§ 'Each district health authority shall operate a comprehensive computerised call and recall system for cervical cytology screening of all women within the district over 20 years every three years.'.—[Ms. Harman.]
§ Brought up, and read the First time.
§ Ms. HarmanI beg to move, That the clause be read a Second time.
Every year, over 2,000 women in this country die of cervical cancer. At least half would be saved if we had a proper, comprehensive computerised call and recall system in operation. Women are still dying of cervical cancer, and, because of the Government's failure to act, they will continue to die. The reason is quite simple. Instead of asking themselves only how much money they can save, the Government ask themselves only how much money they can save. As long ago as 1981, the Government were told by their own expert committee for gynaecological cytology that they should take action. They were told that cervical cancer gives an early warning signal and that that signal can be detected by taking a smear, which is a completely painless procedure, and examining it in a laboratory. If a pre-cancerous cell is discovered, the condition can be treated.
There was nothing tendentious or controversial about the report. Indeed, it appeared at the end of many years of international debate and experience. Despite their rhetoric about preventing ill health, the Government have failed to act on the report's recommendations. The report proposed that each district health authority should set up a computerised scheme and invite women to have smear tests, and that the tests should be repeated at regular intervals. The report firmly stated that it was not good enough simply to urge women voluntarily to come forward for a test. That approach had been tried and had failed, and women were still dying of cervical cancer.
The Government did not act on that advice. It was not that they disagreed with the advice; they just did not follow it up. I am certain that they would never have even begun to act had they not been pushed month by month and year by year, and we still have not got there. What has been achieved stands not at all to the credit of the Government, but to the credit of those outside the Government who have relentlessly campaigned on the issue. I pay tribute to my hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) who, as shadow Health Minister, led the campaign in Parliament.
If a woman asks me whether she should have a smear test or wait until she is called for a test by her local health authority, the best advice that I can give her is, "I do not think that you should wait to be called, because you might be not be called for a further five years and you could be dead before then." If the Minister is honest, she will admit that that is still the best advice. Indeed, I recently saw her on television urging women to put themselves forward for smear tests. Why does she still have to give that advice 231 seven years after she was told that the Government must set up a call and recall system on a district basis? Sadly, the answer is because the scheme is only just starting.
7.45 pm
After the Government's announcement last year that they intended to require district health authorities to set up a call and recall scheme, I became concerned that, for the sake of political advantage, the Minister might announce to the nation that the cervical cancer problem had been solved and that no one need worry about it any more.
To check whether the problem had been solved, staff in my office and I telephoned every district health authority which, according to the Government, was due to set up a computerised call and recall scheme between March 1987 and the end of March this year. There were 83 of them. The survey was based on speaking to each district health authority about what was happening in its area. The survey showed that by the end of 1993, 36 per cent. of the districts will not have called all women between the ages of 20 and 65 years for their first smear test. That means that, 12 years after the Government's expert committee's report was published, there will still be women who have never had or even been called for a smear test.
The very least that the Government can do is to accept the new clause and agree that, up to and possibly beyond 1993, their failure to act will result in the unnecessary death of women from cervical cancer. The Government's failure to act is directly attributable to their obsessional opposition to public spending and to the Health Service. There can be no other explanation for their failure to act on such clear medical advice.
In 1981, when the Government were told that there was conclusive evidence that cervical cancer could be detected and prevented, they should have jumped at the chance to save lives, but, perversely, they are the enemy of medical advance and the opponent of new life-saving treatment. They see them only as extra demands on the Health Service. As well as being morally bankrupt, that approach is a false economy. The British Society of Clinical Cytology estimates that it costs £30 million a year to nurse and treat the 2,000 women who die from cervical cancer, to say nothing of the financial support that is needed for the children whom they leave behind.
All is not well even where computerised call and recall systems are in operation. The Government have failed to ensure proper laboratory services to back up the schemes that are being set up. National Health Service laboratories are finding it hard to recruit staff because the pay does not compete with private sector pay. I shall refer to two districts, although the picture is the same throughout the country.
A report to the Oxfordshire health authority on laboratory work loads states:
During this financial year there were no suitable applicants for the ‖ vacant post. The inability to fill the vacancy is due to lack of applicants with suitable training. Trained people are rare on the job market and if they exist they find it difficult to move to Oxford because of house prices.It goes on to state:Two other vacancies have been filled by trained MLSOs who do not have cytology experience. These two people are being trained by experienced MLSOs hence cutting down on the productivity of the latter.In the Bloomsbury district health authority last year, five out of 11 laboratory posts were vacant. It is worrying that the Government are so unconcerned that they do not 232 even know the full level of laboratory vacancies throughout the country. I hope that they will not once again leave it to us to do a survey of all laboratories to show the full national picture of vacancies. The Government must take action.
The problem is that the Government are trying to provide the service on the cheap, and laboratory staff are voting with their feet. This means that the more women are called for a smear, the longer they will have to wait for the results to be sent back to their doctors. In a parliamentary answer to me, the Government acknowledged that already 53 districts—more than one fifth of the country as a whole—are taking one month or longer to send the results of smear tests back to women's doctors.
This means that at least one fifth of the districts are already failing to achieve the targets set down in the Government's own guidelines for the turnround time on smear tests. I urge the Minister to find out how many vacant posts there are in the laboratories and to ensure that the pay is increased so that this responsible job becomes attractive and the Health Service can compete with the private sector.
Let me ask the Minister two specific questions relating to the inaccurate diagnosis as negative of smear tests at the women's hospital in Liverpool between 1983 and 1985. That occurred because of what was later officially described in a report as
a massive error of professional judgment".First, will the Minister tell us whether compensation has been assessed and paid to those women who went on to develop invasive and untreatable cervical cancer as a result? Secondly, I should like the Government to report to us on the progress of the national quality control checks on smears—a procedure that was revised after the Liverpool episode.Will the Minister require health authorities to recall women at three-year intervals? In the past, the Government have not been very good at taking expert medical advice, even when it has been unanimous. They have failed in that respect on this issue. Here is another opportunity for them to take the advice of medical experts. Medical opinion, including the opinion of the British Medical Association, is now unanimous that women must be tested every three years, and not just every five years. A report of the inter-collegiate working part on cervical cytology screening, conducted by the Royal College of Obstetricians and Gynaecologists, the Royal College of Pathologists, the Royal College of General Practitioners and the Faculty of Community Medicine backs up the argument that the interval between tests should be three years.
In Oxford it was assessed that to leave the test for five years would be
bad medicine, especially when disease prevention is a priority. It would result in twice the number of invasive cancers of the cervix in this District.I should hate the Government to respond to the problems in the laboratories and the district health authorities by simply saying, "We will leave the interval at five years." The Government should take the issue seriously. They should make sure that they sort out the problems in the laboratories, and they should require district health authorities to screen women every three years.The Government must also ensure that district health authorities, family practitioner committees and general practitioners have enough resources to run the schemes 233 successfully. We do not want to find that in two years' time district health authorities are having to make difficult decisions about whether to keep their cervical cancer screening programmes or to make cuts in some other life-saving services.
Will the Minister set up a national advertising programme to encourage women to go for tests, because we are concerned about the take-up rate? Even for the schemes that have been going for some time it is difficult to know what the take-up rate is because there have been problems with the computer software which the Government have not ironed out. There is not a great deal of hard evidence about the take-up rate, but we suspect that it is lower than it should be.
We know that the take-up rate for cervical cancer tests would be greatly improved by a television advertising campaign. A letter calling a woman for a smear test would have more effect if, before it dropped on her mat, she had seen advertisements on the television explaining the importance of responding to the call and going for a test. The Department of Trade and Industry has recently spent £5.6 million on its television advertising campaign on the so-called enterprise initiative. It seems to me that if the DTI can spend that sort of money on advertising a bogus initiative, it is well worth the Department of Health and Social Security spending money on an advertising campaign that would actually save women's lives.
§ Mrs. Gillian Shephard (Norfolk, South-West)I think that I am right in saying that all family practitioner committees had computers installed for call and recall as long ago as February and that all of them now have the complete age/sex registers on computer.
I have a particular interest in this matter because before entering this House I was chairman of a health authority which had its computerised call and recall system in place last June. It seems to me that the hon. Member for Peckham (Ms. Harman) has painted an unnecessarily gloomy picture. We are one of the few countries that now has a fully computerised and comprehensive call and recall system, and only an impractical person would imagine that such a system, which has involved many, many hours of personnel input, could possibly work instantly, correctly and perfectly—as we all hope it will—within a few short weeks.
I know from practical experience that in my own health authority it took some time for the gremlins described by the hon. Member for Peckham to be smoothed out of the computer. Earlier, my right hon. Friend the Minister for Health said that we were talking about pragmatism and principles. The principle has been recognised and is in place, but pragmatically we have to wait to be sure that it is working effectively everywhere.
Obviously, all hon. Members have every sympathy with the aim of the new clause in reducing screening time to three years. However, I know from practical experience that if we pile task upon task on GPs, family practitioner committees and health authorities, we severely risk losing the advantage that we have gained in having installed the system already. If we overload the system now, before the initial difficulties are smoothed out, we shall not be able to respond to the needs of women in this very important area of preventive health care.
234 I quite agree that one of our first aims must be to raise the consciousness of women about the importance of cervical cancer and I am sure that all of us, as Members of Parliament, are busy doing just that. However, I am not sure about the effectiveness of a television campaign. Most people are perfectly capable of responding to an invitation that falls on their doormat; I am sure that my constituents are. The important point is that the principle has been recognised and the machinery is in place. As I said before, we are one of the few countries that has recognised the importance of having such a system and is carrying out the work and I strongly urge that we should not overload the system so that we lose the advantage that the Government have put in place for all women.
§ Mrs. Llin Golding (Newcastle-under-Lyme)It cannot be said too often that cervical cancer killed 2,000 women last year. This killer disease can and should be eradicated, but how many health authorities are experiencing the problems that we have in North Staffordshire?
On 21 January, I wrote to the Minister about a women who had had a smear done on 15 September last year but who had received the results on 6 January this year; she had waited 16 weeks. Unfortunately, that lady had an abnormality that required immediate treatment, but she had had to wait 16 weeks. On 10 February, I had a letter from the Minister saying that the waiting time in north Staffordshire was between 10 and 12 weeks. On 16 February, I had a letter from the community physician for north Staffordshire saying that the waiting time was eight weeks.
On 19 February, I had a letter from the district health authority chairman saying that the waiting time was now eight weeks in North Staffordshire. There had been problems with maternity leave and sickness but the tests were now being sent to other pathology laboratories and the waiting time was down to eight weeks. On 24 February, I had a letter from a lady who had had her test on 15 October and whose results were returned on 18 February. That was 18 weeks waiting time. She said that she had never felt so depressed about anything in her life, and that week after week she had worried herself silly.
On 8 March, the Minister replied to me and claimed in her letter that the waiting time was eight weeks in north Staffordshire. On 25 March, I received my smear test result, almost 11 weeks after I had had the test. Meanwhile, I have had a letter from the chairman of the family practitioner committee which said that the committee was considering abandoning all tests in north Staffordshire for four weeks because it could not cope.
For some time, north Staffordshire has had a call and recall system. Like the hon. Member for Norfolk, South-West (Mrs. Shephard) I served on a district health authority when this system was installed. It is a good system but what comfort is it to the women of north Staffordshire when the family practitioner committee says that it cannot use its expensive life-saving system because it cannot cope? What comfort has the Minister to offer the people of north Staffordshire?
§ 8 pm
§ Mr. Peter GriffithsI am sure that we have all listened with concern and perhaps shock to the speech of the hon. Member for Newcastle-under-Lyme (Mrs. Golding). I am sure that my hon. Friend the Minister will take note of what has been said. The House resolving to reduce the 235 period of recall under a computerised system would not alter by one jot the situation that the hon. Lady had described. The position would not be improved by the new clause.
We need a far more personal approach to testing and re-testing. I wished to intervene in the speech by the hon. Member for Peckham (Ms. Harman) to say that, no matter how efficient a computerised recall system may be, there will always be those who, because of moving from one place to another or because of living in houses in multi-occupation, do not receive the regular postcard recalls. It is important to seek to place the responsibility firmly on women to ensure that it is their task to seek the important advice that they can get from testing.
§ Mr. GalbraithHow can that be done?
§ Mr. GriffithsI am about to make some suggestions about that, and I can do so without the hon. Gentleman's help.
No hon. Member has mentioned an approach to women who are at the receptive age young women at school or at college. That is the time at which young girls should have drawn to their attention the fact that these tests are not carried out just once or that at some time in the future they ought to seek them, but that it is a process in which they have a personal responsibility for their own health and well-being in the years to come. A campaign directed at sixth forms and colleges would be perhaps the most effective way of setting in train the responsible attitude that we wish to see.
Because of age and lifestyle, some women are acknowledged to be particularly at risk, and they should be reminded of their responsibility. If they move from one part of the country to another and then move on again, they should not wait for the system to catch up but should seek treatment. The weakness of the new clause is exemplified by the attitude of some Opposition Members who interrupted me when I suggested that we should ask women to help themselves. The idea that we can rely on a computerised system is quite wrong. The primary responsibility for health care rests with the individual, and we should start to inculcate that feeling in schools and colleges.
§ Ms. RuddockI support the new clause moved by my hon. Friend the Member for Peckham (Ms. Harman), with whom I share a local district health authority. I commend to the House the practice of that health authority, Lewisham and North Southwark. It takes the view that the greatest public interest and the specific health interest of women can be served only by having a call and recall system with a three-year interval for women between the ages of 20 and 65. That is the scheme that the authority has put in train. It is one of the health authority districts that was able to meet the Minister's deadline, and it sent out its first call list by 31 March. It was able to do that only because of the extreme dedication of the staff who are pioneering the scheme and who carried out all the work prior to the Government bringing in the legislation.
Having decided to carry out the scheme, the authority found, as all health authorities will find, that there are constraints on finance and personnel. Let us first examine the financial constraints. The simple smear test will not in itself save the lives of women. It must be backed by expert colposcopy if we are to take advantage of the best medical practice. In Lewisham and North Southwark, there was 236 until recently a five-month delay for colposcopy. I hope that Conservative Members will note that that means that women who are told that the smear is abnormal will wait in absolute terror until they are called for the vital further work that will confirm whether the abnormality is trivial or signals terminal illness.
The provision of colposcopy services has not been adequately dealt with to enable it to match the simple smear test and the call and recall provisions. For Lewisham and North Southwark district health authority to deal with that problem and to reduce the five-month delay to one month, which is its target, and to deal adequately with the only 40 per cent. response that it expects from the call-in system, it has had to find £27,000 in capital and an extra £13,000 in revenue.
The Government have not provided that money. It has had to be found by taking money from one part of the budget to fund another part. In order to fund the system, other parts of the Health Service in Lewisham and North Southwark have had to be cut. No woman and, I hope, no man who wants to see this life-saving system in operation wants to see it instituted at the expense of other parts of the much needed Health Service.
Will the Minister confirm that at the moment category one carcinoma in situ is not being subjected to colposcopy examination? I understand that that is the case in Lewisham and North Southwark, although the authority believes that the ideal and best clinical practice demands that such conditions are properly investigated. It would be extremely serious if the scheme for encouraging women to come forward for testing were to be inadequate so that pre-cancerous stages were not subjected to the best possible clinical investigation.
Finally, I turn to the question of technicians. As my hon. Friend the Member for Peckham said, there is a shortage of medical laboratory scientific officers. My district health authority is aware of this and is enthusiastic about recruiting trained people. The authority has told me that when it advertises it receives no applications from that category of health worker. It is partly to do with the fact that wages are so low but it is also because there are far too few people with adequate training. The health authority is in a position to offer skilled people to provide training. It would like to have training on a regional basis, but, of course, again there is no provision and there would be no funding unless it stole money from some other part of the budget.
I ask the Minister to tell us whether any advice is being given to general practitioners about spatulas. As has been said, there is far too high a rate of false negatives. We should like to know whether that could be improved, as some of the literature suggests, by encouraging GPs to cease using the Ayre spatula and to use the Aylesbury or some other spatula. Clearly it is in all our interests that, once women are in the computerised system, they should not be misled, especially when there are ways in which we could improve the accuracy of the diagnosis.
§ Dr. Lewis Moonie (Kirkcaldy)I must apologise to hon. Members for coming to the debate late. I was chairing a Committee upstairs and I came as soon as I could. I am grateful for the opportunity to speak on this subject.
I am aghast that there can be any question of Government Members opposing the new clause. Screening for cervical cancer is the epitome of a preventive medical technique. In the whole sphere of cancers, it is the only 237 occasion on which we can find a pre-cancerous lesion and treat it successfully in every case. Therefore, it is mandatory for us to use the techniques that are available to maximise a woman's chance of benefiting from such a technique. I know of no medical opinion anywhere in the world that would recommend anything other than a three-yearly period for screening. If the Minister can offer any other informed evidence on the subject, I would be only too glad to receive it. The economic and medical case is unanswerable. It saves lives and, in the long run, it saves money because the treatment of women who develop cancer is an expensive business.
As I have said, it is a preventive medical technique and that means that we must encourage women, if possible, to take advantage of it. We can do that by three methods. The standard procedure in health education is to inform women, to increase their knowledge and hopefully to modify their attitudes. Through doing that we can hope to change their behaviour. It is always easy to inform people about a technique, but it is much more difficult to change their attitude and much more difficult still to change their behaviour.
We are talking about two groups of women. We are talking about a group who will benefit from screening of any sort; those who will respond to the request to come for screening. That group includes the majority of women about whom we are talking. Sadly, there is another group who do not respond to any form of call by letter for many reasons.
In my area in Fife, one of my former colleagues has conducted extensive research on the subject of women's attitudes to screening and the things that modify their take-up of it. For example, the availability of screening, when they can go, facilities for looking after children and whether they can attend when they are at work all play a key role. Perhaps most important is the issue whether they can have a woman doctor to carry out the technique. That is very important for many women, particularly older women.
Not only do we need an efficient system for those who will take advantage of it; we need to conduct research into modifying general behaviour. We must not rely on the individual's behaviour alone. Appeals to individual behaviour do not work and that is why I oppose them. I notice that the Minister agrees with that.
Even if every woman on the average GP list were to respond to the call—let us say there are 800, and that is an overestimate—screening every three years instead of every five would mean a difference of less than two cases per GP per week. That is taking no account of the fact that half of the women may be attending a community health clinic anyway. That is not an overwhelming burden of work for a GP, and it is wrong to suggest that it is. It is something with which they could easily cope. I commend the new clause to the House and I hope that it will be passed.
§ Mr. GalbraithI want to respond to the comments by the hon. Member for Portsmouth, North (Mr. Griffiths). I do not disagree with him, but I want to develop what he said. He said that the way forward is for people to look after their health and that it is all about taking a cold shower in the morning, going for a run, and so on. Those 238 methods are favoured by the Minister. He said that each individual has responsibility for his or her health, and we accept that. However, on top of that is another important layer and that is what is involved in the new clause.
There should be a suitable call and recall system to ensure that as many women as possible have the test. That is what it is all about. We are not talking about removing responsibility. There will always be people who will accept responsibility for themselves, but, as I have said, there is another layer.
I want to re-emphasise what was said by my hon. Friend the Member for Kirkcaldy (Dr. Moonie). As he said, the systems involved in the technique are curative. Other systems of screening for cancer, such as chest X-rays, barium meals, and so on, can detect a cancer which may be excised, thereby preventing complications. However, that is less than curative. This type of screening detects a pre-cancerous condition, which, if dealt with, can be cured and cancer does not develop. That is the important difference and that is the importance of the new clause. That is why we are asking all hon. Members to support it.
§ Mrs. Rosie Barnes (Greenwich)I want to add my weight to the request for a proper review of laboratory technicians, their career structure and pay levels. It is a severe problem in my area and it may well be more responsible than any other single factor for the delays in women receiving a response to a test that they may have had some weeks or months previously.
I was approached recently by a dedicated laboratory technician who had been in her present location for many years. She said that on average once every two months she is offered a job in the private sector for about double her current salary. She is dedicated and is staying in the NHS but is seeing staff leave at a considerable rate. That problem needs to be resolved.
Advertising has already been mentioned tonight and a call has been made for an advertising campaign to be used to draw attention to the value of responding to the system. I find it intriguing that whenever a call is made for advertising in a matter such as this we hear streams of advice about how advertising is not really effective. I do not find that argument convincing. We all know that the private sector spends millions of pounds. It conducts research on its advertising and its effects and it does that because it works. It would work just as effectively in this area in encouraging women to come forward.
We all know that women who read the medical pages in newspapers, watch television programmes and perhaps listen to the valuable work that "Woman's Hour" on Radio 4 has been doing, are likely to be influenced and to come forward. However, there are women who watch television between 7 and 8 pm who are not listening to those programmes or reading the articles, but whose lives may be saved by triggering them into attending. I recommend that that be given serious consideration.
§ Mrs. CurrieThis has been an interesting short debate, and I am particularly grateful for the comments made by my hon. Friends the Members for Portsmouth, North (Mr. Griffiths) and for Norfolk, South-West (Mrs. Shephard). We share the views expressed on both sides of the House about the possibility of saving lives by the mass screening of adult women for cervical cancer. Opposition Members know that I mean that.
239 The major killer of women before their time in this country is not cervical cancer but breast cancer. As hon. Members know, we are developing a full breast cancer screening programme throughout the country, and we shall be the first major country to have such a system. The next largest killer of women before their time is lung cancer. Indeed, in Scotland, it is the biggest killer. Hon. Members know my views about that subject, and I hope that they share them.
Cervical cancer is significant, because most deaths from it are unnecessary. In its treatable, pre-cancerous phase, which may last 10 years or more, it is symptomless, and the simple, cheap way to find it is the smear test, which has been available for nearly 25 years. If it is not detected in time it kills, and the number of deaths from it stand at 2,000 per year, although the figure has been dropping slowly over the past decade.
For many years, the number of cases of invasive cancer has been about 4,000 per year. If we had not reached those ladies in the way that we have, the death rate would have been much higher. However, our concern continues, because the majority of deaths are among older women who have never been screened and perhaps have not visited their doctor for many years. An opportunistic system, which is the system which has operated in other countries, simply will not do.
We agree with the hon. Member for Peckham (Ms Harman) that we need a systematic mass screening service for which all women receive invitations to attend. Our other major concern, which the hon. Lady did not mention, is that there is a new, more aggressive form of cancer appearing in small numbers among younger women. It is relatively rare and may be linked to a virus. Changes in behaviour may assist in preventing its further spread, and links with the increasing smoking behaviour of young women have been implied. That is why the practice that has been extant for more than 20 years of concentrating attention on older women is not enough. Of course large numbers of younger women are tested already—for example, when receiving contraceptive advice—but the bulk of the 4 million tests that are currently being carried out are on younger women.
I listened to the hon. Member for Peckham with great interest. I have read the articles that she has written. There was one in the Morning Star this week. For the past few weeks she has been saying that I am wrong in saying that the system is about to be up and running. When people say that I am wrong there are three possibilities: they are right—occasionally that happens—they are being mischievous or they are dim. The hon. Lady is not right, she does not look like the sort to cause trouble, so I am left with the third conclusion—[Interruption.] If the hon. Lady will listen, I shall explain why the thought keeps flicking into my head that perhaps she is being a bit dim about this matter.
For over 20 years, Governments have been trying to introduce a comprehensive screening system for precisely the reasons that the hon. Member for Peckham has given, which I endorse. The new clause asks us to introduce a new system, but that is unnecessary because we have already done so. In 1966, the Labour Government said that GPs should be responsible for screening, and they offered incentives for them to do so, and we have continued that system. However, that did not work because the take-up was poor.
240 In 1971, the Conservative Government tried to set up a national recall system based in Southport using manual records. Given the complexity of the task, we should not be too surprised that it did not succeed.
In 1981, the Government decided that the system would work better at local level. Many highly successful screening services were set up following the 1981 initiative, such as the one in Cambridge, and there are some excellent, long-established services in Scotland that have been well-researched and written up.
By 1985 it was apparent that having a variety of schemes—some manual, others using computers and some having different software—was fine in areas that were well organised and enthusiastic, but they left out large parts of the country, often parts where cervical cancer was a problem. In 1985, my right hon. and learned Friend who is now the Chancellor of the Duchy of Lancaster decided that we should move to a call and recall system, consistent throughout England, so that all women could have a chance of accepting an invitation to be screened.
The computer implementation programme was carried out between December 1985 and February 1988. Originally, it was scheduled to take a full three years. It has cost £10 million, involved installing computers at 65 different sites, providing more than 750 VDU terminals for the family practitioner committee staff, and converted over 33 million clerical records. It has been a massive exercise. The entire family practitioner system has been cornputerised, offering many exciting opportunities for prevention of disease in the future.
No one has said what I am about to say. We should all thank and congratulate everybody concerned in that major exercise. It has involved an enormous amount of work not,—just as the hon. Member for Lewisharn, Deptford (Ms. Ruddock) said, some years ago, but in recent weeks and months as well.
§ Mr. Frank Dobson (Holborn and St. Pancras)The Minister says that in 1985, with some burst of insight, the Government decided that schemes should be implemented. Will she say why, with computerised call and recall systems, national standards and national publicity having been recommended in every part of the country since 1981, the Government did not do a damn thing until 1985?
§ Mrs. CurrieThe hon. Gentleman is fairly typical of Socialists in this country. He is interested only in what happened in the past. We are interested in what is happening now.
We have completed the computer implementation programme six weeks ahead of schedule. As a result, every English family practitioner committee has a computerised register, and all but nine of the 190 district health authorities have screening systems under way. The rest, which are mainly in one Thames region, will be no more than four weeks behind. We are the only country within the European Community with such a comprehensive programme, and this achievement puts us ahead of all the major nations.
France, Italy and even West Germany, which has a much higher spend on health than ourselves, have no nationwide service, and only 30 per cent. of at-risk women are screened in West Germany. Further, America, Spain and Holland do not have such a system. In the western world only Sweden, Finland and tiny Iceland have a 241 similar system. It is time that Opposition Members recognised that we have such a system. They should say, "Well done, and congratulations to all concerned."
It is worth pointing out that some of the areas that are not yet on target, but which will be on target within the next few weeks, have had a screening system for some time. Inevitably, implementation of the system is at different stages in different districts. Some areas have had the system for a long time, some are issuing prior notification lists to GPs, some are concentrating first on a particular age group or a particular number of GP practices and others are undertaking a gradual introduction to check the system, particularly where equipment is newly installed.
On publicity, we do not rule out a national campaign, but all the evidence shows that local efforts are much more effective. There is plenty of evidence, including a recent edition of the British Medical Journal, that a sympathetic and personal invitation from the GP produces the best response. We are even advised that the colour of the letter should be pink, as it produces a better response. There will be much local publicity. For example, the northern region is considering a publicity campaign to encourage women to respond to the programme. All 16 districts have been live from 1 April. Yorkshire region tells me that its system is up and running. The system is up and running in Trent region, and it became operative in Leicester on 31 March. Mersey region tells me that it held a press conference earlier this year when all five Cheshire districts started up, thus giving women an opportunity to respond.
It is clear that we should remind people, including GPs, that we are testing for microscopic changes that are rare. If someone is told that she has an abnormal smear, almost certainly it does not mean that she has cancer. It probably means that there was something wrong with the slide or that she has a mild infection. The microscopic changes that lead to cancer are still very rare; the vast majority of slides are clear. The best advice that the hon. Member for Newcastle-under-Lyme (Mrs. Golding) could give to her constituents is, "Do not worry," and that is entirely right.
§ Mr. GalbraithWill the Minister give way?
§ Mrs. CurrieNo, I do not have time.
European Cancer Week, which will run from the first week of May, will give wide publicity to a 10-point code against cancer. Two of them advise women to be screened for breast and cervical cancer. Therefore, in that particular week and in European Cancer Year—next year—we shall have the opportunity to raise the issue nationally.
Opposition Members raised the question of laboratory backlogs. Those are monitored every month and we chase the small number of district health authorities that have backlogs. The vast majority do not. In north Staffordshire, the average delay at 23 March was confirmed at eight weeks. Some slides from before Christmas have been held back because the health authority wanted to distribute batches of slides to other laboratories, but they will all be dealt with in the usual way. The hon. Member for Peckham should remember what I said earlier. The median times between the time when the very first pre-cancer stages are detectable and the point at which cancer becomes inoperable is 12 years. On that basis, I am sure that the hon. Lady's constituents are being well looked after.
242 8.30 pm
As for staff shortages in laboratories, the number of screening staff has increased by nearly 12 per cent. between 1985 and 1986—the last year for which I have details. It is worth reflecting on the fact that the total whole-time equivalent of screening staff in England was 778 at 31 December 1987, and during that year the total number of smears taken was 37 million. The Royal College of Pathologists and the British Society of Clinical Cytology recommend that a screener should deal with 7,000 smears a year. I invite Opposition Members to do their sums. Nationally there are sufficient staff. Occasionally there are local problems and, when there are, we chase them.
§ Mrs. Rosie BarnesWill the Minister give way?
§ Mrs. CurrieNo. I do not have time, because we have a long debate.
The hon. member for Peckham said that it will take five years to screen everyone. Of course it will. If the hon. Lady is seriously suggesting that we call in millions of women next week all at one go, then she is dimmer than I thought, or else she is deliberately attempting to mislead the women of this country. As she is a nice lady on the whole, I do not think that she is doing that. In any case, we need a steady throughput for the laboratories and, where necessary, the treatment centres. The same point has been made to us about the breast cancer programmes.
As for the hon. Lady's statement that some of district health authorities will not be screening, even in five years, I can say categorically that she is wrong. If she has any information to the contrary, I hope that she will tell me which health authorities are involved and I shall deal with them. I make that promise to the House.
I should like briefly to deal with the three-year interval. The new clause would set the recall interval at three years. We have told all health authorities that recall should be at least every five years. That was based on careful consideration of all the clinical and epidemiological data available.
A report by the International Agency for Research on Cancer, which was published in 1986, says that efficient five-yearly screening between the ages of 20 and 64 reduced the chances of a woman developing cervical cancer by 84 per cent. That is our target. It is also the advice which I received recently in Finland, which has had a five-yearly system for many years and has seen a sharp drop in its death rate.
If we were to move to a three-year system, the number of lives that might be saved would be very small. We want to save those lives as well, but, first, we are keen to save the 84 per cent. of lives that are achievable with five-yearly screening. That is our first target. We are already saving lives. We have said to those health authorities which are reaching a high proportion of eligible women regularly that they are free to increase the frequeny of the screening, and some of them have chosen to do so. That is why the revised guidance which we issued in January to the health authorities and the family practitioner committees said that recall should be at least every five years.
The hon. Member for Peckham, who I know is interested and concerned about this issue, should reflect on what would happen if we moved to a three-year system before we have achieved a high overall response. The keen women would come again and those women who are at 243 risk still would not come. 'That is what would happen. In my judgment, and in the judgment of our medical advisers, that is not the way to proceed.
The hon. Lady is concerned about take-up. So am I. She will see that we have set up the computer system so that we now get much better information on take-up. There has been mention of the quality of smear tests and of the reading of smears. Many of those points have been covered in the recent circular, a copy of which is in the Library.
We are also concerned about the training of staff. The training of staff is being carried forward. The hon. Lady might care to listen to the debate on clause 13 tomorrow for some interesting information.
The hon. Member for Lewisham, Deptford asked about spatulas. The Aylesbury spatula is available under the central supply arrangements. The Committee on Gynaecological Cytology will review all the spatulae and the brushes at its next meeting, which is in July. If necessary, the central supply arrangements can be adjusted in the light of its recommendations.
§ Ms. HarmanThe Minister looks as though she is reaching her last page. I do not want her to sit down before she has answered my points about women in Liverpool who have suffered invasive cervical cancer, unless I am too dim to have noticed her reply. Incidentally, the last time the Minister said that I was too young to understand. Now, apparently, I am too dim. I await to hear the next reason why I cannot understand.
§ Mrs. CurrieAll I can say to the hon. Lady is, if the cap fits, wear it.
We understand that some women in the Mersey area have started legal proceedings. Therefore, it would not be appropriate for me to comment at this stage.
Lastly, I should like to say that nobody need wait for the invitation. If a woman has never been screened or has not been screened for more than five years, or if she has any problems such as pain or discharge, she should go to her doctor now. If that eminently good advice were to be followed and if Opposition Members could possibly endorse it, we should save lots of lives.
§ Ms. Jo Richardson (Barking)I found the Minister's speech, delivered at a rate of knots, so complacent that it was breathtaking. She gave us a lot of interesting information, and I join her in one thing—in congratulating the people who have undertaken the massive job of computerisation. I do not know that they will thank her for her congratulations, because they had no funds with which to do it. They had to find the money by paring funds for other essential services. In the new clause, we are emphasising the fact that the Government have to fund the health authorities to enable them to provide this essential service.
The hon. Member for Portsmouth, North (Mr. Griffiths) also took my breath away when he said that the best way to deal with the problem was to let women look after themselves and not to worry about calling them in: at least that seemed to be the import of what he said. I have to tell him that that would not cut the death rate, but would increase it. Women cannot always get the service that they require when they want it, even if they go for it. I think the hon. Gentleman said that students might take advantage of the system. Many health authorities do not screen women before the age of 35.
§ Mr. Peter GriffithsI was not suggesting that students need to be tested. My suggestion was that the process of education should begin at school and in college, to remind women of their obligation to supplement the system by their own responsibility.
§ Ms. RichardsonObviously I misunderstood the hon. Gentleman slightly. Nevertheless, the point he was making stands—that women should start thinking for themselves. That would be fine if the service was provided in all the regions by the family practitioner committees and if there were well women clinics in every hospital to deal with it. If that were the case, I would accept it.
Our new clause responds to current epidemiological evidence and to the recommendations to the Department of Health and Social Security from the British Medical Association's medical services committee. The BMA says
that the introduction of an adequately funded cervical cytology programme which offers a cervical smear test to women over the age of 20 at three-yearly intervals, together with adequate follow-up facilities"—that is very important—comparable with those of many other countries, would indicate the determination of the Department of Health to reduce significantly the numbers of deaths each year from cervical cancer.The Minister has had an opportunity tonight to demonstrate that determination but, sadly for thousands of women, I think that she has shown, despite the information that she has been given, a terrifying complacency that will not satisfy them. From all that has been said, it is clear that the present highly unsatisfactory and, indeed, dangerous, situation is to be allowed to continue.
§ Mr. Nigel Spearing (Newham, South)My hon. Friend will know that, although strapped for cash, Newham district health authority has made great strides in this respect. To take up my hon. Friend's point about the BMA, has she noted that the Minister said that a three-yearly test would save a few more lives, but that she does not intend to accept our new clause because, although she has not spelt it out, it would cost too much money? If that is not the reason, I hope that my hon. Friend will invite the Minister to get up and say why she does not accept our new clause.
§ Ms. RichardsonMy hon. Friend has made the point. I should be happy for the Minister to intervene and answer him, and I invite her to do so, but the Government are not prepared to fund such a scheme. It is all very well for the Minister and others to say that some lives will be saved in this way, but it will not be all that many. One life is worth saving. We should not fall into the trap of saying that if there are tests for 83 per cent. it does not matter about the remaining 17 per cent.
Arrangements for screening of cervical cancer, which claimed the lives of 2,203 women in 1986, vary widely. The survey carried out by my hon. Friend the Member for Peckham (Ms. Harman) confirmed that, seven years after the recommendation of the Government's own expert committee, lack of money has prevented health authorities from carrying out the committee's advice. More than half the 81 districts due to set up computerised programmes are offering only five-yearly screening. Virtually all are imposing varying upper age limits—from 55 years to 60, 64 or 65 years. Again I refer to what the hon. Member for 245 Portsmouth, North said. If a woman is 56 years old, she might find that she cannot be tested because in her health authority area screening stops at 55.
The Minister recently sent a letter to all Members of Parliament on this topic. What she said in her letter has been exposed by my hon. Friend's survey and by the BMA. I quote again from the BMA, because what it says is very important, and the BMA is usually influential in this House. It said:
At present arrangements for screening in health authorities vary widely. Some authorities have introduced programmes based on three-yearly intervals, whereas laboratories in others are refusing to accept specimens more frequently than five years. This is confusing for the public and creates difficulties for doctors in their relationships with patients … Optional flexibility and lack of clear guidance on the nature of local programmes are guaranteed to make matters worse.8.45 pm
I recall the 'sisterly warning' that I gave the Minister when she announced her "special responsibility" for women's health. I warned her then that women would not take kindly to sensationalism and publicity stunts in place of well-thought-out policies to improve women's health care. I am pleased that since that time we appear to have won the Minister, at least in word, away from her previously held view—not all that long ago, I remind her—that universal screening was neither desirable or effective. However, in deed, I am sad to say, she has been a sensational flop in securing and directing the resources that are needed for a safe, secure, nationwide call and recall system. She has also, unfortunately, shown a gross insensitivity, in my opinion, to women's well-founded anxieties about some of her pronouncements.
Recently the Minister told women not to "sleep around". I do not think that those were the words she used, but, whatever the words, that is not the way to address the problem. That is no way to speak to women, of any age, about their personal sexual relationships. The Minister grins broadly, but I do not think that women take very kindly to such slighting remarks. The Minister should be aware by now of the fact that no one knows exactly the cause of cervical cancer.
Although there is some evidence to suggest that there may be a connection between a wart virus passed on during sexual intercourse and cervical cancer, or having sex at a very early age or with several partners, the Minister must remember that only a tiny proportion of women who started having sex at a young age, or who have had many partners, develop cervical cancer. Many women who develop cervical cancer have had only one partner.
Such so-called advice is an insult to women and a cheap cover-up by attempting to blame the victims for the Government's abject failure to give a clear lead in providing both the resources and the statutory obligation to provide three-yearly screening on a call and recall basis.
The fact is that 96 per cent. of cases that are caught at the pre-cancer stage are curable by laser treatment. The remainder can be cured by other treatment. I refer to a letter that I received recently from a 29-year-old woman in south Devon. She has been able to have regular smear tests because, as she says, she is articulate and able to insist upon her rights, though she does not know whether that applies to other women in her own region or in other 246 regions. She has had abnormal results which at first were regarded as an infection and treated as such, but a few months ago the problem was classified as dysplasia, pre-cancerous cells.
She was referred to the colposcopy clinic at Torbay hospital and it was confirmed that she should have laser treatment. However, the laser equipment was broken, and it had been broken for some time. She was told by her consultant gynaecologist that there was no prospect of the laser equipment being repaired. That equipment had been donated by the league of friends of the hospital, which had raised the money for it. A trust had been set up to provide money for the maintenance of the laser equipment, but the money has run out.
That young woman wants to know what the Minister intends to do about that equipment. I shall send the Minister that letter, from which she will see that it is a very sad case. If hospitals have to be supplied with laser equipment and other equipment after raising money by jumble sales and coffee mornings, that is not our idea of a National Health Service, and that is not the way to save lives.
§ Mr. Michael Jack (Fylde)I have here a copy of the West Lancashire Evening Gazette, in which one of the local journalists talks bravely about her exceedingly successful treatment for cervical cancer. I hope that we are not going to start trading blows. The hon. Lady has cited a problem. I am equally able to cite a success for our system.
§ Ms. RichardsonI am glad to hear of the hon. Gentleman's success story. I only wish that there were Success stories everywhere. I do not say that there are not many of them, but my point is that we must not allow any cases to be failures. It is no good saying that, because we have so many successes, a few failures do not matter. That is not the way to deal with women's lives.
For the Government to plead that they cannot spare more money in the regions for this specific purpose is rubbish. For them to give away £2 billion in tax cuts to the richest—funding them with social security cuts that take £1 billion from the poorest—and then refuse to implement the kind of scheme that we put in is unforgivable.
The Government are constantly crowing that the economy is booming and have shown themselves more than ready to legislate to increase and enforce central Government control where it is neither welcome nor beneficial. Yet they refuse every opportunity to legislate and give a clear commitment and direction where the demand and need for action on cervical cancer screening are glaringly clear.
I invite my hon. Friends, and challenge Conservative Members, to join me in support of new clause 1.
§ Question put, That the clause be read a Second time:—
§ The House divided: Ayes 205, Noes 279.
250| Division No. 255] | [8.50 pm |
| AYES | |
| Abbott, Ms Diane | Beckett, Margaret |
| Allen, Graham | Beggs, Roy |
| Alton, David | Beith, A. J. |
| Archer, Rt Hon Peter | Bell, Stuart |
| Ashley, Rt Hon Jack | Benn, Rt Hon Tony |
| Ashton, Joe | Bennett, A. F. (D'nt'n & R'dish) |
| Banks, Tony (Newham NW) | Bermingham, Gerald |
| Barnes, Harry (Derbyshire NE) | Bidwell, Sydney |
| Barnes, Mrs Rosie (Greenwich) | Boateng, Paul |
| Boyes, Roland | Hoyle, Doug |
| Bradley, Keith | Hughes, John (Coventry NE) |
| Bray, Dr Jeremy | Hughes, Robert (Aberdeen N) |
| Brown, Gordon (D'mline E) | Hughes, Simon (Southwark) |
| Brown, Nicholas (Newcastle E) | Illsley, Eric |
| Brown, Ron (Edinburgh Leith) | Janner, Greville |
| Bruce, Malcolm (Gordon) | Jones, Barry (Alyn & Deeside) |
| Buchan, Norman | Jones, leuan (Ynys Mon) |
| Buckley, George J. | Jones, Martyn (Clwyd S W) |
| Caborn, Richard | Kaufman, Rt Hon Gerald |
| Callaghan, Jim | Kilfedder, James |
| Campbell, Menzies (Fife NE) | Kinnock, Rt Hon Neil |
| Campbell, Ron (Blyth Valley) | Kirkwood, Archy |
| Campbell-Savours, D. N. | Lambie, David |
| Canavan, Dennis | Leadbitter, Ted |
| Carlile, Alex (Mont'g) | Leighton, Ron |
| Cartwright, John | Lewis, Terry |
| Clark, Dr David (S Shields) | Litherland, Robert |
| Clarke, Tom (Monklands W) | Livsey, Richard |
| Clay, Bob | Lloyd, Tony (Stretford) |
| Clelland, David | Lofthouse, Geoffrey |
| Clwyd, Mrs Ann | Loyden, Eddie |
| Cohen, Harry | McAllion, John |
| Cook, Frank (Stockton N) | McAvoy, Thomas |
| Cook, Robin (Livingston) | McCartney, Ian |
| Cousins, Jim | Macdonald, Calum A. |
| Cox, Tom | McFall, John |
| Crowther, Stan | McKay, Allen (Barnsley West) |
| Cummings, John | McKelvey, William |
| Cunliffe, Lawrence | McLeish, Henry |
| Cunningham, Dr John | McTaggart, Bob |
| Dalyell, Tam | McWilliam, John |
| Darling, Alistair | Madden, Max |
| Davies, Rt Hon Denzil (Llanelli) | Mahon, Mrs Alice |
| Davies, Ron (Caerphilly) | Marek, Dr John |
| Dewar, Donald | Marshall, David (Shettleston) |
| Dixon, Don | Marshall, Jim (Leicester S) |
| Dobson, Frank | Martin, Michael J. (Springburn) |
| Doran, Frank | Martlew, Eric |
| Douglas, Dick | Maxton, John |
| Duffy, A. E. P. | Meacher, Michael |
| Dunnachie, Jimmy | Michie, Bill (Sheffield Heeley) |
| Dunwoody, Hon Mrs Gwyneth | Michie, Mrs Ray (Arg'l & Bute) |
| Eadie, Alexander | Milian, Rt Hon Bruce |
| Eastham, Ken | Mitchell, Austin (G't Grimsby) |
| Ewing, Mrs Margaret (Moray) | Molyneaux, Rt Hon James |
| Fatchett, Derek | Moonie, Dr Lewis |
| Fearn, Ronald | Morgan, Rhodri |
| Field, Frank (Birkenhead) | Morley, Elliott |
| Fields, Terry (L'pool B G'n) | Morris, Rt Hon J. (Aberavon) |
| Flynn, Paul | Mowlam, Marjorie |
| Foot, Rt Hon Michael | Mullin, Chris |
| Forsythe, Clifford (Antrim S) | Murphy, Paul |
| Fraser, John | Oakes, Rt Hon Gordon |
| Fyfe, Maria | O'Brien, William |
| Galbraith, Sam | O'Neill, Martin |
| Galloway, George | Orme, Rt Hon Stanley |
| Garrett, John (Norwich South) | Parry, Robert |
| George, Bruce | Patchett, Terry |
| Gilbert, Rt Hon Dr John | Pendry, Tom |
| Godman, Dr Norman A. | Pike, Peter L. |
| Golding, Mrs Llin | Powell, Ray (Ogmore) |
| Gould, Bryan | Prescott, John |
| Graham, Thomas | Quin, Ms Joyce |
| Grant, Bernie (Tottenham) | Randall, Stuart |
| Griffiths, Nigel (Edinburgh S) | Redmond, Martin |
| Griffiths, Win (Bridgend) | Reid, Dr John |
| Grocott, Bruce | Richardson, Jo |
| Hardy, Peter | Roberts, Allan (Bootle) |
| Harman, Ms Harriet | Robertson, George |
| Hattersley, Rt Hon Roy | Robinson, Geoffrey |
| Haynes, Frank | Rogers, Allan |
| Heffer, Eric S. | Rooker, Jeff |
| Henderson, Doug | Ross, Ernie (Dundee W) |
| Hinchliffe, David | Ross, William (Londonderry E) |
| Hogg, N. (C'nauld & Kilsyth) | Rowlands, Ted |
| Home Robertson, John | Ruddock, Joan |
| Hood, Jimmy | Salmond, Alex |
| Howarth, George (Knowsley N) | Sedgemore, Brian |
| Howells, Geraint | Sheerman, Barry |
| Sheldon, Rt Hon Robert | Wallace, James |
| Shore, Rt Hon Peter | Walley, Joan |
| Short, Clare | Wardell, Gareth (Gower) |
| Skinner, Dennis | Wareing, Robert N. |
| Smith, C. (Isl'ton & F'bury) | Welsh, Andrew (Angus E) |
| Snape, Peter | Welsh, Michael (Doncaster N) |
| Soley, Clive | Williams, Rt Hon Alan |
| Spearing, Nigel | Williams, Alan W. (Carm'then) |
| Steel, Rt Hon David | Wilson, Brian |
| Stott, Roger | Winnick, David |
| Strang, Gavin | Worthington, Tony |
| Taylor, Mrs Ann (Dewsbury) | |
| Taylor, Matthew (Truro) | Tellers for the Ayes: |
| Turner, Dennis | Mr. Alun Michael and |
| Walker, A. Cecil (Belfast N) | Mr. Allen Adams. |
| Wall, Pat |
| NOES | |
| Alison, Rt Hon Michael | Dover, Den |
| Allason, Rupert | Dunn, Bob |
| Amess, David | Durant, Tony |
| Amos, Alan | Emery, Sir Peter |
| Arbuthnot, James | Evans, David (Welwyn Hatf'd) |
| Arnold, Jacques (Gravesham) | Fallon, Michael |
| Arnold, Tom (Hazel Grove) | Farr, Sir John |
| Ashby, David | Favell, Tony |
| Aspinwall, Jack | Field, Barry (Isle of Wight) |
| Atkinson, David | Fookes, Miss Janet |
| Baker, Rt Hon K. (Mole Valley) | Forman, Nigel |
| Banks, Robert (Harrogate) | Forsyth, Michael (Stirling) |
| Batiste, Spencer | Forth, Eric |
| Bellingham, Henry | Fowler, Rt Hon Norman |
| Bennett, Nicholas (Pembroke) | Fox, Sir Marcus |
| Benyon, W. | Franks, Cecil |
| Bevan, David Gilroy | Freeman, Roger |
| Biggs-Davison, Sir John | Fry, Peter |
| Blackburn, Dr John G. | Gale, Roger |
| Blaker, Rt Hon Sir Peter | Gill, Christopher |
| Body, Sir Richard | Glyn, Dr Alan |
| Bonsor, Sir Nicholas | Goodlad, Alastair |
| Boswell, Tim | Goodson-Wickes, Dr Charles |
| Bottomley, Peter | Gorman, Mrs Teresa |
| Bowden, Gerald (Dulwich) | Gorst, John |
| Bowis, John | Gow, Ian |
| Boyson, Rt Hon Dr Sir Rhodes | Gower, Sir Raymond |
| Brandon-Bravo, Martin | Grant, Sir Anthony (CambsSW) |
| Brazier, Julian | Greenway, Harry (Ealing N) |
| Bright, Graham | Greenway, John (Ryedale) |
| Brittan, Rt Hon Leon | Gregory, Conal |
| Brown, Michael (Brigg & Cl't's) | Griffiths, Sir Eldon (Bury St E') |
| Bruce, Ian (Dorset South) | Griffiths, Peter (Portsmouth N) |
| Buchanan-Smith, Rt Hon Alick | Grist, Ian |
| Burns, Simon | Ground, Patrick |
| Burt, Alistair | Grylls, Michael |
| Butler, Chris | Hamilton, Hon Archie (Epsom) |
| Butterfill, John | Hampson, Dr Keith |
| Carlisle, Kenneth (Lincoln) | Hanley, Jeremy |
| Carrington, Matthew | Hannam, John |
| Carttiss, Michael | Hargreaves, A. (B'ham H'll Gr') |
| Cash, William | Hargreaves, Ken (Hyndburn) |
| Chope, Christopher | Harris, David |
| Churchill, Mr | Haselhurst, Alan |
| Clark, Dr Michael (Rochford) | Hawkins, Christopher |
| Clarke, Rt Hon K. (Rushcliffe) | Hayes, Jerry |
| Colvin, Michael | Heathcoat-Amory, David |
| Conway, Derek | Heddle, John |
| Coombs, Anthony (Wyre F'rest) | Hicks, Mrs Maureen (Wolv' NE) |
| Coombs, Simon (Swindon) | Hicks, Robert (Cornwall SE) |
| Cope, John | Higgins, Rt Hon Terence L. |
| Cormack, Patrick | Hind, Kenneth |
| Couchman, James | Hogg, Hon Douglas (Gr'th'm) |
| Cran, James | Holt, Richard |
| Currie, Mrs Edwina | Hordern, Sir Peter |
| Davies, Q. (Stamf'd & Spald'g) | Howard, Michael |
| Davis, David (Booth ferry) | Howarth, Alan (Strat'd-on-A) |
| Day, Stephen | Howe, Rt Hon Sir Geoffrey |
| Devlin, Tim | Howell, Ralph (North Norfolk) |
| Dickens, Geoffrey | Hughes, Robert G. (Harrow W) |
| Dorrell, Stephen | Hunt, David (Wirral W) |
| Douglas-Hamilton, Lord James | Hunt, John (Ravensbourne) |
| Hurd, Rt Hon Douglas | Patten, John (Oxford W) |
| Irvine, Michael | Pawsey, James |
| Irving, Charles | Peacock, Mrs Elizabeth |
| Jack, Michael | Porter, Barry (Wirral S) |
| Jackson, Robert | Porter, David (Waveney) |
| Janman, Tim | Portillo, Michael |
| Jessel, Toby | Powell, William (Corby) |
| Johnson Smith, Sir Geoffrey | Price, Sir David |
| Jones, Gwilym (Cardiff N) | Raffan, Keith |
| Jones, Robert B (Herts W) | Rathbone, Tim |
| Jopling, Rt Hon Michael | Redwood, John |
| Kellett-Bowman, Dame Elaine | Rhodes James, Robert |
| Key, Robert | Riddick, Graham |
| King, Roger (B'ham N'thfield) | Ridley, Rt Hon Nicholas |
| King, Rt Hon Tom (Bridgwater) | Rifkind, Rt Hon Malcolm |
| Kirkhope, Timothy | Roberts, Wyn (Conwy) |
| Knapman, Roger | Roe, Mrs Marion |
| Knight, Greg (Derby North) | Rossi, Sir Hugh |
| Knowles, Michael | Rost, Peter |
| Knox, David | Rowe, Andrew |
| Lamont, Rt Hon Norman | Ryder, Richard |
| Lang, Ian | Sackville, Hon Tom |
| Lawrence, Ivan | Sainsbury, Hon Tim |
| Lee, John (Pendle) | Sayeed, Jonathan |
| Lennox-Boyd, Hon Mark | Scott, Nicholas |
| Lester, Jim (Broxtowe) | Shaw, David (Dover) |
| Lightbown, David | Shaw, Sir Giles (Pudsey) |
| Lilley, Peter | Shaw, Sir Michael (Scarb') |
| Lloyd, Sir Ian (Havant) | Shephard, Mrs G. (Norfolk SW) |
| Lloyd, Peter (Fareham) | Shepherd, Richard (Aldridge) |
| Lord, Michael | Sims, Roger |
| Luce, Rt Hon Richard | Smith, Sir Dudley (Warwick) |
| Lyell, Sir Nicholas | Smith, Tim (Beaconsfield) |
| McCrindle, Robert | Soames, Hon Nicholas |
| Macfarlane, Sir Neil | Spicer, Sir Jim (Dorset W) |
| MacKay, Andrew (E Berkshire) | Stanbrook, Ivor |
| Maclean, David | Stanley, Rt Hon John |
| McLoughlin, Patrick | Stern, Michael |
| McNair-Wilson, Michael | Stevens, Lewis |
| (Newbury) | Stewart, Allan (Eastwood) |
| McNair-Wilson, Patrick (New Forest) | Stewart, Ian (Hertfordshire N) |
| Stokes, John | |
| Madel, David | Sumberg, David |
| Major, Rt Hon John | Summerson, Hugo |
| Malins, Humfrey | Tapsell, Sir Peter |
| Mans, Keith | Taylor, Ian (Esher) |
| Maples, John | Taylor, John M (Solihull) |
| Marlow, Tony | Taylor, Teddy (S'end E) |
| Marshall, John (Hendon S) | Tebbit, Rt Hon Norman |
| Martin, David (Portsmouth S) | Temple-Morris, Peter |
| Mates, Michael | Thompson, D. (Calder Valley) |
| Maude, Hon Francis | Thompson, Patrick (Norwich N) |
| Mawhinney, Dr Brian | Thurnham, Peter |
| Maxwell-Hyslop, Robin | Townsend, Cyril D. (B'heath) |
| Mayhew, Rt Hon Sir Patrick | Tracey, Richard |
| Mellor, David | Tredinnick, David |
| Meyer, Sir Anthony | Trotter, Neville |
| Miller, Hal | Twinn, Dr Ian |
| Mills, Iain | Vaughan, Sir Gerard |
| Mitchell, Andrew (Gedling) | Waddington, Rt Hon David |
| Monro, Sir Hector | Wakeham, Rt Hon John |
| Moore, Rt Hon John | Walden, George |
| Morris, M (N'hampton S) | Walker, Bill (T'side North) |
| Morrison, Hon Sir Charles | Waller, Gary |
| Moss, Malcolm | Walters, Dennis |
| Neale, Gerrard | Ward, John |
| Neubert, Michael | Wardle, Charles (Bexhill) |
| Newton, Rt Hon Tony | Warren, Kenneth |
| Nicholls, Patrick | Wells, Bowen |
| Nicholson, David (Taunton) | Wheeler, John |
| Nicholson, Emma (Devon West) | Whitney, Ray |
| Onslow, Rt Hon Cranley | Widdecombe, Ann |
| Oppenheim, Phillip | Wiggin, Jerry |
| Page, Richard | Wilshire, David |
| Paice, James | Winterton, Mrs Ann |
| Patnick, Irvine | Winterton, Nicholas |
| Patten, Chris (Bath) | Wolfson, Mark |
| Wood, Timothy | Tellers for the Noes: |
| Woodcock, Mike | Mr. Robert Boscawen and |
| Younger, Rt Hon George | Mr. Tristan Garel-Jones. |
§ Question accordingly negatived