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Miss Julie Kirkbride (Bromsgrove): May I give a broad welcome to the Secretary of State's comments? May I also congratulate him on finally understanding that if we are to have a health service fit for the 21st century, the old Stalinist structures have to be dismantled?

We can understand why the right hon. Gentleman did not want to come to the House today, given the grim faces of Labour Back Benchers. Will he spread a little more happiness by telling us whether, in the negotiations that he intends to have with health service managers and workers and the private sector, he will also consult the health service trade unions on his proposals to end national pay bargaining?

Mr. Milburn: I do not think that the hon. Lady is up to date. We have been negotiating with trade unions, as the hon. Member for Woodspring said, for the past two years on a new national framework for pay and conditions in the NHS which would also allow for local flexibility. The hon. Lady called the NHS "Stalinist"—

Mr. Simon Burns (West Chelmsford): No, she did not.

Mr. Milburn: She did; Conservative Front-Bench spokesmen were not listening to their Back-Bench colleague. That is precisely what the hon. Lady said. It seems to me that the Conservative party is becoming more like a modern-day Trotskyist sect. Condemning everything it does not like, including the NHS, is Stalinist.

Mr. David Hinchliffe (Wakefield): As a moderniser, I welcome the idea of devolving decision making nearer to the patient. My concern with the Secretary of State's proposals relates to the clear parallels that can be drawn with what the Conservative Government announced in the early 1980s in terms of the introduction of the internal market and the consequences of that, and the introduction of private sector management. Some of us suffered from private sector managers in our localities. Bearing in mind the concordat that establishes the relationship with the

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private sector and what the Secretary of State proposes for management, can he tell those of us who have anxieties about the direction that the Government are taking whether any limits will be placed on the involvement of the private sector in the NHS under the Government?

Mr. Milburn: I know that my hon. Friend has a well-deserved reputation as a Labour moderniser on such matters. I agree that devolved decision making is the way forward. The right combination of national standards needs to be in place. However, we have to accept that none of us as Ministers delivers one iota of care. The care is delivered outside Parliament by doctors, nurses, therapists, cleaners, cooks, porters, managers and other staff. We surely need resources and power to be located in their hands rather than ours.

There is a fundamental difference between the situation that my hon. Friend describes in the early 1990s and now. It is worth remembering how far we have come in just four years. When we got into office there were no national standards, no means of inspecting standards, no means of levering in good practice to replace bad and no means of evaluating new drugs and treatments when they came on to the market. For the first time, we have national standards and independent inspection, and it is right and proper that within that framework the NHS should improve services for patients.

The crucial limit to private sector involvement is the fact that, as I said in my opening statement, I profoundly believe, as I know my hon. Friend does, in an NHS that provides care according to the right principles, the right values and the right ethos. I believe that care should be available according to the scale of people's needs, not the size of their wallets. That is the position on the Labour Benches; I am not sure that the same is true on the Opposition Benches.

Glenda Jackson (Hampstead and Highgate): As another moderniser, may I ask my right hon. Friend whether he agrees that delivering high-quality services to patients is, in the main, dependent on a well skilled and highly trained work force? If managers are brought in from the private sector, how will he guarantee that they do not replicate the activities of their colleagues in the wider world who have, in the main, turned their backs on in-house training and simply meet their staffing needs by poaching from others?

Mr. Milburn: I do not think that we should try to kid ourselves. In the public sector there are good managers and, sadly, some pretty poor ones, just as there are good and bad managers in the private sector. The best managers, whether they are in the public or the private sector, recognise that if they are to provide improved services to customers or, in this case, to patients, they must invest in their staff and make sure that there are more staff and that they are skilled. That is what I expect to see in all parts of the public services, and it is certainly what we need in the NHS.

Mr. Julian Brazier (Canterbury): In between all the new plans, initiatives and restructuring, can the Secretary of State find the time to visit the Kent and Canterbury

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hospital? I understand that last Friday, just before my arrival at the accident and emergency unit, the hospital had squirrelled away most of the people waiting on beds in corridors. Eighteen remained, some of whom had very serious conditions and some of whom had been there for over 24 hours. That is totally unsuitable care. Ten consultants appeared, at a few hours' notice, to say that the crisis in capacity cannot go on. When will the Secretary of State take action on the crisis in acute health care in east Kent?

Mr. Milburn: The hon. Gentleman talks about a crisis in capacity, but he really must have a word with his Front-Bench colleagues because the way to solve the crisis in capacity is to invest. That is what we are committed to doing, and it is a shame that the Opposition are not.

Lynne Jones (Birmingham, Selly Oak): I agree with my right hon. Friend that the NHS is too big to be managed from Whitehall and that it should have access to the best expertise. What concerns me is accountability. There are two ways of getting accountability. The first is through competition, but genuine competition requires a surplus of provision, so that patients can choose who provides their service. Even if that were possible in the NHS, surely it is not desirable purely because of considerations of efficiency and expense. The second way to get accountability is through elected representatives, but sadly it seems that that is not an option, as is demonstrated by the National Health Service Reform and Health Care Professions Bill, which we will be considering later today. What will my right hon. Friend do about the accountability deficit in the NHS?

Mr. Milburn: On the first point, my hon. Friend is right to say that the only way to expand informed choices for patients is to increase capacity in the NHS. As she is aware, from July this year we will be able, for the first time, to give direct choice to NHS patients. Those who have been waiting six months for heart surgery will be offered the choice of continuing to wait, probably longer, for treatment at their local hospital or, provided that it is clinically appropriate, travelling further to get treatment elsewhere. That will not only increase public confidence in the NHS but drive change and provide incentives for hospitals to treat more patients to higher standards. As for issues of governance, my hon. Friend is right that NHS trusts have quite wide-ranging powers of autonomy, but they are constrained by the current governance structures. Effectively, we appoint five non-executive directors and blithely assume that that is representative of the community's interests. Like my hon. Friend, I believe that that is not necessarily so. We shall want to discuss with the best performing hospitals and primary care trusts whether we can change the accountability structures for the best performers to strengthen the relationship between local health services and the local communities that they serve.

Mr. John Redwood (Wokingham): Will the Secretary of State confirm that under his interesting scheme some NHS hospital trusts will be able to buy and sell assets on their own account without seeking Government

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permission and will be able to borrow money against those assets without needing Government guarantees or permission? Is that the position?

Mr. Milburn: As for buying and selling assets, NHS trusts can currently do so. However, under the current regime, which, I recall, was initiated under the right hon. Gentleman's Government and which we have continued, an NHS trust that sells assets of spare land, for example, is not allowed to keep the proceeds for itself. We should consider a different regime for the best performing hospitals; if those that have spare capacity, land and assets want to sell them, they should get the proceeds.

Ms Julia Drown (South Swindon): Can the Secretary of State assure the House that discussion of organisation and reorganisation in that fashion will not divert attention from the key task of delivering the NHS plan? To that end, can he assure the House that he will debate those issues with the NHS modernisation board and patient groups which, I understand, have not discussed or floated them to date?

Will my right hon. Friend also explain to the House the difference between franchising management and dealing properly with NHS management? There are procedures to deal with managers who do not perform; I hope that the House agrees that that minority should be properly dealt with and disciplined if necessary. How does my right hon. Friend envisage managing trusts in which, say, 80 per cent. of the managers are good but 20 per cent. are bad? At what point should the whole lot be franchised out, thereby losing some very good NHS managers along the way?


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