HC Deb 02 May 1984 vol 59 cc449-61

'It shall be the duty of any Family Practitioner Committee to promote health education within their area.'—[Mr. Dobson.]

Brought up, and read the First time.

Mr. Dobson

I beg to move, That the clause be read a Second time.

Mr. Speaker

We will take with this the following:

New clause 20—Free medical services— 'All services for which Family Practitioner Committees are responsible shall be available free to:

  1. (a) persons over 60 years of age and under 19 years of age;
  2. (b) pregnant women;
  3. (c) women who have had a baby within 12 months;
  4. (d) war pensioners;
  5. (e) persons in receipt of family income supplement or supplementary benefit;
  6. (f) persons receiving less than the national average wage and their dependants, and
  7. (g) persons suffering from such medical disorders as the Secretary of State may determine by regulations.'.
New clause 21 — Jurisdiction of Health Service Commissioner— 'All aspects of the work of Family Practitioner Committees shall be within the jurisdiction of the Health Service Commissioner.'. New clause 22—Deputising services— 'It shall be the duty of each Family Practitioner Committee to establish, run and monitor a deputising service for general medical practitioners in their area, the service to be financed by those practitioners using the service and may where a Family Practitioner Committee considers it appropriate be provided in conjunction with one or more other Family Practitioner Committees.'. New clause 23—Cancer screening— 'It shall be the duty of each Family Practitioner Committee to establish, run and monitor a call and recall system for screening all female persons of the appropriate age group in their area for breast cancer and cervical cancer.'.

Mr. Dobson

These new clauses are related to family practitioner committees. It has become clear in recent months that the Minister has been dissatisfied with the functioning of these committees. Their inadequacies were clearly highlighted in the monitoring of the deputising services. Having been a member of a family practitioner committee I have always been rather dubious about their role and have felt that it needed to be strengthened to give them more positive, more innovative and more preventive functions.

When I suggested this in Committee I was roundly denounced by Conservative Back Benchers who said that I was putting forward Socialist dogma and worse. The interesting thing was that when the Minister replied, he said that broadly speaking he agreed with most of what I had said and that when the Government finally published the report of a working party on family practitioner committees I would be fairly satisfied with it. Indeed, that has proved to be the case.

I shall pick out one or two items that we regard as positive functions for family practitioner committees that should be emphasised. We do not think that there has been anything like as much progress with health education as there should have been. It is clearly a grass roots matter. It is no use trying to do it all from the centre through the Health Education Council or through the hospital service because most people's only contact with the Health Service and the only time they think about health matters is when they need the services.

In the Labour party we have been receiving considerable representation about health education and environmental health from the trade union movement and in particular from women members of trade unions. My hon. Friend the Member for Oldham, West (Mr. Meacher) and I recently met a delegation of women from the Amalgamated Union of Engineering Workers who put forward some cogent points for improvements in health education. One suggestion was the improved labelling of drugs and pharmaceutical products, in particular those affecting pregnant women. If a drug might adversely affect a pregnant woman they suggested that on the container there might be a symbol showing the silhouette of a woman, in biblical terms literally great with child, with a cross over that figure, to remind not just patients but doctors of the potential danger. We have to be sympathetic to doctors because, with the proliferation of drugs, they have difficulty in maintaining an adequate knowledge of the adverse and side effects of all sorts of drugs.

The General, Municipal, Boilermakers and Allied Trades Union, which is not normally associated in the public mind with matters concerning women, has produced an excellent leaflet entitled:

Your reproductive health at work — A GMB guide to hazards in the work place". It is worth pointing out that it refers not just to the reproductive hazards for women but also for men, who can be affected by radiation or dust. There should be far more emphasis within family practitioner services on preventive measures. Although this might not be done exactly as suggested by the new clauses, there should be a specific duty on family practitioner committees to do far more to promote the general health of the community as well as trying to deal with people when they get sick.

A more specific aspect is screening for cervical and breast cancer. These types of cancer are particularly susceptible to treatment if they are caught early enough. If those two terrible afflictions are diagnosed early by a screening programme, in nine cases out of 10 things can be put right and lives can be saved. The arrangements are exceedingly hit and miss. The Government have abandoned the national cervical cancer recall system to save on the salaries of 156 lost jobs. That was not a good move. I admit that the system was not particularly satisfactory, but nothing has taken its place.

We believe that family practitioner committees should take a more positive role in screening women for cervical and breast cancer. It would have been difficult to do that with the old manual record systems, but with the computerisation of FPC records we should get on with it. It would be easy for FPCs to send letters to every woman in the appropriate age groups. Not only should women be recalled for further screening, they should be sent letters calling them for an initial screening at the clinic or by their GP. At least 2,000 women a year die of cancer of the cervix. We cannot let the matter rest until a proper screening system is established. The job would be best done by FPCs. New technology makes it possible and cheap. I hope that the Minister will agree with us.

The operation of deputising services is more controversial. The monitoring of deputising services is inadequate. It is difficult, even with monitoring, to reconcile the demands for proper health cover at night with the profit motive of the deputising companies.

There is a conflict between the profit motive of the private deputising services and patient care. One could argue that the GP service is being privatised quietly at night and at weekends in some areas by the extension of the deputising service. Like Topsy, the service has just grown. It would be best all round if FPCs organised deputising services when local doctors believe that they are needed. Then there would be no conflict of interest. There would be clear responsibility. Professional and lay people would be readily equipped and available to organise and monitor the service. Standards would be bound to be raised.

The only people who could object to a publicly organised, non-profit making service are those who profit from the private companies which are supposed to provide the service. Such a service would be a credit to the medical profession and FPCs. Patients would be reassured by knowing that they could rely upon a public service rather than a hit and miss commercial deputising service.

Mr. Gordon Wilson (Dundee, East)

I sympathise with the hon. Gentleman's case, but is he not taking it too far? Surely the patient would feel better if treated by a known doctor who knows the case and the family, rather than by a stranger whom he has never seen before and will probably never see again, whether that stranger is from the private or public sector.

Mr. Dobson

If we debated that we should be here for a long time. Everyone would like to be treated by the same doctor at any time of the day or night, at all times of the year. Many doctors still do their best to provide that service. However, there has been a shift in the medical profession and in public expectation towards accepting treatment by a responsible, qualified doctor who has access to notes and knows what he is doing. At present 20 per cent. of people covered by general practitioner services are heavily covered by deputising services. We must accept that they are here to stay, but we must ensure that they function properly, however far they may have come from the ideal of the old-fashioned family doctor. [Interruption.] The hon. Member for Dundee, East (Mr. Wilson) does not agree with me, but there we are.

New clause 21 seeks to expose the entire functions of family practitioners' services—I do not mean individual doctors — to the scope of the Health Service ombudsman. In Committee I moved a rather obscure amendment to a schedule, and the Minister chided me for proposing something that did not cover as much as I might have suggested, so now I am suggesting the lot. Everything that family practitioner committees do should be open to examination by the Health Service ombudsman. At present, if someone who goes to a family practitioner committee is dissatisfied, he can go to the ombudsman with one part of his complaint, to the Council on Tribunals with another part, or to the General Medical Council with another part. That is unreasonable. The Minister responded to this by saying that the parliamentary ombudsman, who is also the Health Service ombudsman, is on the Council on Tribunals. He could have gone further and said that he is a member of the commission for local ombudsmen. That means nothing to an individual who is dissatisfied with something that the family practitioner committee has done. We have an obligation to provide an easy, ready and sympathetic channel to deal properly with all complaints.

The Minister rightly said in Committee that he fears the development of the American idea of defensive medicine, where doctors are always considering what lawyers and courts might say about their actions. I agree that that would be a most reprehensible development, which we should do everything we can to fend off. However, the development of defensive medicine and adversarial activities in courts springs partly from the commercialisation of medicine in the United States which, thank God, is not yet so widespread here. The best method of avoiding defensive medicine is to provide a clear, cheap public means of obtaining satisfaction without resort to the courts. It would be a useful development if the Health Service ombudsman could extend his activities into this area.

Finally, I come to new clause 20, which relates to free medical services, and advocates that large groups of people should be entitled to free medical services. At present 70 per cent. of people are exempt from prescription charges, 45 per cent. are exempt from dental charges, and, as we learnt tonight, 35 per cent. are exempt from charges on glasses. We are seeking to bring them together to ensure that they are treated in the same way. Paragraph (a) states that all persons aged more than 60 should be entitled to free prescriptions, dental treatment and glasses. We do not want a distinction between men and women at 60 or 65, and we should equalise up rather than equalise down.

The exemption from charges should be extended from people aged 16 to people aged 19. At present, youngsters are exempted from charges if they are in full-time education. However, many of the parents of youngsters in full-time education are better off than are the parents of those not in full-time education.

We believe that the exemption from charges allowed to young people undergoing full-time education should be extended to those young people in part-time education and on training schemes and those who are in badly paid employment, because at the moment some of the worse off young people pay charges while young people at Eton do not.

Most of the other categories are fairly obvious and most of those that we have itemised exist already. We suggest also that people who receive less than the national average wage and their dependants should be exempt from all health charges. We take the Government's arguments in the Health Service debate last week at face value. They said that the charges should be paid only by those who could afford them. If the Government maintain that view, we believe that those earning less than the national average cannot afford them, and, therefore, we should like to see the exemption extended to them.

We wish to empower the Minister—he may have the power already although it is expressed rather obscurely—to include in the exemptions—if that is the right way to describe it—a series of medical disorders which, for these purposes, would include blind or partially-sighted people so that they would not have to pay for glasses. That was a matter to which we referred earlier.

I have always been a total objector to all health charges. I believe that we are putting forward a compromise in these amendments. I believe, in principle, that all Health Service provision should be free of charges. I hope that the Labour party will enter the next election with a commitment to an immediate and specific reduction in all charges when we become the Government, and the elimination of all charges within a specified time. The Prime Minister was almost announcing a 1,000-year Reich on Sunday, and needless to say the Labour party cannot yet specify what will go into its next election manifesto. We shall be aiming to reduce health charges as rapidly as we can, and I hope that we shall completely eliminate them.

We have included these proposals under the FPC part of the Bill because we want to emphasise, among other things, how important family practitioner services are. They are at the core of health provision. We should like to see the services improved and a more positive approach from Ministers and family practitioner committees. We should like to give a boost to all those working in the family practitioner-based services and ensure that all people benefit equally from the services that are being provided.

Mr. Meadowcroft

I support the group of amendments spoken to by the hon. Member for Holborn and St. Pancras (Mr. Dobson). Until I heard his last few words I had not realised that he was a member of that select coterie which, from time to time, when hon. Members are not listening too clearly, believes in utter candour.

He strangely told the House that he could not tell us precisely what would be in the Labour manifesto for the next general election.

Ms. Harriet Harman (Peckham)

He does not write it on his own. There are more of us than there are of the hon. Gentleman. We want our say.

Mr. Meadowcroft

I am not sure that that was entirely sedentary. The hon. Member for Holborn and St. Pancras was telling us about the part that related to health. If we were coming towards a general election he might hope that with a bit of luck new clause 20(f) might not pass through the House because it is the proposal that would cause a vast amount of public expenditure, although I suspect that we all have a great deal of sympathy for his proposals. Three new clauses are particularly practical, and there should be no disagreement about them—they are new clauses 18, 20 and 23.

My experience with family practitioner committees has been almost universally bad. When I have come into contact with them in recent years, I have not been much impressed by their liberality and generosity of spirit towards the wider Health Service. In one respect they are one of the most self-defending organisations in the Health Service. The strange thing is that all that the Minister says about freeing the optical service, spreading it more widely and enabling it to become free of monopolist tendencies goes in the opposite direction when he refers to the FPCs. We are going away from a broader involvement of the FPCs in the Health Service, towards a narrower definition of what they should do. If one takes the narrow road, and opposes the new clause tabled by the hon. Member for Holborn and St. Pancras, the danger is that one encourages general practitioners to believe that the Health Service is about enhancing their specialties rather than insisting that, for example, one might see a paramedic before seeing a general practitioner. We are considering whether we can spread out the FPCs, given that they are to be free-standing bodies in future.

11 pm

The hon. Member for Holborn and St. Pancras also referred to deputising services. One point that has not come out clearly is that one of the big factors determining whether they work satisfactorily is the relationship between where doctors live and where they practise, which has not been sufficiently examined. When doctors live and practise in the same area, particularly in inner city areas, they are not as anxious for private deputising services to come in, not least because the distances that they have to travel at night and the weekend are far less. They are more inclined to carry out those services themselves. I have noticed that in my own city. Those who live and practise in the same area, by and large tend to do more of their outof-hours calls than other people. The Minister might consider that matter, and encourage general practitioners to live and work in the inner city areas.

One of the great problems of trying to develop secure communities, in which health plays such a part, is that many of the professionals whom the people look up to do not live in the areas in which they work—not just doctors, but social workers, teachers and even probation officers. The tendency is to believe that success means getting out of such areas. That is particularly true of doctors, who are respected in such areas. Therefore, one hopes that a change will come about by giving the FPCs responsibility for deputising services in the way suggested by the new clause. There is much to be said for doctors' co-operatives, which work successfully in parts of the country. Anything that the FPCs could do to encourage doctors to work in co-operatives, on a non-profit-making basis, would be helpful.

The ombudsman, whether the parliamentary ombudsman, the local ombudsman or the Health Service ombudsman, does not pick up cases when something goes wrong, but has influence in assisting people to resolve a problem before there is a formal procedure. It is interesting to see how the existence of the ombudsman has had that effect in many cases. Where sometimes one part of a service might close ranks and prevent something from coming out into the open, the fact that the matter might go to the ombudsman has an effect. Therefore, it seems to be a logical and beneficial step to say that we should bring the affairs of the FPCs within the remit of the Health Service ombudsman.

Therefore, I am happy to commend this group of new clauses to my colleagues.

Mr. Couchman

I am mystified by new clause 18, which suggests that family practitioner committees should have a duty to promote health education within their area". A responsibility for health education is vested at present in the district health authorities, through the community services of those authorities, and it would be nonsense to transfer that duty from the district health authorities to the FPCs. Often on a comparatively limited budget, the DHAs are doing a good job. With their comparatively limited and largely clerical staff, the FPCs would be in no sense able to take on that duty. New clause 18 is complete nonsense.

My family are very pleased with the results that screening has had for us, and we have reason to be very thankful for it. I therefore have great sympathy for new clause 23. It is likely that when the FPCs acquire the hardware and software that the hon. Member for Holborn and St. Pancras (Mr. Dobson) mentioned, they will be in the best position to mount a proper screening service for breast cancer and cancer of the cervix. However, that clause is lumped in with new clause 20, which again seems to me to be nonsense. The House has already expressed its view on this matter today. I know that it is not the hon. Member for Holborn and St. Pancras who decides which clauses should be lumped together, but if new clause 18 is pressed to a vote my hon. Friends and I will have to vote against it, and that is unfortunate because there is much merit in new clause 23.

New clause 18 is nonsense and should be withdrawn. New clause 20 is unacceptable to this side of the House because of its enormous financial implications. We heard last week that Health Service charges at present provide 3.2 per cent. of the income of the NHS. That figure is derisory. The hon. Member for Holborn and St. Pancras wants to have no charges at all. We are already close to that position. However, there is no such thing as a free presciption. Someone must pay. If new clause 20 is adopted, it will be the taxpayer who pays.

If this group of new clauses is pressed to a vote, I shall support the Government.

Mr. Kenneth Clarke

The hon. Member for Holborn and St. Pancras (Mr. Dobson) has said that I made it clear in Committee that I was not satisfied with the current performance of all the FPCs. That is indeed the case. Many of those who serve on the FPCs would like them to play a more positive role and look forward to the Bill as giving them an opportunity to do so. The hon. Gentleman is a dissatisfied former member of an FPC. He told us that he had made such a nuisance of himself on the committee—no doubt on behalf of his constituents—that someone ensured that, when the time came, he was not reappointed. I know of several ex-members who resigned because they found the FPCs a frustrating way of trying to achieve things. We must raise the performance of the FPCs to the level that the best of them already achieve.

The House is divided about our proposals to give the FPCs a stronger, independent, free-standing status. Indeed, not all my hon. Friends agree with the Government on all counts. However, once we have taken on powers to appoint the FPCs directly, and have given them the independent status they desire, we must lift their performance generally and give them a more positive role to play.

When we discussed the role of the FPCs in Committee, the hon. Member for Holborn and St. Pancras, other members of the Committee and myself were in agreement about a remarkably wide range of objectives. Since then, a joint working group has considered how the FPCs should operate when the changes come into effect.

The report it produced contains many of the ideas that the hon. Gentleman commended to the Standing Committee and with which I agreed. In publishing it, I made it clear that once the Bill came into effect we must expect the FPCs to fulfil at least three important objectives. First, they must develop positive policies for the promotion of the family doctor, pharmaceutical dispensing and dental and optical services in the locality. Secondly, they must be properly accountable to Ministers, Parliament and — equally important — to the general public for those policies and the way in which they carry them out. Thirdly, they must collaborate closely with district health authorities responsible for hospital and community services so that the planning and financing of the National Health Service may be considered as a whole.

Many of the ideas set out in that report have commended themselves to the people who have since seen it. In particular, they have advocated annual programmes, five-year strategies and so on of the kind that the hon. Gentleman—entirely unscripted and unprepared, I am sure—advocated in the Standing Committee.

I trust, however, that the hon. Gentleman will not press the new clauses because, for a variety of reasons, each has a combination of technical and other defects.

New clause 18 seeks to impose on FPCs a statutory duty to promote health education in their areas. My hon. Friend the Member for Gillingham (Mr. Couchman), as a former chairman of a district health authority, anticipated what I intended to say when he pointed out that responsibility for health education at local level lay with district health authorities which already had many staff working in this sector—community physicians, doctors, nurses and, specifically, health education officers.

I shall not go into details today about what we hope to see achieved in this area. I am sure that all who have spoken in this debate, including myself, agree about the importance of health education. We are discussing how it should be carried out, not whether it should continue to be a high priority.

In so far as the FPCs have a role in this, it is a much lesser one than the DHAs. The report that we produced states: collaboration arrangements should be used to co-ordinate family practitioners' health promotion efforts with those of the DHA. I support that view, but I do not believe that we should place a specific statutory duty for one area on FPCs when district health authorities are in the lead on these matters.

Mr. Dobson

We are not proposing that the duty to promote health education should be taken away from the district health authorities but are seeking to impose an additional duty on family practitioner committees. This is especially important, as most people's contact with the Health Service is with their GP. Most people attend what might be described as Health Service premises only when they go to their GP's surgery. Good though the efforts of some district health authorities have been, therefore, we feel that the message is not getting through and that the best way into most people's homes and minds is through the family practitioner committees.

Mr. Clarke

We want collaboration between the two bodies — the district health authority and the family practitioner committee — but we do not want needless duplication and pointless competition between them. As my hon. Friend the Member for Gillingham said, the direct employees of a family practitioner committee are mainly clerical staff. Otherwise, it is responsible for the services provided by a number of independent contractors —family doctors, pharmacists, and so on—who, I agree, have a key role to play in health promotion. The district health authority, however, actually employs health education officers and is thus bound to be the lead authority in the area.

We wish the two bodies to collaborate because family doctors and the health care teams of nurses and others who work with them are in the forefront of public contact with the Health Service and could do much more about health promotion. Nevertheless, we believe that the district health authorities should be primarily concerned, drawing in the FPCs—or rather their contractors—so that they come closer together in planning their services and FPCs can collaborate with DHAs to ensure that proper notice is taken of the role that general practitioners have to play.

I shall take the new clauses in numerical order. As my hon. Friend the Member for Gillingham said, new clause 20 goes far too far in reopening the question of charges of all kinds, and in seeking to extend the exemptions. It widens the present exemptions in several material ways. As I said in a debate on this subject only last week, the exemptions which apply at the moment were introduced by a Labour Government in, I think, 1968, and have been applied ever since.

11.15 pm

As the hon. Member for Leeds, West (Mr. Meadowcroft) said, the hon. Member for Holborn and St. Pancras was very frank about his views, and no doubt he sees this as the first step towards spending that £350 million a year from Health Service revenue, or forgoing it. The hon. Member for Oldham, West (Mr. Meacher) said that that would be the aim of the Labour party if it was ever returned to power. The hon. Member for Holborn and St. Pancras got carried away by his own enthusiasm. He is so concerned about those with poor eyesight that he wants to give them all free prescriptions for colds, and everything else as well. As the hon. Member for Leeds, West and my hon. Friend the Member for Gillingham pointed out, by going for those receiving less than the national average wage and exempting them from all charges, the hon. Member for Holborn and St. Pancras is taking a substantial amount of revenue away from the Health Service. We all know that at present, that revenue could be put to better purpose within the NHS by the health authorities. Therefore, I do not agree with the new clause.

I turn to new clause 21 and to the subject of the Health Service commissioner. I have not even mentioned drafting problems so far, and I shall not rely on them. However, in Committee, I accused the hon. Member for Holborn and St. Pancras of taking too narrow a view and of tabling an amendment that had a solely technical effect. As he says, he has now gone the whole hog. All commercial contracts for supply and, perhaps more importantly, all personnel matters, such as disputes with the staff, should go to the normal tribunals for determining such matters. We cannot give the ombudsman dual jurisdiction with the tribunals.

The hon. Gentleman is, I know, concerned about complaints procedures. We should all like to see them better understood by the public, and we should like the public to feel that they get a fair and objective deal when they complain to FPCs. However, the formal procedures for complaint before FPCs exclude the Health Service commissioner. The remedy lies in an appeal to the Secretary of State. But the informal procedures—as the hon. Member for Leeds, West said — are quite important, as much of the sense of grievance sometimes felt by patients or relatives vis-a-vis the family doctor can be sorted out if someone explains clearly what happened and why. There is no need for a vastly formalised complaints procedure to give someone a feeling of satisfaction.

We encourage FPCs to use those informal procedures. All our guidance says that more emphasis should be placed on them by FPCs. We disapprove of those FPCs which treat complaints as either formal or nothing. When they follow the informal procedures, they are subject to the jurisdiction of the health ombudsman. It is quite right that he should be enabled to look at them. It is only when we turn to matters that are subject to other appeals and the possible decisions of tribunals, that the health ombudsman is excluded.

We had a longer debate in Committee than is possible now, but I tried to explain then that to open up the complaints procedure and to try to make it more satisfactory, we are producing a leaflet that will explain to patients how they can pursue their complaints with the FPCs. With the FPCs, as with all other services, getting the public to understand what they should do if they feel a sense of grievance would represent a substantial step forward, which would not, I am sure, be resented or feared by responsible professionals. We shall continue to do our best and to live up to what I said upstairs in Committee. I think that the hon. Member for Holborn and St. Pancras, however, has now gone too far the other way. The new clause gives the ombudsman far too much responsibility.

New clause 22 touches on deputising services. I certainly cannot conceal that I was far from satisfied by the way in which many FPCs were carrying out their duty to monitor deputising services last year. I am glad to say that we are now well advanced in getting out a new circular and guidance that will ensure that the present guidance is updated, and implemented by the FPCs. We shall insist that the new family practitioner committees apply it properly.

The hon. Member for Dundee, East (Mr. Wilson), who is no longer in his place, seemed to wish to abolish all deputising services. That was slightly unreal, because the single-handed practitioner would be expected to be on call 24 hours a day, seven days a week, and would have a legitimate cause for grievance. No doctor can be expected to work excessive hours. No doctor should be over-tired when examining his patients in the morning because he has been overworked the night before.

Most practices are able to make some arrangements between themselves or with neighbouring practices by means of the co-operative agreements that were described. The majority of general practitioners in England do not use commercial deputising services, and the recent row was with the minority who do use them. I am not at the moment over-enamoured of all the commercial deputising services, because one of them ran a fairly scurrilous campaign, putting leaflets in surgeries and so on which tried to suggest that the Government were proposing to close down all the deputising services. That caused an understandable amount of fuss with large areas of the profession.

As our proposals were so misunderstood, we have restated what we propose on frequency of use. We have restated what has always been the case—that in ordinary circumstances no practitioner should use deputising services all the time for all his out-of-hours services. No approval should be given for deputising seven days a week, although there will always be the doctor who has broken his leg or is in some other health difficulty and needs special arrangements.

We have asked FPCs to monitor the use of deputising services, to impose reasonable restrictions on use, to bear in mind the need to get the maximum continuity of care possible in relation to the reasonable expectations of doctors, to judge each practice on its merits in the light of the conditions of the locality and the problems of the practice, and to come to a reasonable balance between the interests of the doctors and the interests of their patients.

When we produce the final circular I trust that we shall succeed in satisfying everybody and in explaining to doctors and patients that we are not closing deputising services. On the other hand, we shall not allow general practice to become a nine-to-five job five days a week, which it never has been and never will be in Britain.

Dr. Alan Glyn (Windsor and Maidenhead)

I think there was a genuine misunderstanding. When the announcement was first made, I do not think that the Department made clear exactly what it wanted. There was a general impression that deputising services were to be shut down completely. If they were, it would militate against the individual practitioner who must, as my right hon. and learned Friend said, use the deputising service far more than it is used by any group practice.

Mr. Clarke

I entirely agree with my hon. Friend that there was a misunderstanding. He is a general practitioner and understands these matters. There was a failure of communication between myself and certain sections of the profession about what we had in mind in regard to monitoring. I accept my share of the blame for any failure of communication; the giver of the information and the receiver probably got their wires crossed. Other people were less than helpful in their contributions to the debate —not the Labour party on this occasion, but one of the commercial deputising services of which the hon. Member for Holborn and St. Pancras so greatly disapproves.

I hope that the problem has now been sorted out to the reasonable satisfaction of everybody concerned, and that we shall have arrangements which will be supported in all parts of the House and by the profession.

The new clause talks about monitoring, which is an important duty of the FPCs and will be an important duty of the new sub-committees with the lay membership, to which I attach considerable importance in what we are now proposing. There should be lay representation in monitoring deputising services. The hon. Gentleman will not be surprised to know that I do not think that family practitioner committees should establish and run monitoring services. We do not envisage FPCs employing doctors. We are content with the present arrangements whereby family doctors are independent contractors. The Labour party may wish to take steps in the direction of salaried service. The present Government do not, and see no advantage in that direction either for the profession or for the public.

New clause 23 deals with the important subject of screening for female cancers, breast cancer and cervical cancer. Screening for cervical cancer is important, because it is a cancer which, if detected at an early enough stage, is curable and reversible, and the otherwise would-be victim need fear no more. It is sad to say that there are many unnecessary deaths from this cancer which could be detected by proper screening. Young, articulate middle-class women are eager to be screened, and tend to want to be screened more often than is necessary, in the opinion of the powerful independent committee that has advised us. On the other hand, many older working-class women who have had a number of children are unaware of this facility, and do not take advantage of the service. That is the root of the problem that we still have to tackle.

As to recall programmes, we closed down the national programme based at Southall not to save the jobs or money, but simply because it was not working. We had a well-intentioned recall system there, but not many people were responding to the recalls. Experience shows that the local ones work better.

I hope that I have said enough to show that I regard this as a serious matter, and that I will not be accused of retreating into technicalities when I say again that the responsibility is that of district health authorities, most of whom have screening programmes. The ones that do not ought to have them, and ought to get on with it. They have been told by us to get on with it.

Many use the family practitioner committees. We must not have people falling over each other, or competing. The district health authority in my opinion should continue to have the responsibility. I hope that, where local recall systems, are defective at present, effective ones will be set up as rapidly as possible.

Mr. Dobson

I hope that this is not a matter of party political dispute. I accept that the Minister takes this matter seriously. The family practitioner committee is die only part of the Health Service which has the name and address of every female patient in its area. The FPCs are the only people who can conceivably run a call and recall system with access to every woman. The district health authority is not in that position. District health authorities have had this responsibility, but, for one reason or another, including the fact that they do not have the names and addresses, have been unable to discharge it properly.

Mr. Clarke

Some district health authorities do it well. A considerable number use the family practitioner committees as an agent which makes everybody happy, including the hon. Gentleman and me. Other agencies have a campaign in which they recall women who have been screened after a suitable interval—which in our opinion is five years. People such as the Family Planning Association and the family planning clinics have names and addresses. Indeed, they do a great deal of first-time screening of women already. It should be made clear that the district health authorities are the most appropriate people to have the local recall arrangements.

We are not quite ready for national breast cancer screening. People often misunderstand the situation on breast cancer screening. There cannot be any civilised, sensible man who would argue about the desirability of screening for any potentially fatal disease if an effective screening method is available. There is still insufficient evidence to be certain that mass screening is effective in reducing deaths at a much earlier stage, in determining whether screening does any good and, if it does, deciding how best to do it. The Government are funding a large-scale programme to evaluate breast cancer screening. We are at an experimental stage throughout the country, and are spending £700,000 on the screening. A quarter of a million women are going through the screening programmes that we are financing.

Until we are able to evaluate the trials, we cannot make a decision on a future screening programme. That is disappointing to some people. That does not mean that we under value it, but, whatever the understandable impatience of people, one has to proceed on a scientific basis in medical matters. That means that one evaluates the method that one is using, and acts when one has some scientific evidence to show that it is effective. Meanwhile, we recommend that all women should regularly examine their own breasts, and we give them guidance on how to do so. Useful leaflets on breast self-examination are widely available from the Health Education Council, and from the Women's National Cancer Control Campaign. Self-examination looks an encouraging prospect, not least because the woman herself is obviously in the best position quickly to detect changes in her breast than other methods that have been tried. However, we shall see what the evaluation produces.

11.30 pm

I do not believe that any of the new clauses touch on subjects on which there is any controversy or hostility between us, except possibly the lunatic desire of the Labour party to continue promising to get rid of health and prescription charges, when it knows perfectly well that when in government it will not be able to do so, just as it has been unable to do for the last quarter of a century or more.

However, I hope that we can meet the spirit of the new clauses by lifting the performance of the new FPCs, but meanwhile the new clauses are not a necessary addition to the Bill.

Mr. Dobson

By leave of the House, I beg to ask leave to withdraw the motion.

Motion and clause, by leave, withdrawn.

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