National Health Service

HC Deb 06 November 1981 vol 12 cc220-81 9.36 pm

The Secretary of State for Social Services (Mr. Norman Fowler)

I welcome this debate on the National Health Service. The Health Service does face problems—and I will talk of those—but it also has many achievements and its reputation with the public remains high. In the past 30 years it has accomplished a great deal and it has a crucial role to play in the future as the major provider of health care in the United Kingdom. It is for that reason that the Government have given priority to it both in terms of spending and in terms of policy. There is a crucial point here for the House to consider. Policy on health is not just about financial comparisons, one year with another; it is also about how resources are actually used. For that reason, the Government have developed policies which have slimmed down the organisation of the Health Service so that more resources can actually go directly to patient care. We have sought to move resources from institutional care to community care wherever that is possible. We have also sought to tackle problems not just because there is a massive pressure group to respond to but because there is a real need, and unless the Government take action no one else either will or can.

A clear example of what I mean by that comes from the Queen's Speech and our promise to introduce a mental health Bill which we will be publishing next week. The Bill is about the status and legal position of those mentally disordered people who need special protection or control. As the House will recall, the Mental Health Act 1959 introduced by my right hon. and learned Friend the Member for Hertfordshire, East (Sir D. Walker-Smith) swept away many of the old legal constraints and ensured that legal provisions were applied to the minority of the mentally disordered for whom they were essential. We are then dealing with a small minority, a minority consisting of just over 7,000 patients, who are detained in hospitals under the 1959 Act compared with about 130,000 patients who have been admitted informally as voluntary patients. Nevertheless, if the 7,000 are to be deprived of their liberty, either in their own interests or for the protection of others, we must ensure that this is done in a way which fully recognises their rights.

The system for detention established under the 1959 Act is sound in principle, but it is now in need of overhaul.

The Bill will seek to remove the uncertainties of the law, clarify the position of staff who care for detained patients and improve and add to the safeguards of those patients. The Bill will halve the time before a patient's detention in hospital or period under guardianship has to be reviewed by a mental health review tribunal. In other words, reviews will be more regular. The Bill will also set up a new special health authority called the Mental Health Commission, which will have an important responsibility as a watchdog for detained patients. Its members will visit hospitals where patients are detained and monitor procedures for detention. This will be an important and valuable safeguard for detained patients.

There will doubtless be health issues upon which the two Front Benches disagree strongly. I hope that we can also agree that there are other issues upon which there are not party divisions and upon which there is common agreement that we should make progress. I believe that this is one of those and it is for that reason that the Government will be publishing next week with the Bill itself a White Paper that will set out the reasoning behind the Bill. I give the assurance that we shall be ready to consider changes that are urged on us in debate upon it.

My right hon. Friend the Home Secretary will be giving careful consideration to the judgment delivered in Strasburg yesterday by the European Court of Human Rights on the position of the special group of detained mentally disordered patients who are subject to restriction orders. The Bill will provide an opportunity to debate the issues arising and to amend the legislation if necessary.

The Bill is aimed at an area of real need and I believe it demonstrates the point that providing additional resources is only part of the problem that the Health Service faces. I accept that many of the mentally ill and mentally handicapped do not come within the scope of the Bill. In particular, I am concerned about the position of the mentally handicapped.

The basis of our policy is to give the mentally handicapped the fullest possible life and the best chance to achieve their full potential, and to do this as far as possible in the community rather than in institutions. That policy was set out in the 1971 White Paper "Better Services for the Mentally Handicapped". Some of the progress from hospital and institution to community has been encouraging—for example, in the case of mentally handicapped children.

There should be no doubt that large hospitals do not provide the right environment for a mentally handicapped child to grow up in. Wherever possible they should live at home or, if that is not possible, in small units which can provide a homely setting. The number of children now resident in hospital is falling steadily. That is notably good news. The total is 2,000, well under half the figure for the early 1970s.

As a further encouragement to getting long-stay children out of large mental handicap hospitals we are making available £1 million over four years, which we will match pound by pound against a similar amount raised by voluntary organisations for this specific purpose. The aim of the experiment is to seek to set up projects which will provide some of these children with more appropriate surroundings.

Let me stress, in case there is any misunderstanding, that we shall be issuing later this month the guidelines on the scheme to those organisations which are interested, for we are clear that the voluntary sector has a tremendous contribution to make to this initiative. Many voluntary organisations are already thinking about schemes to provide better units for children who are moved out of hospital. So there is some encouraging news regarding mentally handicapped children.

For adults resident in large mental handicap hospitals, the picture is much less happy. There are still about 15,000 people in these hospitals who have no health reason to be there. We cannot be happy with such a position. I am concerned that we should make progress here as quickly as possible so that the numbers in hospital should be further reduced. As an immediate priority, we should be seeking to develop new arrangements to enable these people also to move out of hospital. I hope to have more to say on policy in this area over the coming weeks. I hope that the House will agree that this is and should be an area of priority.

I referred to the considerable pressure which those responsible for the Health Service must feel as regards the mentally ill and mentally handicapped, but clearly there is a range of problems which the Health Service will have to face during the 1980s. One of the problems is enabling sufficient provision to be made for the elderly.

We should avoid generalising because, of course, a great many of our older people are very fit and make a continuing and active contribution to their families and to the life of their neighbourhood. But clearly problems are raised both for the Health Service and for the personal social services. By the end of the century the number of people aged 75 years and over is expected to increase by about one fifth and the number aged 85 and over is expected to increase by one half. It must be the duty of our society to make proper provision for the elderly and this will continue to be the Government priority.

Mr. Paul Dean (Somerset, North)

Will my right hon. Friend take this opportunity, at the beginning of the Session, to reaffirm the Government's pledge that the real value of pensions will be maintained over the lifetime of this Parliament?

Mr. Fowler

The commitment which my right hon. Friend the Prime Minister gave on this subject has been repeated in the House on a number of occasions. My right hon. Friend gave the commitment that the Government would fully compensate pensioners for price increases over the lifetime of this Parliament. I take this opportunity to confirm that that pledge will be maintained. I respond entirely to the important issue that my hon. Friend has raised.

Mr. Laurie Pavitt (Brent, South)

The right hon. Gentleman has referred to responding to real needs. Will he give further consideration to the rundown of chiropody services? Bearing in mind the increases that he has mentioned, we shall need more chiropodists, not fewer. The number of chiropody students is falling because of lack of resources.

Mr. Fowler

I shall consider that. It is an issue on which one of my most distinguished predecessors, my right hon. Friend the Member for Leeds, North-East (Sir K. Joseph), who is now the Secretary of State for Education and Science, felt strongly.

Mr. Jack Ashley (Stoke on Trent, South)

I am sure that the House will welcome the right hon. Gentleman's assurance on pensions. Will he give a similar assurance that the income of those suffering grave hardship, such as the unemployed and invalidity pensioners, will be maintained by the Government?

Mr. Fowler

The House will have to await the result of the discussions that are taking place on that and other matters.

Mr. Mike Thomas (Newcastle upon Tyne, East)

Ah.

Mr. Fowler

That is the only sensible response to make at this stage. It is a response that any Minister would make in any Government, even a Social Democratic Government. God forbid that that should ever be Britain's fate.

Mr. Pavitt

A suitable case for treatment.

Mr. Fowler

Indeed.

At the same time pressures on primary health care service, especially in some inner city areas, of poor housing and shifting population, are again very considerable; while in addition we have the inequalities revealed not only between different parts of the country but between different groups as set out in the Black report. But the test is not our skill in using words to describe the problems facing the Health Service but our skill in developing policies to solve the problems. Here I come back to the question of resources.

If the purpose of the Opposition, in discussing the National Health Service, is to seek to establish that the Government have cut back on the Health Service, they are hopelessly mistaken. For let there be no mistake about the position. This Government are spending more—not just in cash but in real terms—than in any year of the previous Labour Government. More resources are going to the hospital and community health service and more resources are going to the family practitioner service. That is the fact of the matter.

Current spending by health authorities this year is planned to be 4 per cent. in real terms above the level we inherited for 1978–79. If we include capital expenditure by health authorities, the real terms increase over the period is nearer 4½ per cent. and for the spending on the National Health Service as a whole, the increase rises to 5 per cent. These are increases over and above inflation during the period, and we are therefore talking about having achieved a real growth in National Health Service finance allowing us to provide for the increased number of very old people and enabling us to use advances in medical technology which result in more and more effective treatment of patients, in hip replacements and transplants and better diagnostic tests.

But, on top of all that, it means that we can continue the process of reducing the disparities in the levels of funding of the Health Service by ensuring that the relatively more deprived health authorities receive a greater share of available resources. Again, that point must be stressed. This has been achieved at a time when the country, and indeed the whole Western world, is going through the severest recession since the end of the Second World War. The result has been that we are now spending more than £11 billion a year on the Health Service. That is an enormous sum, and it shows the priority that the Government have given to health. I am grateful for the opportunity of emphasising that. I also emphasise that our ability as a nation to continue with the growth that we should like to achieve will depend upon the economic recovery of the country. We must create the wealth to finance the growth. Far from cutting back on the Health Service, the Government have devoted extra resources to it.

Mr. Mike Thomas

Simply to accommodate the demographic change—for example, with more people becoming elderly and living longer—is it not widely estimated that an increase of between 1½ and 3 per cent. a year in real terms is necessary? The Secretary of Slate is talking about an increase of 1 per cent. a year.

Mr. Fowler

We are managing to keep pace not only with the demographic changes but with the technological changes. The figures that I have given establish that. I assume that the hon. Gentleman is the SDP spokesman on health matters. Certainly he is its only representative today. One of the extraordinary things about the SDP is that it has not issued a policy statement on health. We may have differences of opinion, but at least I know where the hon. Member for Crewe (Mrs. Dunwoody) stands and where the Conservative Party stands. I have no idea where the Social Democrats stand on the matter. No doubt I shall know in time. I am sure that the House can hardly wait for that revelation.

I repeat that what is important is not a comparison of finance year by year. The test is what we have achieved with the extra resources—how services have improved, and how the services have benefited the patients, because it is the patients' interests that are paramount.

Reviewing the position, one of the Government's notable successes is that hospital waiting lists have been shortened. At the end of March 1979, a few weeks before the Government took office, there were in England as many as 752,000 patients waiting for admission to hospital, mostly for surgical treatment. During the two previous Labour Administrations the figure had risen from 508,000 to 752,000. The latest figure is that the waiting list is now 630,000. The fall in less than two years is likely to be more than 120,000. That is a considerable achievement, for which I pay tribute to the staff of the National Health Service. It is an achievement on which I am confident that they can improve and one that demonstrates rising and not falling standards.

Although we have not cut the budget, we have cut the waiting lists and tried to cut administration costs. Management costs are being reduced through reorganisation by about 10 per cent. which we estimate will save about £30 million a year.

The creation of new local district health authorities will help to ensure that decisions affecting patients' care are taken by those who are closest and most responsive to the needs of patients and the community. The talks that I have already had with the new chairmen confirm that that will be the effect of the changes.

Another success is that during the past two and a half years we have obtained in the Health Service 1,000 more doctors and dentists and between 8,000 and 9,000 more nurses and midwives. There has been a significant increase in the number of people providing health care. Those are some of the ways that resources are being used. But it is also vital to stress that those responsible for spending thousands of millions of taxpayers' pounds should be constantly aware of the need to be as economic and efficient as possible in use of resources. Certainly I do not regard the Department of Health as any exception to that. The headquarters staff in my Department have been cut by 14 per cent. since 1979, and by 1984 I expect 20 per cent. fewer staff in headquarters than when we took office.

We are shortly to publish a Bill to provide for an employer's sick pay scheme and to unify housing benefits. One of the results of that will be to save an additional 5,000 staff, while the changes themselves make sensible reforms on their merits. In addition, changes in the regional organisation are expected to deliver a further 1,000 staff savings over the next two or three years. At the same time we have reduced interference by the Department in the affairs of the National Health Service—for example, by halving the number of circulars. We aimed for greater efficiency, which has been achieved. The search in the NHS for efficiency savings must continue.

Mr. Nigel Spearing (Newham, South)

The Minister appears to be saying that because the numbers have been cut the NHS is more efficient. Does he agree that it is easy to enumerate figures but not easy to evaluate the effect? Will he assure the House that the numbers are not being made up by contract work or by some other form of expenditure outside the Civil Service, which would mean that the figures are not real in the full sense of employment?

Mr. Fowler

I can give the assurance which the hon. Gentleman wants on his last point. The Bill will set out details of improvements in organisation.

It should be common ground between both sides of the House that, whatever the political complexion of the Government organising the NHS, they must seek to attain maximum efficiency in its administration.

However, whatever can be achieved in better use of resources, every Government will be faced with the problem of not enough resources and ever-increasing demands. We must not turn our back on new ideas or, even worse, say that new ideas cannot even be considered. It is more than 30 years since the NHS was established. It was a pioneer at the time, but since 1948 many other countries have developed comprehensive health care services along completely different lines. We cannot simply shut our eyes and say that our way is necessarily, and without examination, the best. We need to examine their experience and see whether we can learn from them how to cut out the weaknesses in our own system, while keeping its great strengths. That is why my predecessor announced in July the setting up of a working party to look at possible alternative ways of financing health care, drawing on other countries' experiences.

The Government have spelt out clearly that we shall not entertain proposals for change unless they can achieve health care for all, regardless of means. We must also preserve the strengths of our primary care structure, and seek to bring about improvements. Any suggestions that emerge from the review must be tested against those and other key criteria, and we shall not go forward with proposals unless we are satisfied that they offer us substantial advantages over what we have already.

Our Health Service must also be ready with new ideas to respond to changes in health needs. Too much ill health is avoidable and pre-empts resources needed to treat those who are unavoidably sick. That makes prevention a prime objective. Responsibility for taking care of personal health rests primarily on the individual, but there is an important role for Government and health authorities to ensure that people are well informed. That will be a major task for the new district health authorities. To assist them we have reconstituted the Health Education Council with a clearer role and increased resources. We have continued to issue advice, for example, on aspects of diet and nutrition in relation to heart disease. We have taken action to help protect children against avoidable hazards, for example, through encouraging vaccination and immunisation. Those efforts will and must continue.

Looking to the future, it appears that the key word for the 1980s is partnership—partnership in a number of areas. First, there is the scope for partnerships between the different agencies that provide care. Earlier this year we issued a consultative document, "Care in the Community", with the aim of encouraging new ways in which collaboration could take place between health authorities and local authorities. Too often we find that the care that goes to the individual depends upon historic and out-dated patterns. People are treated in large institutions when they should be in the community. We must develop new and imaginative ways in which the resources are switched with the person or with groups of persons, and that is what "Care in the Community" aims to do. That is why we are seeking views on the different suggestions that are set out in it. If surplus National Health Service property and land can be used to help finance these arrangements, that will be for the good of the Health Service generally, and especially for the good of the individual.

Secondly, we want to see partnership with the voluntary sector. That is crucial if we are to produce the level of services and caring that we need for such groups as the elderly, those suffering from mental handicap or disorder and the disabled, who need long-term support within the community. One outstanding example of what can be achieved when the National Health Service, the community and voluntary interests are working together towards a shared goal is the national appeal which Jimmy Savile is mounting for the rebuilding of the spinal injuries unit at Stoke Mandeville hospital. He is pledged to raise £10 million and has so far achieved more than half of that ambitious target. Work is already advanced on site and the unit is due to be completed in 1983. Of course, Jimmy Savile's is a national appeal, but it is an example of what is possible when the public's imagination is caught. There are very many smaller and more local efforts throughout the country which I believe deserve praise and which can again only be in the interests of the patient.

Mr. Pavitt

Does the Minister concede that there has been a severe cutback in local efforts because the rate support grant has been cut? That has meant a diminution of funds for voluntary organisations. Will the right hon. gentleman talk to the Secretary of State for the Environment and ask him not to clobber the voluntary organisations by cutting their resources? With greater resources they could do much more work.

Mr. Fowler

If the hon. Gentleman had studied the Government's policies, including those set out in the last Budget, he would know the priority that the Government have given to voluntary organisations.

Thirdly, I want to see co-operation between the private and the public sectors in health care delivery. We should be clear about what we mean by the private sector. It is in fact a mixture of voluntary, charitable, and commercial enterprises ranging from small nursing homes to modern hospitals capable of undertaking major surgery. A number of the hospitals and nursing homes are run by religious foundations. Health authorities use some of the facilities of the private sector on a contractual basis. Many beds in long-stay private nursing homes are, for example, occupied by patients paid for by the National Health Service. Besides the NHS, the independent sector is small. There are about 2,500 beds available in NHS hospitals for use by private patients, and about 32,000 beds in independent hospitals and nursing homes, mainly in nursing homes. By contrast, the HNS has a little over 300,600 beds in about 2,000 premises. The development of private facilities draws on other sources of finance and increases total health care provision in the country, and therefore helps to bridge the gap between the supply of health care and demand. In other words, the private sector can relieve pressure on hard-pressed National Health Service services either directly or by allowing the NHS to direct resources to other areas. It also provides an alternative. It shows that there are different ways of doing things and this, again, I believe, is a stimulus to an improved National Health Service.

As a matter of principle, I believe that, however good the State service is, people should have an alternative and should have the right to use that alternative. Above all, I believe that a partnership between public and private care is in the interests of the Health Service and of the patient.

Fourthly and lastly, a partnership concerns the health professions themselves. The National Health Service relies upon the dedicated work of its staff, and we must make the best use of its skills. The Health Service is as good as the people who are working in it, and we in this country are extraordinarily fortunate in the standard of devotion of our doctors, of our nurses and of our other staff who work in the Health Service.

I accept that there are problems that the National Health Service has to face. I believe that the Government are measuring up to the challenge of those problems. We are providing a better organisation for the Health Service and a greater emphasis on efficiency. We are now encouraging the change from hospital to community, and that must continue. Our essential aim is to serve the patient. The patient's interest comes first. The Government not only recognise that but are also taking the action that is necessary to meet the challenge.

10.11 am

Mrs. Gwyneth Dunwoody (Crewe)

It is typical of the attitudes of the Government towards health and welfare that there are only two items in the Queen's Speech that refer to either subject. One is a change in the mental health laws, which many of us believe to be long overdue and which we welcome. When the Bill is published, we shall look carefully at the contents. We shall want to know what extra safeguards are built in for the patient in the secure units. We shall want some clear evidence of how the Secretary of State views the work of the Mental Health Commission. We shall want to know the membership of the proposed Commissions and how they are to operate.

I hope that the Secretary of State will not think that I am unduly cynical if I suspect that the reason for including this measure in the Queen's Speech is the fact that yesterday in Strasbourg a case was heard in which Her Majesty's Government were held up to considerable criticism as one of the few Governments who still maintain the sort of laws that are not usual throughout the rest of Europe.

I tell the right hon. Gentleman now that the Opposition will fight tooth and nail the changes that the Government intend to introduce in sickness benefit. One understands why the right hon. Gentleman was careful not to mention this matter in any detail. It will be the first time since the Beveridge report was implemented in 1948 that any Government, no matter what their political colour, have sought to move away from the idea of universal provision towards a completely different scheme—a scheme differently funded and a scheme whose effect on those who are sick is not at present clear.

When the Green Paper was published, a great deal of evidence was given to the Government about the difficulties that would ensue if a scheme of this kind were created. So far as we can gather, the only influences brought to bear on the Government were those of the employers, who are apparently to be totally reimbursed. Yet it seems, again so far as we can gather, that no thought has been given either to small businesses or to those employees of businesses that become insolvent. Nor has any thought been given to the very real difficulties that will ensue with a flat rate payment by the employer for those families who, under the existing system, would expect to get a differential rate of payment. We regard this development as totally reactionary. We shall fight it with every weapon and in every way possible. We shall expect a great deal of the time of the House to be allocated to examining the implications of this development.

The Secretary of State has made great play of the fact that the Conservative Government approve of the National Health Service. After 30 years the right hon. Gentleman says that it is an exceedingly useful organisation, staffed by dedicated people and an organisation that still provides the bulk of health care. That is so true that I would like to have heard it stated in very much stronger terms. The reality of two years of Conservative Government control of the National Health Service is that they have sought in every way possible to undermine its foundations. The Health Service is still the best way of providing health care for the people of this country. The reason is simple. By paying in taxation and by receiving service free at the point of use, when it is most needed, the patient is better cared for than in any comparable service anywhere in the world. It does not matter how many working parties the Government set up. They will not be able to find a better way of providing health care. The Government have almost admitted that in their own speeches.

We are an ageing population. There are increasing numbers of elderly people. I suspect that the Government are saying something very different from the honeyed words used by the Secretary of State today. I suspect the right hon. Gentleman is saying that in future the State system will be left to cope with the mentally and physically handicapped and the geriatric and the psychogeriatric patient while those who can afford privileged care through the private system will be able to get whatever they want in terms of rapid help and advice. If that is the sort of two-tier system that the Government have in mind, I say. here and now, that it will not be acceptable to the people of this country.

The development taking place in private health care makes this clear. I came upon an interesting article in one of our glossy magazines only recently. What is noticeable since the Government came to office is the amount of advertising that the private health care units are putting into trying to boost their memberships. The article to which I refer was headed "Health for sale". It did not say, hon. Members will notice, "Health for the population". The words were "Health for sale". The article asks what are the real advantages and the main benefits to those who choose private medicine. It says, in effect, that there are no waiting lists and there are no difficulties.

The article lists prices that people who want private health care will have to meet. The Secretary of State says that since the Government came to office many of the problems of the Ntional Health Service have been dealt with. The right hon. Gentleman says that the Government are dealing with the problem of waiting lists. I have been involved in the National Health Service for over 30 years. The longer I live, the more cynical I become about the whole question of waiting lists. I believe that we should be looking closely at the manner in which waiting lists are organised.

The right hon. Gentlemn has quoted figures to show that under the previous Labour Government the numbers increased. He points to the enormous change that has occurred since this Government gave greater powers to consultants. The figures that he quotes relate unfortunately—I make no excuses—to the period of the winter of discontent when there was industrial action in the National Health Service and there was a growth of waiting lists. What the right hon. Gentleman does not say is that in many areas with very large waiting lists there is now a growth of pay beds in the National Health Service. I cannot see any justification, where there is any waiting list, for allowing pay beds and private care to be expanded in the same units.

What really concerns me about the Government's attitude is that apparently, by bringing about the proposed reorganisation and by changing the structure and financing of the National Health Service—simply by altering the way that it is operated—they will provide a cheaper service for the taxpayer.

When the Minister talks about financing the service, he never says that the implications of the rigid cash limits that have been applied are far greater than the growth figures that he has quoted. I should like an assurance from him today that in the immediate future he intends to see a 4 per cent. real growth figure applied right across the board. I suspect that that will not happen and that, over and above that, the cuts in local government finance will result in the personal social services being put under greater pressure in that they will find it even more difficult to provide essential back-up services.

We have to ask ourselves what it is that the reorganisation of the National Health Service hopes to achieve. The Minister says that its management is being cut and that a number of posts have been lost. We imagine that that will continue. He says that this is all in line with the Government's intention of making the service more efficient. However, I am becoming increasingly worried about the reorganisation in general. One of the problems in the NHS is the extremely low morale of its staff. The timetable for the reorganisation is falling further and further behind, and many staff—not only administrators but other ancillary staff—still have no idea what they will be doing in the new district health authorities. Some of them are likely to have to wait 18 months before they are told the posts that they are to fill.

Many of the new DHAs will be very small. In terms of finance, this will be a very important factor. If a district health authority is too small, inevitably those specialist services such as those provided for the mentally handicapped will have to fight extremely hard to get a fair share of the available resources. Almost inevitably, the new DHAs will be centred on district general hospitals. I want the Minister to look carefully at the reorganisation and to say whether he is satisfied that all the new services will be able to function in the most efficient way.

I should also like to hear from the right hon. Gentleman why he has taken certain decisions which his predecessor had agreed should be postponed until the new health authorities came into operation. His predecessor said, for example, that consultants' contracts should be looked at in considerable detail and that there should be very wide consultation.

Consultants in the National Health Service not only have a great deal of muscle but are responsible for a great deal of the expenditure. They manage the waiting lists. They decide the use of beds. It is their attitude towards expenditure that frequently determines which equipment will be bought in which hospitals. Therefore, the decisions taken by the consultants in many instances represent a considerable amount of financial decision-making.

Why has the Minister decided, apparently fairly arbitrarily, that the consultants' contracts should not remain with the employing district health authority but should be vested in the region? The right hon. Gentleman will know that in the case of teaching authorities the DHAs have always had responsibility for the consultants' contracts. But even though there may be instances where consultants are employed by two district health authorities, there is bound to be considerable difficulty in the future if an authority finds that, as the employer, it has no right to control the employment of the doctors in its area. I hope that the Minister will say why he has taken that decision. At the moment the reason is far from clear.

Mr. Nicholas Winterton (Maclesfield)

My right hon. Friend said that there was likely to be common ground on both sides of the House about a number of issues althought there would be fundamental differences about others. In this instance, I find myself in entire agreement with the hon. Member for Crewe (Mrs. Dunwoody). I find it difficult to understand why my right hon. Friend, so close to the publication of the report of the Select Committee on Social Services on the structure of medical education, should go precisely contrary to a recommendation of the Committee. I can say on behalf of its Chairman and members that the committee that is gravely disturbed by my right hon. Friend's decision, and I hope that he will explain in detail why the employing authority is not to be responsible for the contracts of the consultants. I share the concern of the hon. Member for Crewe.

Mrs. Dunwoody

I am sure that the Minister will be only too happy to respond to the hon. Member for Macclesfield (Mr. Winterton). However, the consultants have a great deal of influence over and above that which they exercise on expenditure. In many instances, for example, their decisions are behind applications to the Minister to extend private practice.

Private health care is no answer to the problems of the National Health Service. It is untrue to suggest that it supports the facilities provided for the ordinary patient. To appreciate that fully one has only to refer to the figures of the return on capital quoted to their shareholders by the American companies seeking to come here. They are not concerned about quality of service. They are not concerned about improving general facilities for the patient. They are concerned only with making money. That is the rationale of their approach. They regard health care in the same way as most of us regard selling cans of peas. Although that may be perfectly honourable, it is not acceptable in a country that needs much better health care.

We do not need any more evidence than that which is available already. The Minister reminded the House that the National Health Service had been in existence for 30 years. However, his Government have refused resolutely to discuss the implications of the Black report. They have refused to provide the time for the House to discuss the report simply because what it says about health care after 30 years is embarrassing to them. They do not want to look in detail at either the difficulties or the lacunae that undoubtedly exist. Sometimes, when Ministers are asked about the Black report, they say that of course the Government are in favour of its recommendations in theory but that it will cost a great deal of money to implement them. The amounts which they quote change with the Minister who is speaking about it at the time. It is rather like a small child of 2 who has heard of various numbers but who does not know what they mean. When asked how old he is, he replies firmly that he is 10. That appears to be the Government's attitude to the cost of implementing the Black report.

What Black said was very simple and dramatic. Anyone born into social classes IV and V 30 years after the creation of the National Health Service—and certainly anyone born in an underprivileged area—had the following chances of survival: At birth and in the first month of life, twice as many babies of 'unskilled manual' parents die as do babies of professional class parents and in the next 11 months, four times as many girls and five times as many boys. In later childhood, the ratio of deaths in class V to deaths in class I falls … but increases again in early adult life. At retirement, the rates were even more dramatic. It also said that there were inequalities in the utilisation of the health services, and it recommended various practical ways of dealing with the problem. In other words, in areas where the health services are most needed, we must find out why people are not using them to the full and why the services provided are not dealing adequately with the difficulties of the population as a whole.

Black recommended that the Health Education Council, about which the Secretary of State was so enthusiastic, should be provided with sufficient funds—which does not mean an increase of a minimal amount—to set up child accident prevention programmes. It also said that resources within the National Health Service and the personal social services should be shifted more sharply than so far accomplished towards community care, particularly towards ante-natal, post-natal and child health services". A House of Commons Select Committee stated unequivocally that many deaths of children in this so-called civilised, developed country could be prevented if only we were prepared to do something energetic about improving the health care that those mothers and babies receive. Yet today, the Secretary of State gave no indication that he intends to take the report seriously. He has made many comments, for example, about the need for partnership with voluntary organisations. Of course I approve of voluntary organisations, but it is quite specious to suggest that by giving £1 million to voluntary organisations and asking them to match that amount pound for pound we are beginning to deal with the problems set out in the Black report. All we are doing is giving some encouragement to voluntary organisations without ever discussing the question of the resources needed for running new hospitals, providing continuing care or improving the personal social services.

It is true that some charitable organisations provide a service that supports those of the NHS, but it is clear that the best of those units are supported by money from the region in which they operate. Their continuing costs are not left to charitable and voluntary organisations. They are a considered and planned part of National Health Service expenditure. For example, the hospice movement, which many of us would like developed, relies on a close partnership with the NHS. Without that it would not he able to continue. So, at best, it is disingenuous to suggest that voluntary organisations can begin to deal with the scale of the problems that we now face.

The report states: Savings from the current decline in the school population should be used to finance new services for children under 5. The Department, and the Under-Secretary of State who is now sitting on the Government Front Bench, held a conference last week to discuss the provision for the under-fives. Although many interesting points were made that day, it was noticeable that the Government did not at any point give a commitment in terms of finance or support services. Indeed, it took some time to get the Under-Secretary of State for Education and Science to deny that it was the Government's intention to charge for nursery provision for the under-fives. That is a measure of the seriousness with which the Government regard provision for the pre-school child.

The Secretary of State said that in most health care, particularly health education, the responsibility was that of the individual. With the greatest respect, that is the biggest load of nonsense that I have ever heard. The individual cannot deal with the problems of poor housing if he has no money. He cannot deal with the difficulties that arise at work if there are no proper health and safety at work measures. He cannot provide for a better overall income and a better diet if he is living on social security benefits, especially if he has to operate for the first eight weeks of sickness on a system that will rely entirely on flat-rate benefits and take no account of family circumstances. In suggesting that by increasing the amount available for health education we shall change the entire future for the population of this country, the Secretary of State is behaving irresponsibly.

It is more likely that the Government will continue their positive efforts to encourage what they call partnership, but what I call a parasitical relationship between private medicine and the National Health Service. It is not an accident that when private hospitals are set up, they are almost inevitably set up as close as possible to existing NHS units. The better the quality of the National Health hospital, the more the private health care firms will fight to get on to adjacent sites.

The reason is simple. Encouraged by Conservative Ministers, they hope to take from the National Health Service many patients who require simple, straightforward and easy operations and be paid for them at a considerable rate, and to leave to the National Health Service the expensive treatment that will cost much more. At present, private units consistently use the facilities of the NHS for expensive testing procedures that they do not want to pay for themselves.

Why has the Minister never gone out of his way to explain how much subsidy the NHS has given to the private sector? Far from being a support, the private sector is very much like a leech and is as much use to the NHS as it would be to a blood donor. We should also examine the question of the supply of blood to private hospitals. It has never been made clear whether the present arrangements are being paid for at an economic rate or whether private units are simply using the facilities of the NHS without making an appropriate contribution. What goes for those services also goes for the use of rechargeable services, such as ambulances and other ancillary services.

By constantly sending out what the Minister would call reminders, but what I would call demands, to the NHS administrators to use private facilities, the Government are positively trying to push NHS money into the private sector to improve its cash flow position. That is wholly unacceptable. When this party comes to office it will make sure that the private sector is at the very least frozen where it is and we shall also ensure that no private practice is allowed to operate within the National Health Service.

What evidence is there that the money raised by selling facilities and buildings is being constructively used for the benefit of the regions concerned? It is all very well to say that, where necessary, unused facilities should be sold—and I am not in business to support the retention of Victorian hospitals that no longer provide facilities of the standard and type needed by modern patients—but the Government must not shut down even old facilities before providing an alternative for patients in the area. The sale of NHS hospitals is not in the interests of patients unless alternative provision has been made in the most efficient way. I hope that the Secretary of State will cease to pretend that there is positive benefit to NHS patients from the Government's approach.

Mr. Fowler

I shall not cease to pretend anything of the kind. Does not the hon. Lady realise that in 1980–81 health authorities secured an addition to their capital cash limits of £15½ million? All parties should accept in common sense that, if there is surplus land and property, the proceeds should go back to the Health Service. If the nationalised industries had such an arrangement they would put out flags all the way down Whitehall. It is an exceptional arrangement, and the hon. Lady should welcome it.

Mrs. Dunwoody

May I quote a specific case that I have sought to raise in the House for some time? What is the advantage to the NHS of the constant to-ing and fro-ing over the sale of St. George's hospital site at Westminster? It was announced yesterday that it is to be made into an office block, retaining the facade. The NHS will get nothing like the positive benefit that it should from the sale. The Government have not pushed energetically to ensure that a private estate does not walk away with a profit wholly out of proportion to its involvement in recent years. If the right hon. Gentleman is serious about creating extra funds for the NHS he should have ensured that it had a proper deal out of the sale. There is absolutely no evidence of that.

The Minister mentioned capital costs. I admit that there has been too much of a pretence in the past 10 years that capital costs can be cut. Succeeding Governments should have increased the money available to improve NHS facilities. Indeed, I should like to see more new hospitals and smaller units. There is no evidence of new planning for improved hospitals. It takes 15 years from the planning stage to the completion of a modern hospital, yet there appears to be no suggestion that the new DHAs will get a positive injection of capital to enable them to build the premises desperately needed in future.

What is true of the hospital sector is even more true of the personal social services. When talking of mental handicap the Minister said that the Government were delighted that fewer and fewer children were within institutions and more were going into the community. We all hope that the trend will continue, but it will not do so unless money is available. Local authorities are asked to cut back their budgets, and apparently they will be asked to submit to referenda every time that they want to apply a supplementary rate demand, so the money to develop new units to care for the mentally or physically handicapped will not be forthcoming.

The personal social services have been starved of money. There has been a positive fall in the money available, and that at a time when the calls on their services get stronger every day. With growing unemployment and more and more old people in the community the Government need to provide more care, yet the money available is being cut. That is unacceptable and makes nonsense of the mealy-mouthed views that we have heard today. The Government cannot say that they want to move mentally handicapped children—and even more adults—to small homely units if they are not prepared to provide the cash. There is a good deal of talk of joint funding, but the money available for that is infinitesimal compared with the size of the NHS budget.

We are caught in an odd and vicious circle. If the Government are not prepared to give a capital injection to provide smaller units, the local authorities cannot provide them, and it is highly immoral for the Government to insist that patients should be moved out of existing accommodation before new accommodation is available. How much extra money will the Government provide to build the smaller, homely units that will make the care of the child in the community happier and healthier? How much does the Secretary of State intend to contribute to providing special accommodation for the adult mentally or physically handicapped patient?

Let me say on that point that it behoves the Minister to pay tribute to the staff in our special hospitals. Many operate in old buildings that are understaffed and do not have sufficient support services. If the Government put money into that sector it would be some evidence of their good will. Many criticisms of institutional care can be simply dealt with in that way, but there is no evidence of the Government's good will.

Many aspects of the Government's health policy are bewildering. They intend to do away with community health councils, yet they allege that they wish to improve the information and support services available to patients. CHCs do an extremely useful job. It is not good enough to say that they will be dissolved on 31 March without explaining how they are to be reconstituted and who is to serve on the councils. It seems that the Department suggests that in some areas one CHC can cover a number of district health authorities. That is unsatisfactory. There is even a suggestion that the membership should be much smaller. If local authorities are not to have proper representation how can they get over to DHAs what they see as the necessary health provision in their area? Will the Minister undertake to tell the community health councils in good time not only what the future holds for them, but how he expects them to operate, and from where their representatives will come? Even when dealing with voluntary organisations time is needed for nominations to be made and elections to take place.

If there is to be a hiatus between the end of March and the setting up of the new community health councils the impetus will be lost and a lot of the good work that they are doing will be lost to the community. About 73 per cent. of the expenditure on the National Health Service goes on employment and wages. The Health Service is a labour intensive organisation which relies heavily not only on doctors but on nurses. The Government's attitude to nurses' pay is incomprehensible. When the Government came to office they made great play of the Clegg mechanism not being suitable for dealing with comparability, and said that they intended to abolish it and produce what they called "an alternative system". The Minister has referred to it as a "basket". That appears to be an adequate description, but he did not tell us what will happen to nurses' pay.

The imposition of rigid cash limits creates difficulties. The staff in the National Health Service are told consistently that if they seek too high wage increases they will take that money away from the patients and that the patients will suffer as a result. That is a continuing cry. It cannot be allowed to continue. It is impossible to run an efficient Health Service if the roles of doctors and nurses are made more difficult. If we are to have proper staffing ratios and proper conditions of work, Health Service professionals must be properly paid. The question of nurses' pay should be looked at with far more compassion than the Government have demonstrated.

While we are considering the question of internal relations and industrial relations in the National Health Service, will the Minister tell the House what steps he now intends to take to draw to the attention of all health professionals the undertaking that they give when they begin work to respect the confidentiality of patients' records? I raise this matter because of the verdict handed down from the courts yesterday. Some organisations have suggested that they intend to take action against individual doctors because they believed that they were not complying with certain terms of service.

Will the Minister remind National Health Service professionals that it is vital that the confidential details of patient treatment are not given to third parties for whatever reasons, and that it is essential that those working within the National Health Service have confidence in their colleagues? Will the Minister also look closely at the question of the confidentiality of computerised records? We welcome these advances, but it would be wrong if anyone other than the doctor or patient concerned gained access to that patient's confidential records and used them for purposes other than medical care.

The real difficulty in the Government's attitude towards the Health Service is that they consistently seek to change the basis of its operation and the attitude of the general public to it. There are a number of elements in the Government's attitude. It is not only that sometimes the Conservative Party bitterly resents the fact that the Health Service exists to provide cover for all our people. There is something deeper in it than that.

Some recent decisions, such as the charge to overseas visitors, demonstrate the Government's worrying frame of mind. The Government are determined to introduce a form of charging to overseas visitors using the National Health Service, not simply because they see it as a method of recouping the costs from those people who have not paid into the system, but because they believe that if they set up charging machinery they will be able to extend the charge for individual services to residents who cannot be said not to be supporting the service. The Government must make it clear that they will not proceed with charges to overseas visitors.

It is morally abhorrent that anybody who goes to a doctor should have to explain his or her personal position and prove his or her right to be resident in Britain. I am not alone in believing that such a development would be against the interests of anyone with a foreign accent or mien. It would do enormous damage to internal race relations and lasting and irreparable damage to our reputation overseas. The Minister would do well to abandon the suggestion as soon as possible. Such a scheme could improve neither the Health Service nor our reputation overseas.

I am worried about many other aspects of the Government's policies. The Government are seeking means of moving further towards privatisation. A report on dental therapy suggests that we should do away with dental therapists and allow the work of dental hygienists to replace that of skilled dental practitioners. It suggests that moving towards privatisation would improve child dental health care. That is nonsense.

May we have an assurance that the school at New Cross will continue to do its excellent job training dental therapists? If no such undertaking is given we shall know that the Government intend, as usual, to chip away at another form of health provision and to cut services to the general public. That has been the consistent pattern since the Government came to office. They have given positive encouragement to the private hospital. They have made positive suggestions that facilities should be provided for private health units. They have reiterated that voluntary organisations could provide funding for the National Health Service. They have said that only by reorganisation can we do away with the problem of overmanning and inefficiency. Efficiency in the Health Service is best provided by employing trained staff and by encouraging management of a high calibre. It is too simple to say that by cutting management the standard of service will automatically be improved.

It is illogical to argue that districts should cut their staff and improve their internal auditing. A sophisticated National Health Service cannot be provided without proper staff, good administrators and good management.

The real problems are even deeper and more urgent. Health care has been frozen for nearly two years by reorganisation. Morale in the NHS is at its lowest. Members of staff do not know what will happen to them and are deeply distressed by the evidence that the Government, far from wanting to improve the NHS, are seeking positively to undermine it every day.

There is no evidence of good will or of injection of finance into those services which are desperately in need. There is no evidence of new thinking or of imaginitive application by Conservative Ministers to the problems of the inequalities in health. They have done everything they could to bar discussion of the urgent problems and, even today, they have not been prepared to say that they foresee a real injection of cash in the future. That is what is needed. We need not a roll call of the amounts of money that been put in in the last two years, but a continuing commitment towards the provision of a free health service for all people.

It will not be good enough to leave the old and the sick to be cared for by the State, while some privileged groups receive immediate treatment elsewhere. It is vital that the Government must now be prepared to say that their commitment to the NHS is genuine and that they will back it up with a great deal of money and good will in the future.

11.2 am

Mr. Paul Dean (Somerset, North)

Before I refer to some of the points made by my right hon. Friend the Secretary of State for Social Services and the hon. Member for Crewe (Mrs. Dunwoody), I shall say a brief word about one other aspect of the Queen's Speech—that of local authorities.

The relations between Government and local government are not good. There are many well-run local authorities in my constituency, such as Wansdyke and Woodspring, which are district councils which feel bruised and battered. They find that the highly complex grant mechanisms are penalising thrift and good housekeeping. Proposals regarding housing revenue accounts would make a bad situation worse. It is bad for local government and politically insensitive when loyalties to Government polices appear to mean penalties, not encouragement. I urge the Government to act speedily to restore good relations with our natural allies in local government.

Another problem concerns Labour-controlled local authorities which have set out to defy the Government and to ignore public expenditure limits. Many of my constituents and I feel strongly about the activities of our Labour-controlled county council, Avon. It is imposing a 9p supplementary rate, which means an additional £10 million burden on Avon ratepayers. If it goes on spending as it is now, our rates will go through the roof next April.

It is the job of Government to manage the national economy and public expenditure. In the past, local government has been prepared to work within the framework laid down by the national government. If that traditional balance is upset now and the Government feel obliged to reassert control, the Labour Party will have only itself to blame. National democracy as well as local democracy is involved. However, I hope that the Government will proceed with caution.

When I came into the Chamber, copies of the new Bill were not available, so I do not know its details. Any new legislation should be aimed only at those few local authorities which are obviously overspending and undermining the Government's economic policy and ignoring the burdens which they are placing on industry, commerce and individual ratepayers. All that focuses attention on the inequities of the rating system. The time for Green Papers and White Papers is past. All the pros and cons have been rehearsed ad nauseam. We now need action at an early date to reform that inequitable and outdated system.

I now turn to three aspects of social services and health which are referred to in the Queen's Speech. First, there is a reference to a unified housing benefit. That has been worked on for a great many years and talked about for a long time. For those most in need, housing is one of their biggest costs and biggest worries. At present there is duplication between the cash benefits provided by Government and the rent and rate rebates and other assistance available through local authorities. The details of that new unified benefit will be all-important, but I warmly welcome the fact that the Government are now bringing it forward in new legislation.

Secondly, sick pay during the early weeks of sickness is an example of a good idea which got bogged down in major practical difficulties and which threatened additional burdens on hard-pressed employers when they could not be expected to bear them. I congratulate my right hon. Friend on removing the bulk, if not all, of those fears by going for 100 per cent. self-deduction. That is right and it is a welcome proposal.

The Government are still retaining two of the main advantages in the original proposal. They will still cut out the present duplication of sickness benefit in the national insurance scheme and sick pay schemes run by employers, which sometimes means that people are better off sick than being at work. The other substantial advantage that will be retained is the saving in staff that my right hon. Friend will have in his Department.

The third proposal concerns mental health. There have been major advances, in which we all rejoice, since the days of the padded cell. The advances in medical treatment and public attitudes have brought about a veritable revolution for that vulnerable section of our community. However, the more we advance, the more we realise that progress must continue. I welcome the additional protection envisaged for detained patients suffering from mental disorder.

No Queen's Speech debate would be complete, particularly as it takes place at this time of year, without a reference to the important decisions that are being made about public expenditure for the future. I have no doubt that my right hon. Friend is now spending a good many hours discussing those points with his colleagues in the Treasury and in other Departments. There is no doubt that expenditure on the health and social services is under a microscope.

The Department of Health and Social Security is by far the biggest spender of public money. That is more apparent in social security than anywhere else. Expenditure on social security benefits has increased by over 50 per cent. in real terms in the last 10 years. It now amounts to over a quarter of all public expenditure. That creates a real and painful dilemma for any Government. Expenditure on those services together is growing much faster than the growth in our national wealth.

We must recognise that we are dealing with people who are most vulnerable when they are sick and most in need of help when they are dependent on pensions and other benefits. Although I am sure that there is room for greater efficiency and economies in this regard, I believe that the room for savings is very limited.

I was delighted, as I am sure that the House was, to hear my right hon. Friend the Secretary of State reaffirm the Government's pledge that the real value of pensions would be maintained over the period of this Parliament. In difficult economic circumstances and with the enormous and growing financial outlay that it involves, it is a welcome pledge which clearly shows the high priority that the Government attach to caring for those in need.

I believe that the Government were right to say that in seeking to make economies the highest priority should be those on long-term benefits and that the economies should be made on those who are sick or unemployed for short periods. But I hope that in considering short-term benefits they will recognise that there is growing evidence that some of those on short-term benefit are bearing more than their fair share of the necessary economies. I am thinking of the long-term unemployed who have dependent children and who for a variety of reasons are often not eligible for the long-term benefits.

That category deserves special attention from my right hon. Friend. I think, too, of the invalidity benefit which is, of course, a long-term benefit. It has not been uprated to the same extent as pensions. The Government have given the understandable reason that this benefit is not yet subject to tax. The sooner that invalidity benefit can be restored to its rightful place alongside pensions, the better.

The third group requiring special attention are children. The Conservative Party and the Conservative Government believe strongly in the value of family life. When one considers the social security benefits and the tax position, there is evidence that families with children have to some extent lost out. That is not a situation that a Conservative Government can happily accept. Special attention must therefore be given to child benefit, which is now the main support for children whether their parents are in work or out of work.

My right hon. Friend and the hon. Member for Crewe referred to the National Health Service. I am delighted, as I am sure that the whole House is, that my right hon. Friend was able to say that more real resources are being made available for the National Health Service. That is absolutely right and also necessary.

I noted, too, the contrast between the approach of my right hon. Friend and that of the hon. Member for Crewe to the possibility of getting additional resources into health care. Surely, when there are pressing demands which cannot be met at present because the national wealth is not being created, we should encourage the independent sector and the voluntary organisations because those people are bringing in additional resources and are prepared to assist in supplementing the work carried out through the National Health Service. I was therefore very glad that my right hon. Friend could give those words of encouragement. It is as well to remember, too, that this is not confined to one narrow section of the community which happens to be well breeched. I rejoice that trade unions are now organising diagnostic services for their members and insuring them for services of that kind.

Finally, there has been some public dissent within the Conservative Party in recent weeks, but we must not allow the voices of dessent to drown the less vocal but equally strongly-felt and widespread support for the Government on the Conservative Benches and in the country. I believe that the Government are building firm foundations for a healthier economy and a just society. I am confident of their determination to build on those foundations, and I shall support them in that task.

11.15 am

Mr. Laurie Pavitt (Brent, South)

The hon. Member for Somerset, North (Mr. Dean), as always, brings to the debate an expertise in pensions and other matters. I wish to concentrate on just one of the grave omissions from the Gracious Speech. My hon. Friend the Member for Crewe (Mrs. Dunwoody) made a comprehensive speech on the large number of problems that we shall all wish to debate in the Session ahead. I wish to concentrate entirely upon one sector—the rape of the nurses' pay packet, which will take effect shortly if they settle within the present limit of 4 per cent.

The Gracious Speech says that public expenditure will reflect the importance of restricting the claims of the public sector on the nation's resources. It would have been more honest to add the words "Those who don't strike, don't get". The Minister for Health shelters behind two factors—that it is nothing to do with him, it is for the Whitley Council, yet his Government decides the amount of cash available; and secondly, that the responsible and responsive attitude of the nursing profession is such that he knows that it will cause less trouble than any other sector of the National Health Service in terms of pay awards.

In the past year, the Government set a limit of 6 per cent. on pay claims. The only group in the public sector to settle for 6 per cent. was the nurses. The Prime Minister this week spoke about incentives, but the clear message of the Gracious Speech to the nurses in pursuing their pay claim is that the only way to obtain justice is to raise hell and that unless people make themselves a damned nuisance to the Government they will get nothing. I well understand the way in which the nurses' dedication to their patients prevents them withdrawing their labour because they cannot do so without affecting sick people. They do not affect the Minister for Health. They must therefore find other means of making their voice heard. I therefore invite them, as I am sure that they would have the support of a great many hon. Members on both sides of the House, to come to the House to lobby Members of Parliament and when they reach Central Lobby to scream their heads off. They must make a noise, because unless they make a noise nobody will listen. I believe that there will be wide support for any pressure that they put on the Government. I believe that their present campaign that "Nurses are Worth More" will find an echo in the hearts of most members of the community.

The rigidity of the 4 per cent. limit when inflation is running at 12 per cent. means that if the nurses settle for 4 per cent. they will suffer a positive reduction in living standards. This will mean an increase in the number of nurses moonlighting after a very heavy day's work to supplement their incomes. If any workers should be protected against falling living standards, it is those in the nursing profession. I remind the House that there is already a precedent for such protection in the firemen's recent award. When the firemen reached their settlement last year, they obtained a built-in formula against inflation so that in any future pay claims there would be a factor to reflect the inflationary increase. When the firemen received their settlement a few weeks ago, therefore, it was not pegged at 4 per cent. They were given 10 per cent.

Let me compare nurses with other important public sector employees. A new recruit to the police service can expect £4,956, with an increase due in September. An 18 year-old with less than six months' service in the fire service is paid at the rate of £5,170. After three and five years' service, a police constable's basic salary is £6,057 and £6,471, respectively. The rates for a fireman after three and five years are £5,749, and £6,572, now plus 10 per cent. The standards of training are in no way comparable with those demanded for a nurse seeking to become an SRN. Even jobs requiring less training than either the police or the fire service can pay just as well as the job of the trained nurse. For example, postmen aged 19 get £4,361; a postal officer aged 19 gets £4,506–£5,856; a manual worker in electricity supply at the lowest grade gets £5,070–£5,405.

The way in which this country treats the nursing profession is shameful. My real gripe about the percentage payment is that a flat rate increase means that the richer a person is the more they get and the poorer they are the less they get. I cannot help comparing the nurses' last 6 per cent. rise, if it were to be given to a consultant with an A-plus merit award at present on an annual salary of £39,170, with the same 6 per cent. awarded to a staff nurse. The consultant would have an additional £2,350 a year, while the staff nurse would receive £267.

With £267, at today's prices, she would be pleased to be able to save up enough to buy a new pair of shoes during the year.

The Gracious Speech should have made explicit the fact that the coming Session will not renew the attitudes of the past two years and that nurses will be regarded as a special case when it comes to restrictions on public sector expenditure. Even comparisons within the NHS, as the Minister knows very well, show that the nurse remains the poor relation. A typical example is the recent award that was given for London weighting. The settlement recently reached for the period after July 1980 caused anger and resentment among nursing staff in inner London. After pressure, the administrative and clerical Whitley Council managed to give an increase in the London weighting for administrators up to £859, while the nurses were awarded an increase to £679. So in London hospitals we find two colleagues working together in comparable situations, one a nurse and the other an administrator, and the administrator get £180 more than the nurse. As usual, the loser is the nurse.

After two years of this Government, as my hon. Friend the Member for Crewe hammered home with considerable force, the National Health Service is being gradually demolished. There are many other omissions from the Gracious Speech that concern the NHS, many of which were raised by my hon. Friend—hospital closures, the inequalities that were highlighted by the Black report, the £1,000 million that we are spending on pharmaceutical services, the rundown of dental services, the cutback on medical research, health problems of the elderly, and the Select Committee's disclosures and recommendations of perinatal mortality.

The list is so long and the Government's record so shameful that we need to come back time and again to these problems. We need a full debate on these issues—not on a Friday, a flat Friday—so that the country may hear exactly what is being done to their Health Service in which we all have taken so much pride over the years. In the Session ahead I hope that we have a full debate on these matters, either on a Supply day or in some other way. In the meantime, I demand from the Minister for Health fewer pious platitudes, fewer psalms of praise for nurses, and a few more pennies in the nurses' pay packet.

11.24 am

Mr. Michael Spicer (Worcestershire, South)

The hon. Member for Brent, South (Mr. Pavitt) has devoted a great deal of his life to this subject, and the House always listens to him with careful attention when he speaks on it. However, I hope that he will forgive me if I do not follow his line directly.

I begin by congratulating the Secretary of State on his speech and on the Department that he now leads. Clearly, the Government have a success story here. The hon. Member for Crewe (Mrs. Dunwoody) was less than generous. Perhaps I should not expect her to praise the Government, but she should at least acknowledge what was happening, because there is an increase in real terms in expenditure on the National Health Service. She did not even acknowledge the vast amount of new expenditure that is now being spent on the Health Service. To have cut the waiting lists by 120,000, or whatever the figure was, and at the same time to have reduced the administrative staff is surely no mean feat.

I warmly welcome, and this is the reason for my intervention, the part of the Queen's Speech and the part of the Secretary of State's speech which referred to mental health. The Government are absolutely right to take this subject on board after such a long time. Proper attention has not been given to the subject since 1959. It is right that the 7,000 mental patients who are in mental hospitals of one sort or another under the 1959 Act are now to be given a greater sense of security. It is right, too, that the Government recognise the judgment yesterday at the European Court of Human Rights and be prepared to respond to it.

However, I am sure that the Government will not fall into the trap that previous Governments have fallen into, of assuming that good intention is necessarily a substitute for the application of resources where resources are implicit in the intent. I have in mind three examples in mental health, where during the past, particularly since the 1959 Act, there have been good intentions on the part of Government of two persuasions, but where resources were not made available. As a result, the situation for the mentally ill was perhaps made worse than might have been the case before the 1959 Act.

I instance, first, those mentally ill people who are not excessively dangerous but who have been convicted of criminal offences. I am sorry that the hon. Member for Ormskirk (Mr. Kilroy-Silk) is not here. Unfortunately, he has other commitments today. He has done a lot of work in this connection, to which I pay tribute. I had an Adjournment debate on this important subject about two years ago. There are varying estimates of the numbers, but it is generally accepted that about 1,000 people are involved. Those are the people who, because of the workings of the 1959 Act, which started with the most noble intention of getting people out of the older mental hospitals and did not automatically refer them to special hospitals, are now in prison.

The Butler committee, which sat from 1972 to 1975, diagnosed this problem and some of the changes that were necessary in the 1959 Act. However, nothing has been done, although some limited resources have been applied to the concept of regional secure hospitals or hospital extensions to provide special facilities for this kind of patient. No serious effort has been made to refine the Act for these people. That is a perfect example of where one hopes that the Secretary of State will be open-minded and will find a way—within the terms of this legislation—of doing something for those special categories of people. They are in need of special treatment.

I can give another example of the way in which good intentions that are not backed up by resources can lead to problems. The example springs from a specific case in my constituency. There is a hospital there called St. Wulstan's. It was, and still is in some respects, a world leader in the rehabilitation of mental patients. It was one of the world's leaders in providing work experience for mental patients and it has done an immense amount of good work. However, the hospital may well be nearing the end of its useful days. I am glad to see the hon. Member for Birmingham, Stechford (Mr. Davis) in the Chamber, because I think that his wife is chairman of the regional health authority and has great responsibility.

Mr. Terry Davis (Birmingham, Stechford)

My wife has not yet been appointed chairman of the regional health authority, but I believe that she is the chairman of a working party that has been looking into the future of St. Wulstan's.

Mr. Spicer

I am grateful to the hon. Gentleman for having corrected me. I say only that she has an extremely onerous task in relation to that hospital. I hope that the Government will encourage her to do something that she seems slightly disinclined to do. For many years there has been a long debate about the hospital and I raise this issue because it illustrates a general point. If the hospital is to be closed I hope that the Government will encourage her to ensure that comparable facilities are found. That is important.

I do not wish to argue that a regionally based hospital that attracts patients from a wide area is necessarily the answer to rehabilitating patients. There may well be a strong case for applying an approach comparable to that of St. Wulstan's to hospitals that are closer to the community. I am not debating that point. The hon. Member for Stechford has inspired me, because I had not intended to elaborate my argument. I am concerned that Mrs. Davis seems unwilling to take a totally independent and objective look at the comparable facilities. I understand that she has no plans to put in a team that is comparable to the one that she has put into St. Wulstan's—or as independent of her authority as that team—to consider comparable facilities within the region.

I hope that the Government will consider what is happening in that region. I also hope that they will accept that if such a facility is closed—despite the fact that it has done a tremendous amount of pace-setting work—comparable facilities should be provided. I hope that all those in authority at the regional level—whether they are chairmen of working parties or of the body itself—will work hand in hand with the Government to ensure that comparable facilities are provided if that hospital or a similar one is closed. If the Government do not feel inclined to accept that proposition now, I shall press them on it later.

I am sure that this Administration will adopt the same view as previous Governments and will accept that comparable facilities should exist. We must have objective, concrete and independent evidence that such facilites exist. We cannot leave the matter entirety in the hands of those who have a viewpoint about the closure of the hospital.

The third example I want to bring before the House is this. In my area there exists an experiment in the provision of facilities in the community for the mentally ill. I refer to the so-called Worcester experiment for the mentally ill. It is an interesting experiment and I do not deny for one moment that if patients can be taken out of hospitals and allowed to remain in their homes, and if the community can provide proper facilities, such a move is a good thing. I have never met anyone who has denied in principle that this is so. However, if it becomes a euphemism for throwing people back on the streets, we must question the whole approach to such community medicine.

I am not arguing that the experiment in Worcester is turning out in that way. However, it represents another example of the way in which good intentions—if they are not fully supported by resources—can have the opposite result. I am sure that the Government have all those points in mind. Indeed, they are the first Administration for a long time to put legislation on mental health at the forefront of their programme for the year. I congratulate them unreservedly, and I hope that they will be mindful—in constructing that legislation—of some of the principles that I have suggested.

11.35 am

Mrs. Ann Taylor (Bolton, West)

I wish to speak briefly and to raise two important points in relation to the Government's policies on health and two problems that could have long-term implications for health problems in Britain and for the attitudes held within the National Health Service. I shall relate some of my remarks to recent events in Bolton, not only because it is my constituency, but because events in Bolton often reflect events in the country as a whole.

Bolton is still worried about the inequalities that still exist within the National Health Service. Those inequalities are marked and in some respects they are becoming even worse. There are inequalities between regions and social classes. Indeed, my hon. Friend the Member for Crewe (Mrs. Dunwoody) mentioned such things when she spoke about the Black report. I share her disappointment that the Government have never been able to find time to discuss such an important report, which raises many problems and which proves that health care for many of our people is not as good or as adequate as it should be.

Bolton is one of the 10 areas mentioned in the Black report as areas of deprivation. Obviously, people in Bolton are anxious about that. We are anxious not simply because we are jealous of other areas' facilities; we are anxious because we believe that good health care should be the right of everyone, irrespective of geography, class or income.

The inequalities betwen Bolton and the other nine areas mentioned in the Black report are serious disadvantages suffered by many. Such inequalities occur at every stage of life—from birth to old age. My hon. Friend the Member for Crewe mentioned some of the difficulties that exist with perinatal and neonatal mortality. Services for and the life expectancy of old people in different parts of the country vary widely.

I acknowledge that the facts I have mentioned are not only functions of health. There are other matters involved and other issues that should be raised such as housing, environmental pollution, industrial backgrounds and the nature of work. However, these are primarily health matters. Therefore, the Minister has a most important responsibility to introduce matters for debate and to look after the interests of those who presently suffer from inadequate services.

We are not talking only about money for health care. The Government have boasted about increased health spending. Perhaps that would be more beneficial if there were not concurrent problems. As my hon. Friend the Member for Brent, South (Mr. Pavitt) stated, it is not a real increase when the problems are increasing. It is not a real increase in health money when the Government cut back on social services, housing and all the other factors that create more health problems.

The Black report stated that the Government should find additional funding for the few special areas that it identified as being in special need. The Opposition look to the Government to start redressing that balance. We do not see any signs that the Government are taking the health problem seriously or are willing to talk about the Act, let alone helping to find the recommended funds.

There is an increasingly urgent need for the type of programme outlined by Black. I believe that the health problems of an area such as Bolton are deterioating because of the many problems that the Government are creating, especially the unemployment problem.

The Government refer in the Queen's Speech to their concern about the unemployment problem. If we take that statement at face value—which some hon. Members find it difficult to do—and assume that it is true, I ask the Minister to remember his apparent concern for unemployment when he considers health care in the areas outlined by Black. In the past 18 months areas such as Bolton have become even more deprived because of the unemployment level.

Unemployment in Bolton has risen by 50 per cent. since the end of last year. That has undoubtedly had an effect on the health of many people. I am aware that some people in the DHSS would say that unemployment does not necessarily cause bad health. However, I ask the Minister to acknowledge that many families regard unemployment as an unpleasant experience; stress and financial hardship arise from it. Severe pressures are faced by many and they find them difficult to cope with. It is that which affects their health.

We have recently seen the agencies that offer help to needy people who are under extra pressure. Representatives of the citizens advice bureau confirmed that in their discussions with hon. Members. In Bolton, local charities are finding that applications for help have doubled. The Samaritans in Bolton have seen an increase in new callers of 800 in only six months. The local social services department in Bolton has reported a 20 per cent. increase in the past 18 months in the number of children brought into care.

Many pressures that force people to seek help are related to unemployment. If the Government are seriously concerned about unemployment, they should consider it in that context. If the Government want to help, they must take notice of the Black report and do something to help areas of deprivation before the problem deteriorates further.

My hon. Friend the Member for Brent, South mentioned the community health councils. There is uncertainty among community health councils about their future after reorganisation next March.

Bolton has probably one of the best community health councils. The council has involved itself in public participation, has established a day centre for the mentally ill and has had day conferences on important problems such as alcoholism and the effects of unemployment.

The Minister cannot ignore the good work that the community health councils are doing. Unless a decision is soon made about their future nature and they are given a vote of confidence, they will find it difficult to maintain the impetus that presently exists. I ask the Minister to be more specific on the future of community health councils and to give some acknowledgment of the very good work many of them do.

If the Minister—as the Secretary of State earlier said—believes that health care should be health care for all, regardless of means, we believe that that is extremely good. We do not see that being put into effect by the Government. We see the inequalities becoming worse. We see little hope of the unemployed worker in Bolton or anywhere else being able to look after his personal health needs, as the Minister implied he should.

I ask the Minister to consider health seriously as a problem that relates to unemployment. I ask him to discuss the matter with his ministerial colleagues and to mount pressure to make more money available to help deprived areas. I ask him to put pressure on his colleagues to do something about unemployment, which creates so many health problems.

11.45 am

Mr. David Crouch (Canterbury)

The hon. Member for Bolton, West (Mrs. Taylor) spoke about a relationship between health, housing and environmental improvement. Housing and environmental improvements over the past 100 years have, without question, made a greater contribution to improving health within society than all the medical achievements, all the medical knowledge and all the improvements in drug therapy that have been developed in that period. I am sure that my hon. Friend the Minister for Health will agree with that. Equally, I am sure that the Government are not neglectful of the great importance of continuing to improve housing, heating in housing, drainage and environmental health so that pollution is diminished. My right hon. Friend the Secretary of State referred to the Health Education Council. That, too, can make a great contribution to improving the nation's health by encouraging individuals to guard their own health.

I am sorry that my right hon. Friend is not in his place because I am one of his appointees. I have been a member of a regional health authority for over 11 years. In many ways it is an onerous task. It is very time-consuming and causes one to consider problems that would not normally have to be considered in such depth. That is why I have always sought to speak when health matters have been discussed in this place. I am glad that the Opposition have chosen to debate health matters. It is their privilege during the debate on the Queen's Speech to decide which subjects shall be debated.

I wished to say to my right hon. Friend in his presence that I am glad that he has been appointed the Secretary of State for Social Services. I was impressed this morning by his approach to his new appointment. I do not share the views that were expressed by the hon. Member for Crewe (Mrs. Dunwoody). On reflection, I do not think that she meant them wholeheartedly. My right hon. Friend conveyed to me total commitment and devotion to the new task with which he is faced. It is so different from transport matters and from some of the other problems that he has considered in his career in this place.

My right hon. Friend gave an assurance of his support for the NHS, and I welcome that. He mentioned that there should be a responsible place for the private sector. I do not disagree with him on that score. He mentioned, too, his support for the voluntary organisations. I welcome that statement, too, because it is one that should be made. I was interested that he referred to the remarkable achievements of the Jimmy Savile appeal for Stoke Mandeville. However, there are other national voluntary organisations that raise money to help those in need.

One of the organisations with which I have been intimately connected is the Variety Club of Great Britain. It has recently contributed £750,000 to the region which I serve, the South-East Thames region, for an extension to King's College hospital. That was a remarkable contribution. We in the Health Service have to pick up the tab for the revenue consequences, but we are prepared to do so. The Minister's Department had to give its approval. It is remarkable that the Variety Club can find so much money to produce such a valuable extension and addition to an important hospital.

The Secretary of State referred to the examination ordered by his predecessor, my right hon. Friend the Member for Wanstead and Woodford (Mr. Jenkin), into alternative ways of funding the National Health Service. We should look at every possibility of improving the existing system, adding to it or replacing it. We should look to other countries and examine their health services.

I was pleased that the Secretary of State assured us that health provision would continue to be available for all, regardless of their income or position. However, the National Health Service must still be the best that we can provide and find, because it has the best equipment, the most advanced types of intensive care, the latest developments and the greatest reservoir of knowledge. Our great teaching hospitals are properly called centres of excellence and we must maintain them in that position. We must not neglect them. They need resources. Centres of excellence in other countries allocate more generous funds for the provision of the modern equipment that is the essence of health care.

Some of the great teaching hospitals have new wings, extensions, blocks, towers, operating theatres, optical centres and so on. However, I have also seen the Victorian remnants from 120 years ago that still exist in our teaching hospitals, such as wards with two bathrooms and two lavatories for 32 patients. That is something out of another age which we hardly acknowledge today. We cannot put such matters right overnight. There are new developments across the river at St. Thomas's. The Royal Free hospital and Charing Cross hospital have new or partly new buildings, but we must continue to improve the fabric of all our hospitals.

Some years ago I was appalled to find that a 500-bed hospital in Orpington was housed in wooden huts that had been built beside a railway in 1916 to house the Canadian wounded of the First World War. The buildings were extended in the Second World War, with further wooden huts to accommodate the wounded. They are there to this day. However, within the old fabric of the NHS we find a remarkably new and good standard of service and care for hospital patients.

It is remarkable how we use old buildings, decorate and heat them correctly, and make them as satisfactory as possible. Although there is a need for replacing the old buildings—whether they are wooden or Victorian buildings—because they are inadequate, the NHS is not short of the quality of service that comes from all those who work in it, from consultants down to ancillary workers.

I ask for the Secretary of State's assurance that the NHS will not be diminished in the extent and quality of its service. It must remain the first tier—the first class—and not the second tier—the economy class—of our Health Service. I have been saying that for many years. All hon. Members are proud of the Health Service, as are the Government. To have increased expenditure in real terms during the years that we have been in office is proof positive that we are proud of it. We must work towards a first-class NHS, not an economy class service. When we reach the worst crisis in our lives, that of ill health, we need the best service. That is still the NHS, and I hope and expect it to continue to be so.

The Gracious Address announced a Bill to improve the safeguards for detained patients and to make reforms in the law on mental health in England and Wales. Mental health is often debated in the House. However, we do not often make great advances in that area. There is a need for expansion, progress and further expenditure. There is no case, even in today's economic circumstances, for retrenchment and cuts. We often pay lip service to the problems of those with mental handicap and the conditions in which they live in hospitals.

We have heard today that there are 15,000 mentally handicapped persons in our hospitals—5,000 of them mentally ill—who could be discharged if only they had somewhere to go. I have taken part in many detailed considerations of that problem. We always come up against the same stumbling block: we have to wait until we can buy an old building to house such persons. It is never a question of a brand new building, but always an old Victorian building.

Everyone should visit the hospitals for the mentally handicapped, as I have, to see the conditions. Some patients have spent 30 years—perhaps their whole lives—in those hospitals. Now medical science tells us that they should never have been there. They do not need to be in such places today. They can be transferred, but we must first take action. We must train, educate and help them to adapt to another environment outside the colony environment of the hospitals. I have seen houses within the grounds of hospitals that have been converted to care for those patients, and to give them some experience of living in a domestic environment, with no more than one warden to look after them. However, those allowed to live in such houses are different from those who have spent 30 years living in a ward, perhaps having been locked up at night. They require special training to help them to become ready to move to hostel accommodation under the supervision of a warden. We must work towards that aim, and achieve it. That would be enormously satisfying.

We should not put forward the ready excuse that the country cannot afford such measures. No one would say that if they had visited hospitals for the mentally ill. We often hear of the poblems in psychiatric hospitals only after tragedies and disasters have occurred. Only then does the House wake up to the matter. We order an inquiry and hear stories of life in such places as Ely, Normanton, Rampton and St. Augustine's, in my constituency near Canterbury. We all say that such tragedies are wrong and must not happen again. There is a great outcry, we spend a little money patching up the problem, but then we get on with other business and forget about it.

We must do better. We need more money. We must achieve greater flexibility, with the resources available to the Health Service and local government, in the financing arrangements between the Health Service and personal and social services. I have seen how we get bogged down when we consider how to transfer money to a local authority to provide hostel buildings to take the mentally handicapped.

The local authorites are the key. Government money must be earmarked for these purposes whether or not local authorities like the idea. A specific amount, whether £100,000 or £250,000, has to be earmarked to provide a hostel or two hostels to accommodate the mentally ill who can be discharged from hospital.

Mr. Tom Benyon (Abingdon)

Does my hon. Friend agree that some money could be cycled through voluntary organisations—MIND and Guidepost Trust, to name but two—that do great work in extracting people with mental handicap from institutions where they have been institutionalised over many years and introducing them to sheltered accommodation such as hostels?

Mr. Crouch

I am sure that that can be done. I have talked about flexibility. This is an area where flexibility should apply.

There is a need to release people who can be released. There is, however, the problem of those who cannot be released because of the danger that they may cause to society and themselves. They are said to number about 7,000 people. They must not be forgotten. They are a great problem—a problem that we have a duty to do something about. The people who have to stay in hospital should not simply be locked up. They have to be treated, educated and given help. They have to be given a hope in life. They can certainly be given a better life. They need more than the existing Victorian buildings.

Many of the old mental colonies, as they were called, built in the middle of the last century, were designed on the basis of another building altogether. They were a copy of the prisons of the last century, with exercise areas around the accommodation. In a prison, the accommodation would be called a cell. It is the same in some of the old mental hospitals that I have visited. This is not the way to keep people in secure conditions. There is another way. I have seen the ambitious and not very expensive proposals and designs to build secure units in an entirely different environment in the country where such people can be kept in a civilised and better manner from the point of view of the environment and their health. This is a medical responsibility; it is a moral responsibility. We have also what is no less than a responsibility in human rights to ensure that we improve the conditions of these people.

I wish to refer to the new district health authorities. I have played some part in the selection of members in my region. I was amazed and impressed by the quality of people from a great variety of backgrounds who put themselves forward for this voluntary work. There is no pay for them, although there is for the chairman. These are not simply older, retired people seeking a fulfilment and an interest in life. A great many younger people in active work have put themselves forward for this additional public service work. This development should be encouraged. It will help us in the new organisation of the NHS to know that there is no shortage of good people coming forward. We have changed the organisation of the National Health Service yet again. This time it must be right. It cannot tolerate any more disturbances. Let us be sure that we get it right.

I do not wish to teach my grandmother to suck eggs, but it is surprising how we assume that everybody chosen to serve on a district health authority will automatically know what to do. It is amazing how differently people approach this responsible task. It is very different from being elected to the board of a company.

Health circular 81/6 discusses the duties of members and stresses that they should not be too investigative or inquisitorial in their approach to their work. Nor should they concentrate on trivia. They must find something in between to determine their approach. Some members of regional health authorities rather nit-pick. They try to do the officers' jobs for them. There is nothing worse for officers than to have somebody breathing down their necks in this way.

The members of a DHA know their area far better than people at regional level and far better than people at the Elephant and Castle—that is why we have delegated authority. They should confine themselves to seeking out the priorities for their areas, allocating resources accordingly and determining strategy for their officers to implement. If necessary, they can criticise officers and call them to account for not observing the direction in which the district authority is seeking to proceed.

The new membership is well balanced. There will be a proper balance between those with a medical background—such as consultants, GPs and nurses—and those with a wider background of experience in administration and management. Some will have important experience in mental health. There will be local government members with experience not just of local government but of the personal social services, resource allocations, housing, education and environmental health.

Trade union representation on the DHAs is also very important. It is laid down specifically that a trade union nominee should be not a member of a union directly involved with the Health Service, but one who can bring a wider perception of the trade union point of view. My experience is that such people have never ceased to be of the greatest value in bringing an understanding of the problems which arise all the time. Problems in labour relations can occur between an authority and a consultant, just as much as between the authority and the ancillary workers. I hope that all the trade union nominations have now been made, as I had a feeling that the TUC had been rather slow in making its proposals and suggestions. We need trade union members.

Members of the DHAs not only determine the priorities, policies and strategies but have to ensure that those policies and strategies are applicable to local conditions. These newly-appointed lay members have to be sure that they can achieve the much-needed breakthrough with local authorities on joint financing and on developing the provision in the local authority personal social services to work alongside the National Health Service provision.

I make one final comment on the job of an authority member. It is not just to meet two or three days a month to consider budgets, priorities and resources and to argue with and possibly to check on the officers. One of the most important duties of a member is to get out to the coal face, to get out into the front line. A member should see what it is like to he in a health centre. He must talk to GPs. He must visit the hospitals and see the patients in them. He must also see hospital workers, from the consultants down to the junior housemen, the nurses, and ancillary workers. Such visits make a tremendous difference to a member's understanding of resources and priorities, and I attach the greatest importance to them.

For those who decide early in life to work in the National Health Service, the job is fascinating and rewarding. That goes for doctors, nurses, those in other specialties and even those working as ancillaries. Still to be found in the service is a devotion to the care and cure of the sick, and it is found at all levels. Most of those whom I have mentioned have had to work very hard and have had to pass examinations to get there. It has meant years of sacrifice and devotion. But their lives as a result are fulfilling and satisfying. The same opportunity presents itself to lay members who work in the Health Service, and it is also there for these new men and women coming into the district health authorities. They have not had to work so hard or to pass so many examinations, but their contribution can be just as important as that of the most devoted administrator, doctor, nurse or other employee in the Health Service. Without the devotion and drive of these lay men and women, the Health Service cannot overcome its problems, no matter how much money we pour into it.

12.8 pm

Mr. Jack Ashley (Stoke-on-Trent, South)

I was interested to hear the views of the hon. Member for Canterbury (Mr. Crouch) and his comments on people in mental health hospitals. I intend to make that issue the main burden of my speech. Before coming to it, however, I want to comment briefly on two other speeches to which we have listened in the debate. The first came from my hon. Friend the Member for Brent, South (Mr. Pavitt). I have to tell the Minister that the fight for our nurses will be supported very strongly by the Opposition and, I hope, by many Government supporters. Most of us feel very deeply about the subject. My hon. Friend the Member for Brent, South speaks extremely eloquently and forcefully, and I was glad to hear his views. We intend to press the subject of nurses' pay very strongly in the coming Session.

The second speech on which I comment is the one which we heard from the hon. Member for Somerset, North (Mr. Dean). I was delighted to hear his views on the long-term unemployed, invalidity pensioners and children. These are issues about which I feel deeply. The cuts in the real incomes of the long-term unemployed and of invalidity pensioners are deeply resented, as is the Government's failure to increase child benefit properly. These are matters about which the Opposition will be fighting strongly, as are many of the topics raised by my hon. Friend the Member for Crewe (Mrs. Dunwoody).It will take far too long for me to enumerate them all, but they will also be taken up by Opposition Members in the coming months.

My main point concerns the proposed mental health Bill. I welcome the Government's promise to introduce a new Bill on this important issue. I also welcome the undertaking by the Secretary of State to consider the suggestions for change that have been put forward during the debate. That was a generous offer, which will be taken up. Although he did not accept the suggestions, he undertook to consider them and I am grateful.

I should like to make some suggestions to Ministers on which they can act within the Department. First, though, I should like to raise one point on which they can consult the Home Secretary. It concerns human rights for mental health patients. In the light of yesterday's judgment of the European Court of Human Rights, Ministers should recognise that it is damaging to Britain for it to be seen to be apparently kicking and screaming behind the rulings of the European Court. We need an assurance from the Home Secretary that his powers to act without reference to the courts will be removed. I hope that the Ministers listening today will discuss the matter with the Home Secretary and urge him to surrender those rights. The House is entitled to an early response to the judgment of the European Court of Human Rights that we are in breach of the European convention.

One of the most fundamental issues to be dealt with in the proposed Bill on mental health is whether a person detained in a mental hospital can be forced to undergo medical treatment against his will. Voluntary patients have the same unquestioned and unqualified rights as patients suffering a physical illness, so the question applies only to compulsory mental hospital patients.

It has been proposed that there should be a second medical opinion—I emphasise the word "medical"—especially for treatment that is irreversible, hazardous and not fully established. That applies to much psychiatric treatment. The 1978 White Paper on the subject proposed that a second opinion should be sought when a patient refused to consent to treatment. Very few people will argue with that recommendation, but the issue is "What sort of second opinion?"

The Royal College of Psychiatrists prefers simply a medical second opinion, whereas MIND and that splendid campaigner, Larry Gostin, prefer a multidisciplinary second opinion. That is a crucial difference. I believe that merely having a medical second opinion before imposing treatment against a patient's will is monstrous. It reveals a failure by doctors to see beyond the blinkered confines of their profession and an inability to distinguish between medical practice and human rights.

Doctors are no more qualified as experts on human rights than hon. Members are qualified as experts in prescribing medical treatment. It would be foolish to deny that a doctor is the best person to prescribe medical treatment, but it would be equally foolish to claim that a second medical opinion would provide an independent and valid basis for imposing treatment against a patient's wishes. The second opinion would not be independent of the constraints that are inevitable and understandable between professional colleagues.

If there is one person who will support a doctor, it is another doctor. The same applies to lawyers and policemen. It is, therefore, ludicrous to suggest that another doctor should be asked to give an independent second opinion, especially on the question of human rights. The professional ethic induces agreement or, at the very least, it reduces disagreement.

A second opinion that was merely medical would be invalid because it would take no account of the need for personal representation by the individual, it would not be separate from the doctor and the detaining authority, and it would not be open to the patient and the public. Any new measure concerning the imposition of medical treatment against a patient's will must be multidisciplinary, independent of the doctor and the detaining authority, recognised by the patient and subject to public scrutiny. It is only by accepting those important provisions that we can make real progress. I beg the Minister to take account of those fundamental points.

A further issue of deep concern relates to the rights of elderly, mentally ill people who are denied Health Service care. The Government's attitude is either regrettably negative or blandly evasive—or it may be an unhappy mixture of both. The Guardian reports that in Enfield hospital, admissions for psychogeriatric patients and long-term mental health patients have been stopped. Officials of MIND believe that that is by no means an isolated case. It is inexcusable in a specific area, but, if it is a general problem, it raises the most serious issue of the failure of local government and national Government to carry out their clear obligations.

What are the obligations? A senior civil servant in the DHSS has written: There is no absolute duty to provide a particular service in a particular place; other local authorities and financial resources may legitimately place constraints upon the provision of particular facilities. Therefore, if a local authority chooses to turn elderly mental patients away from hospital, according to that civil servant, the Government feel that it is the business, and only the business, of the local authority.

The House will want to know how widespread is the practice of turning away from hospitals old mentally ill people in desperate need. This is where the Government are evasive. I put down a question to the Secretary of State: how many hospitals in the United Kingdom have stopped admission of long-term mental patients and psycho-geriatrics; and if he will list the health authorities and hospitals concerned. The Under-Secretary of State said: I regret that information about any districts where there have been reductions in the beds available for this group of patients, resulting in a reduction in admissions, is not available centrally. That shoulder-shrugging attitude tells us more about Ministers than about the subject. We cannot tolerate Ministers, including the Prime Minister, exposing their bleeding hearts about compassion when simultaneously they show that degree of indifference.

We are talking of a grave deprivation of care for old, mentally ill people. No one would dream of turning them away if they were suffering from cancer or any serious physical illness. What is the difference between that and mental illness? That is a straight question for the Minister, and I should appreciate an answer at the end of the debate. If the Government wanted the figures they could call for them and obtain them. I hope and expect that the Minister will change his mind and his attitude.

In the same batch of questions I asked the Government if they would introduce legislation to place upon health authorities a duty to provide a particular service in a particular place for long-term mental patients and psycho geriatrics even when constraints are placed on public expenditure". My object was to focus on the plight of these needy people and to seek to give them higher priority because they are at the bottom of the pile.

The Minister said that he was "concerned". He said that he would keep this matter under careful review, but"— and there is always a "but"— there are no plans to alter the duties placed on health authorities by the National Health Service Act 1977." [Official Report, 23 October 1981; Vol. 10 c. 203–4.] Such evasive and negative responses to serious deprivation reflects great discredit on the Ministers concerned. Their responses are inadequate and unsatisfactory. I hope that they will be changed. If they are not—and this is a promise—the issue will be raised throughout the life of this Parliament.

I turn to the vital need to take mentally handicapped people out of antiquated institutions and to put them into small modern units with places in the community. I welcome the Secretary of State's acknowledgement that there are in institutions no fewer than 15,000 mentally handicapped people who have no medical reason for being there. He also said that there were in institutions about 2,000 children who should be provided with community based care. I believe that the Secretary of State's estimate is conservative. We are far too sanguine as a nation about mentally handicapped people being deprived of community based life and care.

I accept the Secretary of State's assurance that he is anxious to do what he can to help them. I welcome his statement. The responsibility of hon. Members on all sides of the House is to seek action—and seek it quickly. The economic case is powerful and should be grasped eagerly by the Government, who are so concerned about the economy, because community care is much cheaper than institutional care. A great deal of the £125 million a year spent on hospital care can be diverted into community care. The cost of looking after those people would then fall rapidly. That could be a cost-cutting exercise without depriving mentally handicapped people. The Government should grasp that quickly.

However, to achieve that major change requires a large transfer of funds from the NHS to the local authorities. That in turn requires interdepartmental understanding and co-operation and close liaison between Government and local authorities. That is a major task. I do not want to underestimate it.

The Secretary of State and the Ministers in his Department must get together with other Departments and work out what needs to be done. They must improve liaison with local authorities and try to persuade them to accept that change. They must transfer the money. If that major co-operative endeavour between Departments and between national and local government is achieved, a tremendous amount will be accomplished. If that is done, I urge the Government and the DHSS to monitor the progress, or the lack of it, made by local authorities. That is important. Above all, it is important to seek action on the proposals outlined in the Green Paper entitled "Care in the Community". To be more specific, the Government should give a definite date for removing all children from institutions, preferably a date two years from now. I should like an answer on that. I should also like a date for when the Government hope to remove all adults from those institutions. No doubt that will take longer.

I hope that my proposals will be considered by the Minister. Given a determined effort, there is nothing that we cannot achieve in this area. If we succeed, we can make a contribution to the lives and happiness of thousands of mentally handicapped adults and children. That is something well worth fighting for.

12.33 pm

Mr. Nicholas Winterton (Macclesfield)

We have had an excellent debate. It is always a great pleasure to follow the right hon. Member for Stoke-on-Trent, South (Mr. Ashley) because, whether or not one agrees with everything that he has said, I do not believe that anyone can be but impressed by his knowledge and the care and compassion with which he espouses his cause and his cases. He has advanced excellent arguments to my hon. Friend the Minister for Health. I am confident that his remarks will receive full consideration in my hon. Friend's reply.

I congratulate my right hon. Friend the Secretary of State for Social Services on his constructive speech. Initially I hoped, judging by the opening remarks of the hon. Member for Crewe (Mrs. Dunwoody), who is a neighbour of mine in Cheshire, that she would continue the constructive approach to the debate. However, she delivered a disagreeable diatribe and was not prepared to see anything good in what the Government are trying to do. I am sure that with hindsight she will admit that some of the measures that have been already introduced by the Government and some of the proposals in the Queen's Speech are positive and will be helpful to the health of the young and old.

I take up immediately a point that I raised by way of intervention during the hon. Lady's speech. It relates to the Secretary of State's decision to place the consultants' contracts with the regions rather than with the district health authorities. I deeply regret that decision, because inevitably it must be tied up with the placing of the junior hospital doctors' contracts. I suspect that as a result of this decision those contracts will be placed with the districts. The view of the Select Committee on Social Services, which carried out a full inquiry into postgraduate medical education and the structure of medical education, was that junior hospital doctors' contracts should be placed with the regions and consultants' contracts with the districts. If the Minister reads the evidence given to the Committee and the conclusions that we reached, I think that he will appreciate the very good reasons why we made the recommendations that we did in our report.

I know that my hon. Friend shares much of my concern about the perinatal and neonatal mortality figures. We have had discussions about the inquiry carried out by the Select Committee on Social Services into this matter. As my hon. Friend knows, I am concerned that the Government have not accepted sufficient of the Select Committee's recommendations. I therefore regret that there was no indication in the Queen's Speech that the Committee's recommendations would receive Government attention and would be contained in proposed legislation. The unanimous view of the Committee was that this country could save substantial sums of money if modest sums were spent on improving perinatal and neonatal care. We believe that hundreds of millions of pounds could be saved over a period of years if the recommendations contained in our report were implemented. My hon. Friend, with his wide experience over many years, is a highly respected figure in the medical world. He is therefore aware of the cost of maintaining handicapped people from birth to death. Our recommendations would ensure that far fewer handicapped babies were born.

I turn briefly to the point raised by the right hon. Member for Stoke-on-Trent, South and others with regard to the amendment, I suspect, to the Mental Health Act 1959. My hon. Friend will no doubt be aware that there is concern in a number of quarters that one Bill will not be sufficient and that there should be two separate pieces of legislation to deal with the mentally handicapped on the one hand, and the mentally ill on the other. This is very important. My hon. Friend's Department will by now have received a letter from me stating that the chairman of MIND in the North-West is deeply concerned about what might be contained in the legislation. He hopes that the Government will pay particular attention to the views of those who are deeply involved in this area and will ensure that a clear distinction is drawn between the needs and requirements of the mentally ill and those of the mentally handicapped.

I intend to use the opportunity of this debate on the Gracious Speech to make a number of comments on matters outside the Health Service, and I wish to direct one or two comments to the subject of local government. I must make it quite clear to the Government that, although I am deeply concerned about the irresponsible local authorities which seem to ignore the requests of Government to contain expenditure, the proposals outlined by my right hon. Friend the Secretary of State for the Environment with regard to the use of referendums are unacceptable to me. I say that as one who served in local government for a number of years. If we place any value upon the integrity and independence of local government, I believe that the use of referendums is unacceptable because, inevitably, local government representatives have to stand for election every few years, just as Members of Parliament do. It is therefore important that this matter should be highlighted at a very early stage, as indeed it has been in a number of speeches on the Gracious Speech.

I asked Mr. Speaker whether it was possible for me to range widely in this debate. He said that I could, and that I need not direct my remarks entirely to the Health Service. Trade union reform is clearly an area in which action is long overdue, and the step-by-step approach of my right hon. Friend the present Secretary of State for Northern Ireland was unacceptable to me. If the views expressed to me by constituents, including employers, people who are not members of unions, and active trade unionists, are anything to go by, there is no doubt that the Government's Bill will be popular in the country at large if it deals with the worst abuse of the closed shop which still exists—the removal of financial and civil immunities from the trade union movement—and if it contains reference to further action on secondary picketing and secondary action, as well as action on the political levy. In my view, it is wrong that an individual who wishes to obtain work and who wishes not to pay a political levy should have to contract out—in other words, publicly declaring that he does not support the Labour Party. That is unacceptable to me. If the Government were to introduce legislation whereby an individual who was a member of a union had to contract in to pay a political levy, that would be much more just. I hope that the Government will direct their attention to that issue. I am delighted that I have the support of the hon. Member for Newcastle upon Tyne, East (Mr. Thomas).

Mr. Alfred Dubs (Battersea, South)

What about company shareholders?

Mr. Winterton

I remind the hon. Member that company shareholders have the opportunity, and often exercise their right, to express their views on political contributions at company annual general meetings. The hon. Gentleman will be fully aware that at present industry is expressing its concern about some of the tactics and policies of the Conservative Government by substantially reducing its political contribution to the Conservative Party. To an extent, therefore, shareholders have a say. However, they do not always have to identify themselves, because they can often vote by proxy. However, most shareholders are prepared to argue their case at the annual general meeting.

Mrs. Dunwoody

I am not quite clear whether the hon. Gentleman is saying that there is something wrong in identifying oneself. Is he saying that trade unionists who are Conservatives should not admit to the fact in public?

Mr. Winterton

No, but I do not believe that the place of work is necessarily the best place to show one's political affiliation. Moreover, because of the stranglehold that some trade unions have in places of work, it could be disadvantageous to an individual to show his political affiliation or to demonstrate to colleagues that he does not support the Labour Party and is therefore not prepared to pay the political levy. I believe, too, that it is wrong for an employer to act as a paymaster for the trade union movement. However, I do not wish to protract this argument. I make the point because it is very much part of the Queen's Speech; indeed, it is its linchpin. The further steps that the Government intend to take in this area will have a direct impact on the increased efficiency of British industry.

That leads me to the subject of industry and employment on which I have spoken out very forcefully in this Parliament, and I intend to continue to do so. The Government have urged increased efficiency and competitiveness in industry. But that very same Government, and often those very same Ministers, have added huge additional costs to industry through Government action and Government decisions—for example, the increases in the national insurance contributions, and the monopoly public sector price increases, which are around 30 per cent., in gas, electricity, postage and telephones. I emphasise that these are all monopolies, and industry has no alternative but to go to them for the services that they provide. The hon. Member for Crewe should remember that that compares with an average increase in the private sector last year of only 6 per cent. That is an important point.

In addition, the huge increases in oil costs have sadly resulted largely from the Government's actions in increasing excise and other taxes on derv and petrol. Several of my colleagues and other hon. Members saw fit to bring pressure on the Government. In the last Session we were at least able to get the Government to reduce the 20p increase in derv prices by 10p. It is outrageous that the Government should tell British industry, particularly the private sector, to increase its efficiency and competitiveness and then load on industry, particularly the private sector, huge additional costs.

About nine out of 12 of the redundancies that have taken place under this Government have been made in the private sector. The Government have dramatically cut back on public capital expenditure although that can often be beneficial to the private sector. However, they have utterly failed to contain revenue or current expenditure. Therefore, I warmly welcome the announcements in the Gracious Speech about further privatisation. That could be of great benefit in terms of a reduction in revenue expenditure. Public revenue expenditure is a millstone that hangs not only round the Government's neck but round that of private industry. After all, private industry creates the wealth from which the Government can fund all the desirable projects that the country needs and that many people expect. I am not interested in the theories of Professor Hayek, in those of Mr. Friedman or even in those of Keynes. I am interested in the realities of proper, permanent employment and in the real industrial situation.

I turn to the industry that I champion in the House—the clothing and textile industry. I know that you, Mr. Deputy Speaker, have had a great affection for it for several years. However, 1980 was a year of rapid contraction in those industries and at least 120,000 jobs were lost. Two hundred mills were closed and productivity was reduced by 17 per cent. Ian McArthur, head of the British Textile Confederation believes it to have been the worst year in living memory for the industry. Although, fortunately, the situation has stabilised to some extent this year, many firms are still on short-time working and are surviving, as Mr. McArthur says, by the skin of their teeth.

Foreign imports remain, as they have been for the past 30 years, the principal threat to the British textile and clothing industry. Manufacturers sincerely hope that the new phase of the multi-fibre arrangement, which is now under negotiation, will tighten controls on the levels of such imports. After all the fervour of the Cancun summit in Mexico, the Brandt report and the speeches made by my right hon. Friend the Member for Sidcup (Mr. Heath), it remains true that we shall never be able to compete with the Third world either in the cost of raw materials or in labour costs. Indeed, I have discussed that point with many manufacturers.

I shall be specific and quote from an article in a paper edited by Christopher Lorenz. It relates to Coats Patons, one of the more successful and progressive textile and clothing firms in Britain. The article states: Coats Patons calculates its international labours cost comparisons once a month … for use as a management tool in making investment and production decisions. The UK is used as the basis of this index (100) and the relative figures are calculated on the basis of base wage rates in different countries, charges on labour such as national insurance and payroll taxes and the latest exchange rates. The paper represents the United Kingdom, on the single shift index, as 100, Italy as 122, West Germany as 133, Canada as 134—the highest—and the United States as 117. Those are all advanced countries and I now deal with the developing countries. Portugal is represented as 40—some 60 points below the United Kingdom's 100 index—Brazil as 31, Peru as 23, India as 13, the Philippines as 10 and Indonesia as 6.

The textile industry has been rationalised and has installed the most sophisticated high-technology equipment. How can the textile industry compete with the wage rates and conditions of work in other countries when it is faced with onerous national insurance and exchange rates as well as many other on-costs? The developing countries benefit by those factors as much as by those figures I have indicated.

Clearly, we do not stand a cat-in-Hell's chance of competing unless we have a firm and robust renewal of the multi-fibre arrangement. Our textile and clothing industries employ more people than the iron, steel and coal industries put together. It is worth considering the amount of help that those industries receive in comparison with the textile and clothing industries.

In Industry North-West the former Minister for Trade, the present chairman of the Conservative Party, said: We hope that by the end of this year the overall framework for the new MFA will have been agreed. In 1982 we will then have to go on to renegotiate each of the bilateral agreements under the MFA which are currently allowing us to exercise control on low-cost imports of individual products through 400 quotas against 27 countries. The article continues: I do not apologise for looking after the interests of the British textiles and clothing industry—it is one of our great industries with a bright future, exporting last year goods worth £2.2 billion, employing over 600,000 people and still producing 70 per cent. of all the textiles and clothing purchased in this country. It has faced enormous upheaval over the past few years but it looks like coming out of this period of adjustment in a much slimmer but more competitive, more ambitious and more export-orientated form. An outline negotiating mandate for the European Commission was agreed by the Council of Ministers in Brussels. It gives the Commission a broad set of directives but it contains, nevertheless, the essential elements for obtaining all the provisions the British Government has been pressing. I know that it is not the Minister's responsibility, but I hope that the assurances given in June will be honoured by the Government in the negotiations and that the new MFA—MFA 3—will include all the promises and assurances given by the Minister.

The Minister concluded his article by saying: Obviously this mandate is going to be refined over the next few months. But the approach gives the Commission the negotiating hand necessary to achieve the tough and effective successor to the present MFA to which we are committed. Those words are very firm. The article continues: The judgment on progress to date must be 'so far so good'. The British industry has reason to be encouraged. I hope that the industry has good reason to be encouraged. It is the major employer in the North-West and it is an industry that deserves the support of the House.

I shall be parochial and turn specifically to the North-West. I shall quote not an employer, not the director of the British Textile Confederation, not one of my right hon. or hon. Friends but Jack Brown, the general secretary of the Amalgamated Textile Workers Union since 1976, a man for whom I have the utmost respect. In referring to the industry's future he said: we look to the renewal of the multi-fibre arrangement which regulates international trade in textiles and clothing, to establish stricter conditions, particularly the need to relate imports to the level of consumption in the United Kingdom and also to provide for imports to be suspended when our own industry is in difficulty. Apart from this, what about the future? Although we have to look to Government and the EEC for realistic agreements, in the last resort many of the industry's problems can only be solved by the industry itself. Is not that a sound piece of advice to come from a trade union official who has great respect among his members, bearing in mind some of the outpourings about the way in which the Government must intervene in British Leyland?

There is much that can be done and is being done in the midst of darkness. There are some shining lights in the midst of that darkness. Some companies are competing successfully in an appalling recession. They will do better when there is an upturn in the world economy. The "Think British" campaign has brought employers and unions together. It is designed to instil in the British mind the need to think British before buying and to recognise that buying imports causes unemployment at home. It is a campaign that is growing in strength. Despite what we read in the media about there always being a confrontation between employer and employee—the latter being organised labour, which is the trade union movement—here is a fine example to be found in industries which are some of the largest employers in Britain. It is an example that demonstrates that trade unions, employers and the work force can co-operate. That is tremendously encouraging.

I shall quote one of my constituents who is a member of the "Think British" campaign, Mr. Frank Oxley of Oxley Threads. Despite the recession, he is ploughing substantial money into his company. He says: I can understand that any textile company in Lancashire—particularly one which is completely vertical—which is spending money at this time on plant and machinery, could appear an exception. My reasons for doing this are quite simple. I am confident that the public are awakening to the fact that they have the power to demand British goods and, in doing so, bring hope to British manufacturers to satisfy their demand, and hope to the unemployed. I also believe that eventually sanity will return to those politicians"— that means us in this place— who for so many years have 'written off' British textile manufacturers and turned to the Third World producers. It is obvious to any thinking person that to create wealth and prosperity we must have employment and not unemployment. Every million who are unemployed cost the Government revenue amounting to £5 billion a year. That does not include the £1 billion plus that is being devoted to job creation and temporary employment. I hope that capital projects, which were so close to the heart of my right hon. Friend the Member for Sutton Coldfield (Mr. Fowler), who is now Secretary of State for Social Services, will be uppermost in the minds of some of his colleagues in the Cabinet. Such projects could create permanent, proper and useful employment.

In conclusion, I shall quote the chairman of the "Think British " campaign, Mr. Jolly. In a letter to the Prime Minister he stated: Please help us in our work, because there are areas in which only you and your Government colleagues can help us in our efforts to preserve employment. In particular please keep a close watch on the purchasing policies of the main buying agencies for the armed forces and the National Health Service etc. These have an important effect on the textile and clothing industry". I have ranged widely in my speech and I apologise if I have gone on too long. However, the debate gives a Back Bench Member an opportunity to highlight to the Government areas that concern him and his constituents. I hope that some of what has been said on both sides is heeded and that action is taken.

Mr. Deputy Speaker (Mr. Bernard Weatherill)

Order. It has been intimated that the reply to the debate will begin at 1.30 pm. Three hon. Members have been sitting here all morning trying to catch my eye, so if they stick to 10 minutes each we can get them in.

1.1 pm

Mr. Mike Thomas (Newcastle upon Tyne, East)

The hon. Member for Macclesfield (Mr. Winterton) will forgive me if I do not follow his line of argument. However, I share his concern for constituencies in the North-West. I also share the tribute that he paid to the right hon. Member for Stoke-on-Trent, South (Mr. Ashley) who made an impressively non-ideological contribution to the debate that was in stark contrast to the contribution made by the hon. Member for Crewe (Mrs. Dunwoody).

I am flattered that there is such pressing interest from no less a figure than the Secretary of State in the developing health service policies of the Social Democratic Party and its Liberal allies. The Government will not precipitate us into an election as soon as we should like. Perhaps in 1983 or 1984 we shall have our moment, but we do not need to rush into policy statements. We shall take a considered approach to the matter. I shall not be tempted very far by the Secretary of State.

Mrs. Dunwoody

People may find out what the hon. Gentleman's party stands for.

Mr. Thomas

I shall try to tell the hon. Lady what it stands for in a moment.

It is the first time that I have acted as spokesman for my party in a debate about health matters, so I have not had the opportunity to present my views. The Social Democrats intend to take a non-ideological approach to the matter, which will be in stark contrast to what the House has heard today.

The Government's position is encouragement for the private sector and benign neglect for the public sector. Although civil servants have already influenced the Secretary of State's prose style—which seems to have an element of turbidity obscuring the ideology since he took over the post—I am sure that he will recover from that when he is more firmly in the saddle. However, we can see the underlying trend.

It is remarkable that the hon. Member for Crewe is now a Right-winger in the Labour Party, running on the Manifesto Group's slate, and much vaunted as a triumph for the Right in the elections to the national executive committee of that party. She must tell us clearly whether her party is suggesting that it is wrong for people to spend their after-tax income on health care. If she believes that it is wrong, she must say so. If she does not believe that it is wrong, she should explain what she means when she confuses the worthy cause of the dental therapists at New Cross school—whose cause I support—and refers to them in the context of privatisation, which has nothing to do with the matter. It is a gratuitous introduction of a nonexistent ideological point.

Mrs. Dunwoody

The hon. Gentleman has not read the report.

Mr. Thomas

I have read the report and met the dental therapists concerned. There is no question of privatisation. [Interruption.] If the hon. Lady does not like what I say she had better get used to it because there will be more.

There is no question of ideology with the dental therapists. It concerns an administrative decision about a group within the dental services. I do not share what appears to be the Government's developing view, and neither does the hon. Lady. It is not an ideological matter, and it is depressing that she is so anxious to make it so.

Mr. Michael Spicer

Would the hon. Gentleman apply those principles to education, and will he tell his friend, now fighting the by-election in Crosby, about his views on education?

Mr. Thomas

Unequivocally. There is no doubt about Mrs. Williams' view on that matter. She does not believe that it would be right to deprive people of the right to spend their after-tax income on private health, if they wish to do so. She has been quite clear about that. No amount of distortion and abuse by either side of the House will alter that fact.

Mrs. Dunwoody

The hon. Gentleman asked about education.

Mr. Thomas

I am sorry, I thought I had said education. I must make it clear that I am referring to spending after-tax income on education.

The Social Democratic Party will remain fully committed to the NHS. We cannot foretell the economic position of Britain in 1983–84. However, there is no doubt that we shall sustain the real level of increase in expenditure on the NHS that is necessary to meet the demographic changes that the Government are not meeting—although, perhaps, they may be going some way towards that.

The Social Democrats take a clear, libertarian view of private health. We are equally determined to deal with any deleterious effect on the NHS from the private sector. The private sector should bear the full cost both of services and personnel, especially for training.

Two general areas concern me, both of which were referred to by the hon. Member for Crewe. One is the redressing of disparities in the NHS between groups and regions, and in the regions between the more prosperous areas and the inner cities. The other is shifting the balance of resources from the hospital service to the community care area. The Government's Green Paper contains many fine words. However, in the current climate there has been no reallocation of resources to enable those words to take effect. The local government measure published today will, inevitably, make that aim even more difficult.

My party will not produce great shopping lists of promises to increase nurses' pay, deal with consultants and so on. It will wait to evaluate its position in 1983–84 and then consider what economic resources are available.

I turn to the other half of the Secretary of State's responsibilities. We are debating the Gracious Speech against the background of 3 million unemployed. There is unrest in the Government's ranks about that issue. That showed clearly in some of the contributions today, as it did in the censure debate on 28 October, when the hon. Member for Staffordshire, South-West (Mr. Cormack) said of the Government: They have directed vast sums to assist the unemployed and create cosmetic jobs, while appearing not to understand the miseries of unemployment". At the Conservative Party conference the right hon. Member for Chelmsford (Mr. St. John-Stevas) referred to unemployment as a moral issue. I represent a constituency in which one in every five men is unemployed. In some streets more than half of the men are unemployed. Therefore, I cannot but share the right hon. Gentleman's view. Unemployment is a moral issue. The Government's approach to the present level of unemployment is fundamentally immoral.

The hon. Member for Staffordshire, South-West also said in the censure debate: It is right to recognise inflation as a scourge, but unemployment is a scourge, too."—[Official Report, 28 October 1981; Vol. 10, c. 924–6.] He voted for the Government that night, but said that his support could not be guaranteed and that he would judge the Government by the hope they brought to the unemployed. Those sentiments were echoed in speeches by the right hon. Members for Sidcup (Mr. Heath) and Chesham and Amersham (Sir I. Gilmour). I believe that they were echoed in the private thoughts of hon. Member after hon. Member on the Conservative Benches. Those right hon. and hon. Members can take no comfort from the Queen's Speech. One has only to look at the manner of its presentation and the order in which the topics occur to see that the Government's priorities have not changed.

The first priority is inflation, which, incidentally, is still higher than it was at the time the Government came to office despite all the protestations about policies that were supposed to reduce it. The second priority is monetarism and continuation of monetarist policies. The third priority is industrial competitiveness, worthy enough in itself, but not much comfort to industries that have gone out of business. The fourth priority is cuts in public spending—a subject to which I wish to return. Public spending represents another broken pledge because unemployment is far higher now than at the time the Government took office. Indeed, the Financial Secretary to the Treasury seems to have organised the Treasury into bragging about how public spending is going up.

Concern about unemployment is expressed in the Queen's Speech, but there is no specific measure to deal with it except a general sentence which talks about direct help to those most pressed by the recession. One of the reasons why the Secretary of State, not his predecessor, is here today, is that he is prepared to contemplate, as his offering to the Treasury in the coming round of cuts, a cut in the real value of benefits which will further undermine the position of the unemployed and the very poorest in the community. It will affect the long-term unemployed and families that depend on supplementary benefit.

What is going on is explained in the Sunday Telegraph of 18 October. Perhaps the right hon. Gentleman will deny the article if it is not true. The article states: Subject to Cabinet approval, Mr. Fowler, Social Services Secretary, and Mr. Brittan, Chief Secretary to the Treasury, who has been seeking cuts in Whitehall spending programmes, are believed to have agreed to pitch increases in unemployment and social security benefits in November next year at about four per cent below the level of inflation then". If the Secretary of State wants to deny that, he can stand up and do so. The fact is that he does not do so. Hon. Members know the reason. It is that these considerations are in the Government's mind. I wish to tell him that the Social Democratic Party will oppose proposals of that kind vigorously.

Unemployment benefit has already been cut by 5 per cent. in lieu of the ultimate taxation of the benefit. There is no commitment that the cut will be restored when taxation is introduced. We would be glad to hear such a commitment from the right hon. Gentleman. As a result, the two-child family with an unemployed head of household is rather more than £4 worse off in real terms. That same family in 1977 was receiving about 51 pet cent. of the average take-home income of male workers. In 1980, it was receiving 42 per cent. The figure is now probably lower than 1980, itself the lowest for 20 years.

The earnings-related supplement to unemployment benefit will go in January. The impact is unknown. Child benefit has already been cut in real terms. Will the right hon. Gentleman commit the Government to restore and to maintain the benefit in real terms? I suspect that he will not. There is also the shortfall of one per cent. applied to all benefits over which hon. Members have argued for so long. If inflation is above 10 per cent. in November—as sure as hell it will be—there will be another shortfall. Will the right hon. Gentleman confirm that the shortfall will be made good?

Will the Secretary of State confirm, above all, that the supplementary benefit levels, the safety net to which Government spokesmen have constantly retreated when arguments on this topic have taken place, will not be cut in real terms? Not to increase them in line with inflation is effectively a cut. Cuts occur through failing to match inflation levels. Two million of the poorest people, many of them children, depend on supplementary benefit. I should like to see the Government and the new Secretary of State repeat their commitment to maintain the inflation link.

We shall judge the Government, as, I think, will many of their supporters both inside and outside the House, and as will the electors of Crosby on 26 November, by the Prime Minister's election promise on 30 April 1979 when, in a broadcast, she said We regard it as a privilege to say to the old, the sick, the needy and the disabled"— it is strange and worrying that she omitted the unemployed— 'Don't worry, we shall look after you'". I turn finally to the promise made by the Secretary of State to introduce a mental health amendment Bill. In the light of yesterday's decision of the European Court of Human Rights and the six previous decisions, the right hon. Gentleman could hardly fail to do otherwise, and I am extremely pleased with his decision. However, I should make it clear that the Bill ought to deal with the specific criticisms made by the judges in the court and the great degree to which our present provisions contravene the Convention on Human Rights. A Bill which does not deal specifically with those matters will not be acceptable to the House. I judge from what I read in the press and from the remarks of the Secretary of State that what he proposes may not cover these aspects specifically. We shall want to give careful consideration to the Government's White Paper, and we may want to take up the right hon. Gentleman's generous undertaking today to consider changes to his proposals, which I was glad to hear him make.

I join the Secretary of State in hoping that the majority of matters relating principally to the National Health Service will not become matters of party political contention in the House. I deplore the way in which, on both sides of the House in the past, and progressively on the part of the official Opposition, there has been a desire to introduce ideological elements into this debate where, frankly, they do not exist. The one assurance that I can give the Secretary of State is that, although my colleagues and I will go after him hard where we disagree with him and where we think that his ideology is getting in the way, we shall never go after him on purely ideological grounds.

Mrs. Dunwoody

That is because the SDP has not got any.

Mr. Thomas

The hon. Member for Crewe may care to look outside at the electors and see where her ideology is getting her party. We do not intend to make that mistake. I hope that we can consider this subject in a much more civilised and intelligent manner than is the custom in some debates in the House.

1.17 pm

Mr. Neil Thorne (Ilford, South)

I shall not attempt to take up any of the remarks of the hon. Member for Newcastle upon Tyne, East (Mr. Thomas). In the first place, I intend to confine my speech to the National Health Service, and in the second I understood the hon. Gentleman to say that he was not proposing to disclose any of his adopted party's policy proposals at this stage and, therefore, I do not believe that there is anything for me to take up.

I listened with great interest when my right hon. Friend the Secretary of State said that it was the Government's determined aim to provide a more equitable distribution of resources between regions in the NHS. However, I am concerned to discover whether such a division causes injustice within regions. For example, if a region has a disproportionate number of teaching hospitals, do they cause deprivation elsewhere in the region? Teaching hospitals, of course, receive special contributions in respect of the numbers of medical students whom they train, and they carry out some very specialised work, partly in the nature of research. But is sufficient credit given for all this out of the total NHS budget?

My constituents find themselves within the boundaries of the North-East Thames regional health authority. I understand that in the year ending 31 March 1981, the costs per in-patient day were £95 for St. Bartholomew's and the London hospitals, £88 at the Royal Free hospital and £87 at University College hospital, all with occupancy rates of 79 per cent. or more. In the same year, the costs for non-teaching hospitals with more than 100 beds and similar occupancy rates were all less than £80 a day, with King George hospital, which caters for the majority of my constituents, as low as £63 a day and Rush Green hospital, also within the region, as low as £55 a day.

When we consider the respective costs per patient case, the difference is much greater. The London Hospital tops the regional list at £1,015, followed by the Royal Free at £950, Bart's at £892 and University College hospital at £722, whereas the cost at King George hospital is only £473. Therefore, while my right hon. Friend has rightly set about fairly distributing resources throughout the country, may I ask what steps he has in mind to ensure that there will be fairer distribution within the regions, and at the same level between the regions? The present system places an enormous burden on those responsible in the regions—the chairman, administrator, treasurer, regional nurse and regional medical officer—when confronted with the division of resources between competing claims. I urge my right hon. Friend to examine the matter in depth and I hope that he will be able to ensure that my constituents are not unfairly treated.

1.21 pm

Mr. Alfred Dubs (Battersea, South)

Before I come to my main point concerning the problems of the elderly, I should like to say a little about an omission, to my mind, from the Secretary of State's speech. As far as I can tell, he did not once mention any policies that he wishes to adopt on smoking, which, as the House knows, is the biggest single cause of premature death in this country. It is estimated to account for nearly 100,000 deaths a year, which could be prevented if more positive action were taken. The voluntary agreement negotiated between the right hon. Gentleman's predecessor and the tobacco companies expires in July next year. There is not very long between now and then for the Government to put forward their policies for action after July 1982. Nothing was said about it in the Queen's Speech.

I hope that the Secretary of State will be able to say that he is still as unhappy as his predecessor appeared to be with the agreement that was reached with the tobacco companies. I hope that he will make clear his commitment to tackle the scourge caused by smoking, because otherwise he will be in neglect of his duties to the health and well-being of people in this country.

I come now to the needs of the elderly. I am aware, as I am sure the Secretary of State is, that the needs of the elderly are not entirely encompassed by the responsibilities of his Department. Nevertheless, under the National Health Service and the personal social services there is much responsibility for the needs of the elderly.

Certainly, in the London area, there have been significant cuts in the number of beds available, both acute and geriatric. Although acute beds do not cater entirely for the elderly, at least half the occupants of them are elderly people. More specifically, there is a shortage of psycho-geriatric beds. I hope that the Government will not allow the shortage to continue without taking positive steps to remedy it. There is pressure, not only on the hospitals, but in the community, to look after these people and to provide a decent bed for them.

As a result of the cuts in the number of beds—certainly in the London area—one would have hoped for a compensating increase in community care by the National Health Service, but sadly that does not appear to have happened.

I accept that one possible factor—surprising in these days of high unemployment—is that there is a shortage of qualified community nurses. Nevertheless, I believe that a shortage of money and nothing else accounts for the lack of increase in support for community services by the National Health Service.

Not only is community care by the National Health Service a problem. There have also been cuts in local authority personal social services. In my area it is estimated that cuts in social services spending have averaged 7 per cent. a year, at a time when there are increasing numbers of elderly people in the population—particularly people over the age of 75—who are the main group in need of more help and support. There seems to be an inconsistency between cuts in the number of hospital beds available and reductions in support in the community for elderly people who are not able to go into hospital to be looked after.

As regards local authority personal services, we should consider particularly reductions in home help support, social work support and increased charges for meals on wheels, with possibly a lesser service, and also—certainly in my constituency—cuts in transport. Transport is vital to remove the sense of isolation from elderly people and to enable them to go to day centres, luncheon clubs and so on. There is increasing pressure on the elderly at both ends of the scale—lack of community support and fewer hospital beds. The problem is exacerbated by the poor housing, lacking basic amenities, in which many of them live. There is, therefore, pressure on the Health Service to keep people in hospital longer because their homes are not adequate for their condition.

As a result of the pressures there is a greater burden on local authority old people's homes—part III homes. The average age of people in the homes is now 85, although 20 or 30 years ago the average age of people entering such homes was 65 or 70. They provide a good standard of care, but only by stretching resources and capabilities beyond reasonable limits.

The additional problem is that, whereas matrons of homes are willing and struggle hard to keep elderly people in them rather than move them to hospital—if beds are available—hospital beds may be occupied by elderly people who require not medical but nursing care. There is a gap in local authority provision, as part III homes are not intended to provide nursing care on a 24-hour basis. If they were able to, or if a new type of part III home were set up—possibly by collaboration between the National Health Service and the local authorities—elderly people could be moved into part III homes with nursing care. It may not save money but it would provide a better environment than the bleakness of even the most caring hospital ward.

It is generally agreed that as many elderly people as possible should be kept in the community. Part III homes are only halfway there. People's own homes may not be adequate, and thus there is a need for sheltered housing, which is a good intermediate stage between elderly people living in their own homes and living in an institution. However, it works only if there is adequate community care to enable them to lead reasonably independent lives. As hon. Members know, sheltered housing provides basic support, such as alarm bells and a warden on call around the clock.

As a result of policies followed in many inner cities, an increasing sense of isolation is felt by elderly people. They are cut off partly as a result of local authority spending reductions—I quoted transport cuts—but also as a consequence of other policies. It is distressing to get repeated requests from people for accommodation nearer to their elderly parents. They wish to support and help them. Sadly, because of the inner city housing crisis, it is all too seldom possible. As a result, they are obliged to live a long way away from elderly parents, in flats in inner cities, and increasing burdens are placed on the Health Service and local authority personal services. It is one tragedy that comes from the demolition of inner city communities. Through lack of decent housing we have forcibly separated elderly people from their adult children, and the burden falls yet again on an over-stretched NHS and local authorities, which are already subject to savage Government cuts.

I urge the Secretary of State to think again. For all the pious words and sentiments we are not treating the problems of the elderly as we should and we are neglecting a large section of our population as a consequence.

1.30 pm

Mr. William Hamilton (Fife, Central)

I am grateful to my hon. Friend the Member for Birmingham, Stetchford (Mr. Davis) for allowing me 10 minutes out of the time that he intended to take to make his speech from the Opposition Front Bench. I shall deal exclusively with nurses' pay. The Minister will not be surprised at that. I do so partly because I am a Member sponsored by the Confederation of Health Service Employees and partly because I have family attachments to the nursing profession.

Since the National Health Service began it has been assumed that it cannot function properly and efficiently without a professionally trained, well-paid nursing profession with a high morale. It is accepted that since the inauguration of the Health Service our nurses have been greatly appreciated and grossly underpaid by successive Governments. Periodic reviews have taken place. The Halsbury committee reported in the mid-1970s and later there was a review by the Clegg Commission. The problems of nurses' salaries were temporarily alleviated. However, in subsequent years the erosion of inflation has led to nurses suffering a reduction in their standards of living. The Nursing Mirror of 23 September stated: nurses are in a desperate situation once again. A campaign on this matter has begun and it will intensify in the next few months. On receipt of the literature relating to the campaign I wrote to the Minister making the relevant suggestion that he and his Department should decide to treat nurses' pay no less generously than the pay of the police, of members of the Armed Forces or of firemen.

Before the general election the Minister for Health made precisely that suggestion. He said that the nurses were no less important to the community—and I put it no higher than that—than anybody in the Armed Forces, the police or the fire service. If one compares the pay increases received by members of those three services—and good luck to them—with increases given to nurses in the last three years, it is clear that nurses' pay has fallen back.

Not only did the Minister for Health make that proposal but a junior Home Office Minister made the same suggestion before the election. Therefore, at least two Ministers in the current Government believe that nurses' pay should be linked with that of the police, of members of the Armed Forces and of the firemen.

I wrote to the Department in connection with the campaign and received a letter in reply from the Under-Secretary of State dated 29 October. It is breathtaking in its complacency and smug self-satisfaction about the Government's record. It states: a great deal of progress towards solving the problems of nurses' pay has been made, mostly since this Government took office last year. That should be noted. The great achievements of the nursing profession and the great increases in nurses' standard of living have taken place mostly in the last two and half years.

It is true that the first increase that the nurses received was to implement the Clegg Commission's proposals, but last year they had to make do with 6 per cent. when the rate of inflation was 12 per cent. That alone eroded the nurses' standard of living, but, in addition, whenever nurses' salaries go up, the cost of their lodgings goes up. I meet nurses almost every day and invariably they tell me that, far from their standard of living rising, it has gone down. The Government are now proposing for the current year cash limits of 4 per cent., so the nurses will be expected to accept 4 per cent. this year when the rate of inflation will be not less than 10 per cent. and probably more. Therefore, once again the nurses will be compelled to accept an erosion of their standard of living by a Government who say that all is well.

In his letter, the Minister said that that agreement was reached last year by making promises that new machinery on nurses' pay based on comparability with outside professions would be introduced. I venture to suggest that he sought to blame the unions for the delay in implementing his proposals, which is absurd. The Clegg Commission outlined the great difficulties in indulging in a comparability exercise. I forecast that there will be no such machinery between now and the date of the next election. The nurses will have to abide by the cash limits laid down by the Government until the election. If that happens, I hope that the nurses will be as militant as their gentility allows.

Successive Ministers play on the reluctance of nurses to strike. They know that they are on to an easy thing. In the early 1960s, when the Tory Government introduced their first pay policy, the nurses were the first group to be subjected to it. I talked later to the then Chancellor of the Exchequer, Selwyn Lloyd, about that policy. He said that the Government had to start somewhere. That Government started with the weakest. That is why the present Government find the nurses fairly easy meat. They can impose on them their arbitrary cash limits.

The Nursing Mirror was more realistic than that complacent letter from the Minister. Certain figures are quoted, some of which I shall put on record. For example, a staff nurse, who is a highly qualified nurse and probably the key nurse on any ward in any hospital, receives a starting salary of £4,450. A raw police recruit going into the service with no qualifications, or relatively none, starts with £4,956. That is not counting the recent increase that the police received last September. An 18-year-old recruit to the fire service with no experience whatever, compared with three years training for a staff nurse, starts at £5,268–£800 more than a fully qualified staff nurse. In the Armed Forces, the average percentage increases over the past four years were 12.8 per cent. in 1978, 32.5 per cent. in 1979, 16.8 per cent. in 1980 and more than 13 per cent. in 1981. When one expresses those increases in either money or percentage terms, there is no doubt that, when compared with the Armed Forces, the police and the firemen, the nurses have lost out over successive years.

I hope that the Minister will give us two assurances: first, that he will fight against the imposition of the 4 per cent. on anything connected with nurses' salaries, and, secondly, that he will establish the comparability machinery within the next 12 months. If he cannot give those two undertakings, I hope that he will simply say that from now on the Government are committed to linking nurses' salaries with those in the three public services to which I have referred.

1.41 pm

Mr. Terry Davis (Birmingham, Stechford)

First, I take this opportunity to congratulate the right hon. Gentleman on his appointment as Secretary of State for Social Services. I am sure that he will take the comment in the spirit in which it is intended when I add that I hope his approach to the Health Service will not be based on the ideas which characterised his approach to public transport.

We have had a wide-ranging and interesting debate. Time does not allow me to comment on all the contributions from both sides of the House. My hon. Friend the Member for Fife, Central (Mr. Hamilton) used his time well, as he always does, to make out the case for the nurses. I say no more than that I agree with everything that he said.

I should refer in passing to the contribution of the hon. Member for Worcestershire, South (Mr. Spicer), as he referred to the very interesting problem of St. Wulstan's. He mentioned that my wife happens to be chairman of the working party appointed by the regional health authority to look into that problem. I make no complaint about the hon. Gentleman's reference to my wife. Nor is it for me to reply on behalf of the Government—at least, not before the general election. I believe, however, that as a member of the health authority my wife would be acting on behalf of the Government—a paradox which sometimes gives me some cause for amusement.

I am sure that the hon. Member for Worcestershire, South is absolutely right to say that whenever the closure of a hospital or other health institution is considered one must be careful to ensure either that there is no need for the facility or that comparable facilities are available elsewhere. I make no further detailed comment about St. Wulstan's, except to say that I believe that the hon. Gentleman has been invited to visit other facilities to ensure that they are comparable and I hope that he will take up the invitation.

Mr. Michael Spicer

The main thing is that the authorities themselves should be assured in their own minds through an independent committee of inquiry that comparable facilities are available. To that extent, my views are irrelevant.

Mr. Davis

The hon. Gentleman's views are extremely important. I have always been most interested in his views on all matters. I am sure that his right hon. Friend the Secretary of State will wish to be sure that comparable facilities are available, but I think that the hon. Gentleman should avail himself of the invitation that has been made to him as he, too, owes it to everyone to ensure that his comments are correct.

I am more critical of the hon. Gentleman's reference to the reduction in hospital waiting lists for operations, for which he claims credit for the Government, as I believe the Secretary of State also did. There are many reasons for the reduction in hospital waiting lists, but I can think of nothing that the Government have done which could account for that reduction. I suspect that the real credit is due to the many people performing many different roles in the Health Service, to whom the Secretary of State himself and the hon. Member for Canterbury (Mr. Crouch) paid tribute. I believe that it is the work of those people that has produced the reduction in waiting lists.

The Secretary of State also referred to the reduction in administrative staff. I hope that the Government will find time to tell us whether that is a genuine reduction, or whether it is helped by the employment of so-called temporary staff. I am thinking especially of clerical and secretarial staff who are being employed by regional health authorities for long periods at great expense to the Health Service. After all, the regional health service must pay not only the wages of the clerks and secretaries but a premium of 10 or 15 per cent. to the secretarial agency.

I was interested in what the Secretary of State said about the Health Service budget. He was right to say that we cannot simply make financial comparisons between one year and another, although he then went on to do just that, mentioning an increase of 4 per cent. in real terms since the general election. However, the point is that we must compare the resources allocated to the Health Service with the need. That is frequently missed in arguments about the size of the health budget.

We need to spend more in real terms each year. That is partly a result of demographic change, as it is called, and means, basically that there are more elderly people in the population. I agree entirely with what my hon. Friend the Member for Battersea, South (Mr. Dubs) said about the important role of personal social services and the need to expand the services provided for elderly people. I am sure that my hon. Friend will agree with me that even after that expansion has taken place there will still be a need for the Health Service to do more for elderly people, and because we have more elderly people each year the demand on the Health Service is that much greater.

Secondly, the increase in the Health Service budget is necessary as a result of the development of more expensive techniques. When challenged in an intervention during this debate, the Secretary of State said, without any reservation or qualification, that an increase of 4 per cent. in real terms meant that the budget had kept pace with both these factors. That was an interesting response. He was so firm that I am sure that he must have some figures to justify that categoric statement. I hope that the Minister for Health, in winding up, will give us these figures. Will he say what percentage increase in real terms has been necessary since the general election for demographic change, and what percentage increase has been necessary to cater for technological advance in medical treatment?

I imagine that there is support from all sides for the concept of partnership between the Health Service and local government and between the Health Service and the voluntary sector. However, some caution is necessary about the Secretary of State's enthusiasm this morning. Too often, the idea of partnership between the Health Service and local government and between the Health Service and the voluntary sector is put forward as a way of reducing what is then described as the burden on the National Health Service.

I take as an example the Secretary of State's announcement of £1 million to be used to provide more appropriate surroundings for mentally handicapped children. Of course the Opposition welcome that announcement, but I hope that the Minister of State will explain some of the details. The Secretary of State said that the money would be used to match pound for pound the money provided by the voluntary sector, but will this be restricted to the capital costs of smaller units or will the Government also help the voluntary sector with the running costs? After all, if children are moved from large institutions run by the National Health Service to smaller units run by the voluntary sector, there should be a saving to the National Health Service. What do the Government intend to do with that money? As these mentally handicapped children are transferred from hospitals to homes, do the Government intend to transfer the cost of looking after them?

Now I turn to mental health and the Bill that is mentioned in the Queen's Speech. My right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley) made a most interesting and valuable contribution to our debate, as did the hon. Member for Canterbury. It is widely agreed that the existing legislation needs to be overhauled, and to that extent the Opposition welcome the Bill. However, again, we do so with caution. The fact that there is widespread agreement about the need for reform and reorganisation is no guarantee of improvement. Ten years ago there was general agreement about the need for reorganisation of both local government and the Health Service, yet it is now agreed equally widely that the measures introduced by that Conservative Government were disastrous.

Therefore, the Labour Party will approach the Bill with caution as well as interest. Our attitude will depend on the Bill's contents and on the White Paper which is going to be published next week. In our view, it would have been better if the White Paper had been published first because that would have allowed more time for contributions and comments. Nevertheless, we welcome the willingness which the Secretary of State expressed today to listen to the arguments and to adopt a receptive attitude to any amendments that the Opposition may put forward. I shall not be surprised if that willingness is put to the test.

I emphasise two points. First, our attitude will be based on what is best for the patient and not on what is cheapest for the Government. Secondly, whatever the contents of the Bill may be, it is clear that it will be concerned not with mental health but with mental illness and its treatment. If the Government were concerned to improve mental health and to prevent mental illness we would have heard a different speech from the Secretary of State. I did not hear one word about the prevention of mental illness as distinct from its treatment. I am not surprised. Any discussion about prevention must begin by looking at the causes of mental illness. How can we consider the causes without referring to the stress caused by unsuitable housing and by the rising tide of unemployment?

Indeed, that is the main criticism of the Government's policy on the National Health Service. It is a policy for illness, not health. The most disappointing part of the Secretary of State's speech was his reference to prevention. Having said that it was a prime objective of the Government, he washed his hands of any responsibility for it by restricting the Government's role to the provision of information on which well-informed people can act. As my hon. Friend the Member for Crewe (Mrs. Dunwoody) pointed out, that is an incredibly restricted view of what needs to be done in the light of the Black report, with its emphasis on the link between unsuitable housing and ill-health, low income and ill-health, occupation and ill-health—factors that were admirably described by my hon. Friend the Member for Bolton, West (Mrs. Taylor)—and on the link between unemployment and ill-health. The hon. Member for Macclesfield (Mr. Winterton) referred to the cost of unemployment in financial terms but neglected to mention the financial cost to the National Health Service.

Indeed, that part of the Secretary of State's speech was a step backwards from the inadequate policies of his predecessor. I shall illustrate that point by reference to the Government's attitude towards smoking. I assume that there is no change in the Government's belief that smoking is harmful. During a debate on this subject a year ago the then Secretary of State for Social Services, the right hon. Member for Wanstead and Woodford (Mr. Jenkin), announced new restrictions on cigarette advertising. Of course, he was criticised by some of my hon. Friends for not having gone far enough, but at least there was no difference between us about the Government's responsibility for controlling cigarette advertising and sales promotions by the tobacco industry. The right hon. Member for Wanstead and Woodford had no scruples about accepting that responsibility. He did not conceal his view that the agreement with the tobacco industry was not good enough. Now, apparently, the new Secretary of State thinks that it is enough for the Government to ensure that there is a health warning on the side of cigarette packets. When the Minister replies, I hope that he will make it clear that he, at least, has not changed his mind. Indeed, I hope that he will go further and tell us what has been done to monitor progress on the agreement that was concluded a year ago.

Mr. Pavitt

In that debate the then Secretary of State gave me an assurance that he would not block legislation and that hon. Members would have the right to decide. He kept his word. When I produced my Bill, Government Whips did not block it. I hope that the Minister will give the same assurance for the Bill that I shall introduce, probably later this month.

Mr. Davis

I hope that will be the case, and I hope that my hon. Friend's Bill will succeed. However, that does not absolve the Government from their responsibility. A year ago, I listened to the then Secretary of State for Social Services and it was clear that he felt that the agreement concluded with the tobacco industry was unsatisfactory. Indeed, he said that was why the agreement had been made for two years and not for four years, as the industry had wanted. Nevertheless he announced certain steps forward.

I hope that the Minister will tell us what progress has been made. After all, we are now more than half way through that agreement.

First, what progress has been made towards the reduction of 30 per cent. in the expenditure on advertising? Secondly, what progress has been made in the reduction of the average tar yield? Thirdly, is the Minister satisfied that all poster advertising near schools and playgrounds has been removed? Finally, will the Minister tell hon. Members whether the Department has started negotiations for a new agreement to take effect after July? When we recall the difficulties experienced by the Government in obtaining the current agreement and the delay that caused, it is surely reasonable for us to expect that negotiations have been initiated towards a new agreement. On the subject of negotiations, will the Minister also tell us about his discussions with the BMA and the Overseas Doctors' Association, which he promised nine months ago? I refer to the question of language tests for overseas doctors and the discrimination between overseas doctors from the Common Market and those from other countries. When attention was drawn to this discrimination during the debate in February, we were promised by the Minister that discussions would take place. However, when I accompanied a delegation from my own trade union, ASTMS, to see the Minister about that question two months later, I was surprised to learn that the Minister had not contacted either the BMA or the Overseas Doctors' Association. I was even more surprised, two months later, when ASTMS contacted the Minister again, to be told that he had still not talked to the BMA or the Overseas Doctors' Association.

The Minister's failure to deal with this issue may be regarded as a small matter. However, it is an important matter to those who work in the Health Service. It is also important as an example of lack of action by the Government in trying to improve the Health Service. There are many other matters where the Government's lack of action can be seen. We have had the Royal Commission's report on the Health Service. We have had a report on the orthopaedic services and the waiting time for appointments and operations. We have had the Acheson report on primary health care in London. Then there is a report on the acute hospital sector. We have had a report on the study of community care and a report on the study of respective roles of hospitals and the geriatric sectors for the care of elderly patients. Above all, we have the Fagin report on unemployment and its effect on families' health. Most importantly, we have had the Black report on inequalities in health.

There was nothing in the Queen's Speech, or in the Secretary of State's speech this morning about any of those reports. The right hon. Gentleman said that the test was not his skill with words but his skill in developing policies to deal with Health Service problems. There are plenty of problems in the Health Service. We have had plenty of reports about those problems. During this year we shall be looking for plenty of action.

1.58 pm

The Minister for Health (Dr. Gerard Vaughan)

This has been a wide-ranging and welcome debate. In opening it, the Secretary of State clearly outlined the considerable progress we have made in health care since we took office. Further, he dealt with the methods by which we are restoring patients' needs to first place in considering health care planning. That ideology runs through all our thinking. That shows clearly in our decision to introduce a mental health Bill with special safeguards for patients in mental hospitals.

I was glad to hear the support of hon. Members, particularly my hon. Friends the Members for Canterbury (Mr. Crouch) and Worcestershire, South (Mr. Spicer), the right hon. Member for Stoke-on-Trent, South (Mr. Ashley) and the hon. Member for Birmingham, Stechford (Mr. Davis). My right hon. Friend the Secretary of State said that we are looking for common ground between the various political parties on health care. We feel strongly about that.

I wish to be as helpful as I can. I shall answer as many of the questions asked by hon. Members as I can in the time available to me. I shall find it difficult to answer the questions of the hon. Member for Crewe (Mrs. Dunwoody). I share the views of my hon. Friend the Member for Macclesfield (Mr. Winterton) about the hon. Lady's speech. It did not demonstrate any common ground. I found it disheartening. I suspect that it was disheartening also for her colleagues on the Opposition Benches.

Mr. William Hamilton

No.

Dr. Vaughan

The hon. Lady spoke for 49 minutes and I cannot recall her making one constructive comment. Instead, she gave us an extraordinary mixture—I mean this in the kindest possible way—of rebuke and misinformation. I found the rebuke extraordinary when contrasting the Government's record of the past two and a half years with that of the previous Labour Government's five years of health care. When we took office I was astonished by the extent of the drift, dither and delay that was taking place. Entire hospitals were falling into disuse because of uncertainty over their future. Decisions that could have been made because all the information was available were not being made for various reasons.

Mrs. Dunwoody

So the Government are closing the hospitals.

Dr. Vaughan

Remarks of that sort demonstrate the hon. Lady's ignorance. Much of what she said was completely inaccurate. It is not for the first time that I find myself having to point that out to her. For example, she talked about the future of community health councils. She implied that there was still uncertainty about their future. There is no uncertainty. The hon. Lady's suggestions were reflected in some of the comments of the hon. Member for Bolton, West (Mrs. Taylor).

We announced a year ago that there would be a future for the councils and that they would be retained. We made it clear that in many areas we think that they provide an extemely valuable service. I remember saying in the House that I had not had representations from one council about something that was going on locally—usually arrangements for a hospital or the possible closure of a hospital—that did not contain valuable comments. We value what the councils have to tell us. We have said that they will be retained and that there will be a council for each new district health authority.

There will be three exceptions—the Isles of Scilly, for geographical reasons, Weston-super-Mare and Liverpool, there being special problems in the last area. I shall be surprised if the hon. Lady says that she does not agree that those are sensible exceptions. I note that the hon. Member for Liverpool, Edge Hill (Mr. Alton) is nodding his head in agreement.

Mr. Dunwoody

rose——

Dr. Vaughan

The hon. Lady knows perfectly well that we shall be issuing a definite circular in the near future.

Mrs. Dunwoody

When?

Dr. Vaughan

The hon. Lady knows that consultations have taken place. It crosses my mind that she was trying to create anxiety and to score a purely political point when she cast a query over the future of the councils.

The hon. Lady talked about St. George's hospital in terms that could only suggest that we own the hospital. She knows perfectly well that we do not. We own only a small part of the site. She knows also that the site is not really suitable for a hospital these days and that we have a new hospital to replace it. There will be a new St. George's hospital at Tooting.

The majority of the site belongs to Grosvenor Estate. We have joined in supporting that organisation in an application for planning consent, which I understand has been agreed by the local council. However, the issue will still have to go to the GLC. The greater the return that we can get from our small part of the site the more resources will return to the NHS, resources which we can use for other purposes.

The hon. Lady then talked about joint funding and suggested that we had not increased the amount of money available for that. We have increased it in the past two and a half years from just over £30 million to £73 million this year. The figures for the past few years show that £241 million was available for joint funding. We have lifted—because it makes sense and that is how the Government approach health care—virtually all the restrictions on how that money is spent, provided that it is spent in a way that the health authority and the local authority agree is sensible.

The sad thing is that many local and health authorities, especially local authorities, have not taken up the money that is available. Out of the total of £241 million we find that not only has £10 million not been spent, but it is not planned to be spent. It is sad, when there is so much need for resources—about which we have heard a great deal—that there is money available which the authorities do not have the imagination, initiative, resource or drive to use. That is one of the things that we ask them to pursue urgently.

Mr. Dubs

Does the Minister agree that a proportion of the money spent on joint finance is being used to compensate for cuts made by local authorities in their personal and social services? Does he also agree that the money should not be spent in that way, although it is understandable that the local authorities—hard pressed by the Government—are forced to do so?

Dr. Vaughan

That is the wrong way in which to look at the matter. The money should be spent in a way which both the health authority and the local authority regard as beneficial to patients. We would be glad if the money were used for patients in various kinds of half-way accommodation. If it is used to help patients to enter the community, the Government will support it fully. There is wide variation in how the money is used. The Government should distribute information about how authorities are using the money rather better than they do at the moment.

On the question of the health education council, the hon. Lady (Mrs. Dunwoody) implied that we did not put funds behind health education. That is rubbish. We regard health education as an important part of health care and an important part of our preventive care plans. We have virtually doubled the money available to it in the past two and a half years. This year, and for three years to come, a special sum of £1 million will be added especially for anti-smoking campaigns. Next year around £2.3 million will be allocated for that purpose alone. The hon. Lady cannot suggest that the Government are not increasing health education resources.

The hon. Lady made a most extraordinary statement. If I heard the hon. Lady correctly, she suggested that we should charge for blood. She said that if blood went to the private sector it should be paid for. If the hon. Lady has any contact with those working at the grass roots of the Health Service, she will know that we in Britain are proud that we have the finest blood transfusion service in the world. It is crucial, in the view of those donating their blood, that it should not be sold or used commercially.

Mrs. Dunwoody

I am glad to make my point clear, because the Minister is now saying something different from what he said before. The Minister will know from being a doctor that there is a shortage of whole blood in the NHS. There has been a suggestion that it was the Minister's intention to allow the waste products to go for commercial development, when he knows that those who donate their blood do so because they believe that they are performing, as indeed they are, a useful service. If he is handling that advantage to commercial private units without imposing a handling charge, I wish to know why.

Dr. Vaughan

I am afraid that the hon. Lady has changed the direction of her point. She did not make that point earlier, and we can all read it in Hansard. When she rushes into areas about which people have strong feelings, she should choose her words more carefully. It will cause immense distress——

Mrs. Dunwoody

Answer the question.

Dr. Vaughan

The hon. Lady knows that she has side-tracked the issue to a wholly different aspect, that of making the fullest use of the various fractions from blood. The Government have considered that question. We have also considered whether the private service, when it makes use of NHS blood, freely donated, should pay not for the blood—that would be against the donors' wishes—but for the cost of transporting the blood and other services.

The hon. Lady made a spurious statement about waiting lists. She implied that the high waiting lists under the Labour Government resulted from the winter of discontent. The waiting lists rose under the Labour Government and we criticised them for it. How does she explain the fact that the waiting lists rose every year during the five years of the previous Government? There was not a sudden jerk—they rose steadily each year.

Mr. Nicholas Winterton

There were five years of discontent.

Dr. Vaughan

The hon. Member for Stechford cast doubts on our claim that we have reduced the waiting lists. It is a curious coincidence that they rose every year until the Conservative Government took office, and have come down every three months since then, with the exception of one month.

Mr. Terry Davis

May I intervene on that point?

Dr. Vaughan

Not at the moment because there are a number of points of concern to patients with which I wish to deal. We must wait and see how time progresses.

The hon. Member for Crewe mentioned consultants' contracts and implied that the Secretary of State had had a sudden change of policy. That is absolute rubbish. The Government announced in "Patients First" that they hoped that the profession would agree that consultants' contracts should be held at district level. That has been happening satisfactorily with the districts that have teaching hospitals. The suggestion was the subject of extensive consultation between the Government and the various professional bodies. As a result, it became clear that the majority of professional bodies wished the consultants' contracts to remain at regional level. That was not what we had recommended. However, the Government do not believe that they should, at every level, tell professions how to run their affairs. A decision was taken that the contracts would be held at the region. That was before the views of the Select Committee were published. My hon. Friend the Member for Macclesfield knows that we considered carefully the Committee's views. It was a question of balance of judgment. In the end, we decided that the consultants' contracts, as well as the senior registrars' contracts, should be held at the region. We decided that in the teaching districts the consultants' contracts should be held at district level together with those of junior doctors.

If the ill-considered words of the hon. Member for Crewe about dental therapists are read by them, they will cause a great deal of distress. She knows that there are difficulties of employment for a number of dental therapists. The dental strategy review group said that too many dental therapists were being trained and that it would be wise to close down one of the schools of training. It made clear that the future of dental therapy, certainly at the moment, was not in doubt and that the safeguards for people doing the work at the moment should be met. The hon. Lady knows that these recommendations are up for general consultation. If she wishes to submit views on dental therapists, I shall be interested to hear them.

Mr. Nicholas Winterton

My hon. Friend has announced that junior hospital doctors' contracts will be held at district level. Is he not concerned, like the Select Committee, that this could result, particularly at times of economic difficulty, in districts seeking to staff their hospitals with junior doctors rather than having sufficient consultants? One of the concerns felt by the Select Committee was that, as a result of restraints, which are understood, junior doctors could be employed in increasing numbers. The Select Committee wanted more consultants and a standstill on the recruitment of junior doctors in order to provide better standards of health for the people. Is not my hon. Friend worried about this point?

Dr. Vaughan

My hon. Friend makes an important and typically constructive point. I have said that arrangements are now decided for consultants' contracts to be held at the region. The precise arrangement for junior contracts is not yet settled. This is a matter we shall want to discuss with representatives of the junior doctors. Perhaps the most confusing——

Mr. Pavitt

rose——

Dr. Vaughan

I shall not give way, if the hon. Gentleman does not mind. Perhaps the most confusing of all the remarks made by the hon. Member for Crewe were those relating to private practice. I do not know how they will read in Hansard. After making some obscure remarks about freezing private care on one side, she appeared to say that she would abolish private practice altogether.

Mrs. Dunwoody

Within the National Health Service.

Dr. Vaughan

If she actually said that, I suggest that it is totally irresponsible. It is most unsatisfactory for someone who ostensibly speaks for her party to get up and make contradictory remarks of that kind. If she would like to make her position clear I shall be glad to give way——

Mrs. Dunwoody

rose——

Dr. Vaughan

—in one moment. It would seem that she has learnt nothing from the mistakes made in the past which left an enormous amount of bitterness within the National Health Service and damaged seriously, as she should recognise, the confidence of various professions working within the National Health Service. Her remarks reminded me of some even more extraordinary remarks she made when she and I were together on a platform at a hospital in London. The hon. Lady was asked about Labour Party policy for the Health Service. She said that she was not able to say what Labour Party policy would be and that she was not able to say what would be the policy on private practice. I do not understand how she can fit those remarks with the remarks that she made today. I gladly give way to the hon. Lady.

Mrs. Dunwoody

I am grateful to the hon. Gentleman. What he omits to say is that my remarks about private practice were concerned with details that a working party sitting at that time would decide in relation to how private practice was to be treated. That is still true. I stated clearly and unequivocally—I am sorry that the hon. Gentleman had difficulty in understanding me—that I do not believe in the exercise of any form of private practice within the National Health Service. We have made clear, as we shall continue to make it clear, that we regard that as totally inimical to the development of good health services. I hope that is clear.

Dr. Vaughan

I shall be greatly interested to read the hon. Lady's valuable remarks in Hansard. They are still pretty obscure. [HON. MEMBERS: "Oh."] I take it that the hon. Lady would commit her party to provide the extra resources to replace the income that comes at the moment to the National Health Service from private beds within the National Health Service. It also sounds as if she contemplates providing resources to cover the whole of the private sector, which would be an interesting and expensive development.

The main reason why the numbers on Health Service waiting lists have gone down is the improvement in morale and the tremendous efforts which enormous numbers of nurses and doctors have made to bring them down. The Duthie report shows that. But another reason is the increased numbers of operations and surgical procedures that are being performed by the private sector, taking off the back of the National Health Service work that it has not always been able to do in the way that we should like it done.

My hon. Friend the Member for Ilford, South (Mr. Thorne) commented on the distribution of resources and made some very important remarks about the functions of the region. The regional authorities have a very difficult task which, in my view, they carry out very effectively. But that does not mean that there are not local difficulties between one district and another and that the system could not be improved. I took careful note of what my hon. Friend said, and we shall look into these matters further.

My hon. Friend the Member for Macclesfield made a number of important remarks about consultants' contracts. I hope that he feels that my own comments have answered most, if not all, of his. However, if there are further matters that he wishes to raise with me, I shall be glad to discuss them with him.

The right hon. Member for Stoke-on-Trent, South covered a wide range of subjects. I was glad to hear of his support for the proposed mental health Bill. I noted his general remarks about mental health. I thought that he made an extremely interesting comment about geriatric patients who had been refused admission to hospital. I agree with him strongly that community care is cheaper than institutional care. It is not only cheaper, of course. For many patients it is very much better. One has only to see the difference between an elderly person in a very institutionalised institution and another who is able, 'with support in the community, to go about her daily affairs, including shopping and travelling, to realise how true that is. We put very high priority on this. If I have time, I shall have some remarks to make about the Age Concern report that came out yesterday.

The right hon. Member did not seem to recognise, however, that the decision over cancer, for example, is a known and unequivocal one. Someone with cancer must be treated in hospital. But when it comes to some of these other areas of psycho-geriatric care, the decision is much less clear. It must be for the professional people—not only the doctors, but the nurses and community staff—to decide which geriatric patients would be better treated in hospital and which would be better treated in the community. My hon. Friend the Under-Secretary of State was right when he said that this was not a matter about which we wanted to keep central records because it should be dealt with locally.

The right hon. Member for Stoke on Trent, South and a number of other hon. Members spoke of the urgency of transferring funds from the hospital sector to community services as they became available with changes in population. A great deal was made of this by the London Advisory Group, under Sir John Habbakuk. However, it does not seem to be understood by many people that the advisory group recommended—we supported the recommendation—that there was too wide a spread of activities in London health care and that too many places were trying to do everything, whereas it would be much more effective and efficient to do in the acute specialist centres the acute specialist work and to cease trying to do specialised surgical work in the non-specialist centres.

Many people seem to have taken that as an indication that the surgical beds would be closed down in London, which is not the case. It is suggested that the surgical beds should be reduced in number and transferred progressively to the surgical centres and that the beds released should then be used for geriatric and other community patients. Therefore, it is not a reduction but a change of use of London beds, and it is for each health authority to decide how it sets about doing that.

The hon. Member for Brent, South (Mr. Pavitt) and the hon. Member for Fife, Central (Mr. Hamilton), who spoke compassionately, are well known for their close interest in the nursing services. Nurses have had a major increase in salary in the last two and a half years. We cannot argue that an increase in salary for a regional nursing officer from £10,000 to £21,000 a year in two and a half years is not a substantial recognition of the responsibilities that she carries.

We are as concerned as Opposition Members that nurses should be properly looked after and that we should recognise that they have given undertakings not to strike. That does not surprise me because it is a fundamental part of good nursing. I ask Opposition Members to put their views and to put pressure on the other nursing unions to try to get a similar undertaking. They have not been apparent in doing that so far. At present, these undertakings are from the Royal Colleges and there is something of a silence from other nursing bodies.

I made a statement on behalf of the Secretary of State at the Harrogate conference last year. If the nurses want it, we would hold a futher inquiry into their career structure and salaries. However, it was clear at the conference that they did not want that, so I offered instead direct discussions between the Government and the various nursing organisations. In August of last year I wrote to both sides of the Whitley Council saying that we were anxious to get on with the matter. I asked them to let me know whether there were any difficulties. The management side was able to give me its views quickly but, for various reasons, the staff side found it necessary to take longer. I have seen each side separately and have suggested that it would now be right to have a meeting with both sides—a tripartite discussion. We are anxious to get on with the matter, and if there are ways of making the relativities and comparability of nursing salaries better and fairer, we should be glad to consider them.

Mr. Pavitt

rose——

Mr. William Hamilton

Will the Minister meanwhile give an assurance that if the proposed machinery cannot be put into effect within the next 12 months, nurses' pay will be linked to that of the police and Armed Forces? They would be satisfied with that.

Dr. Vaughan

The hon. Gentleman knows that I cannot give that assurance off the cuff today, but we have a sincere intent. I, and many in the nursing professions, want a change of distribution within the nursing structure, a greater emphasis on the clinical nurse and a fresh look at the career structure of nurses generally.

Mr. Pavitt

rose——

Dr. Vaughan

I apologise to hon. Members whose points I have not been able to answer in the time available. I thought it was important to cover the points that I did, and if there are other aspects that hon. Members would like to take up, I and the Secretary of State will be glad to answer them.

The hon. Member for Stechford asked about tobacco policy. There has been no change in Government policy. He knows perfectly well that our policy is to progress by education and greater public understanding wherever possible. Discussions are taking place about how progress should be made.

It would be easy for the Government to criticise the points made by the Opposition, but that is not our view. We are, however, surprised, when one looks at the records of the previous Government and this Government, that we have not had more recognition of our achievements. We believe that we have made considerable progress.

Debate adjourned.—[Mr. Brooke.]

Debate to be resumed on Monday next.