§ [Relevant document: Third Report from the Social Services Committee ( House of Commons Paper No. 547 of Session 1987–88) on Resourcing the National Health Service: Prospects for 1988–89.]
§ Motion made, and Question proposed,
§ That a supplementary sum, not exceeding £538,303,000, be granted to Her Majesty out of the Consolidated Fund to defray the charges which will come in course of payment during the year ending on 31st March 1989 for expenditure by the Department of Health and Social Security on hospital, community health and related services, including a grant in aid.—[Mr. Maclean.]5.23 pm
§ Mr. Frank Field (Birkenhead)
I thank the Liaison Committee for today's debate and for drawing attention to the estimates and supplementary estimates that we are specifically voting today. I welcome the Under-Secretary of State for Health and Social Security, the hon. Member for Derbyshire, South (Mrs. Currie), to the debate. No doubt, Mr. Deputy Speaker, she will wish to catch your eye and respond to the debate. She has a somewhat schizophrenic attitude to public expenditure. Some days she is in favour of cutting it, and some days she is in favour of increasing it.
At the beginning of the debate, it is important to establish just how large the estimate is. In cash terms, class XIV, vote 1 is the largest ever single vote in the history of voted expenditure. The vote covers what most of us would call in shorthand the health authorities' budgets. We are debating the supplementary estimate, which involves an amount of about £538 million, the vast majority of which is to cover the additional pay costs to health authorities of pay awards to doctors, dentists and professions allied to medicine. At the beginning of the debate, we are discussing the supplementary estimate and the review body's recommendations.
I ask the House to bear with me if, on occasion, I must quote from official documents. The debate is technical and it is important that certain matters are clearly put on the record.
The pay review body stated:our recommendations will result in a substantial increase in the pay bill. This flows largely from the exceptional circumstances associated with the introduction of the new clinical grading structure, which will affect the vast majority of the nurses, midwives and health visitors covered in our review … It is in our judgement right that the new pay structure should be sufficiently flexible to provide a fully satisfying career within the clinical field. But the cost of introducing it is unavoidably high.I stress that the pay structure should be "sufficiently flexible" to achieve the objective.
It seemed that the review body had two objectives in mind. The first was to make a major change in the relative position of nurses in the pay league. I asked staff in the House of Commons Library whether they would update 1323 the 1974 Halsbury report on staff nurses and compare it with the pay review body's proposals. Although the results are not exactly the same, they are certainly comparable. We must take note of that objective. Those hon. Members who have fairly long memories will remember how important the Halsbury report was in its attempt more adequately to pay nurses.
The second objective of the pay review body has been summed up by many hon. Members, but perhaps best by the Prime Minister. It was not summed up most eloquently by the Prime Minister, but, as she runs the show, what she says normally goes. Therefore, it is worth paying attention to how she puts a message on the record. She said that she was anxious that those directly involved in patient care should have a pay structure that reflects their skill, qualifications and responsibilities. The review body's first objective was to lift the relative pay of nurses, and its second objective was to provide a pay structure that would keep nurses in wards rather than in administration.
The Select Committee welcomed the statement that the Government intend fully to fund the pay award. It was one of our constant pleas to the Government. I do not wish to make party political points by drawing attention to the number of times the Government rejected our plea. It is important to note what the Secretary of State said when he announced the Government's decision on the pay review report. Again, I apologise to the House for quoting, but it is important to be clear about what everybody said in the debate. In a press release, the Secretary of State said:In reaching this decision"—to accept the review body's recommendations—the Government has again demonstrated its commitment to the nurses and the other NHS professions concerned … The Government will be implementing all these awards in full from 1 April, and will meet the full additional costs … from the Reserve. In consequence, these awards will be fully funded.That is where the debate began. From that point, certain doubts have been raised about what is meant by "fully funded". Once again, as recently as 14 July, the Prime Minister introduced some doubt when she addressed the House. In response to an oral question she said:The amount that has been made available was the amount that was estimated by the nurses' pay review body. That full amount has been put forward. [Interruption.] The formula used for estimating the total sum required was agreed between representatives of National Health Service chairmen and the review body. That amount is intended to be the amount which they said regrading of the structure would cost."—[Official Report, 14 July 1988; Vol. 137, c. 546]Again I emphasise the Prime Minister's point about what it was said that the pay review body award would cost. When one reads the pay review body's words, one realises that we are not debating an estimate but that we are looking at an estimate based on an estimate based on an estimate. That is the very point that the Select Committee drew to the attention of the House in its third report, which is the basis of this debate.
The House will be pleased that this is the last quotation that I wish to put on the record—
§ Mr. Field
Well, I may give hon. Members more quotations a little later.
1324 The crucial quote from the review body is as follows:Our estimates are necessarily approximate because they themselves are based on estimates. First, the Health Department have provided earnings and paybill estimates for 1988–89 at current rates of pay and allowances, together with recent manpower figures … Secondly, since assimilation of staff to the new clinical scales depends upon local decisions based on a process of examining individual posts, it is impossible to predict with any certainty the numbers who will he receiving each level of pay. Our calculation of the cost of the recommendations for these staff is based on an estimate by the Health Departments of the numbers which in their view will be placed in each of the new grades. For these reasons, the actual cost of our recommendations may well differ from our estimates".I shall repeat the last sentence because it is crucial to this supplementary estimates debate. After listing the basis of the estimates based on the estimates of the estimates and coming up with that figure, the pay review body stated:For these reasons, the actual cost of our recommendations may well differ from our estimates".That has led us to the current position.
Late last night I wrote to the Under-Secretary of State listing some of the questions which I hope will be answered in this debate. In order not to disappoint my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith), I may well quote from them a little later.
It is clear from the press reports and the information that we are getting back from the local areas and our contacts with those in the nursing profession that the regrading is not going as smoothly or as positively as those of us who welcomed the Government's original statement had hoped. Indeed, there is some difficulty in answering quite simple questions about the allocation of funds from this supplementary estimate.
One question to which I hope we shall get a clear answer in the debate is: how have the Government divided the total sum? Has it been divided down on a per capita basis for the regions or according to the number and seniority of the nurses employed in those regions? Secondly, is it true, as some of us have heard, that the regions are holding back some of the money partly because they do not know how the review will take place at a local level but also perhaps because they hope to get some spare cash out of it? That applies to the regions that have done relatively well in the distribution.
Thirdly, what is actually happening at district level? Are the reports correct which Opposition Members and, I am sure, Conservative Members have received—that the districts are cash-limiting the review exercise and that because there is a cash limit local hospitals are changing or limiting the structure on to which the nurses can be fixed? If that is so, it is not only a serious matter for our consideration, but it goes back on the second objective which the Prime Minister laid down when she welcomed the pay review body's findings and the Government's full implementation of the recommendations, and said that we should have a flexible pay scale or, in other words, one large enough so that people with various skills, abilities and training can, at the end of the week, receive pay which to some extent matches the skill that they bring to their daily jobs. Those are the three important questions which we hope will be answered before the end of the debate.
As I said at the beginning of my remarks, most of the debate will be used to discuss the pay awards and the funding of this year's increase in pay, but although many of us are concerned only with the nurses, the estimate does not relate only to nurses. It also covers doctors and their 1325 pay award. Can the Minister enlighten the House about reports that the money available for the doctors' award may be insufficient to fund their increased subscriptions for medical defence insurance, two thirds of which will be met for the first time by the health authorities? What will happen to the Whitley council pay awards? I know that the hon. Member for Eastleigh (Sir D. Price) hopes to catch your eye, Madam Deputy Speaker, in a moment, and will no doubt raise that point.
The current position is compounded with irony. The reason why the Select Committee, many hon. Members who are not members of the Select Committee and many outside organisations which are concerned with the National Health Service pleaded with the Government to fund this year's pay award fully was to take out of the Health Service debate the element of uncertainty that arose in previous years when the pay award was not fully funded. We have a clear statement from the Prime Minister and the Secretary of State down that the Government will fully fund the award, yet there is massive uncertainty again in the National Health Service about the position on pay and how the pay bills will be met in October this year.
So that I do not disappoint my hon. Friend the Member for Strathkelvin and Bearsden, I refer the House to paragraph 26 of the third report of the Select Committee on Social Services. Some time ago, we drew attention to the nightmare that we thought might exist if the Government appeared somewhat mean in implementing their pledge of fully funding the pay awards. We stated in the report:The most immediate effect of the Nurses' Pay Review Body Report will be to increase uncertainty about the budgetary situation in the autumn when most of the award will become payable on a back-dated basis. There is no certainty at present about whether the sum allocated in the Supplementary Estimates will be sufficient to meet the full additional cost to health authorities of the pay review body awards.Since the publication of the report the number of questions to which we need answers has increased. I listed three of them earlier and I hope that the Minister will take them on board. In the letter that I wrote to her last night, which I expect she did not receive until this morning, I listed other questions which I should like to draw to the attention of the House. I for one am uncertain about the level of the basic pay increase for those nurses who will not get an increase in pay because their position has been regraded. I have asked questions about the basis of allocating the total sum and whether it was on a per capita basis, the RAWP basis, or on the pay bill basis.
Can the Minister tell us something about the instructions that the Government have issued to the regions and districts about implementing the pay award? Do those instructions—I am sure that they exist—tell local health authorities that they should get on with the regrading exercise in the spirit of the review and that they should not be concerned with the total cost, or are the Government anxious to limit the cost of the findings of the pay review body? If that was their original intention, and given the extent of disquiet, will the Government think again and issue new instructions? What steps will the Government take to ensure that all the additional funds, for which I hope we shall vote today—without a Division—will be spent on pay and will not be earmarked for other projects within the Health Service?
1326 It is not my intention to argue a case other than that we are considering an original estimate, which represents the largest single estimate, in cash terms, for health authorities. I do not dispute that, in their initial response, the Government were anything but proper and generous to the nurses and the other groups when they said that the pay award would be met in full. Sadly, however, we are a little older and a little wiser since the Government made that first statement and we know that life in the real world is rather complicated.
Since the original Government statement regional and district health authorities have had to try to implement the Government's intentions and there have been two reactions. First, nurses are beginning to say, privately and publicly, that they do not believe that they will get the pay increase that they thought they would get as a result of the regrading arrangements. I am not talking about those who will not be regraded and who, therefore, will receive a modest pay increase—that was the intention all along—but the remaining 85 per cent. who were led to believe that they would receive a substantial increase in their pay. The nurses' disquiet about their pay is spreading a degree of despondency within the Health Service the like of which has not been seen since before the Government announced their intention to implement the pay review body recommendations in full.
Secondly, if additional funds over and above those that we are debating today are not made available in the autumn it is clear that, as well as increasing staff demoralisation, looming on the horizon will be the prospect of further cuts and ward closures. When the Minister replies I hope that she will say that the Government have listened carefully and that they will meet the issues that we have raised.
§ Mr. Jerry Hayes (Harlow)
The hon. Gentleman has referred to cuts and closures, but I am sure that he would be the first to agree that it is not just a question of finance. What does he think about the small minority of consultants who are causing tremendous problems in the regions and districts? Last week in my district health authority, west Essex, a theatre had to be closed to be cleaned. That meant that the anaethetist lost his session and that he did not have much to do. He was asked to go five miles up the road to St. Margaret's hospital in Epping to work with the surgeon. That would have helped a lot of people with serious problems who needed operations. However, the anaesthetist refused to do so and that meant patients had to be turned away and operations cancelled. The senior consultant anaesthetist of the district, rather than telling the man that his behaviour was ridiculous, warned surgeons at St. Margaret's hospital that anaesthetists would not—
§ Madam Deputy Speaker (Miss Betty Boothroyd)
Order. I must remind the hon. Gentleman that he is making an intervention, not a speech.
§ Mr. Field
The answer to those questions is yes. I wish that the hon. Member for Harlow (Mr. Hayes) was as gentle with me when asking for my views in Committee.
1327 We are not debating a motion that criticises the Government for not giving resources to the Health Service. I have bent over backwards to draw attention to the Government's generosity, but I hope that the Government will keep faith with the nurses and, if need be, come up with extra funds.
I know that one cannot always appeal to the best instincts of the Government to achieve the right results; therefore, I appeal to their political instincts. It would be absurd for the Government to make this record allocation and then, in October, to end up with a disgruntled work force because the pay review body recommendations had not been fully implemented and because further cuts were imminent. My grandmother used to say that it is not worth ruining the ship for a hap'orth of tar. We may need more than a hap'orth of tar to ensure that the review body recommendations are implemented in full. I appeal to the Government's instincts to do right by the Health Service and also to their political instincts. The Government have funded a large increase in the Health Service budget, but this winter they must not end up in the same position as last winter.
I thank those people who helped us to draw up our report, namely our three advisers, Nicholas Bosanquet of York university, Dr. Steve Engleman of the university of Edinburgh and Dr. Ken Grant of the City and Hackney health authority. May I also thank the staff of the Select Committee, which is headed by Helen Irwin. Those of us who work on that Committee know what an extraordinarily talented group of people we have around us. The only caution I have in drawing the House's atttention to that fact is that the Secretary of State and the Under-Secretary of State are listening. If the Secretary of State was truly interested in value for money he would poach our staff to work in his Department.
There has been an on-going debate about the implementation of the pay review body recommendations and the Minister for Health has gone on record as saying:I have every intention of ensuring that it"—the pay review body recommendations—is carried out in good faith."—[Official Report, 12 July 1988; Vol. 137, c. 178.]No one is seeking to doubt the Government's good faith so far, but we have enough evidence to suggest that the Government must make a firm statement about what they will do if it turns out that the supplementary estimate that we are debating and for which we are seeking approval is not enough to meet their commitment to implement the pay review body recommendations—a commitment welcomed by the House. Such implementation would raise the pay of nurses and other workers within the NHS to a better—although not necessarily a fairer—level than it has been for a long time.
§ Madam Deputy Speaker
Order. This is an appropriate time to remind the House that we had a debate on this subject on 5 July. There is a great deal of interest in today's short debate and, unless hon. Members cut their speeches short, many will be disappointed at the end of the day.
§ Mr. Alistair Burt (Bury, North)
It is always a great pleasure to follow the hon. Member for Birkenhead (Mr. Field) whose fair-minded approach not only to life, but to life in this House, is a model for many. His concluding remarks remind me of the slightly suspicious child who does not truly believe in the sweetshop's existence, but who suddenly finds himself inside it. He then prefers to spend his time searching around the heavily laden shelves for something that might not be there rather than enjoying the goodies all around him. Therefore, I do not intend to follow the hon. Gentleman in his study of the potential difficulties arising from what he admitted to be the most generous cash vote ever passed by way of a supplementary vote. I wish to consider some of the positive aspects.
I shall relate my remarks to the general structure and financing of health authorities and I shall consider my district health authority in detail. I am pleased to have this opportunity to speak in this debate, as my father has worked in the Health Service all his life as a general practitioner. He practises in Bury and is also chairman of the family practitioner committee.
Although I shall not say a great deal about primary health care, I take this opportunity to pay tribute to all those involved in primary health care and to all those who work in family practitioner committees for their excellent work. I pay particular tribute to the FPC of Bury for what it has done recently in computerising its cervical cancer screening system and acting as a model for the north-west. My brother also works in the National Health Service. He is an anaesthetist who works in a London hospital, so I have something of a medical background, although my own life took me in a slightly different direction.
Recent debates on the NHS in this place have been characterised by three trends—first, the lack of enthusiasm and general support from Labour Members for a subject in which they are supposed to have such a deep concern; secondly, an over-concentration on selective history; thirdly, a lack of ideas about how to deal with the future. In the most recent Opposition day debate on the subject, those three characteristics came together. Those Opposition Members who bothered to take part waxed lyrical about the origins of the Health Service. They paid full and due credit to Bevan and lingered long over the injustices intended to be put right by the shining step into tomorrow when the NHS originally came into being.
However, Opposition Members' tragedy is that that love of history, which is so much part of the Labour party's tradition, can become a quicksand and entrapment, denying them the flexibility to consider the present problems and thus develop new ideas for the future. It was lost on no one in this House that the most effective contribution from Opposition Members came from the right hon. Member for Plymouth, Devonport (Dr. Owen) who made the speech that should have been made by Members on the Labour Front Bench.
Although Labour Members remember that rich heritage in a lyrical way, Conservative Members are entitled to remember another heritage, particularly bearing in mind the size of the estimates that we are discussing today. If I had spoken 10 years ago, I would have been concerned about the desperately low morale of Health Service workers in my constituency, owing to strikes in the service. I would have been asking about the low pay of nurses and why inflation had destroyed their 1329 rises. I would have been angry that the economic collapse had cost my constituents their new general hospital in the capital expenditure wash of those days, which had left the district as the only district in the north-west not to have a new general hospital in the past century. However, I appreciate we are not here to deal with history. In these estimates, we are concerned with the present and the future.
I want to consider the grassroots example of my own health authority of Bury. Those hon. Members who know the area in which I was born and brought up will know that Bury, Ramsbottom and Tottington are not part of a great rolling shire. It is not an unduly privileged area. It is as average a constituency as one could wish to find—apart, of course, from being the most important, as each hon. Member would say of his constituency. The story of that health authority over the past few years and the way in which it has coped with the finance given to it and has planned to cope with the finance given to it and has planned to cope with the finance symbolised by the estimates before us is the story of how one health authority has adapted and responded to change in a demanding world.
It is an appropriate opportunity to pay tribute to all those who work in those local services in the Bury health authority—the nurses, doctors, all the professionals in primary care in hospitals and in the community and all those who support them in the various ancillary services. It is also an opportunity to be grateful to those who administer the enormous funds that we are debating today, including Mr. Philip Bacon, the district administrator, all those who work with him and those who have been chairmen of the health authority. Great chairmen include the late Aubrey Clayton from the Labour party and the present chairman, Mr. Ted Schofield, from a Conservative background.
When talking about this size of budget, it is easy to get lost in great national statistics. They tend to smother what is really important to people at the grass roots, in the surgery, in the community, in hospital or in any other form of care. We sometimes forget that when we are talking about those vast sums. What matters is what is being delivered to the person in the surgery. When I think about that and about some of the examples of what my health authority has done in the past few years and what it can do with those sums that we are discussing today, I can see that we are in a different world from that we hear portrayed by Labour Members.
Let me quote some examples from an ordinary health authority in the north-west of England. In 1979, the number of staff employed in direct patient care was 1,020. On 31 March 1988, that number had risen to 1,307. Over the past five years, nine additional consultants have been appointed. Over the next 12 months, we hope to make five more appointments. That will mean that, since 1982, there has been an increase of 40 per cent. in the level of consultant staffing in the health authority. The number of in-patients treated in 1978 was 19,412. By 1987–88, that had arisen to 25,571. In terms of capital development, since 1979, there have been over 40 separate developments, costing a total of £17 million.
When my right hon. Friend the Prime Minister comes to the Dispatch Box to talk about the Health Service and deliver some statistics, Labour Members often express concern, but statistics are about real people. One cannot 1330 walk around a statistic, but one can walk around my new hospital, the first phase of which was completed on the 40th anniversary of the creation of the Health Service.
§ Mr. David Sumberg (Bury, South)
My hon. Friend referred to the new Fairfield hospital. Does he acknowledge that we had been waiting for that for 18 years, that it took a Conservative Government to put it there and that the people of Bury are now benefiting from it?
§ Mr. Burt
My hon. Friend is right. If we had been talking about this size of estimate 10 years ago, our constituents would have had the hospital 10 years earlier.
One cannot shake hands with a statistic, but one can shake hands with one of the nine new consultants whom we have appointed over the past few years. One cannot comfort a statistic, but one can comfort one of the thousands of patients who have been treated in the past year as a result of the increased efficiency in the local health services.
§ Mr. Jim Cousins (Newcastle upon Tyne, Central)
Perhaps the hon. Gentleman would like to come a little further north, to Newcastle. where 322 hip operations were put in the waiting list initiative for this year. That was much to be welcomed. Hip operations in an area like Newcastle are very important, as there is a large number of elderly and dependent people. I would have been the first to say so if those operations had been carried out, but, unfortunately, as the regional health authority has banned all new consultant posts for this year because of the lack of certainty about funding, those operations were taken out of the waiting list initiative. Perhaps the hon. Gentleman would like to come north and explain to the 322 people concerned.
§ Mr. Burt
The point at issue is whether the resources are effectively administered. First, 15 or 20 years ago, there would not have been a waiting list for hip operations because such operations could not be done. The number of such operations has grown tremendously. Secondly, the way in which the waiting lists are constructed locally and the way in which the regions deal with their resources is a matter for those regions. The statistics that I have given are for my health authority and show how it looks after our people.
The way in which the resources are applied has to do with the way in which they are administered. Over the past couple of years, as the Health Service has come under increased scrutiny, it has become clear that what is at the root of the problem, is not money but the way in which different authorities and regions look after that money. Recent surveys, including the Sunday Times awards for district health authorities, show that the greatest problems lie in the way that some districts look after the money that they are given. Perhaps the hon. Gentleman should ask why his authority has not done something else with that money.
§ Mr. Burt
I cannot give way because so many other hon. Members wish to speak in the debate.
The problems that underlie the estimates cannot be hidden. There is no doubt that the Health Service has problems on the horizon that must be faced—the problems 1331 of an elderly and aging population and the problems of regrading to which the hon. Member for Birkenhead referred.
We must not miss the opportunity to emphasise the positive aspects and the care with which the Government are looking at the problems of the Health Service for the first time. The difference between the two sides of the House is that Opposition Members are trapped and hidebound by history and are producing no ideas on how to deal with the problems; for them it is merely a matter of increasing the amount of money going into the Health Service. All the ideas about reform and about dealing with the problems come from Conservative Members.
I wish strongly to stress to the Minister first that there is a great deal of good inside the National Health Service. The way in which my health authority is coping with its cash and the way in which it will cope with the extra money that will come through the estimates shows that there are good district health authorities that are well managed and well run. Within those health authorities are people who have lessons for other health authorities. It may be necessary to draw good people from the National Health Service who are working in districts that are proving to be efficient so that they can go to regions such as that represented by the hon. Member for Newcastle upon Tyne, Central (Mr. Cousins) and help put right the problems of administration.
We must not lose sight of the fact that there are good people in the National Health Service who must not be lost in a general view that we must have only outside advisers in the Health Service review. We must make sure that the good people who work in the Health Service and who know the system are given the opportunity to put forward their ideas about reforming the system.
Secondly, we must ensure that the scope for private health treatment and for liaison between public and private care continues. That might be a way of dealing with the problem of waiting list operations. The district health authority in my region adopted such a solution to problems of National Health Service waiting lists, liaised with private hospitals and started to reduce those lists.
Thirdly, we must remember that the patients, our constituents, the people with whom we deal are not interested in the slightly arcane problems of how a service is delivered. What matters to them is that that service is delivered. One cannot ask someone who is desperately ill whether they mind going into a private hospital. They need a job to be done, and if that job has to be done through a mixture of public and private care, it still has to be done. What matters is that the service is delivered, not the ideology behind the way in which it is delivered.
Lastly, the review should take account of the importance of building a new consensus on National Health Service spending. We realise that the National Health Service is a precious asset. Over the past few months, we have been talking about change. Today we are talking about the use of resources in the new estimates and the hon. Member for Birkenhead was kind enough to be generous in his remarks about Government spending. There is a great deal of consensus. This place emphasises differences, but if we are truly to serve the people we represent we must make the most effective use of the estimates that we are voting today. If we are to produce the 1332 best ideas of how to run the Health Service in future, those ideas must coalesce. The money we are debating today will give the Health Service a great start. With that start, with the vision of the future and the ideas from this side of the House and with decent people to administer them, we shall have a Health Service in future of which we can truly be proud.
§ 6.3 pm
§ Ms. Harriet Harman (Peckham)
I begin by extending thanks to the Select Committee on Social Services for the extremely important work that it has been doing and to my hon. Friend the Member for Birkenhead (Mr. Field) for the way in which he opened the debate. The report produced by the Select Committee is extremely timely and is about an issue of concern to people throughout the country.
It is absolutely clear what the Government must do. They must give the Health Service enough money to pay the nurses the increases that they have been promised. If the Government do not do that, the consequences will be disastrous. Either thousands of hospital beds will have to be closed to pay the nurses their increase, or the nurses will not get their pay increase, they will feel cheated and demoralised, they will leave the Health Service, and beds will have to be closed because there will not be enough nurses. For the sake of all the patients waiting for treatment on growing waiting lists, the Government must promise tonight to pay the nurses their pay increase.
Nurses have considerable training, they do a responsible job and they work anti-social hours. Yet the problem of nurses' pay slipping behind has been a perennial one. It is absolutely clear that nurses' pay is a classic case of sex discrimination. If most nurses were men rather than women, we would not be facing that problem year in, year out.
In the past, the fact that nursing did not provide attractive long-term career prospects was masked by the continuous supply of 18-year-old girls ready to take up nursing. Not enough attention—indeed, hardly any attention—was paid to keeping experienced older nurses within the Health Service. It was assumed that every nurse who did not return to nursing after having children would be replaced by an 18-year-old girl. That was very wasteful of the skill and experience of older nurses, but it was overlooked until demographic changes meant that there now are not enough 18-year-old girls to take the place of the 30,000 nurses who leave the Health Service every year.
The Government have tried to imply that the nursing shortage is a problem only of particular nursing specialties, or only in London and the south-east, but that is not the case. At the beginning of this year, I conducted a survey of all district health authorities and 120 replied. It revealed that 83 per cent. reported difficulties in filling nursing vacancies. I should like to go into some detail about the findings of the survey, as it is still the most up-to-date survey on nursing shortages throughout the country.
It is not the case that there are nursing shortages only in paediatrics and intensive care. My survey showed that 60 per cent. of districts have shortages in mental illness nurses, 48 per cent. in theatre nurses, 40 per cent. in nurses in geriatric care, 36 per cent. in intensive care nurses, 31 per cent. in nurses nursing the mentally handicapped and 29 per cent. in paediatric nurses. We are talking about a 1333 national problem which hits geriatric wards and paediatric wards, intensive care and care in the community. It is the Government's responsibility to sort it out.
As children in Birmingham had their heart operations cancelled, it was exasperating to hear Ministers saying, "It is nothing to do with us. It is not our fault. It has nothing to do with resources; it is the nursing shortage." The nursing shortage is very much bound up with the question of pay.
Nurses join the Health Service because they want to help others, because the work interests them and because they believe in the National Health Service. The Price Waterhouse survey carried out on behalf of regional chairmen confirmed that that was the case. Nurses leave the Health Service because of pregnancy. They do not return to nursing after having their babies because of low pay and lack of job satisfaction.
Against the background of a nationwide shortage of nurses that was putting services at risk, the pay review body recommended an average 15 per cent. increase for nurses, and we welcome that. In April, the Government led everyone to expect that the pay award would be fully funded and that the Government had made that commitment.
That was reflected in the headlines at the time. The Guardian said:Nurses pay rise stems tide of health debate";The Independent:Tory nerves calmed by 15.3 per cent. award for nurses";The Sun:Loadsa loadsa money for our super nurses";The Star:A welcome tonic for the NHS";The Daily Mail:Record rise for nurses";and the Daily Express:15 per cent. pay joy for nurses".The Government basked in the glory of that good publicity. On 21 April, the Prime Minister said:the Government have decided that the cost in excess of the allocation already made for this year should be met from the Reserve."—[Official Report, 21 April 1988; Vol. 131, c. 528.]On the same day, the Secretary of State announced that the Government would provide £749 million. He said:In consequence, these awards will be fully funded.The problem is that the £749 million he mentioned was an estimate. The pay review body warned that its estimates of the cost of the pay awardare necessarily approximate because they are themselves based on estimates.The agreed plan was to introduce new clinical grades according to what each nurse was actually doing. The average pay award of 15 per cent., with some nurses receiving up to a 60 per cent. increase, would then be paid at the end of the year.
Managers, in consultation with the unions, are carrying out that review, but there is no sign of the relief that swept over nurses and managers in April. That has gone. Reports are beginning to emerge that at local level in all regions managers are downgrading nurses. The Nursing Standard of 16 July accuses health authorities of being cowardly. Its editorial states:Cowardly because they are not willing to return a higher percentage than that allocated for fear of another round of cost cutting to pay for the extra cash.1334 An internal memorandum from the North-West regional health authority, leaked to The Guardian, revealed that the allocation that the Government had made for the pay award wasat least £3.3 million short.The authority said that the options available to it included spending cuts, slowing down the regrading exercise—that is, cheating the nurses—or manipulating the regrading to reduce the cost—that is, cheating the nurses.
The Prime Minister and her health team have lately become rather shy and convoluted when talking about the pay awards. Although, when pressed, they repeat the magic phrase "fully funded", they are careful at the same time always to mention that they mean fully funding the specific sum of £749 million extra. That puts local managers in an invidious position. Should they respect the integrity of the clinical grading review and risk a large pay bill, for which they will not be reimbursed and which will trigger a massive round or service cuts? The size of the review body pay award and the number of nurses in the National Health Service mean that underfunding would have disastrous effects on services.
The North-West regional health authority reckons that the cost of the award will be not the anticipated 14.5 per cent. but between 17 per cent. and 21 per cent. The additional cost, if that were to be reflected nationally, would be an extra £140 million, or even as much as £360 million. If health authorities were forced to find, taking the lower estimate, £140 million from service reductions, 7,000 beds would have to be closed for a year. Regional health authorities will not be certain of the extent of any underfunding until at least halfway through the financial year. To meet a shortfall of £140 million, they would have to cut 14,000 beds for half a year.
We have to face up to these figures if we are to understand the scale of the consequences, should there he underfunding. If it were to amount to £150 million, t hat would represent the loss of 10,000 heart transplant operations, or 45,000 coronary by-pass operations. The Minister is laughing, but that is exactly why managers and nurses are nervous. If she were to listen to what they are saying, she would be less complacent. It is because they are facing up to the figures while she is not that they are concerned.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
I think I heard the hon. Lady say that we should have to give up 10,000 heart operations. Will she please tell the House how many heart operations we used to do and how many we do now? It is not 10,000, or anything like it, thank God.
§ Ms. Harman
That is absolutely beside the point. [Interruption.] Yes, it is beside the point. I am trying to explain to the House, but the Minister fails to understand, that there is great uncertainty and fear at local level. People believe that there is to be a trade-off between the pay awards and nurses. It is about time that the Minister understood—[Interruption.] The hon. Member for Gillingham (Mr. Couchman) says from a sedentary position that the uncertainty and fear are spread by me and my friends. That is not so. We are responding to genuine concern at local level.
I intend to read letters from nurses who express the fear that is felt at local level. No wonder that managers and nurses are nervous. It is no good trying to improve nurses' morale by improving their pay if at the same time their pay 1335 increase is funded by cuts in services. Nurses' complaints have never been just about pay. They are also about cuts in services.
Cuts in services due to the underfunding of pay awards have been bad enough in the past four years. I remind the House that there was a £32 million shortfall in 1984–85, a £36 million shortfall in 1985–86, a £12 million shortfall in 1986–87 and a £24 million shortfall in 1987–88. No wonder managers fear underfunding for this round. If the underfunding this year is as large as £140 million, the cuts will be catastrophic. It is fear of underfunding that is interfering with and gnawing away at the base of clinical regrading.
The pay review body warned that it is difficult for local managers to insulate their judgments about grading from their preoccupation with budgetary constraints. Indeed it is. Nurses suspect that managers are downgrading or undergrading nurses to fit the amount of money that they think they will get, rather than risk the service-cutting consequences of sticking to the regrading. They are aided and abetted in this by DHSS guidance, which the unions fear undermines clinical regrading.
I shall give just one example. I said at the beginning of my speech that the idea was that nurses would be graded according to what they do and that it would not involve restructuring, yet the DHSS has told managers that they are to be allowed only one grade G post per ward. If two sisters on a ward have equal responsibilities that ought to qualify them for grade G, they will have to compete for one post. Instead of the two sisters receiving the pay increase that they are expecting, only one will get it. The other will be downgraded. The clinical grading review was supposed to improve morale, not to set nurse against nurse and leave the profession feeling cheated.
I shall read letters from nurses at local level to scotch the complacent view of the hon. Member for Gillingham, who thinks that this is my invention. A nurse in West Yorkshire wrote:Our AUGM"—that is, the assistant unit general manager—has said that the Authority must work to a 15 per cent. budget and that unfortunately most of us will be disappointed.A nurse in Dorset wrote:If the grading process is not implemented fairly it will only cause more nurses to leave the National Health Service and lead to further industrial action which may on this occasion prove fatal.It is signedfrom one very discouraged nurse.A nurse in Cheshire wrote:It is also becoming increasingly apparent that managers are taking every opportunity to downgrade job descriptions.I shall not read out all the letters of protest, because there are so many of them, but they show that this does not seem to be an exercise that is successfully raising nurses' morale.
If regrading is used to cheat nurses out of the pay increases that they are expecting, they will become even more demoralised. Nurses' hopes will have been raised only to be dashed. I had hoped that we should not be accused of being alarmist, but if we are accused of being alarmist and of stoking up fear it would be very easy for the Government to reassure people by simply saying that they will fund the pay awards in full. I notice that the 1336 Under-Secretary of State for Scotland, the hon. Member for Stirling (Mr. Forsyth), said in a Scottish Office news release:I deplore the campaign of rumour and innuendo which COHSE in Scotland are mounting".However, he then said that the additional funding of £92 million for Scotland is expected to meet, without shortfall, the cost of the review body pay award to nurses in Scotland. But the question that is begged is, what if it does not do so? Everybody is keeping quiet about that.
It is not as though we cannot afford to give nurses decent pay rises. The National Health Service is not too expensive. We spend less, as a percentage of our national wealth, on health than America, France, Germany, Italy or Holland. The Treasury has enough money available to enable the Minister to say from the Dispatch Box that managers can carry out the grading review with integrity, because it will be funded.
The Treasury has deliberately underestimated revenue by up to £3 billion. It is receiving more tax than it admits, and it is selling more assets than it expected to sell. It is doing so to pull the wool across the eyes of the hon. Lady, who is in a spending Department. It is trying to distract her from calling for extra spending. But the NHS need not be kept short of cash. The Secretary of State for Health could pay the nurses and keep beds open.
Earlier this year, the Government were faced with widespread protests about cuts in services and the declining morale of nurses. It was that massive protest, supported overwhelmingly by the public as well as by those providing health care, that forced the Government to promise full funding of the pay award. If the Government betray the nurses, they will cause a storm of protest far greater than that which we saw earlier this year.
The Government need not allow uncertainty to continue and morale to ebb. All that needs happen is for the Minister clearly to announce tonight that she will fully fund the pay award. We shall listen carefully to her words, as will managers and nurses all over the country. It is no use the Minister saying that she will fully fund the estimated costs. Estimates, by definition, can be wrong. The Minister must say that she will fully fund the pay award. If she does not, it will be clear that managers must choose between cutting services or cheating nurses. The Minister should end the fear and uncertainty that has cast such a shadow across the Health Service.
When the pay award was announced and the Government declared that it would be fully funded, the Secretary of State said:It is good news for the staff, good news for the patients and good news for the country.That promise must not be broken.
It is not just nurses who are concerned about their level of pay this autumn, because there is a legacy of anger among other workers. There is a resentment among porters, cleaners and catering staff, who have been offered only 5 per cent. They already make up a large proportion of the working pool of people who, although they work long hours, have to rely on benefits to supplement their income. There is also concern about laboratory staff pay levels. Medical laboratory scientific officers are paid about 50 per cent. less in the Health Service than they would be in the private sector. As a result, it is difficult to recruit and to keep those staff. Laboratories are short-staffed, with those remaining coming under more pressure. One district health authority has been compelled to suspend its cervical 1337 cancer screening because of a backlog of smears for analysis. There is no chance of the Government, in paying the nurses, robbing Peter to pay Paul. They cannot take from other parts of the pay bill to finance the nurses' award.
I ask the Minister to take this opportunity to make a statement about the Government's plans to introduce eyesight test and dental check-up charges. When the Health and Medicines Bill was debated on Report, not a single Conservative Back Bencher supported the Government's proposals to charge for eye examinations. The Government will face a major row if once again they bring their proposals to make those charges before the House. The people most likely to lose are the elderly. It is they who most need eye tests, and who are most likely to be deterred by charges. We should not have to wait until October for a statement on this important matter. The Under-Secretary of State for Health and Social Security is present and it is for her to say whether those charges are to be reintroduced, or whether the Government will drop that wretched and unpopular proposal.
§ Mr. Nicholas Winterton (Macclesfield)
First, I must apologise to the House and to my hon. Friend the Minister for not being present for the beginning of this debate. I apologise also to the hon. Member for Birkenhead (Mr. Field) who leads the Social Services Select Committee with great distinction in this Parliament. I fear that I may go over some of the ground that he has already outlined, but that is because there is on the Select Committee—on which it is a great honour to serve—an immense consensus among Members representing most parties on how the problems of the Health Service directly relating to the estimate we are debating should he tackled.
The hon. Member for Peckham (Ms. Harman) will forgive me if I do not immediately follow her on the path down which she led the House, albeit that I have sympathy with the sentiments she expressed, if not the language that she used, in respect of eye test and dental examination charges. As a member of the Social Services Select Committee, I hope that the Government will take a mature attitude to what happened in another place earlier this week and will give serious consideration to the view expressed there—which was endorsed by the overwhelming majority of the Select Committee's members—that it is undesirable to charge for eye tests and dental examinations, and that, to some extent, that goes wholly against the preventive medicine campaign that my hon. Friend and other Ministers over the years have organised and undertaken in the length and breadth of the country. I say to my hon. Friends on the Treasury Bench that I shall not be able to support the Government if they seek to overturn the decision that was taken in another place on that matter.
I understand that the problems of nurses and nurses' pay has so far dominated this debate. I have immense sympathy with the Government, who I believe made an announcement in good faith that they would fully fund the recommendations of the independent nurses' pay review body. However, we know that on this occasion that body did not recommend a straightforward pay increase but a complex, total regrading of nursing staff at every level. It is for nursing and other managers throughout the Health Service to undertake that very difficult duty carefully.
1338 However, I say to my hon. Friends on the Treasury Bench and to my hon. Friend the Under-Secretary of State in particular, who I understand will be intervening later, that if in the light of a considered and responsible clinical regrading of nurses it is seen that the Government underestimated the amount that needed to be allocated for pay, I hope that they will have the courage and the determination—and perhaps I ought to address this remark to my hon. Friend the Minister and not to the Government as a whole, because DHSS Ministers must fight their own corner—to go to the Treasury and ask for further resources to meet the cost of the clinical regrading which is a critical part of the Health Service structure. It will be irresponsible and bordering on the immoral if the Government, having stated to the people of this country and to their own supporters in the House that they would fully fund the pay award, dc not in the event carry through that promise and assurance.
Other statistics have been quoted relating to regional and district health authorities throughout the country. The hon. Member for Birkenhead may have mentioned our discussions in the Mersey region with the chairman of that authority, Sir Donald Wilson. He is currently chairman of all the regional health authority chairmen, so he holds a responsible and important position. His senior managers indicated to the Select Committee when it visited the Mersey region—particularly the Wirral and Macclesfield health authorities—that in their estimate it was likely to be £.1.5 million underfunded, and that is after it had undertaken a well-considered and responsible nurses' regrading.
If the Mersey region, which is currently a RAWP loser, is expected to provide the necessary funds, and if there is inadequate money within the cost improvement programme to pay for the nurses needed and the regradings that are necessary, patient services will inevitably be cut.
As the hon. Member for Peckham knows—and as the Minister for Health knows—my district health authority has had to reduce theatre sessions to stay within budget. That is increasing critical waiting lists in important categories, not least orthopaedics. I have been a member of the Select Committee for more years than I care to remember—for longer than any other hon. Member has sat on any other Select Committee. That has, I hope, given me an understanding of the Health Service that not all hon. Members have the privilege to possess. It has been of immense interest to me for nearly 14 years, and I have made contact with almost every branch of medicine. It is critical that the Government reconsider. If additional supplementary resources are required, they should be provided this year.
The nurses' pay review body dealt not only with a single year's increase, but with the critical aspect of regrading. We must ensure that we retain the nurses whom we have, and encourage other young men and women to come into such a magnificent career. As the hon. Member for Peckham pointed out, we can no longer rely on the many 18-year-old young ladies who were happy to come into nursing, perhaps seeing it as a vocation, but a vocation lacking the salary to reward their skill and care. Many were fortunate to come from families that could provide them with assistance, but that is no longer so. The competition in the market place for able young women—and men, for that matter—is very great. Unless we are 1339 to lose more nurses, the Government must look again at the total cost this year following the nurses' clinical regrading.
I understand the Government's position. It would, perhaps, have been irresponsible to say, "Whatever the total cost, we will meet it." Those responsible for undertaking the regrading might have regraded more generously than was merited. There is no doubt that some nurses merit regrading and others do not. I believe that the Royal College of Nursing has in general taken an amazingly responsible attitude throughout this difficult period, and continues to do so.
Time and again the Government tell us that they are trying to achieve better value for the massive sums that they spend in the Health Service. The hon. Member for Birkenhead began by admitting that the Government had given generously. That is to the credit of the hon. Gentleman, who represents not only Birkenhead but the Labour party in this place. We do not often hear such a constructive approach to the opening of a debate on a vital issue.
The Government also say that they want better management. If that is the case, they must provide the wherewithal first to allow the Health Service to operate more efficiently and secondly to give the management the tools to enable them to make the right decisions, with proper knowledge of all the facts. They are certainly not able to do that at present. I recently visited the King's Fund college where I had the pleasure of addressing people on a course in management within the National Health Service. A number of them said to me, "We are concerned that the Health Service is not committed to management, and that the Government are not either, despite the Griffiths report and all the talk that followed its publication. If they were committed, they would be more determined to provide us with the equipment to enable us to do our job." Adequate resources for computer systems and information technology will play a vital part in enabling health authorities to provide value for money, and to enable consultants and others to make informed decisions.
The hon. Member for Peckham mentioned laboratory assistants, medical physicists and pathology staff. All those groups are vital to the Health Service, but there is a problem over pay. They are not remunerated in accordance with their skills, and, with the growing competition in the market place, the Health Service will undoubtedly be starved of people who are vital to the provision of an efficient service and value for money. Accordingly, I make a special plea on behalf of all who are employed in the professions allied to medicine.
Let me also make a plea, as I have done elsewhere, for medical secretaries. Time and again—not just during the Select Committee's current inquiry into the resourcing and structure of the Health Service, but during other inquiries—consultants have said, "We are here because of our operating skill, but we are unable to work to the extent that we should like because we have not the back-up staff." Only recently when we visited Guy's hospital, just across the river, a leading consultant said that he was losing his medical secretary because she was going elsewhere for a better salary. The hospital was unable to pay the salary that was essential to maintain that vital member of staff. I 1340 have referred outside the House to the case of Mr. Lennox Holt, a rheumatologist in Manchester, who told me that his work was being gravely impeded because he could not employ the right quality of medical secretary to enable him not only to do his job but to refer the case notes back to other doctors who would follow up the care and treatment of his patients.
Let me make two more brief points. We have severe problems with capital spending, and perhaps I could link that to my continuing concern about care in the community, to which the hon. Member for Peckham referred. It worries me dreadfully that managers throughout the country are deciding to close psychiatric hospitals—and other hospitals, for that matter. I am particularly concerned about the position of the mentally ill, but inevitably my concern extends to the mentally handicapped.
Those managers are trying to run down the psychiatric hospitals and discharge patients into the community, where there are inadequate facilities for them. There are not enough trained and qualified staff to maintain an acceptable level of care and treatment. The managers are then disposing of the hospital sites for large capital sums, many of them for development. Once those sites are lost, there will be too little long-stay hospital care for the more severely mentally ill, particularly those suffering from schizophrenia. There is growing anxiety about decisions that some health authorities are being forced to take because of the resource problems that they are facing which will result in chaos and suffering for groups within our society about whom we should be concerned.
Some time ago the Select Committee undertook an inquiry into care in the community. Some of the recommendations that we made, which have not been accepted by the Government, are as relevant as, if not more relevant than, they were when we produced our report. The Government should take a greater interest in what district health authorities are doing in closing psychiatric hospitals and hospitals for the mentally handicapped. We could produce a situation such as exists in Italy today. It closed those hospitals and people are now on the streets, sleeping on park benches, under bridges and in the call-in day centres and night shelters. Those people no longer have the care and medical attention that they require to contain their condition and enable them to maintain an acceptable standard of life.
Debates such as this give those of us who study the Health Service carefully an opportunity to express some of our deep anxieties. Such hon. Members come from both sides of the House. If the hon. Member for Peckham had tackled this subject in the caring and responsible way that the hon. Member for Birkenhead did, rather than concentrating so much on the entirely political issue of the nurses' pay review body, its recommendation and the full resourcing of the award, we might be able to find the common ground which would enable the House to produce policies and proposals, perhaps as we did when the Health Service was founded 40 years ago, without any bickering.
So often the nurses are used as a political weapon by one party with which to beat the other. [Interruption.] That is the case. I represented the Conservative party when I spoke alongside the leader of the Labour party and the leader of the Liberal party at a nurses' rally in Central hall, Westminster, and I was pleased to do so. I said that I would fight to make my Government implement in full the 1341 pay review body's recommendation. The Government announced that they would do that and I expect them to live up to that assurance in full. Not only should they implement it in full, as they have agreed in principle to do, but if there is a shortfall because of the regrading due to an error in underestimating that, they should if necessary come forward with a supplementary estimate to ensure that the pay review body's recommendation can be implemented in full.
This is a vital subject. Despite the bickering and anger that occasionally flares across the Floor of the House, I feel instinctively that there is a growing consensus on how to tackle the problems of the NHS. I cannot speak for my hon. Friends. They fight their fight in their own way. I shall fight my fight in the House in the way that I have done ever since I came here 17 years ago.
I hope that the hon. Member for Peckham, perhaps in private moments with me, will accept that the private sector, of which she made no mention, is not generally in competition with the NHS, behind which I stand 100 per cent., but is more complementary to it. It works in co-operation with the NHS and it can make a growing contribution in filling some of the gaps that for a time will inevitably exist within the NHS.
I hope that the Government will continue to look sympathetically on the needs of a service that is close to the hearts of the overwhelming majority of the British people, and, perhaps, of all the political parties here. It is also probably close to the heart of 99 per cent., if not 100 per cent., of Conservative voters.
§ Mr. Barry Jones (Alyn and Deeside)
The hon. Member for Macclesfield (Mr. Winterton) made an independent speech and I hope that the hon. Member for Bury, North (Mr. Burt) listened carefully to what he said and the manner in which he said it.
The vote deals with expenditure in excess of £15 billion and I want some of that unimaginable sum for a highly important, much under-rated sector—the provision of fully trained speech therapists in our state schools for the benefit of youngsters suffering from speech defects. If those defects arc not tackled, boys and girls at school will never realise their full potential. To say that in 1988 is to point to something that is desperately wrong.
Perhaps hon. Members will agree that youngsters are only young once and that the happiness of their families will be blighted if parents know that their children are not getting the expert attention or sufficient time to mitigate and/or eliminate their speech defects.
I want to quote from several letters that I have received from constituents on the matter. The first, from a Mrs. Davies, says:The school is a marvellous place and our son has achieved a great deal since going there over four years ago. The nursing sister whom we had absolute total confidence in is unfortunately retiring at the end of July 1988 and we have learnt to our horror she is to be replaced with a nurse who will only be on duty for 24 out of the 37½ hours at present, which means our child will be at school for several hours a week without a qualified nurse on duty to attend to any emergency which may arise.She goes on to say:there are about 75 pupils at school. Over 50 of these pupils need regular speech therapy. We have one part-time speech therapist. The school needs two full-time speech therapists 1342 plus an assistant. We as parents arc not asking for these things for ourselves but for our children. It is their right. They cannot go to ordinary schools.My constituent ends:Please, please help us to get the nursing staff and speech therapists that our children are entitled to. Please, we beg you to help us in our campaign.Another of my constituents, Mrs. Gerrard, writes:My husband and I arc parents of a child who attends Dorin Park Special School in Chester. We are extremely concerned and worried to find that there is no full-time 'Speech Therapy' at the school.That is a school, incidentally, that the parents praise highly. The letter continues:It is extremely vital that two full-time speech therapists, plus an assistant be employed at Dorin Park. As parents we cannot understand the reasons behind neglecting to employ someone, the education of the children being foremost. The children must come first and not the cutbacks. We would be extremely grateful for any help".Mrs. Gerrard has a five-year-old child who suffers from severe cerebral palsy. I believe that the House would wish that such a fine school should have a full complement of speech therapists.
I repeat at this juncture that the budget for votes 1 to 5 exceeds £15 billion. On behalf of my constituents, and thousands of parents elsewhere in England and Wales, I claim a bigger share for speech therapy and physiotherapy.
§ Ms. Hilary Armstrong (Durham, North-West)
My hon. Friend the Member for Alyn and Deeside (Mr. Jones) has raised the issue of speech therapy. I must tell him that I was rung by a speech therapist at 8.15 this morning who said that she had read in The Guardian that morning that the House would debate the estimates. She asked whether the pay award would be fully funded today and she asked me to ensure that the Minister addressed the issue of speech therapists' pay, because speech therapists had been struggling to get their pay award for many months. Whether it will be fully funded is another issue that they have been anxious to find out about. I am grateful that my hon. Friend has raised the matter and I hope that the Minister will make a reply that will give the speech therapists some hope that the pay award will be made and funded.
§ Mr. Jones
I am grateful to my hon. Friend for her apposite intervention. I am certain that the Minister will respond fully on this important matter.
I shall conclude my remarks on speech therapy by quoting briefly from a letter sent to me by Mrs. Dorothy Price, the chairman of the governing body of Ysgol Del yn, a special school. She says:The children have very specific needs which require the expertise of qualified therapists. The feeling is that if we don't have a statutory right to provide the necessary service surely we have a moral obligation.She goes on to say:We are reneging on our responsibilities to these young people if we don't provide the service that has been shown to be needed.First, I ask the Minister, in the knowledge that those matters are appropriately to be described as a moral issue, whether the Government will enable those youngsters to have a statutory right to that necessary service. Secondly, will the Government give extra cash to the authorities that must deliver speech therapy and physiotherapy services? Thirdly, have the families of deprived children the right to take that case and similar cases throughout England and Wales to the European Court? Fourthly, w ill the Government launch a campaign, under the auspices of the 1343 careers service, to promote careers in speech therapy and physiotherapy? Fifthly, will the Government give speech therapists and physiotherapists sufficient salary and status to attract applicants for training and for designated and advertised posts?
I note that £1.5 million was paid in 1987 to British Telecom in respect of the priority fault repairs service for general practitioners and pharmacists. I further note that for the current year £2 million is earmarked. That is extraordinary. Are the telephones of GPs and pharmacists so very faulty? I know that British Telecom is making a small fortune from repairing those faulty telephones—if it is repairing them—so why is priority repair hideously expensive? Does the Minister know how many telephones needed priority repair in 1987? We know that British Telecom's profits in 1987 were huge. Was its telephone service to GPs and pharmacists as unreliable and bad as the figures suggest? I look forward to receiving from the Minister a breakdown of the figures, which are to be found under the appropriate vote heading. If £2 million is earmarked for the repair of GPs' and pharmacists' telephones, there must be something very wrong indeed.
The social fund stands at £179 million and is for budgeting and crisis loans. It is also for community care grants, maternity expenses, funeral expenses and heating expenses in exceptionally cold weather. I do not think that the social fund is enough, and I would urge the Government to enlarge it.
I know from my work as an hon. Member who holds regular surgeries that the social fund is the last bastion of defence for the poverty-stricken and those who are destitute. One of my constituents came to me in distress, saying that he needed a new pair of shoes, and I said that I would try to help him. In the end, I am glad to say, the Department of Health and Social Security offered him £30. My constituent, who was under great pressure, had to repay that £30 loan which was described as a "budgeting loan".
My constituent desperately needed the pair of shoes but he did not feel that he could repay the loan at £3.50 a week. After all, he came to me because he was not managing on the weekly cash that he had. In the end, a kindly social fund officer rescheduled the budgeting loan at £1.41 a week. My constituent accepted that, but he is under immense pressure in finding that £1.41. He does not have a lot of money—
§ Mr. Deputy Speaker (Sir Paul Dean)
Order. The hon. Gentleman is straying a little outside the terms of the debate. We are discussing hospital community services and related services, whereas the hon. Gentleman is straying into the social services. I am sure that he will bring his remarks back to the subject under debate.
§ Mr. Jones
I am glad of your intervention, Mr. Deputy Speaker. You have brought me back into strict order, but I thought that while we were discussing the Supply estimates I could make the point on behalf of a desperate constituent.
I support my hon. Friend the Member for Peckham (Ms. Harman) on the question of nurses' pay. I have had deputations and much correspondence on the subject and 1344 the nurses in my part of the world tell me that, although a pay award of 15 per cent. has been trumpeted, many of them may receive only 4 to 5 per cent.
The hon. Member for Macclesfield made a strong and independent point about charges for dental examinations and eye tests, which we have debated in this place and on which we know the other place has a point of view. If the Government do not listen to the points made in another place and by the hon. Member for Macclesfield, the well-being of several million pensioners will be at risk. I urge the Government to listen carefully. If they do not, politically they will suffer greatly.
§ Sir Michael McNair-Wilson (Newbury)
As we all know, this debate takes place during the year of the 40th anniversary of the National Health Service. We all agree that in the 40 years for which the service has existed it has expanded enormously away from the concept of a tick-over service once outlined by Aneurin Bevan. It is now treating more patients, with more staff, in more hospitals, for more illnesses and disabilities, than ever before. What is more, it is receiving more Government finance than at any time in its history.
As has been said, the supplementary estimate will give our nurses the largest pay award that any Government have given the nursing profession. Opposition Members carp about the pay award as if it were the Government who had decided upon the award and the Government who were going to restrict it. Yet, as I am sure Opposition Members will have heard, my right hon. Friend the Prime Minister said on 14 July:£803 million was the figure estimated not by the Government but by the nurses' pay review body."—[Official Report, 14 July; Vol. 137, c. 547.]They will also know that Mr. Trevor Clay said:There are many problems at local level. But some managements are succeeding in some districts. Why can't others make the same speed?I cannot criticise any Government who provide £803 million for the nursing profession. I hope that the grading problem will be sorted out as soon as possible. We must all recognise that it is a new dimension in nursing. We all know that it will produce difficulties and we should not imagine that they will be sorted out in a matter of three of four months. To hope for that would be unreasonably optimistic.
This supplementary estimate relating to the nurses' pay award has already produced much controversy in the Chamber. That suggests that, like the Supply estimate on which it is based, it is a source of controversy between the two sides of the House, as estimates have been in the history of the Health Service. We are all aware that Supply estimates and the inevitable supplementary estimates are merely guesstimates—no doubt informed guesstimates—by the Treasury and the DHSS. They are not estimates that are demand-led by the Health Service, the regions and the districts. They are figures chosen by Treasury officials to fit an extrapolation which may or may not be correct and which we seek to improve as the months of the financial year pass with supplementary estimate after supplementary estimate until we arrive at a figure that we think approximates to the resource needs of the NHS.
§ Mr. Rhodri Morgan (Cardiff, West)
Does the hon. Gentleman agree that, in South Glamorgan health authority, nurse is being set against nurse? Operating 1345 theatre nurses are being told that there are only a certain number of grade G posts, so some of them will have to go down to grade F, even though they have the same responsibilities as their colleagues on grade G
§ Sir Michael McNair-Wilson
I do not want to get involved in grading. I am not an expert on it, nor have I had complaints about it from my district health authority. In fact, I have not had a single letter about it.
I want to pursue my point about the estimates. They are the only way by which the Health Service is funded. We pass them year after year and we have a right to expect that they should be more than informed guesstimates. They should have some bearing on the demands within the service. Those demands are the yardstick of the resources that need to be provided.
I am pressing my hon. Friend the Minister for a better way of funding the NHS than the system that has obtained in the past 40 years. These estimates, both supplementary and Supply, do not give me the basis for calculating how the global figures in them are reached. I do not know whether they assume additional savings within the Health Service, or a percentage increase in the number of patients to be treated and staff to look after them, and whether they take into account the effect of inflation on the equipment that hospitals will have to buy. I do not know what emphasis they place on savings in general health care. We all know that about £100 million has been saved by privatising certain services in the Health Service in the past nine years—mainly domestic and catering services. But what savings could be made by using the private sector of medicine to relieve demands on certain parts of the NHS for specialist treatment? Does the Department have a figure? if so, are those savings assumed in the estimate, let alone the supplementary estimate? Without such knowledge, statements about underfunding have little validity.
Yet underfunding was almost the keynote of the third report of the Select Committee on Social Services. The report, entitled "Resourcing the National Health Service: Prospects for 1988–89", gives two definitions of underfunding: first, it isthe amount of funding less than that required to maintain current service levels and planned development";secondly, in a retrospective sense, it isthe amount of funding required to maintain the service at a constant standing in relation to changes in demography, technology and policy aims.Neither definition refers to further measures aimed at making existing funds go further with better management.
I admit that in paragraph 11 the Committee states that it accepts that the better use of resources can lead to higher performance but it goes on to say that thatdoes not of itself solve the continuing problem of underfunding.That is such a definite statement that one must assume that the Committee is arguing that, with or without savings, the National Health Service is underfunded. I cannot help wondering whether the Committee has allowed itself to be persuaded by certain district and regional health authorities that such is the case.
I cast doubt on the Committee's conclusions because some health authorities appear to do rather better out of their budgets than others. As reported in The Times last week, some hospitals also seem to have a better record for treating patients than others. I recognise that, as the Committee pointed out, if budget savings or lower average 1346 costs mean treating more patients, that can lead to increased total costs. However, the obverse of that argument seems to be that the fewer patients treated, the lower the costs. That is clearly a self-defeating concept.
I am not arguing against more money for the NHS, but the old Parkinson rule—that expenditure tends to rise with income—still holds good, and I would be sorry if the Select Committee's comments were read as if they endorsed those who argue that the NHS is as efficient with its budget as it can be and that large additional sums for it are imperative to stave off further reductions in hospital services. It cannot be for nothing that the Trent and Birmingham health authorities have asked BUPA to provide them with a system for costing the services that they give. Probably I am not comparing like with like—I speak with a special interest in the matter—but I wonder why kidney dialysis units run by private health care companies for the NHS can provide dialysis that is 30 to 40 per cent. cheaper than the NHS dialysis units, and still make a profit. Carrying that argument to its natural conclusion, the present figure of 47 new kidney patients on dialysis per million could be almost doubled, which would put us right up alongside the top levels in western Europe. Will my hon. Friend explain, if she can, that wide diversity of charge?
Another area in which considerable sums of money could be saved and a better service provided is hospital laundry. By September 1987, privatisation of laundry work had saved £8.1 million, but considering that laundry and linen services cost the NHS £231 million a year, according to the National Audit Office report published in April 1987, one must wonder whether that is the best that we can do—
§ Sir Michael McNair-Wilson
No, I shall not. Other hon. Members want to speak and the hon. Gentleman will have his chance.
A member of the laundry service in my constituency tells me that he believes, and it is the considered view of his trade, that savings of as much as £100 million are waiting to be made if private launderers are encouraged to tender for hospital contracts. Despite all the talk about privatising services since 1983, the amount of hospital laundry work, by value, being handled by the private sector has decreased. Yet I know from experience that the supply of sheets, pillow cases and blankets is often extremely haphazard in the National Health Service—
§ Sir Michael McNair-Wilson
No, I shall not give way. It is no good shouting at me.
The service spends at least: £100 million on disposable linen substitutes, although I doubt whether anyone prefers them to ordinary linen. When I was a patient in one of the hospitals in Oxford, I was asked by the nursing staff to take up with the administrator the wretched supply of linen and blankets to the patients. I was asked to do that because, as a Member of Parliament, I was assumed to 1347 have some clout with the administrator. I am glad to say I did have some, because we did get a better supply—but what a miserable state of affairs.
I ask myself why the private sector is finding it so difficult to submit tenders for hospital laundry. I am told that the private sector, when asked to tender, is asked to tender in such a way as to make the chances of it wishing to proceed extremely improbable. I shall give three examples. When the Lewisham and north Southwark district health authority asked a private tenderer to submit a tender for its laundry service, it required a book containing 226 pages. The tender documents for the Peterborough hospital contained 186 pages and that for south-east Kent contained 238 pages. My constituent told me that one tender document was six books long and took him nearly four hours to read.
I shall quote a letter from a hospital laundry contractor who supplies hospitals all over western Europe. This is a letter that the contractor wrote to the district general manager of the Airedale health authority, giving his reasons for not tendering for the work. It said that the companyis sorry to have to inform the Airedale Health Authority that it cannot submit a tender under the conditions to tender laid down by the Health Authority. This is in spite of investing hundreds of man hours and many thousands of pounds in the exercise to date.The letter continues that the companyhas twenty years' experience of providing Full Rental Textile Care Services to hundreds of hospitals, clinics and old people's homes. It is part of a Group whose whole raison d'être is serving healthcare institutions. It cannot permit itself to enter into a contractual obligation which it believes to be neither commercially responsible and reasonable nor potentially a successful service to the customer.That company told me that its standard contract is usually only five pages long, but the three examples I have given involve tender documents hundreds of pages long. One is forced to the conclusion that health authorities do not want to put their laundry service out to tender, whether savings can be made or not, and achieve that objective by asking for massive tender documentation. I remind the House that we are talking of little, simple things such as linen, blankets and towels. By imposing unreasonable contract terms, they do their best to dissuade private tenderers, despite the willingness of those same tenderers, to invest in the necessary equipment. They, or those responsible for running the laundries, prefer to have it in-house, perhaps because the wage structure relates to the number of pieces processed per week. Dare I say that hospital laundry managers have a vested interest in exaggerating the piece count? The private sector tell me that when they win a tender, the number of pieces processed falls by between 17 and 40 per cent., simply because payment is made on a different basis.
By the same token, is there any reason why the capital accounting procedures used in hospitals should favour in-house as opposed to external tenderers? In-house tenderers are allowed to discount their equipment purchases at the unrealistic figure of 5 per cent., and we all know what the standard price for money is in the market.
I have touched on three areas of National Health Service spending where the private sector can provide services that could mean major savings. Major savings mean getting more out of the resources that are available. If we are to move away from the idea that the National 1348 Health Service is chronically underfunded, we have to improve both the way in which we draw up our estimates and ensure that the resources available are used as wisely and prudently as possible.
§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
Although this has been a short debate, it has been interesting. I welcome the opportunity to take part as a Front Bencher in a debate on a report of the Social Services Select Committee, having for a number of years taken part in such debates as a member of that Select Committee when I was a Back Bencher.
It is a pity that the words of the Chairman of the Select Committee, the hon. Member for Birkenhead (Mr. Field), were not listened to by more of his hon. Friends. When he got to his feet, I counted two of his Front Bench colleagues listening to him and five Back-Bench Members, which, of course, has been par for the course in recent health debates. When the Labour party spokesman got to her feet a little later the number went up to seven Back-Bench Members, but, of course, that included the Chairman of the Select Committee. I am afraid that it needs no more figures to demonstrate the real interest of the Labour party in issues to do with health care.
I shall answer briefly one or two of the points that have been made. The hon. Member for Peckham (Ms. Harman) asked for a statement on dental and eye charges. I do not know whether she heard it, but a statement was made earlier today by my right hon. Friend the Leader of the House, and I have nothing to add to it.
The hon. Member for Alyn and Deeside (Mr. Jones) asked a number of questions, including questions about speech therapy and British Telecom. I hope that he will understand that, because of the short time available, I cannot answer his questions in detail, but I undertake to write to him.
We have had three splendid speeches from Conservative Members. I congratulate my hon. Friends the Members for Bury, North (Mr. Burt), for Macclesfield (Mr. Winterton) and for Newbury (Sir M. McNair-Wilson). I especially appreciated the excellent, robust speech of my hon. Friend the Member for Bury, North. I enjoyed the elegant and thoughtful remarks of my hon. Friend the Member for Newbury, who might like to know that, on provisional estimates for renal dialysis, it looks as though the number of new patients per million is now up to about 50, so we have further progress there.
I hope that my hon. Friend the Member for Macclesfield will forgive me if I deal with his points in a moment.
As for the priority given to Health Service spending, the figures speak for themselves. This year alone the Government are spending some £23.5 billion on the NHS in the United Kingdom. Our spending will rise by nearly £2 billion over last year. That is a cash increase of some 9 per cent., or about 4.5 per cent. in real terms after allowing for general inflation. We have allocated a slightly higher proportion of our money to the regional health authorities in England this year, so the figures should be 9.5 per cent. in cash terms and 4.8 per cent. in real terms for the RHAs.
§ Mrs. Currie
Spending on the National Health Service this year will have risen by 39 per cent. in real terms since 1978–79. That compares with an increase in public spending as a whole of 16 per cent. in real terms over the same period. In other words, spending on the Health Service under this Government has risen two and a half times as fast as public spending in general. I am sure that the Chairman of the Select Committee will agree that this is the biggest budget that the National Health Service has ever seen.
My hon. Friend the Member for Bury, North—who has left us—left us with the picture of Labour Members and, sadly, one or two Select Committee Members acting as bewildered children in a shop full of goodies, looking for the gaps on the shelves. My only concern is that his metaphor was a shop full of sweets—I would have preferred a shop full of fruit, but the point is well made.
§ Mrs. Currie
I should like to get a little further into my speech, because I want first to answer some of the points made by hon. Members who have been here the whole time.
Hospital and community health service spending on staff for all groups in the United Kingdom last year, including agency staff, was more than £11 billion. Of that, the estimated pay bill for our nurses and midwives was £5.2 billion; for doctors and dentists in the hospital and community health service it was £1.6 billion; and for the professions allied to medicine it was just over £500 million. We have accepted the estimates of the full cost of this year's review body awards which come to £803 million for nurses and midwives, £168 million for doctors and dentists, and £45 million for the professions allied to medicine. The £538 million sought in the summer supplementary estimates is the additional amount required on top of the 4.5 per cent. included in the public expenditure White Paper for England for the hospital and community health service. The hon. Member for Birkenhead is nodding. He is with me, even if no one else is. Other items are included in other supplementary estimates.
The difference between these estimates and those in the review body report is accounted for by employers' costs, that is national insurance and superannuation. The assessment of the hon. Member for Birkenhead of the historic size and importance of this supplementary estimate is far more accurate than the somewhat trite remarks of the hon. Member for Peckham.
We are employing more nurses than ever before. The last count last September showed a further increase to record levels. In England, there are 405,200 whole-time equivalent nurses and midwives—that is 490,000 on a head count. In itself that makes the regrading exercise so much more of a headache. It is a fact that more nurses in our employ are better qualified than ever before, including in the community nursing service where more than 80 per cent. of staff are qualified. I believe that that is all to the good.
It is a firm Government policy to improve nursing education through Project 2000 and to reduce the service burden of students so that they are no longer treated like skivvies. We feel just as strongly as the Royal College of Nursing about that and I believe that our stand has been courageous and welcome.
1350 It is also a firm Government policy to look after nurses and midwives for their own sakes and because they are our core work force. In this country we rely very heavily on nurses and we have relatively fewer doctors compared with other countries. Our job and theirs is to look after the patients and we can do that only with a skilled, productive work force in a professional atmosphere with high morale whose contribution is recognised in the pay packet.
§ Mr. Galbraith
I am slightly worried that the Minister will not answer the very important question that we raised. If more money is required as a result of regrading than that already set aside by the Government, will they find the additional money to fund fully the regrading exercise?
§ Mrs. Currie
The hon. Gentleman is aware that I think very highly of him. However, every time he rises I cannot help remembering that he came to this House after being a consultant in the National Health Service. He gave up £10,000 in salary to do so. We are certainly looking after someone very well out there. If he will bear with me, I hope to answer his question in full shortly.
We hope that the Opposition will not vote against the mammoth package of extra money for the nurses and midwives. I noted that the Labour party had a vote last night to which attention was drawn earlier by my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard). The national executive committee of the Labour party had to decide whether the Royal College of Nursing should be allowed anywhere near the Labour party conference. There was another split in the Labour party. There was a vote of 21:1 against the RCN going to the Labour party conference. The one was the Leader of the Opposition and the deputy leader was among the 21. I have checked up on this and I can state that the RCN is welcome at the Conservative party conference. I confirm that we expect to see the RCN at Brighton in October.
We have had plenty of humbug and hypothetical questions tonight. If the Labour party had won the 1979 general election there would not have been a nurses' pay review body or a supplementary estimate of the size that we are discussing. My concern about the Opposition's approach and that of the Select Committee on Social Services on occasion is that they are so negative. Every change is seen as a problem and every effort to cope with problems is seen as a failure, even when it is a blazing success. Every improvement is ignored and every opportunity to run down achievement is seized. The hon. Member for Birkenhead again described the pay awards as very generous. We are content to accept that compliment.
I want now to consider what is happening in Macclesfield. As my hon. Friend the Member for Macclesfield is aware——
§ Mrs. Currie
The hon. Lady has not given me enough time to answer all the questions that she asked. I will come to them in a moment. I hope that she will allow me first to pay a courtesy to my hon. Friend the Member far Macclesfield who served on the Select Committee for Social Services with such distinction for so long.
If my hon. Friend the Member for Macclesfield does not mind, I want to read a letter sent to me by Mr. Richard Jordan, who lives in Macclesfield. I imagine that he is a constituent of my hon. Friend. I checked with Mr. Jordan 1351 and he said that he would be delighted if I were to read out his letter. His handwriting is a little shaky and hon. Members will understand why in a moment. He wrote: "Dear Mrs. Currie,I am fed up with hearing the complaints about the NHS, of course everybody wants more money, but please tell us all how wonderful the service is, the Macclesfield General and West Park Hospitals have brought me through two heart attacks and now two strokes, hence my bad writing.All the staff at our hospitals are marvellous and I hope you will praise them. Doctors in our village on the spot at home within minutes, ambulance, doctors, nurses, equipment is here within the half hour, immediate doctor and nurses attention on arrival at hospital, food very good, with varied menus, sisters and nurses nothing too much trouble.When I had my strokes the doctor and even the specialist from the hospital called at home to confirm my condition and examine me. My local doctor saw to the nurses, physiotherapy, calling and providing me with a wheelchair, stick, chair, and everything including oxygen etc. I felt that the NHS has done so much … We are so grateful to the NHS and feel sure there are many more people who feel the same way.He comments further about the cheerful and expert service. That is the service in Macclesfield, and it is repeated throughout the country.
The hon. Member for Birkenhead asked one or two specific points. I will consider those and then consider the regrading exercise in some detail.
§ Mr. Nicholas Winterton
As my hon. Friend the Minister has referred specifically to my constituency, I want to confirm everything in Mr. Jordan's letter. I have splendid doctors, wonderful nurses and, as my hon. Friend the Minister knows, a new district general hospital. However, with regard to my local hospital, perhaps she will refer to the fact that its new operating theatres are closed for several sessions a week when they could be relieving people who require hip replacement or knee joint replacement operations. They are closed because there are inadequate resources to staff the hospital and theatres to operate 100 per cent. of the time. We have growing waiting lists in important specialties. I fully accept that we have an excellent hospital and that it provides fine service, but perhaps my hon. Friend the Minister should direct her attention to the point that I have raised.
§ Mrs. Currie
As my hon. Friend is aware, part of the difficulty in some of the theatres, as has been shown in recent research studies, has arisen in obtaining the key staff, especially the nurses, to work in them. That is why we are undertaking a clinical grading review so that highly qualified staff who accept a lot of responsibility should be paid appropriately. We are certain that that will help to alleviate the problems in future.
§ Mrs. Currie
If it is a matter of being a little late perhaps the hon. Member for Birmingham, Ladywood (Ms. Short) will stay here a little longer and hear what I have to say.
§ Mrs. Currie
The hon. Member for Birkenhead asked about Medical Defence Society subscriptions. As he is aware, the doctors' and dentists' review body recommended that two thirds of the costs of subscriptions should be reimbursed directly. 1352 As the hon. Gentleman will realise, the cost to the health authorities can be estimated quite precisely and they have been included.
The hon. Member for Birkenhead also asked about Whitley. As he is probably aware, the settlements are coming in fairly close to the figures that we anticipated. Others are not yet settled, and we do not normally speculate while pay negotiations are still under way, for obvious reasons. I hope that the hon. Member for Birkenhead will be satisfied with that reply.
Let us consider the regrading exercise. I suspect that there has been some misunderstanding and I want to assist the House. First, it does not apply to all nursing staff. Managers and students are excluded by agreement. About 85 per cent. of our nursing staff are affected, but that means that we are talking about a large proportion of the half a million nurses that we employ. The nurse managers are the subject of a separate grading exercise. Students will be affected by Project 2000. However, under the 1988 review body awards, the minimum for senior nurses will be 5 per cent. The minimum for students will be 6.3 per cent. and the minimum pay rise for all the nurses will be 4.2 per cent.
The hon. Member for Birkenhead asked several questions about how the pay bill was divided and calculated.
§ Mrs. Currie
The hon. Member for Birkenhead asked some questions and I am answering them. He obviously did not know the answers.
The Government set up a sample survey of staff and asked them of what their work consisted. We tried to work out, by grossing up, how many staff will be involved in changing grade. We gave the figures to the review body along with our considered views on the increase in pay needed for other reasons such as inflation or the extra costs of living in London. We accepted what the review body said about the costs of the exercise to the National Health Service. I shall remind the House of precisely what Sir James Cleminson said in the review body's report. In paragraph 154 he says:Our estimates are necessarily approximate because they are themselves based on estimates.We provide estimates of manpower levels and pay bills every year. That is how the DHSS cash was calculated, and we accepted the figures in good faith. If the hon. Member for Birkenhead thinks about it, he will agree that the method that I have described is easily the obvious method of calculation. Had he recommended it, I would have said that it was an intelligent and serious approach to a fiendishly difficult problem.
With the exception of funds for the London supplement, the total sum allocated to regional health authorities was in proportion to their initial cash limits. This tried and tested method has been used in previous years. We considered doing it differently; other methods have their advantages and disadvantages.
Hon. Members asked whether we are satisfied that the estimates are accurate and whether we will implement the exercise in the spirit in which it was intended. Of course the answer is yes. When such large numbers of staff are to be regraded there are a limited numbers of ways for a Government to respond. They can offer the figures and accept the calculations in good faith—which we did; that meant requesting a set amount of cash as a supplementary 1353 estimate—they can reject all the calculations and use guesswork, which we were not prepared to do, or they can say "Go ahead, never mind the cost." But that implies offering a blank cheque. I accept the strictures of my hon. Friend the Member for Macclesfield that that would have been irresponsible. We have issued much guidance, which is all in the Library. I sometimes wonder why we put it in the Library, because I do not think that anybody reads it.
I shall set out precisely for what the money for which we are voting is intended. I shall set out in public the views that we discussed in private with regional health authorities. The money is to regrade jobs as they were in post on I April this year. We accept that that is a snapshot, but there must be a set date or it is not fair. The money is not for new posts or to fill vacancies as at 1 April. That would be growth, which has already been argued for. Some 1.2 per cent. is provided for RAWP and 1.5 per cent. for cost-improvement and income-generating programmes. There has already been more than 2.5 per cent. growth this year.
The money can be used to replace agency staff. It is not intended to permit health authorities to bow to trade unions or industrial relations pressures. The entire review body system for nurses, midwives and professions allied to medicine was set up precisely because those professions had put their patients first despite industrial action by others. In a press release last week, the Royal College of Nursing told us to get on with it. It said that it was confident that the Government would keep their promises and that the sooner the exercise was finished the better.
The money is not for health authorities to think up their own gradings. This is not a local version of regional pay. We have put our views about regional pay to the review bodies, but that is a completely separate issue. It is essential to have consistency of grading across the country so that the same grade does the same work. Our officials will be visiting health authorities during the summer to ensure that this consistency is achieved. That is only fair and it is what we have agreed with the staff.
The hon. Member for Peckham bleated on about the sufficiency or otherwise of the enormous sum on which we shall be voting. We have received no firm information and we shall not act on rumour, especially rumour put about by one or two trade unions that might want to bid-up gradings, to try to poach members or alarm good staff.
It is early days and there is a long way to go. We are unlikely to have any solid information before the autumn—much closer to the deadline of 31 October. Any other views are pure speculation, and many of them are plain wrong.
I shall write to the hon. Member for Birkenhead in more detail about the issues that he raised, but I should like to put the regrading exercise in context. It is the biggest change to face nursing for many years. It is the biggest personnel activity since the National Health Service was established. It is probably the biggest review this decade of health care staff in Europe. It is certainly far bigger than anything we have handled before and it affects far more staff, every single one of whom is personally assessed and regraded. It is a heck of a lot bigger than regrading the staff in the citizens advice bureau in Birkenhead and it is light years away from the proverbial whelk stall which, on the admission of Opposition Front Bench spokesmen, Opposition Members could not run.
1354 It is worth remembering the regrading exercise in the Halsbury report, which was mentioned by the hon. Member for Birkenhead. I have read the report, which says:Within the time limits which we set ourselves to submit our report we have not been able to carry out evaluation in depth of the work of each grade … what we have seen and heard has left us in no doubt that an evaluation of this kind is urgently needed.That was November 1974. We are undertaking the exercise because we have the management skills and the resources. I hope that the House will honour and recognise our commitment.
§ Mr. Frank Field
There seems to be some question about when the debate should finish. Before I make my brief concluding comments, will you, Mr. Deputy Speaker, say whether I am right in thinking that this debate can run for three hours?
§ Mr. Deputy Speaker
By a resolution of the House of 22 June, this debate can last three hours. If the House wishes, the debate may continue until 8.23 pm. I understand that some arrangement may have been made to finish the debate earlier so that the second debate can begin. The resolution of the House is clear.
§ Mr. McCartney
On a point of order, Mr. Deputy Speaker. I apologise for raising a point of order at this stage, and I understand what you, Mr. Deputy Speaker, said about formal arrangements being made. In her opening remarks, the Minister criticised Labour Members for not being available to debate the Health Service. She did so in the knowledge that her office refused my request for a meeting to discuss underfunding in my constituency. An apology was given on the basis——
§ Mr. Deputy Speaker
Order. The hon. Gentleman is making a point that would be perfectly legitimate in a debate, if he were called.
§ Mr. Deputy Speaker
Order. I made clear the resolution of the House, by which I am bound. I added in parenthesis that I thought some informal agreement had been reached. It is my job to carry out the resolution of the House. I hope that is clear to hon. Members.
§ Mr. Field
I am grateful to you, Mr. Deputy Speaker, for saying that and I hope that hon. Members have heard your remarks. My hon. Friends and some Conservative Members have been present for all the debate. My hon. Friends do not now wish to take part, so I can therefore bring the debate to a conclusion.
I think that the Whips have an important lesson to learn from tonight's proceedings. I hope that it will be learnt by Labour and Government Whips. It is not pleasant for hon. Members who have been present throughout the debate—who have much expertise and who wished to contribute to the debate—to be leaned on so that some informal agreement can be adhered to. That is a sour note for me to begin my summing up on, but perhaps it is appropriate, given the comments made by the Under-Secretary of State for Health and Social Security.
1355 I have merely two things to say. Many hon. Members made efforts to divide what I said from the sentiments that were expressed by my hon. Friend the Member for Peckham (Ms. Harman). Perhaps my hon. Friend made her points more gently than I did, but there was certainly no disagreement between us. It was strange for the hon. Member for Macclesfield (Mr. Winterton) to have to make his point. Apart from the hon. Members for Newbury (Sir M. McNair-Wilson) and for Bury, North (Mr. Burt), who did not think that it was necessary to discuss the estimates, there was no disagreement at all.
Opposition Members are concerned about one central issue, which I put to the Under-Secretary of State. I hope that she heard the message, if not from Opposition Members, from practically every Conservative Member who has spoken in the debate. They are as pleased as we are about the size of the supplementary estimate. They and Opposition Members are pleased that, officially and unofficially, we welcome the Government's commitment fully to fund the pay award. We have raised a single crucial question. Is the regrading exercise to be screwed up because of a cash ceiling, or will the Government give the green light so that the regrading exercise can take place and fulfil the review's expectations that the Prime Minister outlined?
Being the written word, Hansard does not take account of the way in which hon. Members shake their heads. It is important for us to recall that, when I asked whether the exercise is to be cash-limited, the Under-Secretary of State said no. She shook her head like one of those dogs that sit in the back of cars. When the cars stop, their heads move. It was a terribly important intervention from her.
§ Mrs. Currie
The hon. Gentleman should beware of reading anything into my gesture when, at one stage, I talked to the Whip, who was sitting on one side, and to my Secretary of State, who was sitting on the other side. I apologise if I made my point in a rushed way, but I am conscious that a large number of hon. Members are waiting to speak in the next debate, and we must be courteous to them also. We did the calculations in good faith. We accepted the recommendations of the review body in good faith and in good heart. We are voting today on the biggest supplementary estimate that the Health Service has ever seen. The regrading exercise is being done in detail for 500,000 people.
We have no hard information and no information that will confirm any of the rumours or negative comments that are being put about. We already have some information that we may well have got it right. I hope, and I am sure that the hon. Gentleman also hopes, that all the experience that is going into the matter will bear fruit and that the net result will be some contented nurses and well-cared-for patients.
§ Mr. Field
From the Under-Secretary of State's careful statement I hope that we may infer that, when we return after the summer recess, we may seek more time to consider a further supplementary estimate so that we can make a reality of the Government's commitment fully to fund the nurses' pay award.
§ Mr. Nicholas Winterton
Will the hon. Gentleman, who is Chairman of the Select Committee, agree that my hon. Friend the Under-Secretary of State herself admitted that 1356 the pay review body stated that this is its best estimate? Therefore, there could clearly be an error. Should we not be able to accept from that, if indeed there is an error after a responsible clinical regrading is carried out, that the Government should have the courage and decency to come forward with another supplementary estimate?
§ Mr. McCartney
As Chairman of the Select Committee, will my hon. Friend ask the Under-Secretary of State to reconsider the matter and agree to meet me and discuss the basic point relating to the underfunding of my health authority?
§ Mr. Field
I shall not give way to the Under-Secretary of State. As my hon. Friend spoke, she was beckoning with her first finger. I hope that, when the regrading exercise is completed, the Under-Secretary of State is as happy to give signs to all the nursing profession as she is to give them to my hon. Friend the Member for Makerfield (Mr. McCartney).
We have an informal agreement to which the Select Committee was not a party. We have used four minutes of the time allowed for debate on the next topic, and I apologise for that. If the Whips want informal agreements, they should talk to the right people, and, in this case, it is Select Committees.
§ Original question deferred, pursuant to paragraph (4) of Standing Order No. 52 (Consideration of estimates).