular hospitals that tended to close.

    That caused great perturbation among Members of Parliament in the early 1980s, and it was recognised that something needed to be done. Hence reforms were introduced by the then Secretary of State for Health in 1991. He gave GPs the right to be fundholding, which gave them greater flexibility, but where GPs were not fundholders and local authorities entered into contracts, the over-reliance on the contracting process–I accept the point–restricted choice and made it more difficult to exercise.

    Hon. Members can score points about that. They can say, “You got it wrong, so it does not matter that we made it worse.”

    Dr. Stoate: Will the right hon. Gentleman give way?

    Mr. Lilley: No, I will not. I am being frank and honest and not trying to make partisan points. I am saying that not everything was perfect about the reforms. Therefore, we should try to make them better, not worse. If the problem was that the system was based too much on contracts and not enough on money following patient choice, we should move towards a system in which money follows patient choice. That is what I want, and what I hope my hon. Friends will increasingly propose as an alternative.

    Dr. Evan Harris: I have listened to the right hon. Gentleman with interest, and I think he is right in that abolishing extra-contractual referrals and renaming them contract service level agreements reduced, at the margins, even such choice as was available. Those were reforms introduced by a Labour Government who claimed that they would get rid of the internal market.

    Mr. Lilley: Indeed, and not only I, or politicians in general, have said it. No less a person than the director of the College of Health said of the directive that did abolish the residual right of choice through ECRs that it would mean patients‘ having “less choice than ever” in the history of the NHS. She was absolutely right, and we should go back to giving patients more choice. A precondition of that, however, is our giving patients and GPs facts on the basis of which they can make informed choices. There has been some progress in that regard, but I want to see more.

    I welcomed the announcement that information would be provided about the performance of individual heart surgeons. I hope we will learn from the example of the Americans, who ensure that such information is related to patients‘ pre-operative condition. That makes possible a much better assessment of surgeons‘ performance and ability. There should also be sensible discussion of what the figures mean. Mr. Yacoub, a surgeon who deals with the most difficult heart cases, may sadly lose more patients than someone dealing with minor cases; but everyone knows that he is the best heart surgeon, and will therefore be anxious to be treated by him. People are intelligent enough to use the information that they are given, so let us make more facts available to patients.

    Most important of all, let us make the money follow the choice. When a patient chooses a hospital, that hospital should be rewarded for treating the patient: it should receive the money it needs to provide that treatment. The more popular and successful a hospital is, the more able it should be to treat patients. Funding should not depend on how soon a hospital runs through its budget and has to close wards. We must also give hospitals more independence and autonomy, so that they can reflect the desires of patients without needing to respond continually to directives from on high.

    Mr. Dawson: The right hon. Gentleman is making interesting points, some of which I agree with; but is he not missing the most fundamental fact of all? It is a commonplace among Labour Members that poverty underlies ill health. The right hon. Gentleman‘s Government did not face that fact–they hid from it–but this Government are prepared to confront it. Is it not the case that until the Conservatives are ready to face that uncomfortable truth, they will never have any credibility in terms of reform and improvement of public services?

    Mr. Lilley: I do not agree that the cause of ill health is poverty. Poverty is a bad thing: we ought to be against it, and try to get rid of it. Ill health is a bad thing, which often causes poverty, and we ought to try and get rid of that. I refer the hon. Gentleman to an article that appeared in the British Medical Journal on 5 January this year. It stated

    “Evidence favouring a negative correlation between income inequality and life expectancy has disappeared.”

    According to the BMJ, the latest analysis of the figures suggests that there is no longer any attempt to pretend that inequalities in society create the problem of poor health. That, however, is not the central issue of the debate, and it is certainly not the issue on which I want to concentrate. I think we all agree that we want to get rid of poverty, regardless of its precise correlation with health.

    I have emphasised the importance of restoring choice, giving people information that will enable them to make informed choices, ensuring that money follows choices, and giving hospitals the independence they need to respond to those choices. I can give a constituency example showing how important that can be. As I have said, the constituency is surrounded by five hospitals. One–I will not name it, because steps have now been taken to improve it–has the worst record in the country for treating patients after hip operations. One in six patients used to die within 30 days of their operations. My constituents had to go to that hospital, however, because the local primary care trust was contracted to send them there. Only when we exposed concerns about the figures did the doctors say “We knew, but we could not afford to change the contract because that would have destabilised the health economy”. They could not make a marginal change; it was all or nothing.

    Siobhain McDonagh (Mitcham and Morden): Will my right hon. Friend give way?

    Mr. Lilley: I am glad to be the hon. Lady‘s friend, and I will respond to the warmth she has displayed by giving way in a moment.

    Only if hospitals can respond to the choice of patients, and those patients are allowed to move if they want to, will changes be made. The change will usually be modest; even if the information is made available, we see no huge change in referral patterns. If that happens, however, there will be a sufficient change to induce hospitals to recruit surgeons who are more skilled in certain areas, and return others to performing operations at which they were particularly good. I now give way to the hon. Member for Mitcham and Morden (Siobhain McDonagh).

    Siobhain McDonagh: I thank the right hon. Gentleman, and apologise for embarrassing him by calling him my friend.

    The right hon. Gentleman mentioned statistics relating to orthopaedic surgery in a hospital in his constituency. Is it not significant that the Government have introduced the Commission for Health Improvement? Is it not significant that local people do not have to worry about those figures, because they have been made public? Although the system is not perfect yet, I assure the right hon. Gentleman that it has brought confidence to people in my constituency who now believe that St. Helier‘s problems are understood. Would he care to congratulate the Government on CHI?

    Mr. Lilley: I have already welcomed the increased release of information. We began a process; it has been continued, and I welcome that unreservedly. I do not think that it was NICE that released the figures–[Hon. Members: “CHI.”] Some Greek letter of the alphabet, anyway. Whoever released them, however, I am all in favour of it.

    I do not think we should pretend that everything the Government have done is wrong, or that everything we did was right; but, clearly, the Government‘s general tendency has been wrong up to now. I want to investigate the possibility that they are now beginning to move in the right direction.

    The Government‘s initial response to my proposals was to dismiss them. They said that choice of the kind I was advocating had never existed in the health service, and that it was nonsense to say that they had removed it. They then said the exact opposite–that they had not removed it, and that it still existed–until I pointed out that it had been removed. A Minister then said that, under my proposals, patients would be chasing around the country for shorter waiting lists. That is a bit rich, coming from a Government who are sending patients chasing around Europe–around the Mediterranean now, we understand–in search of hospitals with shorter waiting lists. Why cannot patients at least be given the right to go to hospitals that may have shorter or no waiting lists if they are prepared to do so, or find it convenient?

    The Prime Minister said that my proposals would lead to hospitals‘ competing with hospitals. That is just a bit of silly rhetoric. No one wants to see anyone doing down another hospital; what we want to see is hospitals striving to satisfy patients, and to offer them the best care in the most convenience and favourable conditions. We certainly do not want people to slag off competitors in the way that the Government may have implied that they would.

    It seems that the Government are beginning to move in the right direction, at least in their rhetoric. Having spent four years centralising, they are now at least talking of decentralising. Having ridiculed the idea of patient choice, they have now said that heart patients who have been on the waiting list for six months–and who are still alive–will be allowed to go to another hospital elsewhere in this country, or even abroad.

    That is welcome. It is extraordinary that the Government have chosen to enshrine the move in a bureaucratic process that almost requires minders for anyone considered foolish enough to avail themselves of the choice, but the idea is right in principle. It is sad that it is so limited, and that it is available only to people who have managed to stay alive for six months while waiting for a heart operation. I should like the opportunity to be spread more widely.

    The Government have also said that they will encourage greater independence for some hospitals. Those that have met their 248 targets will be allowed to be independent of those targets. Those that have not met the targets will be required to remain in the system and will be threatened with the terrible possibility of private enterprise management, as has been mentioned before. Well, that will be the day. I would certainly welcome other management groups making available other services to people, with money following choice and standard costs applying to other not-for-profit hospitals, as well as to NHS ones.

    Is the Government‘s recent change of tack a genuine conversion? Will it be successful? I hope that it is genuine, but I fear that it will not succeed. There is something innate in the left-of-centre mind that makes it find centralising, regulating and controlling solutions more satisfactory than those involving delegation, individual choice and independence.

    By and large, Labour Members–on the Back Benches, but on the Front Benches too–remain genetically centralisers. It is in their genes. All the Government have done, I am afraid, is to steal some Conservative rhetoric while retaining the Labour substance. They have spliced together our right-of-centre rhetoric with the left-of-centre practice that is in their genes. The result is a sort of genetically modified Government–a particularly dangerous and odious form of Government.

    However, I hope that I am wrong and that the Government are moving in the right direction. I am certain that my right hon. Friend the Member for Chingford and Woodford Green (Mr. Duncan Smith) is doing the right thing by examining what is happening in other countries and looking at best practice abroad. He is wise to take a measured and timely approach.

    I am pretty sure that, when my right hon. Friend the Member for Chingford and Woodford Green has completed his studies, he will conclude that other countries very often offer greater diversity of provision. They have local autonomy in management, more money follows patient choice, and patients have more opportunity to make choices. If we adopt elements of successful best practice abroad and incorporate them into the NHS, we will do more to improve the quality of health care and ensure more successful treatment outcomes than anything that this Government have so far done or promised.

    22 January 2002 c812-22,835,852