Health and Pensions

Hansard transcript from House of Commons Health Debate 14.11.02

The Secretary of State for Health (Mr. Alan Milburn): The Queen's Speech has at its heart a commitment to public services. Government Members stand for public services because we stand for a fairer society. For us, public services are social justice made real. On the national health service, we stand where we have always stood—for an NHS that is paid for by all and available to all, and provides patients with care that is free, based on the scale of their need, not the size of their wallet.

The NHS plan that we published two years ago sets out how we can build on those values to implement our programme of investment and reform for the health service. The Bills in the Queen's Speech drive forward the reforms, just as the Budget drove forward the investment. Just six years ago, spending on the NHS was falling in real terms. By 2008, it will have doubled in real terms. There is a similar story for social services. Whereas just six years ago, real terms spending there was rising by just 0.1 per cent. a year, it is now set to rise by 6 per cent. a year. Britain today has the fastest growing health care system of any major country in Europe.

The Budget laid to rest the decades-old fallacy in this country that somehow or other we could have world-class health care on the cheap. We cannot. A cheap health service delivers what the Conservatives delivered: cuts of 60,000 hospital beds, cuts of 23 per cent. in nurse training places and of 25 per cent. in general practitioners in training, and 400,000 more people waiting for hospital treatment at the end of their term in office than at the beginning. If we want world-class health care, it has got to be paid for. We on the Government Benches believe that it is right to ask people to pay a little more in tax to get a lot more into the national health service.

The Opposition imposed a three-line Whip against extra health spending—not a soft three-line Whip, but a hard one. Amazingly enough, there was not a single Tory rebel in sight.

Mr. Peter Lilley (Hitchin and Harpenden): No one denies that the Government have accelerated expenditure, but can the Secretary of State confirm that the number of in-patient operations has grown more slowly since 1997?

Mr. Milburn: I think that I am right in saying—if not, I shall correct myself in writing to the right hon. Gentleman—that the number of hospital operations has grown by about 500,000 since 1997, the number of people seen in out-patients has grown by well over 1 million, and the number seen in accident and emergency has grown by about 500,000. However, the right hon. Gentleman must not become fixated by what happens in hospitals alone. I do not know about in his constituency, but in mine, for example, procedures that used to take place in hospital are happening in the community, in out-patient departments, in GPs' surgeries, or in health centres. It is of course important that the appropriate care be given in the right place, but if he believes—but I am sure that he is not falling for this fallacy—that national health service treatment is purely about hospital treatment, he has got it sadly wrong.

Conservatives often call for extra investment in their local health services, and I am prey to interventions from right hon. and hon. Members on such matters. However, if they are going to argue—as they do in interventions, Adjournment debates and questions—for more money for their local health services, they have to explain why they voted against more money for the whole health service. Conservative Members are not stupid—that is the preserve of the Liberal Democrats—and they know that resources deliver results. Why have we got 40,000 more nurses working in the national health service than in 1997? For the simple reason that we put the money in. Why are 10,000 more doctors working in the NHS? Because we put the money in. Why is the biggest hospital building programme in the history of the NHS happening, and why are there more, rather than fewer, beds in hospitals for the first time in 30 years? Because we put the money in.

Gregory Barker (Bexhill and Battle): No one doubts that, in keeping with the Secretary of State's comments, the taxpayer is paying a great deal more for the NHS than when Labour came to power in 1997. However, can he tell us why, after five years, 1 million people are still on NHS waiting lists?

Mr. Milburn: If I were the hon. Gentleman, I would exercise caution in two respects. First, when the Conservatives were in office for 18 years, they managed to increase waiting lists by 400,000. We have been in office for five years, and we have cut hospital waiting lists by 100,000. Secondly, it is no good his arguing that what is needed is more investment in the national health service if Conservatives are not prepared to put investment into it. We will not get waiting lists or waiting times down unless we grow the capacity of the NHS.

The hon. Gentleman must have read—I have read it, for heaven's sake—the Conservative policy document that was launched last month, entitled "Leadership with a Purpose". If ever a title expressed the triumph of hope over experience, that was it. The document states in bald terms:

    "Conservatives do not support the tax and spending increases the Government has announced."

The hon. Gentleman and his right hon. and hon. Friends should be extremely cautious about arguing for more money for the NHS, unless they are prepared to vote for more money for the NHS.

It is true that waiting times for hospital operations are still too long, but it is worth recalling that the number of patients waiting more than 12 months for NHS treatment is down by 40 per cent., compared with March 1997. A year ago, the maximum wait for a heart operation was 18 months; today it is 12 months, and by next April it will be nine months. That is still too long, but the trend is in the right direction and, most importantly, during the past few years death rates for cancer have fallen by 6 per cent. and for heart disease by 14 per cent.

The Conservatives often say that they are opposed to our targets to reduce waiting times for treatment, yet they also know that waiting is the public's No. 1 concern about the NHS. By and large, once people get into the system they are satisfied with the quality of their treatment. Why? Because the doctors, nurses and other staff provide a high quality of service. It is the wait for that service that is the problem for far too many people. Does anyone seriously believe that waiting times would be falling so consistently had it not been for those targets?

We know what the Conservative strategy is. The hon. Member for Woodspring (Dr. Fox) expressed it eloquently when he said that the Conservatives have to persuade the public first that the NHS is not working, secondly, that it never worked, and thirdly, that it never will work. However, for millions of our fellow citizens the NHS is working. It is delivering high-quality care for millions of people every week.

We should be candid about two things, however. First, although there is progress, there is a long way to go. Turning around decades of neglect is not a battle for the short term; it is one for the long term. We have a 10-year NHS plan for one simple reason: it will take time and effort, as well as sustained resources, to deliver the world-class health care that we all want.

Secondly, investment alone will not deliver. The NHS needs reform as well as resources. Why? Because the world has changed and the NHS must keep pace.

 

Mr. Edward Garnier (Harborough): Will the Secretary of State remind me which year of the 10-year plan we are in?

Mr. Milburn: I think that I answered questions from the hon. and learned Gentleman when I introduced the plan in the House. We published it in July 2000, so I think that he can work out where we are.

Mr. Frank Dobson (Holborn and St. Pancras): Not without a fee.

Mr. Milburn: I am grateful to my right hon. Friend—at least, I am at this stage.

Sometimes, people in this country pretend that we are the only ones having to confront change—that our health care system is the only one to face changes in demography and an ageing population, the enormous possibilities but new pressures brought by new drugs and treatments, and the rise of a more consumerist set of public expectations. However, those waves of change are washing over every health care system in the world. That is why health care reform is at the top of the political agenda in almost every developed country.

The NHS is in a better position than most to confront those pressures. In a world where health care can do more but costs more than ever before, it is an enormous strength to have an NHS providing services that are free, and based on need, not on ability to pay.

The NHS provides what some call the security—what Nye Bevan called the "serenity"—of knowing that we all pay in when we are able to do so, so that we can all take out when we need to. The health of each of us depends on the contribution of all of us. That is the great strength of the NHS. Those values and principles are as strong for Britain today as when the national health service was first formed.

We must be honest, however; there are weaknesses, too, in the organisation of the NHS. In 50 years, health inequalities—the gap between rich and poor in terms of health outcomes—have widened rather than narrowed. Figures released by the Office for National Statistics just last week show that a boy born today in Manchester will live on average ten years less than a boy born in Dorset.

Uniformity in provision has not produced equality of outcome, nor has it produced equality of opportunity. Too often, the poorest services are in the poorest communities. If we want an NHS that is more tailored to the needs of local communities and more attuned to different local problems of poverty and deprivation, we have to move away from monolithic services and centralised control. Different communities have different needs.

Mr. Paul Goodman (Wycombe): Will the right hon. Gentleman give way?

Mr. Milburn: In a moment.

Overall, levels of infant mortality in our society are falling—thankfully—but in some of the poorest sections of society they are rising. In parts of London, 100 languages are spoken, which puts pressure on the NHS. In a city such as Bradford, the incidence of heart disease among Asian men and women makes the work of the NHS there different from its work in other parts of Britain. Fairness rightly demands that standards in heart or cancer services should be broadly the same in one part of the country as in another. That is why we have put in place a national framework of standards.

Mr. John Bercow (Buckingham): Given that one of the weaknesses of a national pay bargaining system is that it inevitably fails to take into account higher costs of living in parts of the country where there are staff shortages that we need to tackle, will foundation hospitals have absolute discretion and control over pay? If not, how and to what extent will that freedom be circumscribed?

Mr. Milburn: I will deal with foundation hospitals in general in a moment, but pay is a very important question, and not only for those hospitals. Today, NHS trusts have discretion and have had it for many years. Indeed, many exercise it. When trusts are recruiting an anaesthetist or a nurse, there will often be an element of local discretion in their pay.

As the hon. Gentleman is aware, we are negotiating with the trade unions that represent the 900,000 health workers—nurses, porters, cooks, cleaners, scientists and technicians and so forth. This is the fourth year of our negotiations for what we call the agenda for change pay system. Those negotiations are going well. I hope that we can reach fruition before too long. At their heart is the simple idea that in a national system in which people rightly demand equity we need a broad national framework for pay so that people have some certainty about the sort of pay that they are likely to receive. However, as the hon. Gentleman and all right hon. and hon. Members know, different parts of the country have different housing and labour market pressures, so there needs to be some local flexibility in that national framework. That is what we need—a national framework and some local discretion.

I expect the first generation of NHS foundation hospitals as well as subsequent generations to want to take on board the agenda for change agreement, provided that we can reach it. They will therefore be able to exercise discretion and flexibility, but there will be a broad national framework too. We will see where we get to with the negotiations. I am not pre-judging the outcome and there is clearly some way to go, but we are making progress.

Dr. Brian Iddon (Bolton, South-East): I am pleased about my right hon. Friend's statement on dealing with constituencies with real health need. He will know that I have been campaigning for five years on behalf of my constituency, which started second from bottom in terms of being furthest from target. Although we have had a lot more money—I praise the Government for delivering that—we are still in that position relative to all other health authorities. Will he assure my constituents that we will target the real need that exists in certain constituencies—for example, Manchester, which he just mentioned?

Mr. Milburn: I cannot assure my hon. Friend about that particular case. As he knows, the formula is still under review. However, when we make allocations to primary care trusts later this year, those will be based on a new formula that will give greater recognition to the problems of health need and health inequality of which he is all too painfully aware—and so am I. We have to get the balance right between recognising that there are different labour markets and different pressures, which the hon. Member for Buckingham (Mr. Bercow) mentioned, and acknowledging that there are different health needs and big health inequalities. The formula will need to address that balance.

Mr. Dobson: Will my right hon. Friend confirm that after the 1997 general election we found that places such as Bolton and Tower Hamlets were far behind the notional sums to which they were entitled under the national formula, whereas Surrey, for example, was far in advance of its notional sum?

Mr. Milburn: My right hon. Friend's memory is serving him extremely well. That is precisely the case and, as he knows, in the past couple of years we have adjusted the formula to recognise, first, that the current formula does not properly respect the health needs of different local communities—parts of Greater Manchester and the surrounding areas, for example, have benefited from that change—and secondly, that we also face labour market pressures in different parts of the country. Incidentally, those pressures are not confined to London. We made those adjustments pending the full-scale review of the formula.

Dr. Jenny Tonge (Richmond Park): Is the Secretary of State not being rather stupid himself in assuming that the inequalities of health in the population are due solely to the provision of health care? Surely they are as much to do with poor housing, environment and education, which are also the responsibility of the Government.

Mr. Milburn: I am almost deeply wounded by the hon. Lady's accusation. [Interruption.] The party of the vulnerable knows how vulnerable I feel.

The hon. Lady is clearly right to say that there are background causes for health poverty. Poverty is one, poor housing another and a bad environment a third.

Mr. Eric Forth (Bromley and Chislehurst): And lifestyle.

Mr. Milburn: The right hon. Gentleman is right; lifestyle is another issue. However, the hon. Lady is wrong in one fundamental respect. My right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), who intervened earlier, could also have said that when we considered these issues, there was inequality not only in outcomes but in access to service. People in the better off parts of Leeds, for example, have three times the access to heart surgery that those in the poorest parts have, despite the fact that the incidence of heart disease is higher in the poorest parts.

That is because there is, unfortunately, an iron law about the provision of public services. People who are more articulate and better off—the middle class—tend to do better out of the public services than working-class people. We must put that right. I do not believe that national standards or uniformity of provision will, on their own, necessarily address the very different problems in various communities. National standards are beginning to deliver results to reduce unfairness in areas such as cancer, heart disease, care of the elderly and mental health. In the next few weeks, we will publish similar plans to improve diabetes services.

While I am on the subject of mental health, let me say that we will press ahead with reform of the mental health laws. The laws today are rooted in the 1950s. We need to strike a better balance between safeguarding the rights of individual patients and protecting both patients and the public. The draft Bill that we issued for consultation, after we had consulted following a Green Paper and a White Paper, has produced around 2,000 responses. When we have finished considering them, we will bring forward the Bill during this Session.

Dr. Julian Lewis (New Forest, East): Will the Secretary of State confirm that the Bill will not concentrate solely on the understandably controversial matter of people with untreatable personality disorders, but will also pay attention to an issue that has worried many of us—that people who have to have in-patient care for serious depression are put cheek by jowl with people who are seriously psychotic? In other words, there should be separate therapeutic environments for people with very different types of mental disorder.

Mr. Milburn: The hon. Gentleman makes an extremely good point. Inevitably, all the headlines will be about one aspect of the Bill; that is understandable. However, the Bill in its entirety is not about that issue. It is about how, from a system fundamentally based on 1950s legislation, to get a better balance between safeguarding individual patients' rights, and protecting the community as well as individual patients. It is absurd that, although most treatment takes place in the community rather than in hospital, because the current legislation does not allow compulsory treatment for the minority of patients who need it in the community, doctors must wait until they become so seriously ill that they are a threat to themselves or to others before they are admitted to hospital for compulsory treatment. That is palpable nonsense, and it is not good for the patient or for the community. That is what we must change. We will consider the responses extremely carefully. Make no mistake, reform must happen in mental health services, just as it must across the whole national health service.

National standards make a difference. Through the Commission for Health Improvement, the very real variations in performance that exist in the NHS are being tackled. Indeed, as the Queen's Speech made clear, we will now strengthen the system of national inspection so that there is more information, not just about health services in the public sector, but about health services in the private sector too. Wherever NHS patients are treated they have not just the right to a common ethos and a common system of inspection, but a right to know that standards are high. Our objective is to have good services not just in some places, but in all.

Laying down national standards does not by itself raise standards. That can happen only when staff feel involved and communities are more engaged. The top-down, centralised structure in the NHS has too often inhibited local innovation. Too often when I talk to front-line staff, they feel disempowered. Local communities feel disengaged. Individual patients have little say and precious little choice.

In today's consumer age that structure is no longer sustainable. Therefore, our reforms are designed to shift the balance of power in the NHS so that standards are national, but control is local.

Mr. Andrew Lansley (South Cambridgeshire) rose—

Dr. Evan Harris (Oxford, West and Abingdon) rose—

Mr. Milburn: I give way to the hon. Member for South Cambridgeshire (Mr. Lansley).

Mr. Lansley: While the Secretary of State is talking about national standards and access, will he tell the House to what extent the intention that there should be specialist stroke units in each district general hospital, which was the April 2002 target, has been met? In addition, will he reiterate the intention that all stroke patients should be treated in specialist stroke units by April 2004?

Mr. Milburn: The hon. Gentleman is referring to the national service framework for elderly care services. He is right that the intention is to have specialist stroke services by April 2004 in all parts of the country. We have made progress towards that, and I know that it is happening. We have two years to go, and we are making good progress. We have to learn from the stroke services that are being set up. I visited a specialist stroke service in the Freeman hospital in Newcastle, and I know what a difference it makes, not just to the care of the patients but to the morale of staff, who feel that they can use their specialist skills for the purpose for which they were designed—is to make sure that older people, in particular, get the quality of care that they need. We have made a start and I am confident that we will achieve our ambitions.

Dr. Harris: The Secretary of State talked about the importance of reform, and in these exchanges he has given the impression that only his party supports reform, and the Liberal Democrat and Conservative parties do not. I am happy to accept that the onus is on Opposition parties to recognise, as I do, that radical reform of the health service is necessary. Having started with insults, if he remains to hear my contribution, which he does not usually do—[Interruption.]—he will have an answer. The Secretary of State cannot start by insulting parties and then slope off before they are given a chance to respond. I accept his challenge that before criticising the reforms proposed by the Government, Opposition parties have to have their own proposals. That would be a test of effective opposition, and I hope that he will remain to hear what is offered on the menus today.

Mr. Milburn: As for my attendance at the hon. Gentleman's speeches, there are questions of decorum and good taste. I have heard him speak in this place and say different things almost in the same sentence to the same audience. I will stay and listen to him today. How is that? I must have nothing better to do.

Mr. Kevin Hughes (Doncaster, North): Now that my right hon. Friend is coming to the part of his speech about reform, will he take time to explain to the House how the introduction of foundation hospitals will not lead to a two-tier service? In addition, if foundation hospitals are going to improve services, will he say why they are to be introduced only in those areas where existing hospitals already give their communities good service?

Mr. Milburn: I will answer my hon. Friend's question, but I hope that he will let me get to the relevant section of my speech. If he wants to intervene then, I shall be happy to allow him to do so. As I have said, we want to have national standards and local control. Next year, local PCTs will control three quarters of the NHS budget. They will have three-year budgets so that they can plan and deliver a better balance between prevention and treatment, and between services in the community and services in hospital.

They will also be free to commission services from the most appropriate provider, regardless of whether that provider is in the public, private or voluntary sector. That will permit a greater diversity of provision and greater choice for patients.

In our country, of course, there has always been choice in health care, but it has been the exclusive preserve of those who can afford to pay. Equity demands that that choice is available to all, not just to some. People should not have to opt out of the NHS to get high-quality treatment. They should be able to get choice on the NHS.

We have made a start, with heart patients now choosing where they should be treated. Our plan is to extend choice to all NHS patients. The more that hospitals do and the more patients they treat, the more resources they will get. Those local services that are doing less well will get more help, more support—including financial support—and, where necessary, more intervention. They will not be left to sink or swim. Conversely, those doing better will get more freedom.

Mr. Hilton Dawson (Lancaster and Wyre): Will my right hon. Friend assure me that everything that he has said about improving the quality of health services can be read across to the social care services? Will the important measures that he is introducing to extend devolution and local decision making refer to both health and social care, and to crucial partnerships at local level?

Mr. Milburn: My hon. Friend makes an extremely important point, and perhaps I have been remiss in not making it clear that a common set of principles should apply to all our public services. We want to raise standards everywhere, not just in some places. That is why we instituted national standards and systems of inspection, and why we made available the help and support that we now give. When the Government came to office, we had no way of generalising good practice. There was no mechanism by which we could tell the best clinicians and managers to take the lessons that they had learned from their working environments to other organisations that needed help, so that those organisations could learn the same lessons. However, that is what we do now.

My hon. Friend the Member for Lancaster and Wyre (Mr. Dawson) will also be aware that the response should always be the same where there is consistent management failure, be it in the private or the public sector. In such cases, we should change the management and bring new people in. The purpose of the new franchising proposals is to bring in new management. In those places where we have adopted it, that approach is beginning to produce results.

The same disciplines must apply in the social services as much as in the health service. That means that help, support and, where necessary, intervention are available in those areas that are not doing very well. Conversely, there are also incentives to improve, which brings me to the issue of NHS foundation hospitals.

NHS foundation hospitals will be part of the national health service. They will treat NHS patients according to NHS principles and to NHS standards, but they will be controlled and run locally, not nationally. Indeed, they will draw on traditions that many Labour Members will recognise—the traditions of the co-operative movement and of friendly societies and mutual organisations in this country and abroad. NHS foundation hospitals will be owned and controlled by local communities, replacing central state ownership with a modern form of local public ownership.
How will that work? People living in communities served by a hospital will be its members and, therefore, its owners. Staff will also be members. Local people will elect representatives to serve as hospital governors. Those directly elected hospital governors will make up an absolute majority on the trust stakeholder council. The council in turn will hold the management board that is responsible for the day-to-day work of the hospital to account, elect the chair and non-executive members of the board and approve the appointment of the chief executive.

For the first time since 1948, the public will be genuinely at the heart of our key public service—the national health service. This reform will help bridge the democratic deficit that has for too long kept the public out when they should have been brought in. I will shortly publish a prospectus setting out more details on NHS foundation hospitals, but I can tell the House one more thing today.

Some people have concerns that foundation hospitals are about privatisation. That is simply not true. NHS foundation hospitals will be there to serve NHS patients, not to make profits or to distribute dividends. To prevent any future Government pursuing a privatisation agenda in the NHS, there will be a legal lock on the assets of NHS foundation trusts to protect them from the demutualisation that we have seen in the building society sector in recent years or any future threat of privatisation. Our reforms are about giving life to the Labour ideal of common ownership, not resurrecting the corpse of Tory privatisation. Our aim is to bind NHS hospitals ever closer to the communities that they serve. In that way, NHS foundation hospitals will be part of the NHS and will always remain part of the NHS.

Mr. Gareth Thomas (Harrow, West): As someone rooted in the co-operative traditions to which my right hon. Friend refers, I warmly welcome the proposals for foundation hospitals, not least because they offer the prospect of replacing local quangos, which are too often not accountable to local people, with democratically elected boards. Will my right hon. Friend be sympathetic to those local communities that are unhappy with the way in which their local hospital is run when they come to him asking for their hospital to be made a foundation hospital?

Mr. Milburn: I sympathise with my hon. Friend's point. I am aware of the views he has expressed and the measures that he has tried to take forward in the House to bring co-operation and mutualisation out of the last century and into this one. We have an opportunity to do that now through the NHS foundation hospital model. I want to deal with my hon. Friend's question and that asked by my hon. Friend the Member for Doncaster, North (Mr. Hughes).

We will start with the best performers; the first generation of foundation hospitals will be drawn from existing three-star trusts. Forty per cent. of the three-star trusts are in 25 per cent. of the most deprived areas in the country—places such as Bradford, Hackney, Liverpool or Sunderland. I do not know whether those hospitals will want to apply for foundation trust status, but I do know that, as more hospitals improve, more will become foundation trusts. As my right hon. Friend the Prime Minister has said, there will be no arbitrary cap on the number of foundation hospitals, so the charge that the policy is about creating a two-tier health service is simply not correct. This is not elitism; it is localism. It is not privatisation; it is a genuine form of public ownership. It is aimed at getting the best health care for the public by giving more control to the public.

Glenda Jackson (Hampstead and Highgate): I am particularly concerned about localism. My right hon. Friend has previously given examples of how, for example, working class areas do less well than middle class areas in obtaining access to national health services. How will everyone's vote be equal? In my constituency, there are huge disparities of wealth and for many people English is not their first language. How can we be assured that foundation hospitals will genuinely reflect local issues? That is central if we are to make a success of them.

Mr. Milburn: The ballot box will be the great equaliser. In the end, whether people obtain access to services is at least in part dependent on their background and, sadly, their class, but their ability to exercise the vote is dependent on their willingness to exercise it. Everyone will have an equal vote and an equal say, and they will be able to determine who serves as hospital governors. For the first time we can ensure—within the framework of the standards we have set, and with a common NHS ethos and a common system of inspection—that hospitals genuinely serve the needs of the local community.

I know that many Members will have their doubts, but I fundamentally believe that we have an opportunity to construct a new model that is consistent with the values and principles of the national health service, while giving more control to those who need it: the staff on the front line, and the communities that they serve.

Mr. Peter Mandelson (Hartlepool): My right hon. Friend does indeed seem to be describing an entirely new and imaginative model for the entire public service. Would he characterise it as the end of old-style, centralised, Morrisonian nationalisation as we know it?

Mr. Milburn: I do not really want to intrude on family matters, but I think that it does mark a break from the past, in terms of structure but not of values. Values endure, and I believe that the values of the national health service are fundamentally right—although views differ in different parts of the House.

It is clear from what happens in other European countries that it is possible to have both diversity of provision and the right values for care. We can have a range of service providers, but the service that they give to public health care can be based on a common set of values. I think that that is right, not because diversity should be an end in itself but because alongside the national standards for the delivery of equity must be local services that meet local need. If we are honest, we will acknowledge that over the last few decades that has not been possible, and that we must change the structure and the organisation.

Mr. Goodman: If a foundation trust falls in the Government's rankings from three-star to two-star status, will it remain a foundation trust?

Mr. Milburn: As I have said, in due course we will present a prospectus that will deal with issues such as that. I can say, however, that if foundation hospitals are part of the NHS family and are delivering services to NHS patients, they must abide by the same disciplines as other NHS hospitals. That means that they will receive ratings, and will be subject to the same inspections as other parts of the NHS. [Interruption.] If the right hon. Member for Hitchin and Harpenden (Mr. Lilley) would stop chuntering and start listening, it might be helpful to all of us. If he wants to intervene, I will happily give way.

Mr. David Tredinnick (Bosworth) rose—

Mr. Milburn: I will have my dose of complementary therapy in a moment. First, let me deal with the question from the hon. Member for Wycombe (Mr. Goodman).

The expectation must be that as we are going to introduce the new arrangements in phases, and as the phases will begin with the best performers, foundation trusts will maintain—with greater freedom—a high level of performance.

Mr. Bob Blizzard (Waveney): Where foundation hospitals are operating in the way described by my right hon. Friend, fully accountable and responsive to local communities through the ballot box, will money from the Department of Health go to them directly rather than through local primary care trusts? Would that not make foundation hospitals more accountable to the community than PCTs?

Mr. Milburn: No. I think it right to have one form of commissioning. As I said earlier to the right hon. Member for Hitchin and Harpenden, we must ensure that all the growing resources for the NHS do not end up in the hospital sector. Hospitals will not be able to do what they need to do—reduce waiting times for treatment, improve the quality of care and so on—unless there are good services in the community, and in primary care as well. That is why we need strong local commissioning of services, which is the purpose of PCTs. They must be able to decide where resources should go in order to benefit the local community. Some will go to the hospital sector and some to the community sector; most, I expect, will go to the public sector, although some may go to the private sector. But alongside the providers must be commissioners of services.

Mr. Tom Levitt (High Peak): I am attracted by the model that my right hon. Friend has described, but what exactly does he mean by "accountable to local people"? There is no hospital trust in my constituency, and the four major hospitals that serve it are outside not just the constituency but the region. How might my local people be involved, at some time in the future, in this form of local democracy?

Mr. Milburn: I hope that when my hon. Friend sees the prospectus, he will agree that our proposals will achieve that.

Different trusts serve different populations, and not all trusts are the same. The Royal Marsden is a specialist cancer hospital. In a sense it does not really have a local community; its community is the community of patients whom it serves. They come from all parts of the country, because it is a tertiary centre. In my part of the country there is a very local trust that serves a distinct set of local communities. I do not know about my hon. Friend's area.

We must establish some principles for governance, but the governance structures must be flexible enough to take account of different needs and different local communities. That is why we will not lay down hard and fast rules, apart from saying one simple thing: if direct elections are to take place and if the mandate is to come from the local community, there must be an absolute majority of people from the local community serving on the stakeholder council, so that the public drive the changes that are necessary.

Rob Marris (Wolverhampton, South-West): When British Rail went through its botched privatisation we experienced fragmentation and then, following redundancies brought about by the privatised railway companies, a shortage of engine drivers in particular. Wages went through the roof. If we are to have local autonomy in regard to foundation hospitals, how will the Secretary of State avoid fragmentation and a consequent wage explosion when there is a shortage of health professionals?

Mr. Milburn: We will avoid fragmentation by means of the national framework of standards that we have established over recent years. Much of that framework, incidentally, was opposed by the Opposition. When my right hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) introduced legislation to create the National Institute for Clinical Excellence and the Commission for Health Improvement and when we started to establish national service frameworks, both moves were opposed, because the Opposition genuinely want a free market in health care. We do not want that. We want national standards, and equity in the system.

My hon. Friend asked about wages in a constrained labour market. That applies to many, although not all, professions in the NHS, but even today there is an element of local pay bargaining. As I tried to convey earlier, we must have—and can have—a national framework, while respecting the fact that different local labour markets face different pressures. For instance, there is a problem at the John Radcliffe hospital, in the constituency of my right hon. Friend the Member for Oxford, East (Mr. Smith) , the Secretary of State for Work and Pensions. That is largely because of local housing costs. It is different in my constituency.

Unless we can enable employers to act, we will never be able to tackle the different recruitment and retention problems.

Mr. Jim Cunningham (Coventry, South): Is my right hon. Friend saying that the new structures will replace the trusts?

Mr. Milburn: Yes, in a word. As we said in the NHS plan, the more performance improves, resources bite and reform takes hold, the more autonomy will be earned throughout the health service. This is a big change, but I believe it is the right change.

That brings me to the final measure in the Queen's Speech, the delayed discharges Bill. I believe that we owe a duty to today's generation of older people, because it was they who built and sustained public health and social services in our country. They deserve dignity and respect in old age, but being trapped in hospital when they want to be cared for at home denies them both. Delayed discharge from hospital is a serious problem. Since we put in an extra £300 million last year to deal with it, rates have fallen by more than 20 per cent., but even today, 5,000 older people are needlessly in hospital when they are ready to leave.

The Community Care (Delayed Discharges etc.) Bill, which we have introduced today, brings fundamental reforms to deal with that problem once and for all. Under the current system, for as long as the elderly person remains in hospital, for good reasons or bad, they remain there at the cost of the national health service. Under the new system, when the patient is ready and able to leave hospital, the cost will pass to social services. Where social services fulfil their responsibilities, we will look to give them extra rewards. Where they do not do so, they will have to pay the hospital for the costs that it incurs in providing care for the patients.

The interests of older people are not served by a blurring of responsibility. The costs of care should fall where they belong. The Bill will help to ensure that the money that we have made available to social services is spent on them, so that capacity can be built up and not cut.

Mr. Stephen Pound (Ealing, North): I am very grateful to my right hon. Friend for giving way. A decent, well-performing social services authority such as the London borough of Ealing with find itself being charged £2.2 million a year, on its anticipated figures, through the £120-a-night charge because of forces beyond its control. I am sure that he has considered the fact that, in many cases, the beds that are needed to move people away from hospitals providing acute care are simply no longer available in the community.

Mr. Milburn: I understand the capacity problem, but we will again have a problem if we think that the only way of caring for older people is placing them in residential care homes. Of course, the care homes sector is extremely important, but it is worth listening to what older people themselves say about where they would like to be cared for. Overwhelmingly, they would prefer to be cared for not in a care home, but in their own home.

I understand the difficulties in different parts of the country. That is precisely why we provided in the Budget for a doubling of social services investment from this year to the next. That is not a 5 or 10 per cent. rise, but a doubling in the resources available to social services. However, social services must fulfil their responsibility. If my hon. Friend the Member for Ealing, North (Mr. Pound) stops to think about it, he will recognise the current problem. The hon. Member for Woodspring may stand up in a minute and say that what is happening is all about fining social services, but I disagree with that language. If he wants to use it, I say to him that social services are effectively fining the health service, because the costs are incurred in hospital, which cannot be right. Partnership works only when the health service and social services each accept their responsibilities, so we need an incentive for them to do so. That is what the Bill provides.

The reform programme set out in the Queen's Speech draws on the traditions of social and community ownership that I believe inspired the founders of the national health service. It sticks firmly to the principles on which the NHS was founded, but places a new premium on local accountability for local services. Reform cannot be achieved by holding on to the structures of the last century; it has to be shaped by the expectations of this century. Reform means investing not only extra resources in front-line services, but power, trust, ownership and control.

We on the Labour Benches have had the courage to raise the resources; we must now have the courage to make the reforms.

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