Care in the Community

HC Deb 19 April 1989 vol 151 cc391-432 7.13 pm

Mr. Ronnie Fearn (Southport)

I beg to move, That this House condemns the Government's lack of policy and action on community care; believes that projected demographic changes call for a long-term strategy to cover the many types of care that an elderly population will require; further believes that the proposals contained in the White Paper, Working for Patients, will diminish the effectiveness of family practitioner services and the future provision of community care; and calls for the necessary funding to be made available to allow the health and care services to expand and develop in a way which will contribute to freedom from ill-health and freedom to live life to its full potential through providing packages of care that recognise the needs of the client, the family and informal carers within the community.

Madam Deputy Speaker (Miss Betty Boothroyd)

Mr. Speaker has selected the amendment standing in the name of the Prime Minister.

Mr. Fearn

For many years, we have heard a great deal of Government rhetoric about care in the community, but we have not seen any Government action to make that concept a reality. The Wagner report, the Firth report and the Griffiths report were all virtually ignored for no other reason but that their recommendations did not fit Government ideology. Another reason for delay is the realisation by Ministers that community care, which they adopted as a means of reducing hospital and community service costs, will not relieve pressure on the public purse.

Uncertainty about future organisation and finances means that planning for community care services has come to a standstill. It is now extremely urgent that decisions are taken. Confusion over areas of responsibility, accountability and funding, which has worked to the detriment of those in need, cannot be allowed to continue. The Government must respond.

I do not hold out much hope that the Cabinet working group chaired by the Prime Minister will come forth with proposals that will meet the requirements that the majority of those involved in community care believe are needed. A proper system of care in the community requires a commitment to provide adequate funding—a commitment of a kind for which the Prime Minister is not renowned. Also, the recently published abysmal results of a year's work by top officials conducting the National Health Service review do not inspire confidence in the Government's ability to produce workable and acceptable solutions.

How such a supposedly widespread review and reform of the Health Service can be completely void of any reference to community care, particularly when the proposed reforms would have a direct and disturbing effect on community services—as was pointed out in our recent booklet, "Dead On Arrival"—is beyond me. It transpires that "Working for Patients" has little to do with patients and more to do with costs. I hope that the members of the Cabinet working group on community care will not make the same mistake. When they consider the proposals, I hope that they will keep uppermost in their minds several basic concepts.

Among them is the necessity to put people first, recognising the rights of carers and their clients as individuals to exercise a degree of choice and control. Others are the right of the individual to live life to the full and the provision of support, including financial support, to carers and their clients so that those clients may live within the community as long as they wish, while recognising the rights and needs of their families and of other informal carers.

There must also be created a genuine partnership between clients, carers, the state, and the voluntary and private sectors. Finally, there must be provided a network of services giving carers and the individual client a pack age of support best suited to his or her needs.

Government inaction is not the only cause for concern, because continual pressures on and incentives to health authority managers to close down mental health facilities have had awful consequences. Thousands of mentally ill people are discharged from hospital without alternative care arrangements being made for them. The past 10 years have seen the loss of 40,000 beds. Some of those people have been made homeless and are wandering the streets, while others find themselves under the jurisdiction of the courts and prison services. Many others are in bed-and-breakfast accommodation without any support from the medical or social arms of the public services.

The neglect of the mentally ill is an appalling indictment for a country that claims to be civilised and increasingly prosperous. At what cost is our new-found affluence? Any community care legislation should embody Griffiths's statement: No person should be discharged without a clear package of care being devised and without being the responsibility of a named care worker.

Mr. Simon Hughes (Southwark and Bermondsey)

Does my hon. Friend accept that in the inner cities—which are meant to be the focus of Government policy, investment and attention—there is increasing pressure on right hon. and hon. Members in all parts of the House because of the large number of patients discharged from long-stay mental hospitals into what is allegedly care in the community?

Mr. David Steel (Tweeddale, Ettrick and Lauderdale)

It is not only in the inner cities that that happens.

Mr. Hughes

My right hon. Friend says that it happens not only in the inner cities, but in general that is where former long-stay mental patients are being discharged into the community in enormous numbers. It is a community in which no care is provided upon their arrival, and in which acute problems of mental illness and sickness afflict not only the patients themselves but their families and the immediate community, with no prospect of any help being provided.

Mr. Fearn

That occurs not only in the inner cities but in every town and city and in rural areas. The Schizophrenia Fellowship's drop-out centre in Southport is overflowing, and the staff have no idea where to send people who have nowhere to stay at night.

We must accept that individual clients and carers have some right to chose the care that suits them. It may be that short-term or long-term residential care is required. Therefore, it should always remain an option and should be available through private, voluntary and public provision.

Community care debates often place emphasis on the elderly. We are an aging nation. We are also a nation that is not coping with the present needs of elderly people. How can we expect to cope in future unless those in authority recognise the problems and plan for them? Today, single elderly people and couples who can no longer fend for themselves, and some who are incontinent, unable to feed themselves or in need of non-urgent medical attention, receive very little support in the community because the social services are short of staff and resources due to Government cuts.

Mr. Peter Thurnham (Bolton, North-East)

The hon. Gentleman mentioned Government cuts, and in his opening remarks he criticised the Government for failing to provide adequate resources. Will he cast his mind back to a document he wrote last July in which he called for annual increases of 2 per cent. in spending on the National Health Service and compare that with the Government's record of a 4.5 per cent. increase in real terms?

Mr. Fearn

I not only stand by my suggestion for a 2 per cent. increase in real terms, but stress that community care has received very little assistance. Health authorities are reluctant to take on elderly people in case they find themselves in a Catch-22 situation. Some hospitals will admit patients, but as soon as an assessment establishes that there is no medical need or that hospital treatment has been completed, the patient is discharged, regardless of the home situation and without continuity of care. The financial squeeze on health authorities has resulted in a reduction in the number of places in nursing homes they are willing to finance. The rigorous conditions of DSS regulations mean that one must impoverish oneself before any fees can be paid, and the recent ceiling on fees paid by the DSS, which makes no allowance for the wide variation in property prices, has made the availability of residential and nursing home care a matter of privilege, particularly in the south-east.

Mr. Matthew Taylor (Truro)

I represent an area where there are many residential nursing homes. Only recently I have received letters from the proprietors of those homes desperate about the increase in fees, and letters from residents desperate about the lack of an increase in their allowances. Those homes are becoming unable to continue to retain DSS claimants and they are being forced to make a choice between breaking even and continuing to care for those patients.

Mr. Fearn

My hon. Friend is quite right. In his constituency of Truro and certainly in other areas, nursing home proprietors fear that sooner or later the crunch will come and they will have to decide whether to discharge the people in their care. I know from their organisation that that is not what they want and that they will resist it for as long as possible.

Mr. Michael Jack (Fylde)

If things are so bad, why do so many organisations wish to start nursing homes and rest homes?

Mr. Alex Carlile (Montgomery)

It is the get-rich-quick syndrome.

Mr. Fearn

I do not believe that it is the get-rich-quick syndrome, as my hon. and learned Friend suggested, because I believe that there is a great deal of care in the nursing homes and associations. Such institutions require help. Voluntary organisations are also finding it extremely difficult to operate within the DSS ceilings, and in some cases that leads to desperate situations.

Mr. Carlile

Does my hon. Friend agree that, although there are some splendid private nursing homes, by and large the best quality nursing home care is provided by local authorities which can provide the most flexible nursing home services? Does he agree that the way in which private nursing homes are changing hands for massive sums of money suggests that an element of the get-rich-quick syndrome is at work?

Mr. Fearn

I certainly agree with my hon. and learned Friend's first point about local authority nursing homes. I have visited many homes throughout the country and they are run extremely well.

If we cannot look after our elderly people now, what of the future as the number of people over 75 and over 85 increases substantially, as does their rate of dependency? The Royal College of Nursing estimates that an extra 10,000 places in residential nursing homes would need to be created every year for the foreseeable future to cope with those demographic changes. That figure is calculated from an assumption that only 4 per cent. of the elderly population will require such care. That percentage is below that for other developed countries. Currently, between 21 and 22 per cent. of people over 75 suffer from various forms of dementia and require 24-hour nursing care. If that rate continues—there is no reason to suppose that it will not—there will be 80,000 to 100,000 more dependent people by the year 2000. Who will plan for their care?

In a society which is increasingly mobile and transient, in which moving to another part of the country to retire is becoming the norm, it should not be left to local government or health authorities. It is, and will be, a national problem. A Ministry for community care which has strong links with local bodies should be responsible for overall strategy planning and development of care for the elderly.

In the past few years there has been a programme of closures of hospitals for the mentally handicapped, and the resettlement of mentally handicapped persons into community-based services. The care of those people often requires high levels of staffing and specially trained staff. As those skills are not always readily available in the community, some transfers have been unsuccessful. There will always be a hard core of people in every category who require special, specific and highly skilled care. We must ensure that, whatever the arrangements for community care, they are flexible enough to maintain the quality of life of those people.

Much of the debate on community care is concerned with cost, but it is a sector that may never be truly costed simply because of its very nature and the different levels of care and support required and provided. It is also clear, as Griffiths states, that most people do not consider that an effective system of care in the community can be conducted on the cheap. Whichever way community services are organised, there is already an apparent need for more social service staff and an increase in training. If local government is to be the lead agency, which I very much doubt, given the Prime Minister's fear of allocating too much to local authorities, an intensive training and retraining programme may be necessary. If community care is to be truly effective, it must be given the resources to match its needs.

The availability and quality of care services should bear no relation to the individual's ability to pay. The proposals that I hope the Government will introduce very soon will be scrutinised very thoroughly to ensure that there is not a two-tier system of community care, as is the case in the NHS review.

It is evident that many people who are in need of care would not be receiving attention if it were not for the informal carers. The majority of carers are women. There are more married women staying at home in Britain today to look after elderly relatives than there are staying at home to look after children. Not all those in need of care are elderly and there are many informal carers looking after people who are mentally ill, mentally handicapped or disabled.

The stress of the continual dependence is often made more difficult by the added financial pressures. Many of the informal carers are elderly and some have already spent years bringing up a family. Thousands are now at breaking point. As a society we are in danger of creating more difficulties and increasing the number who may become dependent unless we begin to look after our carers.

The act of caring must be a positive choice, for that immediately relieves some of the tension and stress. In all areas we must provide more day centres, day and night sitting services, short and long-term respite care, transport and other support services. Above all, it is time we recognised the value to the community that is provided by informal carers. To relieve some of the burden and widen the area from which carers may be drawn, the Social and Liberal Democrats would like to see the Government introduce a carers benefit.

Community care is a complex issue and there are many subjects I have not covered, including the plight of the disabled. Some of their difficulties and some of the problems facing the elderly could be relieved by the full implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986. I call upon the Government to implement that Act in full. Also, without further delay, they should bring their proposals for community care to the Floor of the House so that they can be debated and acted upon. A year ago Sir Roy Griffiths said: doing nothing is not an option. Since then the problems have increased and the longer the Government delay, the more desolation, distress and degradation will be suffered by those in need of our services.

Primary care is not altogether a distinct and separate subject from community care. After all, the general practitioner is situated within the community and is responsible for the quality of health care available to the community. The proposals contained in the White Paper and associated documents will be damaging to the quality of primary care services. I am not talking about self-governing hospitals of general practice budgets. I believe that those are non-starters and that they will have little take-up. The damage will be done by the central plank of the proposals, which is the introduction of competition in the belief that it will lead to improvements overnight. To achieve competition, doctors' pay is to be increasingly linked to the number of patients on their list. To sustain income, doctors will compete with each other for patients with supposedly improved services and publicity. Yet it is strikingly obvious that an increase in the number of patients will result in less time being spent with the individual. Time is needed to discover the underlying cause of disease.

The practice of preventive medicine and heath promotion at individual patient level requires time for consultation and discussion. There will be no time to visit schools, factories or other sectors of the community to spread the health promotion message. The increase in list size will make home visits increasingly scarce and, once again, those most in need, such as the elderly, will suffer most. Doctors in rural areas and in some inner cities will find it impossible to increase their list size. That will make practice work untenable or, at least, unattractive. Patients will face a reduction in services and in some areas the loss of any general practice medical service. That is a heavy price to pay merely to satisfy the Prime Minister and the supporters of the free market philosophy.

The Government have acknowledged the problem in Scotland and introduced separate proposals to safeguard rural practices. Perhaps the Minister will use this opportunity to explain to those who live in sparsely populated areas in England and Wales how their services will be protected. He does not seem to think that the problem ever warranted a mention in his recent letter to most hon. Members, which was dated 14 April and which I received today. Dr. Farrow, the chairman of the rural practices committee of the general medical services committee, has described the proposals as a "devious blow" which will probably result in the rape of the rural practice. That quotation can be found in the British Medical Journal which quoted his speech at the British Medical Association council on 1 March.

The proposals contained in "Promoting Better Health" and "Working for Patients" are unacceptable and, in their present form, will diminish services rather than develop them. The future of rural communities and services is at risk. The Minister must address those concerns positively.

Our anxieties about the quality and range of services are further exacerbated by other Government proposals. The set requirement to spend 20 hours in the surgery at first seems innocuous. However, it will cut down the amount of time that some doctors can spend visiting their patients and in the community. In rural areas, the distance between split-site surgeries, the travelling time required to visit patients and patients' transport difficulties are real problems that the Government have failed to address.

Mr. Matthew Taylor

There is a particular concern about the hours requirement for doctors who also work in hospitals. The main district hospital in my area is located in the middle of my constituency and many of the doctors are involved in hospital work. They are faced with either withdrawing their services from the hospital or being penalised for not meeting the hours they are required to serve in the surgery. That is an immediate and real dilemma. Perhaps the Minister will be able to respond to it.

Mr. Fearn

That is a good point, and I hope that the Minister will respond.

Also unworkable and damaging are the terms that apply to the proposals on prevention and immunisation. Leaving aside the issue whether those should be the subject of incentive payments, the Government have set targets that are ideally correct but unrealistic in practice for many doctors. Parents are often unwilling to have their children immunised and, in inner-city areas where the population is transient, none of the screening or immunisation targets is ever likely to be met. Many doctors will stop providing the service altogether rather than experience the hassle.

Each practice has a very different mix of patients and problems and each health care provider should, working to certain standards, have the flexibility to provide the service best suited to the area. The rigid guidelines that the Government are attempting to impose will be harmful to the development of good practice.

Medical audit and peer group review is welcome in theory, but unless it is accompanied by the necessary level of funding and support it will be a non-starter. Unless doctors have the staff and computer back-up required, they will become medical bureaucrats and accountants, tied to their desks shuffling endless bits of paper while their waiting rooms overflow. Will the Minister tell us how the figure of £250,000 for medical audit announced in the White Paper was arrived at? Will it be reviewed in the light of representations that have been made about its inadequacy?

The Government's proposals take no account of the need to increase preventive medicine and ignore the costs of smoking, bad diet, alcohol abuse and poor housing. They do nothing for those most in need of help—those with disabilities or handicaps, the elderly, the frail, the deprived, the isolated and the homeless.

The Government's failure to respond to the Griffiths report and their proposals in "Promoting Better Health" and "Working for Patients" highlight Ministers' complete lack of understanding and ignorance about health, personal social services and the needs of the people who use, and want to continue to use, primary care and community care services.

The next decade will see greater demands placed on medical and community services from an increasingly elderly population and by diseases such as AIDS. This year could have been the year in which the Government met the challenge and laid out their plans for the future. Instead there is silence on community care and cuts in primary care.

While the Government play political games with our health care services, millions of people will remain trapped in their homes in poverty, deprivation, illness and hardship. The Government neither see them or care for them. It will be left to a future Government to release them, and I hope that that will be sooner rather than later.

7.40 pm

The Minister of State, Department of Health (Mr. David Mellor)

I beg to move, to leave out from 'House' to the end of the Question and to add instead thereof: 'expresses full support for the Government's policy of community care and for the proposals set out in the White Paper, Working for Patients; commends the Government's record on the funding and development of primary health care and community care; and believes that the White Paper, together with the Government's earlier White Paper, Promoting Better Health, will help family doctors to develop the services which they provide for their patients, strengthen the provision of primary care in general and complement the development of policies for community care, improve the quality of care for all patients, and ensure that all those concerned with delivering health care make the best use of resources available to them.'. The debate, which I was glad to see on the Order Paper, should have provided the hon. Member for Southport (Mr. Fearn), given his background in local government, with an opportunity to make a thoughtful speech about the problems of community care. I am sorry that he did not take the opportunity to do so, but instead resorted to a melange of lowest-common-denominator party politics. He seemed to be reading large chunks of a British Medical Association brief. I do not expect high standards from Opposition Members, but is a Social and Liberal Democratic party health policy to be written by the BMA and parroted by its spokesman in the House without recognition of the opinions of people who are concerned about a consumerist Health Service and want it to have consistency of standards? We did not have an especially distinguished performance from the Social Democratic party yesterday, but at least there was admission of concepts such as internal markets, which are necessary for a developing Health Service.

The hon. Member for Southport appeared to be nothing more than a mouthpiece for a trade union, which I always thought was the traditional role of the Labour party.

Mr. Robert Maclennan (Caithness and Sutherland)

rose—

Mr. Mellor

I shall give way in a moment.

I can at least say that I listened to all the speech of the hon. Member for Southport, which is more than can be said for the leader of the SLD, the right hon. Member for Yeovil (Mr. Ashdown). The right hon. Gentleman disappeared about two thirds of the way through his hon. Friend's speech. I do not know whether that was caused by the quality of the hon. Gentleman's speech, but no doubt we shall be told.

Mr. Alex Carlile

Cheap.

Mr. Mellor

Hon. Members who say that they represent a different sort of politics shout and jeer as though the hon. Member for Bolsover (Mr. Skinner) has been giving them lessons. It is perfectly legitimate to inquire—it is much more edifying than the words that tripped from the lips of the hon. Member for Southport—why the leader of the SLD felt compelled to leave halfway through his hon. Friend's speech.

Mr. Carlile

rose—

Mr. Mellor

I shall give way in a moment.

There were some interesting deficiencies in the remarks of the hon. Member for Southport on community care. He spoke of it as though it was exclusively the preserve of other people. It is interesting that, as we run up to county council elections, not a word or sentence was wasted on the community care policies of the various Liberal county councils. It may be that when it comes to putting these great ideas into practice there is not much about which those who have held office for the SLD can boast.

I shall enjoy showing how the hon. Member for Southport was wrong about cuts. It was interesting to hear his remarks about cuts in primary care, because expenditure on it has increased by 50 per cent. in real terms.

Mr. Carlile

Will the hon. and learned Gentleman give way?

Mr. Mellor

The hon. and learned Member for Montgomery (Mr. Carlile) knows that I am halfway through a point. If he contains himself a little longer I shall give way, but if he wants me to carry on and prevent other hon. Members speaking I shall happily do so because that is the only effect of sedentary observations. If he allows me to go on, I shall give way in my own good time and allow him to make a substantive speech.

If hon. Members want a sensible debate, they should start sensibly. I cannot allow talk of cuts in primary health care when expenditure on it has increased 50 per cent. in real terms over the past 10 years. The number of GPs has increased 20 per cent.; the number of dentists has increased by almost 20 per cent.; the number of GP support staff has increased by 50 per cent.; and the number of practice nurses has almost doubled.

Expenditure on community care has increased sharply in real terms. There is much room for sensible discussion on the issue, which fitfully appeared in the speech of the hon. Member for Southport. The Government are working hard to consider the implications of the Griffiths report. It is not a matter for sneering, second-rate, lowest-common-denominator politics. The quality of care that we should be offering an increasingly aging population and who is best placed to provide it are serious issues.

There were one or two refreshing aspects in the speech made by the hon. Member for Southport. He acknowledged that, in considering the proper provider market, we should not, as do the official Opposition, consider only local authorities. We must consider the role of health authorities and the private and voluntary sectors. Interestingly, in the Janus-faced way in which the SLD deal with these matters, the hon. Gentleman's remarks seemed to stimulate a lively debate among his right hon. and hon. Friends. The hon. and learned Member for Montgomery appeared unable to agree about the quality of private nursing homes. The crucial factual background that provides the basis for sensible debate was again lacking.

The hon. Member for Truro (Mr. Taylor) would have us believe that private nursing is all doom and gloom. When we took office in 1979, the amount of social security paid to elderly people in private residential nursing homes was £10 million. By one of those massive cuts inflicted on the nation by this Government, we expect the amount paid this year to be £1 billion. That not only shows the Government's contribution to the care of the elderly but raises some difficult questions about the proper gatekeeper role.

The hon. Member for Southport—I could not help feeling that a good speech was trying to get out—raised a matter about which we are all concerned: what we do in the community through integrated care services to prevent elderly people from going into long-term residential care. I do not often meet elderly people whose ambition is to go into long-term residential care; most of them wish to avoid it for as long as possible. It is sad that "it-says-here-BMA rhetoric", lowest-common-denominator politics and inaccurate party charges disfigured what could have been an interesting debate about an issue that will not go away and, sooner or later, will have to be considered in depth.

Mr. Matthew Taylor

The Minister has rather let his bile run away with him. He accused my hon. Friend the Member for Southport (Mr. Fearn) of parroting the views of the British Medical Association. Why has he felt reduced to writing to Conservative Back Benchers, asking them to ask members of the Conservative party throughout the country to write to their local media to parrot his views? Is it acceptable to parrot the views of the Minister, but not those of doctors who care for patients?

Mr. Mellor

I do not think that we should have a one-sided debate and I believe that there will come a time when people think about these matters a little more rationally. The cynical exploitation of patients by the BMA's tendentious leaflet will seem shocking to people other than the Government. Each of us must determine what role we play in these debates. It is sad and regrettable that hon. Gentlemen from the Social and Liberal Democratic party seem to think that their policy on primary health care can be devised for them by the BMA. I would have thought that they would want to stand up for the patients and not just articulate the opinions of doctors.

Mr. Tom Clarke (Monklands, West)

rose—

Mr. Mellor

I shall not give way yet. Many of the doctors' opinions are based not on fact, but on tendentious assertions.

Mr. Clarke

May I gently remind the Minister that this debate is about community care? So that we are not unfair to him at a later stage, I ask him firmly to use this opportunity to give us the Government's views on the Griffiths report.

Mr. Mellor

I will not use this opportunity to give the Government's view on the Griffiths report. If the hon. Gentleman penetrates further into the motion, he will see that it deals with primary care as well as community care. The hon. Member for Southport said specifically that he was now turning to primary care, and I did him the service of turning to primary care a little earlier in my speech than he did in his.

I shall now turn to community care. The Griffiths report raises interesting issues. It raises the issue of how we deliver community care to an increasingly significant number of people requiring it. It requires difficult decisions to be made about the manner in which the provision is delivered, by whom it is delivered and whether distinctions are made between those who provide the services and those who provide the resources, as well as the framework in which the service is resourced and the quality tests that are put in place. To those of us who have to consider such matters seriously for implementation, they are difficult matters. For those outside, it can become merely a party game. Until the Government announce their decision, people ask where the decision is and jibe about why it has not come forward. The moment the decision comes forward, people shout the odds about what a terrible decision it is and ask why such a rushed hotch-potch has been inflicted on the public.

Mr. Maclennan

rose—

Mr. Mellor

I shall give way in a minute. I am giving way too often and I do not want to be long.

We intend to bring forward our response to the Griffiths report as soon as the various Ministers have considered it. The hon. Member for Southport was at least accurate in saying that a committee was considering the response. We want to bring forward our response to the report as soon as our deliberations are complete.

I find it disappointing that the hon. Member for Southport, who was an experienced local councillor, could fall so readily for the idea that everything is suffering some sort of blight while awaiting the Griffiths report. Local authorities do not generally wait for the Government to make the decision. They generally—and rightly—assert that they have the powers to carry on doing the job. As we make clear, there is plenty of scope for the further development of community care. The more some local authorities project good community care, the more they can make us forget some of the glaring examples of the inner-London boroughs, which bring the idea of local authority social service departments into disrepute.

The hon. Member for Southport said that there were no resources. He could not be wider of the mark. Between the financial year 1980–81 and the financial year 1988–89, expenditure on personal social services increased by 25 per cent. in real terms. Local authorities propose to spend £3.3 billion in 1988–89 on personal social services. We hear some feeble excuses for inaction, but £3.3 billion is a formidable sum if properly deployed.

It is interesting that, although the hon. Member for Southport spoke for almost half an hour, there was not a word of commendation for any step in community care taken by councils controlled by the Liberals, SLD or whatever we are meant to call them. That silence speaks volumes for the record of achievement that the voters will have the opportunity to consider. I give way to the hon. and learned Gentleman.

Mr. Alex Carlile

I am grateful to the Minister. Will the hon. and learned Gentleman tell the House what specific criticisms he is implying against Liberal-controlled or Liberal-led councils?

Mr. Mellor

I was simply pointing out that if it was as easy to transform the situation as is suggested—[Interruption.] The hon. and learned Gentleman should not bandy charges around without carefully considering the opening speech. I can respond only to the debate to which I have been invited to reply. I would sooner have replied to a more substantial debate than the one on which we seem to have embarked.

Mr. Maclennan

The Minister is trying to treat the points made by my hon. Friends as peculiar party points, yet in the space of 15 minutes, he has not given us any idea of the Government's policy in this area. If we draw attention to the vacuity of the Government's case after 10 years of office and the formidable criticisms made of it by the doctors, we are not alone. The Minister should, at least in this debate, answer the trenchant criticisms of the Financial Times which, last week, devoted its second leader to drawing attention to the fact that the Government had nothing to say on community care.

Mr. Mellor

I am glad that the hon. Gentleman has recovered his vigour after his difficult period of leadership. I have already made it clear that in relation to community care, which is primarily a local authority responsibility, the increase in resourcing has been formidable. From the centre, a host of initiatives have been taken by the Government to improve quality and training. We have now embarked on a thorough look at the manner in which community care is delivered, which the Griffiths report stimulated and on which the Government will give their opinion in due course. It is a sign of the significance of this issue that the Government are taking time for consideration. The Opposition are trying to have it both ways. They criticise the fact that no decision has been reached, just as they will criticise the decision, whatever it is, when it is reached.

I shall now deal with the area in which we have direct responsibility for primary care through the National Health Service. These have been years of conspicuous achievement, and I gave the hon. Member for Southport the figures. Never has there been greater expansion in primary care than under this Government. Never has more been achieved in broadening the base of the NHS and extending out into a range of necessary preventive services than in the 1980s. That was impossible in the years in which the hon. Member for Caithness and Sutherland (Mr. Maclennan) held ministerial office because of the slashing cuts that were made then in NHS provision, as is well known.

When we look at community care, we see a great increase in services throughout, which has been made possible by the increased economic strength of this country. Expenditure on health services for elderly people rose between 1980 and 1987 by 29 per cent., although the growth in the elderly population over that period was only 6.7 per cent. The number of elderly people treated by district nurses increased by 14 per cent., the number of meals on wheels by 11 per cent., the number of day centre places by 16 per cent. and the number of home helps by 28 per cent. This has been a time of growth. We now need to consider the manner in which those services are delivered, their efficiency and quality. I do not resent listening to the contributions of others on this important topic. We shall be glad if, having got rid of all the necessary party politics, we can settle down to have a debate that assists with the difficult issues of coming to terms with the Griffiths future.

It is clear that those who have been innovative in community care, as have several local authorities, can continue with that. We believe that the future of community care lies with the creation of, in effect, a level playing field which would allow all the various agencies to play their part and which would allow the voluntary and private sectors to play an increasing role.

All those decisions will soon be heard by the House when the Government announce their response to the Griffiths report—

Mr. Thurnham

My hon. and learned Friend has mentioned increased provision in the public sector. Does he agree that one difference between the Conservative and Labour parties is the much greater value that we place on the contribution made by voluntary groups? Is he aware of the excellent work done by the Crossroads care attendance scheme in over 130 areas? Will he provide Crossroads with support in other areas, including Bolton?

Mr. Mellor

What my hon. Friend has said about the voluntary sector is entirely right. As he well knows, we have made considerable use of our ability to grant-aid voluntary organisations, both larger ones with a traditional role such as the Red Cross, and smaller ones, such as Crossroads, that have recently come on the scene. It is clear that we now have a much more comprehensive approach to community care than was possible before. We can look forward to shaping with some confidence the framework within which that can be set in the future.

I trust that the House will have no difficulty in rejecting the motion and I urge it, in due course, to vote for the Government amendment.

8 pm

Mr. Tom Clarke (Monklands, West)

I congratulate the hon. Member for Southport (Mr. Fearn) and his colleagues on choosing the vital subject of community care for this debate. I also congratulate the hon. Gentleman on his comprehensive and informed speech, which clearly was not matched by the Minister's response.

If the Minister's comments are the extent of the Government's thinking on the Griffiths report and on community care, the rumours that we have been hearing about a statement being made fairly soon do not appear to be well based. The Minister gave the impression that he had hardly read the Griffiths report. He certainly gave the impression that he does not understand the immense problems of community care.

When the Minister says that the Opposition criticise the Government for not responding to Griffiths, he is right; and when he says again that we may criticise the Government for their response when it comes, he is right again, because we have that right. What we cannot accept is that the Government will do nothing, if only because Sir Roy Griffiths himself said that to do nothing is simply not an option. Indeed, why should we do nothing?

The Government appear to take the view that when, after his intensive examination of the problems, Sir Roy suggested that there was a lead role for local government, he was inviting the Government to produce their prejudices because they do not accept that local government should have a major role. The Government ignore the problems that have been identified and which invite an immediate response.

We are led to believe that in this area, as in others, we should depend on market forces. Indeed, the Minister used the phrase, "the internal market". However, if market forces had been so productive and so appealing, there would not be 30,000 former psychiatric patients on the streets of New York, which has exactly that system, with all their problems unresolved.

The Minister and some of his hon. Friends who intervened referred to resources. I stress that we are entitled to complain bitterly about the unplanned growth in private residential homes, which has been unrelated to any real assessment. It is not as though we said, as a society, on the basis of consultation, that that was the best thing to do. It is not as though Lady Wagner, whose report has also been ignored, suggested that that was the best thing to do; we have drifted towards it. No responsible Government can invest that amount of resources in private accommodation unchecked—the accommodation is not in any sense adequately inspected—and nobody should pretend that that this is the way towards making a major contribution to community care in the 1980s, and as we approach the 1990s.

Strangely, the Minister devoted most of his speech almost exclusively to the subject of primary care. I say "strangely" because all the evidence suggests that the Government's proposals for the National Health Service in their review will add to the problems rather than taking away from them. I am sorry that the Scottish Office is not represented on the Government Front Bench, but I make the point that our experience of the response of general practitioners to the review is typical of the United Kingdom as a whole. My hon. Friend the Member for Kilmarnock and Loudoun (Mr. McKelvey) is hoping to catch your eye, Madam Deputy Speaker, to raise this point.

Although the Minister was switched from the Foreign and Commonwealth Office to his present role because some people perceived that he had an ability to communicate, he might have to do his job a little better when he has examined a letter that was sent to the Secretary of State for Scotland by the Ayrshire and Arran local medical committee, which states: The general practitioners of Ayrshire and Arran held a meeting last night, Monday 17 April 1989. 115 doctors attended and 115 voted against the new contract which was circulated last week. That letter can hardly be taken as a sign that we should have any confidence in the Government's proposals for the Health Service, especially when we consider their bankrupt approach to community care.

The hon. Member for Southport was generous enough to refer to the Disabled Persons (Services, Consultation and Representation) Act 1986. That Act gained its Royal Assent in July 1986 and has been mentioned in almost all of our debates on this subject. We always plead for its implementation, as do the voluntary and professional bodies that have briefed hon. Members in preparation for the debate. Indeed, they are entitled to do so, because many people recognise that section 7, which, as yet, has not been implemented, contains many of the concepts of Sir Roy Griffiths's approach to the dreadful problem of people being discharged from hospital into community care that does not exist. We want to see the Act implemented.

We find it incredible that the Government's circular, issued in February this year, entitled "Discharge of Patients from Hospital"—the Department of Health has also published a document entitled "Discharge of Patients from Hospital"—states: Social Services Departments will expect Health Authorities to liaise with them about the wide range of duties, including those under … the Disabled Persons (Services, Consultation and Representation) Act 1986, which fall to social services and to follow the arrangements which apply locally for carrying them out. Given that the Government are already advertising that Act, as MENCAP has pointed out, it is not unreasonable that we should ask them to provide the resources to implement it and to produce a plain person's guide for individuals and for organisations such as the Schizophrenia Fellowship which, like the rest of us, wants to see a strategy for hospital discharge and assessment of long-stay patients before they leave hospital and enter the community so that their needs will be met.

I am sure, too, that the Scottish Society for the Mentally Handicapped would urge on the Government the need, in Scotland, for the kind of joint planning arrangements that have existed for many years in England and Wales, and which we persuaded a reluctant Government to include in the National Health Service (Amendment) Act 1986, shortly after the Disabled Persons (Services, Consultation and Representation) Act was passed.

All this represents cost-effectiveness in terms of crisis avoidance. The Minister did not address himself to that, though it is a worry for hundreds of thousands of patients and their families, carers and communities. The revolving door syndrome, to which organisations such as MIND have constantly referred, is, of course, unacceptable. We hear, too, that the Salvation Army estimates that up to three quarters of its hostels' male inmates may be suffering from mental illnesses. We know also that many mentally handicapped and mentally ill persons find themselves in prison simply because the courts have nowhere else to send them.

Last Thursday I raised the question with the Home Secretary, and, in reply, he said that he was consulting the Secretary of State for Health. I had expected, and it would have been reasonable for the hon. Member for Southport to expect, the Government to tell us precisely what they are doing to reduce this scandal. What we are seeing, in the name of so-called community care, is a hospital rundown and a pace of community care provision that simply do not match. Closing hospitals or hospital wards, and throwing people into the community—in many cases, on to the streets—into hostels, and so on, is not community care in any meaningful sense. We know that for every psychiatric nurse working in the community there are about 25 working in hospitals. So there is a curious emphasis on the reverse. There is a need to recognise the problems where they exist within the community, not necessarily within hospitals exclusively.

The Minister failed to mention—although, in fairness, I have to say that the hon. Member for Southport did mention—the very vexed problem of the immense weight upon carers in this community—people who are saving the Treasury millions of pounds every year. In fairness, I must also point out that, curiously, these people are omitted from Sir Roy Griffiths' report. In terms of these problems, we as a House must recognise the tremendous worth of carers in every part of the United Kingdom. In many cases those people are doing a supportive job that ought to be seen as the role of Parliament itself.

My right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley), who would have very much liked to be here for the debate, is very keen that we should urge on the Minister the need for a coherent approach to benefits for disabled people. We are told that the Government are considering these matters, and we are entitled to ask when we can expect a response. Our concern is about poverty, homelessness and neglect. The Spastics Society issued a document—to most hon. Members, I think—in preparation for this debate. It introduced us to very interesting case studies.

A document that is to be published soon refers, for example, to the case of June Morris. I know that we shall never forget that our debates and discussions about these matters are about people, about individuals, about the need for a collective response from society. The document says: June Morris is 34 and has lived in a local authority-owned bungalow for three and a half years, having moved there from her parents' home. She has to wait for a home help to come each week, who stays for an hour. She's waiting to hear whether a laundry service could be made available. Having asked for an emergency phone she's awaiting the outcome. The combination of cerebral palsy and arthritis now warrants the use of a wheelchair. However, the kitchen and bathroom are not suitably adapted. The kitchen was looked at in January and again in August, but still nothing has been done … June doesn't believe community care exists—`There isn't any. It should mean that there is someone to turn to when you need help. I had no social worker for a year.' There is not one hon. Member who could not relate similar cases, similar circumstances, all of them unacceptable in this society.

Of course we want to see more respite care; of course we want to see more assessments; of course we want to see more crisis avoidance in the carers' situation. But we cannot have these things unless there is proper resourcing, as well as proper recognition of services that have to be provided. The Association of Directors of Social Services has complained—rightly, I think—about the problems of training. It has reminded us of the vacancies in social work in London boroughs—15 per cent., with a turnover of 28 per cent. Happily, the situation is improving, but we have to do far more to recognise that these problems exist and to make sure that there is proper provision.

The Government are particularly mean-minded—especially in view of the dreadful problems of child abuse and the information that is now available to us—about the recommendation of the Central Council for Education and Training in Social Work on the need for an extra year's training. I hope that, on reflection, the Government will give serious thought to that recommendation, which, in the meantime, has been set aside.

Consumers ought to have a say in these matters. I believe that, were they to give us their views—for example, on housing investment—they would demonstrate that they consider our present commitment to be inadequate. Indeed, as consumers they would, in many cases, relate homelessness to drug or alcohol abuse or related problems. I believe, too, that they would join the Opposition in regretting bitterly the inadequacy of arranging for older children leaving care to go into the community. The Government's social security changes help these matters not one whit. If the Minister of State speaks for the Government when the Children Bill comes before the House, he will have an opportunity to correct what amounts to a scandal, and I hope that he will take that opportunity.

The community charge—the poll tax—is, of course, a perverse incentive in terms of our objectives. Even if they qualify for a rebate, many people in my constituency have to find £60 to £80 annually out of their very meagre pocket money. I do not regard that as being helpful to our objectives.

I want to ask the Minister to consider the many representations that have been made to the Government about land sales. Is money going back to the mental health services? There is very little evidence that it is. Some of the conditions that have been identified are absolutely unacceptable. The recent health advisory service reports on our psychiatric hospitals refer to gross overcrowding and to dirty, shabby, badly repaired, unsuitable, drab, depressing hospitals smelling of urine. The list continues. In many cases the hospitals are dilapidated, and institutional life means that there is no opportunity for people to live in dignity.

Despite the Minister's somewhat weak defence, the Audit Commission, even prior to Griffiths—and Griffiths accepted its view—described community care as being "in disarray". That is entirely unacceptable, but how could it be otherwise when, we are told, the Department of Health is responsible for promoting care in the community, the Department of the Environment rate-caps local authorities that increase their expenditure on community care, and the Department of Social Security guides people towards a form of semi-institutional care in residential homes and, at the same time, administers the new Social Security Act, which has resulted in substantial loss of benefit for many former patients?

These matters are tremendously important, and there is a growing public awareness of them. The evidence suggests that most community care is provided by a member of a family, a whole family, or close friends. Community care should not be considered a marginal policy to be dismissed as being for a marginal group. It should involve mutuality—the responsibility of people to each other, which creates the fabric of a society of which it is worth being part. Whatever other disagreements we may have with Sir Roy Griffiths—there are many—he was right to say that the status quo is simply not an option.

8.20 pm

Mr. Timothy Raison (Aylesbury)

I agree with the hon. Member for Monklands, West (Mr. Clarke) that this is an important subject. I was glad when, at the end of his speech, he talked about the responsibility of all of us for each other. I did not agree with his remark to the effect that carers were doing Parliament's job. It is a great error to examine such matters in terms of statutory provision. It is Parliament's job to pass statutes. However, the hon. Gentleman redeemed himself in his closing remarks. It is important to remember that the statutory services and voluntary services should never take more than part of the responsibility. The major part must still lie with all of us—ordinary people—to care for our own families, relatives and friends.

The Government's amendment asks hon. Members to express full support for the Government's policy on community care. I have in mind an amendment to the amendment. I will vote for the Government to express full support for their record, which is quite good, as my hon. and learned Friend the Minister demonstrated. I cannot say that I fully support the Government's policy, because I do not know what it is. It is in a state of limbo. The reason for the debate is that hon. Members are anxiously awaiting the Government's policy. It will be even easier to support it when we know what it is.

It is understandable that the Government have had to take some time over the matter. It is obviously complicated. At the same time, we cannot deny or duck the fact that we face serious problems arising from delay. I beg my hon. and learned Friend to end the delay as rapidly as possible. Delay is affecting morale and recruitment.

My county of Buckinghamshire has a good record in the way in which it is trying to tackle community care. It has been keen to progress and it has been doing some good work. I have seen good local authority/county council provision of residential homes of one sort or another for people who come out of long-stay hospitals. A few days ago, I saw an excellent provision which had been set up by the health authority, working in conjunction with the Shaftesbury Society, providing a mixture of residential care and day care for the handicapped. We are doing good things in our county.

However, there is a blockage at present. That has quite a bit to do with difficulties in spending the necessary capital if the crucial transfer of individuals from long-term hospitals to other forms of residential care is effectively to take place. We must have decisions. About 95 people in a hospital for the mentally handicapped in my constituency have been identified as suitable for moving out of the hospital into some other form of care. At the moment, nothing can be done because the resources are not available; they must be unlocked. It was put to me that we need some kind of bridging loan to enable the transfer from the hospital institutional care to the appropriate alternative form of residential care. I hope that the Government will rapidly face that issue.

I am not sure whether we have corrected the anomalies that have existed because of the different sources of funding. I understand why we have had such sources—income support, Health Service funding, and so on. The Government have recently been trying to produce a more rational and coherent pattern, but it is important to make sure that we have a better system for dovetailing different sources of funding. I can only repeat a point which was made earlier: areas such as mine with high housing costs have particular difficulties in the provision of residential care when the scales are set on a national basis.

To be honest, my hon. and learned Friend's speech lacked an assessment of the present situation. We all accept the principle of moving people out of big mental hospitals when appropriate. We know that the Government have been genuinely trying to back that policy. However, we need to know what is happening. How many people have come out of such hospitals? How much additional care is being provided for those who still need residential care? The matter is complicated. We arc not arguing that everbody should go from a hospital into another form of residential care, but some people need to do so. Happily, others can go back to their own homes, and that is the ideal solution. The public are entitled to more information.

It is equally important not to be dogmatic. In its good report, the Audit Commission said that community care is not about imposing a community solution as the only option, in the way that institutional care has been the only option for many people in the past. We still need some long-stay hospital provisions. We certainly need a good deal of residential provision. We also need the truest form of community care—more support for people who are able to live at home. The crucial point—hon. Members have been a little chary of facing up to it —is the problem of where we should allocate responsiblity for seeing that things actually happen. The Government are finding that point difficult to resolve. There are good arguments for the different points of view. Griffiths was justified to refer to a feeling that community care is a poor relation; everybody's distant relative but nobody's baby. The job is to assign the baby.

We must accept that co-operation, good will, and even adequate resources are not enough. They are all necessary, but we must define who is responsible for looking after the people about whom we are talking. Whatever scheme we adopt must bring together or allow to operate effectively the medical, personal and social services side and the cash or social security side. That is a truism. Griffiths was right to state that the crucial need was to pick out one point of reference to make sure that each individual has what he or she needs. That means at the ground floor level—at the level of the community carer, the care manager, or whatever we like to call him or her. That is necessary. There must be a responsible organisation to whom that carer may report and for whom he or she would work.

Griffiths was right to say that local authority personal social services departments are best equipped to do the job. Of course the health aspect is important. Nobody—certainly not Griffiths—says that there is not an important health job. Nobody is saying that the social services can do the whole health job. They cannot. Clearly, GPs and community nurses will still be important in future for discovering needs. Social services departments are best placed to do the all-round job of finding out and then making sure that needs are dealt with by a suitable body.

I should have thought that that is in line with the enabling role which the Government nowadays regard as appropriate to local government. My right hon. Friend the Secretary of State for the Environment wrote a pamphlet about that enabling role. Even if there are doubts about piling more and more on to local authorities, it is appropriate that local government should have a co-ordinating role or the job of allocating accountability.

The Royal College of Nursing has argued that we should have a newly designed service, brought about by merging district health authorities, family practitioner committees and the personal social services, all of which, in the view of the college, should be funded by the health side. That is worth considering. No doubt the Government have done so, but I am a little chary of setting up a big new organisation of that kind.

The same doubt would apply to the proposals put forward by the Association of Directors of Social Services, which wants a national community care development agency. If we want to get on with the job, rather than devising grandiose mechanisms, it would be better to keep the social services departments that are in being. They might need more backing and resources to carry out the role, but I would prefer that instinctively to a new mechanism.

Griffiths also talked about the need for a Minister of State with responsibility for community care. One has to recognise that under our constitution Ministers of State cannot have ultimate responsibility; that has to lie with the Secretary of State. However, there is a great deal to be said for a Minister of State working under the Secretary of State to provide a focus. If I may draw an analogy from my experience, I was Minister for Overseas Development; I was not Minister of Overseas Development. I think that few people recognise the distinction. The Foreign Secretary is by statute Minister of Overseas Development. I was Minister for Overseas Development under him and I had to get on with the job. That parallel is perhaps reasonable, although the ultimate responsibility has to lie with the Secretary of State, who is the crucial person when it comes to the scramble for funds in the public expenditure round.

We have had to wait too long. It is urgent to have a decision. I know that the Government are thinking hard about the matter and I understand their difficulties. Unless there are compelling reasons, Griffiths provides the best formula. I look forward to hearing soon from the Front Bench what the Government propose.

8.31 pm

Mr. William McKelvey (Kilmarnock and Loudoun)

I add my congratulations to the hon. Member for Southport (Mr. Fearn) who has given us the opportunity to debate what many people regard as an important issue. I was disappointed at the lacklustre and somewhat arrogant approach of the Minister.

I support strongly the comments of the right hon. Member for Aylesbury (Mr. Raison). If it were up to me, which of course it is not, he would be moved to the Front Bench and I would dispatch the present incumbent back to the Foreign Office where he was doing an excellent job. His attitude towards the Palestinians was much more understandable and correct.

It is not a mistake that the White Paper, which is euphemistically called "Working for Patients", omits any reference to community care and care for the elderly. That does not mean that the Government are not aware of the inadequacies and the disorganisation of community care. I think that they are fully aware of the position. That is why the then Secretary of State for Health, who is now Secretary of State for Employment, appointed Sir Roy Griffiths to make recommendations on care in the community. Most people would agree that the impetus for the report was not concern for the elderly but, rather, concern about money.

There were serious criticisms of the Government's community care policy by the Audit Commission, which was alarmed that much of the £6 billion spent annually on the mentally handicapped was being wasted and was not being spent properly. Sir Roy Griffiths was not appointed to create a model for adequate community care with no cost spared; indeed, quite the reverse was the case. His remit was To improve the use of funds as a contribution to more effective community care. Hon. Members should note that no further resources were brought into the equation. We should underline that.

The Griffiths report was published in the spring of 1988, yet still there is no response to its recommendations other than the answer that we get on every occasion when we raise the question—that the Government are looking at the matter. We have had nothing apart from vague representations from the Minister that something is likely to happen in the near future. That is all we have been told.

Why have the Government remained silent for so long on a report which was excellently prepared, although there is much in it with which I disagree? The suggestions in the report worry the Government. The right hon. Member for Aylesbury outlined some of them. The hardest nut to crack and the worst thing for the Government to swallow is the suggestion by Sir Roy Griffiths and his team that they should give local authorities a leading role as providers of care, assessors and co-ordinators. The Minister indicated clearly that he has no faith in any local authority carrying out those duties.

There has been reference in the debate to the suggestion in the report for a Minister of State for community care, with appropriate departmental support. That proposal is not popular with the Government. If such a post were established, people who are hungry for the financial aid needed to carry out their programmes would have someone to target for funds, and the Government would be seen as attempting to put all those pleas to one side. It is not surprising that the Government are not enamoured of the report. That is supposition on my part, because to date they have not said whether they are enamoured or otherwise. While they are considering the report, hundreds of thousands of people in a very distressed state, out on the streets and elsewhere, need the care that we want to see established.

I disagree fundamentally with some of the Griffiths recommendations. For instance, young unemployed people should not be press-ganged through the youth training scheme or any other scheme into home-help-type jobs, as suggested by Griffiths, simply as a means of getting community care on the cheap. That is not the way that we should go about it.

Neither do I wish to see a two-tier system for the elderly, with tax incentives to encourage private health care, as suggested in the report. My party and the people whom I represent do not think that residential care should be means-tested. We do not want to return to a system with deserving and non-deserving poor. All the people should he treated equally and their needs should be met. There should be greater choice and greater independence for all who require care in the community. That can happen only if the right amount of cash is injected and if it is directed at the right targets. The aim of moving more care into the community and away from residential institutions is laudable, but only where real support and care are available. An aim set for Sir Roy was to reverse the financial incentives operating in favour of residential care.

Residential care is the biggest growth industry in Ayrshire, where there are nearly 10 times as many homes as there were four years ago. There has been an incredible increase in the number of homes. I have visited many of them, and have talked to the people who manage them. The vast majority are run very well. I have no objections to the way in which they are run. The people who live in them are happy, but many of them would be happier if they had been allowed to remain in their own homes, which they cannot do.

The Government must recognise that there must be proper finance available for looking after elderly relatives at home. The carer's benefit should be paid for looking after that person and should not be included as income when establishing a person's level of income support. After all, when one considers how small that benefit is, when compared with the cost of keeping a person in a residential home, there is no reason why the Government should not make that a benefit which is unrelated to income.

The Griffiths report may not be completely to everyone's liking, but it is important because it provides a basis for developing the policies for care in the community which are long overdue. They should have been in place before we witnessed the large-scale closures of hospitals and large-scale openings of residential and nursing homes. We are trying to close the door after the horse has bolted.

I urge the Government to make their responses to the Griffiths report known as quickly as possible, or at least to initiate a whole day's debate on community care for the elderly, the mentally handicapped and all those whom we genuinely wish to assist. I shall cite one case that will clarify my misgivings about the Government's intentions for community care and, for instance, the community care grant.

Yesterday it was reported that more than 40 per cent. of the money made available for community care grants in the Scottish districts is being returned because the money has not been taken up. That is not because people are not trying to get the money, but because the guidelines are so tightly defined—there is no discretion at local level—and the money has not been properly used.

My hon. Friend the Member for Dundee, East (Mr. McAllion), raised with the Minister the case of his constituent who was in a mental hospital for 10 years and was being released into the community. The district council gave the woman a house and an application was made for a community grant of £500 to assist. She was refused that grant because her income was 4p over income support due to her invalidity benefit. That woman really could have benefited from being allowed to live in the community and having a proper start in a new life. However, because of the barriers presented by that extra 4p, she was refused a grant. She may end up back in hospital because she will be unable to cope. There should not be such a rigid attitude towards people who are trying desperately to come back into the community. We should not have such tight legislation which stops a person taking his or her rightful place in the community and being given back much of the dignity that he or she has lost.

8.42 pm

Mrs. Gillian Shephard (Norfolk, South-West)

I am pleased to contribute to the debate. While the NHS review and the new GPs' contract may have been the focus of much professional attention during the last couple of months, a more consistent interest has been expressed over a number of years about the current and future structure of care in the community.

That interest is entirely predictable, given, first, the demographic changes at each end of the spectrum, which eventually will mean that there are fewer people to look after more people; secondly, rising public expectation; and, thirdly, changing family patterns, with implications for carers and the public services. I mean by that the breakdown of marriages. While it might be fairly expected by many that they would look after one mother-in-law, looking after two or three, if they enter into a second or third marriage, might be stretching it a bit. That is a flippant way of saying that obvious lines of responsibility within changing family patterns may be weakened. I believe that we must consider that.

We must also accept that there is a growing involvement of the private and voluntary sector. It has already been said that expenditure in the private and voluntary sector is now approaching £1 billion, which is a considerable sum. It was most unfortunate that the Opposition made a quite unwarranted slur on the motives of people who run the private and residential homes, which I believe will not go unnoticed by them.

The Audit Commission argued that community care is about changing the balance of services and finding the most suitable placement for people from a wide variety of options. It is not about imposing a community solution as the only option in the way that institutional care has been the only option for many people in the past. It is important to stress that definition of community care, which makes it an option within a spectrum. While Governments may always have regarded it as such, until the last two or three years it has been regarded in health and social services circles as a policy leading inexorably away from institutional care of any kind.

Clearly, community care should provide a range of care services through which people may move, both in and out, and including as one of its parts in-patient care, whether short-term, respite or crisis care.

As services are at present organised, community care requires very close and effective co-operation between a number of agencies—health authorities, local authorities, housing agencies, social services, social security, the voluntary and private sectors and, of course, relatives and carers. To quote the Audit Commission again, it must cover prevention, treatment, rehabilitation, health maintenance and social supportive networks. The necessary co-operation between a range of agencies with different power bases, and such a complex range of care to provide, sets a task whose complexity is awesome, although, of course, many achieve it. Indeed, if Governments had set about making community care provision as difficult, as time-wasting, as bureaucratic and as committee-bound as they could, they could hardly have done worse than the present system against which providers have to battle. Especially with reference to joint financing, I was most interested to note the simple pride with which the right hon. Member for Plymouth, Devonport (Dr. Owen) announced yesterday that he had devised the system.

Within that complicated structure, the Government's achievements have been good. For example, the need for mentally handicapped children to live in long-stay hospitals has been virtually eliminated. The adult hospital resident population of mentally handicapped people has been reduced by more than one third. It is difficult to assess the Government's record by public spending measures, precisely because the responsibility for funding is spread between a number of agencies. However, I believe that we can all accept the evidence of the National Audit Office, which found a significant increase in spending on the elderly, the mentally ill and the mentally handicapped between 1977 and 1985. None of us should forget that the debate is taking place within the context of a record spending on the National Health Service of £26 billion and a social services budget of £3.3 billion. We are not talking about a service which is being starved of funds.

Since 1979, much more money has been put into joint finance. That has increased by about 60 per cent. and, more significantly, its take-up has increased from 52 per cent. to nearly 99 per cent. That has been encouraged by interesting new conditions, such as the dowry system, which unblocked Health Service funds for use in the community by the simple expedient of transferring the funds with the patient into the community.

There are some excellent examples of good and innovative work, which demonstrate that quite highly dependent people can be cared for in the community. That is the message emerging from 28 pilot schemes set up by the Department of Health and Social Security in 1983, which were funded by an additional joint funding budget. I mention in particular the Kent community care scheme for frail elderly people, which links devolved budgetary management with the design of individual care packages. In my county, which is Conservative-controlled, we have excellent schemes. For instance, the Lawns in Great Yarmouth, which was formerly a residential home for the elderly run by social services, now provides an interesting, acceptable and popular range of care and help for elderly people. In the Norwich health district we have community care groups with proper appraisal, and West Norfolk and Wisbech health authorities have well-developed day care and drop-in centres linked to private residential care.

The picture of the last 10 years of community care under the Government shows steady progress, although it has been a little unevenly distributed. We have seen increased spending and some solid evaluation of what does and does not work. That is important. The Government face a daunting task in framing their response to Griffiths. Whatever structure is devised, the problems that I have mentioned will remain. There is the complexity of the mechanisms which involve many agencies and at least three Departments of State. There has been steadily increasing expenditure on the private and residential sectors, mainly for the elderly, which many of us welcome, and in which standards of care are monitored, thanks to the statutory agencies. However, it must be accepted that criteria for admission, and therefore for financial support, are not monitored. This is becoming a bottomless purse.

The Government also need to consider a number of models for the provision of community care. Some hon. Members have mentioned the local authority model. There are elements that can be commended to Ministers in the response to Griffiths by the Association of Directors of Social Services. The response mentions a mixed economy for care and service provision, a good national framework for regulation of monitoring, which everybody welcomes, and strengthened local accountability by care managers.

There is also the health authority model, in which existing community health services might be grouped together and subsume local authority services that are being nationally funded. There is the possible client group model, where we might transfer responsibility for the mentally handicapped to social services and responsibility for the mentally ill and some elderly people to the health authorities. Then, of course, there is the model of an entirely new agency which might plan and buy in care from local authorities, health authorities, voluntary organisations and the private sector.

In preparing their response to Griffiths the Government will want to consider the not inconsiderable amount of change planned for the National Health Service, especially in primary care. It might be difficult at present to give the National Health Service something else to worry about, although many of the worries expressed in yesterday's debate are entirely unfounded. I do not wish to see any more delay in the Government's response to the Griffiths report because some planning decisions are being held up pending that response. Given the complexity of the task and its importance to patients, which can only increase, I hope that the Government will take the time that they need to produce the right and most effective response, because I suspect that the ramifications will be with us long after the White Paper has been absorbed into professional practice.

8.52 pm

Mr. Alex Carlile (Montgomery)

I propose to speak about general practitioner services, but before I turn to the merits of the case I should like to speak about the way in which the Minister of State, Department of Health approached the question of how general practitioner services should be run in future. I think he knows that I have a considerable regard for his political and forensic and especially his legislative abilities. However, in his approach to general practitioners he has given the impression of coating himself with testy arrogance as a biscuit with bitter chocolate. That has caused great offence, not only to general practitioners but also to members of the public interested in the National Health Service.

It seems that the Minister is not too keen on listening to reasonable argument in the debate, but I know that he is always prepared to listen to opera. I shall draw a brief operatic analogy. General practitioners look upon the Government's blandishments in relation to general medical services rather like Bluebeard's bride at the entrance to his castle. I do not allege that the Minister is Bluebeard——that is his right hon. and learned Friend the Secretary of State. The Minister is merely the doorkeeper. General practitioners believe—in my view, rightly—that every time they, like Bluebead's bride, pick up one of the gilded offerings inside the castle, they find beneath it the curse that the Government are bringing upon the National Health Service.

I remember the bad old days of general practice. I am the son of a general practitioner who practised in an industrial Lancashire town. He is retired now and is a very old gentleman, but he had experience in private medicine, albeit not in this country, experience in hospitals and many years' experience in general practice. At one time he, like many other GPs, was single-handedly stemming the tide rather like King Canute. All over the town where we lived one could see queues of sometimes 30 or 40 patients outside each poorly maintained surgery, especially on Monday mornings. My father was a single-handed practitioner and on his half day off we had to escape from the house in which he had his surgery. He had to arrange that half day with another doctor, and if we stayed at home he would have no rest. As a result of the pressure he faced, I was sent by him to a good school with a foundation that provided for the sons of dead general practitioners to be educated for nothing. Many people were educated by way of the medical foundation in Epsom college.

In the mid-1960s and early 1970s, times changed, very much for the better. Nowadays, in most if not all parts of this country, we have group practices with much better facilities and offering a good service to patients. That happened in my father's practice. Those group practices are also able to contribute to the community. For example, the Department of Social Security depends upon general practitioners for its medical boards. How many GPs will still be able to do that work after they are compelled to work 20 hours a week in their surgeries?

Since childhood, and especially since I became a Member of the House, I have had an opportunity to observe a rather different sort of general practice, the rural medical practice. In preparing the new GP contract and in planning whatever strategy they have for general medical services in England and Wales—interestingly, there is a difference in Scotland—the Government have chosen to ignore almost completely the special needs of rural areas and rural medical practice.

Rural practices in my constituency, in other parts of rural Wales and probably elsewhere in the United Kingdom are, on the whole, well organised and provide a high standard of service. If a patient has an accident in my constituency the chances are that he is 30 miles from the nearest major casualty hospital. He goes either to his GP or to one of the little local hospitals where the GP carries out the casualty work and performs small operations and stitches up people. If he lives in a rural area such as mine, the chances are that he will be able to go to a branch surgery not in a far distant town but in a nearby village. The chances are that when he telephones the doctor's surgery and asks for an appointment and outlines any difficulties in getting to the surgery the doctor, assessing the needs of the patient, will take the entirely reasonable decision that the patient should not come to the surgery but that the doctor should visit the patient.

That is the special nature of rural medical services as they have developed and, on the whole, they are good, very good. I pay tribute where it is due to the Government for allowing those services to develop in a way that is beneficial to the community. But I ask the Minister why the Government have now decided to pull the rug from under good rural practitioner services. I shall refer to some specific matters which are evidence that the Government want to do just that.

As a direct result of the changes proposed to the GP contract, there is absolutely no doubt that doctors will be unable to visit their patients as often as they have in the past. A very good general practitioner whom I know well told me recently—and this was confirmed by other doctors at the meeting—that sometimes in a morning he can visit only three or four patients because of the distances involved. My recollection of my childhood in a busy town is that my father used sometimes to visit six or seven patients in one street. It is quite different in rural areas. If rural doctors are forced to spend 20 hours in their surgeries, they will spend some of that time twiddling their thumbs, looking for something to do, when they could be out visiting their patients. That cannot be in the public interest.

What is more, our community hospitals in places such as Welshpool, Llanidloes, Machynlleth and Newtown depend upon the GPs not sitting in their surgeries but going to the hospital to carry out the hospital services. This they will be unable to do if they are forced to sit in their surgeries for as long as 20 hours a week.

The Government have set targets for vaccination and cervical smear rates. In order even to maintain their income—the doctors in Montgomeryshire are not suggesting that their incomes are too low and should be substantially increased—doctors are to meet certain targets if the new contract comes into being. But these targets are wholly unrealistic in rural areas. The 90 per cent. vaccination target is impossible to achieve. Whooping cough vaccination, included as it is in the compulsory criteria for payments, will set ethical dilemmas which will affect all doctors, for not all are as convinced as perhaps the Minister is about the value of that vaccination.

One of my local practices campaigned especially hard on the need for cervical smears by writing and speaking to patients when they come into the surgery; but it still fell short of the target of 80 per cent. which the Government seek to set for cervical smears. Because it is unrealistic to try to reach those targets in rural areas, some doctors will decide that the targets will never be achieved, that as a result they will not be paid for the work they do and that they may just as well withdraw the service and leave it to somebody else to provide cervical cytology. That cannot be in the interests of women in rural areas.

I urge the Minister, who I know is listening to these points, to consider them seriously, for they are all real problems put to me by real doctors.

Another problem relates to minor surgical operations. In Scotland the principle has been recognised that in rural areas, provided the doctor does five procedures in a month, he will be paid for those procedures. But under the contract which is sought to be imposed in England and Wales, on rural as well as on urban doctors—and it is only the rural doctors who can do large-ish numbers pro rata of surgical procedures—they are told that they will be paid for minor surgical procedures only if they do five in a session.

I can tell the Minister what will happen. A patient will go to see Dr. Jones. Dr. Jones will explain that he would like to do his surgical procedure but will be paid for it only if he does five in a session. He tells the patient that he will collect five and then the patient can come back and have his surgical procedure carried out. So Mr. Evans visiting Dr. Jones may have to wait a month before his surgical procedure is done.

What happens now is that Mr. Evans, a patient who may live 15 miles from his doctor's surgery, will go to the surgery and will have the minor procedure done on a one-off basis by appointment. That is serving the consumer. That is fulfilling the aspiration that the Government rightly have for the medical profession.

Mr. Richard Livsey (Brecon and Radnor)

The 20-hour rule for GPs will prevent doctors in rural practice from carrying out the procedures that my hon. and learned Friend the Member for Montgomery (Mr. Carlile) has mentioned. This will restrict their opportunity to carry out minor surgical procedures. I am sure that my hon. and learned Friend will agree.

Mr Carlile

Yes, I agree with that. It reinforces the point that I was making.

I wrote to the Secretary of State in detail on 30 March setting out my misgivings about the GP contract for rural services, and I await his reply to those specific questions with great interest. I will mention two now. The Government's proposals mean that there will be far fewer part-time general practitioners. This is very much against the interests of women, in particular, for there are many women doctors who are perforce rather than by choice part-time practitioners. Some live in my constituency. The payment arrangements—effectively, the removal of the basic practice allowance—mean that practices will be disinclined to employ women part-timers in the future. As it is, it is very difficult in some areas for women to find a woman practitioner to go to—and many wish to, for very good reasons.

I ask the Minister to consider this and to try to ensure that the part-timer, particularly the woman doctor, providing excellent service can continue working in general practice.

The last point I wish to draw to the Minister's attention is that of reimbursement to GPs for ancillary staff and for premises. One of the great developments that I saw as I grew up in a doctor's household was the improved ancillary facilities provided by successive Governments and the chance given by those Governments to doctors to have better surgeries. It happened in our family practice and in many others that I know well. This sort of provision gave a great impetus to good-quality general practitioner services.

The new arrangements suggest, however, that those reimbursements to GPs for ancillary staff and for rents are liable to be cost-limited and reduced. As a result, general practitioners will seriously reconsider any increase in their staff numbers. Some of my local GPs now employ practice nurses who can provide in some cases a rather more intimate service in minor matters than can the busy GP in his surgery. Practice nurses are a very important part of medical practice in rural areas. But doctors will have to reconsider employing them.

In addition, I am aware of at least one £500,000 surgery rebuilding scheme—not in my constituency but in that of my hon. Friend the Member for Brecon and Radnor (Mr. Livsey)—that the practice is now considering abandoning as it cannot rely on the reimbursement initially promised to service its great undertaking. The practice consists of doctors who are, in mid-Wales terms, in a medium-sized town. If they do not develop their new medical centre, because of changes in the contract and in the arrangements for payment for GPs, it could be another 20 years before the town's services are improved. That would be a matter for regret.

I ask the Minister, therefore, to go back to his Department and have another look at rural GP services. In particular, we should bear in mind the fact that there is no logical case for saying there should be one thing for rural services in Scotland and something quite different for Wales and rural England. As the proposed contract stands, those rural services will suffer and, I am afraid, it will be the Minister and his right hon. Friend the Secretary of State who will be blamed.

9.9 pm

Sir Geoffrey Pattie (Chertsey and Walton)

There was discussion earlier in the debate about the Griffiths report, about which I shall make some brief remarks. Sir Roy Griffiths, as the Prime Minister's health care adviser, has impeccable credentials. The problem has been that he has not come up with a convenient set of recommendations. It appears that the Government have taken longer to prepare their response than the Committee took to prepare the report in the first place.

Chapter 7 of the Griffiths report, paragraph 5, states: There is a need for central government to make an early clear statement of the objectives and values underlining its community care policies, clarifying its view of the role of the public sector. The delay in responding to the report is profoundly unsatisfactory.

We could ask, "Does a delay matter?" It would not matter if there were no problem. We might then ask, "Is there a problem?" Everyone is agreed that certain aspects of the community care policy command widespread support, particularly the concept that health care can best be provided within the community—especially if that means that we can get away from the use of large mental hospitals which, all too often, are a legacy of the last century. It has always been recognised that a problem would arise if a mismatch occurred between the closure of mental hospitals and failure to provide adequate care for patients in the community. Unless community care is adequately in place before patients leave mental hospitals, adequate bridging finance must be made available. My right hon. Friend the Member for Aylesbury (Mr. Raison), who made an excellent and cogent speech, used the term "bridging finance", which is the key to the current problem.

It is obvious from the evidence before our eyes that such a mismatch has occurred. Many people have been decanted out of mental hospitals and are now part of the so-called cardboard cities, which are an affront to any society that claims to be civilised. Market research on this need not he involved. Within a few hundred yards' walking distance—never mind driving distance—of the Palace of Westminster, one is likely to encounter such people. I am not suggesting that all those one encounters on these walks are former mental patients, but it is estimated that half of them are.

Some people like the life on the road; others have run away from home to try to find fame and fortune. However, if the usual estimate of 8,000 or 9,000 are sleeping rough in London tonight, about half that figure will be former mental patients. Therefore, a large number of people are clearly incapable of sustaining themselves in society without adequate support.

It is clear that voluntary groups are incapable of filling the gap. They carry out admirable work but cannot be expected to shoulder the entire load. Obviously, the Minister will hardly reveal the Government's response to the Griffiths report today, but it would be nice if he gave some sign of when that might come—other than the usual "soon"—or "in the spring". Sir Roy Griffiths reported on 12 February 1988, which was a long time ago. It would be constructive, and certainly helpful to me, if the Minister were prepared to recognise that the problem exists, and that people are living in such conditions, who are on the streets due to the inadequacy of the present system.

I imagine that, privately, the Minister must be unhappy about this aspect of what is otherwise an impressive health care system. Many of my hon. Friends have made reference in the debate to the large sums of extra money and additional facilities that have been provided. That is satisfactory and I support it. However, in this one matter, the evidence is there to be seen by all of us who are prepared, as it were, not to drive past on the other side. It shows that many of our fellow citizens face extreme difficulties tonight because the present policy is not working. What will the Government do about that?

9.17 pm

Mr. David Hinchliffe (Wakefield)

I hold no particular brief for the hon. Member for Stockport (Mr. Fearn) but, having listened to his opening speech, I feel that he deserved a more comprehensive response than he received from the Minister. Frankly, the Minister's response consisted of a series of insults and cheap jibes. Several Conservative Members have made serious points in the debate. I am sorry to have to make these remarks when the Minister has left the Chamber, but I was disappointed that he was not prepared to address the issues which have been raised by hon. Members from both sides of the Chamber.

The Minister's response to the opening speech made it clear that the Government do not have a policy on community care. In the brief time that I have tonight, I shall address myself to some of the implications of the Government's non-policy on this serious and worrying subject. If anyone needs convincing of the fact that the Government's ideological blinkers have so often overridden any element of human concern, they need only look at community care. By allowing the policy on community care to be determined by the free movement of market forces, they have set back proper community care by decades.

It is important to consider in detail the consequences of a market-based policy of community care, because, if the Government have a community care policy, it is based on the movement of market forces. I shall pinpoint one or two matters relating to the private sector care of the elderly which worry my constituents, many hon. Members and me.

I listened to the observations of Conservative Members talking about the amount of money which has been put into community care by the Government. Huge amounts of public money are being mis-spent in the name of community care. There are people in institutions on income support who do not need to be there and would be far better cared for outside them, in their own communities, with proper community care.

The Minister mentioned the figure of £1 billion being spent on income support in the current financial year. That is the figure that was given by the Association of Directors of Social Services for the previous financial year. I suspect that it is a conservative estimate and that, if one attempted to find out what the figures were at local level, one would find that the DSS does not keep records of the amount of money paid in income support to private residential care. Therefore, we are talking about a guesstimate.

A year ago the Public Accounts Committee said that up to a quarter of income support claimants in residential care could have remained in their own homes if they had the proper community services and support. At least £250 million per annum is being spent on residential, institutional care for people who do not need it. That is the result of a free market policy in community care.

There is also a huge hidden cost to the public purse at local authority level. Problems arise time and again in local authorities' policing of private residential homes. The hidden cost is in the homes that have to be closed and the court cases which, according to the social work press, are happening virtually every week. There are disputes over deregistration and qualifications and conditions on registration. All that is costing public money.

In allowing such a free market policy to rule community care, the Government have developed enormous regional differences in the investment of public money. David Lane, the director of social services in my local authority, Wakefield, compared the amounts paid out in the south coast belt—Devon, Dorset, Hampshire and east and west Sussex—where the population is around 4.5 million and there are 26,000 beds in the private sector, with west and south Yorkshire, where the population is 3.25 million and there are fewer than 4,000 beds. Assuming that 50 per cent. of private beds are paid for through income support—a reasonable assumption—at an average cost of about £8,000 per annum, he calculated that the average authority in the south coast belt would have an annual income of £11.5 million per annum, while in west and south Yorkshire the amount would be £2.2 million. That is an enormous redistribution of public funding from the poorer areas to those with substantial resources.

We have also seen a huge distortion in the type of support services available to the elderly. It saddens me to say this. I entered social work, working with the elderly, back in 1968, at a time when we were proud to boast that we were reducing institutional care and building small homes rather than huge, isolated institutions. Now we see the resurrection of care in such large institutions as society's central response to the needs of the dependent elderly.

I disagree profoundly with that policy. It is not in the interests of elderly people. The only people to gain from it have been the estate agents. It has given new life to rundown Victorian mansions, dilapidated country houses and struggling seaside bed-and-breakfast boarding houses and hotels, which are being used to care for people who, in many cases, have been shunted miles away from where they come from.

The larger the institution, moreover, the bigger the profits. I have asked parliamentary questions about the numbers of beds in such institutions, but I have not received answers because the figures are not kept. I can see with my own eyes, however, that large institutions are being used increasingly for the care of the elderly. They are once more being used as they were in the 1940s and 1950s and at the time of the Poor Laws.

Care Weekly, a social work journal which I read every week, reported on 7 April that Lodge Care plc, one of the increasing number of private companies involved in residential care, was selling off 12 of its 25 homes. The managing director, Graham Elliott, said that it was the smaller homes which were least profitable and had to be disposed of". I concede that there are some good, small private homes offering homely care: I have visited them. But those are the homes that are being disposed of, on the basis that they are the least profitable.

There is, as yet, no profit to be made from preventive services. The profit-making sector—the market—has therefore moved into institutional care rather than preventing people from entering institutions. Strategies for care, having been left to the market by the Government, are now being determined by large business interests rather than by the needs of the elderly. Ladbrokes, for example, now owns about 1,000 residential and nursing care beds. Boddingtons brewery and the Vaux brewery group are also involved.

Does anyone honestly believe that those organisations are motivated by concern for what is in the best interests of dependent elderly people? Are they involved merely in acts of charity? Of course they are not. We all know that their involvement is based on hard-headed business decisions and profit motivation. They are diversifying into areas where they know that a quick killing can be made. Dependent elderly residents who have no one to stand up and vouch for them are the pawns in this increasingly big-business game.

The Government know that their community care policies are a shambles. That is why the Minister made no defence of them in response to the hon. Member for Southport. He did not even refer to issues raised by hon. Members on both sides of the House. My hon. Friend the Member for Monklands, West (Mr. Clarke) mentioned that the Audit Commission had said that community care was in disarray and that the Government were getting poor value for money, which I think is an understatement. The Government have been sitting on the Griffiths report for over a year. The report, in my view, is full of holes: its vision of community care is very narrow, as my hon. Friend has made clear in a document produced by the Labour party. There have been many criticisms of it, but the important point is that it provides a basis for thought and debate on a matter that desperately needs both.

Urgent action is needed, rather than the complacency demonstrated by the Minister tonight. If I had more time, as I hope that I shall when we debate the Griffiths report, I should spell out what I think should be done. For the moment, however, let me make three brief points.

First, we need to reverse the present trend back to care in isolated institutions. Choice of care is a myth and a nonsense: the Minister conceded that. Of all the elderly people whom I have admitted to residential care in my time in social work, I cannot think of one who wanted to go into an institution. Sadly, however, the way in which the Government have allowed their policies to develop has resulted in that often being the only option. They have shunted investment into institutional care rather than into preventive community care.

In our debate before Christmas, the Minister virtually conceded his concern about the fact that any woman over 60 or man over 65 could obtain income support, fit as a fiddle, and then go into residential care. The system is nonsense. We must stop this open-ended income support for private care, and redirect public funding towards preventing institutionalisation rather than actively encouraging it.

What could have been achieved in funding proper community care if the Government were not ideologically committed to the role of the free market? What could have been achieved with the amount of money that has been thrown into the explosion of private residential care? What could have been done with all that wasted money? The Public Accounts Committee suggests that £250 million is the sum spent on sending people to institutions who do not need to be there.

What could have been done every year with that kind of money in providing proper community care, home helps, meals on wheels, support units, befriending services, day care, social clubs, community nursing, social support, sheltered housing, and numerous other elements of community care—all of which avoid the need for people to enter institutions and allow them to remain living in dignity in their own communities, surrounded by the people with whom they have lived all their lives?

Imagine what could have been done with that amount of money, had the Government not been tied to the vision of the free market and to the blind dogma that they apply to every area of their policy. To leave the care of vast numbers of the most vulnerable people in our society to the whims of the market, as the Government have done, is scandalous.

9.29 pm

Mr. Michael Jack (Fylde)

I enjoyed the speech of the hon. Member for Wakefield (Mr. Hinchliffe) because it reminded me that we have something in common—we were both brought up in Yorkshire.

The hon. Gentleman referred to the fact that there is a predisposition for elderly people to move to the south coast or to my own constituency of Fylde on the west coast of England. When I was selected to contest a seat in Lancashire, I apologised for the fact that I came from over the Pennines. However, one day I was told by one of my supporters, "Don't worry that you come from Yorkshire. Half of Yorkshire is here already." Many people move to different parts of the country because that is where they want to retire and where they wish to be cared for.

The hon. Gentleman's narrow view of the source of care in the community must be criticised, because many of the people who have moved to the west coast of England are impressed by the diversity of care in the community, in both the public and the private sector, that is found there. The hon. Gentleman does not realise that a vast spectrum of resources is available to individuals. It ranges from income support, which the hon. Gentleman also criticised, to the provision of services to people who have adequate assets of their own—perhaps from the sale of their houses—and who currently benefit from the development of sheltered accommodation by the private sector and from the growing development of continuing care that is also to be found in the private sector. However, even those people, as they grow older, may require more institutionalised forms of community care.

The hon. Member for Wakefield criticised the Government's response to the Griffiths report. We would all like to see an early response, but it was not the act of a reluctant Government to ask Sir Roy Griffiths to concern himself with community care. His report opens with the statement: Mr. Norman Fowler asked me to take an overview of community care policy. The Government asked for that to be done and, in the nicest sense, they knew what they were letting themselves in for—a report from somebody who would seek an answer, and an answer of accountability. The Government were aware of the contribution that Sir Roy had made to earlier reforms of the Health Service when they sought the application of his intellect to the problem of community care and his ideas.

Sir Roy produced a brief but enormously thought-provoking response that sought to answer the questions, as my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) pointed out, of bringing together the enormous diversity of community care. I suggest that rather than calling it community care, we should talk about the development of a community of carers. By that I mean the bringing together of all agencies—private and public, voluntary and individual—that make up the concept of community care.

Our country's capacity to care is enormous, and the good will felt towards the elderly is considerable. However, some education remains to be provided in terms of attitudes towards those who are mentally ill, mentally handicapped, or both. If they are to be properly received in their communities as they arrive there from long-stay institutions, we must educate ourselves on the need to receive them positively into our number and to provide them with the necessary care.

When considering recommendations such as those in the Griffiths report, we must decide whether we are looking for a top-down solution or a bottom-up solution. A top-down solution involves the kind of national institution that we would perhaps want to monitor. My hon. Friend the Member for Norfolk, South-West spoke in great detail about the various models that could be used. I am interested in a solution that grows from within the community. My hon. Friend identified the multiplicity of sources of community care. The essence of community care is the flexible response to the needs of the community.

In my constituency there is one of the finest community hospitals. It is so good that I was recently asked, "Mr. Jack, why is this new hospital opening in your constituency? Is it not a private hospital?" I had to say that it was not. It is a new community hospital opened under the auspices of the National Heath Service. It provides day care facilities, and a broad range of other services for the elderly, including physiotherapy and special wards dedicated to the rehabilitation and training of elderly people to help them re-enter the community.

I visit that hospital regularly for personal reasons, as my mother is there, recovering, we hope, from a stroke. I look around the hospital and I see the quality of the care that is available. It occurred to me that it is an ideal centre to base community care and to set up a buying and enabling agency to cater for the needs of the community as identified by the social services, general practioners and the private sector in rest homes or nursing homes. A buying or enabling agency centred in that hospital could draw resources from the community to provide care for elderly people. It could be broadened to serve the interests of mentally ill and physically handicapped people to provide a broadly based community service.

How do we adapt that on a national level? I am attracted by the suggestion in the White Paper for hospital trusts. By definition, trusts seem to encompass all those who care about a particular matter. We have identified a broad range of sources for community care, so let us imagine a national care trust in which the interests of the Government, the social services and the private sector could be represented and where funds for the various budget heads catering for the needs of the community and the care of the elderly and the mentally ill could be accumulated and redistributed according to need to different parts of the United Kingdom. It is for the communities to ascertain their present needs and try to identify their resource needs to continue and develop existing services.

Community care has been prevented from working, in the way referred to by all hon. Members who have spoken, by the friction between health authority services and the social services. There have been differences of opinion. I used to hear them when I sat on the Mersey regional health authority, where we found it difficult to overcome the frustration at the lack of progress towards the right provision.

The Griffiths report give us the opportunity to seek a solution in which the wheels of the relationship between the different agencies can mesh and run more smoothly. The smoothness with which care in the community can be delivered will mean a great deal. I applaud the comments made abut the need to allow elderly people to stay in their own homes. I pay tribute to my constituent, Mr. Stephen Hay, who runs a private rest home and has developed a private care in the community programme. His wife, who is a trained SRN makes domiciliary visits and supplies a broad range of services to elderly people in their own homes. His service is already over-subscribed, but how much better and how much more caring a service could be supplied if my hon. and learned Friend the Minister of State would appeal to his ministerial colleagues in the Department of Social Security to free the shackles on income support and use that money more creatively. Such creativity would allow communities to respond to the many and diverse needs of the elderly and mentally ill patients.

There is much work to be done, but we have sufficient resources. My hon. and learned Friend referred to the money available through income support. Perhaps he did not have time to mention the £1 billion in attendance allowance. Such expenditure is not a sign that the Government do not care or are being mean with resources. It is a sign that the Government recognise the demographic issues and are trying to respond to them while creating a flexible response that will bring together the best of the private sector and the best of the public sector to provide care in the community.

Sad to say, the problems of the mentally ill have not been referred to in the debate. I say sincerely to my hon. and learned Friend the Minister that the most difficult case with which I have had to deal since coming to the House involved the mother of a schizophrenic boy. She writes to me asking who will look after him when she dies. I have been to the district health authority, the regional health authority and even to my hon. and learned Friend's Department but all they say is, "tomorrow". That lady's tomorrow may come but she looks to me to provide an answer within the community for the problems of her son, Dennis. That is the challenge of mental illness and I feel certain that my hon. and learned Friend will respond to it.

9.40 pm

Mr. Archy Kirkwood (Roxburgh and Berwickshire)

I have listened with interest to the discussion and I commend my hon. Friend the Member for Southport (Mr. Fearn) on the way in which he opened the debate. It is an important subject and that has been reflected in the speeches.

I listened with particular interest, as I always do, to the speech of the hon. Member for Monklands, West (Mr. Clarke). Interesting contributions were made by the right hon. Members for Aylesbury (Mr. Raison) and for Chertsey and Walton (Sir. G. Pattie). I should like to draw a line under the ministerial intervention in reply to my hon. Friend's opening speech by saying that we should leave past records behind us in the time remaining in the debate and look to the future. I recognise that a subject such as the provision of community care is difficult for the Government because it cuts across Government Departments. Also, I am not daft and I recognise that there are substantial funding implications if we are to get right the future provision of community care.

Having said that, and falling over backwards to be as amenable to the Government as I can, I must say that there is a blockage in the system. It is not right for the Minister to say that it does not matter if time passes while we get the provision right. It is wrong that two and a half years have passed since Sir Roy Griffiths was given his commission. It is a year since he produced his report, and people are suffering as a result of the delay. The lack of planning and the hiatus that has been created by the Government's unconscionable delay is not good enough. It is an indictment, and the speeches made by hon. Members, including Conservative Members, have shown that it is unacceptable.

The difficulties were well rehearsed two or three years ago, before Sir Roy Griffiths was given his commission, by the Select Committee on Social Services and by the Audit Commission. Hon. Members have referred to the points made by those two bodies. I shall point out one or two of the important points that remain with us. The problem confronting the House is that community care is delivered by a vast array of organisations with different structures and different funding mechanisms. No one has overall responsibility for co-ordination. I had hoped that the debate would produce an indication of how the Government will resolve that confusion or, indeed, whether they intend to do so. That is the key question which has suffused all the arguments that have been deployed.

The funding mechanisms that the Government have been using—as I have said, there is a difficulty with different Departments being involved—have sent conflicting signals to the people responsible for the discharge and provision of the services. Health authorities have been cash limited, local authorities have been rate-capped and the DSS, particularly in relation to residential and nursing home provision, was demand-led and the provisions have been produced on a demand-led basis. The Minister is beating his chest and saying that the Government have increased expenditure from £10 million to £1 billion in that sector, but that was not planned. The Minister is making a virtue of something that took him and the Department by surprise. The Government must resolve the different funding mechanisms. That may be difficult, but they must grasp the nettle.

Sir Roy Griffiths was asked to consider the geographical discrepancies between local authority and health board areas. It is extremely difficult to achieve coherent delivery of community care. The two-and-a-half-year delay has been quite unreasonable.

Community care will inevitably become more important, given the increase in the number of elderly people and the demographic changes that will occur between now and the year 2000. The Government are also considering the OPCS report on disability, and I pay tribute to the work done by the hon. Member for Monklands, West on that. District health authorities have been closing hospitals and local authorities have been finding it increasingly difficult to train and obtain funds for social work departments.

Three clear messages came from the Griffiths report. First, Griffiths gave local authorities a clear vote of confidence on the way in which they currently discharge their duties and the way in which they will do so in the future. That may cause the Prime Minister and the Cabinet some ideological difficulties, but only a planning role would be involved. Griffiths was suggesting an essential co-ordinating role, so Conservative Members should not put about scare stories of local authorities being given tremendous extra powers, which the Government do not want. Griffiths's recommendation was broadly right, and if local authorities are not involved in co-ordination, another agency should be.

Secondly, the funding recommendation is fundamental. The idea of a community care grant paid for from a local authority's agreed overall plan is extremely attractive. A Minister for community care, whoever he or she may be, would have some input into agreeing such overall plans, so, again, the Government need not divest themselves of control of these important funding systems.

Thirdly, the delivery of tailored services to meet individual client needs is an important improvement that which the Government should embrace.

There are only three, or perhaps four, options open to the Government. They could fully implement the Griffiths report, but people would accept phasing if the Government made it clear that they accepted the broad tenet and thrust of the recommendations. Alternatively, they could opt for limited acceptance of the report and engage in consultation on the need for joint planning, setting up community care managers and funding for training and pump priming. We believe that that would be a second-best alternative which would result in a lack of overall planning and co-ordination, which, more than anything else, is needed.

I should be worried if the Government placed responsibility for community care with another body jointly funded by health authorities and local authorities. Perhaps more worrying are scare stories that the Government may be considering entirely privatising community care and handing it over lock, stock and barrel to the private sector.

Mr. Mellor

indicated dissent.

Mr. Kirkwood

I see the Minister shake his head. He seems to be ruling that out of court. If he is prepared to say that in his response to the debate, he would allay some of the fears that have been expressed to me recently.

The Minister must accept that there is overwhelming support for the Griffiths solution. If the Government set their face against the report, they will do so at their peril. They must bear in mind important issues such as the fact that there is no correct way of providing care in the community. It is right that there should be plurality of provision, diversity and local initiatives. The Griffiths report made a virtue of that and drew it to the fore of the argument when it said: The aim must be to provide structure and resources to support the initiatives … the innovation and the commitment at local level and to allow them to flourish; to encourage the success stories in one area to become the commonplace of achievement everywhere else. To prescribe from the centre will be to shrivel the varied pattern of local activity. That is the essence of the Griffiths report.

I implore the Minister to give us some idea when we shall receive a statement about what is happening in the Cabinet committee carrying out the review. Is it going over all the ground again? Is it commissioning its own evidence? Will that evidence be published? There are a host of questions. This debate was designed to elicit the answers from the Government. I implore the Minister to use the short time available to him to try to open the doors of Whitehall on this important subject and to tell us what is going on.

9.51 pm

Mr. Mellor

I spent last evening discussing the vexed question of AIDS with a group which included the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood), and he knows how much I agree with his insights on that matter. It is a pleasure to follow him in this debate. I am sorry that I cannot satisfy his curiosity on all his points, although I found his speech interesting and valuable. As the debate has progressed, it has proved possible for hon. Members of all parties to come to grips with the complexity of the issue.

I assure the hon. Gentleman that there is no question of privatising community care, but the clear analysis given in the Griffiths report needs to be tested against certain other competing possibilities. That is done purely in the context of provision within the public sector, while allowing proper access to provision made by the voluntary services and by private providers, which the hon. Member for Southport (Mr. Fearn), as he made clear in his opening speech, saw as a part of his party's policy.

I can assure the House that we do not want to take a moment longer than necessary in considering the report, and I hope that it will not be long before a full statement can be made. During the debate, there was no shortage of points on which we could all agree.

I am sorry that I missed the first half of the speech by the hon. Member for Wakefield (Mr. Hinchliffe). He was right to remind me of the debate we had before Christmas, when we shared some of the insights he mentioned. He mentioned factors that are very much at the heart of our consideration of the Griffiths report. But I am sorry that he felt compelled to say that we have no community care policy. We have a community care policy that meets the points that he emphasised; hence the care we are taking in analysing the Griffiths report.

It is the key to our policy that people should he able to live their own lives for as long as possible and that we should respect people's independence, and work to protect it. It is our policy to ensure that it is only in the final analysis, when other community-based options are no longer viable, that people move into long-term residential care. That is why I am dissatisfied with the absence of a gatekeeper role. As those are our baste beliefs, there has to be a range of community services, from domestic assistance to home helps and nursing care, going on to residential care. We want to ensure that those services can be provided by a range of different providers but although, as my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) made clear, that is not an easy thing to achieve, we must achieve it and it is a priority for us to do so.

The hon. and learned Member for Montgomery (Mr. Carlile) made his points with his customary vigour and clarity. I well understand why he and some other hon. Members representing rural areas are concerned about the contract and that nothing should be done to damage the expansion of rural practices, to which, as the hon. and learned Gentleman acknowledged, we have committed so many resources. Indeed, we have played a full part in revolutionising today's primary care, when compared with what it was when the hon. and learned Gentleman first became conscious of it. Rural doctors have nothing to fear from the changes that we propose. The various arrangements for the contract will make it easier, not more difficult, to take on practice nurses. Those are matters of hard practicality, not of principle and certainly not of dogma.

We are concerned to try to ensure that we achieve greater consistency in primary care not only by putting within the contract a basis for rewarding general practitioners for the efforts that they have made, but by creating incentives for them to do more. That is a practical business. I assure the hon. and learned Member for Montgomery that we are looking at the various points that have been raised, not only by Members of Parliament following the extensive discussions that we know are taking place with doctors, but also from our own discussions. I have been having at least one meeting and often two meetings with GPs every day for the past fortnight, and I shall have another large one in the west country tomorrow. That is not being done as a public relations exercise. We are listening, and we are taking note.

The draft contract that my right hon. Friend the Secretary of State has submitted is not necessarily the last word. Attention has been drawn to the Scottish contract, which was issued following discussions here in England. We shall not hesitate to make changes to the contract if we are persuaded that the present arrangements do not achieve what we have set out to achieve. I hope that the hon. and learned Gentleman finds that helpful. I shall certainly take careful note of what he has said.

Mr. right hon. Friends the Members for Aylesbury (Mr. Raison) and for Chertsey and Walton (Sir G. Pattie) raised a question with which I chose not to deal in my opening speech in this short debate because, although ministerial contributions could expand endlessly, I wanted the opportunity to hear the anxieties of the House. I left out the important points about mental handicap. I accept that it is essential for us to justify not only the necessary policy of closing the large Victorian institutions for which nobody would want to make a strong case, but to emphasise that we have managed to build up in the community facilities which mean that people are not left to wander abroad, but have facilities in the community that enable them to lead, we hope, an altogether more satisfactory life.

It is worth noting that between 1976 and 1986—we must remember that there has been continuity of policy on this subject—the hospital population of people suffering from mental handicap fell by about 15,000 places while the number of day care and residential places in the community rose by 50 per cent. over and above that to a total of 26,000. Expenditure on services for mentally handicapped people increased by 62 per cent. over the period 1978–79 to 1986–87.

We aim to ensure that no institution is closed if there is not the proper provision in the community to ensure that continuity of care is provided. I am well aware that hon. Members of all parties have expressed concern about whether that has been achieved in every instance. Indeed, we have under active consideration the question whether there needs to be some fine tuning of our policy in this respect. That matter is being considered, as well as the proposals of Griffiths, and I hope that we shall be able to announce our conclusions shortly.

Another question that I did not have time to deal with is that of carers. Of course, through the invalid care allowance, through our £10 million policy of innovation throughout the country, under the "Helping the Community to Care" banner, we are committed to assisting carers. These are all revolving policies, which I look forward to having future opportunities to debate in the House.

Question put, That the original words stand part of the Question:—

The House divided: Ayes 41, Noes 159.

Division No. 167]	[10 pm
AYES
Alton, David	Beith, A. J.
Ashdown, Rt Hon Paddy	Bruce, Malcolm (Gordon)
Barnes, Harry (Derbyshire NE)	Buckley, George J.
Barnes, Mrs Rosie (Greenwich)	Callaghan, Jim

Carlile, Alex (Mont'g)	Maclennan, Robert
Clarke, Tom (Monklands W)	Mahon, Mrs Alice
Oixon, Don	Meale, Alan
Dunnachie, Jimmy	Michie, Mrs Ray (Arg'l & Bute)
Eastham, Ken	Patchett, Terry
Ewing, Mrs Margaret (Moray)	Pike, Peter L.
Fatchett, Derek	Powell, Ray (Ogmore)
Fearn, Ronald	Ruddock, Joan
Forsythe, Clifford (Antrim S)	Skinner, Dennis
Golding, Mrs Llin	Steel, Rt Hon David
Haynes, Frank	Taylor, Matthew (Truro)
Hinchliffe, David'	Wareing, Robert N.
Howells, Geraint	Wigley, Dafydd
Hughes, Simon (Southwark)	Wilson, Brian
Johnston, Sir Russell
Kilfedder, James	Tellers for the Ayes:
Livsey, Richard	Mr. James Wallace and
McKay, Allen (Barnsley West)	Mr. Archy Kirkwood.
McKelvey, William
NOES
Alexander, Richard	Greenway, John (Ryedale)
Alison, Rt Hon Michael	Gregory, Conal
Amess, David	Griffiths, Sir Eldon (Bury St E')
Amos, Alan	Griffiths, Peter (Portsmouth N)
Arbuthnot, James	Ground, Patrick
Arnold, Jacques (Gravesham)	Hague, William
Arnold, Tom (Hazel Grove)	Hamilton, Neil (Tatton)
Ashby, David	Hanley, Jeremy
Baker, Nicholas (Dorset N)	Hannam, John
Bellingham, Henry	Hargreaves, Ken (Hyndburn)
Bennett, Nicholas (Pembroke)	Harris, David
Bevan, David Gilroy	Hawkins, Christopher
Blackburn, Dr John G.	Hayward, Robert
Boswell, Tim	Heathcoat-Amory, David
Bottomley, Peter	Hicks, Robert (Cornwall SE)
Bowis, John	Hordern, Sir Peter
Braine, Rt Hon Sir Bernard	Howarth, Alan (Strat'd-on-A)
Brandon-Bravo, Martin	Howarth, G. (Cannock & B'wd)
Brazier, Julian	Hughes, Robert G. (Harrow W)
Bright, Graham	Hunt, David (Wirral W)
Brooke, Rt Hon Peter	Irvine, Michael
Brown, Michael (Brigg & Cl't's)	Jack, Michael
Buchanan-Smith, Rt Hon Alick	Janman, Tim
Budgen, Nicholas	Jessel, Toby
Burns, Simon	Knight, Greg (Derby North)
Carlisle, John, (Luton N)	Knowles, Michael
Carlisle, Kenneth (Lincoln)	Lawrence, Ivan
Carrington, Matthew	Lee, John (Pendle)
Carttiss, Michael	Lennox-Boyd, Hon Mark
Chapman, Sydney	Lester, Jim (Broxtowe)
Chope, Christopher	Lightbown, David
Clark, Dr Michael (Rochford)	Lilley, Peter
Clarke, Rt Hon K. (Rushcliffe)	Lloyd, Peter (Fareham)
Coombs, Simon (Swindon)	Lord, Michael
Cope, Rt Hon John	Lyell, Sir Nicholas
Davies, Q. (Stamf'd & Spald'g)	Macfarlane, Sir Neil
Day, Stephen	Maclean, David
Dorrell, Stephen	Major, Rt Hon John
Douglas-Hamilton, Lord James	Mans, Keith
Dover, Den	Marlow, Tony
Durant, Tony	Marshall, John (Hendon S)
Evennett, David	Marshall, Michael (Arundel)
Field, Barry (Isle of Wight)	Martin, David (Portsmouth S)
Fishburn, John Dudley	Maude, Hon Francis
Fookes, Dame Janet	Mayhew, Rt Hon Sir Patrick
Forman, Nigel	Mellor, David
Forsyth, Michael (Stirling)	Meyer, Sir Anthony
Forth, Eric	Miller, Sir Hal
Fowler, Rt Hon Norman	Mills, Iain
Freeman, Roger	Miscampbell, Norman
French, Douglas	Morris, M (N'hampton S)
Gale, Roger	Moss, Malcolm
Garel-Jones, Tristan	Moynihan, Hon Colin
Gill, Christopher	Needham, Richard
Gilmour, Rt Hon Sir Ian	Neubert, Michael
Goodhart, Sir Philip	Norris, Steve
Goodson-Wickes, Dr Charles	Oppenheim, Phillip
Gow, Ian	Paice, James
Greenway, Harry (Ealing N)	Peacock, Mrs Elizabeth

Porter, David (Waveney)	Thompson, D. (Calder Valley)
Raison, Rt Hon Timothy	Thorne, Neil
Redwood, John	Thurnham, Peter
Shaw, David (Dover)	Townend, John (Bridlington)
Shaw, Sir Giles (Pudsey)	Trippier, David
Shaw, Sir Michael (Scarb')	Trotter, Neville
Skeet, Sir Trevor	Twinn, Dr Ian
Smith, Sir Dudley (Warwick)	Viggers, Peter
Speed, Keith	Waddington, Rt Hon David
Speller, Tony	Walker, Bill (T'side North)
Spicer, Sir Jim (Dorset W)	Waller, Gary
Spicer, Michael (S Worcs)	Watts, John
Stanbrook, Ivor	Wheeler, John
Stern, Michael	Widdecombe, Ann
Stevens, Lewis	Wilkinson, John
Stewart, Allan (Eastwood)	Wilshire, David
Stewart, Andy (Sherwood)	Winterton, Mrs Ann
Stradling Thomas, Sir John	Wood, Timothy
Summerson, Hugo
Taylor, John M (Solihull)	Tellers for the Noes:
Taylor, Teddy (S'end E)	Mr. Tom Sackville and
Tebbit, Rt Hon Norman	Mr. Michael Fallon.
Thatcher, Rt Hon Margaret

Question accordingly negatived.

Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 30 (Questions on amendments):—

The House divided: Ayes 147, Noes 41.

Division No. 168]	[10.12 pm
AYES
Alexander, Richard	Forsyth, Michael (Stirling)
Alison, Rt Hon Michael	Forth, Eric
Amess, David	Freeman, Roger
Amos, Alan	French, Douglas
Arbuthnot, James	Gale, Roger
Arnold, Jacques (Gravesham)	Garel-Jones, Tristan
Arnold, Tom (Hazel Grove)	Gill, Christopher
Ashby, David	Gilmour, Rt Hon Sir Ian
Baker, Nicholas (Dorset N)	Goodson-Wickes, Dr Charles
Bellingham, Henry	Gow, Ian
Bennett, Nicholas (Pembroke)	Green way, Harry (Ealing N)
Bevan, David Gilroy	Greenway, John (Ryedale)
Boswell, Tim	Gregory, Conal
Bottomley, Peter	Griffiths, Sir Eldon (Bury St E')
Bowis, John	Griffiths, Peter (Portsmouth N)
Braine, Rt Hon Sir Bernard	Ground, Patrick
Brandon-Bravo, Martin	Hague, William
Brazier, Julian	Hamilton, Neil (Tatton)
Bright, Graham	Hanley, Jeremy
Brown, Michael (Brigg & Cl't's)	Hannam, John
Buchanan-Smith, Rt Hon Alick	Hargreaves, Ken (Hyndburn)
Budgen, Nicholas	Harris, David
Burns, Simon	Hawkins, Christopher
Carlisle, John, (Luton N)	Hayward, Robert
Carlisle, Kenneth (Lincoln)	Heathcoat-Amory, David
Carrington, Matthew	Hicks, Robert (Cornwall SE)
Carttiss, Michael	Howarth, Alan (Strat'd-on-A)
Chapman, Sydney	Howarth, G. (Cannock & B'wd)
Chope, Christopher	Hughes, Robert G. (Harrow W)
Clark, Dr Michael (Rochford)	Hunt, David (Wirral W)
Clarke, Rt Hon K. (Rushcliffe)	Jack, Michael
Coombs, Simon (Swindon)	Janman, Tim
Cope, Rt Hon John	Jessel, Toby
Davies, Q. (Stamf'd & Spald'g)	Knight, Greg (Derby North)
Day, Stephen	Knowles, Michael
Dorrell, Stephen	Lawrence, Ivan
Douglas-Hamilton, Lord James	Lee, John (Pendle)
Dover, Den	Lennox-Boyd, Hon Mark
Durant, Tony	Lester, Jim (Broxtowe)
Evennett, David	Lightbown, David
Fallon, Michael	Lilley, Peter
Fishburn, John Dudley	Lloyd, Peter (Fareham)
Fookes, Dame Janet	Lord, Michael
Forman, Nigel	Lyell, Sir Nicholas

Major, Rt Hon John	Stern, Michael
Mans, Keith	Stevens, Lewis
Marlow, Tony	Stewart, Allan (Eastwood)
Marshall, John (Hendon S)	Stewart, Andy (Sherwood)
Martin, David (Portsmouth S)	Stradling Thomas, Sir John
Maude, Hon Francis	Summerson, Hugo
Mayhew, Rt Hon Sir Patrick	Taylor, John M (Solihull)
Mellor, David	Taylor, Teddy (S'end E)
Meyer, Sir Anthony	Tebbit, Rt Hon Norman
Miller, Sir Hal	Thatcher, Rt Hon Margaret
Mills, Iain	Thompson, D. (Calder Valley)
Miscampbell, Norman	Thorne, Neil
Morris, M (N'hampton S)	Thurnham, Peter
Moss, Malcolm	Trippier, David
Neubert, Michael	Trotter, Neville
Norris, Steve	Twinn, Dr Ian
Oppenheim, Phillip	Viggers, Peter
Paice, James	Walker, Bill (T'side North)
Peacock, Mrs Elizabeth	Waller, Gary
Porter, David (Waveney)	Watts, John
Raison, Rt Hon Timothy	Wheeler, John
Redwood, John	Widdecombe, Ann
Shaw, David (Dover)	Wilkinson, John
Shaw, Sir Giles (Pudsey)	Wilshire, David
Shaw, Sir Michael (Scarb')	Winterton, Mrs Ann
Skeet, Sir Trevor	Wood, Timothy
Smith, Sir Dudley (Warwick)	Young, Sir George (Acton)
Speed, Keith
Speller, Tony	Tellers for the Ayes:
Spicer, Sir Jim (Dorset W)	Mr. David Maclean and
Spicer, Michael (S Worcs)	Mr. Tom Sackville.
Stanbrook, Ivor
NOES
Alton, David	Livsey, Richard
Barnes, Mrs Rosie (Greenwich)	McKay, Allen (Barnsley West)
Beith, A. J.	McKelvey, William
Bruce, Malcolm (Gordon)	Maclennan, Robert
Buckley, George J.	Mahon, Mrs Alice
Callaghan, Jim	Michie, Mrs Ray (Arg'l & Bute)
Carlile, Alex (Mont'g)	Patchett, Terry
Clarke, Tom (Monklands W)	Pike, Peter L.
Cook, Robin (Livingston)	Powell, Ray (Ogmore)
Dixon, Don	Ross, William (Londonderry E)
Dunnachie, Jimmy	Ruddock, Joan
Eastham, Ken	Skinner, Dennis
Ewing, Mrs Margaret (Moray)	Steel, Rt Hon David
Fatchett, Derek	Taylor, Matthew (Truro)
Fearn, Ronald	Wallace, James
Forsythe, Clifford (Antrim S)	Wareing, Robert N.
Golding, Mrs Llin	Wigley, Dafydd
Haynes, Frank	Wilson, Brian
Hinchliffe, David
Howells, Geraint	Tellers for the Noes:
Hughes, Simon (Southwark)	Mr. Harry Barnes and
Kilfedder, James	Mr. Alan Teale.
Kirkwood, Archy

Question accordingly agreed to.

Mr. Speaker

forthwith declared the main Question, as amended, to be agreed to.

Resolved, That this House expresses full support for the Government's policy of community care and for the proposals set out in the White Paper, Working for Patients; commends the Government's record on the funding and development of primary health care and community care; and believes that the White Paper, together with the Government's earlier White Paper, Promoting Better Health, will help family doctors to develop the services which they provide for their patients, strengthen the provision of primary care in general and complement the development of policies for community care, improve the quality of care for all patients, and ensure that all those concerned with delivering health care make the best use of the resources available to them.