§ '(1) A patient who is removed by a general medical practitioner from the patient list of that practice shall have a right of appeal to the Family Health Services Authority.
§ (2) On receiving an appeal under subsection (1) a Family Health Services Authority or a health board in Scotland shall determine whether:
- (a) the decision to remove the appellant was based on a breakdown of the relationship between patient and general practitioner or
- (b) the decision to remove the appellant was based on financial or other reasons.
§ (3) Where the Family Services Authority determines under subsection (2) above that a breakdown of relationship with the patient was not the sole or main reason for removing the patient they shall require the general medical practitioner to restore the patient.'.—[Ms. Harman.]
§ Brought up and read the First time.7.39 pm
§ Ms. Harriet Harman (Peckham)
I beg to move, That the clause be read a Second time.
The purpose of the new clause is to protect patients. Under the new business ethos imposed on the family doctor service, every patient will have a price tag on his head. For some patients, that price will be too high for their doctor and they will risk being culled from their general practitioner's list.
The tragedy is that the new clause is necessary because there will be pressure to jettison uneconomic patients, which will be exerted in three ways. First, the pressure will come from the new GP contract imposed on the family doctor service. Secondly, pressure will come from the cash 548 limits on the amount of drugs that family doctors can prescribe, and, thirdly, because of cash limits on the funds of those GPs who opt to hold their own practice budgets.
The GPs have been doing their sums, and they have discovered that, in some cases, the removal of a family that refuses immunisation for their children could make a difference of more than £3,000 to them. Doctors are also discovering that they could be better off if they removed from their lists some women who, possibly for perfectly good reasons, do not want or do not need a cervical smear. They have also discovered that they could be better off if they removed from their lists elderly and chronically ill patients who might need night visits.
§ Mr. A. J. Beith (Berwick-upon-Tweed)
Some GPs have discovered that, if they exclude a convent from their lists, they would no longer be penalised for failing to meet cervical smear targets, which would be wholly inappropriate and unnecessary for such patients.
§ Ms. Harman
The hon. Gentleman demonstrates the inflexibility of the target system.
Doctors have done their sums, they know how things are working out and we must listen to them. Patient organisations share the fears expressed by doctors because they will be made vulnerable in a situation in which they have no rights. At the very least, the Government should accept the new clause, as it would give such vulnerable patients at least some legal protection.
The Government are also making patients vulnerable through the cash-limited indicative drug budget. There is no doubt that that budget will be cash-limited, because the aim of that budget, as stated by the Government, is a downward pressure on spending. The Government refused to accept our amendment that would have meant no cash limits on indicative drug budgets and that no patient would be denied a necessary drug as a result of such cash limiting. For all their assurances, the Government refused to accept our amendment; therefore, their assurances are in flat contradiction of the intention behind that indicative drug budget and their refusal to accept our amendment.
Patients who need a large number of drugs, such as those who suffer from cystic fibrosis, whose drugs can cost as much as £1,000 per month, or patients who need hormone replacement therapy or fertility treatment may find that their GPs overspend their drug budgets and thus risk having their pay docked. In such circumstances, those who use many drugs will soon turn into uneconomic patients—GPs have already expressed their fear about that. Given that the indicative drug budget is a mechanism for downward pressure on spending, it poses a threat to those whose continued presence on GP lists creates an upward pressure on spending.
The Government are also making patients vulnerable through cash limits on fund-holding practices, as those doctors who opt to become fund-holders will have their budgets cash-limited. The Government have repeatedly denied that, but the British Medical Association believes that that is the Government's aim. The White Paper said that the accident and emergency departments of hospitals would be monitored to see whether the patients in those departments are genuine cases instead of refugees from practices where the budget is running out and the doctor has advised patients to avoid a cash limit on the budget by going to casualty in an attempt to be taken in as an accident and emergency case.
549 With a cash limit on drugs, hospital tests and treatments, the elderly or chronically sick patient could soon become uneconomic for the GP who is a practice budget holder. The Secretary of State and other Ministers have said that hundreds of applications have been received from GPs who want to become budget holders. The least that the Secretary of State could do would be to place the names of the relevant practices in the Library, so that patients depending on those practices will know whether their GP is planning to opt out.
I note that the Secretary of State smiles, but why should there be anything to hide? I also want to know about the nature of the applications: are we talking about a vague expression of interest or something much firmer? We should know the details. It is not good enough for the right hon. and learned Gentleman to make assertions and then laugh when we ask for further and better particulars.
§ The Secretary of State for Health (Mr. Kenneth Clarke)
The hon. Lady has said that I was laughing, but my immediate thought was how she would react the moment she got the list of the particular doctors. Given her approach to the Bill from beginning to end, she would circulate the areas of the practices involved with leaflets giving her broad-brush descriptions of our proposals, as she has just done, to try to frighten the patients about that prospect. I disapprove of the approach that the hon. Lady has consistently adopted to our proposals. Those doctors who have expressed an interest in being fund holders—850 practices have done so—would deeply disapprove of the hon. Lady's campaigning style being brought to bear on their patients.
§ Ms. Harman
The Secretary of State should allow the patients and the community served by those practices to judge for themselves whether they accept our fears or whether they are prepared to accept the Secretary of State's assurances. He does not want us to know the details, because he knows that we share the concerns of the patients and that he is out of touch with them.
On previous occasions, the Secretary of State and other Ministers have asked why doctors would take the decision to be a budget holder if it was likely to be so damaging to their patients. Under the new NHS contract system, GPs will be caught between the devil and the deep blue sea. If they stay as they are, they will lose their most important clinical freedom and right to operate on behalf of their patients—exercising choice about where to go for tests and treatments. If doctors opt for a practice budget, it will be cash-limited, and that will have a chilling effect on the drugs, tests and treatment that they are able to offer their patients. It might even lead to doctors having to cull patients from their lists. Doctors are faced with an invidious choice, and those patients whose GPs become budget holders may be put at risk if they are uneconomic.
Our new clause gives patients a right of appeal. If a patient is not struck off a list because of a breakdown in relations, the family health services authority will have the opportunity to reinstate the patient on a GP's list. We are not talking about those circumstances in which the patient and the GP have a genuine row, but where patients become 550 uneconomic because of the three reasons I have given. In those circumstances, there is a financial disincentive in keeping that patient on the list.
When such cases come to light, it will be no good the Secretary of State blaming the doctors and saying that they represent the rotten apple in the barrel. It is no good the Secretary of State simply accusing us of scaremongering. There is genuine concern among patients and doctors. The new clause is backed by the Consumers Association.
We remain fundamentally opposed to cash limits on indicative drug budgets and to cash-limited practice budgets. There is not a shred of evidence that the family doctor service is extravagant or bad value for money, yet the Government press ahead with a whole range of cash limits to try to cheapen the family doctor service.
The next Labour Government will ensure that the family doctor service is free to put patients first and care before cash. The least the Government should do now is give patients the benefit of the doubt in situations where there is great upheaval in the family doctor service. The new clause would provide a safety net in those circumstances.
§ Mr. Kenneth Clarke
If I respond briefly to the remarks of the hon. Member for Peckham (Ms. Harman), hon. Members may be able to confine their remarks later and thereby help to deal with the shortage of time.
I have considerable respect for the hon. Lady as a political opponent, but at times I find her political style startling, even somewhat unpleasant—[HON. MEMBERS: "Oh!"] She relies on the repeated assertion, in somewhat strident terms, of alleged facts about our reforms which we have demonstrated time and again to everybody else's satisfaction—and I sometimes think to hers—are totally factually untrue.
The hon. Lady revived yet again her usual talk about cash-limited drug budgets leading to people with serious conditions perhaps being threatened with loss of treatment. She knows that we have satisfied everybody, from the BMA onwards, that that is not the case. She used a dreadful phrase about patients being culled from doctors' lists, when we have demonstrated in all the cases that she has raised that talk about it being the consequence of the contract and so on is utter nonsense.
The hon. Lady puts such matters forth in letters, press releases and speeches in chilling tones, regardless of the factual background to what she is talking about and with the deliberate intention of trying to whip up fears, particularly among patients, about the consequences for them of things which she says are in reports.
When the hon. Lady cannot bring herself to make a totally untrue assertion yet again, she has started using the phrase, "Doctors have said that." The Daily Mirror is fond of that sort of statement. I am reminded of those cheapjack advertisements making ridiculous claims for some fringe product which say, "Doctors have said that," and then a startling and unsupportable proposition is made on behalf of some dubious product.
§ Mr. Kenneth Hind (Lancashire, West)
My right hon. and learned Friend has made it clear that the underlying impression given by some of the remarks of the hon. Member for Peckham (Ms. Harman) about doctors disposing of patients and so on is that doctors are money-grabbing and uncaring. The bottom line of such remarks must represent a deep criticism of doctors, casting 551 doubt on their dedication and veracity. Not only do I believe her to be wrong, but there is no reason to believe that doctors would behave in the way she suggests.
§ Mr. Clarke
I agree with my hon. Friend. As for doctors culling patients, the hon. Lady once cited a case on the Floor of the House which I was able to identify and follow up. She knows that the doctor concerned made no claim that the removal of the patient from his list had anything to do with our review or with the White Paper. I imagine that the hon. Lady has seen the correspondence in that case.
I looked into a similar case in Burnley. After the hon. Member for Burnley (Mr. Pike) raised the case with me, the doctor concerned persisted in allegations, although he was unable to substantiate them. In the case cited by the hon. Member for Peckham, the doctor made no attempt to claim to me that the incident that she was exploiting had anything to do with my White Paper or with the contract proposals.
§ Ms. Harman
Publicity was attracted to the case to which the right hon. and learned Gentleman referred, my having raised it in the House. I am afraid that the doctor withdrew the comments that he had originally made—[Interruption.] My assistant telephoned the doctor and asked him to give his version of why the patient in question had been struck off, and he told my assistant that the woman was an uneconomic patient because of her requirement for night visits. He patiently explained to my assistant how the new deputising rules would work and how the patient would mean him being out of pocket. My assistant took a verbatim note—I asked her to take such a note, being myself legally trained—and when the matter was raised in Parliament, the doctor changed his story. That is an honest description of the position.
§ Mr. Clarke
The hon. Lady now knows that he withdrew it because he could not substantiate the claims that he had made to her assistant. The hon. Lady alleged that the patient—who turned out to have had a long history of a somewhat difficult relationship with the doctor—would be more costly because she required night visits. As the hon. Lady knows, under the former arrangements, for each night visit the doctor concerned received £20.25. Under the new contract, from the beginning of next year he will receive £15 if he uses a deputising service but £45 for each visit made personally or made by a colleague from his practice or from a local group.
In that case, the doctor did not persist in the claim because it was plainly not true. It was clear that the claim that there was some financial motive for removing the patient from the list was a fiction. From the doctor's point of view, it was probably a polite excuse to a patient whom he wished to get removed from his list because patient and doctor were not getting on well.
If the hon. Lady wishes to persist in such matters, she must look at the consequences of the new contract, which she knows, above all else, places obligations on doctors to extend their services to their patients in many cases, for example, by offering initial check-ups, check-ups every three years, and annual contacts for the over-75s and so on. It increases the payments for patients over 65 and 75 compared with the previous position and pays doctors for services that they may choose to offer or targets that they may seek to attain.
552 We have debated the contract. It is nonsense for any doctor to seek to demonstrate that a particular patient is being removed from the list because the financial attractiveness of that patient is less than it was under the old contract. Only the Daily Mirror still pursues that campaign and only the hon. Lady seeks to give it some credibility by persisting in the matter.
If I were to go over the whole question of cash-limited drug budgets, I would encroach on the time available to other hon. Members. It was a total invention from the word go to suggest that drug budgets would be cash-limited. We rely on the White Paper and everything that has flowed from it to disprove that. We have made it clear all along that in no circumstances would any patient ever be refused the medication or equipment that he or she used and that no doctor would be exposed to any risk of penalty for giving drugs or equipment to a patient who needed them. The hon. Member for Peckham knows that those assurances are reliable and have been accepted by everybody. She just likes, for campaigning reasons, to keep a heavy emphasis on cash-limited drug budgets. with references to other patients.
Underlying all that is a problem which hon. Members might seriously wish to address, and that is what happens when the relationship between doctor and patient breaks down or becomes troublesome to one or the other, without necessarily there being any fault on either side. I am not talking about pharmaceutical treatment. It may be, in conversational terms, that the chemistry does not work between a doctor and patient.
Since the NHS began, a doctor has always had an absolute right to ask a patient to withdraw from his list without giving any reason.
§ Mr. D. N. Campbell-Savours (Workington)
If what the right hon. and learned Gentlemen says is true, why did he not include in the Bill a simple clause saying that a general practitioner shall not do any of the things that we are suggesting a GP might be in a position to do? Had he done that, we would not be having this discussion.
§ Mr. Clarke
I am not sure that it is right to take away from the doctor the right to say to a patient, "I would rather you left my list", or "I would rather your family left my list." The trouble with the new clause is that it will present the doctor with serious difficulties because it insists that a patient can go through an appeal process and get on to that doctor's list. There is no doubt that the doctor-patient relationship should, wherever possible, be based on a good relationship of confidence and trust on both sides. There may be occasions where a responsible GP has perfectly good reasons for not wanting a patient any more. It is seriously debatable whether it would be in everybody's interests to introduce such an appeal process.
The snag is that, as every doctor knows, there has always been a small minority of doctors who, over the years, have been reluctant to take on certain patients. There is no doubt that under whichever system—it has nothing to do with my reforms or the new contract—some patients impose a much greater workload on the doctor and the practice than others.
If there are many chronically sick and elderly patients and patients who have intensive courses of care, there is no doubt that those patients make up the doctor's workload. Most doctors are lucky enough to have their work with 553 those patients compensated for, to some extent, by a raft of patients on the list who are never ill from one year to the next and whom they never see. The method of paying doctors has always included capitation and a combination of other factors so that the list as a whole is the basis of the GP's remuneration.
There have always been some doctors who have been extremely reluctant to take on to their lists elderly people, the chronically sick and people who might make demands on them at night. The British Medical Association and I would describe as unscrupulous any doctor who took this policy too far. The vast majority of doctors are not like that and accept that it is largely chance that determines their workload. They accept that it is their professional duty to give the best treatment that they can to their patients, in line with their needs. Recently, a few doctors who want to shed their workload and have had difficulty trying to find a reason for shaking off a difficult patient have slipped into the habit of blaming the reforms or the new contracts. I regret that they are being encouraged in that by the hon. Member for Peckham.
The idea that in future we should announce a formal appeal mechanism to allow patients who do not want to be removed from the doctor's list to get on to that list is debatable. In the last resort, if a patient cannot get a doctor—there are some patients who have been on every doctor's list and there is no longer a doctor left who is willing to accept them—there is a provision whereby the family practitioner committee can require a nominated doctor to take the patient on to his or her list.
It is difficult to improve on that system. Sometimes one feels sorry for a patient who has been removed for no apparent reason, and there is nothing that one can do about it. However, I say on behalf of the Government, and personally, that I am not attracted to a full appeal mechanism whereby patients can try to force themselves back on to the list of a GP who may have perfectly good personal or professional reasons for not wanting the patient.
I rose early in the debate because I felt that this issue should be disentangled from the Bill. To campaign and frighten elderly patients by saying that they will be "culled"—that was the word used—from their GP's list because of our proposals is distasteful, disreputable and takes campaigning against the proposals much too far.
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. I remind the House that we are debating this issue under tight time constraints.
§ Mr. Nigel Spearing (Newham, South)
I am grateful to be called immediately after the Secretary of State, who constantly amazes me. I always think of him as a decent man somewhere inside a less decent man, and the decent man is sometimes trying to get out. He had a cheek to talk about unpleasantness on the part of my hon. Friend the Member for Peckham (Ms. Harman) as he has not been at all pleasant in the way in whch he has dealt with medical and ambulance matters in the past few months. I have twice attended debates in the House about the ambulance service from which the Secretary of State has been absent. I am glad that he is here today. His last contribution was more in the line of the decent right hon. and learned 554 Member for Rushcliffe (Mr. Clarke) who, I am sure, uses his best bedside manner on the patients who come to his surgery, as they come to all of us.
I agree immediately with the right hon. and learned Gentleman that the relationship between the general practitioner and his or her patients is absolutely fundamental—just as there is, or should be, a fundamental relationship between any of us who aspire to be reasonable Members of Parliament and our constituents. The analogy is not that far from the truth. The trouble is that the Secretary of State has misunderstood the inevitable overall effect of the Bill, when enacted, on that relationship. As I understand it, he has accurately outlined the present position—any GP can ask any patient or tell the family practitioner committee that a patient will no longer be on his panel. Similarly, patients can remove themselves from doctors' lists. The reserve power that he mentioned works quite well psychologically, and doctors and the officers of the FPC keep some sort of equilibrium. Until two days ago I was unaware that that was the system.
Why do my hon. Friends and I feel it necessary to support an amendment which adds to the system? Is it not true that the relationship between a patient and a doctor is extremely personal and crucial? In another context we use the phrases "in sickness or in health," and "for better, for worse". We all know that at some time any of us might have an interview with our GP which could have the gravest implications for us and our families. We know of friends and relatives who have gone through that.
The Bill could potentially—I believe that it will—transform the fundamental relationship between GPs and our constituents. That means that 60,000 to 80,000 people per hon. Member—perhaps 60,000 or 70,000 of the Secretary of State's own constituents—could be affected. The conditions in which all general practitioners function will be greatly changed. Those conditions will be changed from a structure which many doctors who are middle aged and older have experienced, and in which they were brought up. The younger ones believe that the framework of their chosen profession may not be perfect but it should not be primarily a business concern, involving constant calculations about costs, time and choice of hospital, in the structure presented in the Bill and about which we have heard ad nauseam in the past few months.
The attitude of mind that all GPs must bring to their profession could be transformed by the Bill. If that did not happen, the Government would consider the Bill a failure. Therefore, the circumstances in which doctors meet patients, organise their daily lives, work out their accounts, relate to partners in the same practice, relate to the FPC and consultants in this, that or the other type of new hospital together with other changes that will rapidly come about as a result of the Bill, will transform their attitudes.
The attitude of the patient to the doctor will inevitably change. The Secretary of State has said,—he may be absolutely sincere in this,—that there will be no element of disincentive to dissuade doctors from taking on patients. He upbraided my hon. Friend the Member for Peckham for suggesting such a thing. However, there has been sufficient evidence in Committee, in the House and from general practitioners to show that many patients will not believe that. The Secretary of State is a politician, as we all are, and he knows that it is not a matter of what it is, but what the voters think that it is. That is real politics as we know to our cost and sometimes to our benefit. If there is 555 a scintilla of suspicion by any patient that the doctor's attitude is being influenced or even controlled by some force that is beyond the doctor's professional opinion, the relationship between them will be ruptured or at the very least it will not be so good as it is under the current system.
§ Mr. Kenneth Clarke
I agree with the hon. Gentleman about that, but does he agree with me that he should discourage those members of his party who run campaigns suggesting that doctors will wish to cull elderly patients from their lists? That gives the individual elderly patient a feeling of unease. He wonders, "Will my doctor throw me off his list? Am I somehow an expense to my doctor that he does not want?" That is a fiction, but it is the kind of political campaign which causes unease to patients and damages the relationship between patient and doctor.
§ Mr. Spearing
The right hon. and learned Gentleman is repeating what he said to my hon. Friend the Member for Peckham. I understand that organisations representing vulnerable people have said virtually the same thing. We do not know the details and consequences of the structure being erected because there has been little experiment or trials with it. General practitioners view that structure with considerable apprehension. On that fact alone, I suggest that my remarks are accurate.
The right hon. and learned Gentleman's premises are fundamentally wrong because the Bill does not necessarily support what general practitioners regard as good, professional medicine and practice. If he had asked them in what way they wanted to improve the medical service, he might have come up with something better.
§ Mr. Rhodri Morgan (Cardiff, West)
My hon. Friend goes to the heart of the matter. The fears of doctors and patients are not thought up by my hon. Friend the Member for Peckham and the Daily Mirror in some Pied Piper of Hamlin conspiracy to mislead everyone. We can all look across the water to the United States of America where doctors no longer make house calls because they are compelled to have a commercial attitude. In this country, thank God, someone can still ask for a house call without worrying whether he will be thought to be a burdensome patient. We want to preserve that system, but doctors and patients are worried that it may be lost. That fear has not been dredged up by the Daily Mirror—it is deep in the consciousness of all who value the NHS.
§ Mr. Spearing
I agree with my hon. Friend. I shall conclude with two facts which illustrate both what he has said and the case that I am making.
A few months ago a man came to my surgery. He was ill and he was also nursing a sick wife. He was concerned because he thought that his general practitioner was not providing sufficient medication. He said that his wife was sometimes screaming with pain because painkillers were not available. I thought that he was right. I made inquiries of the City and East London family practitioner committee, which said that some sort of monitoring was taking place and that the doctor in question had been given a communication on the matter.
The doctor's judgment may have been correct—I take it from the FPC that he is a humane and considerate doctor—but the position that I have outlined exists today under the present structure, even before the other criteria proposed by the Secretary of State are introduced.
556 My second fact, which the right hon. and learned Gentleman cannot deny, is his view—as I understand it from general practitioners—that there will be some movement between good general practitioners and less good general practitioners. I understand that a good general practitioner thinks that about 2,000 patients on a mixed list is about right, given some sort of balance. Is it not a fact—the right hon. and learned Gentleman can deny it if he so wishes—that, as with the hospital structure, he foresees that the good general practitioners will attract more patients and that the not-so-good ones will attract fewer patients?
I understand from doctors that, once over that figure, time is taken up, pressure raised and the job becomes difficult to do. Market forces do not operate in a doctor's surgery as they do on a production line, but unless doctors have misunderstood the position, they believe that to be the assumption behind most of the legislation—which is at its worst in respect of the opting-out provisions for hospitals that we debated earlier. Time and again we have heard that the most effective and efficient unit will attract more so that unit costs will reduce and everybody will gain—even if they have to go up the motorway in an ambulance. That is the Government's philosophy. It will not work for general practitioners and it will not work for the NHS.
The Government are undermining that tracery of human relationships on which most medicine works and they stand in danger of taking away the nerve trains within the Health Service. It is fatal for the body when the nerve trains are attacked. The Government should have ascertained more about the problems. If they continue with their proposals, the Health Service as we know it today, which has been built up over many years with the support of professional organisations, will be ruined. That will be the responsibility of the right hon. and learned Gentleman, and of his right hon. Friend the Prime Minister who lies behind that dreadful market philosophy.
§ Mr. Charles Kennedy (Ross, Cromarty and Skye)
I shall be brief. As both the Secretary of State and the hon. Member for Newham, South (Mr. Spearing) acknowledged, there is a difficult balance to be struck. Articles about general practitioners have appeared in the Daily Mirror from time to time. My concern is not the concern expressed by the right hon. and learned Gentleman about general practitioners. He has proved himself adept in and enthusiastic about doctor bashing, so it is rather ironic for him to rise to their defence like a knight in shining armour.
If too much emphasis is placed on the suggestion that doctors will want to shift patients from their lists—I do not accuse the hon. Member for Peckham (Ms. Harman) of doing that, as the right hon. and learned Gentleman did—there will be genuine anxiety. However, my political concern is that it helps to add to the rhetoric in which the right hon. and learned Gentleman has invested so much time, not least about the contract.
I recognise the practical problems outlined by the right hon. and learned Gentleman, but some reassurance is needed. A nod in the direction of an appeal mechanism would be at least a step forward. However, the problem lies rather deeper than that, in the practical impact of the contract. We have debated contracts with the Secretary of State both in Committee and in the House, and I repeat the 557 point that it is only logical, given the financial underpinning of the new contract, that, if there is to be an incentive for doctors to move to larger lists, many patients may find treatment inadequate. In areas such as mine, the Borders, and other rural parts, the right of appeal raises the legitimate question whether, as the list sizes of GPs grow to such an extent, the practices will be viable in terms of patient care.
What is the equivalent right of appeal for a patient who may want to move to an adjoining practice but in an area which is sparsely populated or geographically spread? We might be talking about a practice which is 20 miles away. That would not offer people without access to transport facilities the kind of patient choice which the Secretary of State tells us he is anxious to establish through the Bill. Therefore, does the Secretary of State feel that there is a deficiency in the legislation because it does not deal properly with appeals? Although he may not be sympathetic to the right of appeal outlined in the new clause, he may feel that the principle should be enshrined in the legislation.
Two basic points are not adequately addressed by the Bill. The first relates to the resources put into general practice. The Secretary of State outlined how GPs can benefit financially from the range of services offered, the number of voluntary calls, spot checking and so on. If we are advocating a preventative medicine approach, I do not think that enough emphasis has been placed on public campaigns and on public involvement. A golden opportunity has been missed.
In an intervention in the speech of the hon. Member for Peckham my hon. Friend the Member for Berwick-upon-Tweed (Mr. Beith) spoke about the practical idiocy involved in the new contract when we consider the circumstances of key categories of patients. As the Secretary of State will be aware, that has given rise to much concern.
The extreme example of cervical testing in convents has been mentioned, but there have been many examples, as I am sure the Secretary of State has seen, of single female patients having had unfortunate experiences in trying to establish virginity. We can think of the effect that that would have on the doctor-patient relationship. I hope that that will be taken into account by the Secretary of State, however dismissive he is of the clause as drafted.
Patients should have a greater say and should be conversant with their rights. They should have an input to the range of services and options for treatment offered by their GP. If there is not to be an appeal system, I should have thought that the Secretary of State would have taken the new clause as a green light for a proper patients' charter. The hon. Member for Newbury (Sir M. McNair-Wilson) has played a distinguished role in furthering the issue in recent years, and there has been cross-party support for a charter.
The opportunity has been missed to introduce a patients' charter, whatever the BMA might have said. The Secretary of State has accused those on the Labour Front Bench of using foul means. On a constituency basis, he must be aware that many people are concerned, because uncertainty and change always create concern among patients. Surely he recognises that much of the sting could have been taken out of the issue by the introduction of a 558 charter. Although the Secretary of State dismisses the clause as drafted, many of the issues raised by it are legitimate and highlight deficiencies in the legislation and in the contract which could have been remedied, but sadly have not been.
§ Sir Michael McNair-Wilson (Newbury)
I cannot support the new clause, because the concept behind it is improbable. If my general practitioner did not want me on his list, I could not see myself appealing to remain on it, because the doctor-patient relationship is one of trust and confidence, and if that is damaged the object of having an appeal is unimportant.
If I could catch the attention of the hon. Member for Peckham (Ms. Harman), I think she strayed, perhaps inadvertently, on to a subject which deserves more consideration than it has been given. I agree entirely with my right hon. and learned Friend the Secretary of State that there should be targets for things like cervical smears and immunisation. He is right to set target figures at which the maximum remuneration will be paid.
The question that worries me was addressed in an article in The Daily Telegraph only last week by Dr. John Lockley. He put a simple case: if a doctor asked all his women patients whether they would agree to a cervical smear and 79 per cent. agreed, but the effective I per cent. said no, he would lose perhaps as much as £1,000 in remuneration because of one or two patients whom another GP might not want on his list.
By the same token, if a GP offered immunisation to mothers of young children and if 89 per cent. agreed to immunisation but the essential 1 per cent. refused, the doctor would lose the remuneration which he might reasonably expect to get because the service had been offered. It would not be the unwillingness of the doctor to provide the service that denied him the remuneration, but the refusal of the patient to take up the service that was on offer. Therefore, it seems difficult to sustain the argument that that will not affect the attitude of doctors or will not put a strain on doctor-patient relationship unless we can find another way of satisfying the requirement of the target.
Dr. Lockley offered a solution. He suggested that, if a lady patient refused a cervical smear, the doctor should be allowed to ask her to sign a form confirming that he had offered the service but that she did not want it. If a doctor could show that he would have crossed the target line, he should be able to obtain the maximum remuneration because in effect he was offering a service which was not taken up. I should like my right hon. and learned Friend to address that point in his reply.
On drug budgets, I have no difficulty in supporting the concept of a GP having a cash-limited drug budget. The medical profession should be as answerable as any other on how it spends money. I declare an interest as a kidney patient and as president of a kidney charity. I am fortunate enough not only to be on dialysis but to receive a drug called erythropoetin as a dialysis patient. That drug has made all the difference to my haemoglobin level, my energy level and, indeed, to my general well-being. Any kidney dialysis patient suffering from anaemia, a very common problem with kidney failure, will want to be on EPO if possible.
My consultant told me that he did not have enough money to afford to give all the renal patients in his ward that drug. He wondered whether I would mind asking my 559 GP whether he would prescribe the drug for me. I duly wrote to my GP with that request and my GP came to see me. He said, "Of course I'll prescribe it. I know you, and I have treated you ever since your kidneys failed." However. he told me that he was worried because he said that he was not my consultant and the drug is not licensed. He said, "I don't know its side effects, but I have been asked to prescribe it for you wondering to myself whether I am entering into a commitment which may have some unforeseen results." He questioned whether that was calling his professional judgment to account. He wondered whether he should be indemnified or whether he should ask the Department to give a ruling to clarify the position.
If a consultant can do that with an unlicensed drug, why can another consultant not do the same? Will the GP, with his cash-limited drug budget, be able to absorb that cost which originally belonged to a hospital, but which the hospital is passing to the GP to enable the hospital to provide the drug to more people? That is an important point, although I admit that it affects only a small number of people in terms of kidney patients. However, that is an example of what might happen in future.
§ Mrs. Alice Mahon (Halifax)
I will be very brief. When the Secretary of State said that the only people who were raising alarm were people like my hon. Friend the Member for Peckham (Ms. Harman), he was misleading the House.
Many organisations representing ill people or people who need special services have produced for hon. Members on both sides of the House briefs expressing their fears. I want to refer to a very respected association—the Family Planning Association—which has expressed fears similar to those expressed by my hon. Friend the Member for Peckham.
There have been many reports in the media about patients being struck off a GP's list. Three of my constituents were struck off in as many months. I am very concerned, because they belong to a particular category of people. They were all women with young children, and arguably they would all take up a lot of a GP's time.
In its brief, which it sent to hon. Members on 21 February, the Family Planning Association states that it isdeeply concerned that women requiring certain treatment due to reproductive health problems could either be at risk of being dropped from their existing GP's lists or find it hard to register with another practice. These women need the securityof the proposals in the new clausewhich place a legal obligation on … authorities to ensure that all people within it's registered population have access to a GP who can meet their needs.The Family Planning Association refers also to women who need treatment for infertility or for chronic gynaecological complaints such as endometriosis, which require expensive drugs or referrals. Many consultants and GPs consider the profitability of the patient. We cannot get away from that.
The Family Planning Association is also concerned that women between the ages of 25 and 64 who do not want a smear test or have the test elsewhere, such as at a family planning clinic, may find themselves unwelcome because their presence on a GP's list affects the doctor's payment for carrying out the tests. That could also apply to people with HIV or full-blown AIDS, and they could experience difficulty.
560 I have referred only to a brief from the Family Planning Association because I am deeply concerned that women's health problems will be affected by the Bill. I am sure that other hon. Members could pick a dozen others which stress the same problems. That is not scaremongering: it is telling the truth. Those organisations are responsible, and the Secretary of State should take note of them.
§ Mr. Michael Morris (Northampton, South)
I must declare an interest as I have been married to a general practitioner for 30 years and I am also an adviser to two pharmaceutical companies.
I do not think that the scenario painted by the hon. Member for Peckham (Ms. Harman) is likely to happen initially. However, I emphasise "initially". If it happens, my right hon. and learned Friend the Secretary of State for Health will have to live with it because he included the provision in the contract in the first place.
I hope that my right hon. and learned Friend the Secretary of State listened carefully to my hon. Friend the Member for Newbury (Sir M. McNair-Wilson). My hon. Friend referred to articles that appeared in the Daily Mirror. Articles also appeared in The Daily Telegraph, as my hon. Friend for Newbury (Sir M. McNair-Wilson) said, and I would be happy to pass a copy of it to my right hon. and learned Friend if he has not seen it.
The article has a sub-headingPity the doctor who looks after a convent—or a hostel for the handicapped".We should also pity the GP who has a large ethnic community of women who, for religious reasons, might not want to have smears. The article is considered and understandable. There must be some provision whereby a conscientious objector should not form part of a target. I understand why my right hon. and learned Friend the Secretary of State produced a target that was not 100 per cent. because that allows for some slippage.
However, the distribution of difficult patients is not perfect. However hard a GP tries, in some cases he will not be able to make his target. He will then have to choose. For the moment, the vast majority of GPs will accept those people, but my right hon. and learned Friend will have to address that problem when he considers the pricing and re-pricing of the contract. If not, all hell will be let loose again and that cannot be in anyone's interest.
I made a note on my memo pad of the drug erythropoetin for kidney patients. As I understand it, there is a scandalous situation in the North West Thames regional health authority where that product is on a limited licence and consultants are being told that they can use only a certain amount of the drug on a limited number of patients. That blows apart the whole idea of drugs budgets at the hospital level.
We are all aware of what has been happening in recent years. Hospitals have told people that the minute they leave hospital they will not get any supplies and the GP will have to provide the medicine. I hope that my right hon. and learned Friend will listen with care to the marvellous case history outlined by my hon. Friend the Member for Newbury.
I was not a member of the Standing Committee that considered this Bill. However, I wonder why clause 18 on indicative drug budgets is still in the Bill. My right hon. and learned Friend the Secretary of State is on the record as saying that no patient will go without his or her medicine. However, he has not told us what happens if the 561 regional health authority has overspent once all the GPs have finished prescribing. He has not told us whether that money will come from supplementary provisions or from some other health service. My right hon. and learned Friend has had the pharmaceutical price regulation scheme, which has worked perfectly well. He can normally use PACT—prescribing analyses and costs—although I cannot understand why we have not had any PACT for the September to December quarter at level I. It is extraordinary that the Department of Health, its underlings and its subsidiary and ancillary organisations are falling down. That is another example where something that had been running reasonably smoothly has stopped running for some reason.
I hope that either my right hon. and learned Friend will drop clause 18 altogether or that it will be dropped in another place. We never learn. Some interesting work has been done in the United States on formularies by some people called Moore and Newman. Research in 47 states showed that not only did the states with formularies fail to achieve savings in prescription drug expenditure but they were required to spend more on other services. Against that background, one would think that we would not introduce formularies into this country.
The hon. Member for Peckham spoke about budget holders. I understand that there has been a statement that there will be 850 practice budget holders. The hon. Lady has a point. As sure as eggs is eggs, the names of practices that are budget holders will get out. The Health Service is not exactly the most secure service. It would be far better if practices which wish to take part in pilot schemes openly admit to doing so. The fact will get out, so they might as well say it up front.
It is no surprise to anyone who knows anything about general practice that people are applying for practice budgets. One need only examine the attractive administrative bonuses given to everyone who applies. It is a highly profitable area. Some might phrase it differently, but either way it is not surprising.
My hon. Friend the Member for Newbury was right when he said towards the end of his speech that the relationship between a GP and the patient is special. If, for one reason or another, it breaks down, it is right for both parties that the patient should go to another GP. The allocation system has always worked well to the benefit of both parties. To that extent, the new clause is unnecessary.
§ Mr. Tom Cox (Tooting)
As my hon. Friend the Member for Peckham, (Ms. Harman) said, the new clause is important. The speeches of the last two Conservative Members who have spoken show the breadth of concern on the matter. The Secretary of State should start paying attention. He claimed that all the anxieties and problems raised on this issue have been built up by my hon. Friend the Member for Peckham, but that is not true. Several Opposition Members have given examples of the problems, but the Secretary of State can be in no doubt that many Conservative Members could also give examples of the same problems.
I dealt with the case recently of an elderly constituent who rang her doctor and asked him to visit her. She was told that she was no longer on his list. She was given absolutely no reason. Even the Secretary of State can understand the great fear that that created in her and her 562 family who said, "Look, Mum, don't complain—don't be a nuisance". Is that the way in which our Health Service is developing? Will it develop under the conditions outlined by my hon. Friend and other hon. Members who have spoken about the costing of drugs?
The Secretary of State says that the problems that we have described do not exist. I have sent several letters in recent weeks to the Secretary of State from medical practitioners in Wandsworth health authority expressing deep anxiety about what is happening. I received a letter yesterday dated 9 March from the chair of the South West Thames regional health authority. She says:I know how difficult things are in Wandsworth. If you would like me or the officers to meet with you we will be only too happy to do so.That was from the chair of the regional health authority which covers Wandsworth. Does the Secretary of State believe that she would write such a letter if she were not worried about the circumstances of that health authority?
I wish to make some specific points about the problems of my constituent. It is all very well to say that if there is a breakdown in the relationship between patient and doctor, the best thing is for the patient to find another practitioner who will take the patient on to his or her list, but how is that done? In the case of my constituent, it took a considerable time to find another doctor who would take that elderly lady on to his list. The new clause is important because no one should be removed from a list until they have been given a reason for their removal and a list of other doctors prepared to take the patient. Otherwise who is supposed to look after patients until they are put on another list?
There should be a right of appeal. We often hear about the rights of working people, as affected by many issues, but where are patients' rights? Why are they not given the right to say that they are not happy with the attitude adopted by their GP and that they want the right to appeal? Patients need more than the right to appeal. Often we are dealing with elderly, disabled people who, sadly, do not always understand procedures. The procedures should be made clear to them and help and advice should be made available so that if they wish to appeal they have the opportunity to do so. If we are really committed to the rights of patients, the conditions outlined in the clause are essential. They should be supported not only by Opposition Members but by Conservative Members who have participated in the debate.
§ Ms. Harman
I thank my hon. Friends who spoke in support of the new clause and the two Tory Back Benchers who made important speeches. The best way to deal with the matter would have been to have no financial disincentive for GPs to keep expensive patients on their lists. Then we should not have to worry about an appeals procedure. Because those legal safeguards are not written 563 into the Bill to protect people from becoming uneconomic patients, we intend to press the new clause to a Division. I hope that hon. Members who expressed reservations will either vote with us or at least abstain.
§ Question put, That the clause be read a Second time:—
§ The House divided: Ayes 197, Noes 264.566
|Division No. 125]||[8.47 pm|
|Abbott, Ms Diane||Fyfe, Maria|
|Adams, Allen (Paisley N)||Galloway, George|
|Allen, Graham||Garrett, John (Norwich South)|
|Alton, David||Garrett, Ted (Wallsend)|
|Anderson, Donald||George, Bruce|
|Archer, Rt Hon Peter||Godman, Dr Norman A.|
|Armstrong, Hilary||Gordon, Mildred|
|Ashton, Joe||Gould, Bryan|
|Banks, Tony (Newham NW)||Graham, Thomas|
|Barnes, Harry (Derbyshire NE)||Griffiths, Nigel (Edinburgh S)|
|Barnes, Mrs Rosie (Greenwich)||Griffiths, Win (Bridgend)|
|Barron, Kevin||Hardy, Peter|
|Battle, John||Harman, Ms Harriet|
|Beggs, Roy||Hattersley, Rt Hon Roy|
|Beith, A. J.||Henderson, Doug|
|Benn, Rt Hon Tony||Hinchliffe, David|
|Bennett, A. F. (D'nt'n & R'dish)||Hoey, Ms Kate (Vauxhall)|
|Bermingham, Gerald||Hogg, N. (C'nauld & Kilsyth)|
|Blair, Tony||Home Robertson, John|
|Blunkett, David||Hood, Jimmy|
|Boyes, Roland||Howarth, George (Knowsley N)|
|Bradley, Keith||Howells, Geraint|
|Brown, Gordon (D'mline E)||Howells, Dr. Kim (Pontypridd)|
|Buchan, Norman||Hoyle, Doug|
|Buckley, George J.||Hughes, John (Coventry NE)|
|Caborn, Richard||Hughes, Robert (Aberdeen N)|
|Campbell, Menzies (Fife NE)||Hughes, Roy (Newport E)|
|Campbell, Ron (Blyth Valley)||Hughes, Sean (Knowsley S)|
|Campbell-Savours, D. N.||Illsley, Eric|
|Carlile, Alex (Mont'g)||Ingram, Adam|
|Cartwright, John||Janner, Greville|
|Clark, Dr David (S Shields)||Jones, Barry (Alyn & Deeside)|
|Clarke, Tom (Monklands W)||Jones, Ieuan (Ynys Môn)|
|Clay, Bob||Jones, Martyn (Clwyd S W)|
|Clelland, David||Kennedy, Charles|
|Clwyd, Mrs Ann||Kilfedder, James|
|Cohen, Harry||Kirkwood, Archy|
|Coleman, Donald||Lamond, James|
|Cook, Robin (Livingston)||Leadbitter, Ted|
|Corbett, Robin||Lestor, Joan (Eccles)|
|Cousins, Jim||Lewis, Terry|
|Cox, Tom||Livsey, Richard|
|Crowther, Stan||Lloyd, Tony (Stretford)|
|Cryer, Bob||Lofthouse, Geoffrey|
|Cummings, John||Loyden, Eddie|
|Dalyell, Tam||McAllion, John|
|Darling, Alistair||McAvoy, Thomas|
|Davies, Rt Hon Denzil (Llanelli)||McCartney, Ian|
|Davies, Ron (Caerphilly)||McFall, John|
|Davis, Terry (B'ham Hodge H'l)||McGrady, Eddie|
|Dewar, Donald||McKay, Allen (Barnsley West)|
|Dixon, Don||McKelvey, William|
|Doran, Frank||Maclennan, Robert|
|Duffy, A. E. P.||McNamara, Kevin|
|Dunnachie, Jimmy||Madden, Max|
|Eadie, Alexander||Mahon, Mrs Alice|
|Eastham, Ken||Marek, Dr John|
|Ewing, Harry (Falkirk E)||Marshall, Jim (Leicester S)|
|Ewing, Mrs Margaret (Moray)||Martin, Michael J. (Springburn)|
|Faulds, Andrew||Martlew, Eric|
|Fearn, Ronald||Maxton, John|
|Field, Frank (Birkenhead)||Meacher, Michael|
|Fields, Terry (L'pool B G'n)||Meale, Alan|
|Fisher, Mark||Michael, Alun|
|Flannery, Martin||Michie, Bill (Sheffield Heeley)|
|Foot, Rt Hon Michael||Michie, Mrs Ray (Arg'l & Bute)|
|Foster, Derek||Molyneaux, Rt Hon James|
|Foulkes, George||Moonie, Dr Lewis|
|Fraser, John||Morgan, Rhodri|
|Morris, Rt Hon A. (W'shawe)||Sillars, Jim|
|Mowlam, Marjorie||Skinner, Dennis|
|Mullin, Chris||Smith, C. (Isl'ton & F'bury)|
|Murphy, Paul||Smith, Rt Hon J. (Monk'ds E)|
|Nellist, Dave||Smith, J. P. (Vale of Glam)|
|Oakes, Rt Hon Gordon||Smyth, Rev Martin (Belfast S)|
|Orme, Rt Hon Stanley||Soley, Clive|
|Paisley, Rev Ian||Spearing, Nigel|
|Patchett, Terry||Steel, Rt Hon Sir David|
|Pike, Peter L.||Steinberg, Gerry|
|Powell, Ray (Ogmore)||Taylor, Mrs Ann (Dewsbury)|
|Prescott, John||Taylor, Matthew (Truro)|
|Primarolo, Dawn||Thompson, Jack (Wansbeck)|
|Quin, Ms Joyce||Turner, Dennis|
|Radice, Giles||Wallace, James|
|Randall, Stuart||Walley, Joan|
|Redmond, Martin||Wardell, Gareth (Gower)|
|Rees, Rt Hon Merlyn||Wareing, Robert N.|
|Richardson, Jo||Welsh, Andrew (Angus E)|
|Robertson, George||Welsh, Michael (Doncaster N)|
|Robinson, Geoffrey||Wigley, Dafydd|
|Rogers, Allan||Williams, Alan W. (Carm'then)|
|Rooker, Jeff||Wilson, Brian|
|Ross, Ernie (Dundee W)||Winnick, David|
|Ross, William (Londonderry E)||Wise, Mrs Audrey|
|Rowlands, Ted||Worthington, Tony|
|Ruddock, Joan||Young, David (Bolton SE)|
|Sheerman, Barry||Tellers for the Ayes:|
|Sheldon, Rt Hon Robert||Mr. Frank Haynes and Mrs. Llin Golding.|
|Shore, Rt Hon Peter|
|Adley, Robert||Chapman, Sydney|
|Alexander, Richard||Churchill, Mr|
|Alison, Rt Hon Michael||Clark, Dr Michael (Rochford)|
|Allason, Rupert||Clark, Sir W. (Croydon S)|
|Amess, David||Clarke, Rt Hon K. (Rushcliffe)|
|Amos, Alan||Colvin, Michael|
|Arbuthnot, James||Conway, Derek|
|Arnold, Jacques (Gravesham)||Coombs, Anthony (Wyre F'rest)|
|Arnold, Tom (Hazel Grove)||Coombs, Simon (Swindon)|
|Baker, Rt Hon K. (Mole Valley)||Cope, Rt Hon John|
|Baker, Nicholas (Dorset N)||Couchman, James|
|Baldry, Tony||Cran, James|
|Banks, Robert (Harrogate)||Currie, Mrs Edwina|
|Batiste, Spencer||Curry, David|
|Bellingham, Henry||Davies, Q. (Stamf'd & Spald'g)|
|Bendall, Vivian||Davis, David (Boothferry)|
|Bennett, Nicholas (Pembroke)||Day, Stephen|
|Benyon, W.||Devlin, Tim|
|Biffen, Rt Hon John||Dorrell, Stephen|
|Blaker, Rt Hon Sir Peter||Douglas-Hamilton, Lord James|
|Body, Sir Richard||Dover, Den|
|Bonsor, Sir Nicholas||Dunn, Bob|
|Boscawen, Hon Robert||Eggar, Tim|
|Boswell, Tim||Emery, Sir Peter|
|Bottom ley, Mrs Virginia||Evans, David (Welwyn Hatf'd)|
|Bowden, A (Brighton K'pto'n)||Favell, Tony|
|Bowden, Gerald (Dulwich)||Fenner, Dame Peggy|
|Bowis, John||Field, Barry (Isle of Wight)|
|Boyson, Rt Hon Dr Sir Rhodes||Fishburn, John Dudley|
|Brandon-Bravo, Martin||Forman, Nigel|
|Brazier, Julian||Forsyth, Michael (Stirling)|
|Bright, Graham||Forth, Eric|
|Brown, Michael (Brlgg & Cl't's)||Fowler, Rt Hon Sir Norman|
|Bruce, Ian (Dorset South)||Fox, Sir Marcus|
|Buchanan-Smith, Rt Hon Alick||Franks, Cecil|
|Buck, Sir Antony||Freeman, Roger|
|Budgen, Nicholas||French, Douglas|
|Burns, Simon||Gale, Roger|
|Butler, Chris||Gardiner, George|
|Butterfill, John||Garel-Jones, Tristan|
|Carlisle, John, (Luton N)||Gill, Christopher|
|Carrington, Matthew||Glyn, Dr Sir Alan|
|Carttiss, Michael||Goodhart, Sir Philip|
|Cash, William||Goodlad, Alastair|
|Chalker, Rt Hon Mrs Lynda||Goodson-Wickes, Dr Charles|
|Channon, Rt Hon Paul||Gorman, Mrs Teresa|
|Gorst, John||Miscampbell, Norman|
|Gow, Ian||Mitchell, Andrew (Gedling)|
|Grant, Sir Anthony (CambsSW)||Mitchell, Sir David|
|Greenway, John (Ryedale)||Moate, Roger|
|Griffiths, Peter (Portsmouth N)||Monro, Sir Hector|
|Grist, Ian||Montgomery, Sir Fergus|
|Ground, Patrick||Morris, M (N'hampton S)|
|Grylls, Michael||Moss, Malcolm|
|Hague, William||Moynihan, Hon Colin|
|Hamilton, Hon Archie (Epsom)||Neale, Gerrard|
|Hamilton, Neil (Tatton)||Nelson, Anthony|
|Hampson, Dr Keith||Neubert, Michael|
|Hanley, Jeremy||Newton, Rt Hon Tony|
|Hannam, John||Nicholls, Patrick|
|Hargreaves, Ken (Hyndburn)||Nicholson, David (Taunton)|
|Harris, David||Nicholson, Emma (Devon West)|
|Haselhurst, Alan||Norris, Steve|
|Hayhoe, Rt Hon Sir Barney||Onslow, Rt Hon Cranley|
|Hayward, Robert||Paice, James|
|Heathcoat-Amory, David||Parkinson, Rt Hon Cecil|
|Hicks, Mrs Maureen (Wolv' NE)||Patnick, Irvine|
|Hicks, Robert (Cornwall SE)||Pawsey, James|
|Higgins, Rt Hon Terence L.||Peacock, Mrs Elizabeth|
|Hill, James||Porter, Barry (Wirral S)|
|Hind, Kenneth||Porter, David (Waveney)|
|Hogg, Hon Douglas (Gr'th'm)||Portillo, Michael|
|Holt, Richard||Price, Sir David|
|Howell, Rt Hon David (G'dford)||Raison, Rt Hon Timothy|
|Howell, Ralph (North Norfolk)||Rathbone, Tim|
|Hughes, Robert G. (Harrow W)||Renton, Rt Hon Tim|
|Hunt, David (Wirral W)||Rhodes James, Robert|
|Hunt, Sir John (Ravensbourne)||Ridsdale, Sir Julian|
|Irvine, Michael||Rifkind, Rt Hon Malcolm|
|Irving, Sir Charles||Roberts, Wyn (Conwy)|
|Jack, Michael||Rossi, Sir Hugh|
|Janman, Tim||Rost, Peter|
|Jessel, Toby||Rowe, Andrew|
|Johnson Smith, Sir Geoffrey||Rumbold, Mrs Angela|
|Jones, Gwilym (Cardiff N)||Sackville, Hon Tom|
|Jones, Robert B (Herts W)||Sayeed, Jonathan|
|Jopling, Rt Hon Michael||Scott, Rt Hon Nicholas|
|Kellett-Bowman, Dame Elaine||Shaw, Sir Michael (Scarb')|
|Key, Robert||Shephard, Mrs G. (Norfolk SW)|
|King, Roger (B'ham N'thfield)||Shepherd, Colin (Hereford)|
|Kirkhope, Timothy||Sims, Roger|
|Knapman, Roger||Skeet, Sir Trevor|
|Knight, Greg (Derby North)||Smith, Sir Dudley (Warwick)|
|Knight, Dame Jill (Edgbaston)||Smith, Tim (Beaconsfield)|
|Knowles, Michael||Speed, Keith|
|Knox, David||Speller, Tony|
|Lang, Ian||Spicer, Sir Jim (Dorset W)|
|Latham, Michael||Stanley, Rt Hon Sir John|
|Lee, John (Pendle)||Stern, Michael|
|Leigh, Edward (Gainsbor'gh)||Stevens, Lewis|
|Lennox-Boyd, Hon Mark||Stewart, Allan (Eastwood)|
|Lester, Jim (Broxtowe)||Stewart, Andy (Sherwood)|
|Lightbown, David||Stewart, Rt Hon Ian (Herts N)|
|Lilley, Peter||Stradling Thomas, Sir John|
|Lloyd, Sir Ian (Havant)||Sumberg, David|
|Lloyd, Peter (Fareham)||Summerson, Hugo|
|Lord, Michael||Taylor, Ian (Esher)|
|Luce, Rt Hon Richard||Taylor, John M (Solihull)|
|Lyell, Rt Hon Sir Nicholas||Taylor, Teddy (S'end E)|
|Macfarlane, Sir Neil||Tebbit, Rt Hon Norman|
|Maclean, David||Temple-Morris, Peter|
|McLoughlin, Patrick||Thompson, D. (Calder Valley)|
|McNair-Wilson, Sir Michael||Thompson, Patrick (Norwich N)|
|Madel, David||Thornton, Malcolm|
|Malins, Humfrey||Thurnham, Peter|
|Mans, Keith||Tracey, Richard|
|Maples, John||Trippier, David|
|Marland, Paul||Trotter, Neville|
|Marlow, Tony||Twinn, Dr Ian|
|Marshall, Michael (Arundel)||Vaughan, Sir Gerard|
|Martin, David (Portsmouth S)||Waddington, Rt Hon David|
|Mawhinney, Dr Brian||Waldegrave, Rt Hon William|
|Maxwell-Hyslop, Robin||Walden, George|
|Mellor, David||Walker, Bill (T'side North)|
|Meyer, Sir Anthony||Waller, Gary|
|Mills, Iain||Ward, John|
|Wardle, Charles (Bexhill)||Wood, Timothy|
|Watts, John||Woodcock, Dr. Mike|
|Wells, Bowen||Yeo, Tim|
|Wheeler, Sir John||Young, Sir George (Acton)|
|Wilkinson, John||Tellers for the Noes:|
|Wilshire, David||Mr. Tony Durant and Mr. Kenneth Carlisle.|
|Winterton, Mrs Ann|
§ Question accordingly negatived.
§ Mr. Kenneth Clarke
On a point of order, Mr. Deputy Speaker. I am sure you will confirm that the hon. Member for Peckham (Ms. Harman) exercised her undoubted right in refusing me leave to speak twice. Thereby she deprived me of an opportunity to reply. May I assure my hon. Friends that I will answer their points in correspondence, and may I point out that the discourtesy to the House was that of the hon. Lady, not mine?
§ Mr. Deputy Speaker
I have an apology to make to the Secretary of State. I had not realised that a right of reply is accorded to the Minister in charge of a Bill. I was quite incorrect to check him when he sought to reply. I hope that he and the House will accept my apology. I, too, can be wrong.