HC Deb 04 December 1986 vol 106 cc1150-68

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Peter Lloyd.]

8.00 pm
Mr. Michael Shersby (Uxbridge)

My purpose in speaking on the motion for the Adjournment is to draw the Government's attention to a very worrying problem of comparatively recent origin: the heavy cost to health authorities of providing temporary medical and nursing cover in our hospitals. That is resulting in health authorities having to use expensive agency staff to fill the gap caused by a shortage of junior hospital doctors and nursing staff. The problem is a national one. It may be more acute in the North-West Thames and South-West Thames areas but I suspect that it also exists in other parts of the country such as Manchester.

I am greatly concerned about the effect it is having in Hillingdon, in which my constituency is situated. The Hillingdon health authority is currently facing an excess of expenditure of around £350,000 as a result of the extra cost of using agency doctors and nurses. As a result, two wards have had to be closed, one in Hillingdon hospital and another in Mount Vernon hospital situated in the constituency of my hon. Friend the Member for Ruislip-Northwood (Mr. Wilkinson). My hon. Friend would have been present for the debate had it started later, as most of us had expected. I know that his absence from it at this early hour does not suggest a lack of interest. He is greatly concerned about the position in Mount Vernon hospital and so are his constituents in Ruislip-Northwood.

The closures are temporary, but had they not been implemented Hillingdon would have overshot its budget by £500,000 by the end of this year. In Hillingdon's case, an overshoot of £500,000 might have been manageable were it not for the fact that the authority is carrying over a debt of £1 million accumulated over the past two years. That is the result of the transfer of resources away from the Thames regions to other parts of the country under the resource allocation working party procedure adopted by the previous Labour Government when the right hon. Member for Plymouth, Devonport (Dr. Owen) was the health Minister. I am glad that, as a result of the many representations made by London Members, a review of the RAWP formula is now in progress. I hope that the review will soon be completed and that as a result less money will be taken away from the Thames regions and proper account will be taken of their requirements.

Transitional problems arising from resource allocation have, I am pleased to note, been recognised by my right hon. Friend the Chancellor of the Exchequer. In his autumn statement he allocated £30 million for easing transitional problems in London. I hope that, when my hon. Friend the Under-Secretary of State replies, she will give me an assurance that some of that £30 million will soon be coming to North-West Thames, Hillingdon health authority in particular.

My duty as the Member for Uxbridge is to leave my hon. Friend the Under-Secretary of State in no doubt about my concern and that of my constituents and the medical staff as to the seriousness of closing down those two wards. That concern has been powerfully reinforced by the chairman of the district medical committee, Dr. Diana Rimmer, whose views I have communicated to my hon. Friend the Under-Secretary of State.

In a letter that Dr. Rimmer has written to me on this problem, she said: The results of these closures are all too easy to predict. Within no time, the general surgeons of both hospitals will be treating emergencies only. Little or no 'cold' surgery will be performed—there will be no beds for such patients and waiting lists will escalate. In addition to the implications for the waiting lists, continued closure of these two wards into January and February 1987 will lead to even greater problems. During the January/February period, as you must be aware, the demand on medical beds increases enormously. It is common practice for medical patients to occupy surgical beds at this time. We have no reason to believe that in this respect the situation this winter will differ from previous years. It can be seen that it is a matter of considerable concern to the district medical committee.

In addition, the chairman of the Hillingdon community health council, Mrs. Shirley Court, has also expressed her concern to me. I ask my hon. Friend to take careful note of the fears that the council expresses. It was for the reasons expressed by the health authority, the district medical committee and the community health council that my hon. Friend the Member for Ruislip-Northwood and I had an urgent meeting with the Minister for Health on 6 November. He was most helpful and, as a result of our discussion, it quickly became clear that the National Health Service is facing new problems of national dimensions.

That was well reported in an excellent article by Jill Sherman in The Times on 24 November. She said: Health authorities are being forced to pay huge sums to private locum agencies providing temporary medical cover as more doctors opt for high private rates. Hospitals are paying up to three times the amount they would pay for doctors under the National Health Service system and the charges are spiralling. One health authority said that agency fees had completely wiped out all the saving it had made through putting other services out to tender. That illustrates very quickly the national nature of the problem.

In looking at the difficulty of recruiting doctors to provide temporary medical cover there are several factors which immediately come to notice. I am told that more doctors today are going into general practice earlier because the financial rewards are greater. They are doing that because it is more attractive than if they work in a hospital as a senior house officer. Although straight salary comparisons are difficult, my research has shown that, after a few years in general practice, a doctor would have a net income of £25,080, perhaps more. A senior house officer or registrar earns less. The average salary for doctors on the first two points of the registrar scale and the first three points of the senior registrar scale are between £16,206 and £19,484. Therefore, the incentive for working in hospitals is, and always has been, the prospect of ultimately becoming a consultant. Unfortunately, there is a shortage of consultancy posts. That prevents regional health authorities from putting them forward for approval. That is due to the diversion of resources from the south-east and the Thames regions in particular. Because of that, an authority such as mine, Hillingdon, has to spend more than it should on junior hospital doctors. It simply cannot pay more consultants.

The shortage of junior hospital doctors would have been evident much earlier had it not been for the extensive employment of overseas doctors in NHS hospitals. However, since 1 April 1985, the Department of Health and Social Security has imposed new restrictions on the employment of those doctors who now have to obtain a work permit in order to practise in the United Kingdom.

The result is that the pool of locums has been greatly reduced. Overseas doctors can now come to the United Kingdom only if they are to work in approved training posts. Traditionally, temporary medical cover has been provided by a pool of United Kingdom doctors who are willing to do agency work, but for the past six or seven years Britain has relied increasingly on the pool of overseas doctors to do the job. That, perhaps, has been an unwise practice, particularly as that pool has now dried up.

Therefore, the drift to general practice and the drying up of the overseas doctors pool has created a severe shortage of medical manpower. The shortage is being overcome by using medical agencies, some of which I understand are single doctor agencies, which charge much higher fees than health authorities would normally pay. They also charge a substantial commission, which I am told is of the order of 20 per cent. The fee is as much as 200 per cent. higher than the National Health Service figure in some instances. Let me give a few examples.

Whereas the National Health Service would expect to pay a doctor £332 for one week's work, one of these agencies would charge £612 for the same week's work. At the top of the scale, whereas the National Health Service would normally pay £500 for one week, the agencies are charging £900. One agency I know is offering a junior doctor £500 for one weekend's work. No wonder my local health authority is overspent.

As I said earlier, this is not exclusively a North-West Thames problem. I am told that other health authorities around Manchester and Birmingham have tried to fill the gap in temporary medical cover by recruiting doctors from other countries within the European Community. Apparently, doctors recruited from these countries have only to pass a language test. What we are seeing, in fact, is a violent swing away from service in National Health Service hospitals to general practice. If this trend continues, I am told that there will eventually be a shortage of opportunities to serve in general practice.

I wonder whether my hon. Friend can give me any assurance that those general practitioners who want one will be able to find a job in general practice in, say, three years' time. I ask this question because many people in the National Health Service now feel that what is needed is a properly organised flow of doctors into NHS hospitals and into general practice and an avoidance of these violent swings from one extreme to another. If that is to be achieved, something must be done about the remuneration of doctors in the hospital service.

What, then, is the solution to this complex, multi-factorial problem as it affects doctors? I believe that there are some steps that would go quite a long way towards solving the problem in the short term. First, better planning of how many doctors go into general practice and how many go into NHS hospitals would be an enormous step forward. I shall be interested to know whether my hon. Friend has it in mind to bring forward any proposals to make such organisation possible.

Secondly, I believe that the Government should consider the regulation of medical agency fees to stop them overcharging the National Health Service. Out of the £500 which an agency charges a National Health Service hospital for a weekend's work from a junior doctor, the agency commission is certainly in the region of £100 or more. What, I ask, is the difference between having a pharmaceutical price regulation scheme to govern the cost of pharmaceutical products supplied to the National Health Service and the regulation of the fees that are charged by agencies to supply doctors to the National Health Service?

A third step that would help would be an improvement in London weighting. At the moment it is far from satisfactory, bearing in mind the very high cost of housing in London and the south-east. Accommodation is a very real problem. I hope, therefore, that the Government will encourage the further sale of surplus land owned by the National Health Service, so that it can invest in better accommodation for staff.

In this respect I am pleased to be able to tell my hon. Friend that, once again, Hillingdon is leading the way. Following the sale of land at Harefield hospital, it will be able to provide 12 new units for medical staff, financed entirely from the proceeds of the sale. In short, we need good quality accommodation for medical and nursing staff. This can be provided if a deal is done with the developers when land is sold off. I hope very much that my hon. Friend will press other health authorities to do more in this regard.

Fourth, more flexibility is required to create senior house officer jobs in National Health Service hospitals. This problem was referred in the Department of Health and Social Security publication entitled "Achieving the Balance", to which my right hon. Friend the Member for Brentford and Isleworth (Mr. Hayhoe) paid so much attention when he was Minister for Health.

I turn to the problem of providing temporary nursing cover. The principal problem is the availability of young people to train as student nurses. There is real difficulty in 1986 in attracting sufficient students to enter nursing. The problem of availability is illustrated by the number of 18-year-olds who will be available as potential entrants over the next few years. By 1994, for example, the number will decrease by 25 per cent. This is due to demographic factors—to the drop in the birth rate. Looked at another way, there will be a drop of 25 per cent. by 1994 in the number of students with five O-levels to whom this country will look to provide sufficient students to enter the nursing profession.

Another problem affecting nursing today is that career options have widened considerably over the past 10 years. There is much more competition for the available students from other careers, such as the police force, the teaching profession, industry and commerce, and so on. Undoubtedly, pay is a major problem. Few hon. Members will deny that nursing is not particularly well paid. The figures speak for themselves.

A staff nurse, after training at the age of 21, will receive £7,200 a year. A policeman, or a woman police constable, at the age of 21 will receive £7,752, but a year later, at the age of 22, will receive £9,756, plus London weighting and the London allowance, giving the very substantial figure of £11,700 for a 22-year-old officer.

I am not saying that the police should not be well paid for the difficult and dangerous task that they perform, but I make the point that many nurses also perform difficult and dangerous jobs. Several of them have lost their lives in recent years when dealing with violent patients, and many of them work in hospitals in inner London areas where safety in the streets is not all that we should like it to be.

If, therefore, we look at the comparisons, a staff nurse of 22 will be receiving £4,500 less than a policewoman of the same age. The improved prospects for teachers' pay and the opportunities available in many other fields make powerful competitors against the nursing profession. In my judgment, the problem is that low pay for nurses has now become part of folklore. I am told that some teachers advise against nursing as a career because of this factor.

As with doctors, accommodation is also a problem. The cost of local housing is a major factor in the North-West Thames region. I am told that the accommodation of learner nurses is subsidised when they are living outside hospital, but that every time they receive a pay rise the subsidy drops. What is needed, then, is an allowance for accommodation that does not vary during the training period.

Another problem that needs to be faced is the condition of residential accommodation, which is often poor and which acts as a disincentive to recruitment. I urge my hon. Friend to ensure that money from land sales is used to upgrade sub-standard accommodation. A major improvement programme is needed for nurses' accommodation. This should be widely publicised. I believe that it would be a major factor in aiding recruitment.

I hope that my hon. Friend the Minister will consider the possibility of encouraging local health authorities to co-operate with building societies and form housing associations to enable nurses to gain entry to the purchase of accommodation through equity sharing schemes. Even if a nurse bought only 25 per cent. of the equity in a flat or maisonette it would help her if she moved to another part of the country. She could sell her share and have a useful nest egg to help in purchasing accommodation elsewhere.

The United Kingdom Central Council for Nursing, Midwifery and Health Visiting has developed a new framework known as Project 2000 which involves the introduction of a level of nurse to be called a registered nurse. Such a nurse is likely to be someone with five O-levels or someone who, although not having the necessary O-levels, can pass an entrance test. I wish to pay tribute to the sterling work that enrolled nurses have given to the National Health Service. It is important that the Project 2000 proposals, ambitious though they are, ensure that enrolled nurses have a continuing role to play.

Shortly after I was fortunate enough to be offered this Adjournment debate, I received a letter from a Nurse Dawson from Birmingham. He told me that he was glad that I was raising this subject on the Adjournment. He said in his letter: Many Enrolled nurses have done S.E.N. training (a) because they do not wish to become involved with management of wards; (b) they want to be seen as a bedside nurse; (c) they do not hold the qualifications to do State registration. I hope that Project 2000 will do nothing to diminish the recruitment of those excellent bedside nurses on whom so many people depend. I hope that we do not push the academic qualifications too far up the scale and perhaps exclude people from nursing who might otherwise have given the country valuable service.

Another factor which I must mention tonight and which is affecting the supply of nurses dramatically is the fact that the Australians have run an advertising campaign offering better conditions of work and a new lifestyle which has resulted in 2,000 qualified nurses being attracted away from Britain to work on the other side of the world. That is a very serious matter because all those nurses who have been attracted away from Britain have all been trained at the expense of the British taxpayer.

Information on Australian nurses supplied by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting gives the number of verifications of qualifications issued in respect of United Kingdom nurses, midwives and health visitors seeking to practise in Australia. It shows that from 1 April 1984 to 31 March 1985, 732 nurses went to Australia. But from 1 April 1985 to 31 March 1986, 2,220 nurses went to Australia. The number of nurses, midwives and health visitors from Australia whose applications for registration in the United Kingdom have been accepted was 782 in 1984–1985, roughly balancing the outflow, but in 1985–86 it was only 624.

A major factor in the increase in emigration has been a positive campaign to recruit nurses to go to Australia, following a decision by most of the Australian states to transfer nurses' education from the hospital sector to the advanced education sector. That has diminished the contribution of nursing students as part of the work force and created a need on the part of the Australian authorities to recruit additional qualified staff.

I hope that when my hon. Friend the Minister replies she will say something about the recruitment of our qualified nurses to Australia. That is having a major impact on the ability to retain the nurses that we so badly need in Hillingdon and in other parts of the North-West Thames region. The London weighting allowance should be increased from £876, which is payable on the outer fringes of London, if only to take account of the high cost of accommodation. After tax, £876 is not much money in November 1986. If that sum was increased, it would do much to help overcome the present shortage.

I emphasise that Hillingdon is 10 per cent. down on qualified staff. That means 200 posts. We are 20 per cent. down overall, including learners. That means 400 posts. That position compares with 8 per cent. under establishment on qualified staff and a full complement of learners only two years ago. The drop in numbers is a recent phenomenon and needs urgent action.

As my hon. Friend the Minister must know, Hillingdon has not sat idly by while that position has developed. It has run an advertising campaign in the press and on local radio. It has produced a video programme for schools and has conducted a vigorous recruitment campaign in the Republic of Ireland. I do not know what the Republic of Ireland will have to say about that and I am rather relieved that the right hon. Member for South Down (Mr. Powell) and the hon. Member for Newry and Armagh (Mr. Mallon) are now no longer in their places or they might have had something to say about our poaching Irish nurses.

But, despite all those efforts, a third of Hillingdon's budget for nursing staff is now paid out in fees for agency nurses. That amounts to £900,000 a year. If the authority did not have to use agency nurses, that sum would be reduced by about £280,000. That is because learner nurses earning £4,325 to £4,875 a year are having to be replaced by agency staff nurses who are paid £8,121 a year and auxiliary nurses who are paid £5,897 a year. Nursing agencies, unlike medical agencies, are restricted on the amount they can charge by way of commission or fees to 11 per cent. That is a desirable measure.

At 30 September 1985 in the North-West Thames region there were 1,060 whole-time equivalent hospital nursing and midwifery agency staff employed. That is a substantial figure and further illustrates the cost of the operation.

Today our nurses are no longer drawn from that pool of young women who were previously subsidised by their parents. Today they must often bring up a family. Many of them are female one-parent families. Others are male nurses who must bring up a family on a nurse's income. Only if conditions of pay and accommodation are improved can their service to the community be properly recognised. We need a full-scale review of nursing as a career and we need to market it with much more vigour in future if the problem is not to get worse.

I have one or two ideas which might alleviate the position still further. Firstly, will my hon. Friend the Minister consider lifting the requirement for the payment of superannuation so that it is not paid for the first five years of employment after qualification? That practice is commonly adopted in the private sector. Secondly, will she make residential allowances more generous? Thirdly, will she consider the possibility of introducing free meals for nursing staff in hospitals? These days, many employees enjoy free or subsidised canteen meals, so why should not nurses have something similar?

I invite my hon. Friend the Minister to consider a major new deal for nurses. Cannot we tell nurses, "The NHS will train you. It will offer you a highly worthwhile and properly paid job. Will you in return agree that when you have qualified you will work in an NHS hospital for X number of years? If you do so, you will receive a gratuity, based on the number of years of active service rendered."? Those years need not be consecutive, as we want to attract women back into nursing after they have interrupted their careers to bring up a family.

That suggestion is based on the service cadetship scheme for medical students, and perhaps it could be applied more widely in the NHS. We must do something like that, because the cost of training an enrolled nurse is now £7,700. The three-year training for a registered general nurse, previously a state registered nurse, costs £11,700. The total cost of training all such nurses in England for the financial year 1985–86 was £449 million. If those very substantial sums are not going to be allowed to run down the plughole to Australia, we must provide some additional incentives for our nurses to remain and help here in Britain.

I repeat that I have raised these matters at greater length than would have been possible in other circumstances because of my grave concern at the possibility that ward closures at Hillingdon hospital and Mount Vernon hospital could become prolonged. That could result in increased waiting lists, which would be quite contrary to everything that my hon. Friend the Minister stands for, as well as to the Government's policy of cutting waiting lists. I have raised this matter at such length only because the need is urgent. I very much hope that my hon. Friend will be able to respond to some of the solutions that I have suggested tonight.

8.31 pm
The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I congratulate my hon. Friend the Member for Uxbridge (Mr. Shersby) on raising this most important subject. I agree that it has proved valuable to have had a little more time than might otherwise have been the case, although some right hon. and hon. Friends who may have wanted to attend could not do so, as the debate began earlier than had been expected.

I also congratulate my hon. Friend on the considerable detail that he gave in presenting his several cases. I did not manage to catch everything that he said, and if I do not answer all his points I hope that he will allow me to write to him. I know that he had a recent meeting with my hon. Friend the Minister for Health and with my hon. Friend the Member for Ruislip-Northwood (Mr. Wilkinson) and that he then aired some of the issues which he has raised tonight. He has thus shown the excellent, determined and assiduous way in which he represents his constituents by putting their interests to Ministers. I hope that they have taken note of that and will accord him due credit.

I shall deal first with the national question of agencies and look at some of the background, rules, costs and numbers involved, the reasons for the problems and whether they are exactly as my hon. Friend the Member for Uxbridge has suggested. I shall also mention some of the suggestions that we have received. I shall then deal with Hillingdon, although I shall mention it in passing before then.

The first question is: why do we employ agency nurses and locum doctors at all? We feel that nursing posts should ideally be filled by directly employed staff, as that will ensure the maximum continuity of patient care, a reduction—we hope—in the number of management and supervision problems, the provision of clinical training and the promotion of team work. Much the same considerations apply to doctors or, indeed, to many of the other staff who work in the Health Service.

The relevant circular HC(83)2 points out that, on the other hand, there are times when agencies provide staff that we need. The first paragraph states: Whilst it is recognised that nursing posts in the NHS should ideally be filled with directly employed full or part-time staff…there will inevitably be circumstances where urgent short-term needs arise. In these circumstances qualified staff from nurses agencies can prove valuable provided they are used as part of a planned management of resources. Authorities are reminded that they should take account of their likely need for agency nurses in drawing up their budgets. The need for cover for doctors is generally greater than it is or should be for nurses, because of study leave and gaps that arise as juniors move through a series of short-term training posts. Doctors are expected to cover colleagues' absences where practicable. Where they are unable to do so, the long-standing practice is to engage locums. Agencies are used for urgent needs, or where a locum is unavailable. Therefore, the situation for doctors and nurses is slightly different.

We estimate the total cost of employing an agency nurse is little different from that for the directly employed nurse with similar qualifications. Directly employed nursing staff are entitled to annual and sick leave, while payments to agency staff are limited to the mid-point of the NHS pay scale and they attract on top of that only the agency fee plus VAT. Those rules are strictly set out in paragraph 9 of the circular.

On that basis, therefore, costs should not be a primary consideration in relation to nurses. Locum doctors are paid on the same basis as regular staff—again on the mid-point of the NHS pay scale. In agreeing terms with agencies, authorities are again required to have regard to NHS locum rates. As a result, in the period between 1979–80 and 1985–86, spending on locums as a proportion of the hospital and community health services medical and dental bill has remained constant at about 3.4 per cent., or approximately £38 million in current terms. But estimated expenditure on medical and dental agency staff is now about £17.5 million, which is approximately 1.55 per cent. of the pay bill compared with about 0.8 per cent. in 1979–80. Thus, we have seen a steady growth in the percentage of the pay bill going on agency medical and dental staff, although it still remains a very small percentage of the overall bill.

How many staff are we talking about? The number of agency nurses fluctuates over the years and, indeed, between the seasons. We are able to take figures only on a quarterly basis, which is not quite as tight as we might like, but those figures at least show that the fluctuation is what would be expected if the agency nurses are being used properly to satisfy urgent needs. About 87 per cent. of agency nurses are employed in four Thames regional health authorities and the postgraduate special health authorities where the authorities share recruitment difficulties for nursing with many employers outside the NHS in a wide range of trades. At September 1985, the number of agency nurses employed in England was 4,120, which is about 1 per cent. of nursing and midwifery staff. Again, the percentage is quite tiny.

It is worth noting that several regions—the Trent region, the Northern region and the North-Western region—do not use agency nursing or midwifery staff at all, and the majority use only a very small number. It is really only the North-West Thames authority that uses agency nurses to any substantial extent.

The proportion of doctors and dentists wholly employed as locums in England, at 3.9 per cent., has remained essentially unchanged for the past five years. The number of doctors and dentists employed as locums in England at September 1985, at 1,802, is not split up in the way that I would like, and I do not have any information on the number of agency staff employed. It may be that until very recently it was not a problem, so the figures were not identified separately.

Is the use of agency staff a problem? To some extent, I take issue with my hon. Friend on this score. Nurses should not present a problem of expense because the cost should be the same. I heard what my hon. Friend said about the difficulties in Hillingdon, but it appears that in Hillingdon qualified nurses employed by the agency are replacing learners employed by the authority. That is not comparing like with like. If we compare qualified nurses employed by the agencies with those employed by the authorities, the cost should be much the same. If through deliberately using agency nurses, or through some weakness or decision of management to do things slightly differently, the nursing mix changes, we shall find, as my hon. Friend has said, that the use of agency nurses will push up the bill. The health authority will be getting qualified nurses instead of learners—not like for like. There may be a number of reasons why that is or is not appropriate.

Mr. Shersby

I agree with my hon. Friend, but one of the reasons is the shortage of learner nurses.

Mrs. Currie

I shall turn to that issue at a later stage. I am glad that my hon. Friend accepts that if we compare like with like there should not be a problem of excess expenditure.

It must be accepted that most agency staff who work as nurses also work somewhere else. That means that they may become tired or careless when working as agency staff for the National Health Service. That can be the position whether they are working for the Health Service during the day or for another organisation. I have checked, and there is no firm evidence from the United Kingdom Central Council for Nursing, which is the disciplinary body, that there are difficulties and that tiredness is influencing nursing standards. However, it is something that we shall watch with great care. It would be foolish to take a dim view of agency staff who work for somebody else for part of the time without firm evidence to support that view. If account is taken of patterns of unemployment throughout the country, we may prefer to see two people rather than one person doing two jobs, especially in some parts of the country where there is a problem.

We can learn from the nursing agencies and our use of them that staff often want flexibility, and that is what the agencies are able to offer. There is a problem of continuity, especially if agency staff are being used, where perhaps the management of nursing resources might be slightly better organised. In other words, management has an important input into patterns of employment. It is essential that an agency is not telephoned to fill a gap that management should have directed some attention and thought to filling permanently.

My hon. Friend has accurately identified some of the problems of cost with agency doctors. Doctor agencies are not controlled in the same way as nurse agencies and the rules about the level of fees are not anywhere near as tight as those which apply to nurses. One of the things that worries us is that if medical staff in any numbers start to choose the agency form of employment, they may help to create the gaps that the agencies fill. We would be concerned if there were any evidence that that was happening to any degree. In the absence of the detailed figures that I had hoped to offer my hon. Friend, it is difficult to comment further about that. It is obviously a matter that we shall take carefully into account. I think that my hon. Friend has done a service by raising the question in this form this evening.

It is essential that the patient should not suffer. I would prefer to know that whenever we spend money the patient will benefit. It would be worrying if any health authority were to spend more money, only to offer a weaker service as a result.

It is worth saying that the fundamental cause of the shortage of junior locums and medical staff generally is that demand from the health authorities has outstripped available supply. The supply of medical staff is still increasing slowly, but much of the growth in the Health Service recently has drawn on increasing numbers of doctors. Shortages are occurring in posts that are seen as offering poor career prospects. Unfortunately, some of the explanations that are commonly advanced, such as one or two that my hon. Friend touched upon, seem so far not to fit the facts. For example, the total number of senior house officers—SHOs—in post has been growing. The total increased by 165 between 1983 and 1985, despite widespread reports of recruitment difficulties. The increase in the number of United Kingdom-born doctors has more than offset the reduction in overseas doctors. Immigration controls in April 1985 appear to have had no detectable impact on the previous trends in the inflow and stock of overseas doctors.

Whatever we may feel about the conflict between the role and attraction of the general practitioner compared with the hospital doctor, the GP option is an increasingly popular first choice of career. There are, however, still more than enough doctors for hospital career positions.

One of the possibilities is that a reduction in junior hospital doctors' hours may boost the demand for locums, and that is a factor that we have considered. My hon. Friend will know that the Government have taken positive steps to encourage the reduction in junior doctors' hours. Contracted hours were 91.6 a week in 1976 and they are now down to 86.5, of which 57 are spent working while the rest are on call. I take the view that these hours are still far too high and that more effort must be made to reduce them. Some staff are still extremely hard-pressed, and we expect authorities to keep the need for the most onerous duty rosters under constant review. We need to know why anyone should be working one in two or even anything more onerous than one in three.

It has been suggested that our initiative has boosted locum demand, but that is not borne out by the reports that have been produced by health authorities. For the rotas more onerous than one in three where reductions have been sought, locums were already routinely provided for planned absences in all but a few instances. The gap may have been only about 200 posts, and certainly nothing like the gap filled by locum and perhaps agency doctors. That does not seem to have been a major source of worry. If we are successful in reducing substantially junior hospital doctors' hours, it may be that the gap will widen.

What about shortages of staff? Should we not employ more doctors overall? We are employing more doctors. Under this Government, medical and dental manpower in the hospital and community health services, let alone GP manpower, has grown by about 6,000 full-time equivalents, which is about 13 per cent. I suspect that this is one reason why the gap has begun to open recently in the way that it has.

In Hillingdon, there are supra district and regional specialties, such as plastic surgery, radiotherapy and cardiothoracic surgery, which may mean that slightly greater recruitment difficulties are experienced in Hillingdon than elsewhere in the region. I know that the health authority submitted a request in its short-term programme for additional SHO positions. It has not managed to persuade or convince the management of the necessity for these positions, and it may be that further discussion is required.

Is an increase in doctors' pay necessary? That is a matter for the independent review body, which keeps the relative rewards of hospital doctors and general practitioners under close scrutiny. During the Government's period of office, the pay of doctors and dentists has increased by over 28 per cent. in real terms, and consultants are marginally ahead of GPs.

Mr. Shersby

I am interested in the information that my hon. Friend is giving me, but is she aware of the number of health authorities experiencing difficulty in recruiting senior health officers in each specialty? Of 88 districts which replied to a recent survey undertaken by the National Association of Health Authorities, it seems that 70 per cent. were experiencing difficulty in recruiting orthopaedic specialists; over 40 per cent. were experiencing difficulties in recruiting anaesthetists; and just under 40 per cent. were experiencing the same difficulty in recruiting those who specialise in accident emergencies. I am sure that the figures on a national scale are quite different. I ask my hon. Friend to direct her attention towards some of the problems that occur in the Thames region, where I suspect that we may have the sort of south-east problems that affect many other walks of life.

Mrs. Currie

The pressures on areas of work, such as orthopaedics, are not just pressures or demands for doctors; they are pressures and demands for theatre time and for the full range of services required, mainly because orthopaedics and other areas of work that my hon. Friend mentioned are major success stories of the Health Service. My right hon. Friend the Secretary of State, in a recent speech, said that we expect the number of hip operation patients to rise from about 28,000, as they were in 1979, to around 50,000. Therefore, resources will be found to ensure that that can be done. I am sure that my hon. Friend will agree with me that, as we talk about inputs, one of the things to which we pay attention is output. The problem he identified and the report he mentioned is on my desk for consideration.

It is worth reminding some of those who are considering in which part of the NHS they should make their medical career that a new entrant to hospital services now averages £12,160, and a top consultant can get £57,640, including the maximum distinction award, which is probably more than anybody in the Government gets. In that sense, it is still a well-paid profession, and quite rightly, too, as they are the leaders of the National Health Service.

Possible short-term solutions include using GPs in hospitals on a sessional basis. They enjoy doing it and make a valuable contribution. The possible short-term solutions also include improving the training quality of hard-to-fill posts.

Mr. Shersby

I am fascinated by the comment that general practitioners welcome the opportunity to work in hospitals. Does the Minister say that general practitioners in my constituency will welcome the opportunity to respond to a call to work in Hillingdon hospital after a busy day in general practice? As a Member of Parliament, if, at the end of a busy working week, after my constituency surgery, I asked to put in yet another stint, I should not feel very happy about it. General practitioners are not at all happy about this wonderful opportunity that is being offered to them. I ask the Minister to re-examine the brief that she has been given on that topic. I shall be fascinated to know in how many areas local GPs throw up their hands with joy at the opportunity of being able to work in hospitals.

Mrs. Currie

Knowing my hon. Friend as I do, if he were asked to do an extra stint after he had done his constituency surgery, I am sure that, on behalf of his constituency, he would do just that. The incidence of GPs doing clinical assistant sessions around the country is quite common. On one occasion recently I received a delegation from a group of people in another part of the country who were concerned about a reduction of service in one of their local hospitals. One of the reasons they were concerned was that GPs would lose their opportunity to do clinical assistant sessions. It is important that, where it is done, it is seen as part of a GP's career, an additional interest and use of his or her expertise, and not simply as a way of filling gaps. This system is widely carried out. I understand that GPs thoroughly enjoy doing it and like having the opportunity so to do.

Two other possibilities are including posts in rotation to offer an attractive package of general professional training—as my right hon. Friend correctly said, the main difficulties come up in certain specific areas of work—and, perhaps, increasing the use of cross cover between specialties and firms. I was impressed by an orthopaedic unit in my constituency, because the people in that unit told me with some pride that they never cancel an operation. When I asked them how they managed to do that, they simply said, "If one of us cannot do it, the others will." In other words, if someone is booked in for surgery and perhaps has been waiting a long time, the team operates strictly as a team and someone will ensure that my constituent has her operation on time, as expected. She will never know about it, but I am aware of the amount of management co-operation and mutual trust that goes into ensuring that someone will look after that patient and do a good job for her. It is possible that more co-operation of that kind could enable us to improve the training and the kind of work that doctors are able to do and ensure that some waiting lists are reduced.

We have been asked why we do not set up NHS locum agencies for doctors. Some authorities are doing just that, including North-West Thames region, which covers my hon. Friend's constituency. A medical bureau called Thames Health Personnel was set up in April 1986. It is based in South-West Hertfordshire district. The aim of that bureau is to place all requests for medical locums with one agency to provide a cost-effective and efficient service. There are six user districts of this service, all in North-West Thames, including Hillingdon. It is too early to assess the impact of this initiative on recruitment in the user districts, but we are following this problem with some interest.

In Wales, Locum Bank Wales is attempting to match available doctors on temporary work with vacancies occurring throughout the Principality. Trent regional health authority recently announced a computerised regional locum bank. I understand that Mersey regional health authority has plans for a clearing house for SHO posts. We do not rule out a national data base. So far, there has been no strong demand from the NHS management for such a data base. It may be that regional or inter-regional developments are the right scale for this sort of operation.

We watch all these developments with considerable interest. They increase the freedom of choice of doctors, make use of spare doctor manpower that may not be available on a full-time basis or may be available only on a temporary basis, and enable us to fill gaps in the Health Service as they occur.

It has been suggested that we might ban the use of medical agencies or impose maximum charges. The authorities must manage the local services. Some find that they can dispense with agencies; others do not. If we were to ban the use of agencies, it would reduce flexibility and the ability of authorities to respond to short-term staffing crises.

Partly as result of this debate, we have asked the health authorities how they would react to fee ceilings. There has been no strong demand for them from NHS management. If we receive evidence of a worsening problem, we shall ask them again, but it would be wrong for us to impose a change if the NHS management system, which we so laboriously set up, does not consider that there is a need. We issued guidance to health authorities on their role in the use of nurse agencies in 1983, and in 1980 we agreed to a code of practice with representatives of medical agencies. If necessary, we will revise it, but at the moment there seems no great pressure on us to do so.

My hon. Friend mentioned some long-term solutions and correctly identified "Hospital Medical Staffing—Achieving a Balance." At the moment, we are consulting on this matter. The consultative document sets out the proposals. The Government are vigorously pursuing these proposals, and we shall take account of responses to the consultation. The ideas are worth considering carefully.

As my hon. Friend will be aware, I was a member of the Social Services Committee at the time it produced its 1984 report on hospital medical staffing. I was signatory to that report. Again, some of the solutions that were proposed are long-term. The Committee's main point was that Ministers should devise an operational plan to bring about agreed changes in hospital staffing structure that would pick up some of the problems that my hon. Friend identified. Following discussions with the health authorities and with the professions, we have published proposals for such a plan. We are consulting and we shall develop a detailed plan for implementation in the light of the response.

The employment prospects for nurses vary region by region. Some authorities still have difficulty in recruiting sufficiently qualified staff in some locations and specialties, particularly mental illness and mental handicap. It is perhaps a matter of sadness that those shortages do not show up so much as the shortages in acute services which may not be nearly as difficult. But shortages also affect acute services, such as operating theatres and intensive and renal care.

At present I have on my desk several proposals from health authorities obliged to reduce the number of beds in hospital wards to release enough nurses to man the intensive therapy units, not because of financial cuts, but because they simply cannot lay hands on the highly skilled and highly qualified people who can do that type of stressful work. Therefore, they feel there is no point in having lots of patients in beds if they cannot provide intensive care. That is an agonising decision for a health authority to take, but sometimes it appears to be necessary.

About 80 per cent. of our national recruitment publicity is directed towards mental illness and mental handicap. It is as much to try to change the image of that type of work and to attract people into this important area as anything else. Authorities have been asked to consider a wide range of possibilities, and, indeed, my hon. Friend is right to draw attention to our worries about the future.

At present we draw the overwhelming bulk of our nurses from young school leavers—18-year-old girls with O-levels and usually with A-levels, although only O-levels will be the required qualification from 1986 onwards. In 1981, there were 480,000 18-year-old girls. By 1994 there will be only 300,000. That drop gives an idea of the rapid shrinkage of that pool from which nursing and, indeed, the other health care professions, such as physiotherapy, draw their recruits.

I was present today at the launch of the central clearing house for nurse training, which will be a big help in ensuring that we know how many people are applying for nurse training, what their level of qualifications may be, and that they go to nurse training places, so that we do not have too many applications in one place and vacancies in another. But among the other things that we are looking at seriously is an alternative to the traditional recruitment markets—men and mature entrants—and possibly to the qualifications for entrance to see whether they have become a barrier rather than a door, making sure that we do not exclude people who have all the right talents and abilities who are perhaps deterred, as my hon. Friend rightly said in the case of the nurse who had written to him, by the way in which some of the most senior nursing training is presented.

We are most concerned to reduce the wastage of learners and qualified staff. We cannot afford to lose nurses as we have been doing. That means finding out why people leave and whether there is some way in which we can encourage people to stay. That means, instead of insisting on established and traditional ways of working within a hospital, asking whether the qualified personnel, to whom we have access, might want to work in a slightly different way. That means encouraging qualified staff to come back to nursing, looking at what they want and how they would like to work.

It is curious that there are no recruitment difficulties in certain areas, such as in recruiting practice nurses to work in a GP's surgery. That seems to be the kind of work that these good people want to have, in which case it is not for us to say that they are wrong, but to find out what would suit them and encourage them to come back into nursing in one way or another.

We need to examine the skill mix and deployment of qualified and less qualified staff and to establish the right skill mixes where they are most needed. There is a difference between an intensive therapy ward and a ward which is looking after people recovering from minor surgery. It is important to get that mix right and to ensure that we use our expensive and increasingly scarce personnel in the right way.

It is important that we should reduce levels of absence that can be avoided. Obviously, there are absences that cannot be avoided, such as when nurses are training. We should consider sickness and the extent to which nurses find aspects of the stress of the job difficult to take. It may be that by looking after our staff just a little bit better—or even a darn sight better—we may encourage them to stay and have a rather higher percentage of them available to us and to our patients than we have at present.

My hon. Friend mentioned Project 2000. He knows that it will not be published until January, and he will understand, therefore, if I do not comment further on it. But his remarks about SENs, which will be welcome to them, have been carefully noted.

What are we going to do about all this? My hon. Friend mentioned the more experienced nurses and the importance of paying them properly. That, as we know, is being looked at now. The management and staff sides of the nurses and midwives staff negotiating council have begun a review of the clinical grading structure. The review will examine the duties and responsibilities of nurses over the range of jobs, including specialised areas. We hope that once a new grading structure is agreed it will be possible for the review body to recommend appropriate pay levels. The council aims to complete its work in time for the 1988 pay review. It will be some time before we see the benefit of that, but its proposals may be far reaching and will, I hope, take up some of the problems raised by my hon. Friend the Member for Uxbridge.

My hon. Friend also asked about Australia. I do not need to quote the figures again, as I provided them in a written answer. My hon. Friend is quite correct. This year we have lost almost 2,000 girls and gained about 600. It is probably worth remembering that the campaign in Australia has been the result of serious shortages of nurses. That was caused by a switch to using academic students instead of trainee nurses on the wards. That caused a loss of service commitment. We must be aware of the possible dangers of that and also of the possible attractions. I shall make no further comments on that.

The recent experience is not entirely unhappy. Recent experience in recruiting, training and keeping nurses has been worthy of note. For example, the numbers discontinuing nurse training have dropped. There has been a reduction in the number of nurse learners discontinuing training as a proportion of the average number in nurse training. It was nearly 9 per cent. in the year ending 31 March 1980. It was about 5.6 per cent. in the year ended 31 March 1986. That figure should be reduced further if possible, and any reform of nurse education should have that as an objective.

We have also been able to recruit increasing numbers of nurses despite the comments that have been made. The total number of nursing and midwifery staff, including learners, unqualified and agency staff—bearing in mind that agency staff are only 2 per cent. of the total—by 30 September 1985 was 401,200 in whole-time equivalent terms. In other words, there were even more bodies than that. That was an increase of 42,700 over the figure in September 1979.

An estimated 24,000 of that increase was accounted for by additional staff necessary to maintain the level of service as a result of a reduction in working hours from 40 to 37.5. That still leaves an increase of almost 19,000 for service expansion. At the same time, the proportion of qualified nursing midwifery staff increased from about 54 per cent. in 1979 to 59 per cent. in 1985. I would hazard a guess that, if my hon. Friend the Member for Uxbridge asked his local district health authority to calculate the proportion of qualified staff that it now employs, he would discover that some of the increase in spending on the nursing budget is accounted for by whether they are employed by the agency or the Health Service direct. That trend has been followed throughout the country. I am sure that my hon. Friend would agree that that is a welcome trend. We want qualified staff on the wards; that is what we pay and train them for.

The number of nurse learners entering training has also been very satisfactory. From information supplied by the English National Board for Nursing, Midwifery and Health Visiting, I can tell my hon. Friend that 23,705 entered training in England in the year ended 31 March 1986. Most of the change in recent years has been the result of the drop of 19.2 per cent. in enrolled nurse training, perhaps for the reasons mentioned by my hon. Friend. The numbers entering registered nurse training decreased by only 3.2 per cent. over that period.

Dr. Bendall, the director of the English national board, may allow me to quote her again. When we were discussing this matter at lunchtime at a press conference, she said that she felt that some of the drop in SEN enrolments was the result of comments made in some of the discussion about Project 2000. She said: I think that we have shot ourselves in the foot on that. That is the view of a most distinguished servant of the nursing profession. It is obvious that sometimes lessons are learned in difficult circumstances.

Should we improve pay for nurses? We are doing just that. Since 1984, nurses' pay has increased by more than 11 per cent. in real terms. That is a significant total increase that many other staff groups would welcome, as would others in the private sector. The scale maxima for sisters and staff nurses have risen since 1984 from £8,103 and £6,094 to £10,800 and £7,750 respectively. In addition, there are premium payments for nights, weekends, overtime, certain specialties and London working. As a Trent Member, I should point out that the pay levels are better than women in some parts of the country could expect for other types of work, so some of the difficulties correctly identified today are problems of London.

Should there be a contractual obligation on nurses to continue in NHS employment for two years or some other period?

Mr. Shersby

In talking about a contractual obligation, I had in mind the provision of an incentive linked with an understanding or an agreement.

Mrs. Currie

I take that point. In fact, I have tried it in another incarnation. When I was chairman of the Birmingham social services committee I was keen to increase the proportion of trained staff substantially. At one stage, in the mid-1970s, only about 30 per cent. of our social workers were trained and qualified. We therefore entered into a commitment with staff who undertook training for the certificate of qualification in social work whereby they were to work for us for two years after their training. It worked a treat, but after the two years they left so one was merely postponing the time at which staff might go if they had strong reasons for doing so. I believe, therefore, that we need to identify why people leave, widen the pool from which we recruit them and make it possible for them to stay. Some of the incentives mentioned by my hon. Friend would then be marginal rather than central to the argument.

It is also worth pointing out that as nurse training is the major training for the caring professions one would expect to train a large number of people who then go on to other things. Many go into other caring professions, such as social service departments, which do not train nurses. They also go to work in the private sector which, with one or two exceptions, does not train nurses. I believe that for some time to come we must regard ourselves as the major training engine generating a supply of qualified caring staff for the most important of professions. In other words, we should not expect them all to be working in the Health Service. It is important to bear in mind the wider input that the training expenditure helps to provide.

My hon. Friend mentioned accommodation and asked whether health authorities were encouraged to sell off land and property to provide better facilities. They are indeed encouraged to do that, and also to improve property needed for residential accommodation. There are two circulars outstanding—HC(85)19 and HC(86)8—both of which stress that the improvement of residential accommodation should be the first charge on proceeds of sale, exactly as my hon. Friend has suggested.

In fact, Hillingdon is relatively well provided with staff accommodation. According to action plans submitted last year, the district has 1,070 units, of which only 840 were occupied. Half the occupation was by professional trainees and half by other staff. Proposals were made to reduce holdings for other staff by 200, leaving trainee accommodation untouched, which would result in a holding of about 645 units. Health authorities are not now required to implement those proposals if they judge it necessary to do otherwise so as to attract staff. The NHS management board has been looking urgently at the problems of recruitment in London, taking into account a wide range of issues, of which accommodation is one.

I did not manage to catch all the suggestions that my hon. Friend made, but I shall read the Official Report with great care. I think it highly unlikely that we shall start giving free meals to nurses, as he suggests. Indeed, the pressure is on us—rightly, in my view—to reduce the subsidy on staff food rather than to increase it. I am sure my hon. Friend will agree that we wish to pay our staff in cash and not in kind. That principle runs through the social security reform and we have removed from large numbers of people the right to free school meals and have given them cash instead so that they benefit not just when the children are at school and eating school meals but for the whole year. Similarly, I would prefer nurses to have cash and not simply a benefit on the occasions when they choose to eat in the staff dining room, whether or not there is a healthy eating policy there.

Mr. Shersby

I agree with my hon. Friend. The major review that is now in the pipeline should certainly help to solve that problem.

Mrs. Currie

I take note of that.

I should now like to turn to Hillingdon. My hon. Friend the Member for Uxbridge might like to stay for the Adjournment debate that follows this one because my hon. Friend the Member for Harborough (Sir J. Farr) and I serve this nation in a part of Britain which was a major beneficiary from RAWP. I look forward to hearing what my hon. Friend the Member for Harborough has to say.

The Government are committed to RAWP. We are reviewing it and looking hard at some of the points made by my hon. Friend the Member for Uxbridge. He is right when he says that an extra £30 million has been set aside for the RAWP bridging fund, and we are waiting to see what the health authorities propose to do with that money. I cannot give my hon. Friend the commitment that he seeks, but I have no doubt that his health authority has taken note and will make an appropriate bid.

In Hillingdon, as in every other health authority area, the amount of revenue that has gone in has increased. In 1982–83, the amount was £46 million and it went up to £54 million this year. There has been a hike of £3.5 million to Hillingdon in the last 12 months. That is a substantial increase and, on top of that, £6.8 million has gone in in capital spending in the last four years. I am sure that that will be of considerable benefit to local people.

We have been talking about input, but the output is patients. I note with interest that the number of in-patients treated in Hillingdon, despite that extra money, has remained virtually static, at 40,000 a year. The number of day cases treated has also remained static, at about 3,000 a year, which is a tiny percentage of the overall level of work. It is less than 10 per cent. and many local authorities are treating 20 or 25 per cent. day cases; in some ways that may be a much cheaper method of looking after patients and increasing throughput.

The number of out-patient attendances has risen from 224,000 to 231,000 in the last four years. That increase is welcome and it is important to put it on record. My hon. Friend is quite right when he says that the Hillingdon health authority has overspent. At the end of September it was overspent by about £800,000 and its projected year end overspend is approximately £1.6 million—if it carries on as it has been doing until September. However, the district has given the region a guarantee that it will not be overspent in broad terms by the end of the financial year.

I am informed that Hillingdon health authority is doing something quite wise. It is holding a reserve in excess of £1 million to offset any unforeseen expenditure over the winter months and to meet any capital expenditure that the health authority may wish to undertake. It may well be that, with careful management of its resources, it can keep the promise made to the region without damaging patient services too much. I am sure that the authority will be grateful to my hon. Friend for raising that matter in this debate.

We all recognise that Hillingdon has serious problems about waiting lists. The waiting list for general surgery, trauma and orthopaedics and urology went up between March 1985 and March 1986. The worst waiting list is for plastic surgery, where over 2,700 people are waiting. That list has been coming down, but by a long way it is still the worst one of the authority's waiting lists. My hon. Friend will know that a waiting list fund has been set up for the two years from April which will allocate £50 million nationally to accommodate problems like that. We are expecting bids from the regional health authorities for this money and I understand that the North-West Thames regional health authority will give Hillingdon priority management attention. That is the order of the day. If that is not a hint, I do not know what is. At the very least, we expect to see some bids coming in, and after that it is a question of how much money is available for the national bids.

I hope that I have dealt with at least some of the problems identified by my hon. Friend. I shall write to him about those that I have missed. The locums and the agencies literally help to fill a gap. They generally do a good job and I wish them to know that we value the work that they do. On that basis, I am glad to respond to my hon. Friend.