Primary Health Care

HC Deb 25 November 1987 vol 123 cc259-74 3.30 pm

The Minister for Health (Mr. Tony Newton)

With permission, Mr. Speaker, I will make a statement about the Governments plans for improving the primary health care services. Those plans are set out in the White Paper entitled "Promoting Better Health", which has been published today. Copies are available from the Vote Office.

The primary care services — those provided outside hospitals by family doctors, dentists, pharmacists, opticians, community nurses and others — account for nine tenths of all patient contacts with the National Health Service. They cost over £5,000 million a year.

In 1986 the Government set out their proposals for improving primary care. They attracted over 2,000 written comments and were the subject of public consultation meetings chaired by Ministers in different parts of the country. We are grateful to all those who commented, and to the Social Services Committee of this House for its constructive report published earlier this year. The White Paper includes a detailed response to that report.

The consultations showed a wide measure of support for the Government proposals, in particular for placing the promotion of better health at the centre of the stage. The White Paper shows clearly the amount of preventable disease in this country, and it contains many proposals for tackling this problem. Those include the setting of targets for family doctors to achieve higher levels of vaccination, immunisation and cervical cytology screening; more health promotion sessions in general practice; a greater role in health education for pharmacists; regular health checks for particular groups, such as the under-fives and elderly people; a new contract for dentists which will encourage prevention; an extension of the primary care team to include chiropodists, physiotherapists and others and action to see that the skills of community nurses are better used, in connection with which we are issuing today a circular to English health authorities advising on the steps to be taken following the Cumberlege report on community nursing.

To achieve those aims we shall be making general practitioners' contracts more sensitive to actual performance and will look to family practitioner committees to monitor more vigorously the contracts they have with family doctors. The White Paper also emphasises the needs of the consumer of primary care services. In particular, it sets out ways of giving people much more information with which to choose their practitioner and of making it easier for people to change doctor. It also provides improvements in complaints procedures.

The various measures that the White Paper sets out — which include also compulsory retirement for the older doctors and dentists and more effective improvement of primary care premises — will affect all parts of the country. We expect them to bring particular benefits to inner cities and other deprived areas. In addition, the White Paper sets out the Governments intentions for improvements specific to such areas, for example by paying particular attention to their dental, pharmaceutical and community nursing services.

All primary care professionals have a part to play in the improvements we seek, and the White Paper describes our intentions for each part of the service. The Government have already made provision for a large increase in expenditure on the family practitioner services, and are prepared to invest substantially more on top of that. In many cases, the actual amount will depend on the outcome of the negotiations that will now take place with each of the practitioner professions. The White Paper makes clear our intention to proceed quickly with the introduction of blood glucose testing strips for diabetics, which I believe will be widely welcomed in the House.

Expenditure on family practitioner services has already risen by £1.5 billion, or 43 per cent. in real terms, since 1978–79. That is reflected, for example, in the increase of nearly 4,000 to over 30,000 in the number of general practitioners, and a consequent fall from over 2,200 to fewer than 2,000 in the average number of patients on each doctor's list. To achieve the strategic development set out in the White Paper will mean giving still greater priority to these services as a whole, and we have therefore thought it right also to look carefully at priorities within them. We have concluded that it is reasonable to secure some additional resources for development by asking those who can afford it to pay for sight tests and to meet somewhat more of the overall cost of dental care, through a system of proportional charges extending also to examination costs, for which at present no charge is made. The proportional charge system will be simpler, and will relate patient charges more directly to the costs of the particular treatment. It will benefit regular attenders who look after their teeth, some of whom will have no increase or may even pay a little less. Current exemptions from dental charges will, of course, continue for children, adults on low income, expectant and nursing mothers and certain other groups. NHS sight tests will remain free for children, those on low income, the blind and partially sighted and other specified categories.

Existing plans already provide for additional expenditure by 1990–91 of some £570 million in real terms. That will be further increased by the substantial extra resources that the Government will make available to finance the improvements that I have described today. Towards the additional expenditure as a whole, the extra payments which people will make towards dental care and sight testing will contribute some £170 million by 1990–91.

The necessary legislative provisions, together with other health measures, are contained in a Bill which will also be published today. The proposals in the White Paper and the Bill will generally apply throughout the United Kingdom, but my right hon. Friends the Secretaries of State for Wales and for Northern Ireland, and my right hon. and learned Friend the Secretary of State for Scotland, will be considering the ways in which certain of our proposals will require to be adapted to the particular circumstances of those countries.

Our proposals will enable people to make more informed choices of practitioner, will give them access to higher quality services and, above all, will place the greatest emphasis on preventing illness and promoting positive good health. I believe that it is a strategy that will be widely welcomed and supported.

Mr. Robin Cook (Livingston)

The Minister praised the constructive report of the Select Committee. I would find his flattery more sincere if in the past half hour I had been able to find a single case in which he accepted a single recommendation from the Select Committee in which it differed from the consultative document.

Why, in particular, has the Minister rejected the unanimous recommendation that he re-examine the integration of the family practitioner committees that run the GPs with the district health authorities that supply the community nurses with whom they are supposed to work? What is the point of expressing pious hopes that health professionals will work together as a team, when he has decided to keep the administrators playing in two separate teams? If he seriously expects family practitioner committees to monitor "more vigorously" the quality of primary care, why is his Department choosing this year to cut their administrative budgets, and why have the committees been told to expect more staff cuts next year? Is the Minister aware that they are expected to shed 600 posts by next March, that Birmingham has suspended all planning functions, that East Sussex has stopped monitoring general practitioners' claims, and that Kingston has halted all inspections of GPs' surgeries? How does he expect us to believe that this small, shrinking band of administrators can make a reality of more vigorous monitoring?

The Minister will be aware that his proposals will be judged on how they remedy the most serious failings of primary care in the inner cities, where large numbers of the elderly, the unemployed and the homeless place special demands upon it. Will he acknowledge that those pressures are being increased month by month by the persistent closure of accident and emergency units, 15 of which have closed in London alone? How will those pressures be helped by payment by performance, which may draw more GPs away from the cities to areas such as Braintree, where it may well be easier for them to hit his targets?

How does the Minister imagine that it will help the chronic problem of crowded, crumbling surgeries in the inner cities to privatise the General Practice Finance Corporation, a proposal to which he did not refer but which is to be found in his White Paper? Is he not aware that that is a rare source of funds for new premises in unfashionable areas where banks will not lend? Why, given the deep public concern about them, does neither his statement nor the White Paper even mention the appalling quality of the deputising services?

Is the Minister further aware that studies suggest that the average consulting time per patient of only six minutes is lower in Britain than almost anywhere else in Europe? Why, then, is he proposing to increase the capitation element to encourage GPs to compete for even longer patient lists? Does he not appreciate that, if he wants to improve the quality of care, he should be encouraging GPs to have shorter lists, not even longer ones?

Finally, the Minister will have anticipated that we unreservedly condemn his proposal to charge for dental examinations and for eyesight tests. Does he recall that in the consultative document there was no reference to charges for eyesight tests and that professional bodies have been unable to comment on the proposal? Even solicitors will still give clients free advice —and will now come cheaper than these NHS service.

How does the Minister imagine that he is encouraging preventive care by discouraging patients from visiting their dentists? Has he forgotten that, when dental charges went up by 25 per cent., the number of fillings fell by 5 million? Is he aware that one in 20 people calling for an eyesight test are referred on for medical examination for conditions such as glaucoma, which can be arrested if caught early enough? How many of them will be deterred by a tenner a test?

To the extent that today's proposals will oblige GPs to give priority not to their most needed services but to their most profitable ones, we wholly reject them. The Opposition will fight to preserve a Health Service that is publicly funded, publicly run and free to the public at the time they need it.

Mr. Newton

Perhaps I should take the last two points first and make it clear that in our view the proposed charges for dental examinations and the proportional system, which in some cases will have the effect of reducing treatment charges, are a sensible move towards generating the additional resources that we can then devote to exactly the purposes that the hon. Member for Livingston (Mr. Cook) outlined in his first questions. We wish to have more money to direct to the improvement of primary care in the inner cities. We wish also to develop the role of the family practitioner committees along exactly the same lines that the hon. Gentleman, too, would wish. In the remote likelihood of the hon. Gentleman ever being a Minister, he would have to face up to the need to find the resources to achieve those desirable objectives. We have tried to face up to that need.

The hon. Gentleman referred to the proposal that family practitioner committees and district health authorities should once again be merged. Whatever may be the merits of the arguments that were fought over in 1982 when the present set-up was introduced, I cannot believe that it is in the interests of any part of the Health Service to have yet another administrative upheaval on top of those that it has already been through. However these authorities were organised, it would be essential to have proper co-ordination. In my view, it is right to concentrate on achieving proper co-ordination, and that is what we are seeking to do by many of these proposals.

The hon. Gentleman asked me about capitation fees. I make the simple point that, with a given number of doctors and a given number of patients, it is impossible for lists to become longer on average. Higher capitation fees will give doctors the incentive, among many others that we are proposing, to provide good treatment to their patients so that they will attract patients against a background of wider choice. The core of our proposals on general practitioners is to change the remuneration system to give greater incentives to those who provide the things that I outlined at the beginning of my statement —more screening programmes, more health promotion sessions and systematic surveillance of the health needs of under-fives and the very elderly. We all wish to see those things brought about.

Dame Jill Knight (Birmingham, Edgbaston)

Is my hon. Friend aware that the eye test is a screening procedure and that many serious illnesses such as diabetes, glaucoma and cancer can be detected at an early stage? Therefore, does he really think that it would be cost effective to deter people from seeking eye tests because they would have to pay £10? Any person in some difficulty with their sight might well be told, on going to see their doctor, to have their eyes tested and that it would cost £10 at an optician but nothing at a hospital. The hospital eye service is already under great strain. Therefore, does it make sense to direct more people to have their eyes tested at hospitals instead of at opticians?

Mr. Newton

I need hardly say that I respect my hon. Friend's views on those matters because of her direct knowledge of them and the views that she expressed when the voucher system was introduced some three or four years ago. The fears that were expressed about the introduction of the voucher system have proved unfounded. It has greatly extended competition, choice and consumer satisfaction. I believe that her fears about this further development will also prove unfounded.

Mr. Ronnie Fearn (Southport)

We do not welcome the statement. It is probably one of the most deterrent things that we have heard. Prevention is what we need, but that is not what we are getting. Charging for eye testing and the inspection of teeth will not assist prevention, as it will not be possible to detect diseases such as cancer if eyes are not tested. It will bring about a medical upheaval. Will pressure from drug companies reflect the advice given by pharmacists to their patients?

Mr. Newton

I see no reason to suppose that that latter fear has anything to do with what we are proposing. We have been strongly pressed by pharmacists, who are an important part of the primary health care professions, to help them extend their role in advising people about health matters and, not least, health education. They constitute a large range of outlets, with many people going to them frequently, where such information can be made available. We think that it is a sensible use of resources to encourage pharmacists to use that asset in the interests of health education generally.

Sir David Price (Eastleigh)

My hon. Friend said that it was his intention that general practitioners' contracts should be more sensitive to performance. Will this enable such GPs to do more preventive medicine or more diagnostics? It is my view that a great deal more diagnosis should be done in general practice, thus relieving out-patient departments. Does he also recognise that this must mean smaller patient lists for such GPs?

Mr. Newton

It may well be that that will lead to reduced patient lists. I said in my statement that they have fallen substantially during the past seven or eight years. The details of the new arrangements will clearly have to be negotiated with the professions, but the basic answer to my hon. Friend's question is that we shall be aiming through the new remuneration system to encourage the sort of things to which he rightly attaches importance.

Mr. Barry Jones (Alyn and Deeside)

Even at this stage, will the Minister think again about his decision to charge for eyesight tests and dental examinations? Does it not fly in the face of his policies on health education? Does he not see it as a colossal mistake?

Mr. Newton

No, I do not think that it does. The proposed charges contribute to our capacity to devote substantial additional resources to the promotion of good health and to the sort of measures outlined in the White Paper, which are directly related to improving the health of the nation. That is the basis on which the proposals have been put forward.

Mr. Roger Sims (Chislehurst)

I congratulate my hon. Friend on the document he has produced, which from what he says includes a large number of items to improve the health of the community. I thank him and our right hon. Friend the Member for Sutton Coldfield (Mr. Fowler) for the enormous amount of time and trouble they put into consulting all sorts of people on the contents of the Green Paper before the present proposals were brought out.

My hon. Friend will be aware that nurses are particularly anxious to play a larger role in community health care and I wonder whether my hon. Friend will enlarge a little on the remarks in his statement referring to nurses. Has there been any development on the suggestions in the Green Paper that pharmacists may play a larger role, particularly in visiting patients for whom they have prescribed preparations?

Mr. Newton

In relation to pharmacists and still more in relation to the optical services, we are looking at ways to pay practitioners to make domiciliary visits to the housebound, which is undoubtedly a gap in present facilities. That is illustrative of the sort of things we can do with the extra resources.

On the matter of nurses, my hon. Friend will be aware that the Cumberlege report recommended the development of so-called neighbourhood nursing services. We believe that that needs to be actively examined around the country. We do not believe that we can lay down a blueprint for all areas regardless of their differing conditions, but there are already some good examples in practice that we believe other authorities could build on. We are anxious to improve the quality of the work done by nurses in general practitioners' practices. We are proposing to reimburse general practitioners directly for the training of practice nurses, which I think will be widely welcomed.

Dr. Lewis Moonie (Kirkcaldy)

How will the proposals in the paper ensure an improvement in the promotion of good mental health?

Mr. Newton

In the same way as they will seek to promote other forms of health —physical health. For example, one of the things for which we shall be able directly to reimburse general practitioners but for which we cannot at the moment, is the employment, alongside chiropodists, physiotherapists and other supporting staff, of staff who can provide counselling services at general practices. That has been pressed for many times and is directly related to the problem raised by the hon. Gentleman.

Mr. Jerry Hayes (Harlow)

I welcome my hon. Friend's statement, particularly the points on more accountability for general practitioners. Does he think that it is about time that consultants were more accountable and that their contracts should be with district health authorities rather than regional health authorities?

Mr. Newton

I think that I have covered enough delicate issues in my statement without going into that one.

Mrs. Margaret Ewing (Moray)

On behalf of my colleagues in Plaid Cymru and the Scottish National party, may I say that we do not like the underpinning philosophy of the White Paper, since it seems that the low income groups, which are often the most vulnerable in health conditions, are less likely to take up opportunities for testing if they have to pay?

May I pursue the Minister on the issue of cervical cytology? It is not clear within the White Paper whether the call and recall service will be part of the main contract. Since that is one illness that could be prevented by effective screening, can he give us an assurance that that will be the case?

Mr. Newton

I should make it clear that all existing exemptions from charges continue to apply under the system that I have proposed, so I do not think that low-income people will be affected. As to cervical cytology screening, around the country we have set targets for the introduction of call and recall programmes. One matter about which I feel particularly strongly, as does my hon. Friend the Under-Secretary, is that we must ensure that the response of women to being called or recalled is raised, which is just as important as having the system in place. That is what we shall be encouraging general practitioners to help to bring about.

Mrs. Virginia Bottomley (Surrey, South-West)

Does my hon. Friend agree with the increasing demand on the Health Service through demographic and technological factors, that it is high time that primary health care provision was properly scrutinised? The right way to provide primary health care is by being effective, efficient and responsive to the demand of consumers and, at last, by ensuring that general practitioners are more cost-conscious. There has been a phenomenal increase in spending in family practitioner services. Is my hon. Friend aware that there will be a wide welcome for the recognition that he is giving other members of the primary health team —chiropodists, physiotherapists and district nurses?

Mr. Newton

I am grateful to my hon. Friend for the support that she has expressed.

Mr. Speaker

I call Mr. Sam Galbraith.

An Hon. Member

A consultant.

Mr. Sam Galbraith (Strathkelvin and Bearsden)

May I echo the call of the hon. Member for Harlow (Mr. Hayes) for consultants to be made accountable? I welcome certain parts of the White Paper, particularly that with regard to a retirement age of 70, and I hope that it is a prelude to the introduction of retirement at 65. I welcome the part of the report concerning more information for patients. This is not advertising; more information will benefit patients. However, I am sorry that the Minister is going the wrong way on the capitation fee. What he is proposing will lead to larger practices, when even general practitioners are asking for smaller ones. The Minister should have taken the opportunity to reduce the capitation fee below £1,700. Will any items for service payments be cash-limited? Will they be cash-limited in general, or will each item of service within that be cash-limited? Will such things as cervical cytology smears or tests for blood examinations be cash-limited?

Mr. Newton

I express my gratitude for the first part of the hon. Gentleman's comments —[AN HON. MEMBER: " About consultants?"] I shall leave consultants out of the matter for the moment, but I understand the direct interest of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) in these matters. The capitation fee issue should be considered alongside the introduction of specific incentives for the sort of particular purposes that I have outlined. There is no question of cash-limiting the tests that the hon. Gentleman mentioned. With regard to the sums that we shall make available for the further improvement of practice premises and for the additional employment of supporting staff of various kinds, we shall make specific sums available to family practitioner committees; they can decide what projects to support, and develop what is called their more "pro-active role" to encourage good services in their area.

Dr. Alan Glyn (Windsor and Maidenhead)

If my hon. Friend is to put a greater strain on general practitioners and increase their primary services, is he satisfied that they will be given sufficient equipment to carry that out?

Mr. Newton

Part of the purpose of the exercise is to achieve precisely that. I should make it clear that we are not seeking to increase the strain on general practitioners generally; we are seeking to increase the rewards of those who are already taking the strain and making a lot of effort, and to encourage those who are not doing that to do so.

Mr. Norman Hogg (Cumbernauld and Kilsyth)

; Will the Minister give an undertaking that he will convey to his right hon. and learned Friend the Secretary of State for Scotland the need for a detailed statement on the implications of the statement and the White Paper for the National Health Service in Scotland, with particular reference to general practitioner services in highland and remote areas, where doctors are having to work in difficult circumstances? Will he ask the Secretary of State for Scotland to comment on the ophthalmic and dental charges, which will have a detrimental effect on the socially disadvantaged in urban and rural Scotland?

Mr. Newton

The hon. Gentleman will have noticed that my hon. Friend the Under-Secretary of State for Scotland is present—[Interruption.] I am sure that in an appropriate way my right hon. and learned Friend the Secretary of State will want to make available any further information about the application of these proposals to Scotland. We all seek to discuss with the professions how we may give better support to doctors who are virtually forced to practise on their own in isolated rural areas. Clearly, that will be of even greater importance in Scotland than in many parts of England.

Mr. Robin Maxwell-Hyslop (Tiverton)

Does my hon. Friend believe that the measures that he has announced today will encourage more people to seek examination of their sight, which also covers incipient glaucoma and conditions like it, and have their teeth examined, or does he believe that the measures will discourage them? Will my hon. Friend say why he believes that the obvious discouragement to both will be beneficial to health? Does he not realise that there are many people on what are, by any standards, very low incomes who are above the threshold for free access to these facilities?

Mr. Newton

I have already said to my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) that similar fears expressed about earlier changes have proved unfounded. It will be open to opticians to offer free sight tests, as they may wish to do in connection with their general business of selling spectacles, even though they will not be able formally to tie patients to buy spectacles from the same place. The advantages and forces of competition will mean that these proposals will not have the effect that my hon. Friend fears.

Mr. Paul Flynn (Newport, West)

In response to a moving letter from a constituent who lost her sight because of detectable glaucoma that was not detected in the early stages, I tabled a question to the Department asking for an extension of eye tests to the plotting of visual fields, which would be a more sophisticated and more effective technique. Is the Minister aware that the International Glaucoma Association thinks that 150,000 people already suffer from glaucoma which has not been detected? Although the statement contains many items of value, the decision to withdraw free eye tests will be seen as an act of crass, wasteful, cruel stupidity.

Mr. Newton

I note the hon. Gentleman's views. I have already made it clear that I do not agree with him. I hope that I understood the first part of his question aright. I must point out that there is nothing in our proposals to restrict what is done in the course of an eye test.

Mr. John Redwood (Wokingham)

Does my hon. Friend accept that, although many Conservative Members welcome any proposals to improve prevention, service and the range of choice, we must be sure that there will not be items of payment for services that encourage unnecessary activity, visits or referrals? The accent must be on a better deal and more choice for the patient.

Mr. Newton

Yes, and among other things we shall seek to ensure that general practitioners have better information about referral rates—for example, by other colleagues in the same area—and we hope that that will assist them in developing sensible practices.

Mr. Eddie Loyden (Liverpool, Garston)

Does the Minister accept that the White Paper is clear evidence of the Government's intention to continue to undermine the National Health Service and to move away from the concepts upon which it was based? Is he aware that testing in that sense is part of preventive medicine? Luckily, I was diagnosed in an eye test as having glaucoma. I am one of probably many thousands of people who have been grateful for the fact that such a test disclosed that illness. Is it not an act of absolute stupidity to end free tests when, in view of public opinion, medicine is following the course of prevention rather than cure?

Mr. Newton

The essential emphasis of the White Paper, as I think I made clear throughout, is on extending the support that we give to preventive health promotion activity by general practitioners and by primary care services generally. The hon. Gentleman's initial remark is, frankly, absurd against the background of a 43 per cent. real increase already on primary care services, a further planned 11 per cent. real increase and the further increases entailed in my statement.

Mr. Andy Stewart (Sherwood)

Is my hon. Friend aware that his statement may have opened up a rift between myself and my daughter, who is a dental surgeon, unless I can tell her this evening when she telephones me that the increased charges for inspection will be spent on dental care in general?

Mr. Newton

I hope that I have made it clear in my statement and answers that we have a number of proposals to improve the standards of dental care and to make some changes in the dentists' contract. We shall certainly seek to promote the standards of primary care generally. I am not in a position to give an undertaking that the money raised in one quarter will be spent only in that quarter and, indeed, unless it were thought that the existing balance of primary care was perfect in all respects, it would be absurd for me to do so.

Mrs. Rosie Barnes (Greenwich)

Does the Minister agree that, in the light of his emphasis on preventive and community medicine, it would be well worth considering even further the role of health visitors and considering increasing the ratio of health visitors to population from one to every 5,000 to one to every 3,000, so that health visitors can do their jobs much more effectively than they possibly can at present?

Mr. Newton

There has been a valuable increase in the number of health visitors. They are a singularly important part of the nursing profession and of the primary care services. Obviously, one of our objectives in encouraging health authorities to look at the proposals in the Cumberlege report and the circular which we have issued is to encourage the type of development which, in general terms, the hon. Lady wants.

Mrs. Elaine Kellett-Bowman (Lancaster)

I welcome the proposals to support doctors in rural areas. Will my hon. Friend say a word or two about dispensing by doctors in rural areas?

Mr. Newton

This is another delicate issue which is not greatly covered in the White Paper. We have no plans at present to change the balance of the arrangements for the rural dispensing committee and the new arrangements under the pharmacists' contract instituted last April which seek to arbitrate between the interests of dispensing doctors and those of pharmacists, not least in rural areas.

Mr. James Lamond (Oldham, Central and Royton)

Is the Minister really saying that, in the face of all the Chancellor's income tax cuts and all the boasting about how borrowing has been reduced almost to nothing, the only way that he can finance these welcome changes to primary care and preventive medicine is by attacking the services that are the backbone of preventive medicine? Is the hon. Gentleman aware that, despite all the high-faluting nonsense at the start of his statement, people in my constituency cannot get a simple flu vaccine, because supplies are not available, it seems, anywhere in the country, and they have to put down their names for the next year?

Mr. Newton

My hon. Friend the Under-Secretary of State for Health and Social Security—the hon. Member for Derbyshire, South (Mrs. Currie)—yesterday gave a first-class answer on flu vacci ne, so I simply refer the hon. Gentleman to Hansard.

Mr. Nicholas Winterton (Macclesfield)

As a Member who served on the Select Committee which produced this report, may I welcome my hon. Friend's statement. It takes much more account of the Select Committee's views than the hon. Member for Livingston (Mr. Cook) said it does. If our general practitioner service, which is the finest in the world, requires more resources to carry out the important task that is set for it, and if the new charges on certain services will reduce the number of people coming forward for those services, will my hon. Friend increase resources for general practitioners and review the charges imposed on certain services?

Mr. Newton

I can certainly give my hon. Friend the assurance that he sought in the first part of his question about extra resources for general practitioners. Indeed, that is one of the main aims of the proposals. However, I would be hesitant about giving him any assurance on the second part of his question because I simply do not accept the fears that have been expressed.

Mr. Dave Nellist (Coventry, South-East)

What is there in the White Paper to deal with that most primary of health care—the treatment of chronically sick babies? I have no doubt that the Minister and the House will join me in welcoming the news of about an hour ago that this afternoon Philip and Diane Barber will see the operation performed on David, their six-week-old son. The Barbers are constituents of my hon. Friend the Member for Newcastle-under-Lyme (Mrs. Golding). What is in the White Paper for the 34 other babies waiting for heart operations around the country? What is in the White Paper to answer the words of Dr. Eric Silove, the consultant paediatric cardiologist at Birmingham children's hospital, who revealed this morning that in the past four days a baby has died because of a lack of operating theatre staff? If the Minister can increase charges for specs and teeth, why can he not do anything about intensive care staff and get these operations moving?

Mr. Newton

As with yesterday afternoon, I shall not seek to respond to the hon. Gentleman in the spirit of his question. I shall simply say that I, too, am delighted that Baby Barber is having his operation this afternoon. I understand that the operation started at 2.30 pm. I very much hope that it is successful and that the baby's parents will have their anxiety relieved.

Mr. Roger Gale (Thanet, North)

I congratulate my hon. Friend on his statement and on the White Paper. Those of my constituents who are employed in the pharmaceutical industry will welcome the statement that the Government are to encourage the maintenance and development of a strong and efficient pharmaceutical industry in the UK and that the Government have no plans at present to extend the selected list scheme into other therapeutic areas or to introduce compulsory generic prescribing. [HON. MEMBERS: "Reading."] Yes, from the White Paper.

Does the Minister intend to stimulate still further investment into research and development and manufacture—particularly research into cures for diseases such as AIDS.

Mr. Newton

The basis of the relatively new pharmaceutical price regulation scheme and of the other steps taken is precisely to encourage a strong research-based pharmaceutical industry in this country. I welcome my hon. Friend's comments and I hope that he in turn will encourage those with whom he is in touch to co-operate with us on other ways of ensuring economic and effective prescribing.

Several Hon. Members

rose——

Mr. Speaker

Order. I shall endeavour to call those hon. Members who have been rising and who listened to the statement. However, I would ask for brief questions.

Mr. Tam Dalyell (Linlithgow)

I have two questions of fact on sight testing. In answer to the informed and reasonable question of the hon. Member for Birmingham, Edgbaston (Dame J. Knight), the Minister said that there was satisfaction in relation to consumer vouchers. What evidence does he have for that? Secondly, on paragraph 28 of the White Paper dealing with domiciliary sight testing, what extra monetary resources are likely to be available? Having received a cryogenic reception in the House on the sight testing proposals, should not the Minister go back to Alexander Fleming house and to his Cabinet colleagues and say, "The House of Commons is deeply unhappy about this. Think again."?

Mr. Newton

On resources, I have made it clear that we have to negotiate with the professions on many of these matters. Therefore, I cannot name specific sums that will go to any particular purpose. However, we shall want sufficient resources to be made available to provide an effective domiciliary sight testing scheme. On vouchers, when I have visited some of the new spectacle establishments that have grown up around the country, and talked to customers there, I have found them well satisfied with the arrangements.

Let me make it clear that we propose a number of improvements in the voucher scheme. Vouchers will be made available for contact lens purchase, which is not permitted at present. The position of the partially sighted will be given special consideration in relation to other voucher groups and the voucher scheme will also be extended to help adults whose spectacles are damaged owing to physical or mental disability. We are making a number of further improvements which I believe will be widely welcomed.

Mr. John Greenway (Ryedale)

Is my hon. Friend aware that his announcement on proportional charges for dental treatment, for which the British Dental Association has been pressing, will be widely welcomed? Can he confirm to the House that the proportional charge that the Government have in mind will be lower because of the phasing-out of the free dental examination? That will encourage people to go to dental practitioners more regularly.

Mr. Newton

They will be lower than they would otherwise have been. I must make it clear that, because of the absurdities in the present system, the effect of proportional charges will vary greatly. Let me give an example. At the moment, for a precious metal bonded crown which costs £68, the patient pays £33, which represents just under half the cost. For a much less good jot)—a synthetic resin jacket—the patient also pays £33, which represents 94 per cent. of the cost. That is ridiculous and, above all, our proposal is more sensible.

Mr. Harry Ewing (Falkirk, East)

Is the Minister aware that his statement will do enormous damage to dental health and eye care? The evidence for that comes from the White Paper. Paragraph 2.13 says that the Government are to introduce charges for dental examination because of massive improvements in dental health in this country. Is the Minister so stupid that he does not understand that the reason why dental health has improved so massively is that we had free inspections? If we go back to the system of paying for examinations, we shall go back to bad dental health.

On the general practitioner service, the Minister should be aware that the massive difference between his Government and the Labour Government is that under Labour the services were always demand-led, and no other part of the Health Service had to pay for increased costs in the general practitioner service. The Minister's statement, on the other hand, makes it clear that other parts of the Health Service will pay for the increase in costs in the general practitioner service.

Mr. Newton

On the point about dental charges, the hon. Gentleman has got it wrong. The principal reason for the great improvement in dental health is that the nation and parents have been taking much greater care of the dental health of children. Under the proposals, all dental treatment for children will be as free as it is now.

Mr. Peter Thurnham (Bolton, North-East)

The provisions of the White Paper are welcome—especially the proposal to set targets so that general practitioner pay is more closely related to performance. Will my hon. Friend say more about the setting of targets, especially for doctors in the deprived inner-city areas?

Mr. Newton

Again, I face the difficulty that we shall need to negotiate with the profession. Therefore, I cannot give my hon. Friend the detailed information that he seeks. I assure him that among the matters to be negotiated will be arrangements to give greater encouragement to general. practitioners to practise in inner-city areas and to give them better premises in which to practise. That is possibly the single most important need that we must consider when improving primary health care. The services are very poor in some of our inner cities.

Mr. Andrew Faulds (Warley, East)

Is it the case, as is widely believed throughout the country, that junior Ministers in this benighted Government—particularly in the Department of Health and Social Security—are given special training in the presentation of policies and supportive arguments in which they themselves cannot possibly have any belief?

Mr. Newton

I hardly dare speculate about that. I have no doubt that the hon. Gentleman intended his remarks as a compliment. I believe that we should all be trained to face up to realities and to find resources to achieve good purposes.

Mr. Richard Holt (Langbaurgh)

Will my hon. Friend accept from me, as a diabetic, that his announcement about diabetes will be widely welcomed? Will he also accept from me, as somebody who uses the National Health dental service, that I am not in the least enamoured of his proposals? What proportion of the charge will be retained by the dentist, what proportion will be passed on to the kitty, and will the dentists themselves be remunerated additionally for becoming tax collectors?

Mr. Newton

Dentists will be no more tax collectors than they are now, because there are already very substantial charges. I need hardly say that the remuneration of dentists will need to be negotiated, as ever, with the profession.

Mr. Ernie Ross (Dundee, West)

The Minister is trying to put on a brave face. As my hon. Friend the Member for Oldham, Central and Royton (Mr. Lamond) said, the Minister is finding it difficult to justify a self-financing package when he should be arguing with the Chancellor of the Exchequer for more funds for the Health Service. Will he ensure that, unlike the occasion of the announcement on Scottish homes, his right hon. and learned Friend the Secretary of State for Scotland comes to the House and makes a statement on the implications for Scotland of the measures in the White Paper?

Mr. Newton

I note again what the hon. Gentleman said about Scotland, and no doubt my right hon. and learned Friend did so too. I see no need to apologise for a statement that provides an additional £600 million for primary care services by 1991, of which a relatively small part will be raised by the measures that I have proposed.

Mr. Chris Butler (Warrington, South)

I do not suppose that the medical profession will be surprised at losing its perquisite of retiring and then immediately being re-contracted. Can the Minister tell me a little more about the compulsory retirement arrangements? Is he aware that some young GPs are very up to date, but some elderly GPs are very wise old birds indeed?

Mr. Newton

I entirely accept that it is not possible to state that at any particular age a particular group of people is totally past it. I emphasise that there is nothing to prevent any doctor from continuing in private practice if he so wishes. However, we think that, as an act of general policy, it is sensible no longer to enter into NHS contracts with people aged over 70. The precise nature of the change will again be the subject of discussions with the profession, and there will be a transitional period. I believe this to be one of the changes that will gain widespread support both in the profession —that has already become evident —and among many outside it.

Mr. Max Madden (Bradford, West)

Why has the Minister set the compulsory retirement age at 70 rather than lower? What is his estimate of the proportion of pensioners who will have to pay for dental and eye checks? Does he accept that, as the proposals to introduce these charges were not contained in the consultation paper or the general election Tory manifesto, they represent a cowardly attack on health prevention?

Mr. Newton

The changes that I have outlined this afternoon for dental examinations and eye tests require legislation, and that is contained in the Health and Medicines Bill that will be published later today. There will be no shortage of opportunity for debate and discussion and for those outside to make their views known.

Mr. Nicholas Bennett (Pembroke)

Does not my hon. Friend agree that the Opposition attacks on the principle of charging are rather hollow because it was their Government who, in 1951, first introduced the principle? Does he further agree that, for those who are not exempt and have good incomes, a £10 charge towards helping to keep their health is very good value? Is that not especially true when compared with, for example, the expenditure of £500 on a holiday? Is that not the sort of value standard that we should be considering?

Mr. Newton

I agree with my hon. Friend. Although £10 is the payment that we make now to ophthalmic opticians for sight tests, the payment to other sight testers, such as ophthalmic medical practitioners, is substantially less. As I have already said, I expect that under the new system there will be considerable pressure to keep charges down.

Mr. Bob Cryer (Bradford, South)

May I draw the Minister's attention to the remarks of his hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight), who pointed out that it is not just a sight test, but an eye test, as the eyes are also screened for diseases? Will not charging act as a deterrent to the very basic primary care the Minister claims he is trying to improve? Is not that same principle applicable to dental charges? Will they not also be a deterrent, and, therefore, will not the standard of dental care decline, with the consequent effect of greater costs in the community through loss of work and working hours and so on? Is it not true the people will face those charges at a time when the Government are pouring some £11 billion into nuclear deterrence? People should know that mass extermination has a higher priority than the dental and eye care of our people.

Mr. Newton

Given that, at current rates, the charge for a dental examination will be about £3 or less, and in the light of what I have said about sight testing charges, I refuse to believe that, in a country whose standard of living is growing as fast as ours, the effects of the proposals will be as the hon. Gentleman suggests.

Mr. Nicholas Fairbairn (Perth and Kinross)

Will the Minister and the House pause and comprehend that if, in the Health Service, we start to identify particular patients to receive treatment in advance of others, it will do grave damage to the NHS and its patients? I am, of course, referring to Baby Barber. Does my hon. Friend understand that if we were to alter our system of funding drugs, and not have huge companies that, in America, do not accept such disciplines, Britain would have the enormous advantage of ordinary drugs, the Health Service would benefit greatly and we would not have to make these appalling decisions of choice?

Mr. Newton

It is certainly true that the various actions that the Government have taken to ensure that the drug bill is effective and economical contribute, as did the introduction of the selected list, to other things that we want to do in the Health Service. It is all about priorities, and much of my statement was about priorities. I think that they are the right priorities.

Mr. Tony Banks (Newham, North-West)

Is the Minister aware that dentists in inner-city areas are already gravely concerned about the deterioration in the state of the teeth of those living in inner cities? Has that not come about because of charges, which are clearly a disincentive? Yet, under the White Paper, charges will rise, and charging for what is currently free dental inspection will add to the deterrent effect.

The Minister mentioned accident and emergency provision. Is he aware that in the London borough of Newham that provision is now approaching breakdown point? I now understand why the Prime Minister does not want to televise the proceedings of the House —it is because the people of this country would see what an evil, rapacious and uncaring bunch the Tory Members have become.

Mr. Newton

I wish to make two points. First, if there is any sort of decline in the standard of teeth in inner-city areas, it is a result of the generally poor quality of primary health services in those areas—something that a large part of the thrust of the document is designed to tackle to bring about improvement. Secondly, one of the pressures on inner-city accident and emergency departments is, again, the inadequacy of the primary care services. not least the extent to which general practice is conducted from lock-up shops. That leads people to go to the local hospitals. Again, we come back to the essential need for the improvement of primary care services, and we are seeking to direct resources to that through this White Paper.

Mr. Robin Cook

On a point of order, Mr. Speaker.

Mr. Speaker

Order. Is it concerned with the statement?

Mr. Cook

Yes, it is.

Mr. Speaker

Well, the hon. Gentleman has the right to ask another question. He does not need to raise a point of order.

Mr. Cook

I am very happy to make my point under whichever procedure you recommend, Mr. Speaker.

I understand that the Minister is addressing a press conference on the White Paper and the Bill at 4.30 pm. The House is in some difficulty because the Bill is not available to hon. Members until it is presented, which may be another 15 or 20 minutes. It would be a courtesy to the House if the Minister did not refer to the contents of the Bill until it is in the hands of hon. Members.

Mr. Newton

Further to that point of order, Mr. Speaker. I entirely accept what the hon. Gentleman said. It may be difficult for me to respond to some of the questions that I may be asked, but I shall try to stick to the spirit of what the hon. Gentleman reasonably asked.

Mr. Cryer

Further to that point of order, Mr. Speaker.

Mr. Speaker

No. The Front Bench has a right to a further Question. I will take points of order after the applications under Standing Order No. 20.