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Dr. Ladyman: The hon. Gentleman quotes the Dutch model, but as chairman of the all-party group on the Netherlands, I can tell him that the biggest issue in this week's Dutch general election—excluding the death of Pim Fortuyn—is long waiting lists in their health care system. The Dutch perceive that their health care system does not work. Social insurance is not the panacea that he perhaps suggests.

Mr. Maples: Nothing is a panacea, and we will never be prepared to pay enough for the health care that we need at a particular point. If I had been making this speech three or four months ago, I would have suggested that my alternative is a better one. Given that the Government have pursued a policy whereby a huge sum of money is being raised in order to make a difference, my question now is whether the medium of the national health service can translate that into an equivalent increase in health care. If it cannot, it is worth looking at other systems, and it would be sensible to consider the one that I am describing.

Dr. Evan Harris: The hon. Gentleman is right: we need a grown-up debate, and it is wrong to argue that private health insurance will cost X amount, implying that it is more than people are paying in tax. However, as he will recognise, the problem that many have with alternative models concerns equity. It is difficult to find a more equitable way of providing health care than the current system, which, arguably, should prove more efficient thanks to the lack of cost to the administrative system of national and social insurance.

Mr. Maples: If there is a trade-off—I am not sure that there is—we are paying a high price for it. We are enforcing a system on those who would perhaps pay more for their health care, and reducing that care to a level that everybody is prepared to pay for. I want people to be able to top up a minimum guarantee from their own resources. There are many health procedures that people want to undergo—the hon. Gentleman is a doctor, so he knows far more about such matters than I do—but which are not strictly necessary for their health. Perhaps such people are prepared to pay a little extra for such procedures, but at the moment they cannot.

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I have not heard continental social insurance systems being criticised as inequitable. I would imagine that my proposed system would have exactly the same equity as the national health service; however, it would provide rather more choice, and enable people to spend more money.

John Mann rose

Mr. Maples: Perhaps I can move on. None the less, I agree that the jury is out on the matter. We need to wait two or three years and see whether the Government are right and their system works, and I am simply describing the system that we should consider if it does not.

I welcome the Government's change in attitude to the private sector. When I was shadow Secretary of State for Health, we discussed the abolition of various mechanisms such as local health plans, in which local hospitals are used for various purposes. Money certainly did not follow patients under those plans, and I am glad that they are being reinvented. I genuinely welcome that change of heart. Choice in the commissioning of health care will drive improvements in efficiency and quality, and replicate the drivers that one normally expects to find in economic mechanisms in the NHS. I am also glad that the purchaser-provider split is being retained. Internally, at least, that will offer a choice between providers.

The Government abolished fundholding on taking office, and in a sense they have recreated it through primary care trusts. My worry about such trusts is that they are a bit too big. I hope that some flexibility will be allowed internally, so that they will not corral every GP into exactly the same choices. Allowing such flexibility is more likely to drive up efficiency and quality.

The Government will need private sector involvement on both the supply and demand side if they want to meet their targets and ambitions, and we certainly share their ambitions. On supply, we must recognise that many elements of the health service are already provided by the private sector. The drugs industry and the medical supplies industry are private, and hospitals are now built—and in many cases operated—by the private sector. In fact, GPs are private sector contractors to the health service. We as a nation spend well over £1 billion a year on over-the-counter drugs.

One business in my constituency owns several MRI and CAT scanners, and operates them on behalf of hospitals on various bases. Although every head of radiology wants a scanner, some hospitals do not need constant access to one. Given that they cost £1 million, why should such hospitals buy one? That business will supply such a scanner for, say, two days a month. Such scanners are mobile. The business will staff them, or hospitals can staff them themselves. Hospitals can pay so much per week, or so much per episode. The private sector provision of capital is likely to prove more efficient than the purchasing by small and medium-sized hospitals of their own facilities. That system could be replicated across many clinical services, such as pathology. Unlike large hospitals such as the one across the river, some others might not be able to justify a full-scale pathology service. That is another example of how huge capital expenditure items can be more productively shared among several hospitals.

Cataract surgery is the fifth most common surgical procedure. It accounts for nearly 4 per cent. of admissions, 5 per cent. of waiting list admissions, and 11 per cent. of

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total waiting list days. The average wait for a cataract operation is 203 days. Given that most people who are in need of a cataract operation are already pretty old, that constitutes a significant part of their life expectancy. Subjecting people to such waits is scandalous. There is clearly a capacity constraint, whether through choice, or because certain fundamentals are difficult to effect. Commissioning authorities should get together and say, "Let us commission a cataract service from the private sector, which will perform a certain number of operations at X cost per year." That way, perhaps we can eliminate the scandal of the 203-day wait.

The Government could use the private sector to supply health care in several similar areas. The Government will have difficulty in turning money into health care because of the serious short-term supply-side constraints that they will face, and they might find it easier to meet their targets by using the private sector.

Private sector funding could also be used imaginatively on the demand side. Nobody would seriously suggest that private health insurance should be used to provide all health care, but I shall give an example of how it might be used. Ten surgical procedures account for 35 per cent. of all admissions and all waiting list days, and 20 procedures account for between 46 per cent. and 49 per cent. of admissions and waiting list days. A relatively small number of surgical procedures account for a huge amount of the work. That is the old 80:20 rule and—I suppose—it is what one would expect to find, but it is surprising that it is true on examination of the figures.

Given those figures, we might do a lot to reduce waiting times and lists by giving a modest tax subsidy to a limited private insurance subsidy that covered only those operations. That would be sensible for the Treasury to consider. I understand the arguments on private health insurance about dead-weight cost—many people already have insurance, so why give them the tax subsidy?—but the subsidy could be pitched much lower than the cost in lost taxation and still create an incentive. People could be encouraged to spend more of their own money and, in the process, could help the Government to meet their targets by taking some of the pressure off the NHS.

I am glad that we have Treasury Ministers on the Government Front Bench, because I have another idea to suggest. One of the problems that we face is that people are not saving enough for their retirement. When I worked at the Treasury, it was one of the main concerns of senior officials that people are heading for retirements during which they will cost the state a lot of money. However, we could allow people who have significant pension funds to spend some on private health care. Some people have pension funds considerably in excess of what is needed to keep them off state benefits, and we could encourage people to have a retirement fund not only for income purposes but for residential care or nursing care in their old age. If they need an operation or a hospital stay, they could also be allowed to spend money from their fund on that.

Ann McKechin: The hon. Gentleman has expressed some interesting opinions. However, one of the difficulties faced by the NHS is the lack of specialist staff, especially consultants. He mentioned cataracts and the length of the waiting lists in particular, but consultants in Glasgow are already tempted to move to other areas where they are likely to get more private work. If we

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spend too much time focusing on the needs of people with private insurance, it skews the health service away from those who are most in need, which is those who suffer from the worst poverty.

Mr. Maples: I do not know about the Glasgow example, but the supply of health services is probably more flexible and less constrained in the private sector than it is in the public sector, at least in the short term. The Government have decided to chuck a huge amount of money at health services, but because of the constraints they will find it difficult to turn the money efficiently into health care. I do not argue that all the money should be spent in the private sector, but in the Secretary of State's statement on delivering the NHS plan he clearly envisages purchasing services from the private sector. By giving some examples, I hope to suggest an efficient way to spend a marginal amount of the money. The supply-side constraints are less in the private sector, although in the long run there are constraints on both sectors, because the problem is the number of consultants and nurses. Nurses can be trained relatively quickly, but it takes about 15 years to become a consultant.

It will be an interesting experiment to see whether the Government's model and the increase in health spending will work. We will not know for two or three years whether they will. We obviously all hope that the Government get the outcomes they want, but if the experiment does not work we will need to recognise that the model will have been tested close to destruction. Those who have been its passionate advocates will have to be prepared to look at other systems; and I suggest that we should look to our continental partners, who are not all completely crazy, to offer systems that differ from ours. I am glad that the Government are encouraging the use of private sector suppliers and encouraging private sector demand. They are likely to find that a less constrained and more productive way to spend some of the money than trying to increase capacity at the margin in the NHS.


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