§ Mr. Strang
I beg to move amendment No. 9, in page 3, leave out lines 3 to 31 and insert—'1. The number of persons known to the Authority or Board to be persons with AIDS at the end of the period to which the report relates ("the reporting period") having been diagnosed as such—682 This is an important amendment because, in effect, it replaces the schedule to the Bill as amended in Committee. I stress that the work done by the Department of Health and Social Security, my research assistant and others has improved the schedule. There can be no doubt that the Bill is much better as a consequence of all the effort put into the changes in the schedule.
- (a) in that period; and
- (b) up to the end of that period, by facilities or services provided by the Authority or Board.
- 2. The number of persons known to the Authority or Board to have been diagnosed as persons with AIDS by such facilities or services in the reporting period or a previous reporting period and to have died—
- (a) in the reporting period; and
- (b) up to the end of the reporting period.
- 3. Where the number to be reported under any of the foregoing provisions is between one and nine (inclusive) the report shall state only that the number is less than ten.
- 4. Particulars of the facilities and services provided by the Authority or Board, or known to it to have been provided in its district or area by others, in the reporting period for testing for, and preventing the spread of, AIDS and HIV and for treating, counselling and caring for persons with AIDS or infected with HIV.
- 5. The number of persons employed by the Authority or Board wholly or mainly in providing in the reporting period such facilities and services as are mentioned in paragraph 4 above.
- 6. An estimate of the facilities and services which the Authority or Board will provide in the twelve months following the reporting period for the purposes mentioned in paragraph 4 above.
- 7. Particulars of action taken by the Authority or Board, or known to it to have been taken in its district or area by others, in the reporting period to educate the public in relation to AIDS and HIV and to provide training for testing for AIDS and HIV and for the treatment, counselling and care of persons with AIDS or infected with HIV.'.
Paragraphs 1 and 2 of the new schedule relate to the compilation of AIDS statistics for the reporting period and for the cumulative period. A new provision is introduced whereby a report should state the cumulative total of people with AIDS and the number in the reporting period. Paragraph 2 introduces a new provision in that, in addition to the number referred to in paragraph 1, each report should state the cumulative total of people with AIDS who have died by the end of the reporting period and the number of people with AIDS who have died in the reporting period. Clearly it is important for planning purposes to know precisely how many of the people with AIDS are still alive.
Paragraph 3 in the present schedule is to be deleted and new paragraph 3 repeats the provision in old paragraph 4. It provides that, where the number of cases with AIDS is between one and nine, to preserve confidentiality the report should say that the number is below 10. I am happy to endorse the Minister's remarks on Second Reading about the Government's anxiety that there should be no risk to confidentiality. There was a potential risk. We suggested the possibility of banding from nought to 10 and from 10 to 20, but concluded jointly that the best approach was the one in amendment No. 9, by which the number, when it is less than 10, is simply not reported.
The effect of paragraph 4 is to clarify the requirements which were previously contained in paragraph 6 that authorities and boards should report on facilities and services in their area for, inter alia, the testing, treatment, counselling and care for people who have AIDS or are infected with HIV. The amendment clearly differentiates between what is provided by the authority or board and what it knows other bodies have provided locally. It is important to recognise that this is a crucial requirement in the Bill. It will be relatively easy for the AIDS co-ordinator—if that is the person who will have responsibility for this in the district health authority or health board—to report on the work of the health authority or board.
Naturally, we want a comprehensive report—this is what is distinctive about this legislation—which covers the work that has been done by public authorities, local authorities, boards and voluntary organisations. The new paragraph acknowledges that there is a limit to the statutory requirement; we cannot put on a body a statutory requirement which it may not be able to fulfil. The amendment enables us to achieve more effectively what has always been our objective. That will clearly be understood by the district health authorities and officials who will be responsible for producing the reports.
New paragraph 7 amends the wording of former paragraph 8 to draw a clear distinction between action that is taken by a board or authority in regard to education and training as to AIDS and HIV and action that it knows has been taken by other boards locally.
Paragraph 5 clarifies the requirement in previous paragraph 7 to state the number of people who are employed by a health authority or board to work on AIDS or HIV by specifying that the report should cover only 683 those working wholly or largely in these areas. Hon. Members will understand that this is a common-sense amendment to the paragrph.
Paragraph 6 replaces previous paragraph 5. New paragraph 4 sets out the facilities and services that authorities and boards have provided in the reporting period for tackling the spread of AIDS and HIV. This new paragraph requires them to make an assessment of the facilities and services that they intend to provide in the next year. Again, hon. Members will understand that this change is desirable. It was felt that the original required estimate of services for people with AIDS was too wide. For example, we may find an authority stating that it required three new hospitals and using the report for political propaganda purposes rather than making a realistic assessment of what could reasonably be expected to be provided in the coming year. It is better for an authority to state what it proposes to do. There is nothing to stop it adding what it can or would like to do. the provision is widened to include not just AIDS but HIV and its manifestations.
Paragraph 7 replaces paragraph 8 with alterations along the same lines as new paragraph 4. It refers to training for professionals in sectors ranging from testing and counselling to education.
I should like to say something about the reasons for deleting the paragraph relating to HIV. Earlier in the debate the Minister stated that we have put a lot of thought into this because, as my hon. Friend the Member for Wrexham (Dr. Marek) has acknowledged, it is important that the requirement in relation to the statistics on HIV produces data which are useful and give some indication of the rate of spread of the infection nationally and regionally, but perhaps more crucially at district level and, in Scotland, at halth board level. At that level we must monitor the rate of spread of the disease. The AIDS cases are the manifestation of that and we know that that manifestation can take five years or more to appear.
It is not the AIDS cases which are important in relation to the epidemiology of the disease; it is our best estimates of the number of HIV carriers. That is why the Minister was right to stress our determination to ensure that, whatever arrangements are agreed and whatever new paragraph is inserted, under the procedure in which the hon. Member for Southwark and Bermondsey (Mr. Hughes) expressed an interest, they are of value to the Department, Ministers and the community generally in monitoring the rate of spread of the virus and in evaluating over the years— on the basis of that rate of spread nationally and locally— how effective the measures of the Government and the community are in relation to reducing the rate of spread of the virus.
The Minister and I have been pursuing that question in recent weeks and I shall quote the letter that he kindly sent me on 19 March, because it helps to put on record for the benefit of the House not only my interest but the commitment of the Government in this matter. The Minister explained why he felt that we had to withdraw the paragraph in the amended Bill and why he could not at this stage go ahead with a replacement for it. He said:Our main concern rests with the operation in practice of paragraph 3 of the Schedule. We understand that the intention is to make authorities aware of the number of those people in their districts who have been identified as infected with HIV, and to give some idea of the total volume of blood 684 tests that have been undertaken. We support those aims fully and would like to see an amendment to the schedule that leads to this information being obtained.He went on to explain that the Government intend—we hope to achieve this—to secure the amendment in time for the first reports, which will be published in 1988. I hope that it will be possible for the first reporting period to end on 31 March 1988, which is the first reporting year.
I hope that we have reassured the House as to why there is no paragraph in the new schedule on the question of the incidence of HIV and how we shall achieve useful statistics and estimates of HIV infection in different areas. I believe that the House will regard the new schedule as a substantial improvement on the one in the amended Bill.
§ Sir George Young
Paragraph 2 of the schedule requires reports onThe number of persons known to the Authority or Board to have been diagnosed … and to have died".On what information will such reports be compiled? Some doctors may not put AIDS as the cause of death. For example, if a publicly respected figure living in a small village dies of AIDS, his GP may not wish to state that fact on the death certificate. Bearing in mind the way in which AIDS is most commonly contracted, the doctor may seek to save the sensitivities of the family and friends by putting another disease on the death certificate. The dead mart may be known to the authority or Board to have been art AIDS sufferer, but will that death be included in the statistics?
I recall the recent death of Liberace. Up to the moment of his death, his relatives, advisers and friends insisted that he did not have AIDS. I stand to be corrected, but I think that the coroner put AIDS on the death certificate and some litigation resulted.
I understand that AIDS involves, as its name implies, an immune deficiency and reduces the body's capacity to resist other diseases. Those who suffer from AIDS may die of something else. Will the other disease appear on the death certificate? If we are to publish information about. deaths, we are entitled to know how the raw data are compiled and how we can overcome the social problems when the correct cause of death is not recorded on a death certificate.
§ Dr. M. S. Miller (East Kilbride)
I agree wholeheartedly with what the hon. Gentleman is saying, but it would not be lost on anyone examining the statistics that if there were a significant increase in, for example, Kaposi's Sarcoma or in the number of deaths from bronchial pneumonia or other related diseases, we should be dealing not with a relatively simple infection but with something much more sinister. However, I agree with the hon. Gentleman that we need some way to show clearly and concisely what is happening.
§ Sir George Young
I am grateful to the hon. Gentleman. As a qualified doctor, he has covered the issue in a much more professional way than I could. There are other ways of registering the deaths of AIDS sufferers than merely writing AIDS on the death certificate. Perhaps we can detect the incidence of AIDS by looking at the causes of other deaths, but, under the proposed new schedule, they would not appear as deaths from AIDS.
I am glad to see that my hon. Friend the Under-Secretary of State for the Home Department is present, because he has ministerial responsibility for coroners, who are in charge of death certificates. Perhaps they will have 685 to ensure that the Home Office complies with the spirit of the Bill if it gives guidance on how death certificates should be completed when someone dies of AIDS.
The schedule requires certain information to be provided:The number of persons employed … wholly or mainly in providing . . . such facilities and services … An estimate of the facilities and services which the Authority or Board will provide".However, no estimate is required of the costs involved. Is that because this is a private Member's Bill and, therefore, it is not in order to mention money, or is there another reason? I know that my hon. Friend the Minister for Health has made substantial resources available through the National Health Service to meet the growing problem of AIDS. It seemed to me that it would be appropriate for the Government to show how the money was being spent. Will my hon. Friend or the hon. Member for Edinburgh, East (Dr. Strang) explain why costs incurred by the authority or board are not included in the schedule?
§ Dr. M. S. Miller
I apologise for the fact that, due to circumstances beyond my control, I arrived after the debate had started.
We are dealing with a tremendously serious outbreak which is worse than anything that we have known in our lifetime and is perhaps worse than anything that has ever been known; even the black death might not be comparable.
The outbreak has taken us unawares. I do not blame anyone for that, but we certainly have to monitor the situation much more closely and regularly than we should have to monitor an outbreak of smallpox or diphtheria.
I hope that the Minister will tell us what action he intends to take to ensure that information is kept up to date—not on an annual basis, but over much shorter periods. Those who will be deeply involved in the treatment of patients, whether it be palliative treatment or any other sort, and those responsible for providing the necessary funds— the cost will balloon enormously—must be able to call on up-to-date information.
I do not know whether such a provision needs to be put into the Bill. Certainly, no responsible Government could neglect the need for up-to-date information and I hope that the Minister will assure us that those who are involved in treating AIDS and in providing funds will have information about what has been happening in the previous month or so.
§ Mr. Eric Forth (Mid-Worcestershire)
It is always difficult to interrupt a comfortable unanimity on any subject, however important it may be, but occasionally it falls to an hon. Member to fulfil that role.
Some people in politics, perhaps the more cynical, say that if something has unanimous support there must be something wrong with it. I am not sure that I subscribe wholly to that view, but I have occasionally shared it.
My fears are made specific by the proposed new schedule. We are dealing with the fine balanace that must be struck between the provision of information, which may be essential to the end that everyone wants to achieve, and the possible spreading of alarm. I fear that there is a danger that we may come closer than we should like to spreading alarm.
A report will have to be prepared on the number of AIDS sufferers in a health authority area. My hon. Friend 686 the Member for Ealing, Acton (Sir G. Young) mentioned the problem that could be caused in small communities. Even if an authority avoided the possibility of individuals being identified and merely said that there were fewer than 10 AIDS sufferers in its area, attempts might be made to identify them and alarm might be caused unnecessarily.
Some thought must be given to whether we are striking the correct balance between the provision of information for the most laudable purposes and the possible causing of alarm in small communities where none existed before.
I should like to know how far my hon. Friend thinks it will be possible to identify accurately and meaningfully the facilities and services which are allocated to the purpose contained in the Bill. Will they not overlap considerably with other purposes and facilities already in existence? I have some doubts about the meaningfulness of the amendment, particularly paragraph 5, which refers toThe number of persons employed by the Authority or Board".I should have thought that the facilities would be shared to a large extent, or that action would be taken as far as possible within existing resources. I hope that we are not attempting to impart a spurious accuracy to something that will be very difficult to identify.
I am, however, much more concerned about paragraph 6, which has been touched on already. I am worried about it, and I wonder whether my right hon. Friend is as well. I fear that we are about to go down a rather dangerous road. If we requireAn estimate of the facilities and services which the Authority or Board will provide",we shall open up the distinct possibility— as was admitted during the moving of the amendment—of pressure being put on the Government of the day, regardless of party. In an effort to extract more resources from the system, individual boards and authorities may exaggerate the problem, or perhaps say only what they believe is essential to provide the facilities required under the Bill. How will the Government respond to such pressure? If we applied the principle right across the National Health Service, I suspect that any Government would find themselves in the uncomfortable, if not intolerable, position of being told by each board, region and authority, "This is essential: the statute requires it."
We are discussing AIDS now, but such a development could spread to other cases in which a condition requires treatment, or information needs to be provided. The Government of the day would be forced to say whether they could make such provision or, if they could not, why they could not. I am worried that the paragraph could create a precedent and how we will respond.
That leads me to a wider point touched on by my hon. Friend the Member for Ealing, Acton. We see no mention of the costs of the exercise. We know that the facilities are being generously provided already, but we cannot measure the commitment that we are being asked to make. The principle is important. Many people have expressed concern, which I should like to voice today, that we may be committing potentially enormous resources to a largely—although not entirely— self-inflicted condition. It is difficult to square that with the lack of similar provision and concentration of resources on behalf of those who suffer from conditions that they have not brought upon themselves.
687 My hon. Friend knows that I am at issue with him on the subject of needles. I acknowledge that we have at last given needles to diabetics, but that was done only because of AIDS. How can we justify the Bill which, with the best possible motives, devotes considerable resources—we do know how much— to AIDS, to disabled and handicapped people who may be suffering from, say, kidney disease, which is not self-inflicted but is the result of a natural catastrophe? They have a very good claim to more resources, but there is no such Bill for them, to my knowledge. There is a good deal of unease in the community, and I, too, am uneasy about the degree to which we are concentrating on AIDS in the amendment.
Paragraph 7 refers tothe reporting period to educate the public".Here again, there is a difficulty. The term "education" always carries the best possible connotations. It sounds good; everyone approves of education. In the present context, however, the meaning of the word is not beyond controversy. The excellent efforts of the Government to education the public, as they see it, have made many people feel anxious that what to one man is education may spread alarm, panic and unnecessary concern to others.
§ Mr. Deputy Speaker
Order. The hon. Gentleman is straying quite wide of the amendment; his speech would have been more appropriate on Second Reading. The amendment deals with reporting, not with the merits or otherwise of what is to be reported.
§ Mr. Forth
I thought, Mr. Deputy Speaker, that it was in order to explore the meaning of the word "educate" in paragraph 7. However, as always, I shall be guided by you. I hope that I have put my point across.
Although I well understand the concern that has given rise to the Bill, and although I appreciate the unanimity referred to earlier by my hon. Friend, I have considerable reservations about it. I am worried about what may lie behind the schedule, about what it requires in terms of cost and about the wider implications for National Health Service resourcing. It may be felt desirable in the future—perhaps, indeed, by me—to use the Bill as a precedent when dealing with other conditions that are not, as this is, largely self-inflicted.
We shall not be voting on the amendment today, but, if we were, I should abstain or even vote against it. I hope that my hon. Friend will be able to reassure me.
§ Dr. Marek
I shall be brief. I think that there is general unanimity in the House, although not on every aspect of the problem, but, I was very sorry to hear the speech made by the hon. Member for Mid-Worcestershire (Mr. Forth). The hon. Gentleman was arguing for ignorance. He said that enormous resources could be spent on AIDS. Despite the general unanimity, that is one of the points at issue: the Opposition feel that the Government should be putting more emphasis on the problem, and committing more resources to it. At present, those resources are not enormous.
I was also sorry to hear the hon. Gentleman say that resources were being committed to a condition that people had brought upon themselves. That is a shameful statement. The hon. Gentleman should be thoroughly ashamed of himself, but, in his ignorance, he probably will not be, which makes me even sadder.
§ Dr. Marek
Of course it is not true. The number of HIV cases in this country has been estimated at 20,000, 30,000 or 40,000, but I fear that the eventual figure will be considerably higher. All the estimates made so far have been at the bottom of the band. I do not wish to spread alarm, and I do not think that I am doing so, but I feel that the public should know the facts, rather than be kept in ignorance, as the hon. Member for Mid-Worcestershire recommends.
It is the Government's duty to inform the public, unless they have extremely good reasons not to do so— perhaps relating to national security, but that does not arise here. The public are not idiots. If they are aware of the facts, they can consider them and take appropriate action. Leaving the public in ignorance will not help. That is why the Opposition fully support the Bill.
§ Dr. M. S. Miller
AIDS has been visited upon us relatively recently, so, even with scientific knowledge, no one should jump to conclusions about how it is spread. Many aspects of the disease are still in their infancy. We might discover a different pattern in the coming months or years. It is wrong to jump to conclusions about how it is spread or to say that it is self-imposed.
It took a long time to discover that lung cancer was caused by smoking cigarettes. For many years we did not think that there was any relationship between the two. It might be some time before we know the implications of how this disease is spread.
§ Dr. Marek
My hon. Friend makes the point better than I do. Only by knowledge shall we find out how the disease is spread, how it is caused and what can be done to cure it.
I shall say nothing more about the hon. Member for Mid-Worcestershire, because his words speak for themselves. The disease exists in the heterosexual community. It is not something that people have brought upon themselves, as the hon. Gentleman said. It concerns all of us. I am sure that the hon. Member will find no support for his words anywhere in the House.
I do not think that there will be any identification problems if the Bill is passed. As the Minister said, hon. Members on both sides of the House are worried about that possibility. We do not want individuals to be identified.
I am pleased that my hon. Friend the Member for Edinburgh, East (Mr. Strang) intends to continue to consider how the statistics for AIDS and HIV should be collected. Eventually I am sure that we shall come up with a solution.
I am happy to support the amendment in the hope that perhaps in another place certain matters might be put right.
§ Mr. Simon Hughes
I support the amendment. I am grateful to the hon. Member for Edinburgh, East (Mr. Strang) and the Minister for trying to achieve the best criteria for reporting. In Committee I moved an amendment dealing with the breakdown figures. I accept the need for the figures not to be broken down according to district or region because of identification problems.
I hope that when the Minister does his national compilations he will break down the figures by age. That will be particularly useful because it might show whether the campaign is getting through better in some places than in others. It is important to know nationally the incidence 689 of people who have contracted the virus and the disease. That will enable the Government to direct their campaign more efficiently and to provide more widespread information about what we all need to do to try to reverse the spread of the disease.
§ Mr. Rhodes James
I am worried about paragraph 3 of the schedule. I understand the confidentiality problem, about which we are all concerned, but the value of the data that will result from the Bill will be diminished if a report might stateonly that the number is less than ten.Statistically there is an enormous difference between five, three and nine. The value of the schedule might be compromised by that paragraph. That is not a criticism of the schedule as a whole, because it is a great improvement on the original, but it could nullify the total value of the exercise and the statistics.
§ Mr. Peter Bruinvels (Leicester, East)
I apologise for being out of the Chamber, but I went to get the latest AIDS figures, published by the DHSS, which obviously are important to the schedule.
Confidentiality has been mentioned. The region of the reporting doctor might not be the same as that of the patient. That would certainly ensure confidentiality. A patient might receive treatment in a region other than that from which he was first reported or he might he known to a region which has not yet reported.
I am a little worried that certain areas will be known as AIDS-free areas and others as AIDS-covered areas. For instance, the North-West Thames area has the largest number of AIDS carriers at 363, yet East Anglia has only five. I am certain that it is necessary for district health authorities to report, according to the schedule, where the AIDS carriers live and where the deaths occur.
We are talking about 731 United Kingdom AIDS cases and 373 deaths. As my hon. Friend the Member for Mid- Worcestershire (Mr. Forth) said, according to DHSS figures a large number of AIDS cases involve either homosexuals or bisexuals. The total up to the end of February 1987 was 640, of whom 317 have died. I must make one point to my hon. Friend the Member for Mid- Worcestershire—28 cases were not homosexual but were haemophiliacs, of whom 22 have lost their lives.
§ Mr. Forth
I should like to clarify what I said, in view of the remarks by the hon. Member for Wrexham (Dr. Marek). I was very careful to say that the disease was largely self-inflicted. If the hon. Gentleman checks Hansard, he will discover that I used that phrase several times. My hon. Friend the Member for Leicester, East (Mr. Bruinvels) now makes clear the basis for my remarks. I acknowledge that some people do not come into that category, but the great bulk do. That is the difference that I was describing in relation to people with handicaps and diseases of other kinds in which they have played no part whatsoever.
§ Mr. Bruinvels
I have no doubt that that clarifies my hon. Friend's position.
In a written question yesterday I asked about the children of HIV mothers. I am not sure how figures for them can be incorporated, but I hope that they will be.
690 There have been seven cases so far, and four have died. Like my hon. Friend the Member for Ealing, Acton (Sir G. Young), I think that the death certificate in such cases should be clear. I am aware that such cases cause a scare in the neighbourhood and might perhaps undermine the respectability of the person concerned. Anyone— Liberace is a case in point—who dies of AIDS should have the sympathy of the whole House. Such people should be treated not as statistics but as human beings in desperate circumstances who need care and understanding in the last days of their lives.
I welcome the schedule. It is reported that three doctors currently have the AIDS virus. One is in gynaecology and the others are standard physicians. I am not sure how the public will be notified, but I hope that medical men or women who have the AIDS virus will not be allowed to continue in practice. If they did, it could be fatal. People go to hospital to get better. I hope that the Minister will look into that. I know that he is considering what to do about the two nurses who suffer from the AIDS disease. Under the schedule such cases will be recorded as carriers. Those who die from the disease will also be recorded. The Bill is a very caring Bill and it is desperately needed. I congratulate the hon. Member for Edinburgh, East (Mr. Strang) on introducing it.
§ Mr. Newton
I propose to make my speech on this amendment by commenting, as did the hon. Member for Edinburgh, East (Mr. Strang), on the schedule paragraph by paragraph. I shall also comment on the points that arise from that process and pick up any other points that may be left over from the notes that I have made on hon. Members' speeches.
The hon. Member for Edinburgh, East accurately described the purposes of paragraphs 1 and 2 of the new schedule even though, technically, it is amendment No. 9. Those paragraphs help to clarify the intention of the Bill concerning the figures that the reports should contain about the number of people with AIDS. They expand the previous provisions to specify how many of the total number of people with AIDS are living and how many have died. That will be a useful addition to the figures already produced on a national and regional basis by the Communicable Disease Surveillance Centre and the Scottish unit of that centre.
My hon. Friend the Member for Ealing, Acton (Sir G. Young), with the professional endorsement of the Member for East Kilbride (Dr. Miller), raised the question of what the definition of death will be for this purpose, if I may put it that way, and how confident we are that all AIDS cases will be identified as such on death certificates. That is a problem not only with AIDS but with some other diseases and it is not something to which anybody has found a conclusive answer. In some cases there is the obvious risk that the cause of death may be misdiagnosed, but in other cases, for one reason or another— possibly in the interests of attempting to spare people's feelings—some unusual description or possibly circumlocution may be used to describe a cause of death that is thought to be especially unfortunate. There is little doubt that in some cases doctors may be using phrases like "immunodeficiency" to spare people's feelings. However, in such cases it is likely that they will be recognised as AIDS cases by the Communicable Disease Surveillance Centre.
I acknowledge that there is a possible problem for which there is not an off-the-cuff conclusive answer. There 691 are also problems related to the statistics concerning such cases and we are constantly seeking to rectify and improve the position. On Monday of this week there was a significant, though small, specialised conference in London about predicting the course of the AIDS epidemic. Part of the purpose of the conference was to study precisely the way in which the statistical basis of our knowledge and thus our capacity to predict the spread of the disease, can be improved.
§ Dr. M. S. Miller
Perhaps the Minister will study the legal position and the definition of the term "syndrome." I cannot remember ever writing on a death certificate that someone had died from a syndrome; he died from some disease, condition or accident. Will the Minister consider whether it is legal to put down AIDS as the cause of death because it is not a disease but a syndrome? He should consider what the definition of the term "syndrome" would imply.
§ Mr. Newton
I undertake to examine what the hon. Gentleman has said with added vigour in view of his professional background. I accept that there is a difficulty. It has been implicit in remarks made in the House that the actual, immediate cause of death in many AIDS cases is pneumonia. In that case the issue arises as to whether the doctor puts on the death certificate pneumonia arising from or aggravated by the syndrome. I acknowledge that that must be considered. However, I am not in a position today to make further off-the-cuff remarks about that. It is frequently possible to follow up, in confidence, death certificates where the cause of death— for example, pneumonia— is a condition that could be related to AIDS.
If I may attempt to sum up in a sentence what I have been seeking to say, I acknowledge the possible problem that has been highlighted by a particular case in the United States, and I will undertake to consider the comments made today. As with everyone else, we are anxious to ensure, to the fullest possible extent, accurate reporting and accurate information about the prevalence and spread of the disease.
I wish to comment upon something that is not in the schedule, old paragraph 3, rather than paragraph 3 in the amendment. The original paragraph 3 required reports to specify the number of blood samples taken by facilities of the health authority or board for testing for HIV antibodies and the number of such samples which proved positive.
Old paragraph 3 attempted to find some sort of rough proxy of the number of people known to the health authority to be infected with HIV in tha authority's area. am sure that the House will not need reminding—if it did it would have been picked up earlier today— that this is a particularly difficult and complex matter. It is important to ensure that the information given in the reports is not misleading and that it is as complete as possible and that it ties in with the national information system already established by the Communicable Disease Surveillance Centre and the equivalent unit in Scotland. It is important that that information should not jeopardise and is not seen to jeopardise the confidentiality of individual patients.
When we reconsidered the wording of paragraph 3 of the schedule, as it was amended in Committee, against that background we were not persuaded that it adequately met 692 those four criteria. It does not bring information from the Public Health Laboratory Services, which carries out much of the testing, since those laboratories are independent of the health authorities. It does not distinguish well enough between the number of tests and the number of people being tested—some people may be tested more than once. We consulted our experts including the CDSC in an attempt to come up with an acceptable formulation in time for the Report stage, but, in view of the problems involved, we have not managed to do so. Rather than persevere with what is undoubtedly a defective provision in the Bill, we are proposing to delete it.
None of what I have said, which was emphasised in an extract from my letter which was quoted by the hon. Member for Edinburgh, East, detracts from the desirability that authorities' reports should contain information about the extent of HIV infection in the local areas. Clearly that information will be most important for planning purposes, and we shall be giving that matter further consideration in consultation with the C'DSC' together with the health authorities and boards. I repeat the assurance that was explicit in my letter to the hon. Member for Edinburgh, East that we intend to use our powers under the Bill to add the requirement that reports must provide information, to the extent that that information is available, about HIV infection. That will occur just as soon as we have devised a workable solution to the problem, and it will certainly be in time for the preparation of the first report.
The hon. Member for East Kilbride raised a query about the reporting period and said—in my judgment, he was correct— that more frequent, up-to-date information would be required for those who are directly engaged in the provision of services. I accept that, but it is a separate problem. The purpose of the reports is to provide a picture of the overall position and the expected provision of services in any given part of the country by a health authority in England over a period. That information will enable the public to make a judgment about what is going on and how the authorities are responding. In one sense, the clinicians and others concerned with the direct treatment of a clinical AIDS case will not need to have a lot of statistics available to them because they will have the people in their wards or t hose people will be provided with social services. They will know what it happening because they will be able to count the number of people they are treating.
Leaving aside that simplistic point, we are publishing monthly the information that is available to us through the Communicable Disease Surveillance Centre about the number of AIDS cases and deaths in particular regions. My hon. Friend the Member for Leicester, East (Mr. Bruinvels) used the press release giving the February figures, which was published earlier this month. We have also said that we shall publish on a quarterly basis the best analysis that we can make of the increase, for example, in the number of HIV positives who have been identified and the assessment that that enables us to make about the spread of the disease. There are too many uncertainties yet for that to be more than an assessment, using the latest available information, but there is nothing in the Bill that suggests that the only requirement for information is in a 693 report once a year from every health authority. There are several needs for information, which the Government are actively seeking to meet.
New paragraph 3 repeats the old paragraph 4 and provides that where the number of AIDS cases is between one and nine, to preserve confidentiality, the report would say that the number was below 10. I shall not say anything further about confidentiality at this stage. It has been accepted entirely on both sides of the House that confidentiality should be protected.
Again, I take up the point made by my hon. Friend the Member for Leicester, East. Should anyone doubt the potential risk in terms of particular districts, he has only to look at the figures to which my hon. Friend referred, which show that at present there are only two live AIDS cases in the whole of East Anglia—these are the figures notified at the end of last month to the CDSC. There are only two live AIDS cases in the whole of the Oxford region, only two in the whole of the south-west, only three in the whole of the west midlands, and none in Merseyside, although that is simply because all the known people in Merseyside have already died. Therefore, there must be a significant number of health authorities with only one case, if they have any at all. On a narrow district basis, that creates a real risk that confidentiality will be breached. I hope that that will be fully accepted in the House.
Paragraph 4 of the new schedule clarifies the requirement previously in paragraph 6 that authorities and boards should report on facilities and services in their area for, among other things, the testing, treatment, counselling and care of people with AIDS or infected with HIV, while paragraph 7, which was previously paragraph 8, similarly amends the earlier wording to draw a clear distinction between action taken by the authority or board in regard to education and training in respect of AIDS and HIV and action that it knows has been taken by other bodies locally.
As the hon. Member for Edinburgh, East said, the amendments are being introduced to clarify and expand what authorities are to include in their reports about local facilities and local action to tackle AIDS and HIV infection. They make it plain that authorities have a two-part obligation—first, to report what they are providing and the actions that they have taken as authorities, and, secondly, to report what they have learnt about what other bodies are doing in their area. We think that in practice the capacity of health authorities to report on what else is happening in their area will be good because in most cases there are already good links between the health authorities and the other agencies involved, but where such links have not yet been formed we hope that the duty to report will encourage those links to be developed or further strengthened in a way that will enable health authorities to provide a thorough picture of local activities.
Paragraph 5, formerly paragraph 7, clarifies the earlier requirement in former paragraph 7 to state the number of people employed by the health authority or board to work on AIDS and HIV by specifying that reports should cover only those working wholly or largely in those areas. That amendment is introduced to make explicit the intention of the provision—my hon. Friend the Member for Mid-Worcestershire (Mr. Forth) raised this point—that only people employed by the health authority or board who work entirely or substantially in those areas should be 694 counted. A large number of NHS staff may at some time perform some duties in relation to AIDS or HIV, but for planning purposes what is needed is to get a firm idea of the number of people whose main responsibilities are in that sphere.
§ Mr. Forth
Does my hon. Friend agree that there is a danger that that could be slightly misleading? An authority might not be able to identify anyone who fulfils the criteria that he has just mentioned, but may have a significant number of people working in that broad area or allocated to it from time to time. If it reported a low or nil figure, that would not give the assurance that my hon. Friend feels the community needs that the authority was working hard on the matter. Is there that danger?
§ Mr. Newton
In practice, I doubt it. I am sure that health authorities will present such firm data as they think can sensibly be presented within the terms of the schedule. They will say that some people's time is spent to some extent on AIDS, or that as yet they have few cases in their area, so the need for people to be deployed on the clinical treatment of AIDS, as distinct from education and so on, is not there. I do not mean to be too dismissive of my hon. Friend's point. I can see the theoretical point, but in practice I do not believe that there will be a serious problem
I come to paragraph 6, which replaces the previous paragraph 5. As I said, we have provided that authorities and boards set out the facilities and services that they have provided in the reporting period, including the manpower issue, to which I referred, for tackling the spread of AIDS and HIV. The new paragraph requires them to make an assessment of the facilities and services that they intend to provide in the next year, so the new paragraph represents a significant extension of the information to be provided by health authorities and boards in their reports. It replaces the previous paragraph 5, which required authorities and boards to make some assessment of their future provision for people with AIDS. It seemed to us to be sensible to widen the provision so that, in line with the Bill as a whole, it encompasses not only people with AIDS—this point was raised by my hon. Friend the Member for Acton as well as my hon. Friend the Member for Leicester, East— but the much wider group of those infected with HIV which, as the whole House acknowledges, in some ways is the most important figure, or may prove to be the most important figure, for planning purposes. I hope that that has helped to clarify still further the purpose of the paragraphs in the schedule and the reasons for the disappearance of one paragraph in particular from the previous schedule.
§ Mr. Newton
I will come to some of the other points that have been raised, but I happily give way to my hon. Friend.
§ Mr. Bruinvels
I wanted to refer to paragraph 7, which mentionsthe treatment, counselling and care of persons with AIDS or infected with HIV.In view of the articles in the Daily Star and the News of the World, about the two nurses with AIDS and the three doctors, should it be a policy for those who have the disease or who are carriers to treat and care for those who also have the disease or are carriers?
§ Mr. Newton
I am aware of the reports that have appeared in the newspapers to which my hon. Friend refers, but I am not in a position to make any significant additional comment on them beyond the observation that there are few known cases of health care workers becoming infected with AIDS from patients with AIDS despite, in a number of instances, needle-stick injuries. As far as I am aware, there are no known cases in this country or in the United States, where experience is much more extensive for the obvious reason that, unhappily, there are many thousands more cases, of a person becoming infected by a health worker who was himself or herself infected. It is not the purpose of this part of the schedule to identify in the way that I sense my hon. Friend was suggesting. Apart from anything else, some rather acute confidentiality issues would be raised if a report were being made public.
With the exception of some of the matters raised by my hon. Friend the Member for Mid-Worcestershire, to which I am about to respond, I think that I have covered all the specific points that have been put to me during the debate. If hon. Members feel that I have not responded to their interventions, I have no doubt that they will intervene again to remind me of their earlier contributions.
My hon. Friend the Member for Mid-Worcesteshire said that there is a risk that the requirement to publish reports will spread alarm. In many parts of the community there is a degree of alarm about AIDS, but we would be doing no service if we were to do anything to promote the spread or continuation of complacency about AIDS. In many communities it may be that the greater risk is complacency rather than excessive alarm.
East Anglia, for example, has had only five cases of clinical AIDS up to the end of February, and three of those people are now dead. The possibility cannot be ignored, however, that there are significant numbers within East Anglia who are infected with the virus and are HIV positive. We have no means of knowing what the number is because we do not know what the total number is. It is inherently likely, however, that the number of HIV positives is about 30,000 to 40,000. That is what we think most likely at present, but during the week it has been mentioned in one quarter that it could be 100,000. This means that there will he significant numbers of these people in East Anglia.
It would be a mistake to think that because in any given district there has been no AIDS case there are no potential AIDS cases and no people who are infected with virus. The case for making reports public and publishing such information as can be made available is justified in an imperfect world. In the years between now and the end of the century there will be few parts of the country which do not have some experience of AIDS cases, even though the scale and number will undoubtedly vary widely.
My hon. Friend the Member for Mid-Worcestershire spoke about costs and pressures. Even without any requirement to report on anything in particular, it is not unknown for health authorities to seek to put pressure on central Government when it comes to the allocation of moneys and to draw attention to the desirability of having more of it. I entered the Chamber the night before last when my hon. Friend the Under-Secretary of State was replying to an Adjournment debate that had been raised by my hon. and learned Friend the Member for Leicester, South (Mr. Spencer). My hon. Friend the Member for Leicester, East was assiduously joining in the debate with 696 other Leicester Members in making the case for additional funds for the Leicester health authority. I have no wish to encourage him to return to that issue today, still less to encourage demands for more money for Cambridge, Ealing, Gillingham, Reading or Grantham, for example. There are at least two Scottish Labour Members present, and fortunately their demands for more money would have to be directed to a different quarter.
§ Mr. Forth
Let me try to present a different angle. Let us suppose that I introduced a Bill that was based on the fact that 100,000 people die each year from nicotine-related diseases and placed an obligation on health authorities to identify these cases and to report on the resources being directed to them, thus providing a vehicle for specific pressure to be put on his Department centrally to provide more resources to treat the 100,000 suffering from a self-inflicted condition as a result of ingesting nicotine and related materials. It seems that we are departing on a new policy that could be used in future in the way that I have suggested. That is my concern
§ Mr. Newton
I was about to take on board that argument. I hope that my hon. Friend will understand— I accept that he made his case with a qualification and qualified it further later— that whatever view anyone may take about the background to some of those who are HIV positive, or have AIDS, having become ill, I as a health Minister must recognise that they are ill and need treatment. I think that it is right to proceed on that basis. My hon. Friend has now drawn an analogy that is stronger than some of those that he presented earlier, but by imposing a requirement on health authorities to publish reports we are seeking to make a contribution to the effort to prevent AIDS. At present we can proceed only by means of public education and better information in trying to curb the spread of a terrible disease that poses a considerable threat to many. The same considerations do not arise in relation to the treatment of other diseases which, though at least as unfortunate, can be tackled in other ways. It would be wrong for my hon. Friend to convey the impression that the Government are devoting a degree of importance, whether through their acceptance of the Bill or in other ways, to the prevention of AIDS that they do not attach to the taking of effective action against other health problems.
During the past month my right hon. Friend has announced the introduction of a national breast cancer screening programme to tackle that problem. He has also announced a further improvement——
§ Mr. Newton
At the same time, my right hon. Friend announced further steps to try to improve the cervical cancer screening programme which is under way and which represents a significant effort in that area. Within the next month, the health education authority, in conjunction with the Department of Health and Social Security, will launch a major campaign directed at the problem of coronary heart disease, called "Look after your heart"——
§ Mr. Deputy Speaker
Order. I think that perhaps we should now return to reports about HIV and AIDS.
§ Mr. Newton
I am sorry to have compounded the felony of my hon. Friend the Member for Mid-Worcestershire by being enticed down the same path as him. I hope that I have said enough to make clear the lines of my answer. In requiring these reports, there is no question of neglecting other problems or of treating AIDS as special, except that we have a chance to stop that disease from becoming as disastrous as it could otherwise be. The background to the Bill is part of the effort to prevent that spread.
§ Dr. M. S. Miller
There is no doubt that the general thesis of the hon. Member for Mid-Worcestershire (Mr. Forth) is right. He did not actually say what he wished to do, but I disagree with his feelings. In referring to self-inflicted conditions, I should like to make an analogy. It is well known that the commonest cause of death in young men between the ages of 18 and 25 is motor cycle accidents. Everyone knows that that is self-inflicted. All motor cyclists know the risk that they take. Does that mean that hospitals should not treat unfortunate young men who have motor cycle accidents?
§ Mr. Newton
Another piece of specific legislation has proved sensible. I refer to the compulsory wearing of crash helmets. Legislation should be directed to the nature of the problem. This legislation and the subparagraph to the schedule are sensibly directed towards the problem. The seat belts legislation was sensibly directed towards another problem, as was the crash helmets legislation.
§ Mr. Simon Hughes
I hope that the Government will realise that it is important to be consistent and that they will encourage the making of reports, such as that produced the other day by the Health Education Council, so that maximum information may be available, on which all health decisions can be made, and not only what the Government consider, at the moment, to be the most important——
§ Mr. Newton
I must correct the impression given by the hon. Member for Southwark and Bermondsey (Mr. Hughes) that that report was by the Health Education Council. He will know that the council has not considered that report and that it never properly discussed or commissioned it. The council did not know that the report was to be published or that a press conference was to be held. I hope that the hon. Gentleman will, at least, register those points.
Without going down a path which will cause you, Mr. Deputy Speaker, to intervene again in my speech, I have pretty well exhausted all that I can say about this amendment and the revised schedule which it incorporates in the Bill. I hope that, even if I have dissatisfied you by the breadth of my remarks or failed to answer every last point or anxiety in the mind of my hon. Friend the Member for Mid-Worcestershire, I have at least dealt with the other points raised by hon. Members and that I leave them feeling reasonably satisfied.
§ Mr. Strang
I should like to respond briefly to some of the points raised by the hon. Member for Mid-Worcestershire (Mr. Forth). Although I disagree with him, I recognise that some people in the country share his views. This is one of the rare occasions that we have had to respond to that point of view, which is in a minority in the House, about the Bill.
The Minister dealt with the issue of confidentiality. I have given that matter much thought, especially after the Minister raised it on Second Reading. The more that one considers it, the more one will reach the conclusion that the local press—the Minister referred to this specifically—will almost certainly find out about the AIDS cases in its communities, long before there is a published report relating to the 12-month reporting period. I stress that the Minister and I are both aware of that point. The Bill strikes the right balance in maintaining confidentiality so far as the risk exists.
I agree with the Minister that people must understand that this is the biggest threat to public health, certainly for half a century. Therefore, it is right that the community should be worried and should desire to educate itself about the disease.
We have amended the Bill to go some way towards meeting the hon. Gentleman's point about expenditure. Paragraph 6 of the new schedule states that the authority or board will provide an estimate of the facilities and servicesin the twelve months following the reporting period.The existing schedule, at paragraph 5, states:An estimate of the facilities or services which the Authority or Board will require.Therefore, there has been a genuine attempt to meet the hon. Gentleman's anxiety.
I cannot agree with the hon. Gentleman on the "largely self-inflicted" element. We are not only talking about the tragic cases of haemophiliacs who have contracted the disease through blood transfusions and no fault of their own, or about babies. I am sad to say that a high proportion of babies in Edinburgh are born with AIDS. There is the highly-publicised case of Army personnel who returned from Africa and are located in Inverness. It appears from a recent press report that the fears that some had become infected are not justified. I ask the House to consider the position of the wife of one of those service men. Is someone suggesting that her case would be self-inflicted? I appreciate that the hon. Gentleman is not suggesting that.
The disease can undoubtedly be transmitted through heterosexual intercourse, if one party is a carrier - whether female or male. We do not know the efficiency of transmission through normal heterosexual intercourse, but it unquestionably occurs and may well become the main method of transmission. I stress that because some tabloid newspapers have almost implied that that hardly ever happens.
§ Mr. Forth
Does the hon. Gentleman agree that the United States is the main country where that has happened and that it is well-documented? Does he further agree that a comparison between the incidence of AIDS and other related diseases in and around San Francisco and New York on the one hand and in the Mid-West on the other strongly suggests that there is a connection between 699 voluntary practices, such as homosexuality and drug-related practices, and the incidence of the diseases? It would be stupid to deny that, and that is the basis of my point.
§ Mr. Strang
I agree that there is no point in denying the facts. The nature of one particular homosexual act means that the transmission of the disease is unquestionably more efficient and frequent. That is not in dispute. In England, but not in Scotland, a high proportion of cases are among homosexuals or bi-sexuals, but I believe that that will change. The disease will be with us for many years, and because there is much more heterosexual intercourse than homosexual intercourse, there will be more cases among heterosexuals in future.
§ Mr. Deputy Speaker
Order. Now that the hon. Gentleman has dealt with that point, I hope that he will return to amendment No. 9 and the contents of reports.
§ Mr. Strang
The hon. Gentleman referred to paragraph 7 of the schedule and education. Perhaps the most authoritative document available on AIDS is that of the Institute of Medicine of the National Academy of Sciences in the United States. The report states:For at least the next several years, the most effective measure for significantly reducing the spread of HIV infection is education of the public, especially those individuals at higher risk.That is the view of the Government and of most people involved in this problem.
The schedule is important. The hon. Member's concerns should not lead him to oppose the Bill. If it turns out that some of his fears about certain paragraphs of the schedule are justified, any subsequent Government will be able to replace or adjust the paragraphs.
§ Amendment agreed to.