§ Order for Second Reading read.
§ Mr. Speaker
Before I call upon the Minister, in view of the rather late start to the Bill and the large number of right hon. Members and hon. Members who wish to participate, I appeal for short contributions.
§ 4 pm
§ The Minister for Health (Mr. Tony Newton)
I beg to move, That the Bill be now read a Second time.
On 25 November I announced publication of the Government's White Paper on primary health care, "Promoting Better Health". The White Paper set out the Government's strategy for primary health care and our key objectives. These were to make the services more responsive to the needs of the consumer, to promote health and prevent illness, to raise standards of care and to improve value for money.
The Bill, which was read the First time on the same day, paves the way for the implementation of some parts of that strategy, others of which do not require legislation. The Bill goes wider than primary health care, for example, in giving health authorities new powers to generate additional income for patient care in various ways. I shall comment on those provisions later.
First, I should like to say a word about the context of the primary health care provisions of the Bill, which I suspect are those on which much of the debate will focus. As the primary health care White Paper stated, expenditure on family practitioner services has risen by £1.5 billion, or 43 per cent. in real terms, since 1978–79 and our existing plans provide for additional expenditure by 1990–91 of over £0.5 billion more in real terms.
The proposals for promoting better health, taken together, will require sizeable additional resources. Subject to the progress and nature of negotiations with the professions, I expect expenditure on the family practitioner services by 1990–91 to be substantially in excess of £600 million in real terms more than it is today. It was against that background, as I emphasised in my statement on the White Paper, that we concluded that it was reasonable to secure some of the additional resources going into primary care services by asking those who can afford it to meet something more of the overall cost of their health care, with the provisions in the Bill concerning dental charges and eyesight tests, about which I shall have something to say at the appropriate part of my speech.
§ Mr. Eric Forth (Mid-Worcestershire)
I apologise to my hon. Friend for intervening so early, but will my hon. Friend consider looking more widely at our Health Service and consider the French approach, where people are asked to make a contribution whenever they consult the health services? This would broaden the principle he is outlining and upon which he will expand. Is he prepared to look at it on the same basis, because it might give us more resources and may have a wider beneficial effect than the measures he is proposing today?
§ Mr. Newton
I note my hon. Friend's suggestion. He will note that there is no proposal along those lines in the Bill. I would not wish to be drawn to comment on that today.
32 As the House knows, our principal aims, through those proposals, are to improve the standards of care, in particular in the inner cities, and to give greater emphasis to the prevention of ill health. We believe that more can be done for the family doctor service through the practice team by vaccination, immunisation and screening for cervical cancer. The White Paper outlined our plans in those areas for what might be called prevention targets. The intention is that doctors have targets for each of the main preventable diseases and the action taken to prevent them. We shall relate remuneration to the achievement of those targets and encourage greater provision of more general advice on keeping healthy, not only by doctors but by other members of the practice team. We shall introduce a sessional fee for health promotion sessions.
We emphasise also—it is an important point in the broader context of this debate—that vulnerable groups such as elderly people should be properly cared for. In recognition of those needs, higher capitation fees are paid already for each patient over 65 and 75. We propose to discuss with the profession what sorts of additional services should be provided for elderly patients. The routine screening of mobility, sight, emphysema and hearing, and keeping in touch by one means or another with elderly patients, particularly those who live alone, are the sorts of services we have in mind.
The effective development of this approach depends not only on the doctor but on a strong practice team. It is this which lies behind clause 13 of the Bill. We propose to release more funds to enable practice teams to take on extra skills and to carry out the sorts of task I have just described. That may mean, for example, additional practice nurses or the extension of services provided by a practice to include the care that can be given by people such as counsellors, physiotherapists or chiropodists. In inner-city areas, or other areas where a similar problem arises, some practices may wish to recruit interpreters under this heading to help people of ethnic minorities whose command of the English language is limited. Subject to negotiations with the profession, more money will be made available for those purposes.
We also intend to abolish the current central constraints on the type and number of team members whose salary costs can attract direct reimbursemment. Clause 13 substitutes a more flexible system, which rests on giving the local family practitioner committee or health board freedom to determine need and allocate priorities within a budget. Clause 12 will strengthen practice teams by clarifying and extending the scope for reimbursing the training costs of staff. For example, subject to the passage of the Bill, we intend to arrange for general practitioners to be reimbursed for the training costs of practice nurses and for financial recognition to be given to those general practitioners who provide clinical training for undergraduate medical students. Both changes, which have been widely welcomed by the profession, would help to improve the quality of primary care.
§ Mr. Dafydd Wigley (Caernarfon)
Welcome though it may be that physiotherapy, chiropody and other GP services will be extended, how will the Government ensure that minimum standards are retained and that we do not have a patchwork of standards which vary considerably from area to area, withour any guarantee being imposed on the GP services?
§ Mr. Newton
That is precisely why we think it right to move to the allocation of budgets to family practitioner committees and health boards, so that they can have a say in determining the priorities for expenditure in those areas and seek to achieve a better spread and balance of services than we have at the moment. This is something that sometimes affects rural areas, which may be what the hon. Member for Caernarfon (Mr. Wigley) has in mind. More often it affects inner cities and deprived areas, which have been the more common focus of attention.
The more flexible approach reflected in those clauses also affects clause 13, which provides for financial assistance for practice premises through improvement guarantees or under the cost rent scheme to be controlled locally under a cash-limited system. This picks up the hon. Gentleman's point; it enables locally set priorities to be determined and makes it easier to direct funds to the areas where they are needed most. Quite apart from practice team support, it is often the case that the premises of family doctors are at their worst in the inner city and other deprived areas, and we wish to direct extra resources to their improvement.
Family doctors can also be helped to buy surgery premises by obtaining Government-guaranteed loans from the General Practice Finance Corporation. The White Paper announced our intention to seek powers to change the constitution of the GPFC to allow maximum use of private sector funds. We propose that the corporation should become a statutory company under the Companies Act and a trust should be set up to represent the medical profession on the board of the new corporation. The exact shape of the new arrangements will depend on discussions with the corporation and with the general medical services committee of the British Medical Association, as well as with potential investors. Clauses 1 to 3 would provide powers to enable such changes to take place. They would provide also for the GPFC to have greater access to private sector funds in the period before reconstruction.
I have referred to premises in inner cities and to support for general practitioners in those areas. A striking feature of the inner cities is that they have an above average number of elderly doctors—some of them are very elderly— who too often practise on their own.
The responsibilities of family doctors are extremely exacting and we would expect them to become more exacting following the implementation of the proposals that I have outlined. We have come to the conclusion that it is not reasonable to expect doctors to continue to work beyond the age at which they can carry out their responsibilities properly under NHS contracts.
Clauses 5 and 6 are intended to change the present system. They would give powers to introduce a compulsory retirement age for general practitioners and would end the so-called 24-hours retirement, whereby doctors over the age of 65 years can retire, draw their pension and return to practice a day later without any reduction in either pay or pension. Our proposals were widely supported in consultation and by the Select Committee on Social Services. We would expect and hope that the places of retiring doctors would be taken by younger, vocationally trained doctors who are genuinely keen to work in group practices and as members of primary care teams. That we see as contributing to the improvement in the standard services that we wish to see.
§ Mr. Tam Dalyell (Linlithgow)
Dentists often own their own businesses, which means that compensation would have to be paid. Any rapid decision to make dentists sell would depress prices, and perhaps mean they would be treated unfairly.
§ Mr. Newton
The hon. Gentleman has raised a fair point. If he reads the White Paper he will see that it contains passages on compensation for goodwill. That is something that we have in mind and it will be considered in our negotiations with the professions.
I have referred to the £170 million overall that we expect our proposals in respect of dental charges and eyesight tests to contribute to the £600 million-plus of additional expenditure on primary care services that we expect over the next three years.
I shall turn directly to the issue of dental charges and to clause 8, which is concerned with them, because I know that this is a matter of some concern to the House. The House will know that we propose to move to a proportionate charge for dental treatment and to extend that system to dental examinations that are now free. Existing powers already permit proportionate charging for routine dental treatment. Clause 8 is required to enable such charging to cover dentures and bridges and to permit charges for dental examinations. It follows that we intend to move to the new arrangements in stages.
Under existing provisions, regulations will be brought before the House at the appropriate time to provide for proportionate charges from 1 April 1988. The regulations will also specify fixed charges for dentures and bridges at or about the same percentage of cost. Bearing in mind that the current average of the proportion of treatment charges that is met by the patient is 65 per cent. and that there has been no increase in dental charges since 1985—in other words, by next April they will have been unchanged for three years—we expect to set the figure at 75 per cent. At the same time, the maximum charge—I know that the British Dental Association has been concerned about this—will be increased from £115 to £150.
Subject to the passage of the Bill, we would at a later stage move the charges on bridges and dentures to the same fully proportionate system for routine treatment and introduce the proportionate charge for the dental examination. The House will be aware that the principle of moving to proportionate charges for treatment has been widely welcomed and pressed for by the profession. In saying that, I intend only to associate it with the principle, not with a particular rate.
I think that it is generally acknowledged that the present system is difficult for the public to understand, difficult for the profession to administer and difficult for anyone to defend as fair. For example, the present charges for dentures, bridges and crowns vary from 25 per cent. to 93 per cent. of the cost. The cost of routine treatment ranges from 100 per cent. to less than 50 per cent.
I wish to emphasise the need to consider our proposals as a whole. The move to proportional charges will reduce substantially the costs of much routine treatment. For example, on current figures a 75 per cent. charge would cut the cost of a clean, polish and two small fillings from £14.20 to £10.65. I acknowledge readily that that saving will be offset by the proposed 75 per cent. examination charge, which on current figures would be £2.93. Even after allowing for that, the cost of examination and treatment in the case that I have mentioned would be 35 £13.57 compared with £14.20 for the treatment alone on the basis of current charges. We estimate that some 2 million courses of treatment, including the proposed examination charge, will cost less than they do currently. The charges for extensive and more expensive treatment will generally be higher, and the net result of that will be, in our view, to set the signals much more clearly in favour of those who attend a dentist regularly and take proper care of their teeth.
§ Sir Barney Hayhoe (Brentford and Isleworth)
My hon. Friend has talked about regarding the Government's proposals in the round. Does he recognise that some of us who are generally very supportive of the main provisions in the Bill, and who will be voting for the Bill's Second Reading this evening, are sharply opposed to charges for sight tests and dental examinations? We are extremely concerned also about the mounting and increasing difficulties that are facing many hospitals and district health authorities, which have been spotlighted by the important statement of the three royal colleges which has been reported today. Does my hon. Friend recognise that clause 4, which refers to giving greater freedom to district health authorities in raising income, is superficial and peripheral to the fundamental and central problems that have been highlighted by the presidents of the royal colleges, which demand the urgent attention of DHSS Ministers and my right hon. Friends the Chancellor of the Exchequer and the Prime Minister? That should be the message from this House.
§ Mr. Newton
My right hon. Friend has referred to the proposals in clause 4, with which I shall deal later in my speech, and generally to the proposals which I have been outlining, which are perhaps not related directly to hospital and community health services, and described them as peripheral. It is clear to anyone who examines the pressures on the Health Service that it would be wrong to ignore or dismiss any reasonable source of enhancement of the resources that we can put into health care as a whole. That is what I have had in mind—I hope that this will be the view of the House generally—in judging these proposals. We all know that the potential for spending on health is literally infinite. Therefore, we all have a duty to consider every legitimate way of garnering resources to spend on health services.
§ Mr. Peter Fry (Wellingborough)
My hon. Friend has referred to those who are able to pay. Will he accept that there are many pensioners whose income is slightly above the supplementary benefit level who will find it extremely difficult to meet the new charges that are embodied in the Bill? Will he undertake to examine the present exemptions from charges and give consideration to whether they could be widened to take account of the difficulties that will be faced by those on very modest incomes?
§ Mr. Newton
I note what my hon. Friend says. I was about to emphasise that all existing exemptions — I know that this does not meet his point directly—from treatment charges will extend to examination charges. In other words, neither will be paid by children, students, those on low incomes, including the elderly, expecting and nursing mothers, and certain other groups. We are talking primarily about those on supplementary benefit or income support.
36 I recognise the reasons why my hon. Friend has introduced that point. Let me say, in general terms, that the objective of the Government's policy in relation to those over retirement age—which is clearly reflected in the measures that my hon. Friends concerned with social security have been introducing and carrying through in recent months and years — is to build on what has already notably occurred in recent decades: a steady improvement in the general standard of living of those over retirement age, not least with the development of occupational pensions.
I believe that the proper strategy of Government policy — and it is the strategy of our policy — should be to continue to build up the capacity of people in retirement to make choices and decisions for themselves, and thus enhance their independence. It follows from that that when public resources are to be applied by way of exemptions or special concessions, it is right to focus them on those who have not the advantages of, for example, the development of occupational pensions, and are — by definition—too late to benefit from what we are now seeking to do. That, I believe, is the right approach in this and other matters.
§ Mr. Robert McCrindle (Brentwood and Ongar)
While I accept what my hon. Friend has been saying about the desirability of encouraging those who are able to contribute to do so, will he take on board that many of us who will be voting for the Bill's Second Reading this evening for that very reason nevertheless feel strongly that, if it is impossible for the individual to make a contribution towards health care and only the Government remain capable of providing adequate resources, we should look to them progressively to do so in the weeks and months ahead? Many Conservative Members would be forced at this point to endorse the call by the presidents of the royal colleges this morning.
§ Mr. Newton
Let me say for the third time that I note what my hon. Friend has said, and ask him to note what I said to my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) a few minutes ago. I also ask him to recognise that it is too simple by half to associate all the pressures faced by the expanding Health Service solely with demand for additional financial resources.
I thought that one of the weaknesses of the statement issued by the presidents of the royal colleges last night was that it contained little or no serious discussion of the complex causes of some of the difficulties, including, for example, the nursing shortages which have been acknowledged recently in the Birmingham area —[Interruption.] The hon. Member for Derby, South (Mrs. Beckett) says that that has to do with money. But the cardiac clinicians who wrote to my right hon. Friend the Prime Minister at the beginning of last week, in a letter that gained some publicity in the press, made it clear that they felt that they could afford to pay intensive care nurses more within their existing budgets. They did not suggest that it was an overall resource problem; they suggested that it was a question of the structure of pay. We are tackling that through the so-called clinical grading review, on which I hope negotiations are nearly completed. That will give us a basis, through the subsequent recommendations of the review body, to tackle the problem in the way in which it needs to be tackled—in relation to the pay and grading of nurses.
§ Mr. Jerry Hayes (Harlow)
My hon. Friend is absolutely right to say that we must examine the restructuring of nurses' pay. However, let no one be deceived into thinking that it is just because of pay that 30,000 nurses are leaving the profession. They are leaving because they are demoralised.
§ Mr. Newton
My hon. Friend is oversimplifying matters in the same way as the statement by the presidents of the royal colleges. As was made clear in the debate in the House the week before last, no one suggests that there are not problems and pressures in the Health Service—as there have always been—over meeting demand. I do not try to dismiss those problems, any more than I did in that debate, or during the past few minutes. I ask in return only that my hon. Friend accepts that they are complex problems, which are often reduced to excessive simplicities by some of the statements that are put out.
Clause 7 of the Bill broadens the scope of the community dental service, and gives health authorities discretion to redirect the service's resources away from the routine treatment of children—who can be, and for the most part are, looked after in the general dental service —and towards providing health education for children in schools. We are also looking for new contractual arrangements, such as a continuing care, contract and capitation, which — subject to negotiations with the profession—will enable general dental practitioners to devote more time and resources to preventive work with their child patients.
I am bearing in mind, Mr. Deputy Speaker, the injunction from Mr. Speaker about brevity. In conjunction with the profession, we shall be launching a dental health testing campaign to promote dental awareness and regular attendance. The campaign will be directed in particular at young people in inner-city areas, where the standards of dental health are still some way behind those in the rest of the country. We shall also be taking a step designed to enhance the quality of treatment—one step among many, but a legislative step. Clause 9 provides increased powers for the Dental Estimates Board to survey and research norms and standards of treatment, and to deal with dentists whose work appears to be at variance with those standards. The White Paper also referred to our intention to consult the profession about a new counseling and monitoring service of dental practice advisers, which we hope will contribute to the improvement of services.
§ Mr. Dalyell
Why does the Minister think that the British Dental Association has circulated among many of us a powerful memorandum opposing examination charges for adults? Does he agree that charges will mean that people will go to the dentist less regularly, and that, ultimately, the expense will mount?
§ Mr. Newton
I do not find it surprising that the British Dental Association has circulated such a document. However, I disagree with its assessment of the effect of the proposals, especially against the background that I emphasised, possibly at excessive length. The net result is likely to be the provision of significant ranges of treatment — even with the examination charge — at lower costs than are now incurred; and, therefore, greater incentives for people to visit the dentist regularly while they still need modest treatment, rather than leaving huge problems to build up.
38 Clauses 10 and 11 relate to the general ophthalmic services. The first confines free National Health Service sight tests to groups which we have specified: children, those on low incomes, young people in full-time education and those who are registered blind or partially sighted. Those groups account for an estimated 30 per cent. — nearly one-third — of such tests. For the remainder, however, free NHS sight tests will cease to be available.
I should make it clear that there is no question of the Government setting or imposing a particular charge. The figure of £10, which has been quoted fairly widely, is simply the amount that we currently pay for such a test by an ophthalmic optician. For a test by an ophthalmic medical practitioner, it is rather less—just over £6, In the light of experience—following the end of free NHS glasses—with vouchers being provided for the priority groups whom I have mentioned— we can sensibly expect that the extension of competition, which has both reduced prices and notably increased consumer choice for spectacles, will restrain charges. Given that even those who already need glasses visit the optician only once every two or three years, I see no reason to suppose that people will be deterred in the way that has been suggested.
§ Mr. Robin Cook (Livingston)
Let me remind the Minister that when the House last discussed the matter the previous Secretary of State for Health and Social Services, the right hon. Member for Sutton Coldfield (Mr. Fowler), said:we also believe that the access to a free sight test is important in detecting serious eye disease." —[Official Report, 20 December 1983; Vol. 51, c. 295.]What medical advice—I stress the word "medical"—has the Minister received that has encouraged the Government to change their view, and no longer to believe that that is important?
§ Mr. Newton
I shall comment on screening in a few moments. However, I must point out to the hon. Gentleman that we have been seeking to expand and develop our health services as a whole and that we have placed great emphasis on the primary care services. We have rightly kept that policy under review. We launched the primary care consultation, and we have now published the primary care White Paper and this Bill. We have come firmly to the conclusion that we wish to undertake further development of these services in the interests of the general promotion of good health and the prevention of ill health. In the context of furthering and continuing that development, we have thought it legitimate to bring this proposal before the House. It will contribute to the resources that we need to carry out the other developments that we believe are worth while. I make no apology for the fact that we have done that.
§ Mr. Newton
I repeat that I shall say something about screening in a few moments.
Clause 11 safeguards competition, which has had a significant effect by reducing the price of spectacles and increasing choice. We believe that that will restrain the cost of sight tests. We propose to safeguard competition by requiring the optician after a sight test to give the patient a prescription, if glasses are needed, so that he or she can shop around for glasses, as can be done now.
I am aware—the hon. Member for Livingston (Mr. Cook) echoed this point in his interventions — that 39 suggestions have been made that our proposed changes will diminish the role that is played by sight tests in screening for other conditions. The extent to which that argument stands up at all depends on expecting people to be deterred from seeking eye tests. There is no reason to expect that to happen. Sight tests will continue to be conducted at least to the same standards, although opticians may decide in practice—partly because of the competitive pressures to which I have referred—to offer a wider range of tests than is available under the National Health Service. It is a professional requirement of the General Optical Council that the optician should refer a patient to a doctor if he detects glaucoma or diabetic retinopathy. That arrangement — clearly on medical advice—will continue.
§ Dame Jill Knight (Birmingham, Edgbaston)
If opticians are to be encouraged to conduct different types of tests, with some being not quite so thorough as others, who will be responsible if, during a less than thorough test, early signs of diabetes are missed? Will the optician be responsible, although he has been encouraged by the Government to carry out a less than thorough test on his patient, or will the Government be responsible?
§ Mr. Newton
I think that I shall carry my hon. Friend, who knows a great deal about these matters, with me if I acknowledge that the extent of the tests that are carried out by opticians already varies from one practice to another. If it is felt that further steps should be taken either to tighten up the procedures or to impose precisely what should be done, that could be considered. I do not dismiss my hon. Friend's point, but I am uneasy about the apparent willingness to rely for the screening of some conditions, in particular diabetes, on the chance that people go to their optician. Our proposals for general practitioners are designed to encourage, particularly in relation to the very young and the elderly, the systematic overall health screening of those who are most likely to be at risk. It is worth considering whether that is a better and a more sensible approach to these problems than to rely on people going to their optician.
§ Mr. Richard Holt (Langbaurgh)
Will my hon. Friend accept that I have a typical diabetic condition that was found when I went for an eye test? I am not elderly and I am not a child. In those circumstances, would I have had the benefit of a sliding scale option? How much would the minimum charge have been and would the optician have given me that option at the beginning or at the end of the diagnosis?
§ Mr. Newton
I am not, I am afraid, absolutely sure that I have understood the last part of my hon. Friend's question. The charge will depend on what the optician decides to charge. My view is that the pressures of competition, which have significantly reduced the price of spectacles, will similarly restrain, and possibly entirely eliminate, the charges for eyesight testing. However, that is for opticians to decide within a much freer market than exists now. I believe that it will have the same beneficial effect as the move to vouchers has unquestionably had.
§ Mr. Newton
I have already emphasised that there is no question of the Government setting or prescribing particular charges. We shall continue to discuss with the profession the arrangements for reimbursing opticians for eyesight tests that remain free NHS eyesight tests —according to current figures, about 30 per cent. Where there is no question of a free NHS eyesight test —roughly the other 70 per cent. — it will be for the optician to decide how much he wants to charge. I make no secret of the fact that my guess is that in many cases the charge will be rather less than the amount that is paid to opticians for carrying out those tests now. Indeed, it would be very surprising if that were not the case.
§ Mr. Robin Maxwell-Hyslop (Tiverton)
My hon. Friend says that he does not expect people to be deterred by charges for what was previously free. Since that is contrary to what any person would expect the consequence to be, on what objective evidence are his expectations, which seem to be so improbable to common reason, based?
§ Mr. Newton
My hon. Friend will accept that it can only be a matter of judgment, in the light of the experience that we already have of the abolition of free NHS glasses and the introduction of the voucher scheme. We were told that large numbers of people would be frightened and would not have spectacles. I know of no evidence that that has occurred. We were also told that opticians would never be able to provide spectacles that were as good as or better than the old NHS ones at the sort of price that the voucher values represent. One only has to visit one of the attractive spectacle stores that have now been set up to find that such establishments are offering a significantly wider range of much more attractive spectacles that come within the voucher values. I accept that it is a matter of judgment, and I hestitate to quarrel with my hon. Friend's judgment, but in this case my judgment differs from his.
§ Sir Peter Hordern (Horsham)
Is it not possible that the charges are most unlikely to be as much as £10 a visit, and is it not possible that more people will be encouraged to visit their optician? As for the complaints by the principals of the royal colleges, is it not a fact that there are now twice as many nurses and doctors as there were 20 years ago, when these eminent people first started in practice, and that if only they had run their hospitals better and achieved better savings, and if there were not so many hospitals, the Health Service would be a great deal better off?
§ Mr. Newton
I am not sure that I can vouch for my hon. Friend's statistics. Mine usually go back to 1979 for reasons about which the House will speculate. However, I confirm my hon. Friend's view. One need only consider the different periods of day surgery care from health authority to health authority, and, indeed, from hospital to hospital, the differing periods of time that patients spend in hospital following certain procedures or the relative costs of different hospitals and different clinicians to know that there is a good deal of room for improvement among all who are connected with the Health Service. I hope that doctors will reflect on that.
In addition to the contributions to the general improvement in health care services, especially screening 41 and preventive services, with which we expect the resources released by the changes to assist, I should emphasise that the changes will enable us to extend other important services related to eye care. We propose to extend the voucher scheme to help adults who frequently break their glasses because of physical or mental disability. Negotiations will shortly begin with the profession about widening the National Health services to enable practitioners to provide a sight testing service to the housebound. I know that many people who are concerned with community care attach great importance to that point, which will be of real assistance to many elderly people. In addition, the value of vouchers that are available to those who require complex and expensive lenses will be given special consideration to ensure that that group of patients is not placed at a disadvantage.
I have already taken quite some time from the House and shall cover the remaining clauses briefly so that, at least, I shall have given the House some idea of what they contain. Some are principally technical measures to tie up loose ends that arise from earlier uncertainties.
Clause 14 anticipates the integration of the artificial limb and appliance services into the National Health Service in 1991. That has the effect of maintaining continunity of employment to civil servants who choose to transfer to the National Health Service.
Clause 17 confirms the legal basis of fees for licences that are issued under the Medicines Act 1971.
Clause 16 fills the gap in the limited powers of the Secretary of State to make grants for the training of local authorities' social services staff in England and Wales. That may sound a small point, but one aim is to enable us, at some appropriate moment, to put resources into improving the training of staff concerned with child abuse, for which we think we currently have inadequate powers.
Clause 15 removes the power of local authorities to charge health authorities for the services of social work staff. When the National Health Service was reorganised in 1974, local authorities were made responsible for employing social workers and health authorities for employing doctors and nurses. Resources were transferred centrally at that time from the health budget to local government grant arrangements to reflect that change of responsibility. There is no justification for retaining the anomalous powers for local authorities to make the charges. Subject to passage of the Bill, we intend that that should take effect at midnight on the day of publication, 26 November.
I return, as I said I would, to the issue of income generation by health authorities. The Bill is intended to assist health authorities in creating new opportunities to generate additional resources and, not least in connection with the points made during the past half hour by my hon. Friends on the Back Benches, to improve health care. The Bill gives health authorities new powers to supplement their resources by making, for example, better use of their facilities. They will be able to take greater advantage of opportunities to lease space to commercial outlets, such as shops or hairdressers. If they wish, they could sell advertising space in the hospital or at other premises. They will he able to consider providing completely new facilities such as health clubs, for which they can, quite sensibly and properly, make charges.
Several authorities have already made a modest start, for example, by charging taxi companies for the installation in hospitals of free taxi-phones for use by 42 patients and visitors, or by recovering and selling the silver from used X-rays. The Bill is designed to enhance such opportunities and to make it clear, in the statute, that such activities can only be undertaken provided that they do not interfere, in any way, with the main duty, which is to provide services to patients under the National Health Service.
§ Mr. Holt
I am grateful to my hon. Friend for giving way. If an entrepreneurial health authority holds bazaars and all sorts of events and raises a lot of money in the next year, will it suffer a deflation of its allocation by the regional health authority or will it be allowed to keep that money, in addition?
§ Mr. Newton
I intend to make it clear to regional health authorities, without attempting to dictate every detail of their allocation policy, that I expect them to ensure that district health authorities are not put in a position in which it does not seem worthwhile to engage in entrepreneurial activities because they fear that they will not gain or benefit from them.
§ Mr. Newton
Yes, but this may have to be the last time that I do so because otherwise many hon. Members will be unable to speak.
§ Mr. Galbraith
The Minister said that those other functions must not interfere with patients and subsection (5)(a) of clause 4 state that they should not,to a significant extent, interfere with the performance".Will he tell us how he will ensure that they do not interfere with performance?
§ Mr. Newton
The sort of schemes that we would be prepared to countenance will be a matter for monitoring by the Department and by regions. We intend to set up a central unit to distribute the information and to assist health authorities in such matters. I re-emphasise, because I do not want this to be misunderstood, that there is no intention of permitting activities that could be seen as detracting from the services provided under the Health Service to those to whom the health authorities have a responsibility. The purpose is to gain additional resources for the continued improvement of the National Health Service.
The clause gives health authorities much greater freedom as to the way in which they set charges for private patients. Currently, authorities can only recover through charges the costs of the services provided for private patients. We intend that in future they should be able to set charges according to the prevailing market conditions. That should enable authorities to increase their income from such services.
Partly because I have given way so much, I have taken rather longer than I would have wished and shall conclude briefly. In many important respects, the Bill paves the way for the implementation of significant improvements in primary health care in this country, for increasing consumer choice and improving the quality and quantity of services overall. It also provides those new powers that will make a useful contribution to the further development of hospital and community health services. In that sense, 43 it will be a significant and useful step forwared in the continued development of policy for improving the Health Service in this country and, therefore, I commend it to the House.
§ Mr. Robin Cook (Livingston)
Under this Government, the straightest way to the heart of any Bill is to turn to the financial memorandum. From the financial memorandum we learn that there will be no significant effect on public sector manpower, but that there will be significant net savings on public expenditure. I congratulate the Minister on his nerves of steel. Against a background of financial crisis in the Health Service, it takes a thick-skinned and impervious Government to come to the House of Commons to ask it to pass a Bill that will further reduce Government spending on the National Health Service.
I saw the contrast between the needs of the Health Service and the priorities of the Government graphically illustrated yesterday on the front page of my Sunday newspaper. Side by side with the report of the death of baby Barber there was a report that the Chancellor of the Exchequer was considering a 2p cut in the basic rate of income tax next March, plus a cut of 10p in the income tax of top people. Apparently that is because of what is described as the "prosperous" state of Treasury revenues and the "negligible" need for public borrowing next year.
It costs £3 billion to reduce income tax by 2p, leaving aside the extra gilt for the top-rate payers. One third, or even one sixth, of that sum would transform the situation in British hospitals. If the Chancellor of the Exchequer has such money to spare, it is the duty of the Minister for Health to get it for the National Health Service. It is a function of Government to make a judgment between competing priorities for resources. However, only a Government who have abandoned all pretence of measuring social need could persuade themselves this winter that tax cuts should take priority over spending on the National Health Service.
The point was expressed yesterday succinctly by Philip Barber, who was interrupted at a marathon, sponsored game of pool to be told of his son's death, when he observed:There is something wrong in a society which needs me to play pool so that babies can have operations to save their livesYet the Bill confirms that even the Ministers responsible for the nation's health have agreed to share the priority of cutting spending rather than meeting need.
§ Mr. Hayes
I am sure that the hon. Gentleman would not wish to mislead the House in any way. When he talked about the financial and manpower effects he talked about significant net savings, but he did not go on to say that that was because the General Practice Finance Corporation will be a limited company and will not be counted in the public sector borrowing requirement. I am sure that he would like to explain that.
§ Mr. Cook
The hon. Gentleman refers to clauses 1 to 3, to which I shall refer in a moment. If he re-reads the passage that talks of significant net savings in public expenditure, he will recognise that it refers to clauses 1 to 13, which go well beyond clauses 1 to 3.
Clause 13 is likely to be the most profound measure, because for the first time it extends cash limits to the family 44 practitioner service. I noticed that the Minister said that that would be a more flexible system than the present one. We are surrounded by abundant evidence of what this flexible system of cash limits has done to our hospital service. The rest of the nation is appalled at the consequences of this flexible system on the hospital service, yet apparently the Government are so pleased with the results that they propose to extend the system to general practitioners. Clauses I to 3 promise considerable savings to the public sector borrowing requirement, never mind that The Observer tells us that the PSBR is also negligible. Apparently it is the first duty of the Minister for Health to find still more savings to make it even more negligible.
The savings arise from a proposal to privatise, not the family practitioner committees— the Government have not yet reached that stage — but the General Practice Finance Corporation. It was set up because GPs had difficulty in obtaining commercial loans to purchase property in areas of poverty and under-privilege; in other words, in areas where the banks were reluctant to lend. That remains the distinctive contribution of the GPFC. It is astonishing that in a package that we are told is designed to improve primary health care the Government should wash their hands of the major provider of funds for premises in inner cities, where there is the greatest need to obtain more premises and to modernise existing ones.
The Government considered privatising the GPFC in 1984 and rejected the idea. The Minister's predecessor came to the Dispatch Box on Report on the Health and Social Security Bill and positively preened himself on keeping the corporation in the public sector. He said:It shows what a flexible and non-ideological Government we are."—[Official Report, 2 May 1984; Vol 59, c. 366.]By the same token, we can only conclude from today's measure that we are faced with an inflexible and ideological Government. The savings from this bit of ideology are small beer, because the Government have already so reduced the borrowing limits of the corporation that it is allowed to spend only £10 million to £12 million a year. The Government will now receive 15 times that sum in increased income from the proposals on new charges for teeth and eyes.
I shall flag an anxiety raised by several members of the BMA about the breadth of clause 8. Mysteriously, reference to dentists and dental charges vanishes in subsection (2). When the Minister replies, will she clarify the scope of clause 8 and confirm that she is not giving herself powers to introduce by regulation charges on the services of general pracitioners? I shall wait in expectation of her reply when she is briefed.
What we know about the clause is bad enough. It provides for a new charge on having one's teeth examined. Since 1948 teeth have been examined free under the NHS as a matter of principle. The Government propose to raise £50 million by abandoning that free examination. One is bound to observe that they sell their principles cheaply—
§ Mr. Nicholas Bennett (Pembroke)
As the Labour Government did in 1951 with the introduction of prescription and dental charges.
§ Mr. Cook
With the greatest respect, no previous Government, of whatever colour, have introduced a charge for the examination of teeth. Nowhere are we favoured with an explanation of how it will help to prevent 45 dental disease by deterring patients from going for a regular check-up, and deter them it will. I assert that with confidence because, thanks to the Government, we have experience of what happens when dental charges are hoicked up. In April 1985 the Government increased dental charges by 25 per cent. Over the subsequent year the number of fillings fell by 5 million, the treatment of gum disease fell by I million and root treatments fell by more than 100,000. By contrast, the number of patients opting for the cheaper treatment of extraction increased by 5 per cent.
§ Mr. Cook
I shall happily give way when I have finished this point.
It need not surprise Conservative Members that increasing charges has that effect on demand. After all, they, more than anybody else, have put their faith in the market mechanism, and they should be gratified to learn that that faith is justified when patients respond to the pricing signal by staying away from surgeries or opting for the cheaper option of extraction.
§ Mr. Cook
I cannot answer that, but I can say what happened at the local elections, because I was canvassing on the night when that was announced. I can assure the hon. Gentleman that several colleagues and I resisted that charge when it came before the House, and if we had had the support of his colleagues we would have defeated it.
Many will undoubtedly now stay away when they receive the reminder for a six-monthly examination. It is worth remembering that that examination has importance in health care well beyond sound teeth; the dental examination can reveal other medical conditions. To take one topical disease, it is likely that some AIDS carriers will first be detected through thrush of the gums when they present themselves to a dentist. It is important not only for them, but for the rest of the community, that they are not inhibited front obtaining early diagnosis of that condition.
There is also the wider issue of the structure of the charges. The Minister prided himself on the fact that some people will pay less under his new charges, and that may be so. I am prepared to concede that some people may have a smaller bill, but the Minister cannot stand at the Dispatch Box and pretend that that is some sort of general rule. After all, we know that he is budgeting to expect £85 million more in charges from those who visit the dentist, so, demonstrably, most will pay more. In particular, the 100,000 who at present bump against the ceiling of £115 on charges will now bump against the ceiling of £150 per charge.
The Minister said that the charge would be proportional to the cost, but no such proportion is set out in clause 8. On the contrary, clause 8 is drafted in alarming terms which would allow the Minister to recover the whole cost of the charge. I suppose that 100 per cent. may be passed off as a proportion of a sort, but it is hardly what most people understand by the use of the term. Clause 8 gives the Government the power to abolish by order all public support of NHS dental treatment. It puts the dental 46 service on the slipway to an entirely private marketed service, and if anyone concludes that that is fanciful, I would ask who would have thought eight years ago that that is precisely where the NHS optical service would now be?
That brings me to the key proposal in the Government's preventive approach to eye care, which is to introduce charges for eye tests. The Minister said that it would not necessarily cost a tenner. A tenner happens to be approximately what optometrists are paid—£9.30 to be precise. Anything less than that would leave them out of pocket. The Government may argue, as the Minister argued, that they could opt for a lower income and therefore suffer a lower charge
The Minister referred to the market. Markets seek equilibrium when supply and demand are in balance. I should not have to point that out to such a disciple of the Prime Minister's economic philosophy. It would be a curious market which found it equilibrium at the point at which all demand was met. By definition, if the Minister is leaving it to the market to settle the charge, some demand will not be met because it cannot meet the charge. There was no hint in the consultation document of that proposal. There was not a breath of it in the Conservative party manifesto—a point of some relevance.
Mr. Ian Hunter, the general secretary of the Association of Optical Practitioners, told Conservative Back Benchers that most of them had voted for the Government. No doubt optometrists are men of strong political convictions who would have done so anyway, but it is a pity that the Conservative party did not trust them enough to tell them in advance what they were voting for.
The majority of optometrists' clients are pensioners, and pensioners need the eye test most, and they need it most often. Six million pensioners will not qualify for a free eye test. Many of them simply will not go, or will not go as often as they should. They may save a tenner, or perhaps a fiver if the market system operates, but they may also lose their eye sight. The eye sight test is a misnomer. Optometrists offer a full examination of the back of the eye, and they require specialist training and special equipment. They can detect serious health risks such as diabetes and hypertension.
My hon. Friend the Member for Aberdeen, South (Mr. Doran) was in contact with me over the weekend, following a visit from a constituent who visited an optometrist about three months ago. The optometrist examined the back of her eye and immediately arranged for her to see an eye specialist, who referred her to a neurosurgeon. Within a week of her examination, she was operated on for a brain tumour and was advised by the neurosurgeon that had she waited for another two weeks it is likely that she would have lost the use of her legs permanently. In that case a very serious medical condition was revealed by the eye test. I must add that the constituent in question was quite frank in saying that, on her wages as a cook, she would not have gone for that test if she had had to pay a tenner.
The damage that will arise from the introduction of charges is perhaps best illustrated in the case of glaucoma. Three out of four cases of glaucoma are detected by the eye test. I cannot do better than read the observations of the International Glaucoma Association, which says that itcan only conclude that either the Government have not been well advised; or that they have deliberately decided to brush 47 aside as of no consequence the certain increase in the number of people with glaucoma who will not be discovered until the disease is well advanced.I listened with interest to the interventions of the right hon. Member for Brentford and Isleworth (Sir B. Hayhoe) and of the hon. Member for Brentwood and Ongar (Mr. McCrindle) who are no longer in the Chamber. It would have been nice if they had stayed and participated in the rest of the debate, as they feel so strongly. They said that, although they would vote for the Bill, the Minister could not expect them to support the measure.
I have to tell those hon. Members that the Minister made a very interesting statement of particular relevance to Conservative Back Benchers who claim to disagree with his proposal. The Minister said that he believed that adults with means of their own should make up their own minds and make choices for themselves. I believe that that is precisely what those Conservative Back Benchers who are unhappy with the proposal must now do. It will not do for them to stand up in the House and say that they disagree with the Bill and then go into the Lobby and vote for it.
Clause 4 gives expression to the Government's latest fad, which they have termed income generation, and provides a new place in district management teams for a marketing director whose role will not be meeting health needs, but that of finding the sponsor who will pay most to get his name on nurses' uniforms — the Adidas solution to Health Service funding. It is not an optional course, which is being offered to managers as light relief from the stress of being unable to meet health needs. Clause 4 authorises the Secretary of State to direct health authorities to market their services. For good measure, it adds that it is their duty to comply with such directions.
The hon. Member for Langbaurgh (Mr. Holt) made a penetrating intervention, if I may say that without prejudicing his career, when he asked whether the Minister would allow health authorities to keep the fruits of their marketing. He received a particularly Delphic response. I have in front of me the words that the Minister used when he was asked an identical question at a press conference last week. His words on that occasion were slightly less Delphic. He said:Inescapably, we have to look at the totality of resources available from all sources.The hon. Gentleman feared that that meant that the Minister would deduct from the allocation to health authorities the revenue that they had raised from marketing. I have to warn the hon. Gentleman that it will be worse than that. After the Minister has taken his powers to direct health authorities to market the services, and after he has taken the power to oblige them to comply with those directions, he will assume that they are obtaining income from marketing the services, whether or not they are securing that income. It is a fraud on the House and on the nation to pretend that extra revenue will be available for patient care.
Let me make it clear where the Opposition stand on that matter. We believe that the test that has to be applied to marketing services is whether they will improve the service to the patient. If a spot of franchising provides greater variety in the cafeterias, that is well and good. If those cafeterias are run on the principle of a healthy diet, that is even better, although that rules out 90 per cent. of the fast food chains in Britain.
§ Mr. Cook
In the House of Commons, too. What is wholly dishonest is to pretend that clause 4 will unlock a chest of gold that will plug the yawning gap in hospital finance.
Last week the Minister objected to my description of this as tuck shop economics. Ken Grant, the manager of the City and Hackney health authority, who has done more than anyone else to generate income, expressed it in more blunt language than I dare use. He said:In terms of what the NHS needs, the money we are raising is peanuts. It's just that at the moment peanuts are bloody usefulAfter three years the peanuts will amount to £70 million in a full year. To put that in perspective, it is less than half the £168 million by which the Government have underfunded nurses' pay in the past year alone. It is sheer effrontery for a Government who cheated the health authorities on that scale now to claim the credit for allowing them to raise half that money in the market. The basic reason why we are suspicious of clause 4 is that, eventually, the pressures on hospitals to make profit will make the patient pay. Nearly two thirds of clause 4 is about charging patients.
It might be salutary to recall at this point the crushing failure of the Government's previous intervention on charging patients, which encouraged hospitals to expand pay beds by one quarter over six years. Unfortunately for them, those six years turned out to be the same period in which the number of patients wanting pay beds fell by one third. The legacy of that colossal misreading of the market is a mountain of bad debt. Health authorities are writing off £500,000 in bad debt from private patients who slipped to the front of the queue into pay beds and failed to pay for them.
Despite that lesson of history, the Government now want to encourage health authorities to invest still more money in that loss leader. I have evidence of what the Minister has in mind. I understand that on Wednesday, or later in the week, at a press conference he intends to reveal a deal which the Government have struck with Bioplan Holdings to develop private day units in NHS hospitals. One of those is the Hope hospital in Salford, where Bioplan is to build a 12-bed new day centre unit. Another is the Churchill hospital in Oxford, where Bioplan is to equip an existing Health Service day surgery unit and provide 15 private beds. Those are the first two out of six such deals around the country. Each of them will have the capacity to carry out 10,000 operations.
That reflects the trend in America for fast in and out day surgery as the basis of private care—the "Kwik-Fit" approach to surgery. It breaks new ground in reducing health care to a market commodity. It will mean that NHS hospitals and private hospitals will occupy the same sites — in the case of the Churchill hospital, the same building. They will share common staff. It is not even clear whether consultants will operate in their own time or in the time paid for by the district health authority. They will share common laboratory staff—at any rate until such time as the Government privatise the laboratories.
The absurdity of the position is that the district health authorities will provide the sites, lend the staff, run the back-up services and must then pay Bioplan for the treatment of the patients. Of course, the deal has been stitched up behind closed doors, which is the very antithesis of market forces. There was no open tender here.
49 It is a flagrant case of favouritism — and what a favourite to have chosen. Bioplan shares its directors with the British subsidiary of the Hospital Corporation of America. The vice-president of that corporation has observed with engaging frankness:We try to maintain a low profile when we enter a country because we don't want it to appear that — here is a big American company to take over the health care system.With equal candour, two years ago the founder and controlling shareholder of Bioplan stated his health care philosophy at a Financial Times conference. He said:I don't apologise for being commercial—the bottom line to me means profit.How fitting that this Government should choose such a company as a partner. How perfectly that demonstrates where we are going with clause 4 and the joint priorities of that company and the Government.
Meanwhile, back in the state sector, every day we see more clearly the reality of the Government's commitment to the NHS. In Birmingham the reality of health care under the Government is a charity appeal for £500,000 to cover a corridor from the operating theatre so that ill babies need not be wheeled through the mud. In Leeds the reality is parents clubbing together to fund a registrar's post in a children's cancer ward.
At the weekend it was the turn of the royal colleges to issue an unprecedented joint statement. I have not been charged with the health portfolio for as long as the Minister has, but even if I had the years of experience that he has I hope that I would not presume to tell the presidents of the three senior royal colleges that they had not grasped the complexity of the issue. The three presidents said:In spite of the efforts of doctors, nurses and other hospital staff, patient care is deteriorating. Acute hospital services have almost reached breaking point.That statement is a damning indictment of the state of our hospitals this year. The statement demands a response from the Government that matches the magnitude of the crisis that it depicts. That response will require vision and clear-headed choices between priorities. It will require a readiness to square up to providing the resources to do the job adequately. Instead, the House is offered this tawdry Bill about putting petrol pumps in hospital forecourts and charging the elderly to have their eyes examined.
The measures are objectionable enough in themselves. The Bill that contains them is doubly objectionable because it is a pathetic and fatuous irrelevance to the real crisis in the Health Service. We will vote against it tonight with contempt.
§ Sir David Price (Eastleigh)
Following Mr. Speaker's injunction to make brief speeches, I hope that the hon. Member for Livingston (Mr. Cook) will forgive me if I do not immediately answer some of his important points, especially the latter ones. I hope to take up some of them during my brief contribution.
I am the only member of the former Select Committee on Social Services, which spent most of last year examining primary health care, who is present for this debate. I thank my hon. Friend the Minister for agreeing, at least in principle, with most of the recommendations in our report. It would be churlish of me not to extend similar thanks to the Goverment for their White Paper. It is 50 important for us to realise the commitment that they have made. In the preface to the White Paper, the four Secretaries of State say that we mustshift the emphasis in primary care from the treatment of illness to the promotion of health and the prevention of disease.To succeed, that shift will require extra resources. Illness will not just vanish because we decide to work for a healthier nation.
In the long term, if we place more emphasis on the prevention of illness and immunisation, it will be reasonable to expect a reduction in known ailments, with known causes where they are known to be preventable. Former killer diseases such as smallpox, scarlet fever, diphtheria and tuberculosis have been nearly, if not completely, eliminated through public health campaigns, immunisation and the development of antibiotics. Thus, there is an historical basis for the long-term hope that prevention will reduce the incidence of illness. But we have no chance of doing it quickly. Therefore, the extra activity that we hope will come into primary care as a result of the White Paper will require further resources. We know that resources are already under strain, and the hon. Member for Livingston drew our attention—if we needed it—to the statement from the presidents of the royal colleges.
What are the Government doing to provide extra resources? In his statement of 25 November, my hon. Friend the Minister for Health outlined the Government's commitment to putting more resources into primary health care. He reminded us that existing plans already provided for an additional £570 million in real terms by 1990–91. Today, he talked about £600 million. I do not know whether he was rounding up or whether we have got another £30 million out of him.
§ Mr. Newton
I started rounding down and said that we were committed to spending at least another £500 million. The programme of additional expenditure contained in the White Paper will take it from under £600 million to well over £600 million.
§ Sir David Price
My hon. Friend went on to say in his statement that the £570 millionwill be further increased by the substantial extra resources that the Government will make available to finance the improvements that I have described today." —[Official Report, 25 November 1987; Vol. 123, c. 260.]Paragraph 2.6 of the White Paper examines the Government's intentions and suggests that additional resources will be available. That puts a different light on the Government's proposals from what was said by the hon. Member for Livingston and by some of my hon. Friends. Will my hon. Friend the Under-Secretary of State who will reply to the debate spell out more precisely the Government's commitment to provide these extra resources? It is important for us all to know what that commitment is. I will carry the whole House with me when I say that to move forward in health promotion, the prevention of illness and immunisation—all the matters that were set out in the Select Committee report— we shall need extra resources. I believe that the Government are committed to making available those extra resources, but that message is not getting through to the public or to the House. Much of the debate so far has centred on the false idea that the Government are reducing resources.
§ Mr. Peter Thurnham (Bolton, North-East)
It seems a pity that that point has not got through to the 51 professionals. When the discussion document was put out for consultation, no suggestions were made about how the developments could be financed. The professionals were slow to come forward, but they were not slow to be entrepreneurial. My right hon. Friend the Secretary of State has said that the Health Service could consider other opportunities, but the professionals have not been slow to find other opportunities to boost their income. The Sunday Times said that consultants in the Bristol hospital were earning £60,000. Perhaps members of the profession will come forward with suggestions.
§ Sir David Price
My hon. Friend makes a useful intervention which goes rather wider than the scope of the Bill, but he takes me on to my next point. If, as a nation, we are to develop our health services as everybody wants, we must consider new methods of financing them. That takes up my hon. Friend's point.
We must not reject ideologically the use of charges, but we must ask what sort of charges should be made and whether they are acceptable medically. The hon. Member for Livingston made a very telling point. I could put the same point in the language of the Royal College of Nursing which said that we encourage free medical checks of all parts of our body by clinicians except our teeth and our eyes for which we will have to pay. This distinction requires a more detailed justification than we have had so far. I am not opposed to the concept of charges. It is an important matter and we must discuss which charges are relevant. No charge must be imposed which might reduce a citizen's access to services because he cannot afford them.
§ Mr. Galbraith
I do not agree with charges, but there are different types of services for which we can charge, for example, treatment, including prescription of spectacles, and screening. That is an important distinction. People would continue to take up preventive treatment, but they would not take up a screening test.
§ Sir David Price
I sympathise with the hon. Gentleman's point. Let me move from charging to my old hobby horse, which I do not apologise for raising again. We must aim at smaller lists for general practice. I have already quoted the Select Committee's recommendation on this matter and, with the indulgence of the House, I shall repeat it because it goes to the heart of improving the scope of primary health care. We said:With an ageing population, earlier patient discharge from hospital—particularly of children, increasing opportunities for diagnosis in general practice to reduce referrals to hospital, as well as greater responsibility for the management of chronic disease in general practice and a greater emphasis on a range of preventive services, the case for further reduction in the GP list size seems unanswerable.I believe that it is unanswerable. The measures necessary to implement the House's intention for better primary health care — the House supports the White Paper's intentions—must centre upon the reduction of list sizes.
If we wish to improve our primary health care, we must recognise that nurses should play a greater role than they have hitherto and that they are professionally competent to do so. I hope, therefore, that the House will agree with what we said in paragraph 60 of our report, which is clearly relevant to the Bill. We state:There must also be better training for nurses and a proper career structure, if they are to perform an extended role in the 52 community. Steps need to be taken to recognise and raise the status of nurses working in primary care. Practice nurses need training specifically directed towards work in the community.If the Government accept that view, why does clause 12 provide extra remuneration for training by doctors, but does not extend it to nurses? It would be an important improvement to the Bill if a clause to that effect were added.
In the same vein, why are the Government not taking advantage of the Billto permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage"?That was our recommendation 30 with which the Government agreed in principle. In their reply they said that they accepted the proposal, but that they would have to consult the professional standing advisory committees. It is nine months since we made that proposal and a good deal longer since Julia Cumberlege also proposed it. We must take advantage of the Bill because we do not have a Bill like this every year. Therefore, I hope that the Government will add a new clause to that effect.
There are many other matters with which I should like to deal. We issued a long report with 62 recommendations. I wish to put a few of our points in headline form because they are relevant to our debate. We must consider the role of other professionals in primary health care, particularly physiotherapists and occupational therapists. It is important to include social workers in the primary health care team. We must develop pathological and radiological services and bring them closer to the community, giving a quicker back-up to primary health care. The community hospital must support the general practice and act as a satellite to the district general hospital, thus linking the hospital service through to general practice. We must also consider how voluntary bodies fit into the scheme of health care. I wish to impress on the House the need for closer ties between hospitals and general practice. Those ties should be so close that there would be a seamless robe of care from the patients' bedside right through to intensive care, if needed. We do not make this any easier when we separate the family practitioner service from the hospital service. As my right hon. Friend knows, this is one of my hobby horses. Scotland shows a very much better example in these matters.
Occupational medicine has a contribution to make in improving standards of preventive medicine and promoting good health care. The private citizen in ordinary families provides most care. I remind the House that there are more private carers—as the House knows, I count myself among them—than all the professionals in the public and private sectors added together. It is worth reminding the professionals occasionally that we amateurs carry more of the heat and burden of personal caring than they do.
The Select Committee believed that new legislation had only a minor role to play in the improvement of primary health care. It was much more a matter of improved administration, better deployment of staff, more training, additional resources, and, above all, the will to succeed. Like my fellow Select Committee members, I came away from our inquiry optimistic about the prospects for better primary health care, provided that more resources went into the service. I was encouraged by much evidence of good practice in many different areas, including rural areas and inner cities.
53 I welcome the Bill and the White Paper. Unlike some other hon. Members who may speak in the debate, I view them with hope and optimism.
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
The hon. Member for Eastleigh (Sir D. Price) made a number of interesting points. He knows that he and I do not agree on everything, but we have a meeting of minds on some things. We seem to spend our time in the House complimenting each other. He obviously has a very astute and sharp mind if he agrees with me.
§ Mr. Galbraith
Yes, he understands.
The hon. Member for Bolton, North-East (Mr. Thurnham) referred to consultants. Since I have been a Member of the House, I have heard veiled threats about consultants. The hon. Gentleman referred to consultants earning £60,000. Anyone who knows my background will be aware that I have been one of the greatest critics of consultants and some of their practices. My salary would not reach such a level because of my antipathy to private practice, which is the method by which such sums are earned. Many consultants will not indulge in private practice and I was one of them. I hope that we shall not hear any more contributions like that from the hon. Member for Bolton, North-East.
Although the Minister for Health has now left the Chamber, I thank him for allowing so many people to intervene in his speech. That was very laudable. Indeed, it was in stark contrast to the speech made by the Parliamentary Under-Secretary of State for Health and Social Security who, when she replied to the previous debate on this subject, did not allow anyone to intervene. It was odd that the hon. Lady would not allow interventions, especially when she misquoted me for purely party political purposes. I know that I am new to this House, but I would advise her that such action did not help her or her argument. When she replies today, I hope that we shall not hear any silly claims that the Government are responsible for the increased rates of survival of kidney transplant patients. That would do nothing to help the hon. Lady or her argument.
I was very interested to hear the comments of the hon. Member for Eastleigh about primary care and the way forward, and I agreed with some of them. The trouble with the Bill, as the hon. Member for Eastleigh almost admitted, is that it misses the opportunity to make a number of contributions in the right direction. This is a nasty little bit of piecemeal legislation which does not tackle what is at issue. The thrust of the Bill, that primary care should be directed towards the promotion of health and the prevention of disease and that GPs should take more responsibility, is correct.
I welcome a few parts of the Bill. I welcome the parts about doctors retiring earlier and the aspects of GPs issuing information leaflets about services on offer, for example, whether family planning is carried out or whether there is parking for disabled drivers. Those are worthwhile. However, as long as we continue to adopt a piecemeal approach to primary care, we shall not progress.
As the hon. Member for Eastleigh asked, why is the general practioner service still separate from the hospital 54 service in England? We could have brought the primary care services together under a health board incorporating family practitioners, primary care and community units. The health board could have pulled together the physiotherapists, dentists, social workers and GPs. It could have clearly planned a tip-top primary care service. It could have set standards and asked the GPs to follow them. If we wanted to allow financial inducements to practices, they should not have been achieved in this manner. They should not be applied for services, as that might produce unnecessary services. We could have identified a basic practice allowance for practices that were willing to follow standards and attainments set out by the primary care and community health board. The practices that did not wish to follow those standards would receive a smaller basic practice allowance.
I also accept that there is a need to reduce the size of practices to the ideal number of 1,700. Perhaps the Minister will tell us when she replies what in the Bill will induce practices to become smaller. The way to achieve smaller practices is to reduce the capitation fee for patients above the figure of 1,700 and reduce it further above 2,300. I believe that the Bill is a missed opportunity with regard to primary care.
I want to consider clause 4. It appears that not only the Labour party has trouble with clause 4. I will try to be brief as I understand that other hon. Members want to speak. Clause 4 refers to finding additional resources. I want to re-emphasise the point made by my hon. Friend the Member for Livingston (Mr. Cook). Any additional resources will be marginal in comparison with the health care budget. If we want more resources for the Health Service, they must be obtained from income tax. That is the basis on which the Health Service was set up and that is the only way in which extra resources can be obtained. We must remember that, when we refer to increased resources, we are talking about marginal increases.
I am worried about the question of selling hospital services within clause 4. I am not referring to a hamburger chain in a hospital foyer. I do not have hang-ups about that. However, I am concerned about the idea of health boards going out of their way to sell services to patients at a profit. I want to restrict this point for the moment to British nationals otherwise other considerations will have to be taken into account. The selling of services and the provision of pay beds can be achieved only at the expense of other patients within the hospital. No matter what anyone else may say, that can be achieved only at the expense of the rest of the patients within that service.
There are certain reassurances written into the Bill. It is claimed that there will be no interference with performance. I asked the Minister earlier how he would ensure that and he responded vaguely. I know how he will achieve that. The Government will issue guidelines as they did in the Social Security Act 1979. Those pious guidelines are not worth the paper they are written on. No one follows them, they are hopeless. The provisions in clause 4, in many respects, will lead to the deterioration of the service for those who are not paying. That is the only consequence of clause 4.
When the Minister replies, will she tell us, if the guidelines are issued, that the services cannot be sold if the hospital has a waiting list for that service or if a waiting list would be induced as a result of the sale? The Minister might be able to build in a mechanism to prevent some damage that might be caused.
55 I want to refer to some other marginal sources of finance that the Health Service might consider. Such sources of finance might stop us from introducing charges for eye inspections and dental care. There are some areas which have not been examined. The Government are so determined to cut services and so intent on flogging the service off to the private sector that they have not considered the opportunities within the Health Service.
I suggest that the Minister might consider the whole question of domiciliary visits. That service does not incur great expense, amounting to about £10 million. It has probably outlived its usefulness and is considered to be abused. Will she consider domiciliary consultations by consultants with GPs? Will she also consider merit awards? Merit awards involve about £60 million. What can be done about them? Will she also consider drug companies? Before Conservative Members jump up, I am not referring to nationalisation. I am sure that the Minister is aware that the drug companies carry out a considerable amount of research for their products within hospitals. Of necessity, that research involves patients staying in hospital longer and they always receive additional X-rays, scans, investigations and blood tests. Will the Minister consider whether the drug companies should be charged for that research on their behalf?
The only area of charging that would be acceptable is one that does not involve patients. Patients should not be involved. However, we can consider a particular area of charging. Patients may be seen privately at a private consultation and as a result they may move into a National Health Service sector hospital. Patients may also be in a private hospital, but then enter a NHS hospital because the facilities are better there. Will the Minister consider the possibility of charging that private sector hospital—not the patients—when they are moved in? Will she consider charging the organisation responsible for patients entering a NHS hospital and charging it at a rate that it would charge in a private hospital? Certainly, that charge represents more than £100 million, but it is only a marginal amount. However, that idea contains the seeds for considering other methods of raising finance.
I agree that the NHS is receiving more funds than it received in 1979, but that funding is not adequate to provide the services that are required. It is not true to say that we can never meet those requirements. The Health Service in Britain receives less in funds than any other country in Europe apart from Greece. We must find the resources for the NHS. Those resources must come from central Government and from taxation. Therefore, the Opposition will continue to fight for those resources so that we may have a better Health Service for everyone.
§ Dame Jill Knight (Birmingham, Edgbaston)
May I start by saying, wistfully, that I would like to be able to support this Bill. The Bill contains some things that are right. We have a significant number of doctors and dentists who still practise when they are well over 80 years of age—some are even over 90 years of age. There has been a degree—I do not want to mince my words—of cheating about the business of retiring and then going back to work within 24 hours. I believe that the Government are absolutely right to tackle that. I also support the idea of more education and training for professionals in primary 56 care. I also support the few suggestions for obtaining more money—an honest copper or two—by the commercial use of Health Service resources. Why have the Government spoilt it all by bringing in charges for tests for dentists and ophthalmic opticians?
The Secretary of State will already be well aware that he faces the united opposition of the British Dental Association, the General Dental Practitioners Association, the Royal National Institute for the Blind, the Federation of Ophthalmic and Dispensing Opticians, the British Medical Association's committee, the British College of Optometrists and the Association of Optical Practitioners. I must also tell the Minister that a significant number of our hon. Friends are anxious about the proposals in the Bill. There is no doubt that there is also a large body of concern among citizens outside the House.
Can it be that the opposition to this Bill is based either on the anger felt by the public for having to pay more money if they want to be treated or the irritation felt by the professionals over being forced into a position where they receive less money? Does human greed operate those groups as a puppeteer operates his dolls? Or is it possible that there might just be some wise, sound, even altruistic arguments against what my right hon. Friend the Secretary of State intends to do? I believe that that is the case. Both dental and ophthalmic checks keep necessary treatments down to the minimum. Such checks make cases quicker, simpler and cheaper to treat. I believe that it is turning the argument on its head to say that if people must pay for a check it will mean that things will be cheaper in the end because people will find they need treatment at an earlier stage and it will not cost anything like it would if the problem were treated later on. Surely that is what happens now. People have tests at an early stage. How can it be logical to argue that, by making a charge for checks, people will receive cheaper care? I have the greatest respect for my hon. Friend the Minister, but I find it difficult to follow that argument.
In every sense, checks are preventive medicine. Astonishingly, the Bill claims to support such medicine. Early signs of conditions that can be cured or certainly treated often appear in the eyes and the mouth before the sufferer has any idea that he has a serious medical complaint. The hon. Member for Livingston (Mr. Cook) has already told us of such a case. Indeed, this morning a young man told me about how he had gone into an opticians, quite casually, to have a test. He had some time on his hands and he suddenly thought that he had never had his eyes tested and considered the fact that both his parents wore spectacles. As a result of that test he was immediately referred to a hospital because he had signs of early heart disease. He told me that, as a result of that test, he had been saved. The hospital had been able to start treating him early and had given him diet sheets. He told me that he would not have gone in for that eye test if he had had to pay a charge of £10.
There are many examples of the importance of preventive care. Glaucoma has already been mentioned. That complaint is caused by pressure building up within the eye that eventually starts to damage the optic nerve. Often, during the early stages of that complaint the patient does not notice that something is wrong, but if that problem is not caught early the condition is irreversible. Diabetes can lead to kidney failure and, as many hon. Members will know, to blindness. Again, early detection 57 —provided by eye tests — is absolutely essential. I received a letter from the consultant in diabetes at University College hospital and he says:Diabetes mellitus is the leading cause of blindness in people of working age in the UK. Treatment … is able to prevent some 60 per cent. of blindness, but the changes must be detected at an early stage.That is an important piece of evidence.
Cancer can often be discovered by both dentists and optometrists as a result of ordinary, routine check-ups. I am sure that no one in this House needs to be told how important it is to diagnose cancer early—it is a matter of life or death. Dentists can detect anaemias and sexually transmitted diseases. That is extremely important.
Dentists are extremely worried at the proposition that checks will no longer be free. When that was mentioned earlier on in this debate there was a fairly solid outcry from my hon. Friends to the effect that dentists are worried because it affects their pockets. In fact, one letter that came to me from the memberhip officer of the General Dental Practitioners Association states:Because of the way in which dentists' remuneration is calculated (review body—DRSG)—I am sure that all hon. Members know about that—a reduced demand will not and cannot reduce our average net income—charges will be amended next year to make good any deficit. I hope this alone will argue the case that I am not in any way in this argument considering my income.That is a relevant piece of evidence.
Certainly patients are also concerned because there is a great strength of feeling—I must put this on record—that dental treatment is already extremely expensive. Many people complain about the costs of dental treatment. If people are also to be charged for examinations, I do not have the slightest doubt that the majority of people will not go for check-ups. Dentists who have contacted me have told me that, at the moment, we have a wonderful state of affairs in this country. People have better teeth now than at any time in our history. Dentists feel that that will change if the proposed regulations are agreed. They say that an increase in dental disease will cost the NHS far more in the long run—we should consider the long-term effects of the Bill.
Dentists have also said that there will be a lowering standard of general health due to neglected mouths. All this hinges on whether or not people will go for check-ups. However, the highest authorities within the dental profession assume that people will not go for those checkups. They say that, as a result, mouths will be neglected and the effect will be bacteraemia, heart disease, digestive disease and chest complaints. Indeed, one dental surgeon in my constituency came up with an entirely new suggestion. He said that it would be better to do away with free dental treatment for expectant and nursing mothers since there is not a shred of scientific evidence to suggest that the incidence of dental decay is any greater for those women. So perhaps if we are considering costs we might bear that in mind as well.
The dentist also suggested that dentists should not be given a fee for examining people who have no teeth—I was astounded to hear that dentists are given a fee for examining people who have no teeth — when those people come along for replacement dentures. He says that the fee is paid for spotting oral diseases and cancers, but that it is unnecessary to spend any time on testing because such conditions will immediately be apparent during the normal course of fitting dentures.
58 So if my hon. Friend is anxious to save money, there are two little suggestions by people who are in the profession.
Dentists undoubtedly see the free check-up as the cornerstone of National Health Service dentistry. They are in no doubt that people will be discouraged from visiting the dentist regularly and that the present happy situation will deteriorate. Is all this really worth it to save the sum that my hon. Friend has mentioned?
Either the Minister believes that regular check-ups are not important or he thinks that people will still go for check-ups anyway. If the former, I must tell him that all the evidence is against him. I have a feeling that he himself believes that regular check-ups are important, otherwise why is he suggesting that the Government will pay for so many people to have them? If they are not important, there is no point in paying for them anyway. If they are important, are people going to go for these checks'? People who have no money worries will probably still go and have their checks. I am not really worried about those people. I am worried about the broad, middle band of people who do not qualify for free check-ups but who nevertheless cannot possibly find £8 of £10 or whatever the fee will be. One lady tells me,I have a small growth in the pituitary gland which, if it should grow, will jeopardise my sight—starting with the peripheral vision. I therefore have to have sight and fields-of-vision tests twice a year.She goes on,I am the only breadwinner in the family.Do we really think that she could go on having those tests as often as she is supposed to if she had to pay £8 or £10 every time? This lady has a problem in making ends meet as it is.
There will be young parents who will not spend the money if, say, Johnny needs a new winter coat or Jane is growing out of her shoes. If they are faced with either paying for an eye test or buying the clothes, the children's clothes are what they will go for. Parents of young children are like that.
Elderly people a little above the limit for supplementary benefit will not go for their tests either, and they are very much at risk. Elderly people are in a special category.
There are those who must have checks frequently, possibly because of a family medical history. It is the frequency of the testing which will be a cost to them, one that they will be unable to afford.
I come now to a point to which I would particularly request a reply later in the debate. If a patient goes to a doctor in his consulting room complaining of bad headaches and the doctor tells him that he needs an eye test and can either have it from an optician and pay £10 for it or have it free at a hospital, it is obvious that the patient will go to the hospital. Hospital eye departments have been under stress for years. Already we have very serious problems fitting in the patients who need to be cared for in our hospitals. Is it really sensible to direct people to have their free test at a hospital? Or—and I ask my hon. Friend this gentle question—is it suggested that later on the payment will be extended to tests in hospitals and general practitioners as well? If so, I would really rather know it now. But if it is a half-and-half service—free when given by a doctor or in a hospital and chargeable when given by an ophthalmic optician or dental surgeon —the implications are worrying.
59 As regards ophthalmic opticians, I must tell my hon. Friend with as much force as I can muster that it is insulting to tell a man who has been trained for three, four or five years at a university or at an eye hospital that he should give his professional, expert services free and make his money selling frames. That is an offensive thing to say to him, that his professional expertise is worth nothing and that he must get his money by other means. It is particularly offensive when the Government themselves took away the ophthalmic opticians' customary sale of frames in the 1985 legislation. I listened very carefully to my hon. Friend this afternoon when he said that the Government had enabled people to take their prescriptions from the optician and go and buy their frames wherever they liked. That is what they do.
What we are saying is that they must give the test for nothing and will probably not even be able to sell the spectacles to the person concerned. I have no pecuniary interest in this at all but I happen to know quite a lot about it. It seems to me extraordinary to tell a trained, professional man that he must give his services free when testing a person and allow that person to go and get his glasses somewhere else— because that is what we have encouraged them to do. How will the optician pay his bills, for goodness sake? How will he pay his overheads, let alone his salary and those of his staff, his rates and his rent? We really cannot expect him to do all this for absolutely nothing.
§ Mr. Newton
I apologise to my hon. Friend for interrupting her, but it is important that this point be understood. Firstly, I have no intention of being offensive to anyone—I always try to avoid being offensive—and I am not telling them that they should or must give their services free; all I am saying is that it is up to them to decide how they wish to do it. Another important point: while we do not think it right that people should be in a position to say that they will only test a person's eyesight if the glasses are subsequently bought from their shop, there is nothing to stop an optician, if he makes a charge for the test, offering a discount, as others would do in comparable circumstances, if the spectacles are bought from the shop. We are anxious, however, to ensure evenhanded competition.
§ Dame Jill Knight
That does not really invalidate what I said.
My hon. Friend said earlier, and not only here but on another occasion, that it might well be that opticians would provide their expert professional services for nothing in the hope of being able to sell the frames. This is not an acceptable thing to say to a group of professional people. Before the 1985 Bill, successive Governments had for years expected opticians to take a low fee for doing the test and to make their money on selling the glasses. Now we are beginning to say, "Never mind a low fee—none at all" and it is up to them to decide. This is not on.
I was interested to hear my hon. Friend say that there will be encouragement to treat people, test them, in their homes. This has been going on for years. Domiciliary eye tests have been carried out by many ophthalmic opticians; they have never made money on it and look on it as a form of social service. It is very expensive to load equipment 60 into the car and then drive to a person's home. I do not know what fee would be suggested, but they certainly would not be able to do that except at considerable cost.
§ Dame Jill Knight
If they are to be paid, it might be more expensive than my hon. Friend thinks at present. It is a good idea, because some people cannot get out of their home, and cannot go to an ophthalmic optician for an eye test.
I entirely agree that more money must be found for the NHS. I agree with the parts of the Bill concerned with getting more money, but I do not think that we shall solve the problems of financing the Health Service in the way described in the Bill because the demand for the services that are miraculously available now is never-ending. I am certain that we must look at new methods of financing the Health Service. When we are doing that, it might be a good thing to reflect on how willing people are to show their gratitude to and appreciation of the Health Service. The money that comes out of the Exchequer is one thing, but there are so many people in this land who are willing to put more money into the Health Service, but not so that preventive medicine is as seriously hampered as I fear it might be by the Bill.
§ 6.1 pm
§ Mrs. Rosie Barnes (Greenwich)
As several hon. Members have said, it is particularly ironic that we are conducting this debate against the background of the presidents of three royal medical colleges calling on the Government to save the Health Service. They are not Left-wing doctors, militant nurses or even restive Conservative Back Benchers. After all, one of them is the Queen's gynaecologist. It is remarkable that they feel that they should have to say publicly:the Government must do something to save our Health Service".I welcome much of what the Government are trying to do in putting an increased emphasis on primary health care. For far too long, primary and preventive medicine have laboured under a Cinderella image, and their importance has not been reflected in finance and development. Although today the important matters are being brought to our attention, financing is still a major problem.
The White Paper attempts to redress the balance in terms of primary health care, but perhaps it is a matter of regret that it took some eight years to arrive. However, we are glad to see it. It is clear that resources, not just for, this area, but for the Health Service itself, are at the heart of our debate.
The Government have put up a seductive and perhaps logical argument on why we need to find savings within primary health care to pay for the improvements needed in that area, but I firmly reject the principle of charging for health care checks. First, it is clearly the belief and conviction of the people that more of the wealth currently being generated should be spent on our Health Service. We all saw in the Sunday newspapers the rumour that the Chancellor of the Exchequer is contemplating a further 2 per cent. cut in income tax. It was an interesting juxtaposition that on the same page we had the cash plea from the three royal colleges.
The National Health Service benefits all the people, and the best and proper way to finance it is through general 61 taxation. Survey after survey has reinforced the understanding that people are prepared to forgo tax increases to pay for the NHS.
It is nothing short of scandalous that this country spends less on health as a proportion of gross national product than our major European competitors. That figure is declining, not going up. The Parliamentary Under-Secretary of State for Health and Social Security, the hon. Member for Derbyshire, South (Mrs. Currie), stated recently that spending on the NHS would decline as a percentage of GDP over the next few years, or, as she put it, spending would "stabilise". That is at a time when spending had not been increased to meet nurses' pay awards, and health authorities are having to pay for them out of cost improvement schemes. That should be remedied before the Chancellor of the Exchequer hands out any further tax cuts. It should be addressed before we consider further the Bill's implications.
It is not possible to place a greater emphasis on primary health care or attempt to push through major reforms without providing the necessary finance. Other sections of our National Health Service are in desperate need, but if we are to make primary health care an important part of that service, we have to pay for it. Improvements in the long term will be cost effective. There will be a time lag, but primary health care and preventive medicine will have cost benefits in future. That will not happen immediately. We shall still pay high hospital costs for curing current diseases, many of which will be preventable in future if we spend that money on primary health care now.
It is a false economy to save money in that critical area. There is no better example than to compare the cost of having to care for people who develop glaucoma, cataracts, even blindness, cancer and AIDS—many of the diseases that have been mentioned today, which can be detected through simple eye or dental checks—with the cost of continuing free tests. As a result of the Bill, people will have basic check-ups less frequently than they do now.
I shall now examine some of the less contentious points in the Bill. I accept the Government's move to turn the General Practice Finance Corporation into a limited company because that will remove the financial restrictions placed on that body by its being subject to the public sector borrowing requirement. Being allowed to spend only £12 million when there is an estimated need of over £27 million is hardly the best way to ensure that the shortage of doctors' surgeries is made up.
As a Member of Parliament for an inner-city area, which much of Greenwich is, I ask the Secretary of State to ensure that there is as much flexibility as possible in the new system to make sure that general practitioners in the inner cities get the resources that they need. I have no objection in principle to raising money through the commercial means that we have heard about today, but I worry that the Secretary of State is taking such wide-ranging powers. It is clear that he is giving himself the power to direct health authorities on how that extra revenue should be raised, and it will be their duty to comply with the regulations. I should not be so worried about those powers if I thought that it would make a huge difference to the health authorities' budget, but it will not.
I also should not be so worried if I thought that hospital managers had time to devote to those schemes, but they have not. In the same month that the Government issued the White Paper, we had a report from the National Audit Office showing that there is significant unused theatre 62 capacity in the NHS. Surely our hospital managers would be better used in solving the problems that deal directly with patient care. I should not be so worried if I thought that Health Service managers had the expertise to implement the directives, but in many cases that is not what they have been trained to do. It is critical that they should reap the benefit financially, and not have any extra money that they raise deducted from their revenue.
Dental inspection in schools can still take place under the Bill, but it is no longer a duty, which is a great step backwards—as was the withdrawal from the commitment to the nutritional content of school dinners. We have an obligation to ensure that our children's well-being—especially children whose parents do not take them regularly to the dentist—is maintained.
I come now to the specific issue in the charging for check-ups on eyes and teeth. I oppose such charging for three reasons. First, we have always been, and still are, wholly committed to the principle of the National Health Service being free at the point of use. So, I thought, was the Secretary of State; indeed, he is on record as having said so. The introduction of charges for eyes and teeth examinations erodes that principle. What will we have to pay for next? As has already been pointed out, it is ridiculous to be able to have free examinations for any part of the body except the eyes and teeth. Perhaps we should be considering more free check-ups on the lines of those offered by private health companies, which, in the long run, will save the National Health Service money.
Secondly, charges make no sense in health or financial terms. The dental rates study group research clearly demonstrates that charging people for examinations will mean that fewer people have them. Fewer dental and sight examinations will mean less prevention and screening, which will inevitably lead to worse health. Eye disease cases will overburden the Health Service, and other non-related, but detectable, diseases will go undiagnosed until it is too late for simple and effective treatment. This lack of free check-up treatment will overburden our hospitals. GPs will refer patients to hospitals, which will have to pick up the pieces of patients who are not diagnosed as having a serious complaint until it has become very serious.
Thirdly, I challenge the charging element because it is wholly out of keeping with what the Government purport to be trying to do in the Bill. How can one call for greater emphasis on primary care on the one hand and reduce basic access to primary care measures— by charging for them—on the other?
Let us examine some of the categories of people who will be most affected by the Bill. Pensioners are, perhaps, one of the most vulnerable groups of all. About 6.5 million of our 9 million pensioners will have to pay for eye tests under the Government's proposals. Some of them may be able to afford them, but we all know that, as people get older, they worry about their financial security and future, and many of them will shy away from paying £10 if that money can be saved for basic heating bills and other weekly expenditure.
Another category comprises low-paid people, particularly parents of young children, who are not eligible for supplementary benefit or family income supplement. Such people will not come forward for check-ups. I was involved in collecting information for the Central Office of Information before becoming an hon. Member. My work illustrated the point clearly. People who are hard up will make savings first and foremost in this sort of area. 63 The short, simple truth is that eye tests will be missed by elderly people, who will not be screened for many of the illnesses about which we have heard today.
It has been suggested that part of the cost of an eye test can be transferred to the price of spectacles. That is not true for the many ophthalmic medical practitioners who do not sell spectacles but give of their valuable time to perform a service for their patients. There is a lack of logic in the assumption that people who are unfortunate enough to have to wear spectacles should cover the cost of eye tests for the rest of us who may want an eye test but have to wear glasses. Charging for those tests is bad; it goes against the principles of the National Health Service and of basic preventive medicine—both of which the Bill purports to endorse.
I want to draw attention to four omissions—some of which have already been mentioned. First, I want nurses to be able to prescribe. That has already been discussed, and it is not necessary for lengthy further consultations to be held before a decision is made. I also want doctors' capitation fees to be adjusted so that they are not tempted to have lists of patients that are longer than they can adequately cope with, and they can give proper consultation time to the people who come to them for attention. I suggest that capitation fees taper off above an agreed figure—somewhere above the 2,000 mark.
Thirdly, social workers should be included in primary health care teams. That is an idea of the greatest importance. We constantly hear from doctors that they are dealing with the emotional wreckage of our society, particularly in inner-city areas, where they often deal not with a health problem, but with a housing problem. Social workers in a primary team would be the ideal means of dealing with such problems.
Finally, I suggest amalgamating the family practitioner committees with the district health authorities. That would be a sensible move. At present, two potentially rival bodies operate in the same area, which does not seem sensible.
I hope that many Conservative Members will join us in defending the principle of the National Health Service—that it should be free at the point of use—by opposing the Bill.
§ Mr. Jerry Hayes (Harlow)
I am pleased to have this opportunity to welcome the main provisions of the legislation. Some of us have waited a long time for the White Paper and for parts of the Bill. It is only right and proper, as I am sure all hon. Members will agree, that we should have a Health Service based on screening and prevention, as opposed to the sickness service that we now have. It is right and proper that doctors should be given incentives, sometimes in cash, to go into the inner cities and to check the most vulnerable in our society — the under-fives and the elderly.
It is also only right and proper that people should have the chance of being able to complain about their doctor in a more relaxed way. Many hon. Members, I am sure, know of many unfortunate incidents in which incompetent family practitioner committees and skulduggerous doctors have combined to provide little justice for some of our constituents. I am therefore delighted that my right hon. and hon. Friends on the Front Bench have grasped that nettle.
64 It is right that we should change the dentists' contract so as to place more emphasis on prevention. All that is laudable and should be applauded by all hon. Members.
The trouble with the Bill is that it has the Treasury's fingermarks all over it. They seem to reach right up to its throat. How can we say with our hands on our hearts— despite what Opposition Members say, most Conservative Members have hearts—that the Bill really promotes preventive medicine and screening, when we shall be charging people for their first entry into the dentist's surgery and the optician's consulting room? It is difficult enough getting people into the dentist's surgery anyway without slapping a charge on them.
In the very able and eloquent winding-up speech that I expect from my hon. Friend the Minister, I know that she will quite properly trot out the old brief with the statistics about how many people will be exempted. However, it will not really cut a great deal of ice, and in the long run this will cost the Health Service a great deal more money. I am in favour of proportional charging for people who can afford to pay, but let us have it after they have had the professional advice from the optician or the dentist, and not before.
I am glad that the hon. Member for Greenwich (Mrs. Barnes) spoke about the community dental service, because I, too, am concerned about that. The community dental service presently has a duty to examine, and in some cases to treat, children's teeth. Under the Bill that duty will be turned into a power, and we all know what occurs when that happens. Health authorities that are hard-pressed for resources—in other words, most of them—will say that they have an opportunity to cut out a non-acute service. That service will be the treatment of our children's teeth. Admittedly, the British Dental Association has a vested interest in this matter, but it is right when it warns that because of this there is a very good chance that 50 per cent. of our children will not receive free dental care. That cannot be right.
On the broader matter of the Health Service, the Government have a record second to none. We know that we have more doctors and nurses and by how much in real terms we have increased Health Service resources. We know how many hip operations, heart bypass operations and other operations have taken place, and how the waiting lists have decreased. However, there is no point in all of us repeating those statistics like some sort of mantra. Every hon. Member, whatever his party, knows that most health authorities have some serious problems. Unless the Government get to grips with the general problem of financing, I suspect that there will be serious trouble.
My hon. Friend the Minister knows that I went to see her with a delegation about my own district health authority, West Essex. I do not want to bore the House with specific details or with too many statistics, but that health authority is a classic case. It is doing the things that the Government are asking authorities to do. It was the first one in the region to put personal services out to tender, and one of the first in the region to implement the Griffiths proposals. I presented to my hon. Friend a team consisting of consultants, management, nurses and the community health council, and all the members of that delegation were wholly united in their aims on cost efficiency. That is rather unusual, because very often those strands in the Health Service tend to pull against one another rather than with one another.
65 Sadly, we were not able to get the £600,000 that we need, despite the savings that have been made. We have even had to close a hospital, and that was a difficult political decision. It was the right decision, but it was difficult to close a hospital in order to make us more efficient. Despite all that, we will be overspent next year by £1 million, and the situation will get worse. It also means that from 11 December four acute wards will be closed. That means that 20 per cent. of acute beds will be knocked out of the West Essex district health authority, and from that date there will be only emergency surgery for the whole of the district.
What do I tell my constituents? Do I go through the figures showing how much more money we have put into the Health Service, and do I tell them about cost efficiency and about the pay awards? If I do, they will say to me, "Never mind all that. We see demoralised nurses and wards being closed, and we know that when we want to see a consultant paediatrician or an orthopaedic surgeon we will have to wait seven months for the first consultation." As a result of the cost efficiencies, or the cuts, that we have had to make, the waiting lists are increasing at the rate of 100 people a week. That cannot be right. There are swathes of inefficiency in the Health Service, and it contains incompetent management. It is right that such things should be rooted out, and the last thing that I would ask this or any Government to do is to featherbed such people. However, I suspect that just about every district will have such problems by next year.
I should like to propose one or two matters that the Government should take into account. First, doctors' and nurses' pay awards are negotiated nationally. District health authorities have no input whatever, and no matter how generous the Government properly are sometimes, they do not always phase these pay awards, and the district health authorities have to pay a large proportion of those awards on top of cost efficiencies. Next year this will probably cost us about £300,000. If the Government expect us to behave like a business—as the Bill properly expects us to do—and be efficient and cost effective, we should be treated like a business. We should not be expected to go into the market place with both hands tied behind our back. I ask the Government to consider the suggestion that the Treasury should foot the bill after the next pay round.
There is also the problem of private agencies. All hon. Members must have experience of the difficulty in prosperous areas of getting doctors and nurses. When we cannot get them on the National Health Service, we have to go to private nurses' and doctors' agencies, and they charge three to four times the usual amount. What help are we getting with that? Authorities that are efficient and taking the sort of measures that the Government have asked them to take should be favourably considered.
May we have another look at the role of the family practitioner committees? I am mystified, as was the Select Committee on Social Services, about why we had them in the first place. Very often they mirror what is done by district health authorities.
May we also have another look at the role of the regions? I am quite happy to go on record as saying that I am horrified at the way in which my own regional health authority, North East Thames, behaves. Its members are an absolute shower, and the sooner they are all given DBEs and knighthoods, and all of them packed off, the better. I do not think that a region could do any better 66 than have a committee of the various heads, general managers and chairmen of district health authorities, because they could make the strategic plans that are absolutely necessary.
This is a Second Reading debate and we are talking about the principles of the Bill which, apart from the exceptions that I mentioned, I support. However, I will be unable to support it further unless those controversial and very damaging measures to the health of ordinary people are removed. I fear that unless the Government abandon their plan for the charges that have been mentioned in the debate, the Bill, which could be a great landmark in health care, will be nothing but a dusty monument and a graveyard of expectations.
§ Mrs. Llin Golding (Newcastle-under-Lyme)
It cannot be denied that the Health Service is grossly under-funded. When children wait for months for necessary operations and babies die, it is clear to all caring people that more money must be put into the Health Service. What is happening to the wealth of the country that the health of its people should be of so little concern to the Government? Where is all the money going? Where is the £827 million made from the sale of BP shares, the £43 million made from the sale of British Aerospace shares, the £120 million made from the sale of shareholdings in the National Enterprise Board, the £22 million made from the sale of shares in the Suez Finance Company and the £195 million from North Sea oil licence premiums?
The Bill asks health authorities to become garage and petrol pump attendants and shopkeepers to raise money. Have the Government and the Minister no conception of the strain already put on officers of district health authorities — district general managers, treasurers and other officers—who spend long hours juggling figures and looking at changes in funding, the lack of funding for pay increases and the knock-on effects of every hard decision they have to take?
I have worked in 23 hospitals and clinics in my time in the Health Service and I have served for six years on a community health council and for four years on a district health authority. I have never known morale to be so low or known so many people to ask, "What is happening to our Health Service? Will nobody do anything to save it?" What has happened to the money from the sale of land and buildings of the New Towns Development Corporation and Commission for the New Towns, £78 million, the money from the sale of land and buildings of the Property Services Agency, £9 million, the £28 million raised from the sale of land and buildings, leases on motorway service areas, the £3 million from the sale of land of regional water authorities and the £72 million from the sale of land and buildings of the Forestry Commission? The Bill extends the provision for charging for dental and eye examinations. Does the Minister not want people to see what the Government are doing? Is there no concern for the health of people's teeth?
My niece's husband is a dental mechanic and he is very proud of that profession. If I may say so, he is 40 years old today and his wife has ordered him a birthday cake in the form of false teeth. However, it has a large red tongue sticking through the teeth; perhaps that is a comment on the charges for dental examinations. I have often spoken to him about the charges for dental health and he is deeply 67 concerned about the increase in his work load and that early provision should be made to prevent so many people from needing false teeth.
What has happened to the £64 million from the sale of shares of Amersham International, the £97 million from the sale of shares of Associated British Ports Holdings, the £2,703 million from the sale of shares of BT, the £1,053 million from the sale of shares of Cable and Wireless and the £107 million from the sale of oil stockpiles? I could go on, but suffice it to say that from 1979–80 to 1986–87 it is estimated that privatisation proceeds totalled £12.1 billion. With all that money having come in, the Bill restricts the amount that can be spent on some aspects of the general practitioner services. What happens if the money runs out and the need is urgent? Will sick people be told that they will have to wait until the next financial year to be ill? Where is the Tory philosophy of let the market decide; or does that not apply to sick people?
We are informed that British Steel makes a profit, so it must be sold off, for perhaps another £2 billion. Where will that money go? We can rest assured that it will not go into the Health Service to solve the problems of services to mentally handicapped or the elderly, primary care services, acute services, maternity services or all the other services so desperately in need of money. We all know that the money will go to keep people unemployed and to reduce taxes to the promised 25p in the pound, but at what cost to the health of the nation?
I remind the Minister that the Prime Minister promised that the Health Service would be safe in her hands, as well as the 25p in the pound tax. The Minister should be aware that there is real public and professional concern about hospital and community funding. The 1986 report of the Social Services Select Committee, "Public Expenditure on the Social Services", pointed out that expenditure in hospitals and community health services has been lower than in the health services. It has grown by less than 0.5 per cent. annually in real terms in the past five years. People are entitled to know how the Health Service will be funded when the Government have sold off everything that makes a profit. Will the Government have to raise taxes? Where will the money come from, and where has the money already raised gone to?
Mrs. Brown, a constituent of mine, whose small son Andrew is waiting for a heart operation at the children's hospital in Birmingham, told me yesterday that a quarter of all the beds in the hospital, which also caters for children with cancer, are empty due to lack of money, as are one third of the beds in the older children's heart ward and half of the beds in the babies' ward. She told me that only four cots in the intensive care unit were in use last week.
The Bill does not even pretend to consider the health of the nation. Everyone knows that it is expensive to keep a nation healthy and to care for the sick, but when we see the sale of major Government assets we are entitled to ask how the Government will raise the money to finance the National Health Service. Will the Minister tell the House that the Government are no longer prepared to stand by and see sick people suffer? I make no apology for ending with a special plea to the Minister: the young children who are awaiting heart surgery need our help now. Please listen to them and to the nation and please give them some hope.
§ Mrs. Gillian Shephard (Norfolk, South-West)
I am delighted to have been asked to contribute to the debate because I should like to focus attention on the primary health care network, with which most people are familiar, and which is at least as concerned with health as with illness. Debates have been raging in the House and elsewhere about the undeniably dramatic confrontation between technological advance and the public purse, particularly in the acute sector of the Health Service. Meanwhile, the primary health care network continues to deal every day of the week with millions of patients. The review of the network in the Bill and in the White Paper — the first for 40 years and resulting from extensive consultation—was long overdue.
It was to be expected that the controversy, to put it mildly, about the proposed charges for those more able to pay for teeth and eye inspections would overshadow the many positive proposals in the Bill and White Paper for improving the primary care network. A rationalisation of dental charges, to make them more logical and comprehensible, has been sought by the dental profession for a long time. I do not want to make light of anything, but it is a very long time since I had a free inspection from my dentist. He may be quicker on the draw than many people, but I have always been inveigled into having cleaning, brushing or this or that when I have gone for my free inspection.
There is much concern on both sides of the Chamber about charges, particularly the eye inspection charges. They could militate against the emphasis on prevention, which is the main thrust of the White Paper and the Bill. I hope that my hon. Friend the Under-Secretary will give due emphasis to that concern and to the way in which the proposed charges can help to resource some of the other proposals in the Bill. I hope also that she will say that there will be constant monitoring of the effect of the charges.
Some interesting suggestions have been made by hon. Members on both sides of the House about how extra resources can be found for the Health Service. I remind the House of the £160 million which is wasted every year in over-prescribing drugs. That money could be used instead to run 40 geriatric wards. I hope that some attention will be paid to that.
I represent a rural constituency of 1,100 sq miles. A population of 76,000 is scattered rather unevenly throughout it. Some parts of the constituency are 20 or 30 miles from the nearest acute hospital. In those circumstances, the primary health care network assumes an importance that is not experienced by, for example, the populations of Bradford, Bromley or Greenwich.
Of key importance in rural areas is the quality of service provided by the local general practitioner and the ability and-or possibility that he has to work with other health care professionals. I was delighted to read in the Bill that there will be enhanced incentives for the improved training of doctors and other primary health care workers. Better still is the suggestion in the White Paper that there should be negotiations with the profession on special arrangements for releasing for training practitioners who work single-handed. That is a rare mention of a specifically rural problem. There may be practitioners who work single-handed in urban areas, but patients in those areas have the choice of walking to a group practice. In rural areas there may be no choice.
69 The White Paper concerns itself with making services more responsive to consumers' needs and giving patients the widest possible range of choice in obtaining high-quality primary care services. Family practitioner committees will be required to provide more details of qualifications, the success of the doctors and opening hours, for example. That will be helpful, but choice in rural areas will still have to be governed by geography and by the professional catchment area arrangements that are made by doctors. It is entirely reasonable that doctors should create those areas, which are based on how far they have to travel to make home visits. I hope that the information to be provided by FPCs will make entirely clear to patients the rationale for the areas so that there can be no suspicion that an element of professional solidarity may have contributed to their creation.
As nearly 50 per cent. of medical students are now women, it is not unreasonable to suggest that in the near future all patients should be able to consult a woman doctor if they wish to do so. I hope that the negotiations with the profession will take account of the fact that some patients would prefer not to be registered with a single-handed practice while others would prefer not to be with one that does not offer an appointment system. Single-handed practices and others that do not operate the appointment system are not uncommon in rural areas.
I believe that greater competition in GP services will result in enhanced services for patients in urban areas, but in rural areas, where a patient's choice may be limited to Dr. X, I question whether rewarding the doctor for the size of his list will improve his performance. Rewards should reflect excellence, and I am certain that they will in due course. They should not reflect a doctor's geographical location. I am sure that this matter will be borne in mind by my hon. Friend the Under-Secretary when she negotiates with the profession.
Sometimes the strength of a rural community, especially its close-knit nature, can, in reverse, be its weakness. A good example is complaints. Fortunately, complaints about GPs in my constituency are rare, but they can and do occur. I welcome the recognition given in the White Paper to the great difficulty that most patients would feel in making complaints about their doctor. The deference factor is still strong in areas such as mine. In some instances there is a fear—it is to be hoped that it is without justification—of reprisals or at the very least embarrassment, when there can be no question of an individual changing his doctor because of geographical considerations. I warmly welcome the improved, simplified and strengthened complaints procedure which I believe will be effected by circular.
Enhanced powers are to be given to FPCs. They and health authorities will be encouraged to collaborate more effectively. The divisions between FPCs and health authorities are utterly meaningless to patients, the average patient not knowing, and not wishing to know, that a general practitioner looks to one while the community nurse looks to the other. The patient wants care when he needs it, and he wants it to be delivered to him in a way that is professionally co-ordinated and effective. That is why emphasis is given in the White Paper to various forms of preventive work such as immunisation, vaccination and screening. That is to be welcomed, and it stems from the fact that this work is already being undertaken in a variety 70 of ways in the best practices throughout the country. That has been revealed by the work of the Select Committee on Social Services.
I have mentioned previously the work that is taking place in my constituency and, in the interests of being brief, I shall not go into it in detail again. In parts of the Norwich health authority there are multi-disciplinary teams of health professionals who are employed by the health authority. They work closely with doctors, or groups of doctors, to provide a complete network of primary health care. These teams include physiotherapists, clinical psychologists, occupational therapists, speech therapists and dieticians, for example. Also included in the team are health educators, social workers and voluntary co-ordinators.
Artificial divisions between FPCs and health authorities need not be relevant when there is goodwill, as in my constituency, and when the well-being of patients is at stake. It is not the pattern that is proposed in the community nursing review, but it includes several elements of it. It avoids the hazard, as perceived by some, of making all services practice-based rather than community-based. I hope that the circular that was issued last week will encourage health authorities to find their own solutions that are tailored to the needs of their communities.
I hope, too, that the intention behind paragraph 7.13 of the White Paper to give nurses more freedom to prescribe will be pursued without delay. It can only make sense in a service in which increasing demands are being made—that is agreed by both sides of the House—if all the professionals who work in it are used to the full. Nurses should not have to waste valuable time that could be spent caring for patients in obtaining prescriptions, for things such as dressings, from pharmacists and then taking them to patients. They are capable of using their own professional judgment on the timing and dosage of drugs that are prescribed by a doctor. Many professional emotions can be stirred up by the use of the term nurse-practitioner, but she exists already. She certainly exists in the mind of the patient.
I hope that my hon. Friend the Under-Secretary will note some of the matters that I have raised. I cannot emphasise enough the vital importance of primary health care networks in rural areas such as the one that I represent.
§ Mr. David Young (Bolton, South-East)
The Bill is part of the Government's overall strategy towards the National Health Service as a whole. That strategy means the imposition of financial cuts under the guise of lofty aspirations that lie behind the NHS. We should be concerned with whether the necessary resources are being made available to meet the needs of the NHS and not with exactly how much more money is being spent upon it. We have a sick service because the necessary resources have not been forthcoming, not a health service. When the required resources are not available there is much more that is adversely affected than patient care. For example, the morale suffers of those who look after the service.
We have the cheapest comprehensive Health Service in the Western world. About 6.2 per cent. of our national wealth is devoted to it, but much more is spent by other countries on their health services. We spend 50 per cent. less than Sweden, Holland, Germany and France.
71 My district health authority has managed to balance its books this year, but three out of five district health authorities have run into financial difficulties. However, the Bolton district health authority tells me that next year it will be unable to balance its books, although there is a legal requirement for district health authorities to do so. One of the reasons is the underfunding of pay increases by the Government. Moreover, whatever money the Government may save by this Bill will be lost by the employment of agency nurses. In the last year for which figures are available, Bolton spent £115,000 on agency nurses, and I am told by the authority that it will spend £200,000 on agency nurses in the next financial year.
The Government say that 100,000 NHS patients were treated privately last year, with the result that they came off the waiting lists. Private health service hospitals operate at a profit, but it is a parasite service because it is based on resources that are largely provided by the NHS. Private health services do not contribute a penny towards the training of the doctors and the nurses whom they poach from the NHS. My district health authority, which is a very responsible authority, says that that is intolerable. If one is seriously ill or terminally ill, it is soon made clear that private health insurance will either be offered at a prohibitive premium or that it will not be offered at all. Such patients therefore have to be treated by the NHS.
The Government are actively discouraging eyesight and dental care by literally fining those who want to have such regular eye checks. That will affect in particular young workers. The proposals will discourage them from having such checks. My constituency secretary had glaucoma, but because he had an eyesight test the condition was picked up and his eyesight was saved. Had he gone to his optician two months later, he would have lost his eyesight. My father told me that before the NHS was set up he went to Woolworths where there was a test card that he used when he tried on spectacles. He did that to save the cost of a visit to an optician. We are being dragged back by Government to practices of that kind by the terms of the Bill.
The Government argued that fluoride should be added to water to prevent tooth decay in young people, but the Bill does away with the mandatory requirement to carry out school inspections.
§ Mrs. Currie
Perhaps the hon. Gentleman will allow me to deal now with the point that he has made about fluoride.
§ Mrs. Currie
I am most grateful to the hon. Gentleman. May I remind him that included in the White Paper proposals, and also covered by what we are attempting to do in the Bill, is increased expenditure on fluoridation that will assist areas such as the hon. Gentleman's area.
§ Mr. Young
Is it not, then, even more necessary to carry out dental inspections in schools? I did not resent the fact that the hon. Lady was trying to intervene, but those on the Front Bench will have their own time in which to reply. I did not think that I ought to take up the time of other Back Benchers by giving way.
72 As for AIDS, Bolton is in receipt of a Government grant for AIDS training. Largely because of the expertise of Mr. Curtiss and his team, there are 32 HIV patients, 19 of whom are HIV positive and come from outside Bolton: four from Merseyside, 14 from Greater Manchester and one from Lancashire. However, the cost of drugs is about £14,000 a year per patient, which puts further pressure on the district health authority that is trying very hard to balance its books.
Last week I put down a question in which I asked about the cost of employing agency nurses in England and Wales. We shall run into long-term difficulties over that. Bolton is not unique; many of the difficulties that it faces are mirrored all over the country. I got the go-ahead some years ago for the building of a general hospital in Bolton. The building was delayed several times, but at last that hospital is about to be constructed. However, my district health authority tells me that it will not be able to employ sufficient nurses to run it.
In Bolton, 36 per cent. of its nurses are on part-time contracts. It is 186 whole-time equivalents below the funded establishment. The psychiatry department is short of 18 whole-time state registered nurse equivalents and it is short of eight whole-time state enrolled nurse equivalents. The cost of agency nurses in some departments is very high. That is particularly true of the elderly and the acute services. In Bolton there is a shortage of 60 whole-time equivalents for those services.
We must plan for the long-term provision of nurses. Apart from pay, status and fringe benefits are very important. Many nurses prefer to be agency nurses, not just because of the pay but because they have families to look after and can choose the hours that they work.
At the moment, 25 per cent. of student nurses are girls who have left school with four or five 0-levels. By 1995, partly because of a falling birth rate, we shall need 50 per cent. of girls with that kind of qualification. We must ensure that, apart from a good salary, nursing is looked upon as a long-term career by both men and women.
At the moment our problem is not one of recruitment, although we are running into difficulties. Our problem is wastage, and we must stem that. It is no good saying that we could bring in people from the youth training scheme, which is one of the ideas that is being considered to solve the backlog. We must make nursing a career as attractive as Marks and Spencer makes its business to its employees. That company does not deal with its employees as simply so many pairs of hands. I use that expression because it was used to me by one of the senior officers of my health authority when he was talking about what we are doing in psychiatric nursing. He said that auxiliaries were brought in simply on the basis of "pairs of hands", but that they were not experienced and trained staff who could do the job that is required. That is the battleground on which we are fighting.
Finally, the whole problem was summed up in yesterday's newspapers in which attention was drawn to the palatial premises that the Ministry will occupy at Richmond terrace. I do not know whether what was written was true, but if one compares the descriptions of the bathrooms and the chandeliers with the conditions in which the nurses in my authority work, one can see why they feel that morale is at its lowest-ever ebb. True or false, it is typical of the way in which the Health Service works. I justified the Ministry because I am not a vindictive man. I said that, like Lady Macbeth, Ministers may feel that 73 constant ablutions would salve their consciences. Perhaps I am mistaken but I have never thought that the Government lacked a heart. However, sometimes I wonder whether, in dealing with my constituents, that heart has been bypassed.
§ 7.1 pm
§ Mr. Churchill (Davyhulme)
There is much that I welcome in the Bill, especially those parts that are aimed at encouraging health screening and preventive medicine. Therefore, I particularly regret that I shall be unable to support the Government in the Division Lobby tonight. However, by deciding to charge for dental examinations and eye tests, which have hitherto been free, the Government will directly undermine their claimed objective of encouraging more people to go for checks. Indeed, the reverse will be the case.
I am foremost in acknowledging that no Government have done more for the funding and staffing of the National Health Service than the present Government. The Government have undertaken the greatest capital spending programme that has ever been seen in the Health Service in the post-war years. I should like to thank my right hon. and hon. Friends for the improved investment that has taken place in my Davyhulme constituency at Park hospital, where we have an excellent £5 million new geriatric unit and a £1 million coronary and intensive care unit, as well as massive improvements in community care facilities. All that is of enormous benefit to my constituents.
Opposition Members are in no position to criticise this Government's actions on health. No Government imposed such constraints on the funding of the Health Service as did the Labour Government in the late 1970s. No Government treated the nursing profession more shoddily. Therefore, we do not need any sermons from the Opposition's Front Bench, let alone their Back Benches.
The demands on the National Health Service are colossal and seemingly open-ended. In many ways, we have become the victims of our own success. It is rather like building an urban motorway into the centre of the city. No sooner is that done than one finds that more traffic has been generated and that the jams are worse than ever. A similar situation confronts us in health care today. At the moment we have 750,000 more pensioners than a decade ago. What I would describe as "new technology operations" impose an enormous cost burden on the Health Service. Hip replacements have increased 50 per cent. compared with 1978–79. Heart bypass operations take place at four times their rate in the late 1970s. Babies today have a greater chance of survival. All that is due to the expensive care, techniques and equipment that have been developed. The fact that we have a far greater throughput in the Health Service for both in and outpatients also imposes a great burden. On top of that, the cost of high technology equipment, such as scanners and lasers, is enormous and drugs certainly get no cheaper.
The revenue expenditure for the north-west area has increased from £386 million in 1978–79 to £970 million in the current year, which is an increase of 27 per cent. in real terms. That is undoubtedly a massive increase in resources. It is thanks to this Government, who have got the country's economy moving in such a way as to generate those massive resources. We should not have had those extra resources had the Labour party been occupying the Government Front Bench.
74 The problems of funding that confront the north-west region as a whole, and Manchester in particular, with its large number of regional specialties in its hospitals, are enormous. In the south Manchester area, which covers much of my constituency, hospitals are told that they are overspending. They are convinced that they are underfunded.
Many of our hospitals in Manchester are second to none in the calibre of their work, the skill of their staff and the efficiency of their operation. The Christie cancer centre, for example, treats twice as many patients relative to its resources as does the Royal Marsden in London. Likewise, the Manchester Royal Eye hospital is twice as efficient in its use of resources as Moorfields Eye hospital. That is all the more reason to regret the fact that we are unable to use those facilities to the full because of lack of funding. The Department recently offered us £450,000 for a new cataract day centre at the Manchester Royal Eye hospital. That would have been backed by a further £350,000 from private industry. However, we had to turn down that £800,000 package because we did not have the revenue funding to operate it. Understandably, such facts cause enormous alarm and concern. The waiting lists at the Manchester Royal Eye hospital have trebled since 1983. So far as I am concerned, that is a wholly unacceptable state of affairs.
We have been told that 220 acute medical and surgical beds at Withington and Wythenshawe hospitals in the South Manchester area health authority are threatened with closure in the coming months. Work at the excellent lung cancer unit at Wythenshawe is also under threat. I must say to my hon. Friend the Parliamentary Under-Secretary of State that those threatened closures and the threat to patient care which they imply are unacceptable to my constituents and me as their representative in Parliament. I will not stay silent while damage is done to my constituents' interests.
The wild spending of the loony Left council in Manchester has done nothing to help. The total rates bill in Greater Manchester district health authority has increased from £3.2 million in 1979–80 to £9.3 million in the current year—a £6 million increase in rates on our hospitals. It is no wonder that we shall have to close wards and get rid of nursing staff if those sorts of increases are implemented by local government. I look forward to the introduction of the community charge and the unified business rate which, I hope, will moderate those impositions on the Health Service.
My right hon. Friends have made an error of judgment on the optical and dental charges. Naturally, many people can well afford a tenner, but for many others £10 will not be an insignificant sum. Indeed, for some of my elderly constituents it represents more than 12.5 per cent. of their total weekly income. My fear and belief is that the Department will save little in cash terms and what it will save will be at the expense of the health of those who feel that they cannot afford the new charges and so neglect their health.
I fully share the anxieties expressed by my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), who spoke so eloquently earlier, that if these charges are implemented, a significant number of people will not have those tests which give early warning of so many diseases, including glaucoma. It is wrong to charge for such examinations and I hope that in the coming weeks 75 my right hon. Friends on the Front Bench will reconsider this provision, which damages a Bill that in other ways is so commendable.
New sources of funding must be found urgently for the NHS. Part of the solution may be a national lottery. Why not? I would certainly have no objection to that. Part may be to encourage the expansion of private health insurance still further. Those who take out such insurance undoubtedly take an enormous burden from the shoulders of the NHS because in effect they are contributing twice to their health care — once through private insurance and once through taxes. But part of the additional resources must be found from the Exchequer. The Treasury must be told in no uncertain terms that it cannot and must not look to the NHS as a source of funding.
I plead with my right hon. Friends to be rather more imaginative and radical in their approach. Our objectives must be, not to ration demand, but to satisfy it. Under the present system that desirable position will never be obtained. I urge my right hon. Friends seriously to consider introducing the system which seems to work so well in France. There NHS patients have a choice. Yes, they have a choice. What an unthinkable idea in the British NHS! Yet in France NHS patients have the choice whether to seek treatment within an NHS hospital or from a private clinic or hospital at the expense of the NHS, providing that the private clinic's charges are within the scale approved by the health ministry. That is an important proviso. There is no extra cost to the patient.
The consequence of introducing such a freedom in Britain would be twofold: first, waiting lists would be slashed and, secondly, although in the short term the volume of operations would undoubtedly increase, in the long term there would be a reduction in the cost of individual operations. Clearly, anything that can be done by a nationalised organisation can be done far more efficiently and at less cost by the private sector. That would lead to an increase in the effective and efficient use of resources in the interests of both patients and taxpayers.
I strongly urge my right hon. Friends to examine that proposition closely. It would give greater freedom of choice to patients, while securing the most cost-effective use of NHS resources for taxpayers. Both aspects are in line with our party's philosophy. Our people are entitled to a more efficient Health Service in which they do not have to suffer the agony of queuing and in which they can get the treatment that they need when they need it.
§ Mr. Jimmy Wray (Glasgow, Provan)
We are both imaginative and worried. We do not have to be members of the medical or legal profession to understand that the Bill is not about health or medicine, but is about profit and greed. Moreover, it takes the first steps towards privatising the NHS.
The meat of the Bill is in clauses 4 and 8. The Minister said that the Government had decided to increase dental charges from £115 to £150 because they had not been increased since 1985, but he did not say that since 1979 there had been more than a 350 per cent. increase. That provision should obviously be removed from the Bill.
The Minister spoke about the half billion pounds that should be spent on the Health Service, but he did not emphasise that nurses were dealing with an enormous 76 number of cases which they had never dealt with previously; for example, hepatitis A and B, non-hepatitis A and B and the human immuno-deficiency virus. If the Government refuse to spend money on that new problem, we shall have an AIDS epidemic on our hands. The disease is spreading, and the Greater Glasgow health board gives reports every month on the problem and the Government must take heed. Last year the BMA warned the Government that to keep the Health Service at a standstill it would need an increase of 7.8 per cent., not the 6.5 per cent. which the Government were proposing.
The Minister also said that £170 million would accrue from dental charges, which would resource some other need, but he forgot to admit that £1,700 million is needed to bring our hospitals up to acceptable standards.
The Minister spoke about cervical cancer. I am most concerned about it, as my constituency is one of the most deprived areas in Britain. A report by the Greater Glasgow health board talks about the standardised mortality ratios for previous health districts within its boundaries. The mortality rate in the Greater Glasgow health board area in the age group of 40 to 69 years is 70 per cent. higher than it is in Japan, Norway, Sweden and Switzerland. It is on places such as my constituency that we should be spending money.
I read the epitaph of somebody who had passed away from a very deprived area when I listened to the Minister speaking about the extra money that was spent on fluoridation of the public water supply. That really concerned me, because the Bill contains only one clause about medicine. I wonder whether the Minister realises just how many medical products go into the market without passing through the Committee on Safety of Medicines. Hon. Members should consider the amendments to the National Health Service Act 1946 and section 130 of the Medicines Act 1968 which defines a medicinal product. I wonder whether it will be legal for the Government to give money to every health board throughout the country to fluoridate its public water supply. Fluoride in its raw state becomes fluoroacetic acid as soon as it hits water, and I am concerned about that.
It is time that we looked at some of the medicines that are coming on to the market, and at some of the pharmaceutical companies that produce them. There is Temarcpam which is known on the streets as the yellow peril, and Librium, Valium and Pethidin are making their way on to the streets. There is also that famous drug that the doctor prescribes when patients tell him that they have had a bout of depression—Ativan—which ensures that they are depressed for life. The Committee on Safety of Medicines should consider such drugs.
The National Health Service has had crisis after crisis. We are losing 30,000 nurses a year because of low pay, as the Minister said earlier this afternoon. It is nonsense for him to say that £600 million will deal with the Health Service's problems, since £280 million was needed for the nurses' pay increase last year. There are about 668,000 people on waiting lists in England and 81,000 on waiting lists in Scotland. We must do something about that. In Scotland we have lost 750 nurses and 1,600 people who work in the National Health Service. I hope that the Government will invest more money and will realise that we need a Health Service for deprived people living in poverty who can ill afford to pay for any of those services. We know about prescription charges, which have seen a twelve fold increase since the Government came to power. 77 We want a Health Service that is free for all and paid for by the taxpayer, whose shoulders are best able to bear the burden.
I hope that the Minister for Health and the Under-Secretary of State will examine my constituency, where there is great poverty, where people live in squalor and where the environment is so deplorable that Prince Charles talked about it for 10 minutes on the radio. Those are the problems that the Government should try to solve, and one way of doing it would be to spend more money on the Health Service.
§ Mr. Chris Butler (Warrington, South)
I wish to strike a new note by talking about clause 13, and specifically the reimbursement of general practitioners for their practice expenses. I shall home in on the use of computers in general practice. Some hon. Members—perhaps many— will have invested a great deal in new technology, including computers, in their constituencies. Some hon. Members may even have used their computers. Perhaps fewer have used them effectively. I do not know how many pieces of hardware there are in constituency offices —there are probably 57 varieties or more, all doing their own thing — but the real power and dynamism of new technology comes from, to use rather trendy words, inter-operability and interactivity. The dramatic synergy that one can get from new technology comes when computers talk to each other and talk back to their users. There is a new realisation of that in Conservative central office. There is, too, in the European Community, with the INSIS programme. There may even be a realisation among the cloth caps of Walworth road—if they have not yet been made redundant.
Only two paragraphs of the White Paper that gave rise to the Bill are devoted to that important point. The White Paper believes that new technology is a good thing and it notes thata variety of computer-based systems already exists.That is as far as it goes, except to say that in Scotland things are rather more advanced, as they usually are.
General practitioners are ready and willing to use new technology. They are already discovering the value of new technology in their practices, in making up practice accounts and repeat prescriptions, in setting up call and recall systems for immunisation and in noting visits. But the quantum leap that they could achieve has yet to be perceived by the health authorities and by the Government simply because they are all doing their own thing. We must have some pre-planning if we want the radical change about which I am talking. I envisage a data network linking general practitioners, chemists, family practitioner committees, health authorities and hospitals. That would have great advantages in speeding the process of clinical trials, so that the process of getting approval for a drug can be telescoped. It would be of immense benefit to our pharmaceutical companies.
I envisage many other advantages. A general practitioner could discover immediately whether beds were available in the local hospital or further afield and thus make use of unused capacity in the system. That could have a dramatic effect on waiting lists. A patient visiting his doctor could go to the nearby chemist and find his prescription already made up and available simply because of the exchange of information. A general practitioner could obtain immediate information on the cost of drugs, 78 on their side-effects, and on their administration. Family practitioner committees and health authorities could have timely warning of the build-up of epidemics quicker than we have under the notification system. General practitioners could report much more speedily the side-effects of any drugs, and this could replace the creaking yellow card system. New technology could achieve all this and more.
But there is one condition. We must begin to move away from an ad hoc response to our problems to an overview of the position. Only the Government can do that. It is no good leaving it to general practitioners, family practitioner committees or health authorities. To obtain the overview, the Government must take the lead. They could use clause 13 to do that by reimbursing general practitioners for expenditure on equipment that is interoperable and interactive. It need not be expensive. There is a parallel with urban regeneration, where the Government have the vision and provide the pump-priming funds, and then the private sector responds and we obtain a multiplying factor of the public sector funds involved. In this case, the private sector could be the pharmaceutical companies. They would benefit from being on the inside track of such a data network. I hope that we shall make the correct choice between muddling along as we are and the quantum leap that I have described.
Of course, the debate today and all debates on the matters that I have mentioned take place against a backdrop of pressure for more resources for the NHS. The British Medical Association has asked for more. It said:For some years now the money allocated by the Government for the service has been quite inadequate to meet the demands made upon it by the public.That is strong stuff. That was the evidence of the BMA to the Merrison committee, which reported in 1979, after five years of Labour Government. What was the response in that report, which was commissioned by a Labour Government? It was:Whatever the expenditure on health care, demand is likely to rise to meet and exceed it … To believe that one can satisfy the demand for health care is illusory.A signatory of that report was the hon. Member for Cynon Valley (Mrs. Clwyd), who is not here today. This is a tightrope that Governments of all colours must tread, and it ill behoves Opposition Members to have the screaming abdabs about us when their performance was so clearly inferior to ours.
§ Mr. Robert N. Wareing (Liverpool, West Derby)
To keep up the latter points made by the hon. Member for Warrington, South (Mr. Butler), I think that it is a cheek for Conservative Members to try to ignore the fact that without a Labour Government after 1945 we would not be discussing a National Health Service. The establishment of the service was opposed by many Tories. Indeed, the late Sir John Anderson thought that welfare was likely to be a running sore in our economy. Conservative Members probably believe that it is a running sore in the economy now.
The Government have missed a golden opportunity when introducing this Bill. They had a marvellous opportunity to address important problems facing the National Health Service. The Bill could have encouraged recruitment of more nurses, particularly intensive care unit nurses, about whom much discussion has taken place in 79 recent weeks. It could have improved the position of other staff in the Health Service, such as speech therapists and medical laboratory scientific officers. It could have addressed the problem mentioned by my hon. Friend the Member for Glasgow, Provan (Mr. Wray) regarding the dangers of dry Lorezepam, still popularly known as Ativan, which is regarded as mind-bending and about which we now have ample evidence. I asked questions about that drug in October 1984, but the Government have done nothing serious to exercise adequate control over the drug and to prevent its over-prescription, which creates doctor-induced drug addiction among people.
I wish to deal mainly with the charges for eyesight testing which was not mentioned in the Tory party manifesto. Conservative Members need not fear being called to account by their local Conservative associations on the grounds that they were elected on a manifesto which embraced this idea, because it was not there. It could be argued that this is a mere detail, but I can assure the Minister for Health and his colleagues that it is not a detail to those thousands of people who, each year, require attention to their eyesight. The Government have committed yet another fraud against the electorate by introducing this measure. They would not have introduced it just before June 1987. They had every opportunity, but they did not introduce it then. I shall refer to the time when they had the opportunity to do so.
The Government set great store by competition. Free market forces and competition are the gods worshipped by the present Administration. In the White Paper the Minister for Health said that the reason for abolishing free eyesight testing was thatThe Government had decided …to extend the principle of increased competition to sight testing".The Minister argued that we should be discussing whether or not that charge will deter people from visiting an optician for a consultation and an eye test. The report of the Select Committee on Social Services, which took the evidence of the General Optical Council, stated:The evidence we have received has not been so ebullient. The BMA is worried by the lack of reference to Ophthalmic Medical Practitioners' (OMPs) invaluable support service to hospital ophthalmology departments, reflecting the opinion of their Ophthalmic Group Committee that OMPs are 'a sadly underused and undervalued resource in primary health care'.The important section states:The General Optical Council are keen to draw a distinction between a full eye-examination and a sight-test. The former would pick up many defects and abnormalities which a simple sight-test would not be able to detect, enabling the optician to prescribe corrective or ameliorative treatment. Thus waiting lists are kept down in hospital ophthamology departments, and the examination can also be used to monitor diabetes and screen for glaucoma. The GOC claim that there is a growing trend towards the quick eye test as a result of commercial pressure on registered opticians and the employment of unqualified sight testers by unregistered sellers of spectacles.I would argue that that is precisely the kind of scenario that we shall see on a much larger scale if charges are introduced. The Minister for Health in his speech in the House on 25 November referred to the fact that opticians can still provide a free test. However, there seems to be a difference in attracting custom to an optician by providing 80 a free test or by issuing free stamps. Commercial profit is uppermost in the Minister's mind, not the better health of the people. He is applying a commercial criterion.
Of course, an optician can offer a free test and hope that the person being tested will come along as a patient and purchase spectacles from the optician. We could almost call this a loss leader. The optician may make a loss on the sight test, and hope to gain through the sale of spectacles. What is really uppermost in the Minister's mind? Is he primarily concerned with commercial profit or people's health?
Again on 25 November, the Minister referred to the need to secure additional resources for developmentby asking those who can afford it to pay for sight tests and to meet somewhat more of the overall cost of dental care." —[Official Report, 25 November 1987; Vol. 123, c. 260.]He referred to NHS sight tests remaining free for children and certain others on low incomes. He has not adequately answered the question from the hon. Member for Langbaurgh (Mr. Holt) who asked how low an income would be before tests were free. Will the exemption be confined only to those who qualify for income support? In the opinion of most of us, many people of meagre means would qualify for free treatment.
All that is intended to save a mere £170 million. Of course that is cheese-paring, but that is all of a piece with other Government legislation. The same thing is happening in the Social Security Bill in regard to the decision to reverse the Moran judgment on attendance allowance. That will save precious little, but it all adds up to enable the Chancellor of the Exchequer to meet the promised tax cuts for richer people come next April.
There can be no justification in denying a free eye test to poor people simply to help those who can well afford to pay more in tax. We are always told that the Government want those who can well afford it to pay for this and to pay for that. They can pay higher taxes and the Government have the option next April to ensure that public opinion in this country, which is overwhelmingly in favour of maintaining our National Health Service free at the point of treatment, is unchanged.
The stance of the Secretary of State for Social Services is different from the stance adopted by some Tory Ministers in the past. The present Minister for Health was a member for Standing Committee A which considered the Health and Social Security Bill in 1984. The Committee was responsible for going clause by clause through the Bill. The Minister may well recall that his right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), one of his predecessors as Minister for Health, stated when the Government were scrapping free NHS spectacles for most people:It is the health of people that we are, above all, prepared to, and must, protect. The desire to protect the health of individuals is the only legitimate interest of Government in what otherwise is a free transaction between the optician on the one hand and the client on the other".The right hon. Gentleman was talking about free eye tests. The Minister went on to say:We have continued to provide, under the NHS"—and I want to emphasise this—the most important service, an eye test available to everyone free of charge."—[Official Report, Standing Committee A, 24 January 1984; c. 13.]On 26 January the right hon. and learned Member for Rushcliffe returned to this point:We have retained all the essential requirements that we think that the public need—in particular"—81 and I emphasise this again—the free eye test for everyone and the legal prohibition on anyone selling glasses unless there has been a recent eye test,". —[Official Report, Standing Committee A,January 1984; c. 53.]What has changed between January 1984 and December 1987? Should it not be fundamental to health that people should have the chance of a free eye test?
The Minister for Health has argued that the eye test will not cost all that much and he cited a figure of £10. Indeed, he has said that it might be less. Who knows? Who can say? After all, the Minister also said, when challenged by my hon. Friend the Member for Livingston (Mr. Cook), that opticians can charge any price. The Government will not put a maximum price on the tests. There will not be a ceiling. The sky could be the limit. There will be no Government control because they believe in market forces. Market forces means the free play of demand and supply. The price is at the point of equilibrium, not at the maximum amount of demand.
In other words, some people will not be able to afford the price. The Minister for Health may not believe me, but not everyone carries the price of a particular type of medical service in their heads. Many people would not be able to tell us the price of a prescription. After all, prescription charges have gone up about 20 times under this Government, so people can hardly be blamed if they cannot remember the price of a prescription. That charge may be £5, £10 or whatever, but many people, knowing that they will have to put their hands in their pockets—very often there will be little in those pockets—will be deterred simply because they know they will have to pay a sum of money for the test and follow that up by paying for the spectacles. Not everyone is a civil servant from the Department of Health and Social Security capable of carrying statistics around in their heads. Ordinary people do not act in that way.
The result of the proposed changes will be that far more people will be put off going for treatment. The Bill will not necessarily mean that public expenditure will be reduced. Many people who would go for a free sight test today and who would perhaps be the one person in 20 who, after that test, is referred for medical treatment will miss such medical treatment at that time. The result will be that they will be pressed into eye hospitals or into the eye departments of general hospitals at a later stage. There will be a knock-on effect and waiting lists, already high for many conditions in many places, will increase. The result will be more public expenditure and not less. It is not a pun to say that, in terms of public expenditure and patient care, this measure is short-sighted. In terms of savings it is likely to be counter-productive.
The police tell us that many driving accidents are due to bad vision. Such people are in need of eye tests and should go often to have their eyes tested. However, even under the present system of free examinations, they have failed to go for such tests and, as a result, have caused accidents on the road. I suggest that there will be more road accidents as a result of people not having those examinations because they are no longer free.
This is not the first time the Conservative Government have come forward with proposals to introduce charges for eye testing. It was proposed in a new clause presented by the Government when we were considering the Health Services Bill in 1980. At that time, the then Minister for Health, the hon. Member for Reading, East (Sir G. 82 Vaughan), withdrew that clause because there was considerable pressure from both sides of the Chamber and from outside of the Chamber. It would be rather interesting to know—perhaps the Minister for Health or the Parliamentary Under-Secretary will be able to tell us — how many letters have been received since 25 November when the Minister announced the proposed charge. How many letters of support has he received? How many letters opposed that measure? I suggest that he has had none from the medical profession supporting the proposed charge. However, if I am wrong I should be interested to hear.
In 1984 when the Minister and myself served on the Standing Committee to consider the Health and Social Security Bill my hon. Friends argued that the Oglesby report was likely to be the basis for Government health policy in the near future. That report advocated all sorts of charges for people who may be attending hospital, attending the doctor and so on. At that time we were told that the Government had no intention of implementing that report. However, in 1979, when the Conservative party took office, a document was published by the Adam Smith Institute that said that patients should pay for their spectacles, for the eye tests, dentures, dental examinations, for attendance by a general practitioner, and should pay to be in hospital. All those things were advocated by the institute. I suggest that the people likely to be in favour of the present Bill are perhaps the crackpots of the Monday Club and also members of the Adam Smith Institute. Certainly most ordinary, decent people are not in favour of this Bill.
The Bill appears to be the thin edge of an extremely dangerous wedge. Unless certain political events take place as a result of public action—by-election defeats or the defeat of Conservative candidates in local elections—I foresee the day, before the next general election, when the Government will introduce charges for attendance at hospital and for attending the GP. They will get us back to where they really want us to be, in the days before the NHS.
I hope that the Minister can prove me wrong. I hope that he will join with all in this House who have expressed their reservations about this proposal and do as his predecessor did in 1980: withdraw the clause from the Bill. I promise him that the Labour party, and, I suspect, one or two others elsewhere, will fight this clause every bit of the way and publicise what takes place in Committee after the Bill has unfortunately been read a Second time. I can only hope that there are people with guts on the Conservative Benches who will see that the Bill does not reach Committee. However, experience tells me that I am expecting far too much.
§ Mr. David Heathcoat-Amory (Wells)
The hon. Member for Liverpool, West Derby (Mr. Wareing) has predicted a disaster if the charges for eye tests — he concentrated on those, but I assume he also means the charges for dental checks — are introduced. Such predictions are based on the assumption — he did not spell it out in great detail—that the charges will act as a massive deterrent to patients seeking eye tests and dental examinations.
All the evidence that we have shows that when charges are introduced or increased there is a check or even a temporary reduction in the number of patients seeking 83 such examinations or treatment, but soon the position recovers and the upward trend is resumed. The hon. Member for West Derby will know that from the experience of his own party. In 1951 the Labour party introduced charges for false teeth and spectacles. Ever since then, every Labour Government have found it necessary to increase charges to patients of one sort or another. If the hon. Gentleman considers the history of his party, he will discover that, yes, there is a temporary falloff, but the trend generally recovers. I am certainly confident that after the Bill has been enacted and the charges have been in operation for a short time he will find that the number of people seeking eye tests and dental examinations will resume an upward trend. The numbers will certainly remain very much higher than they were eight or nine years ago when his party was last in office.
Charges for these examinations are wholly right against a background of constantly increasing expenditure on the Health Service in general and on primary health care in particular. As the Green Paper made clear, we are set to see a further substantial rise of about 11 per cent. in real terms over the next three years. This money must come from somewhere. Three sources can be identified: first, from internal economies; secondly, and overwhelmingly, from the public sector by way of the taxpayer; and, thirdly, but significantly, from private sources by way of patient charges. People who can afford it should contribute directly towards their health care. I have noticed that very often the most vociferous critics of this principle turn out to be those who are now better off than ever before, whose wages and salaries have risen in real terms over the past few years and who have seen substantial reductions in their income tax.
I have always supported the concept that people should be allowed to retain more of their own money, but the other side of that coin is that we should, and have a right to, expect those people to provide more of the health care and security of themselves and their families. People whose standard of living has risen and whose disposable income has gone up should contribute towards this very substantial increase in expenditure on the National Health Service, the increase that we have seen in recent years and the increase that is planned for the future.
Charges also involve the patients more closely in the efficiency and value for money of the Health Service. What we pay for, we value. Any service — and the Health Service is no exception—is likely to improve if lots of people using it also contribute directly to it out of their own pockets. They form an on-the-spot audit every day of the week of the effectiveness and efficiency of the service that they are getting. If we really want a responsive and patient-directed Health Service, charges such as are outlined in the Bill have a part to play.
Let me strike a note of caution, however, on costs because clauses 12 and 13 of the Bill open the door to some increases in staff. Family practitioner committees will have additional powers to pay for training and education of primary health care staff and also directly to reimburse additional categories of staff — interpreters, computer operators and so on. I have no doubt that these offers will be taken up enthusiastically by general practitioners, and I am sure that most of the staff will be properly employed; but this could quite easily become another engine of expenditure unless we find offsetting economies. Here I 84 identify a very large area of potential waste which the White Paper discussed but about which the Bill is comparatively silent, wastage in pharmaceuticals.
Some doctors still have extravagant prescribing habits. It is conservatively estimated that as a nation we throw away about £160 million worth of drugs a year. The nation's pill cabinets are groaning with pills and medicines which have been prescribed but which are surplus to requirements. Some doctors—and they are not wholly to blame themselves—prescribe two, three or even more months' supply at once. It is not just financially wasteful; it is also unsafe because when the treatment ends or is changed or when the patient dies or whatever it may be, those pills remain in circulation to become muddled up with other pills or out of date, swilling around in the nation's bathrooms and pill cabinets. I would like to go for a 28-day mandatory limit for the supply of pharmaceut-icals—
Mrs. Margaret Bekett (Derby, South)
I thank the hon. Gentleman for giving way. He has spoken very much as someone who has never had to worry about the cost of anything in his life, but he is clearly unaware that many doctors now prescribe larger amounts because so many patients can ill-afford to pay prescription charges; as pharmacists can testify, even in these circumstances many prescriptions are not fully filled.
§ Mr. Heathcoat-Amory
The hon. Lady flatters me—I must look more prosperous than I really am. What she says does not invalidate the point that I make because, as she should know, there are many exemptions from prescription charges, and anyone who is genuinely unable to pay them is exempt. I agree that I am not one of those people.
§ Mr. Heathcoat-Amory
Moreover, what she says does not invalidate my point that we are not just financially profligate but we also endanger patients' health by doing it. Some say that we should go for generic substitution. The White Paper skirts around that. I am attracted to it and have always felt that if pharmaceutical companies need a longer period for paying back their massive investment in new drugs the patent period should be extended. Instead, the White Paper draws attention to the problem and points to a greater role for family practitioner committees.
There still remains, however, a confusion between the regional medical services of the Department of Health and Social Security, which, by and large, hold the information on their computers, and the family practitioner committees which hold the contracts with the doctors. The two should be brought together, and the FPCs should have not just the information but the duty, the responsibility and the power to follow up and take action against that minority of doctors who are unsafe and extravagant in their prescribing habits, because the potential saving here dwarfs anything else disccussed in the White Paper, and there are these additional health benefits.
I approve of the overall tone of the Bill. Prevention is certainly better than cure. In passing, I hope that my right hon. and hon. Friends on the Front Bench do not forget the libertarian tradition in our party, to which I subscribe, which says that responsible adults, if given the right information, are capable of making their own choices. That includes the right to make their own mistakes.
85 Of course, it must be right to point out to people incontrovertible links between, for example, smoking and lung cancer; but I hope that we do not go way beyond that and adopt a hectoring and disapproving attitude towards things which medical fashion may from time to time decree are excessively unhealthy. A balance must be struck. Let us not have too many bans and prohibitions. Let us instead rely on persuasion and education.
The Bill introduces provision for additional medical training of ancillary staff, but there is a bigger training challenge ahead. Increasingly, medical technology is pushing back the frontiers of what is possible, on the one hand, but, on the other, we know that resources are limited and that doctors are in consequence being forced all the time into making implicit judgments when having to allocate priorities. That would remain true even if we doubled expenditure on the NHS. It would be possible to design an NHS that would bankrupt the country, but patients could still be found who could claim legitimately that they were being denied a course of treatment, a wonder drug, an operation or a bit of machinery that they heard or read about and was available in some country.
Therefore, it is inescapable that choices must be made. We must try to maximise the health and happiness of patients with the resources available, which, by definition, are always limited. We must make difficult cost-benefit calculations. My point is that administrators alone are not capable of making them. We must train doctors and other medical staff so that they appreciate the problems involved and share the management burden.
I welcome the Bill and believe that it can be a springboard, so that we can face the challenges ahead, to guide us not just towards a more expensive Health Service — that would be easy — but, much more difficult, towards a better Health Service.
§ Mr. Dennis Turner (Wolverhampton, South-East)
When I listen to the hon. Member for Wells (Mr. Heathcoat-Amory), I wonder whether he perceives that today there are people who are not enjoying an increased standard of living and whose disposable income is not gaining appreciably. Millions of people find the day-to-day and week-to-week grind to maintain and build up standards for their families a real problem.
The hon. Gentleman said that people might temporarily become consumer resistant, but that things will start to level out. Let me tell him what the first test will be when a mother with children is confronted with having to pay the £10 charge, or when a husband who is working out the week's expenditure finds that there is no £10 left at the end of the week for a dental or eye test. Those people will decide their priorities and, as a result of the charges, might neglect to do what is suggested by the Government and not go for a test. If they do not go for a test, their health may deteriorate and give rise to additional costs on the NHS. I suggest that the charges will prevent many people from taking the course that we know is in their best interests and, in the long term, of the NHS.
The Bill cannot in any way inspire confidence in the claim that the NHS is safe in the hands of the Conservative party. Indeed, it does just the opposite. As has been said by many hon. Members, great opportunities have been missed which could have been taken in the Bill.
The great arguments on the major issues involved in the NHS were effectively dealt with and the myth demolished 86 in our debate on 26 November. The arguments were demolished equally by my hon. Friend the Member for Livingston (Mr. Cook) and by the right hon. Member for Brentford and Isleworth (Sir B. Hayhoe), who showed clearly what has happened over the past few years to our Health Service and where the myths have arisen, and we shall hear them again tonight. We know that all is not well with our NHS.
I am privileged to represent Wolverhampton, South-East. The Parliamentary Under-Secretary for Health and Social Security, the hon. Member for Derbyshire, South (Mrs. Currie), said a few days ago that the Black Country had "nothing to moan about." At the moment in the Black Country, in Wolverhampton, Birmingham and throughout the west midlands, as the Minister knows, there is a mounting crisis in the NHS. It is not doing that word an injustice to say that it is a crisis. Over the past few months, in my district health authority, three people have died. They lost their lives because they could not be admitted to any of the hospitals in my area, when they were in a serious health condition. Over the past 12 months, 400 people who were seriously ill have had to be refused admission. They were turned away because no beds were available.
In all our acute bed specialties, with the exception of ophthalmic, there are bed shortages, and in some the figure is the equivalent of 50 per cent. General practitioners in Wolverhampton tell me that the heartache and ordeal of picking up the telephone at 5 o'clock at night to try to find a bed for a seriously ill patient is distressing. General practitioners spend hours trying to find a bed.
We have a renal unit, where the machines are provided by the community. Trade unions and voluntary bodies raised funds, doing it in the way that the Conservative party says it likes it to be done. The funds have all been made available externally. However, the unit is housed in small, makeshift accommodation. We were promised capital expenditure to provide proper accommodation in the near future. Each time that we have asked about that, our request has been turned down. We understand that the Secretary of State has said in the past fortnight that he will reconsider that, but we all know that reconsideration may not mean that that provision will be made.
When I look at my district health authority and listen to the arguments of Conservative Members tonight, a clear message comes through. There is a standard pattern of delivery by Conservative Members. First, quite rightly and defensively, they say, "We appreciate all that the Government have done to assist the Health Service. They have done a marvellous job." They duly give a pat on the back to all and sundry. However, in the second phase of their delivery they say, "But in my constituency I shall stand up and describe all the inadequacies of the service. I shall articulate the needs of our patients, doctors, nurses and the service in general. In that context, the Government are not doing a very good job at all." That is said in enough constituencies to make the Secretary of State and the Under-Secretary a little concerned about the vibes on the state of the Health Service that are genuinely coming from their own Back Benchers.
I believe that for some Conservative Members the Bill is the final straw that will prevent them from going into the Lobby and voting with the Government. That is another sign of how bad we all know the position to be under the surface. It is no good saying that a certain amount of money has been injected, when we know about 87 the serious day-to-day problems. I have given instances of those from my own community in Wolverhampton. Our community health council, our medical practitioners committee and my district health authority all tell me of their bad day-to-day experiences, and they are joined by the chairman of the West Midlands regional health authority in saying that there is a need for greater resources to be injected into the National Health Service, in the west midlands and throughout Britain.
It was clear from our debate on 26 November—it will be so in future debates — that the people of this country regard the situation more in sorrow than in anger. However, I give a warning: one can see that sorrow welling up in our communities and turning to anger. Sensitive men and women are identifying as insensitive a Government who fail to respond to the unassailable case that has been presented. Many Conservative Members should vote against the Bill. Let us provide the resources that are needed to start building a better Health Service for all our people. After all, is it not the test of a civilised society to move forward, rather than to introduce legislation that takes us back?
§ Mr. John Greenway (Ryedale)
I am grateful for the opportunity to contribute to the debate. For the past 15 years it has been my privilege and pleasure to advise members of the dental profession on the financial arrangements and management of their practices. That experience has given me a unique insight into their way of life and the way in which their affairs are financed. I hope to share that insight in a helpful way with hon. Members this evening, as we address the difficult problem of our National Health Service.
The Bill must be seen in the context of recent trends, especially in dental health. Since 1978–79 there has been a 20 per cent. increase in the number of dental practitioners and a corresponding 20 per cent. increase in the number of courses of dental treatment. There has also been strong evidence of improving dental health, to which the work carried out by general dental practitioners has contributed admirably. However, the need for change in the general dental services has become more and more obvious.
Looking back over the past 15 years, one can see that patterns of treatment and dental care have changed dramatically. The need for change was initially reflected in the Government's Green Paper and admirably dealt with in the British Dental Association's response —"Opportunity for Change"—and was further addressed in the White Paper proposals. There is also a continuing dialogue between the British Dental Association, and its general dental service committee and the Department of Health and Social Security on the need for a new dental contract, with which I shall deal later.
We should also reflect on the fact that the need for increased resources for the Health Service and the requirement for increased charges have obscured —indeed, eclipsed—the many good things that the White Paper contains and that I greatly welcome. Nevertheless, it must be said that the announcement earlier by my hon. Friend the Minister for Health that the proportional charge that we will introduce will be as high as 75 per cent. will be a grave disappointment to many dentists. Equally, I am sure that there will be some relief at my hon. Friend's 88 announcement that there will be a ceiling of £150 on the total amount payable. A real fear has been expressed throughout the debate by hon. Members on both sides, that removing the free examination will lead to reduced attendances. I have some sympathy with that point of view, but the issue that must be addressed—it has not been tackled so far in the debate — is what dissuades patients from attending dental practices more regularly.
A study is now being done jointly by the Department and the British Dental Association into "Barriers to Dental Health Care". When that report is published, I suggest that there will be several possible explanations in it of why there is not more regular dental attendance. Cost is one; fear of pain is another; the possibility that people cannot find a dentist who is prepared to treat them on the National Health Service is a third. But I suggest that perhaps the greatest reason for non-attendance is lethargy. There is no perceived need to see a dentist. It will be interesting to see what the report has to say about the image of dentists and dental practices.
Much has been said in the debate about costs and charges, but the fact remains that almost half the population do not attend a dentist regularly in spite of, not because of, the free dental examination. I venture to suggest that it would be interesting if my hon. Friend the Parliamentary-Secretary of State looked into what proportion of the population do not attend regularly, and, of those, how many would be entitled not only to a free examination but to free dental treatment on remission if they went more regularly. More regular dental attendance takes place in the southern half of Britain, where the vast majority of adult patients pay a substantial proportion of the cost of their treatment. So, while it would be easy for me to stand here and say, on behalf of all my friends in the dental profession, that I could not possibly support the idea of phasing out the free examination, that is not my conclusion.
There are two reasons why I say that. First, the proportional charge is lower as a result of the phasing-out of the free examinations. My hon. Friend the Minister for Health accurately elucidated the fact that patients who attend dental practitioners the most regularly will pay slightly less under the proposed arrangements. The message must be got across to the public that if they attend their dentists regularly and keep in contact with them they will be spared large bills for dental treatment.
The second point is that it provides an opportunity for us to concentrate more on prevention. More and more patients when they go to a dental practitioner regularly need less and less treatment. Where did my hon. Friend the Minister for Health first encounter the phrase about a continuing care contract that he used in his speech? That phrase is very much on the lips of many dental practitioners. The general dental service committee has proposed to the Department that there should be a change from the present contractual arrangement and a much greater obligation placed on the relationship between the dentist and his patient by way of a continuing care contract. A proposal has been made for an annual registration fee. This annual arrangement would, one presumes, require funding at a much higher level than the present examination fee of £3.90.
One interesting point arising from the debate is that there are a great number of requirements, and of possible illnesses and diseases, for which the dentist looks when he is examining a patient. Has any hon. Member thought that 89 what we should be addressing is not whether we should ask patients who can afford to do so to contribute towards the cost of treatment, but whether we should ask what is a proper amount to pay a dental practitioner for the work that he does in screening and monitoring dental health? That is the purpose behind the proposal for an annual registration contract. Much research has still to be done about this, but that is the framework within which we can promote much more prevention in dental practice. Dentists have the opportunity and a great obligation to teach their patients more about oral health and about how they can preserve their teeth.
§ Mr. Ronnie Campbell (Blyth Valley)
The hon. Gentleman glibly talks about working people paying. In my constiteuncy in the north-east, unemployment is about 20 per cent. and people are living on the breadline, or, as we call it, in the halfway house. They are frightened to go to dentists in case they receive treatment that will cost about £30 or £40. The Government are proposing to promote some sort of advertising campaign to advise people caught in the poverty trap, not only in the northeast, but all over the country. The hon. Gentleman says that he has the answer, but so far he has not told us what it is.
§ Mr. Greenway
The hon. Gentleman has answered his own question. We want to encourage people to attend dental practitioners more regularly so that they can avoid the £40 bills. Much of the hysteria that we have heard in the debate will not encourage people to go to their dentists because they think that they will have massive bills. That will not he the case if they go regularly, and it is not the case now.
No costing has been proposed for the annual registration contract, but one assumes that the arrangement would take care of all the screening procedures, X-rays, and possibly even the cleaning of teeth. It would be unrealistic in the present climate, given the need of the Health Service for resources, to expect that the patient should not contribute to that contract. There is an opportunity here for us to do a great deal of good to encourage patients to go to a dentist more regularly.
I shall now deal with the timetable. My hon. Friend the Minister for Health said that the Government hope to introduce a proportional charge arrangement in April, with fixed fees for those items that require primary legislation. He said that he would seek to introduce the proportional charge for the examination at a later stage. Will he seriously consider the possibility of bringing in a new contract for a continuing care arrangement at the same time as the proportional charge for the inspection is introduced? That would allow people an opportunity to absorb the major change of emphasis and would allow the positive proposals in the White Paper on dental health promotion to take effect.
I was delighted, and I am sure that members of the dental profession will have been delighted, to hear the Minister say that he is proposing to undertake a major advertising campaign for dental awareness. That is the great priority, because we must increase the priority that the public give to dentistry and dental health. Attitudes must be changed, and I warmly welcome the Government's commitment to promote health education. This must be pursued with vigour and if the funds raised from charges can be used to this effect the money will be well spent.
90 There are many other aspects of the Government's proposals, especially those in the White Paper, that deserve warm support. Extra resources for fluoridation will contribute greatly to preventive policy. More post graduate and vocational training will also help. It has been my privilege to be involved in dental vocational training for 10 years since the Guildford experiment started in 1977. There is a need for that, and for more resources to be devoted to it, and I welcome the Government's commitment to provide them.
We must also review the best means of achieving a more even distribution of dentists. I support the proposal in the White Paper that this should be done, and the review should consider how to make available information to help dentists decide where, when and how to invest in practice projects. We need information about local problems to be available nationally in order to encourage redistribution in a controlled way, so that local practitioners already in-place are not unduly and adversely affected.
The constitution of the General Practice Finance Corporation is also being changed by the Bill. The Government should consider whether to take the opportunity to include dental practitioners in the provision of finance for the newly constituted body.
I know that I have touched only on matters affecting dental practice. The Government's plans for family doctors and health promotion generally offer a better deal for patients and greater opportunities for doctors to improve and widen the scope of the health care that they provide. The Government's plans represent, not just a radical shake-up of the family practitioner services, but a long-awaited and much-needed opportunity to create a system of primary health care that the nation will need, not just in the 1990s, but into the next century.
It is outrageous hypocrisy for the Opposition to say that the Government are not doing enough for our Health Service and then to refuse to support the imaginative initiatives that are contained in the White Paper.
Finally, I pose one question: what sort of National Health Service will we have in 20 years? Some hon. Members who have just come to the House may be fortunate enough to be returned in future elections, and some of us may have a long and distinguished career. I shall tell the House what sort of National Health Service we will have in 20 years. Unless we pursue a policy of encouraging prevention, and unless we educate the public to the effect that they can avoid preventable illnesses, we will not be able to afford a National Health Service beyond the year 2000.
§ Mr. Ronnie Fearn (Southport)
We agree with and welcome some proposals in the Health and Medicines Bill and the White Paper. However, like many hon. Members, for all the reasons cited in the debate, we are totally opposed to the introduction of charges for dental checks and eye tests. The proposed changes make a mockery of the Government's announced intention to improve preventive health care. The proposals were not part of the consultative discussions and document and will prove to be more expensive to the NHS in the long run. Diseases and illness previously detected by opticians and dentists 91 will remain undetected and in the long run patients will go into hospitals, thus increasing hospital waiting lists. I quote from the document "Primary Health Care: An Agenda for Discussion", in April 1986. At page 32, under item 4, "NHS Services", it says:Free NHS sight-tests and prescriptions are maintained for everyone who needs them. The sight-test can identify health problems as well as a need for spectacles, so it is important that skilled sight-testing should remain readily available.We shall not have that when the Bill goes through.
We are concerned also about the removal of the duty placed upon the Secretary of State to provide dental checks and treatment, where necessary, to schoolchildren. We are even more concerned from our reading of the relevant legislation that the Secretary of State's discretionary power to provide those services extends only to children in schools maintained by local government. If the Education Reform Bill becomes law, children in schools that have opted out will be left without a safety net. Is that what the Government intend, or is it a drafting error? I hope it is the latter, but perhaps the Minister will clarify the point.
Like much enabling legislation, the Bill leaves many questions unanswered. The proposal to privatise the General Practice Finance Corporation did not form part of the consultation process. The Government obviously envisage some problems with loans being provided in deprived areas. Do they see other problems arising from the constraints of finance and commerce? For instance, will young single or married women doctors be seen as a good financial or business risk? How do the Government intend to monitor the distribution or refusal of loans? Are there plans to require reports to safeguard against maladministration? We must have more details before we can approve the proposal.
Whether one agrees with the principle of the controversial clause 4, in practice it is not as easy as it looks. It will create administrative and managerial headaches and will add to the overheads and costs, with a corresponding reduction in the income generated. Most importantly, do the Government guarantee that any extra income from those activities will not be offset against allocations by the DHSS? Unless the proposals generate genuine extra cash, they should not be implemented. Does the Minister realise that the subsections of this clause that give him the power to issue directives cover bodies such as the community health councils, and that this may go against the spirit surrounding the setting up of those bodies?
Much has been said against the introduction of cash limits on family practitioner committees, and we add our voice to those concerns. The Bill does not tell us how they are to be allocated. The House should be aware that such limits could be extended to cover all services provided by family practitioners. We know that funds for training are to be cash-limited, but we do not know what form the training must take before it will qualify for reimbursement. That is important. The training should be of a high standard and should have some uniformity.
We support some of the Government's proposals, but some should be removed from the Bill and others require far more investigation. My major worry relates to the Government's real objective behind the Bill and the White Paper. Is it the beginning of the slippery slope to the 92 reduction of family practitioner services supplied by the NHS in favour of some form of privatisation of the services, an objective that they hope to realise without the true and real consultation to which the electorate has a right? I fear that it is the beginning of the end to a truly national health service, which at one time was for all the people, but as we look at it now will not be for all the people.
§ Mr. John Redwood (Wokingham)
I had hoped that in the debate we might have gone beyond the normal exchanges across the Floor of the House, with the Opposition saying that if only there were more money and people it would be all right, and our saying that there are many more people and more money so it must be fine. I should have thought that if Opposition Members believed that only more money and more people were required, they would admit that the hospital and GP services are much better now than they were under the Labour Government, because there is self-evidently much more money and many more people. I should also have thought that they would not turn down any suggestions or good ideas for raising money and bringing more resources into the service, which is exactly what the Bill and White Paper suggest: yet more resources for the service to meet growing patient demands.
Why is it that with all the extra resources there is still unhappiness and patient demands are not being met? Part of the problem lies in the structure of the very large, top-heavy Health Service that we inherited and are living with. The layers of management are legion. Why do we have one group of civil servants at the centre arguing with another group who run the National Heath Service management board? Could there not be unity and a single organisation? Why do we need over £100 million of regional administrative structures and inter-regional co-ordinators to carry the word down and up from the region to the centre? Why have another level of bureaucracy and administration at the district level before getting to the people who run the service and other things for patients in hospitals and general practice clinics?
Why is it, also, that in a money-oriented culture the answer is always more money? If the administrative structure does not accept its responsibility to run the service in the interests of the patients, from a senior level, the answer will always be more and more money because it is the easy way out, avoiding difficult management decisions. Conditions should be placed on the granting of new money to the Health Service to develop a sense of responsibility within it, so that senior people in the Health Service management feel that if a baby is going without an operation, that is their problem and their responsibility. They have £20,000 million to manage their affairs, so such things should not become matters for the national press and the House of Commons but should be dealt with at the local level.
It ill behoves people in the Health Service to grumble about recruiting nurses and other skilled staff when very often the labour organisations oppose the flexibility on pay which is needed to get nurses into the places as required. Why has there been so much delay in getting regional divergencies in pay and extra pay for special skills? Much of the problem lies with the Opposition and the unions, not with Conservative Members.
93 Who answers for the National Health Service? Managers must have powers and responsibilities to answer for the service delivery. I feel that within the administrative structures of the NHS there lies a deep hatred of the small hospital. Why does the NHS always go towards the large and the new, never supporting small community hospitals which are much loved by all hon. Members? It is not a matter of money; it is a matter of management style and it is high time that they were told that the small hospital is valued—
§ Mr. Redwood
I do not have time to give way. It is not a matter of money and resource; it is a matter of management. We need the Bill, which is an important step on the road to providing a service with choice, management responsibility and a variety of sources of money and resource.
I welcome clause 4, which gives hospitals the opportunity to raise money and provide better services by bringing in private capital and skills. Why should patients and visitors not have the chance to get access to a different range of retail activities, types of food and drink and other necessary services? It is high time that hospitals were modernised, and we should encourage private capital and management to do it.
We need a system at general practitioner level to ensure that referrals to hospitals are made on good information about where waiting lists are shortest and where the patient can go, if he chooses, to have his operation performed quickly. There are glaring anomalies and a huge range of differences in standards of patient care that are entirely unrelated to resources and completely to do with management.
It is time that the GP had the power at his desk to help the system and the patient by reducing queues and waiting times by knowing where the shortest waiting lists are to be found. Why are out-patient clinics about the only places left where one can arrive for an appointment only to find that 30 or 40 others have been given the same time? It is not cuts that cause that to happen. That is the result of administrative decisions, and it is a disgrace. It is high time that out-patient clinics had sensible appointment times and that consultants adhered to them. That would greatly improve the standard of service and people's perceptions of it.
Throughout the service we need an ethos that is friendly to patients and marshals the huge resources of the NHS in the best interests of its patients and for no one else. We do not wish to see a producers' cartel. Nor do we wish to see a huge amount of resources going in at the top, and leading to expensive management games, endless rows and pieces of paper passing between regions, co-ordinators and the centre shifting the blame. We want resources to be directed to the bottom. The White Paper and the Bill offer choice and scope for additional funding. The Bill should be warmly welcomed. I hope that it is the first step of many.
§ Mr. Frank Haynes (Ashfield)
I was not surprised by the contribution of the hon. Member for Wokingham (Mr. Redwood), who is one of the whizz kids of the Conservative party. He was working outside the House—
§ Mr. Haynes
I do not need the Minister to say "Of course". The hon. Gentleman was working outside the House on behalf of the Conservative party before 1979 when the policies that the Government are now putting before us began to be formed. I well remember what the Tories were saying during the pre-election period in 1979. I remember also what they did after the 1979 general election. It seems that all Conservative Members in the Chamber are laughing except one or two who were Members before 1983. The great majority of them are new boys.
During the 1979 election campaign the Conservatives were saying that if they formed a Government they would reduce public expenditure. They won that election and they have reduced public expenditure.
§ Mr. Haynes
I do not need the Minister to confirm or deny what I am saying. I am making a speech, not the hon. Lady.
The Government have made across-the-board cuts throughout the land. All services have been cut —[Interruption.] This is no joke; it is a serious matter. Before 1979 the Under-Secretary of State was implementing Conservative policies as the leader of the Birmingham health authority and cutting services. It is no wonder that the Health Service is in a mess when people such as the Minister were involved in health authorities. The hon. Lady is now a Minister and the actions that she is taking these days are even worse than those that she took when in Birmingham.
The Government have imposed cash limits and told health authorities that they cannot exceed them. They are warned that if they do they will suffer the consequences in following years. The message is, "Save your money and cut services." Everyone is scrimping and scraping within the Health Service to provide necessary services for the people, who are our constituents. We hear Conservative Members criticising some of the cuts in the NHS—some of them agree with the criticisms of Opposition Members— yet they vote to support the Government. I do not know how they get on when they return to their constituencies. They probably say that they did not vote to support the measures of which their constituents complain. I do not know what they say, but I know that the Government have created a begging society.
§ Mr. Haynes
I wish the Minister would keep quiet and listen. I never interfere when the hon. Lady is on her feet, so shut up!
§ Mr. Haynes
There is evidence of the begging society in my constituency. The state should provide a heart scanner and yet the people of Ashfield and Mansfield have had to beg on street corners for donations to provide this necessary piece of equipment. There are people in desperate need who cannot afford the private sector, unlike so many Conservative Members. I have received a letter from the mayor of Eastwood town council in my constituency in which he refers to the Nottinghamshire kidney fund. I know of a chap who has worked his soul case out for 15 years to provide money for the fund. Tony 95 Higgins has begged on street corners and worked like a Trojan to raise money for kidney machines. Good luck to him, but this equipment should be provided by the NHS. In other words, it should be provided by the state.
When people are in work they contribute to the NHS by paying their national health stamp. The more one earns, the more one pays. There are billions of pounds being paid into the Government that should be used through the NHS to provide kidney machines and other vital items of equipment. Unfortunately, the money is not being used in that way. It is being used to pay for the advertising of share offers when public undertakings are being privatised. It is used to acquire weapons of destruction. By gum, we shall change all this when the Labour party forms the next Government.
It is sometimes necessary nowadays for individuals to lodge appeals when they need social security benefit. Benefit is often denied to them because of the regulations that the Government have introduced. Some of my constituents are on appeal because they say that they are entitled to benefit and the Department says that they are not. The hearing of an appeal can take as long as eight months. This is shocking. This has happened only since the Conservative Government—that lot on the other side of the Chamber — came into power. Under the Labour Government, those who were entitled to benefit received it. The present difficulties are related directly to public expenditure cuts.
We have been told by a Conservative Member that individuals value that for which they pay. That is true, but we are paying through the nose for the NHS without getting the value to which we are entitled. That is the problem, and that is what we must put right.
Every year the Nottingham Evening Post runs a scheme to raise money to keep the elderly warm. This leads to begging on street corners. The front page of the Nottingham Evening Post carries a headline which asks readers to contribute to enable the elderly to keep warm during the winter, and copies of it are sold by lads on street corners. It is the Government's responsibility to keep the elderly warm, but they are denying that it is. More and more people die each winter under the present Administration. Why is this? They are dying of hypothermia.
The end result is that we get kicked in the constituency and asked, "Why are you not doing something about it?" We are doing what we can in this place, but the Conservative Government have a majority of 101. They can get anything through. Conservative Members say that they do not agree with some of what the Government are doing, but they troop through the Lobby to approve it and to put it on the statute book.
Nottinghamshire county council and my district health authority are falling over backwards to try to provide additional chiropody services, but the county council — which, incidentally, does a marvellous job—is hampered by rate support grant cutbacks, and the chiropody services are suffering as a result. Not so long ago, the Minister talked of providing a decent service in the community, but what happens? People simply do not receive it.
Many doctors tell a retired man who has given a lifetime of service to industry to keep himself active. However, if that person requires a chiropodist—which is 96 often the case in my constituency—he will not be able to get about, because of his bad feet. He sits in a chair, day after day and week after week. Of course, such people can obtain a chiropody service if they pay for it, which is what Conservative Members want. However, because of rate support grant cuts and Health Service cutbacks in my district, a proper, full chiropody service cannot be provided.
It goes on and on. The poll tax is coming next. People will be asked to pay more and more — in particular, many of my constituents who are in the lower income bracket and who cannot afford chiropody in the private sector. They will be told that they must pay 20 per cent. of the poll tax. That means more and more money coming out of their pockets or their purses—if they can find it. That is what the Conservative meant in 1979—"Let us have cutbacks in the public sector. Let us make them pay." And, by God, that is what they have done. Well, once we are given the opportunity to sit on their side of the House and put things right, we shall really look after the people of this nation.
§ 9.1 pm
§ Mr. Michael Irvine (Ipswich)
The hon. Member for Ashfield (Mr. Haynes) said at one point in his speech that Whips should keep quiet. All that I can say after the high-decibel hellfire sermon that we have just heard is that he is one Whip who certainly cannot be said to whisper his message.
What the hon. Gentleman said was more or less what we have been hearing from Opposition Members throughout the debate, although it was delivered at a rather higher volume and in a more declamatory manner than most of the other speeches. On the face of it, it fits in with the strongly expressed criticism from the eminent presidents of three senior medical colleges which was announced today.
Surely, however, the point is this. By its very nature, the National Health Service will always be short of resources. It will always be up against an ever-expanding demand. I am sure that, at any time during the 40 years since the NHS was set up, we could have found three eminent medical men to come forward and declare it to be in a state of crisis. We could also have found, on either side of the House—depending on which party was in power at the time — hon. Members such as the hon. Member for Ashfield declaiming the state of the NHS in pretty violent terms.
The fact is the better that the NHS does, the greater the expectations that it raises. The wider the range of treatments that it introduces, the greater will be the pressure on its resources. Forty years ago, for example, hip replacement operations simply were not available. Today, the NHS not only provides those operations, but provides them in ever-increasing numbers. Does it receive the credit for that improvement? It does not. Still less does the Government of the day. Expectations have been raised; the demand for such operations increases; the waiting lists are attacked as outrageous. That is likely to continue for as long as the NHS exists.
Obviously, taxation is always likely to play an important part in the funding of the NHS. I, for my part, hope that, in the years to come, insurance will play an increasing part in funding medical treatment. However, it is absurd not to look at other ways of raising finance. In particular, it is absurd for Opposition Members to dismiss 97 charges out of hand as a means of raising finance. If medical services are provided free — indeed, if any services are provided free — there will be waste, and where there is waste less money is available to be used where it is most needed. Charges have a very important part to play in making sure that such waste does not occur.
§ Mr. Irvine
I should like to give way, but I know that another Opposition Member wishes to speak after me.
Charges reduce waste. Resources can then be better applied in other directions. My hon. Friend the Member for Wells (Mr. Heathcoat-Amory) made the point that an important merit of charges is that they involve patients much more in improving the efficiency of the National Health Service. If we pay for something, we try to ensure that we get good value for it. Furthermore, charges provide a useful additional source of finance.
There is scope for argument about exactly what the level of charges should be and exactly how and on what items charges should be applied. There is also scope for argument about the level of income above which charges should become payable. If sensible charges are imposed on those who can afford them, they are not merely unobjectionable; they are positively desirable.
The other main way of raising money is embodied in clause 4, which to my mind is the most encouraging part of the Bill. It is high time that hospitals were encouraged to make greater use of their commercial potential. There are large numbers of staff, patients and visitors in hospitals. This makes hospitals very attractive as premises to retailers.
There is other commercial potential too. I do not wish to embarrass the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), but he highlighted one of the other revenue-raising elements that, apart from the attraction of hospitals to retailers who might want to set up shop there, is available to hospitals. He referred to commercial deals with drug companies. In exchange for research and assistance, hospitals could strike advantageous deals with drug companies. That is specifically provided for in clause 4(1)(e). The potential is enormous.
During the opening speech of my hon. Friend the Minister, my hon. Friend the Member for Langbaurgh (Mr. Holt) in an intervention highlighted the fact that each hospital or at any rate each regional health authority must be allowed to retain the benefit of its commercial success. That must be right. It would be absurd and counterproductive if the benefits of the commercial success by individual hospitals and regional health authorities that is made possible by clause 4 were to be nullified by a subsequent corresponding reduction in central funding.
The Bill has met with much undeserved criticism. By and large, it is a very good Bill. I shall vote for it with enthusiasm.
§ 9.8 pm
§ Mr. Keith Vaz (Leicester, East)
It is always a pleasure to follow the hon. Member for Ipswich (Mr. Irvine). He claims a special interest in practically every debate. He last spoke in a debate on Scotland, which is strange for a Member who represents a constituency in East Anglia.
Conservative Members have made great play of the fact that they are seeking to reform the Health Service. Indeed, one Conservative Member posed the question: "What sort 98 of Health Service will exist in 20 years?" It is obvious, not only from the Bill but from the debate that was held two weeks ago, that in 20 years' time we shall have a private health service because the National Health Service will have ceased to exist.
Some comments, especially those by the hon. Member for Wokingham (Mr. Redwood), who has now left the Chamber, are based on fantasy recollections about the natural consumers of the Health Service. When one considers that the hon. Member for Wokingham happens to be a former investment consultant for N. M. Rothschild, one realises that such Conservative Members have no understanding of the needs of the people who seek medical and dental help. Indeed, the Parliamentary Under-Secretary, the hon. Member for Derbyshire, South (Mrs. Currie), seems to operate on the basis that if the Ministry issues a directive to tell people not to be ill, they will cease to be ill, and that if a directive is issued telling everyone in, for example, Leicestershire that they do not have any health problems and have no need to seek a dentist or optician, suddenly, by some miracle, all their problems will disappear. Of course, the reality is quite different.
My hon. Friend the Member for Wolverhampton, South-East (Mr. Turner) referred to the state of the Health Service in his area. I should like to give briefly some statistics relating to the Health Service in Leicestershire. About 8,300 people are on the waiting lists in Leicestershire and about 1,300 are waiting for urgent operations—that is almost 13.6 per cent. of the total.
Even before the provisions of clause 4 become enacted, we have been operating a jumble sale Health Service. The Lord Mayor of Leicester recently launched an appeal for support to build a special unit at the Leicester general hospital. The appeal reached £50,000 but everyone has now discovered that an extension will not be built at that hospital in which to put the new endoscope unit. When clause 4 becomes law — if it becomes law — we shall indeed have a jumble sale Health Service in which the managers of health authorities will, no doubt, hold television game shows and jumble sales to raise funds.
A recent report in Leicestershire stated that the Towers hospital, which is a regional hospital that helps patients with mental disorders, is recommended for closure. I raised that in a question to the Minister, but she has not even seen the report. However, we have been told that it will close in five years. I understand that consultants in Leicestershire are furious about what is happening and about the fact that beds that are needed for operations are not available. Those consultants are to lead a delegation to the Minister in the near future.
We have heard reports in Leicestershire that funds from the National Health Service will be allocated to private hospitals. Indeed, there has been rumour that £240,000 of National Health Service money would be spent on private services in Leicestershire. That is the state of the Health Service in Leicestershire and it is wrong for the hon. Member for Wokingham to say that everything is all right with the Health Service and that it is getting value for money.
In a recent article in a local newspaper, Mr. Paul Bates, the administrator of the family practitioner committee, quite controversially for an administrator in the Health Service, criticised the Government because of the cuts that will be made in the local FPC. It is being told that it cannot circulate vital information to doctors and dentists, that it 99 should slash £50,000 from its budget, that it should not write to 60,000 people a year to tell them that their doctor has retired or died, and that it should not write to 13,000 "season ticket" holders to tell them that their annual permit for regular drugs has expired. It is not allowed to send out annually updated drugs lists to doctors, which give them vital information when they need to prescribe for their patients.
At present there is so much scope to introduce a Bill which will provide resources and a more efficient NHS. No one is pretending that the operation of the NHS is perfect; obviously, there are tiers and layers of management which need to be examined carefully. It is fundamentally wrong that the Government should be allowed to appoint managers from Sainsbury's or other high street firms to become general managers of acute hospitals. That practice must be stopped.
I should like to see a Health Service in Leicestershire, particularly in Leicester city, which provides for the outer estates, such as Netherhall, Thurnby Lodge, Rowletts Hill and Northfields, where there are large council estates and no general practitioners. During the past year, there has been a campaign in Rowletts Hill to set up a baby clinic because mothers cannot take their children into the city centre to have them treated. Recently, a campaign was started to try to provide general practioner facilities in the neighbourhood centres that have been provided by the Labour city council.
We are talking about the erosion of fundamental rights.
§ Dame Jill Knight
I was fascinated and wondered what significance there was in the fact that the hon. Gentlemen removed his shoes before he made his speech. Is he having problems with the chiropody service in Leicester?
§ Mr. Vaz
If the hon. Lady were to visit Leicestershire health authority she would discover that there are severe problems with the chiropody service and that people cannot get the treatment that they need. But that intervention was not particularly relevant to what I was saying.
During the past 20 years, there has been a consensus that the NHS should be supported by both the Government and the Opposition because it is a fundamental right. That right was accepted by the previous Conservative Administration between 1970 and 1974 under the previous Conservative Prime Minister, who is now attacked and humiliated by Conservative Members. We believe that the Health Service is a fundamental right, free at the point of entry and available for all.
The end of the long road on which this Bill embarks is people being charged for a visit to their GP, just as it is proposed that they will be charged when they visit their dentist or optician. The Bill is appalling. It does not serve the needs of local people and those who rely on the NHS, and I hope that it will be opposed.
§ Ms. Harriet Harman (Peckham)
The Bill is introduced by a Government whom no one in the Health Service trusts any more. That is not surprising because they are presiding over an awesome restriction on our health services, but they do not even have the integrity to admit that that is the case. Therefore, people will, rightly, not 100 take at face value the suggestions and powers in the Bill, including, for example, the supposed additional powers for financing the Health Service.
The Minister said that the legislation was about bringing extra funds into the Health Service, but it is absolutely clear from our remarks that we simply do not believe him. The Government's dogged refusal to recognise that there is a problem of underfunding is also absolutely clear. Less than two weeks ago they tabled a motion congratulating themselves on the adequacy of their NHS funding. They do not believe that it is underfunded, and they have shown great anxiety to bring about a major reduction in public spending. That is what the Bill is about. It should have been introduced by the Chancellor of the Exchequer, not by health Ministers. It is shameful that health Ministers are, in practice and in fact, doing the dirty work of the Chancellor of the Exchequer, because the Bill is about reducing further the funds to health authorities.
The Minister said that health authorities must take time off from easing suffering and curing diseases, and must set about the task that the Government think is much more important, which is making money. Health Service managers are rightly cynical about the proposals, and they are convinced that any money that they raised in addition to their existing budget would be clawed back by the Government. They believe that the reward for raising an extra £1 million would be that the following year they would have £1 million taken off their budget by the Government. They believe that, if they raised £2 million, the Government would take back £2 million the following year. Worse, they fear that the Government will make some sort of arbitrary assumption about how much money it is appropriate for each district health authority to raise, and will cut their budget in advance irrespective of whether they raise that amount of money.
It is not just that we fear that the Bill will not involve extra resources for the Health Service. It will also provide a considerable distraction from the job that the Health Service should be doing. Health Service administrators will have to set about leasing Health Service land for camping and caravan sites, running shopping malls and health clubs.
The Minister should make it quite clear tonight what the Government will ask the Health Service to do to try to raise that money. Will they really ask district health authorities to sign deals with undertakers and to set up hotlines for bereaved relatives? We should like to hear the answer tonight in the House. Will he force district health authorities to put up the prices of welfare food? We should like to hear about that tonight as well. Will they make health authorities put up the price of meals in staff canteens and make staff pay for car parking facilities? If they adopt that measure, they will further undermine the standard of living of nurses which will lead to a greater exodus of nurses from the Health Service.
Will the Government ask health authorities to insist on charges for relatives who stay with a sick child in hospital? I should like a specific commitment that the Minister will not ask district health authorities to do that. It is important that, when a child is in hospital, parents are encouraged and enabled to stay with the child to assist the speedy recovery of that child. It would be quite wrong to implement charges for relatives of children in hospital. If there were already charges for relatives, David Barber's 101 mother would be receiving a bill from the health authority in two weeks' time. We must have an assurance from the Government that they will not introduce such charges.
Perhaps the Minister will inform the House which of the 75 suggestions in the leaked report in The Independent they will approve and which they will not be going forward with. It would be helpful if a copy of that report, which was leaked to The Independent, were placed in the House of Commons Library so that Members could scrutinise it. Tonight, we need to know exactly what district health authorities will be forced to do to raise money. Instead, district health authorities should be directing their energy and initiative to improving health care. Already there is a considerable diversion of energy and initiative towards basic fund raising. We want consultant paediatricians to be treating sick children, not spending hours on fundraising committees or telephoning round local companies trying to raise money for basic services.
We are talking about fund raising for basic services, and not just for some additional extras. For example, I received a letter from a consultant at Haringey hospital which was sent to all local organisations asking for money for the appointment of a senior registrar in the microbiology department. That is a department in Haringey hospital, in north London, which obviously has a key role in preventing the spread of infectious diseases such as hepatitis B and AIDS. It is scandalous that, when its work is increased, it has to write to local organisations to try to drum up the £20,000 needed to fill that post. The letter states:I think it is imperative for this community to benefit from such a post and I am therefore writing to appeal to you to seriously consider whether this might be a possibility with your assistance. We are looking to find the sum of £20,000 a year ongoing.That is how the Health Service is having to operate already. If district health authorities have to put even more effort into trying to raise money in that way, the position will deteriorate even more.
The Bill talks about extra resources for the National Health Service, but the underfunding of the Health Service is already choking off and having a chilling effect on voluntary and charitable fund raising. What is the point of spending all one's spare time raising funds to buy the local hospital a special care baby cot if it lies unused because of the nursing shortage? What is the point of raising money to establish a kidney unit if the hospital in which it is to be based is later closed?
The efforts of hospital leagues of friends to raise thousands, hundreds of thousands and even millions of pounds are increasingly swallowed up in the widening black hole of NHS underfunding. That is demoralising them and undermining their will to help to raise funds for the Health Service. Charities are becoming angry. The fact that the Government are undermining existing opportunities to raise money—
§ Mr. Tony Favell (Stockport)
The hon. Lady said that she wants better and more equipment in the National Health Service, more money for staff, more staff and more buildings. How many billions of pounds would a Labour Government invest in the Health Service?
§ Ms. Harman
The British Medical Association, the Institute of Health Service Managers and the Royal College of Nursing have said that, to escape from chronic 102 underfunding, the Health Service needs an extra £200 million a year. Later in my speech I will discuss how the Government are wasting Health Service assets.
§ Mr. Redwood
Does the hon. Lady accept that £200 million a year is a small sum? Is she aware that next year the Government will put an extra £700 million into the Health Service? Why is that inadequate? If she means billions of pounds, why does she not say so? But how would that agree with the hon. Member for Livingston (Mr. Cook), who said that a few hundred million pounds would do?
§ Ms. Harman
Those organisations say that we need £200 million on top of what the Government have said that they will put into the Health Service.
Charities are becoming angry that the Government are increasingly pulling out of key areas in the Health Service and leaving charities to carry the can. Last week, the Imperial Cancer Research Fund bitterly attacked the Government, saying that charities must increasingly prop up the Health Service and that money intended for research into cancer is being sucked into supporting basic services. The fund is sustaining the children's ward at St. Bartholomew's hospital. That should be funded from the mainstream budget; it should not be left to a charity to fund. The fund is supporting most of the cancer treatment, not just the research, at the unit being set up at the Churchill hospital. The shortage of funds is delaying new treatment for cancer patients.
But all this does not seem to bother the Government. Indeed, 10 days ago the Under-Secretary gave the game away when she complained that every new medical treatment created a new waiting list. The Government sees this as a problem. They would be much happier if medicine had not much progressed beyond Victorian times, so that they could say to people, "I am sorry, but we can do nothing for you. You will have to go home." In that way, they could save a great deal of public money.
The Government's obsession with cutting public spending has led to their being the enemy of progress. It has led to their being the enemies of life-saving treatments and of the medical breakthrough. Like most normal people in this country, we want to see medical advance. We see the Health Service as a marvellous asset towards that end. The Government see the National Health Service as a greedy obstacle in the path of their plans to cut public spending.
The Government speak of selling spare capacity to the commercial medicine sector. We see this in clause 4. They talk about it as a way of bringing income into the Health Service, but my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) is right when he says that we must scrutinise this notion of spare capacity being available for selling to the commercial sector. The cheerful talk of spare capacity will cut no ice with the 162,000 people who have waited over a year for medical treatment and who continue to wait. Spare capacity is not a concept which would be understood by the parents of David Barber or by eight-year-old Emma White who waited eight months for an operation. When she finally came to the head of the queue and went into hospital, she waited 17 hours and was sedated for her operation in the Royal Berkshire hospital, only to be told, "Very sorry. You'll have to go home. Your operation can't go ahead." It is odd for a Government who like to talk of the insatiable and 103 escalating demands of the Health Service to start talking about spare capacity. They are not really talking about spare capacity. They are talking about asset-stripping the Health Service for the purpose of commercial medicine.
There is in the Health Service not so much spare capacity as much-needed assets which are locked up and underused because of underfunding. The Government urge the Health Service to be more efficient and to cut out waste, but their under-resourcing and underfunding of the Health Service are leading to inefficiency and waste.
The Government rightly talk of their concern about taxpayers' money. We are also concerned about the fate of taxpayers' money in the Health Service. Taxpayers have invested millions of pounds in operating theatres and yet they are used for only half the time for which they could be used. They lie idle for the rest of the time. This is not so much spare capacity as a valuable resource which is underused and lying idle. Those operating theatres are not used, because operations are cancelled in a bid to save money and because there are not the nurses or beds available for people when they have had their operations.
§ Mr. Churchill
I sympathise with some of the hon. Lady's points, but I fear that she does her case no good by her exaggeration. When her Government were in power, constituents of mine had to wait more than a year to get an X-ray for their stomach. For one of my constituents, the notification that he could go for his X-ray came the day after he died.
§ Ms. Harman
I am not exaggerating. The statistic about operating theatres being used for scarcely half the time comes from a report written by the National Audit Office which was published the week before last.
Taxpayers also invest millions of pounds in training doctors and paying their salaries, but they are then banned by the district health authorities from operating on patients on the waiting list for fear that the budget might be overspent. All the resources and taxpayers' money that go into training doctors and keeping them on the NHS payroll are then underused as they remain idle and frustrated.
Millions of pounds are being lost to the Health Service through theft and underfunding of security measures means that easy pickings are available. Millions of pounds are also lost to the Health Service through the exodus of nurses. My hon. Friend the Member for Bolton, South-East (Mr. Young) was right in his explanation of the problem.
The replacement cost for nurses to the Health Service is something like £100 million a year. Another £40 million a year leaves the Health Service with the nurses who do not complete training. The Minister has said that that has nothing to do with resources. It has everything to do with resources. Who thinks that we would have an exodus of 30,000 nurses a year from the Health Service if they were better paid, if there was a sensible grading structure, and if they were offered flexible hours and child care provision for pre-school age children? If nurses had better conditions such as those, they would stay with the Health Service and that would be a much better return on taxpayers' money. It would also mean that the nurses could be where we want them to be, and where they want to be—at the patient's bedside instead of leaving the Health Service in frustration and desperation.
104 With regard to nurses, the Government have much in common with first world war generals whose attitude was that it did not matter how many soldiers did not return from the front, because there would always be more recruits. But there are not enough nursing recruits. The Government's attitude is a huge drain on the training and investment on nurses.
Millions of pounds are invested in beds, wards and equipment which are wasted because they lie idle as a result of service cuts. In any hospital in any town or city, equipment is piled up and lying idle. That is a shameful waste of resources that could be utilised. The Government are also generating inefficiency. Doctors are involved increasingly not so much in treating patients, but in spending hours on the telephone trying to find beds for patients. That is not what they were trained for or what they should be doing in the Health Service. Towards the end of every day doctors scour the wards looking for any patient who appears to be perky enough to be sent home so that they can free a bed. That is not how we should be running the Health Service. There is also a booming administration industry. Letters are sent to patients booking them in for operations, and letters are then sent cancelling the operations.
Great inefficiency is also generated as a result of the recruitment freeze which is now beginning to bite in district health authorities. Providing health care is team work. There must be a complete chain to make the system work properly. If there is a freeze on the recruitment of nurses, the doctors and lab technicians will not be able to do the jobs that they were trained for and that we need them to do. If there are not enough lab technicians, the doctors cannot do the work that they should be doing and the nurses will not be able to do their work.
The irony is that, because of the district health authorities' underfunding, many district health authorities have to implement recruitment freezes. We have not heard a squeak from the Government about recruitment freezes. Are the Government unaware of the present position? Are they unaware that many more district health authorities are threatening not only to introduce recruitment freezes in an attempt to meet their budgets, but to extend that recruitment freeze to nurses? The Government have remained absolutely silent on that matter.
It is also clear that the Government's concern to improve services in primary health care takes second place to their anxiety to cut public spending. They say that they want to gear the service to prevent ill health and promote good health, yet they cast a shadow across those objectives by planning to introduce charges for eye tests and dental treatment. The hon. Member for Birminham, Edgbaston (Dame J. Knight) was absolutely correct when she set out those arguments. It is obvious that there will be a reduction in screening and preventive treatment.
The Government are also taking powers to cash-limit the family practitioner committees. The BMA echoed the fears of many when it called for the relevant clause to be removed from the Bill. It said:GPs know only too well the consequences of the application of cash limits to the hospital sector and the difficulties created for their patients.If the clause is included and if the Bill is passed, we will see the same crisis hitting the primary care system as we see developing in hospitals.
The Government's plans to improve GP services are also undermined by their failure to fund the family 105 practitioner committees, which should represent a powerful watchdog to plan and supervise an improvement in services. Unless there is proper planning and supervision of such improvements, the improvements that the committees seek in the GP services will not occur. The committees' attempt to argue for such improvements will be nothing more than a pious hope.
The Government are distorting our hospitals and blighting our primary care system by their desire to pull the plug on the Health Service. However, a growing number of people are working together to try to prevent the Government from doing so. Doctors are worried. We have seen the report issued today from the three royal medical colleges. Nurses are angry and are demonstrating. In Cornwall 1,000 nurses have been demonstrating on the streets against the cuts that face a hospital in that region. Health Service managers are growing hoarse from complaining and predicting dire problems. The Government are not listening to any of those people.
The Opposition are listening to the doctors and nurses and to patients who are waiting anxiously for treatment. We will be working to try to prevent the deterioration of the Health Service that is represented by the Bill. It is a pity that so many Conservative Members are afraid to stand up for their constituents by trying to defend and protect the Health Service in their areas.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
This has been a thorough, wide-ranging debate on primary care and the provisions of the Bill.
Large parts of the Bill have received a fair measure of support. I am most grateful to my hon. Friends the Members for Norfolk, North-West (Mr. Bellingham), for Warrington, South (Mr. Butler), for Wells (Mr. Heathcoat-Amory), for Ryedale (Mr. Greenway), for Wokingham (Mr. Redwood), for Ipswich (Mr. Irvine) and a number of others. I am sure that they will understand if I do not answer all their points in detail.
The hon. Member for Peckham (Ms. Harman) asked a number of questions, especially regarding the items in clause 4. I must tell her that we have no such plans as she has outlined. The hon. Lady asked that we place the internal report that we have received in the Library, but the answer to that request is no. Quite simply, the reason for that decision is that the report contains some batty things—which she has described—with which we do not agree, such as a hotline to funeral parlours. The hon. Lady also asked about the price of meals in staff canteens. I must confess that one of the things that I did in Birmingham when I was chairman of that health authority was to investigate the biggest subsidy of all for staff dining—the consultants' dining room at the Queen Elizabeth hospital. I tried to do something about that.
The hon. Member for Livingston (Mr. Cook) made a most interesting speech. In many ways it was an excellent speech for a different purpose—an excellent speech for the deputy leadership of his party. It was a pity that so few of his Back-Bench colleagues were present to hear it at 5 o'clock. We counted 12 of them and we wondered what had happened to the other 200. I listened carefully to his comments, especially those concerning the General Practice Finance Corporation and his comments regarding clauses 4, 8 and 10. I do not know who is advising the hon. Gentleman, but he is not very good. The GPFC will have 106 a much easier time in future when it will be able to raise money outside Government funding. In any case, many GPs already raise a substantial amount of money to fund their activities. That has been done exceedingly well in Stratford where the GPs are only too pleased to show off what they have done.
The hon. Members for Livingston and for Peckham gave us quotes to show that the British Medical Association does not like the proposals in the Bill. I wonder whether they saw the letter from Dr. Wilson, chairman of the general medical services committee, of the BMA, printed in Today on 4 December. That article was headed:Doctors had the best ideas first.I will not quote the whole letter but he clearly stated:The BMA committee which represents all general practitioners proposed most of the innovations which the Government has put forward.I am more than happy to accede to that. The hon. Member for Livingston asked whether clause 8 will allow charges to be made in respect of general practitioners. If he is asking whether clause 8 will allow for the imposition of a charge for a GP's consultation, the answer is no. Similarly, there are no powers in clause 4 to make patients pay for basic health care. We are concerned with income generation, not income replacement. That answers the point raised by another colleague. What it will allow for is charging for special services, just like the old amenity beds which the legislation is to replace. But nothing will get in the way of giving basic health care, and that is clearly set out in both the Bill and the White Paper.
I note the remarks of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith). I will try to do what the doctor tells me in future. He asked me about payment for domiciliary visits and merit awards for doctors. I will convey his views to the British Medical Association. Whether it will take any notice is another matter.
I also note his comments about drug companies and whether we should charge them for the research that we do on their behalf. I take his point, but will merely say that all their research is done on our behalf because we do not fund pharmaceutical research in this country. The Health Service, the Government and the public benefit considerably from the research and the trials that are done under properly controlled conditions in our hospitals.
The hon. Member also asked about charges for private patients in private hospitals. He and his colleagues ought to read clause 4 a little more carefully; I think that they will find that they agree with it. The whole idea is to free our hospitals through clause 4 to enable local managers to charge whatever they like. At the moment, they cannot make a profit and are not allowed to charge for some of the services which Labour Members identified. So we hope that they will vote for the clause. This applies also to the hon. Member for Bolton, South-East (Mr. Young), who called private patients parasites. One of the reasons is that we cannot charge them as much as we ought to.
§ Mr. Galbraith
I thank the Minister for taking my advice. If she sticks with me, she will be all right.
I obviously did not make my point clear. I was talking about the situation in which the patient is seen privately and then comes into the National Health Service as a National Health Service patient, or someone who is in a private hospital and then moves to a National Health Service hospital. Such patients are not charged at the moment. I do not wish them to be charged—they are as 107 entitled as anyone else to National Health Service treatment—but I want the private company which puts them into the National Health Service hospital to be charged because we are giving a cross-subsidy to that private company. Will the Government look into that?
§ Mrs. Currie
I could not agree more. I assure the hon. Gentleman that clause 4, for which I hope he will now vote, will give us the power to do much of what he wants to do.
The hon. Member for Greenwich (Mrs. Barnes) raised a number of points. She said that capitation fees should be adjusted to avoid reducing the time allowed for patient consultation. It is proposed in the White Paper to extend the number of hours that a general practitioner makes available for direct consultation to the patients, which will confer the entitlement to the full basic practice allowance.
§ Mrs. Currie
This, together with the provisions to improve consumer choice and to make it easier to change doctors, should increase competition among doctors and lead to better services for patients. In other words, if patients are not given enough time by doctors they will now be able to do more about it.
If the hon. Lady has any further concerns, may I just refer her to an important book written on the subject in 1976, in which it says:The key to the future lies in sensible and realistic planning to ensure that revenue and capital resources are allocated on the basis of objective criteria, that capital developments proceed at a pace consistent with a realistic revenue projection and that revenue costs and manning levels are kept to an essential minimum … No one who works in the Health Service can avoid the need to examine their practices and attitudes with a view to seeing if the overall cost-effectiveness of the service can be improved".I could not agree more. That was said by the right hon. Member for Plymouth, Devonport (Dr. Owen), when he was a Labour health Minister, at this Dispatch Box. I would refer the hon. Lady to her leader, if she can find him; he does not seem to take as much interest these days in these subjects.
That also answers the point made by my very dear—may I call him Friend?—the hon. Member for Ashfield (Mr. Haynes), who wanted to know what I was getting up to in Birmingham before 1979. The answer is that I was doing my best to resist carrying out the policies of the then Labour Government on the Health Service, when it was being cut to shreds.
A number of my hon. Friends have raised important points. As usual, my hon. Friend the Member for Eastleigh (Sir D. Price) made a thoroughly sensible and distinguished contribution. He asked about average list size. I should just caution him on this. We are keen to reduce the average list size, as he knows, but large numbers on lists are most common in the inner cities, where we also have a high percentage of doctors who are over 70, and many small lists of fewer than 1,000. So we see major changes here, and it is hard to tell exactly what effect the retirement provisions will have on list size. In the end, we are also interested in the output and results that we get. As I am sure my hon. Friend realises, list size is an input.
We are also keen about the commitment to extra resources. I am sure that my hon. Friend realises that some negotiations are going on. We shall have more discussions, 108 particularly with the doctors, so I am a little reluctant to put our negotiating position on the table just yet. I hope that my hon. Friend will accept that.
Several of my other hon. Friends made points, which I shall deal with as I make my speech.
Various hon. Members drew attention to the division between the family practitioner committees and the district health authorities. I have some sympathy with that, but we are stuck with it. The arrangements were confirmed as recently as 1985. I hope that hon. Members will understand that I am reluctant to reorganise the Health Service all over again. I think that it has had enough for the time being. I can see virtue in having the services outside the hospital run by separate bodies, especially as some district health authorities seem to have difficulty running what they have. The aim is to make the family practitioner committees as effective as they can be, so that they do a proper job of monitoring health and the family health services. That is what we intend to do through the Bill.
Nobody can say that we have been stingy with these services. [HON MEMBERS: "Yes, you have."] Opposition Members cannot say that. I am talking about the family practitioner services, which have been given less attention in the debate than they should have received. In 1978–79, gross current spending on the family practitioner services under the Labour Government was about 1–75 billion. It has trebled since then in cash terms and is over £5 billion now. In real terms, that is an increase of 43 per cent. That expenditure represents 24 per cent. of total Health Service spending, which is an increase on the years under the Labour Government.
Since 1979, the number of family doctors in the United Kingdom has risen by nearly 4,000 and now stands at over 30,000. Similarly, the number of staff employed by family doctors in England alone has risen to nearly 30,000, and that is in whole-time equivalents. That is probably about twice as many people.
The number of dentists in the United Kingdom has increased by nearly 3,000 to over 17,000. The number of retail pharmacies in England and Wales has gone up to 10,500 now, and we have 38 per cent. more ophthalmic opticians in England and Wales—around 6,000 of them. I shall come back to them in a moment.
§ Mr. Morgan
Before the Minister is overcome in a paroxysm of self-congratulation and requires medical attention herself, does she accept that there is genuinely a problem of incentive in the NHS, for surgeons and other medical practitioners who attempt to eliminate the waiting lists and find themselves up aganst the cash limits? When they are trying to do that, their general unit manager tells them half way through the financial year, "Sorry, you have done enough operations now. You've got to stop."
§ Mrs. Currie
I take the hon. Gentleman's point, but we have been increasing the incentives for general practitioners, dentists, opticians and pharmacists. As a result, we have many more of them. That is what happens when one gives incentives.
Similarly, the number of courses of treatment has risen dramatically. The number of eye tests now stands at nearly 11 million. The number of courses of dental treatment has gone up in the past 10 years from 26 million to over 31 million, of which 10 million are children. Nearly 3 million pairs of spectacles were issued last year, 209 million visits 109 were made to doctors, and 34 million visits were made by doctors to the home of the patient. Nearly 1 million women went to ante-natal classes in 1985 and the same number of pregnant women had their teeth done at an average cost of nearly £32 each — free to them, of course. My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) is right. There is no evidence that teeth deteriorate in pregnancy, but women tend to get gum disease. Therefore, we have no proposals to change that.
There have been some reductions. There are fewer holes in children's teeth. Half of our children start school with their teeth intact, compared with only a quarter of them when my daughter was born in 1974. About 40 per cent. of those aged 65 to 74 — I am looking at the hon. Member for Ashfield—have their own teeth and expect to keep them. In 1985, 1.7 million pensioners received dental treatment.
Hon. Members on both sides talked about charges. I share the sadness—the hon. Member for Ashfield is not showing his teeth now — of several hon. Members who said that charges for sight and dental checks have obscured discussion on a wider range of worthwhile proposals. However, I have several points to make in this regard. First, for many people, such checks are free and will continue to be so. No one will be denied the service because he cannot pay. About 15 million courses of dental treatment are free—about 45 per cent. of the total—and 2.25 million vouchers for spectacles were issued last year —25 per cent. of the total—and we have no plans to change the exemptions. The proposed charges are hardly high — less than £3 for the dental check-up every six months. That is less than the price of two packets of cigarettes—not every day, but once every six months. Even after the charges are brought in we reckon that more than 2 million courses of dental treatment will be cheaper than they are now. Of course, the idea is to help those who look after their teeth, as my hon. Friend the Member for Ryedale pointed out.
As for the eyesight test, we are convinced that people will not have to pay a fee of the order of £10. The opticians' service is profitable and competitive. Hon. Members on both sides of the House should have a look at The Optician magazine. With the permission of the House, I shall read out some of the recent advertisements for opticians working in the private sector. This one comes from Haywards ophthalmic opticians in Derby, Oadby, Thornaby-on-Tees, Bournemouth, Gateshead, Shrewsbury and Coventry. It offers a salary package in excess of £30,000 for a four-day week, a company car, a pension and a private health scheme. A similar advert earlier in the year states that the private car is anew 2 litre petrol injection Sierra.An advertisement for an ophthalmic optician in Exeter offers a salary package of £35,000 plus. I can well understand—
§ Mrs. Currie
—that under these conditions opticians do not like what we are up to. I am sorry if my hon. Friend the Member for Edgbaston thinks that we are being offensive; but we think they will manage somehow.
§ Mr. Cook
The Minister will appreciate that we are concerned not about optometrists who earn in excess of £30,000 but about the 6 million pensioners existing on 110 much smaller incomes, who will be faced with a charge to which the hon. Lady is exposing them. Will she admit that she is leaving them open to whatever the market charges them?
§ Mrs. Currie
The hon. Gentleman was not here for most of the debate. If he had been, he would have heard some of the answers to that.
I am prepared to extend the hand of friendship to the Opposition and to invite them to stand by their principles — that they care about prevention and good health, women's health, more women doctors and the inner cities —and I invite them to vote with us tonight. If they join us in the Lobby, they will show that they know what they want and what we need for primary care, and are willing to pay for better-trained staff in doctors' surgeries, for interpreters and link workers for ethnic minorities, for staff working with the housebound and the disabled and for the health of our own people. If they do not, one can only conclude that they are more interested in playing politics with the sick than in supporting change to improve health. That is our policy. I commend the Bill to the House.
§ Question put, That the Bill be now read a Second time:
§ The House divided: Ayes 318, Noes 220.113
|Division No. 106]||[10 pm|
|Aitken, Jonathan||Butcher, John|
|Alexander, Richard||Butler, Chris|
|Alison, Rt Hon Michael||Butterfill, John|
|Allason, Rupert||Carlisle, John, (Luton N)|
|Amess, David||Carlisle, Kenneth (Lincoln)|
|Amos, Alan||Carrington, Matthew|
|Arbuthnot, James||Cash, William|
|Arnold, Jacques (Gravesham)||Chalker, Rt Hon Mrs Lynda|
|Arnold, Tom (Hazel Grove)||Chapman, Sydney|
|Aspinwall, Jack||Chope, Christopher|
|Atkins, Robert||Clark, Hon Alan (Plym'th S'n)|
|Atkinson, David||Clark, Dr Michael (Rochford)|
|Baker, Rt Hon K. (Mole Valley)||Clark, Sir W. (Croydon S)|
|Baker, Nicholas (Dorset N)||Clarke, Rt Hon K. (Rushcliffe)|
|Baldry, Tony||Conway, Derek|
|Banks, Robert (Harrogate)||Coombs, Anthony (Wyre F'rest)|
|Batiste, Spencer||Cope, John|
|Bellingham, Henry||Cormack, Patrick|
|Bendall, Vivian||Couchman, James|
|Bennett, Nicholas (Pembroke)||Cran, James|
|Biffen, Rt Hon John||Currie, Mrs Edwina|
|Biggs-Davison, Sir John||Curry, David|
|Blaker, Rt Hon Sir Peter||Davies, Q. (Stamf'd & Spald'g)|
|Body, Sir Richard||Davis, David (Boothferry)|
|Bonsor, Sir Nicholas||Day, Stephen|
|Boswell, Tim||Devlin, Tim|
|Bottomley, Peter||Dickens, Geoffrey|
|Bottomley, Mrs Virginia||Dorrell, Stephen|
|Bowden, A (Brighton K'pto'n)||Douglas-Hamilton, Lord James|
|Bowden, Gerald (Dulwich)||Dover, Den|
|Bowis, John||Dunn, Bob|
|Boyson, Rt Hon Dr Sir Rhodes||Durant, Tony|
|Braine, Rt Hon Sir Bernard||Evans, David (Welwyn Hatf'd)|
|Brandon-Bravo, Martin||Evennett, David|
|Brazier, Julian||Fairbairn, Nicholas|
|Bright, Graham||Fallon, Michael|
|Brittan, Rt Hon Leon||Farr, Sir John|
|Brooke, Hon Peter||Favell, Tony|
|Brown, Michael (Brigg & Cl't's)||Fenner, Dame Peggy|
|Browne, John (Winchester)||Field, Barry (Isle of Wight)|
|Bruce, Ian (Dorset South)||Finsberg, Sir Geoffrey|
|Buchanan-Smith, Rt Hon Alick||Fookes, Miss Janet|
|Buck, Sir Antony||Forman, Nigel|
|Budgen, Nicholas||Forth, Eric|
|Burns, Simon||Fowler, Rt Hon Norman|
|Burt, Alistair||Fox, Sir Marcus|
|Freeman, Roger||Lloyd, Sir Ian (Havant)|
|French, Douglas||Lloyd, Peter (Fareham)|
|Gale, Roger||Lord, Michael|
|Gill, Christopher||Luce, Rt Hon Richard|
|Gilmour, Rt Hon Sir Ian||Lyell, Sir Nicholas|
|Glyn, Dr Alan||McCrindle, Robert|
|Goodhart, Sir Philip||Macfarlane, Neil|
|Goodlad, Alastair||MacGregor, John|
|Goodson-Wickes, Dr Charles||MacKay, Andrew (E Berkshire)|
|Gorman, Mrs Teresa||Maclean, David|
|Gorst, John||McLoughlin, Patrick|
|Gow, Ian||McNair-Wilson, M. (Newbury)|
|Gower, Sir Raymond||McNair-Wilson, P. (New Forest)|
|Grant, Sir Anthony (CambsSW)||Madel, David|
|Greenway, Harry (Ealing N)||Major, Rt Hon John|
|Greenway, John (Rydale)||Malins, Humfrey|
|Griffiths, Sir Eldon (Bury St E')||Maples, John|
|Griffiths, Peter (Portsmouth N)||Marland, Paul|
|Grist, Ian||Marshall, John (Hendon S)|
|Ground, Patrick||Marshall, Michael (Arundel)|
|Grylls, Michael||Martin, David (Portsmouth S)|
|Gummer, Rt Hon John Selwyn||Mates, Michael|
|Hamilton, Hon A. (Epsom)||Maude, Hon Francis|
|Hamilton, Neil (Tatton)||Mawhinney, Dr Brian|
|Hampson, Dr Keith||Mayhew, Rt Hon Sir Patrick|
|Hanley, Jeremy||Meyer, Sir Anthony|
|Hannam, John||Miller, Hal|
|Hargreaves, A. (B'ham H'll Gr')||Mills, Iain|
|Harris, David||Mitchell, Andrew (Gedling)|
|Haselhurst, Alan||Mitchell, David (Hants NW)|
|Hawkins, Christopher||Moate, Roger|
|Hayes, Jerry||Monro, Sir Hector|
|Hayhoe, Rt Hon Sir Barney||Montgomery, Sir Fergus|
|Hayward, Robert||Morris, M (N'hampton S)|
|Heathcoat-Amory, David||Morrison, Hon C. (Devizes)|
|Heddle, John||Morrison, Hon P (Chester)|
|Heseltine, Rt Hon Michael||Moss, Malcolm|
|Hicks, Mrs Maureen (Wolv' NE)||Moynihan, Hon C.|
|Hicks, Robert (Cornwall SE)||Neale, Gerrard|
|Higgins, Rt Hon Terence L.||Nelson, Anthony|
|Hill, James||Neubert, Michael|
|Hind, Kenneth||Newton, Tony|
|Hogg, Hon Douglas (Gr'th'm)||Nicholls, Patrick|
|Hordern, Sir Peter||Nicholson, David (Taunton)|
|Howard, Michael||Nicholson, Miss E. (Devon W)|
|Howarth, Alan (Strat'd-on-A)||Onslow, Cranley|
|Howarth, G. (Cannock & B'wd)||Oppenheim, Phillip|
|Howe, Rt Hon Sir Geoffrey||Page, Richard|
|Howell, Rt Hon David (G'dford)||Paice, James|
|Howell, Ralph (North Norfolk)||Parkinson, Rt Hon Cecil|
|Hughes, Robert G. (Harrow W)||Patnick, Irvine|
|Hunt, David (Wirral W)||Patten, John (Oxford W)|
|Hunt, John (Ravensbourne)||Pattie, Rt Hon Sir Geoffrey|
|Hurd, Rt Hon Douglas||Pawsey, James|
|Irvine, Michael||Porter, Barry (Wirral S)|
|Irving, Charles||Porter, David (Waveney)|
|Jack, Michael||Portillo, Michael|
|Jackson, Robert||Powell, William (Corby)|
|Janman, Timothy||Price, Sir David|
|Jessel, Toby||Raffan, Keith|
|Johnson Smith, Sir Geoffrey||Raison, Rt Hon Timothy|
|Jones, Gwilym (Cardiff N)||Rathbone, Tim|
|Jones, Robert B (Herts W)||Redwood, John|
|Kellett-Bowman, Mrs Elaine||Rhodes James, Robert|
|Key, Robert||Riddick, Graham|
|King, Roger (B'ham N'thfield)||Ridley, Rt Hon Nicholas|
|Kirkhope, Timothy||Ridsdale, Sir Julian|
|Knapman, Roger||Roberts, Wyn (Conwy)|
|Knox, David||Roe, Mrs Marion|
|Lamont, Rt Hon Norman||Rossi, Sir Hugh|
|Lang, Ian||Rost, Peter|
|Latham, Michael||Rowe, Andrew|
|Lawrence, Ivan||Rumbold, Mrs Angela|
|Lawson, Rt Hon Nigel||Ryder, Richard|
|Lee, John (Pendle)||Sackville, Hon Tom|
|Leigh, Edward (Gainsbor'gh)||Sainsbury, Hon Tim|
|Lennox-Boyd, Hon Mark||Scott, Nicholas|
|Lester, Jim (Broxtowe)||Shaw, David (Dover)|
|Lightbown, David||Shaw, Sir Giles (Pudsey)|
|Lilley, Peter||Shaw, Sir Michael (Scarb')|
|Shelton, William (Streatham)||Townend, John (Bridlington)|
|Shephard, Mrs G. (Norfolk SW)||Townsend, Cyril D. (B'heath)|
|Shepherd, Colin (Hereford)||Tracey, Richard|
|Shepherd, Richard (Aldridge)||Trippier, David|
|Shersby, Michael||Trotter, Neville|
|Sims, Roger||Twinn, Dr Ian|
|Skeet, Sir Trevor||Vaughan, Sir Gerard|
|Smith, Sir Dudley (Warwick)||Viggers, Peter|
|Smith, Tim (Beaconsfield)||Waddington, Rt Hon David|
|Spicer, Jim (Dorset W)||Wakeham, Rt Hon John|
|Spicer, Michael (S Worcs)||Waldegrave, Hon William|
|Squire, Robin||Walden, George|
|Stanbrook, Ivor||Walker, Bill (T'side North)|
|Stanley, Rt Hon John||Walker, Rt Hon P. (W'cester)|
|Steen, Anthony||Waller, Gary|
|Stern, Michael||Walters, Dennis|
|Stevens, Lewis||Ward, John|
|Stewart, Allan (Eastwood)||Wardle, C. (Bexhill)|
|Stewart, Andrew (Sherwood)||Warren, Kenneth|
|Stewart, Ian (Hertfordshire N)||Watts, John|
|Stradling Thomas, Sir John||Wells, Bowen|
|Sumberg, David||Wheeler, John|
|Summerson, Hugo||Whitney, Ray|
|Tapsell, Sir Peter||Widdecombe, Miss Ann|
|Taylor, Ian (Esher)||Wiggin, Jerry|
|Taylor, John M (Solihull)||Wilkinson, John|
|Taylor, Teddy (S'end E)||Wilshire, David|
|Tebbit, Rt Hon Norman||Winterton, Mrs Ann|
|Temple-Morris, Peter||Wood, Timothy|
|Thatcher, Rt Hon Margaret||Yeo, Tim|
|Thompson, D. (Calder Valley)||Young, Sir George (Acton)|
|Thompson, Patrick (Norwich N)|
|Thorne, Neil||Tellers for the Ayes:|
|Thornton, Malcolm||Mr. Robert Boscawen and|
|Thurnham, Peter||Mr. Tristan Garel-Jones.|
|Abbott, Ms Diane||Corbett, Robin|
|Adams, Allen (Paisley N)||Corbyn, Jeremy|
|Allen, Graham||Cousins, Jim|
|Anderson, Donald||Crowther, Stan|
|Archer, Rt Hon Peter||Cryer, Bob|
|Armstrong, Ms Hilary||Cunliffe, Lawrence|
|Ashdown, Paddy||Cunningham, Dr John|
|Ashton, Joe||Dalyell, Tam|
|Banks, Tony (Newham NW)||Darling, Alastair|
|Barnes, Harry (Derbyshire NE)||Davies, Rt Hon Denzil (Llanelli)|
|Barnes, Mrs Rosie (Greenwich)||Davies, Ron (Caerphilly)|
|Battle, John||Davis, Terry (B'ham Hodge H'l)|
|Beckett, Margaret||Dewar, Donald|
|Beith, A. J.||Dixon, Don|
|Benn, Rt Hon Tony||Dobson, Frank|
|Bennett, A. F. (D'nt'n & R'dish)||Doran, Frank|
|Bermingham, Gerald||Douglas, Dick|
|Bidwell, Sydney||Duffy, A. E. P.|
|Blair, Tony||Dunnachie, James|
|Boateng, Paul||Dunwoody, Hon Mrs Gwyneth|
|Boyes, Roland||Eadie, Alexander|
|Bradley, Keith||Eastham, Ken|
|Bray, Dr Jeremy||Evans, John (St Helens N)|
|Brown, Nicholas (Newcastle E)||Ewing, Harry (Falkirk E)|
|Brown, Ron (Edinburgh Leith)||Ewing, Mrs Margaret (Moray)|
|Buchan, Norman||Fatchett, Derek|
|Buckley, George||Faulds, Andrew|
|Caborn, Richard||Fearn, Ronald|
|Callaghan, Jim||Field, Frank (Birkenhead)|
|Campbell, Menzies (Fife NE)||Fields, Terry (L'pool B G'n)|
|Campbell, Ron (Blyth Valley)||Fisher, Mark|
|Campbell-Savours, D. N.||Flannery, Martin|
|Canavan, Dennis||Flynn, Paul|
|Carlile, Alex (Mont'g)||Foot, Rt Hon Michael|
|Cartwright, John||Foster, Derek|
|Clark, Dr David (S Shields)||Foulkes, George|
|Clarke, Tom (Monklands W)||Fraser, John|
|Clay, Bob||Fyfe, Mrs Maria|
|Clelland, David||Galbraith, Samuel|
|Clwyd, Mrs Ann||Garrett, John (Norwich South)|
|Cohen, Harry||Garrett, Ted (Wallsend)|
|Coleman, Donald||George, Bruce|
|Cook, Robin (Livingston)||Gilbert, Rt Hon Dr John|
|Gould, Bryan||Morgan, Rhodri|
|Graham, Thomas||Morris, Rt Hon A (W'shawe)|
|Grant, Bernie (Tottenham)||Morris, Rt Hon J (Aberavon)|
|Griffiths, Nigel (Edinburgh S)||Mullin, Chris|
|Griffiths. Win (Bridgend)||Murphy, Paul|
|Grocott, Bruce||Nellist, Dave|
|Hardy, Peter||Oakes, Rt Hon Gordon|
|Harman, Ms Harriet||O'Brien, William|
|Hattersley, Rt Hon Roy||Orme, Rt Hon Stanley|
|Haynes. Frank||Owen, Rt Hon Dr David|
|Healey, Rt Hon Denis||Parry, Robert|
|Heffer, Eric S.||Pendry, Tom|
|Henderson, Douglas||Pike, Peter|
|Hinchliffe, David||Powell, Ray (Ogmore)|
|Hogg, N. (C'nauld & Kilsyth)||Prescott, John|
|Holland. Stuart||Primarolo, Ms Dawn|
|Home Robertson, John||Quin, Ms Joyce|
|Hood, James||Radice, Giles|
|Howarth,George (Knowsley N)||Randall, Stuart|
|Howell, Rt Hon D. (S'heath)||Redmond, Martin|
|Howells, Geraint||Rees, Rt Hon Merlyn|
|Hoyle, Doug||Reid, John|
|Hughes, John (Coventry NE)||Richardson, Ms Jo|
|Hughes. Robert (Aberdeen N)||Roberts, Allan (Bootle)|
|Hughes, Roy (Newport E)||Robertson, George|
|Hughes, Sean (Knowsley S)||Robinson, Geoffrey|
|Hughes, Simon (Southwark)||Rooker, Jeff|
|Illsley, Eric||Ross, Ernie (Dundee W)|
|Ingram, Adam||Rowlands, Ted|
|John, Brynmor||Ruddock, Ms Joan|
|Jones, Barry (Alyn & Deeside)||Sedgemore, Brian|
|Jones, Ieuan (Ynys Môn)||Sheerman, Barry|
|Kaufman, Rt Hon Gerald||Sheldon, Rt Hon Robert|
|Kennedy, Charles||Shore, Rt Hon Peter|
|Kilfedder, James||Short, Clare|
|Kinnock. Rt Hon Neil||Skinner, Dennis|
|Kirkwood, Archy||Smith, Andrew (Oxford E)|
|Lambie, David||Smith, C. (Isl'ton & F'bury)|
|Lamond, James||Soley, Clive|
|Leadbitter, Ted||Spearing, Nigel|
|Leighton, Ron||Steinberg, Gerald|
|Lestor, Miss Joan (Eccles)||Stott, Roger|
|Lewis, Terry||Strang, Gavin|
|Litherland, Robert||Straw, Jack|
|Livingstone, Ken||Taylor, Mrs Ann (Dewsbury)|
|Livsey, Richard||Taylor, Matthew (Truro)|
|Lloyd, Tony (Stretford)||Thomas, Dafydd Elis|
|Lofthouse, Geoffrey||Thompson, Jack (Wansbeck)|
|Loyden, Eddie||Turner, Dennis|
|McAllion, John||Vaz, Keith|
|McAvoy, Tom||Wall, Pat|
|McCartney, Ian||Wallace, James|
|McKelvey, William||Walley, Ms Joan|
|McLeish, Henry||Wardell, Gareth (Gower)|
|McNamara, Kevin||Wareing, Robert N.|
|McWilliam, John||Welsh, Michael (Doncaster N)|
|Madden, Max||Wigley, Dafydd|
|Mahon, Mrs Alice||Williams, Rt Hon A. J.|
|Marek, Dr John||Williams, Alan W. (Carm'then)|
|Marshall, David (Shettleston)||Wilson, Brian|
|Marshall, Jim (Leicester S)||Winnick, David|
|Martin, Michael (Springburn)||Wise, Mrs Audrey|
|Martlew, Eric||Worthington, Anthony|
|Meacher. Michael||Wray, James|
|Meale, Alan||Young, David (Bolton SE)|
|Michie, Bill (Sheffield Heeley)||Tellers for the Noes:|
|Millan, Rt Hon Bruce||Mr. Allen McKay and|
|Mitchell, Austin (G't Grimsby)||Mrs. Llin Golding.|
§ Question accordingly agreed to.
§ Bill read a Second time and committed to a Standing Committee, pursuant to Standing Order No. 61 (Committal of Bills).114
§ It being after Ten o'clock, MR. SPEAKER proceeded to put forthwith the Questions which he was directed by paragraph (1) of Standing Order No. 53 ( Questions on voting of estimates &c.), to put at that hour.