Sitting of 5 December 1980

Preamble
The House met at half-past Nine o'clock
PRAYERS
[MR. SPEAKER in the Chair]
Petition

  Blind People
  9.35 am
  Mr. James Wellbeloved: This week has been an important Week for blind people. The plight of blind people has been brought before public opinion by the presentation of a petition signed by 461,716 people. It is my honour and privilege to present that petition to the House this morning. It states:
  To the Honourable the Commons of the United Kingdom of Great Britain and Northern Ireland in Parliament assembled.
  The Humble Petition of the Royal National Institute for the Blind, the National League for the Blind and Disabled and the National Federation of the Blind of the United Kingdom on behalf of all blind people in the United Kingdom, together with that of their wellwishers, friends and supporters,
  Sheweth
  That there exists no social benefit which adequately compensates all blind people for the admitted extra living costs imposed by their handicap;
  That there have been introduced divers benefits in recent years designed to help many disabled people, to wit, the Attendance Allowance, the Mobility Allowance, the Non-contributory Invalidity Pension and the Housewife's Non-contributory Invalidity Pension, which benefits are greatly welcomed as a notable advance in social provision; but from which most blind people are in practice excluded;
  That provision for the blind in this country now lags far behind that of many other countries, including cur major European partners; and including a number of less prosperous countries as well as the leading industrial nations:
  That the Government has acknowledged that the case for a benefit to help blind people with the extra living costs imposed by blindness is now unanswerable;
  That the ultimate solution lies in the introduction of a comprehensive and properly structured disability income;
  That those who have the misfortune to be afflicted by blindness have for all these reasons a legitimate grievance needing immediate relief;
  Wherefore your Petitioners pray that your Honourable House may at the earliest possible date pass legislation to make a benefit payable to all registered blind people over the age of 16 on grounds of blindness alone;
  And your Petitioners, as in duty bound, will ever pray, &c.
  To lie upon the Table.

Perinatal and Neonatal Mortality
9.39 am
The Secretary of State for Social Services (Mr. Patrick Jenkin): I beg to move,
That this House takes note of the Second Report from the Social Services Committee, Session 1979–80, on Perinatal and Neonatal Mortality (House of Commons Paper No. 663) and the relevant Government Observations (Cmnd. 8084).
The hon. Member for Erith and Crayford (Mr. Wellbeloved) has presented his petition as a reminder to the House that health and social services are about priorities. It is wise and timely that we should have had that reminder as we open this debate.
The debate has followed swiftly—some have argued too swiftly—on the publication of the Government's reply to the second report of the Social Services Committee on perinatal and neonatal mortality. I understand the complaints of those who say that they have not yet had enough time to study the Government's reply or to consult the many interests who are involved, yet it seemed to me to be light to seize this opportunity of initiating a debate on the Floor of the House, which might well be the last opportunity before we rise for the Christmas Recess.
You will remember, Mr. Deputy Speaker, that there has been considerable pressure for a debate on the Committee's report. It is obviously more satisfactory that the House should debate that report together with the Government's reply. Of course, this will not be the last word. On the contrary, I see today's debate as giving hon. Members an early opportunity to comment on the Government's response at the start of what will be, I have no doubt, a continuing debate throughout the country.
Having a baby is one of the most momentous events in life. If the pregnancy has been straightforward, if the birth is accomplished successfully and if the child is born healthy and in every way normal, the event can also bring the deepest joy that is given to any of us to experience. Hundreds of thousands of successful and joyous births take place in this country every year, and as we consider today the tragic catalogue of misery, of unhappy pregnancies, and of babies born either dead or seriously handicapped, please do not let these tragedies obscure the reality that the majority—indeed, the vast majority—of births are, indeed, happy events.
But a whole series of reports—Cranbrook, Peel, Sheldon, Oppe, Court—have drawn attention to the problem of perinatal mortality.
It was the Spastics Society which, to its great credit, took up the challenge and launched its "Save a Baby" campaign in 1978. I was one of those invited to address that great gathering in Trafalgar Square to get the campaign under way, in company with seven other hon. Members, including the hon. Member for Eccles (Mr. Carter-Jones), whose commitment to this cause is well known and much admired. I said then, and I believe now, that we need to pursue a sustained campaign to improve on the considerable advance that has been made in recent years in reducing the toll of death and handicap.
It was right, therefore, that the Social Services Sub-Committee of the Select Committee on Expenditure, under the chairmanship of the hon. Member for Wolverhampton, North-East (Mrs. Short), decided to launch its inquiry in November 1978. She will remember that when I was Shadow spokesman on the social services I was able to reassure her that, if there should be a change of

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Government before the study was finished, a new Conservative Government would do what was necessary to enable the Committee, or its successor, to finish the work. We were as good as our word. I was, therefore, very pleased when, after the election and after the establishment of the new Select Committees, the Social Services Committee—once more, under the hon. Lady's chairmanship—took up the subject once again.
Although the Expenditure Committee had taken a great deal of evidence from my Department and from a number of other bodies, there was still a great deal for the new Committee to do. The subject turned out to be much more complex than had orginally been supposed, but the Committee proceeded to tackle it with a speed and thoroughness which must command admiration. For its success in doing so, it owes a great deal to the determination and energy not only of the hon. Member for Wolverhampton, North-East but also, if I may say so, to my hon. Friend the Member for Macclesfield (Mr. Winterton), who has played a notable part in the work of the Committee.
Although in our reply we have been critical of some of the assumptions and recommendations of the Committee, I would not wish that in any way to detract from the overall value which I am sure the report will be seen to have.
I said a moment ago that the great majority of births are accomplished happily and successfully. It is also right to say that substantial progress has been made in reducing perinatal deaths and handicaps over recent years. We spell this out in paragraphs 8, 10 and 11 of the reply.
The perinatal mortality rate has almost halved since 1963, from 29·1 per thousand to 15·4 per thousand in 1978. In 1979 it fell again to 14·7. The 28 per cent. reduction in the perinatal mortality rate in the five-year period from 1974 to 1979 is the most rapid since the introduction of stillbirth registration in 1931.
Before I go any further, I am sure the whole House would wish to underline that very great success. The latest available provisional figure for the first quarter of 1980 suggests that this improvement is being maintained. It has been accompanied by a slight reduction in the variability between regional health authorities from 1974–75 to 1978–79. One fact which I think will particularly please the House is that figures now available by social class from 1975 to 1978 show a greater proportional improvement in social class V than in social class I in both 1977 and 1978.
The Government's reply also spells out the marked increase in resources both in material and staffing that have gone into the maternity services over recent years. Perhaps I may quote from paragraph 13 of the reply to the report and the conclusion that we have drawn:
"In the light of these figures the Government consider that maternity and neonatal services have improved in effectiveness to a degree which it would be hard to parallel in any other of the major acute services. All the indications are of a momentum towards further improvement."
But, as we go on to say,
"while there is much cause for satisfaction, there is no cause for complacency."
So what needs to be done?
I believe that the Select Committee was entirely right to recognise that a further significant reduction in perinatal mortality could not be achieved by a handful of gimmicky measures. Instead, it said the aim should be to make progress over a wide field, and this is an aim which the
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Government entirely endorse. Where we would differ from the Committee is in our emphasis. We see this as implying the sustained campaign to which I made reference a moment ago rather than the immediate implementation of virtually all the recommendations which have been urged.
So our general approach to the Committee's recommendations is that we believe that many of them deserve serious consideration. Some can be accepted outright and immediately, but there are a few on which I am bound to say we have some reservations. We support the general thrust of the recommendations concerned with antenatal care, and those on the role of primary health care services, on health education, on humanising maternity care and on research.
We fully endorse the emphasis placed by the Committee on the value of early and regular antenatal care. The House will remember that we have already announced that in 1982 the maternity grant will become non-contributory, which is seen as a step to try to help those who need, and perhaps do not always get, proper antenatal care. We have allocated a sum of £375,000 to the second phase of the Health Education Council's "Mother and Baby" campaign during 1980–81.
We welcome the importance given by the Committee in recommendation 10 to an increase in the number of deliveries in large units, though we would not necessarily agree that births at home should be phased out further, as the Committee recommended. My view, quite clearly, is that where a mother reasonably insists on having her baby at home, I expect health authorities to provide a domiciliary service that is as safe as circumstances permit. The reply asks health authorities to review their arrangements for this and to ensure that they are known to all concerned.
We certainly accept recommendations 32 and 33 that patient care should be given by fully trained doctors and that much of the work at present done by juniors should be undertaken by consultants; and we also accept that there should be a substantial expansion of the consultant grade in obstetrics and gynaecology. Both these recommendations are in accordance with the policies agreed between the Health Departments and the profession.
We also accept that there should be an urgent increase in the number of consultant paediatricians, and we know that there are sufficient doctors in the training grades in that specialty to fill the posts that might be created.
Mr. Nicholas Winterton: I am delighted by what my right hon. Friend has just said, but will he also indicate whether the funds will be available for the additional positions to which he has just referred and which he and his Department are in favour of having?
Mr. Jenkin: I shall be coming in a moment to the question of funding. The Health Service is the one programme of Government expenditure where the projected rates of growth are being maintained. There are sufficient people in training grades to fill the extra posts recommended by the Committee.
There are many other recommendations which our reply accepts entirely, but I will not weary the House with listing them all. They are there to be read.
When one comes to some of the prospects which are held out by the Committee's report for improvements both in mortality and handicap, I feel bound to sound a note of caution.

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Perhaps the most widely publicised sentence in the whole report was that which estimated the scope for reducing deaths and handicaps. The Committee said:
"About one-third to one-half of the deaths are preventable, if modern knowledge and care were universally applied. This amounts to at least 3,000 to 5,000 avoidable baby deaths a year.
The number of children surviving each year with important handicaps that could have been prevented is probably at least 5,000."
With my colleagues and advisers I have studied the evidence with extreme care, and I dearly wish that I could stand here at this Box and endorse that judgment confidently. Very sadly, I have to say that the Committee's estimates are over-optimistic. As the House will have seen from the Government's reply, we have some doubt about how far improvements of this order could be achieved even if all the Committee's recommendations were fully implemented. Let me explain briefly why.
We are talking about prevention—the prevention of death and handicap. It is not enough simply to say that there are fewer perinatal deaths in other European countries and that, therefore, action by the NHS can of itself bring in the same success here.
There are other factors which operate, and some of those research has not fully explained. For instance, it is a fact that major congenital malformations occur much more frequently in this country than in, say, Scandinavia or other European nations. Of these, only a minority can be said to be preventable. We have a much higher incidence of low birth-weight babies in Britain, but I have to tell the House that medical research has not yet discovered ways of reducing this.
While these and other demographic factors continue, it is simply not realistic to expect a reduction in perinatal mortality to the same level as, for example, in Sweden, where, for whatever reason the demographic factors are different. The target set by the Committee of a reduction of 5,000 deaths would actually place this country's perinatal mortality rate below that of any other country in Europe. Given these facts, I think the House will see that that target, in the present state of medical knowledge—I qualify it by that phrase—is simply not attainable.
Mr. Lewis Carter-Jones: The right hon. Gentleman is quoting from the staff in his Department. Court, Oppe and other experts on the Committee and outside would take issue on this matter. Is it absolutely crystal clear that the advice that the right hon. Gentleman is getting from the Department, which is in conflict with the advice of other experts in the country, is acceptable to him and to the House?
Mr. Jenikin: I hope that the hon. Gentleman will notice the language that: I have used. I am not saying that this is absolutely right. I am sounding a note of caution. The evidence which was adduced to the Committee and the evidence of the epidemiological researches which have been carried out both here and overseas lead me at least to doubt whether the target set by the Committee is realisable. This is not the last word. I shall come to the question of research later. The point is that blandly—I do not want to be unkind to the Committee—to declare that 3,000 deaths a year could be prevented may not, in the present stats of knowledge and conditions in this country, be a realistic target.
Dr. Roger Thomas: Does the Minister accept that smoking has a deleterious effect upon a baby's
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birth weight? Does not this in some way affect the urgency of the negotiations which are taking place between the DHSS and the tobacco industry on this matter?
Mr. Jenkin: I agree that that is a most important factor. It is one of the recommendations in the report which we entirely endorse. Two or three weeks ago I announced the outcome of a short-term agreement that we have been able to make. It is now up to the House to decide how we can carry the matter further. I doubt whether the tobacco companies would agree to go any further. I hope that my hon. Friend the Minister of Health, if he catches your eye, Mr. Deputy Speaker, will be able to enlarge on that matter.
There is clear evidence that the incidence of perinatal death is linked with the general level of prosperity and standard of living of the country as a whole. If one studies the figures, compares the GNP per head and the level of perinatal mortality and makes allowance for all the uncertainties in the methodology, this country does not come out too badly. The United Kingdom is among the lower (3NPs per head in Europe. In fact, we have one of the better figures for perinatal mortality. That is not a matter for complacency, but it is a fact of which we need to take account.
Mr. W. R. Rees-Davies: Is it not a fact that spina bifida cases can almost always be screened out? Are not asphyxia, which accounts for about a quarter of these deaths, and cerebral haemorrhage preventable by mosern methods? Both those categories could be cut substantially provided they are able to be serviced effectively.
Mr. Jenkin: My hon. and learned Friend, who is a member of the Commettee, has studied the evidence carefully. I have no doubt that the points that he makes are right. I hope that when my hon. Friend replies to the debate he will be able to pick up the points mentioned by my hon. and learned Friend.
I turn now to the question of perinatal handicap. The Committee thought that up to 5,000 children survive each year with important handicaps that could have been prevented. I have not been able to find any evidence to support that assertion.
In paragraph 21 of the reply, we draw attention to views expressed by distinguished paediatricians, such as Dr. Aidan McFarlane and Dr. Edmund Hey. At a conference earlier this year, Dr. Hey made the point that
"the idea that perinatally acquired handicap can be relied upon to fall when perinatal mortality falls is a dangerous oversimplification for which very little evidence exists".
I shall not weary the House with other quotations. They are all set out in the reply.
Given that uncertainty, it really is vital that expectations should not be set unrealistically high. In the reply, in paragraph 23, we say:
"Such expectations could only add to the bitterness of parents, and provoke unjustified recriminations against medical and nursing staff in the face of a misfortune which they could have done nothing to aver."
Mr. Jack Ashley: The Secretary of State is right to try to keep the temperature low in view of that disgraceful reply, but some of us will raise the temperature very shortly. These quotations from the report are selective. If the Secretary of State really welcomes the report, why is every quotation and the report? Why is every quotation critical? Why is the right hon. Gentleman being so selective?
Mr. Jenkin: No doubt the right hon. Gentleman will catch your eye, Mr. Deputy Speaker, and make his points later. I have already indicated and will be indicating a great deal of sympathy and support for much that is in the report, because a great deal of it is valuable. If it is right, as I believe it is, to sound a note of caution over some of the assumptions and recommendations, I owe it to the House to do that and not to try to cover them up.
Mr. Nicholas Winterton: In our researches, which my right hon. Friend has admitted were deep, long and considered, we found that there was a considerable shortage of cots in neonatal intensive care units, and it was difficult for consultants and others in charge to decide which babies to admit. If that is the situation, does my right hon. Friend agree that many babies could live normal lives without handicap and might live rather than die if more facilities were available? We found considerable evidence that many neonatal intensive care units were forced, because of lack of cots, to turn away babies who deserved and should have had treatment in those units.
Mr. Jenkin: I hope that my hon. Friend will forgive me, because I am coming to that very important point. I shall deal with it shortly.
What I have said about the expectations does not mean that we should not set our faces very firmly in the direction of maintaining and improving on the steady reduction in the incidence of perinatal death and handicap which is already taking place. Of course, we should do that. We should maintain and, if possible, intensify that progress. I am sure that that is common ground in the House. But, in a field where human fears and human emotions are so closely engaged, it behoves us all to err on the side of caution in estimating what progress may realistically be attainable.
Another field in which we have felt bound to express some doubt about the Committee's recommendations is the part that greater medical intervention can play in the management of labour and the care of low birth weight and sick infants. I take, for instance, the question of foetal monitoring during labour. As the Committee heard, there is a good deal of professional debate about this. Not all obstetricians consider that electronic foetal monitoring should routinely be carried out for all patients. Reports, for instance, from the United States, suggest that routine monitoring tends to increase the rate of operative deliveries, including caesarean sections, without resulting in any conclusive evidence that it reduces the perinatal mortality rate. Therefore, the Committee's recommendation that continuous recording of the foetal heart rate should increasingly become part of the surveillance of all babies during labour seems to me to be putting forward a clinical opinion which, quite frankly, lay Members of Parliament are simply not qualified to express. That must be a matter for the clinical judgment of the doctors in charge.
Of course, no one doubts that foetal monitoring has a very important part to play in selected high-risk cases. But I do not think that it would be right for the Government to come down firmly one way or the other on the wider issue. I am very well aware that many mothers view the routine of foetal monitoring with some apprehension. It gives the appearance of treating every case as though it were one for intensive care, which the Committee indeed recommended. I found it—and I say this in no sense of
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unkindness — a little puzzling that in another recommendation the Committee actually said that the appearance of labour wards should be made to look less clinical and more human. I am not sure how these two recommendations add up. I am not sure that we want to encourage the technological image of the labour ward for the generality of births. Certainly this is a matter for further research, but I do not believe that it would be right for us to come out flatly, as the Committee has done, in favour of foetal monitoring of all babies during labour.
I now come to the question raised by my hon. Friend the Member for Macclesfield about intensive neonatal care. Anyone who has studied, as the Committee did and as I have done, the work of Professor Osmond Reynolds at University College hospital must be filled with admiration of the astonishing success that he and his team achieve in saving life and preventing serious handicap. But, if I may say so — and I hope that Professor Reynolds will forgive me—Ozzie Reynoldses do not grow on trees. He is a very remarkable man.
I suggest that the evidence shows that intensive care of this kind practised at anything less than the highest standards has some very grave drawbacks. Therefore, while we certainly agree on the concentration of high technology and expertise in one or two regional centres of excellence, it is a matter of prime importance that services develop in line with the ability to maintain these highest standards. Of course, that is what we want to see. But merely providing a lot more high-quality equipment without the necessary trained staff to be able to use it to the highest—
Mrs. Renée Short: We did not suggest that.
Mr. Jenkin: I am glad that the hon. Lady did not suggest that, because on that I think that we are in agreement.
I now come to the question of costs and benefits.
Mr. Nicholas Winterton: Will my right hon. Friend give way?
Mr. Jenkin: I must get on. My hon. Friend will—
Mr. Winterton: My right hon. Friend has avoided answering the question.
Mr. Jenkin: All right.
Mr. Winterton: Does my right hon. Friend agree that there is a shortage of neonatal intensive care cots? In our visits up and down the country, we found that there were many hospitals which had this facility but which could not admit all the children that they wanted to admit, and where they could have saved handicap and, in many cases, saved life as well, because the cots to accommodate these young babies were not available.
Mr. Jenkin: My hon. Friend has studied these matters very closely, and he will know that there are many recommendations in the report which we are commending to health authorities — I shall come to those recommendations shortly—to take on board when they are planning their services. This is certainly one of them. I am not saying that the present services are fully adequate. I am not arguing that. What I am arguing is that these things must move in line with the availability of this highly sophisticated equipment and the skills of the teams needed to operate it successfully.

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I now come to the question of costs and benefits, because this is an area, too, where we have some doubt about the Committee's estimates. The Committee itself did not make a precise calculation of the cost of implementing its 152 recommendations. Instead, it divided them into three categories—98 which could be implemented at little or no cost, 40 which the Committee recognised as having significant cost implications and 14 to which no cost or timing were attached.
It was at the press conference given by the hon. Member for Wolverhampton. North-East that the hon. Lady first put forward the figure of £25 million which has since entered into the public debate as if it were a figure approved by her Committee. It was recently, for instance, quoted by the new director of the Spastics Society, Mr. Tim Yeo, in a letter to The Times. I am afraid that I have to tell the House — we make this clear in the Government's report—that this figure is unrealistic. Our estimate is that the recommendations in the Committee's second category alone—the ones that have significant cost implications—would, if implemented, cost at least £60 million a year, and possibly as much as £160 million. Yesterday I answered a question and set out these calculations. Copies of the answer are available in. the Vote Office. I believe that our estimates are very conservative. Some recommendations simply cannot be costed at all.
Mr. Roland Moyle: Is that a net figure which makes allowances for the savings which will occur to NHS services as a result of this?
Mr. Jenkin: I shall be coming to the savings shortly. I am talking about the costs. The right hon. Gentleman is absolutely right. One needs to balance the cost with the projected savings.
But if one looks at the category A recommendations which the Committee suggests could be implemented at little or no cost, one finds that this is simply unrealistic. The Committee seems to have made no allowance at all for the staffing costs of undertaking the detailed reviews or negotiations which are envisaged in at least half of its recommendations or the cost of action arising from those reviews. We have not attempted a detailed costing of the category A recommendations, but we believe that the cost must be substantial.
The right hon. Member for Lewisham, East (Mr. Moyle) asked about the benefits. Clearly, if one can achieve a significant saving in handicap, of course there must be benefits. The Committee did not make a precise calculation of saving, but it put forward a figure of about £153 million over 10 years. The figures depend heavily on the Committee's estimate of the likely reductions in perinatal handicap. But, as I have already warned the House, the evidence does not exist to establish that these would be achievable. While, of course, the Spastics Society's; estimates of the cost of maintaining a seriously handicapped child must be given full weight — the society is quite right — one simply cannot go on to multiply that by the estimated number of preventable handicaps to reach the figure that the Committee has reached.
Therefore, we are driven to conclude—I wish that it were not so—that even on the very conservative basis of costings which we have adopted, on any realistic view of the benefits, measured in financial terms, the cost of
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implementing the report would be not less than four times and might be more than 10 times the estimated savings. It is against that background that we have had to look at the Committee's main recommendation, that of special funding. No proposals for measures which might save lives or prevent handicap should be lightly dismissed. We therefore considered this recommendation with extreme care.
The arguments are spelt out in paragraphs 61 to 65 of the Government's reply, but perhaps I can summarise the case in this way. The Health Service programme has been the only public spending programme which has been virtually spared any cuts in the latest review of public expenditure as a whole. It is inconceivable that, having been already accorded that degree of priority, we could possibly look for extra finance for the report. I am sure that the House must accept that money needed to implement the recommendations which are acceptable must come from the global total of the allocations made to the National Health Service. I am sure that the right hon. Member for Norwich, North (Mr. Ennals) will recognise that he faced the same problem.
Mr. David Ennals: I am staggered that the right hon. Gentleman should refer to me at this stage of his speech. He will recall that it was the Government's decision, when I was Secretary of State, to make a special injection into the National Health Service, of £100 million of which a significant part went to deal with this specific problem. At that time, I indicated the priority that we gave to it. The right hon. Gentleman cannot expect to get any support from me for his decision not to provide a penny.
Mr. Jenkin: I shall come in a moment to the position of the previous Government on this matter. A priority having been accorded and precisely the rate of growth that the right hon. Gentleman left having been maintained, it would be unrealistic to expect the Cabinet to agree to an extra funding on top for this report.
It follows that if we were to set aside a sum out of the money which would otherwise go to health authorities and demand that it be applied exclusively to the improvement of maternity services, we would have to spell out where the necessary cuts to finance this diversion of funds should be made. As we say in the report, more money for a neonatal intensive care cot might be less money for a kidney machine or a hip replacement. The dilemma is a real one, but it must be faced.
In order to try to accelerate the continuing fall in perinatal mortality and morbidity, would it be right to impose on health authorities what would necessarily be a diversion of funds at the expense of other groups such as the elderly and the disabled? Perhaps I may remind the House of what a leading article in The Guardian said on the day after the Committee reported:
"No attempt is made to judge the merits of reducing the deaths of perinatal mortality against the other priorities of the health service. At the end of a long dissertation when the Committee finally asked itself whether its proposals will need more money or some resources from another part of the service, it lamely answers: 'It is not for us to say which'".
The Guardian leader goes on:
"This might be a permissible approach for the new pressure group to take"—
I think it was referring to the Maternity Alliance—
"but it is totally inappropriate for a Select Committee hoping to influence a Secretary of State."
The leader concludes:

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"Government today is about how you make a quart from a pint pot. And if Select Committees want to be influential this is the task to which they must address themselves."
As we say in our reply, the Committee was able to avoid facing the dilemma. As Secretary of State, with statutory responsibility for the promotion of a comprehensive Health Service, I cannot evade it.
Mr. Ennals Mr. Ennals rose—
Mr. Jenkin: I must finish.
That is not the end of the matter. Our main objection is that if we were to top slice, as the phrase goes, and allocate specific sums to health authorities, the Government would be taking the decisions on spending priorities away from the authorities on the spot which are in the best position to assess their own local needs. We believe that health authorities will be able to make the most effective use of the total resources available to them if they have the maximum freedom in deciding how to spend them. If we take the decision away from them by earmarking or by prescription, we are attempting to impose a national pattern on circumstances that must differ substantially from area to area across the country. For these reasons, we have concluded that specific earmarking of finance is not the right way to achieve our objectives. It is absurd to suggest, as some have done, that nothing will happen.
A great many of the Committee's recommendations are, as we indicate in the reply, sound. We shall expect health authorities to act on them. We shall shortly be sending out a circular to the NHS attaching the Select Committee's report and the Government's reply and drawing attention to the proposals to which we attach importance. We shall be monitoring progress. Better monitoring of services is one of the recommendations—not only of this report but of the Committee's third report—which the Government already have in hand.
There are the professions. There is much in the report aimed at doctors, nurses, midwives and health visitors. I shall be writing to the professional bodies drawing their attention to the report and the reply and asking them to follow up the recommendations aimed at them. Progress is being made all the time. The latest figures show a further fall in the perinatal rate. The number of consultants in obstetrics and paediatrics continues to expand. The number of midwives in England and Wales rose by over 300 in the latest year for which there are figures. The training course for midwives is being extended from a year to 18 months. This should increase the proportion of trained midwives who go on to practise. At present, for every two who qualify, only one continues in the specialty. We have recently introduced central funding for the training of midwife teachers.
We are already funding some 18 research projects. Three have been approved in the last 12 months, and the Medical Research Council's comments on the Select Committee's report are attached to our reply. When we send out our policy guidance to health authorities early next year, the maternity and neonatal services will be among the priorities which we shall commend to those authorities.
Today, the House is rightly focusing attention on perinatal mortality and handicap. Many hon. Members will no doubt demand more action. These services,
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however, do not exist in isolation. In the next decade, the number of the over-85s will increase by 30 per cent. Services for the mentally ill leave much to be desired. The quality of life for too many of the mentally handicapped is still deplorable. There is a serious lack of services for the elderly mentally ill. Those who advocate more spending on maternity services must be prepared to say where there should be less spending.
Mr. Ennals: No.
Mr. Jenkin: The right hon. Gentleman says "No". He is abdicating all responsibility. Four years ago, the previous Government felt able—
Mr. Ennals: Will the right hon. Gentleman give way? He has referred to me.
Mr. Jenkin: No. The right hon. Gentleman will no doubt catch the eye of the Chair.
Four years ago, the previous Government felt able to write in "Priorities for Health and Personal Social Services in England", a consultative document published in 1976:
"we suggest that in general the hospital maternity services have attracted too large a share of resources; and that the minimum aim should be to have lowered their cost by about 7 per cent. by 1979–80."
That view contrasts markedly with the tone of this report and the Government's reply. I give credit to the right hon. Gentleman. Happily, by the time the previous Government left office, a different line prevailed. In the 1979 guidance circular, they were already saying that the right hon. Member for Norwich, North had given notice to health authorities of the need for a campaign to reduce perinatal mortality and handicap. Three years earlier, that was not the line they were taking.
It is right to draw attention to that situation. We must not make the same mistake again. All want to see a sustained campaign steadily to build on the progress of the last two decades. In making the National Health Service virtually the only area of public spending where the planned growth will continue precisely in line with the figures left behind by the right hon. Gentleman, we are ensuring that health authorities will have the extra resources to pay for the improvements that all want to see.
The Select Committee report, notwithstanding the reservations I have expressed, points the way, and the Committee deserves the thanks of the House. The Government's reply faces the dilemma squarely and realistically. The action that will flow from it will, I am confident, maintain the momentum of progress. I commend both documents to the House.
10.19 am
Mrs. Renee Short: I start by thanking the very helpful witnesses, both professional and non-professional. We are grateful to them for the help that they gave. I should particularly like to mention the obstetricians and gynaecologists, the peediatricians, the anaesthetists, the nurses and the midwives and also those whom we met and with whom we were able to talk when we travelled round the country to see what was happening outside London. We felt that that was extremely important. We talked to mothers-to-be in ante-natal clinics. We talked to health visitors, social workers, general practitioners and everyone concerned with obstetric services.
I have been impressed by the reaction of many of the health authorities to the report that we published and of the

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professional bodies that gave evidence to us. Many of them have been very disappointed by the Department's reply and by the way in which the Secretary of State has rejected some of the most important recommendations made by the Committee. They are sad that the right hon. Gentleman is not prepared to back up the proposals by increased resources.
I should like to thank also the members of the Committee, of whom, as the Secretary of State said, the hon. Member for Macclesfield (Mr. Winterton) was the only other survivor, with me, from the previous Expenditure Committee, which started this inquiry, it seems a long time ago, before the last election. I must give warm thanks also to our expert advisers, who are eminent in their specialties and who worked devotedly for long hours with the Committee and were unstinting in their help and advice. I thank also our Clerk, who was most supportive, as always, and those of his assistants who helped all the Committee a great deal.
We began our work because we were very concerned at the time with the 1977 figures, which showed that 19·3 of every thousand babies born in the West Midlands then were either stillborn or died in the first week of life, and we noticed the contrast with the figures in East Anglia, for example, where the proportion then was 12·9 per thousand, and the average for England and Wales at that time was. 16·9 per thousand. We wondered why the figures were so high and so varied in the different regions.
We were also concerned to (discover during the course of the first part of our inquiry that, besides the regional variations, there was a serious problem among mothers from some of the ethnic groups, where, again, the figures were very high. For example, babies born to mothers from Pakistan had the highest death rate among the ethnic groups of 25·2 per thousand. We felt that here, clearly, was an actue problem that needed to be looked at.
Our purpose in the inquiry was to underline the need for more rapid progress to eliminate unnecessary suffering and to draw attention to the difficulties which existed and still exist, and which needed and still need to be tackled, and, above all, to save babies' lives and to prevent handicap. That was before us during the whole of our inquiry.
We were interrupted by the general election, of course, and it was not until November last year, when the new Select Committees were set up, that we were able to get back to looking at the problem. During that time, of course, there has been an improvement. The position would have been very serious if there had not been. But our position is still very much worse than that of many other countries, and there must be reasons for this, which the Secretary of State has tended to gloss over.
We list some of the deficiencies in our conclusions. As I said at the beginning of my remarks, we did not just sit in Westminster looking at the theoretical problem. We received a great deal of very valuable evidence about the state of perinatal and neonatal care, and in our visits to the regions we were able to look at these problems for ourselves. Some of the evidence that we took there is published in the wealth of material to which the Secretary of State paid tribute.
We also had the evidence of our own eyes and ears In hospitals and clinics we talked to doctors, midwives, representatives of the regional health authorities and AHAs and expectant mothers. Though, in the nature of things, we were not able to make a comprehensive survey
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along the lines of the proposed monitoring service to which the right hon. Gentleman referred, and which we are glad to welcome, we were a roving eye, and I am sure that the right hon. Gentleman's roving eye, when he gets reports back, will produce some very worrying news for him.
We saw deficiencies in staff and equipment, lack of cover, and primitive, uninviting and overcrowded conditions in clinics and waiting rooms. It is that, coupled with our wealth of evidence, that stands behind our recommendations for more resources, for national standards and norms and for many other improvements that have received a better reception from the right hon. Gentleman than these have done. I shall say more about that in a moment.
In the Department's reply, I do not notice much emphasis being placed on deficiencies. However, one reference which I have noticed occurs in paragraph 42, on page 11:
"The Government have carefully considered whether the introduction of …. standards and norms …. would help to overcome the deficiencies of provision noted in the report."
That sounds rather like an admission of the accuracy of our reports on local conditions. I do not think that the right hon. Gentleman is saying that the deficiencies are not there. I think that he is saying that he cannot afford fresh resources to remedy them. However, he has to think again about this. I do not believe that this House, the medical professions or the people will accept a hand-washing exercise. They are too concerned about the present situation.
If serious deficiencies exist, the onus is clearly on the Secretary of State to explain why the action to overcome them is to be a limited one only. He has not explained that.
Mr. Patrick Jenkin: Will the hon. Lady acknowledge that, of the entire spectrum of public spending programmes, the only one that has been virtually freed from any cuts in the review that my right hon. and learned Friend the Chancellor of the Exchequer announced a few days ago is the National Health Service, and that this retains a built-in growth factor that is precisely that which the Government of which she was a supporter left behind on going out of office? Does she not recognise that there is extra money there to fund some of these recommendations?
Mrs. Short: The right hon. Gentleman takes a rather too easy view about that. The additional resources that are being made available to his Department are not adequate to cover the enormous level of inflation that all the spending Departments are facing. That is really the crux of the problem, and the right hon. Gentleman will have to think again about the pressure that he can put on the Chancellor of the Exchequer to find additional resources for this area, where it is possible to save lives and to reduce handicap. If he does that, he will save expenditure on handicapped and disabled people in the future.
I now say a few words about the main matters on which we differ from the right hon. Gentleman. First, however, I must make it clear that much of what we suggest, including some important recommendations, has been accepted by the right hon. Gentleman. We are glad that he has accepted, even if in a rather qualified way, the framework of committees that we recommend to give a new look to maternity services and which are important also for providing greater knowledge of the facts and better co-ordination at all levels. It is very good that he has

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accepted this proposal for maternity services committees, perinatal working parties and a maternity services advisory committee. These should help to bring together the services being provided so that there can be an expert look at standards.
I have referred already to the Government's new approach on monitoring, which is revealed not only in this reply but in reply to the Committee's third report, which was published this week. I am glad that the right hon. Gentleman has indicated today that he is not quite so "narked" by this report as by the third report.
In their reply, the Government also accept the Committee's description of the present planning system as cumbersome and confirm their intention to improve it. That is good.
The Committee expressed its anxieties about both monitoring and planning in perinatal matters in paragraphs 487 to 491 of the second report, House of Commons Paper 663. This is enough to show that in many respects the right hon. Gentleman agrees with us, and occasionally may even be ahead of us, though not in many respects. His response makes it possible to see how developments in the use of resources—not immediate, and very limited—might nevertheless take place in the directions recommended by the Committee.
I turn to the major recommendations which the Government have rejected. The first is on standards and norms. The Government do not mention, and I doubt whether they acknowledge, the weight of the Committee's point that the maternity services are particularly well adapted to the use of standards and norms, because the demands of the service are fairly predictable and it is an acute service with an established work load which is not subject to major seasonal or regional variations.
We are not worried about the best authorities. We are worried about the less efficient authorities, the losers in the fight for resources, the ones which have not allocated enough to their maternity responsibilities and which have not given maternity the priority that we think it needs. Had there been national standards and norms, would the authorities have been singled out by the Government as requiring urgent improvement in their maternity services?
Monitoring, coupled with medical audit and the work of the new perinatal committees at all levels, will, of course, help to keep up standards, but in my view the need for some kind of national guidelines is made greater by the Government's readiness to transfer responsibility for the maternity services and to implement some of the recommendations in the report.
Mr. Patrick Jenkin: On page 43 of our reply to the recommendations in chapter 14 of the hon. Lady's report, referring to standards and norms, we say:
"The DHSS intend to discuss Recommendations 94, 97, and 98 with the professions."
That must be the first step. If the professions believe that that would be helpful, it would be of great importance.
Mrs. Short: Yes, of course, but the Secretary of State has the advantage of reading the evidence from the professions about standards and norms. I hope that he will give due weight to that part of the professional evidence that we took. But responsibility without the necessary resources will not get us very far, and resources are the crucial part of our recommendations to the Government.
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Local independence is important. We readily understand the Government's motives, though in their reply to this report and the third report they seem almost to be allowing regions and areas to escape from the Minister's parliamentary responsibility. It is less easy to agree that authorities — in particular, districts — can always be relied on to give proper priority to maternity. I wonder what the right hon. Gentleman will recommend in that respect in the guidance document that he will send out. That is a matter in which we are very interested.
One of our witnesses from the North-West region said that it had a great way to go in redistribution of resources within the region. Another witness referred to the quarrelling that took place between areas in pursuit of the resources distributed by regions. Allocations seem to be settled by a kind of dogfight, and, of course, in a dogfight it is the strongest dog that wins, not necessarily the most deserving dog.
If we are not to have standards and norms, I hope that the Department's circular will give guidance to the health authorities.
The right hon. Gentleman gives us, by implication, some hope that that may happen, because he says in paragraph 65 of the reply that the Government
"would not be justified in according … the overriding priority recommended by the Committee."
I come now to the vexed question of finance, the costing problem. Great play has been made of the fact that the Committee underestimated the cost of its recommendations. The fact that the recommendations would cost more than we thought is certainly not an argument for not giving extra resources. As the Government realise, the Committee gives no estimate of costs in its reply, although I agree that we have made some unofficial estimates, £25 million to £30 million being the one put forward. That was not, nor could it be, a once-for-all sum. It could not be that, because it is obvious that many of the costs, such as salaries of new consultants and new staff at every level, are recurring and also because it stands to reason that the recommendations could not be implemented all at once. That was not our suggestion.
It is safe to say that the error made in calculating savings, which are much greater than allowed for, is of about the same order as the error the Department says that we made in our costs. These sums are all difficult to estimate. It is not up to the Select Committee to do the job of the Treasury or the Department in the allocation of resources between different specialties and responsibilities.
We are looking at some of these problems in the context of the examination of the Expenditure White Paper. We commented on the switching of resources. But our job in undertaking an inquiry of this kind is to look at the problems that arise in the area of the responsibility of the Secretary of State. That is what we did. The right hon. Gentleman cannot get out of it by saying that we have not looked at the whole question of distribution of priorities within his Department.
The Committee made no hard estimate of the total costs of our recommendations, because we thought that attempts to forecast future costs would be rather hazardous. One does not have to look far for examples of that. Leaving aside the predictions about the growth in the public sector borrowing requirement, there was an occasion when the

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Department was unable to explain to us an invoice of about £70 million far invalidity benefits which had not been provided for in its estimates.
When it comes to maternity, it is difficult lo cost what is happening, far less what will happen. For example, the Department has been unable to tell us what the maternity service actually costs. If the Department does not know the figure for total expenditure on maternity services, how can we estimate its possible future costs? We are ready to accept that higher figures are more likely than the figures that we have given, though we jib at the top limit mentioned by the Government in paragraph 57 of the reply. The figures for savings which the Government quoted in that paragraph were based only on the cost of a place in a Spastics Society home for 10 years. The figures did not include the cost of medical care or nursing and look no account of lost earnings of the individual concerned and the lost tax, and so on, from his employment.
On the general question of finance, we still believe that the surest way of curing the serious deficiencies that we found and the problem that exists in this country compared with other countries in Europe, and with America and Japan, would be to make some resources available to allow at any rate some progress to be made in implementing the more urgent of the Committees' recommendations which carry extra costs. We could not reach any decision on the reallocation of resources from, say, geriatric services without looking at the whole cost of these services, and that we did not do. Perhaps we could do that at some future time. The Minister says that we should have looked at the problems of dialysis and orthopaedic operations, but, again, that was not the subject of our inquiry.
Therefore, I hope that there is some meaning in the qualifying phrases used by the Government in paragraph 58, where they
"see no early prospect … of making additional investment on the scale that the Committee envisaged".
Let us hope that there will be some additional Investment, even though not perhaps what we expect.
A good deal will be done through the Government's acceptance of he principle that recommendations costing only a little could be considered for adoption immediately. I am pleased that the Government have accepted the need for humanising maternity care. Better clinics, more staff and, therefore, more time for examination and consultation would go a long way towards building up the confidence between doctor and mother-to-be that is essential for a happy birth. Although we are disappointed, particularly about the lack of funds, the reply opens some doors, and I hope that it will set up a new framework in which perinatal care can develop.
Mr. Rees-Davies: The hon. Lady emphasised the lack of investment proposals in the Department's reply, but she is now emphasising some good aspects of it. The Committee recognised that health education is the paramount need. Will the hon. Lady take that up, for the sake of the media? For instance, will she take up the matter of women who smoke and take alcohol, the need for early perinatal education classes and the need for education in schools? It is a most important matter.
The Government have accepted all the recommendations on humanising the service. They have indicated that the proper bodies concerned—almost entirely the health authorities—should stop the overcrowding and not make some of the clinics look like the lavatories at Waterloo
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station. They should look human. Will the hon. Lady emphasise some of those matters, which were agreed by the Committee and on which there is agreed Government policy?
Mrs. Short: The hon. and learned Gentleman is right in drawing attention to those important aspects of the inquiry. If we are to humanise the ante-natal clinics and labour wards, we must introduce a more homely atmosphere and get away from the dead white tiled walls and the lack of comfortable furniture for the fathers-to-be to sit in while they are giving support to the mothers-to-be. All those things can reduce the intimidating atmosphere that so often prevails in many of the clinics and hospitals.
The question of health education was underlined clearly in our report. Small amounts of additional money have been given to the Health Education Council from time to time for this vital work. The Select Committee on Expenditure, which examined preventive medicine before the last election, looked at the whole question of health education and made strong recommendations. Not many of those recommendations have been taken up, but I Commend them and those in this report to the Secretary of State and I hope that he will be able to implement some of them. Not all the recommendations cost a great amount of money. Clearly, the increased programme of health education needs more resources, because there is a wide area to cover. I am sure that the Secretary of State is sympathetic to that.
In paragraph 52 of the reply, the Government quote with approval a sentence from the Baird committee report, which recognises the importance Of socio-economic factors. The Secretary of State mentioned that in his speech. The report says that in the short term it is difficult to improve socio-economic conditions. Of course, it is. On the question of home births versus hospital births, many people are living in accommodation that is not suitable for a birth at home, and they do not necessarily live in old substandard houses. I am thinking about the tower blocks of flats, of which there are many in my constituency. The lifts are constantly breaking down. I cannot imagine what would happen to a woman starting labour and waiting for an ambulance if the lift had broken down. How would she get down the 14 flights of stairs?
Those problems have not been sufficiently faced by the Department. Are we to wait until we improve the socio-economic conditions and to to say that until then we shall not do very much more about reducing the perinatal mortality rate?
In the main, the Committee concentrated on medical intervention, and the Secretary of State underestimates that. It has been clearly demonstrated that medical intervention saves lives and prevents handicap. For example, the mortality rate in the Paddington area, which has the largest number of lower social class groups in London, was reduced between 1973 and 1976 from 22 per thousand to 9 per thousand—a spectacular reduction—simply by improving medical facilities. The Secretary of State cannot brush aside the value of medical intervention in reducing the perinatal mortality rate.
Through those procedures we have the means of preventing the deaths of some babies. But I emphasise that if we are to develop this all over the country we need more resources, and the Secretary of State must accept that. There is a great deal more to be done, and I appeal to the professions, on which so much responsibility has been

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placed by the Government, to the health authorities, to the great body of interested voluntary associations and to mothers to interest themselves in the recommendations of the report and to try to get as many as possible implemented. We hope that the Department will not lose any opportunity to finance the recommendations in the report and to be positive in its approach.
I ask the Secretary of State and the officials in his Department to think positively about the problem. The Department's reply is more positive than some of the Secretary of State's more recent statements.
The reply contains selective quotations from some of the witnesses. There is a philosophical argument about the reduction of perinatal mortality. Do we take responsibility for positive action, even if it costs money? We must accept that if we are to make progress it will cost money. One of the quotations contained in the Department's reply was from Dr. Peter Dunn, one of the Committee's witnesses. We asked him:
"If there were adequate staffing and equipment, do you think the neonatal mortality level would be brought down in this country?"
His reply was
"Dramatically".
The next question was:
"To the sort of level they have in France and Sweden?"
He replied
"Yes."
The Secretary of State knows that we heard evidence from Professor Papiernik, who has done so much in France to bring down the perinatal mortality rate. The next question was:
"And this conclusion is shared by Professor Butler?"—
professor of paediatrics at Bristol. He replied
"Yes."
We cannot accept our high rates of congenital malformation with equanimity. We reject that attitude by the Department.
Mr. Patrick Jenkin: I am not saying that we cannot make further progress, nor that a good many perinatal deaths are not preventable. I merely sound a note of caution about how far and how fast we can go, given the demographic factors.
Mrs. Short: The Secretary of State is apparently sympathetic to the Committee's findings, but he is not providing the necessary resources. The evidence from Dr. Dunn and the contrast between Britain and Sweden are signals for greater effort in this country to prevent complications in the treatment of potentially normal babies. All that costs money. The Secretary of State cannot wriggle out from under that conclusion and the responsibilities that it places upon him.
There is a great deal of evidence in the report and in the country in favour of a positive determination to get these matters right. I tend to be rather optimistic about all the political problems. I hope that the Department will do its homework and ensure that the proper help is given to the health authorities. I hope also that the Secretary of State will fight hard to find the necessary resources and that he will use our report as ammunition.
10.52 am
Mrs. Sheila Faith: Thank you, Mr. Deputy Speaker, for calling me so early in the debate. I apologise
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because I shall not be able to stay until the end of the debate as I have a speaking engagement in Durham early this evening.
I give a subdued and muted welcome to the Government's reply to the report. I welcome the fact that the Government believe that maternity services are likely to require higher priority throughout the country and have said that
"no proposals which save lives or handicaps can be dismissed lightly."
As a member of the new Social Services Committee, I thoroughly approved when the Committee decided to complete the report commenced in November 1978 by the Social and Employment Sub-Committee of the Expenditure Committee in the previous Parliament. I approved because, like many women, I have personal experience in these matters and because of the deep concern that our rates of perinatal mortality are not improving as they are in other European countries. I also approved because of the serious disparities between the regions and classes which, although diminishing, have been reaffirmed recently in the Black report.
I agree up to a point with the Secretary of State when he says that it is not necessarily true that perinatal acquired handicaps can be relied upon to fall when perinatal mortality falls. Later I shall amplify my fears about a certain part of the treatment. Nevertheless, many of the recommendations would not be costly and would certainly have an effect in reducing physical and mental handicap, as well as mortality.
Many witnesses stressed that early presentation at antenatal clinics is vital. I therefore welcome the provision in the Employment Act that gives employees the right to paid time off to attend ante-natal clinics. Considerable progress has been made in identification and prenatal diagnosis of Down's syndrome. When early visits to clinics are facilitated, particularly by older women, who are most at risk and who form a high proportion of mothers who do not attend clinics early, fewer handicapped children will be born. Screening for neural tube defects increased to 46 per cent. in January last year from 32 per cent. a year earlier, but there is still room for improvement.
The Government have accepted the recommendation to carry out cost-benefit studies of the effect of such interventions to reduce perinatal death and handicap rather than death alone. Increased health education plays a vital role. I pay tribute to Strathleven Bonded Warehouse Park Cakes and the Spastics Society, which have pioneered health education and have provided special provision for pregnant women in their factories. I hope that other firms, particularly those employing large numbers of women, will follow their example.
My hon. and learned Friend the Member for Thanet, West, (Mr. Rees-Davies) stressed the importance of persuading mothers not to smoke cigarettes. The Health Education Council says that that is one of the greatest factors in reducing infant mortality. In the United Kingdom that is important, because women are smoking more and more. Mothers should also be taught the value of a healthy and balanced diet. However, good habits must be taught from birth. The ideal conditions for a foetus developing in the womb are the result of a lifetime of healthy living and are linked to the standard of living.
The idea that health visitors, midwives and other community workers should form a commando group to ensure that extra resources are given to high-risk mothers

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from poor backgrounds and the immigrant communities should produce tangible results. I hope that health authorities will look favourably upon the idea and that my right hon. Friend the Secretary of State will give clear guidance on these and other matters in the report.
The measures to which I have referred — early attendance at clinics, health education and identifying high-risk mothers — should ensure some reduction not only in mortality but, more important, in physical and mental handicap. Nobody can say categorically that if the remedies were accepted in total no further handicapped babies would be born Every year, 18,000 children enter special schools or long-term institutions. The annual bill for such children is £550 million. The cost of caring for one severely handicapped individual in a 50-year life is probably more than £250,000. Even a small reduction in numbers would save a great deal of money.
Perinatal mortality has been reduced in the last 15 years, and that coincides with more financial resources being made available. I understand the conflicting demands made upon the National Health Service's limited resources. I also fully support the Government's overriding priority to bring down their spending and borrowing in order to free finance for productive industry, on which our prosperity depends.
Many of our recommendations might be expensive to implement, but, nevertheless, I say that they would be cost effective. I am glad that the Secretary of State agrees that an improvement should be made in the staffing of the maternity services. I hope that the inquiry into postgraduate medical education will produce remedies that will help to cure the shortage of obstetricians, paediatricians and anaesthetists.
When reading an article in Le Monde relating to the Select Committee report, I could not help noticing that the French word for midwife is "sage-femme" — wise woman, which is a very apt description. Everyone agrees that midwifery is the cornerstone of British obstetric practice. I am particularly delighted that there are to be new measures relating to midwifery training and conditions of service. I hope that midwifery will soon be able to attract more recruits.
I now come to an aspect that causes me concern. Our Committee was told that the resuscitation of extremely premature babies would not cause an increase in the number of babies surviving with serious mental and physical handicaps, but I must admit that I still have some misgivings. The Select Committee visited the neonatal unit at St. Mary's hospital in Manchester in March. I certainly would not denigrate the wonderful work carried out there or the work carried out by Professor Reynolds. We saw babies in incubators, or in intensive care cots as they are now called, some with their mothers anxiously watching over them. Some of those babies were very tiny indeed. I understand that babies are being saved who weigh as little as just over 11b. The progress of those babies should be followed up and they should be given regular and detailed psychological assessment at possibly 2, 6 and 8 years old. Local community services should play a part in that process. That is very important, as some say that there is a degree of handicap in quite a high proportion of low-birthweight babies.
I am glad that the Medical Research Council and the Department of Health and Social Security are supporting research work, which suggests that it will soon be possible in the first few days of life to detect by ultra-sound and
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other techniques those infants in intensive care units whose prognosis is bad as a result of brain damage. Nevertheless, even when those new techniques are obtainable it will still be necessary to monitor closely the progress of the very small babies who are enabled to survive by the use of new technology and expertise.
I know from personal experience the disappointment and deep feeling of bereavement that follows the death of a baby at birth. It must be even more devastating if the baby lives for only a few days or weeks. However, it is a short, sharp sadness and is nothing compared with the anguish that a mother must feel when she knows that her child will never be fit or develop as other children do because of physical or mental handicap. Parents can and do give great affection to their handicapped children and receive affection in return, but many people break under the strain of the constant pressure of caring for those children. Many marriages suffer. Other children in the family also carry a heavy burden.
I am glad that my right hon. Friend says that he will continue to support the report. I hope that as soon as possible he will increase the financial support for our recommendations, which will afford an opportunity to save so many people so much suffering.
11.2 pm
Mr. David Ennals: We are debating this extremely important report only 48 hours after the Government's reply, which has put many of us in difficulty. I am due to open a day centre in Weymouth, and I apologise that I shall have to leave the House almost immediately after my speech. I shall, therefore, make a very short speech, which will be to the satisfaction of most hon. Members.
I pay the warmest possible tribute to my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) for her persistence as Chairman of the Committee and her dedication to duty in the previous Parliament and in this. I also pay tribute to the other members of the Committee, our advisers and all those who gave evidence. Although not a new boy on the subject, I am enough of a new boy on the Committee to be able to pay that tribute. The report is one of the most constructive and comprehensive ever published on the subject. It will take its place in history, if the Secretary of State allows it to. The implementation of the recommendations will be followed carefully not only by the professional organisations that gave evidence to us but by those that warmly welomed so many of the 152 recommendations, which covered almost every aspect of perinatal and neonatal mortality.
The Secretary of State is right to recall that there have been successes. Thank heavens for that! For many years this country's record lagged seriously behind, but between 1974 and 1978 perinatal mortality was reduced by nearly one-quarter. It was the most rapid decline for 30 years. In the same period, the differences between the least and the most favoured regions narrowed. The figure was 7·9 per cent. in 1974 and by 1978 it was 4·9 per cent., which is almost half. It is encouraging to read in paragraph 8 of the report that 1979 saw further advances. There has also been a considerable narrowing of the gap between social classes, which is an issue which greatly concerned the Committee.
The previous Secretary of State can take at least some credit for those achievements. I was a little upset that the right hon. Gentleman chose to condemn his predecessor

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at the press conference that he gave when he published his report. It was a little out of place in view of the progress made and the injection of funds accorded by the former Cabinet.
Mr. Patrick Jenkin: I can assure the right hon. Gentleman that I did no such thing. I was asked about the change in emphasis since the priorities document, and I considered it right to refer to that. I also referred to it in the House today. I was very glad that the right hon. Gentleman took a different view from his predecessor. Mrs. Barbara Castle was Secretary of State when the consultative document on guidelines was published in 1976.
Mr. Ennals: I am grateful to the Secretary of State for his explanation. An additional factor is that after a significant decrease in the birth rate there was an increase. The right hon. Gentleman is right. Every Secretary of State has to look at priorities. At a certain time it was clear that we had to give a much higher priority to perinatal and neonatal mortality.
The Government say in their report that they are by no means complacent, but I feel that their reply is soaked in complacency. They gave no opinion on most of the recommendations but passed them on for others to consider. The professions, the Royal colleges and the health authorities have to be considered. I hope that the Secretary of State will come back to the House and record their opinions. The report was published in August. I hope that nothing will be done to discourage the high hopes that have been raised, particularly among the professions, by the recommendations.
I strongly disagree with the Secretary of State's condemnation of the Committee for what was said in paragraph 15, which has been touched on by my hon. Friend the Member for Wolverhampton, North-East. We said that about one-third to one-half of the deaths would be preventable if modern knowledge and care were universally applied. The number of children surviving each year with important handicaps that could have been prevented is probably at least 5,000. The Government have used the evidence of Dr. Peter Dunn selectively. They suggest that that is the same as saying that all road accidents are preventable. They are. Although none of us imagines that we can prevent all road accidents, we give great priority to trying to do so. That is the objective. The objective of the report is to reduce deaths and handicap to the maximum extent possible.
We cannot do everything at once, but I am particularly disappointed that the Secretary of State declares that the Government will not find new money for the service. I do not know whether our figure of £20 million or £30 million is correct. I understand why the Secretary of State did not give way to me a second time, but the figure of £25 million is identical to the amount taken out of the Health Service by the Chancellor of the Exchequer in his statement on Monday of last week. The Secretary of State should not have accepted that. We need to see more money put into the National Health Service. I hope that he will give some priority to the recommendations that are made in the report. It seems that at present they are to be given no priority.
I have much sympathy with the point that is made in one of the paragraphs of the report that quotes from the
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Baird report. In fact, the same can be said about the conclusions reached in the Black report. When the Government seem to have taken it almost as an article of faith that living standards must fall, that housebuilding must stop, not only in the public sector but in other sectors such as housing associations, and that unemployment must increase, and have put aside the recommendations of the Black report, it is rather galling that they should refer to the Baird report.
It is not only the members of the Select Committee who feel that the Secretary of State's reply fails to rise to the importance of the subject and the significance of the recommendations. I recognise that he has accepted some of the proposals. I do not want to overstate the degree of complacency. However, one paediatrician said to me yesterday "As far as the care of sick newborn infants is concerned, the White Paper is an absolute disaster. It goes less far than the recommendations of the Sheldon report in 1951 and the Oppe report in 1974." I met a group of voluntary organisations yesterday which expressed deep concern that the Government were not prepared to put a penny into implementing the recommendations that have been submitted as a result of long weeks and months of research, evidence-taking and consideration.
The recommendations have not been submitted by a group of laymen. Every recommendation is based on professional advice that was given to us either in the House or when we took evidence. As I have said, the right hon. Gentleman's reply fails to rise to the importance of the subject. I believe that he will come in for some criticism. He must expect that from the organisations that were pinning their faith on the recommendations contained in what they have come to know as the Short report. They saw it as a ray of light. The Secretary of State has almost snuffed it out.
I hope that we have not had the right hon. Gentleman's last word. I hope that following the wide consultation that he says he will have with the professions and the health authorities he will be prepared to debate these issues again. He has not been fair to the House, to the organisations that gave evidence or to the professions that were so deeply involved. They received the report on Wednesday evening, and the House has had to debate it on Friday. That is not a fair way to treat a report of such fundamental importance.
I conclude with an apology to the Minister for Health, who, I understand, will reply from the Government Front Bench, and to my right hon. Friend the Member for Lewisham, East (Mr. Moyle), who will do likewise from the Opposition Front Bench. As I have said, I must leave the House in two minutes from now because I have to fulfil a Health Service engagement.
11.15 am
Mr. Nicholas Winterton: Like the hon. Member for Wolverhampton, North-East (Mrs. Short), the Chairman of the Social Services Select Committee, I pay tribute to those who gave evidence to the Committee, both in the previous Parliament to the Employment and Social Services Sub-Committee of the Expenditure Committee and to the newly founded Social Services Committee in the new Parliament. Many of them travelled great distances and went to great trouble. Many of them have presented us with well-researched papers. Their assistance has been

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of considerable benefit to the Committee in its deliberations and in forming the recommendations that we are discussing.
I pay tribute to the Chairman, the hon. Member for Wolverhampton, North-East, who, I think, did an excellent job. It is interesting that in Select Committees party politics a most disappear, so that those of different political persuasions can work closely and well together on a subject of mutual concern.
I pay tribute also to our three superb advisers—lamely, Professor Osmond Reynolds of University College hospital, Professor Richard Beard of St. Mary's hospital and Professor Eva Alberman of the London hospital medical college. They did work for us beyond that which one normally expects of cur advisers. They worked long hours, many of which were unremunerated. They did so because they share our concern in this area of medicine.
I am grateful to the Government for having responded 10 our report so quickly and for so speedily finding time for the debate. However, only 72 hours have elapsed since we received the Government's response. That has not enabled us to consult as widely as we would have wished or to have read the response from cover to cover. We have not had the physical or menial time to do that, and that is a great pity.
Mr. Ashley: I endorse everything that the hon. Member for Macclesfield (Mr. Winterton) has said so far. However, I have consulted many voluntary organisations in the past 24 hours, and they have all condemned the report. They have not criticised it; they have condemned it. We have not had time to consult properly, but so far no one has had a good word to say for the Minister's reply.
Mr. Winterton: I am well aware of the right hon. Gentleman's concern and of the way he dedicates so much of his time to these issues. I think that he is being rather too scathing of the Government when he says that there is not a word of support or of praise for the Government's reaction. I accept that it is lacking in some areas, but some progress has been made.
We have had the Sheldon report, the Court report and the Oppe report, and now we have the report from the Social Services Select Committee. I support my right hon. Friend in wishing to see much progress towards implementation of the recommendations that are contained in our report. As a member of the Committee, I regret that not all the recommendations have been taken on board by the Government.
My right hon. Friend rightly paid tribute to the ability and talents of Professor Osmond Reynolds and the work that he does at University College hospital. However, he implied—if he wishes to intervene, I shall give him the opportunity to do so—that University College hospital is unique. Does he not obscure the fact that many neonatal intensive care units, especially in North America and in other European countries, get similar results to those achieved at UCH? It is my view and the view of Professor Reynolds, as well as that of many within the profession, that the results that he achieves at UCH could be achieved in many other hospitals if the facilities that he has were made available elsewhere.
Mr. Patrick Jenkin: I am grateful to my hon. Friend for giving me the opportunity to intervene. I said that the unit was unique in Britain. It is, of course, not unique throughout the world. There is not much purpose in
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providing elaborate equipment—I am sure that my hon. Friend has seen, for example, the unit at UCH—if there are not high levels of skill within the team to draw the maximum advantage—
Mrs. Renée Short: Of course. We said that.
Mr. Jenkin: —and to march in step with the advances that have been made. That is the only point that I am seeking to make. I am sure that my hon. Friend understands that the greater provision of intensive neonatal units and ultra-sound equipment must be accompanied by the necessary professional skills to the extent of those possessed by Professor Reynolds and his team.
Mr. Winterton: I fully accept my right hon. Friend's response, but I am sure that he will understand if I find it somewhat unacceptable. As the hon. Member for Wolverhampton, North-East, who was Chairman of the Committee, has just said, there is a shortage of skilled personnel. I intervened in my right hon. Friend's opening speech to indicate my pleasure that the Government had taken on board the fact that extra consultancy and other posts were required. However, my right hon. Friend did not indicate where the funds would come from in order to allow the regional health authorities to make these appointments, which could bring other hospitals up to the standard of University College hospital. I hope that my hon. Friend the Minister for Health will deal with this important matter when he responds to the debate.
I turn to another matter that was raised by the Secretary of State, namely, the doubt which he expressed about the figures that we quote in our report about avoidable deaths and handicaps. The figure of 3,000 to 5,000 avoidable deaths is perhaps regarded by the Department and my right hon. Friend as unrealistic. However, he should pay due regard to the opinion of Dr. Wigglesworth, the leading perinatal pathologist in the world. He told the Committee that perinatal and neonatal deaths were caused by four approximately equal influences—macerated stillbirths, congenital malformations, asphyxia during birth and problems of immaturity. They are all partly preventable with adequate care. He made that point very clearly. I remind my right hon. Friend that his calculations were based on a perinatal mortality rate of 17 per 1,000.
We should appreciate the improvements that have taken place and base figures on 15 per thousand deaths. If he does some arithmetic, I am hopeful that my right hon. Friend will reconsider the view that he expressed earlier. Those 15 per thousand deaths can be broken down as follows, and I have rounded up the figures for the sake of simplicity. Macerated stillbirths would account for four, as would congenital abnormalities. Asphyxia would account for three, and immaturity four.
Reductions in death which are entirely foreseeable yield the following results. Let us assume that we achieve a reduction of one-quarter in macerated stillbirths, which can be done by much better antenatal care. Let us also assume that we achieve an improvement of one-quarter in respect of congenital abnormalities, which can be done by foetal screening. My right hon. Friend referred in his intervention to the importance of screening. We could improve asphyxia by two out of three through monitoring. I know that the professions will confirm that that can be achieved. We could also achieve an improvement of one-quarter in relation to immaturity by neonatal care. That can

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certainly be done, and that was the evidence given to us by experts in our inquiry. As a result, we can save 3,000 lives.
The professions believe that that performance can be further improved with the right facilities and with skilled, professional and talented staff. That would result in an improvement in macerated stillbirths of two out of four. There could be an improvement in congenital abnormalities of one out of four. Asphyxia could be eradicated altogether, because it can easily be done by foetal monitoring. We could also save three out of the four who die as a result of immaturity. In that way, we could save 5,400 lives.
I believe that the evidence that was given by Dr. Wigglesworth, who, as I have said, is the leading perinatal pathologist in the world, clearly indicates that that sort of achievement is well within the ability of the NHS and that such results could be achieved if my right hon. Friend the Minister for Health and the Department allocated just a little more funding to the NHS.
I find it interesting that my right hon. Friend should query our figure of £25 million to £30 million when he cannot provide us with the costs of the maternity services and when the Government's response to our paper gives such a wide figure of anything between £60 million and £160 million. I find it strange that my right hon. Friend can do so and at the same time say that we are underestimating the cost so dramatically.
Mr. Patrick Jenkin: I apologise for the fact that we did not get the reply to the House early enough for it to be printed in Hansard today. However, we have spelt out in a written parliamentary answer how that range of £60 million to £160 million is arrived at. Those figures represent a high and a low. For example, if one takes all the low the figure is £60 million, and if one takes all the high it is £160 million. Those are extremes, and the answer lies somewhere in between.
Mr. Winterton: I do not wish to argue now whether those are high or low sums of money in modern terms. I should be happy if my right hon. Friend were to advance the £25 million to £30 million that we have suggested, because I believe that that would go a long way towards reducing the perinatal and neonatal mortality rate. I appreciate that improvements have taken place in recent years. It appears to me that they have taken place because this House, through hon. Members on both sides, has persistently raised the subject and because the reports that have been produced have concentrated the minds of the Department and the Government on this issue.
I should like to see specific Government action aimed at reducing the rates that exist at present rather than the House having to do so by keeping the subject before the public eye.
Mrs. Renée Short: Perhaps the hon. Gentleman will point out to the Secretary of State that it is extremely galling for us to know that the perinatal mortality rate has been reduced in many other countries on the basis of the work that has been carried out by paediatricians in this country, which has also developed equipment that is used to save low-birthweight babies. It is galling to be told that we cannot afford to expand those resources here when other countries have picked up our ideas.
Mr. Winterton: I agree. That is a crying shame. For example, the latest figure in Sweden is 9.1, which shows that a continued campaign can have dramatic results. I only hope that the Department and my right hon. and hon. Friends will take this matter very much to heart.
I turn briefly to the question of severe handicaps and the figure of 6,000. These are largely due to congenital malformations, such as spina bifida. The not so severe handicaps, which number 12,000, are likely to be largely due to perinatal events such as birth asphyxia or cerebral haemorrhage in premature infants, although it is true that hard evidence one way or the other is lacking.
As was said earlier, spina bifida can be screened out, and asphyxia and cerebral haemorrhage are becoming preventable. Therefore, I am convinced—I am afraid that my right hon. Friend's response does not carry much weight with me — that the evidence that we received from the witnesses who appeared before us clearly indicates that we can achieve not only a great saving of lives but a great saving in the number of young babies who will suffer from permanent and severe handicap.
I do not want to spend time talking about the cost to society of looking after handicapped babies. However, my hon. Friend the Member for Belper (Mrs. Faith) talked about the cost being in the region of £¼ million or more for an individual living for approximately 50 years. On that basis, it would not take very long even for the £160 million to be recouped and for the Government and the Treasury to have a saving on expenditure. Despite the problems with regard to expenditure with which the Government are currently faced, I believe that investment in the right place — I recently said this in another context—will stand this country in good stead.
Mr. Richard Alexander: My hon. Friend has reached a point where he may be able to answer a queston from his knowledge of serving on the Committee. As I understand the report, many of the recommendations do not require immediate funding. There is a long lead-in time to what is required. Does he agree that that is the case? Will he urge our right hon. Friend the Secretary of State to accept that some immediate planning could be carried out for nearly all the recommendations?
Mr. Winterton: The vast majority of the recommendations do not require any expense at all, merely a push, some pressure and guidance from the centre. Whether or not the ultimate decisions will be taken by regional health authorities, the initiative must come from the Secretary of State and his Department. I do not like the idea of regional health authorities vying with each other. That is dangerous. In his opening remarks, my right hon. Friend indicated that the facilities in various areas differed widely. He should become deeply involved in the matter and ensure that there is uniformity of provision in this vital area of medicine.
Interest in perinatal and neonatal mortality stems from a desire to improve the outlook for future generations. With the health and medical professions having the competence and the ability to improve the position dramatically, is it not right that the Government should now provide the incentive, the guidance, the facilities and the limited funds at an early date to bring about the necessary improvements?
Perinatal mortality figures are only the tip of the iceberg. Underneath lies the much greater and more

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serious problem of perinatal handicap inflicted on babies as a result of injury sustained before or during the process of birth. Where such handicap can be avoided, all the necessary action should be taken at once. I repeat that we have the medical skills to bring that about. If only we had the machinery, the facilities and the limited funds, the figures that I mentioned—which were doubted by my right hon. Friend the Secretary of State — could be achieved. We could cut down both the deaths of babies and the number of babies born with permanent and severe handicaps.
There are many, many matters that I could draw to the attention of my right hon. Friend. I repeat that international comparisons, which are shown clearly on pages 10 and 12 of the report, indicate that while the perinatal mortality in England is falling steadily each year, our figures remain significantly higher than those of several European countries. We all know that those figures mean not only a substantial cost to my right hon. Friend's Department and other Government services but—and we must take this into account—much sorrow, sadness and great difficulty to individuals and their families. There is a need for improvement in Britain and ample justification for the recommendations made in the report.
There is good evidence that we could be doing a great deal more to reduce death and handicap. Surely, the evidence that has been given to us by Dr. Wigglesworth is worth taking on board. The Secretary of Slate should take his evidence seriously. If a man of that reputation can say what he has said about the number of deaths and handicaps that could be avoided, my right hon. Friend and his Department should weigh his evidence carefully.
The maternity services have gone through major changes in recent years necessitating the complete reorganisation which, to an extent, we recommend in our report. Some of the changes include the transfer from a domiciliary to a hospital-based service, for very good reasons—they are set out in our report—and the rapid advances of modern medicine such as blood transfusion, general anaesthesia, pain relief in labour and the technology of monitoring. They have all significantly improved the safety of mother and baby.
Those of us who had the pleasure, honour and experience of visiting St. Mary's, University College and other hospitals were amazed at the huge advances that lave been made and the highly sophisticated machinery that is new available and can play such an important part in saving lives. Resuscitation and support of the sick newborn is now a well-established part of medicine which must be carried out in hospitals containing the facilities of modern medicine.
Perhaps those arguments dictate the centralisation of delivery of all women in hospital. However, I emphasise that the Committee felt that it was faced with an almost unresolvable dilemma because many women wish to be delivered in maternity units, such as general practitioner units, that do not have the facilities to deal with possible perinatal and neonatal mortality. Other women wish to be delivered in their homes.
We do not say anything in our report to prevent that happening, but we clearly state that where there is likely to be a difficult birth—and that can be discovered if proper antenatal care starts at the right time — the mother-to-be should have a bed in a hospital where all the latest, most sophisticated and up-to-date equipment is available and where the consultants with the highest
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qualifications in perinatal and neonatal mortality and obstetrics are available to care for her before, during and after birth.
I welcome the report in a somewhat muted way. My right hon. Friend has met some of the requirements—for example the humanising of the ante-natal care facilities. We visited a hospital in the area of the hon. Member for Wolverhampton, North-East and were shocked by what we could only describe as the cattle market atmosphere in that large hospital. Obviously, that is a deterrent to women to attend for ante-natal care. The difficulty of getting to hospitals or clinics for ante-natal care was a consideration that came before us and about which we felt very concerned.
The Government have a heavy responsibility. It is not going too far to say that if the Government do not act a little more positively than they have today through the Department and the Ministers, they will, regrettably—I say this with great reluctance—be responsible for the unnecessary death of a number of babies and the unnecessary handicap of a number of babies who will survive because of the facilites and the medicine that is available today. Babies that previously would have died because of their handicap can now be kept alive, but too often they are handicapped. The Government will be responsible for that. I do not believe that my right hon. and hon. Friends on the Front Bench will want that position to weigh heavily on their consciences.
My right hon. Friend has not responded to the question that I put to him earlier about staffing. He talked about the provision of further consultant posts, but where will the money come from to fund the posts? We made firm recommendations about the problems facing midwives. I said at the press conference when our report was published that I believed that midwives could make a major contribution to improving perinatal and neonatal mortality. But their career structure is highly unsatisfactory. Their qualifications are not properly recognised in their remuneration. From the various representations that I have received since the publication of the Government's response, and from the contacts that I have made in the limited time that I have had available—which have been with one or two of the professional groups such as midwives—I find that they are not satisfied with the Government's response to what they consider to be a well-researched and responsible document.
Mr. Clement Freud: Will the hon. Gentleman accept that there are now 80,000 fully qualified midwives who are not practising their skills? In other words, we have a total of 100,000 midwives, of whom 20,000 are in work as midwives. Would he care to comment on that?
Mr. Winterton: I believe that more people would come back into midwifery—people who have done it previously and perhaps left in order to bring up their own families—and others would be encouraged to go into midwifery, and perhaps also others be encouraged to transfer to midwifery from some other specialty, if the work were more adequately recognised, with the salary and career structure adjusted accordingly. The hon. Gentleman's point is a very good one.
I sympathise with the midwives. I have been fortunate enough to have three healthy children. On one occasion a midwife was very closely involved in the home

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confinement. I am, therefore, well aware of the valuable part that midwives can play in ensuring the safe delivery of babies. This, again, is an area in which I find myself somewhat dissatisfied with the Government's response.
There is one thing that has not been mentioned in the debate and I should like to refer to it briefly before I conclude my speech. I am a little concerned, on behalf of those who have very high moral ideals, that it could well be considered from our report that we are urging the use of amniocentesis on all occasions where high-risk mothers are concerned and that people will be encouraged to have this test whether or not they want it. Let it be made perfectly clear that if a mother-to-be does not want that test there will be no compulsion upon her to have it.
It should also be made clear—several people are under a misunderstanding and there are also some cross-party differences—that induced abortion can lead, in subsequent pregnancies, to the birth of handicapped children. The subject of abortion, of course, raises all sorts of controversies in the minds of hon. Members and of the public outside. I know that there are organisations which are concerned about life and which are also concerned about the life of handicapped people, the place that they have in society, the care that we should devote to them and the status to which they are entitled. I hope that the words that I have just said will help to allay any fears that those organisations may have that we are seeking to undermine the position of parents who may be in a high-risk category and who may be encouraged to have the amniocentesis test in order to ascertain whether the foetus is likely to be handicapped.
I pay tribute once again to my Chairman for the excellent lead that she has given to the Committee and express the hope that this will be a continuing debate. I put this as a challenge to my right hon. Friend the Secretary of State. He indicated that it would be a continuing debate. I hope that his Department will give further consideration to the report and that perhaps in due course, without a further debate in the House, he will come back and indicate that the Government will accept rather more of our recommendations than they have accepted to date.
11.43 am
Mr. Lewis Carter-Jones: I shall partly follow the final remarks of the hon. Member for Macclesfield (Mr. Winterton). I am sure that the Secretary of State will not be surprised when I say that for the small amount we have been given we are truly grateful but that for what we have not had we are very angry indeed.
I should like to take the Secretary of State's mind back to the time, five or six years ago, when I started a campaign in the House with some colleagues. Whenever I spoke I referred to one report or another, but, whether it was Oppe, Peel or Court, the recommendations were the same. Then my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) produced her very efficient and effective report, with the same recommendations, spelt out in some detail. She expanded the recommendations which had appeared in previous reports, and my feeling was that the Short report would be the last report. But then we had the Black report, all of which seemed to have been rejected, in its immediate implication, by the Government.
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When we were associated with the spastics campaign—I am most grateful to the Secretary of State for referring to it—the Spastics Society used the term "priority of priorities" in relation to it. It took the title from the French experience. In another life within this place, the right hon. Gentleman was very prominent and active in the Treasury. It was the French Treasury which decided that, if there was to be a priority of priorities, it should be in perinatal care. The work of the French Treasury and the French Health Ministry has been well documented in the English language by the Wynnes, who have proved conclusively beyond a shadow of doubt that it pays to improve perinatal care.
Arguments have gone to and fro about how much money is available. The Secretary of State took credit for the fact that there have been no cuts. I congratulate him on that. But he has a bounden duty to go back to the Treasury and say "I have a very, very strong case for getting the £25 million." That is all—not his upper figure, but the minimum figure. The sum of £25 million, in this field, could achieve a tremendous amount of success, beyond any shadow of doubt.
If I am angry and cross, the right hon. Gentleman must not take it as personal, but he can take it from me that the 500 questions that I have already asked will continue to be asked unabated. I shall not stop; I shall continue. If his Department wants to get me off its back, he will have to go to the Treasury and say "This guy has got a good point and, what is more, the Social Services Committee of the House of Commons has borne him out conclusively."
When the right hon. Gentleman talked about the regional social class variation, I thought that there was an element of complacency there.
Mr. Patrick Jenkin Mr. Patrick Jenkin indicated dissent.
Mr. Carter-Jones: Well, I withdraw that comment. It seemed like complacency. What worries me is that he will be sending a circular to each of the area health authorities, and that circular will be read in conjunction with his reply to the second report of the Social Services Committee. If the two are put together—the reply and the circular—there will be an invitation to inaction.
Let me explain the point further. During the course of the campaign to which I have referred, we found that there o were 33 area health authorities with a higher than average rate of perinatal death and handicap. Despite intense pressure, I failed to get from the Department what the recommendations were and what action was proposed by those 33 authorities. Intentions are still secret, and we do not know to what they attribute the difficulties; we do not know what demands they need to make in terms of money. I suggest to the right hon. Gentleman that if he looks carefully at those 33 authorities, and if he can get the extra £25 million—that is the minimum figure—he will find that he can do a great deal in those areas.
Another factor that I should like to raise—I raised it before the Select Committee, which is to be congratulated on its excellent work — is the special requirement to identify the women at risk. All the reports that we have had in the past have indicated who are the women at risk. Coupled with that factor is the examination of the problem of poverty in pregnancy. I concede that some progress has been made with regard to non-contributory maternity allowances, but a lot more needs to be done about the cost

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of pregnancy, the build-up of cost during the term of pregnancy, the need for food and warmth and clothing and the need for preparation and training, which are vital.
I am appalled that in the reply there has been a rejection of minimum standards and norms. If we cannot have minimum standards and norms at the point of birth when the risk is greatest, when are we to get them? We talk of perinatal care as being from the twenty-eighth week of pregnancy to the first week of life. But frequently the baby requires more attention in about the first three minutes of birth than at any other time in his life. Therefore, explicit minimum standards and norms should be laid down.
I should like to mention three other factors. The Secretary of State made a concession on the importance of health education. I support him fully on that matter. Indeed, he has arranged for extra money for health education, but it is not enough. I appreciate that he is shaking his head because it is a question of money. However, the right hon. Gentleman can take comfort from the fact that for once in our lives we are debating this emotional issue and it will be reported. The media will take it up, and that will assist in making people more aware of the incidence of perinatal death and handicap. This is one of the few occasions when I have had pleasure from having asked many questions and got results. People do not avidly read Hansard, but when one talks of regional variations local papers take up the issue and people then take an interest. Therefore, we can make people aware of this matter.
I noticed that there was a nice to-ing and fro-ing between the hon. Member for Macclesfield and the Secretary of Slate regarding equipment. The right hon. Gentleman said that if we are to try to humanise hospitals, it will be a bit harsh to bring in all this technical apparatus, which might frighten people.
My right hon. Friend the Member for Lewisham, East (Mr. Moyle) had occasion to set up a committee for me to maintain provision in the Royal Manchester children's hospital — a wonderful hospital. That committee of three, led by Lady Mar, reported that when one walked into that hospital one found eminent paediatricians, lots of equipment, lots of happiness and lots of trust. In the humanising of this service, much depends on the attitude of the staff. The better the hospital, the better the quality of staff and the happier the atmosphere. I should like the profession to note that very carefully.
I give a word of warning about optimism regarding the perinatal death and handicap rate coming down. The right hon. Gentleman has responsibility only in the sense that he is a member of the Cabinet, but the cutback in provision for local authority housing and health facilities will have an adverse effect. Therefore, we may have a reaction causing the perinatal death and handicap rate to rise because of cutbacks in other sectors. I urge the right hon. Gentleman, when development and greater housing requirements are considered within inner city areas and areas of deprivation, to give careful thought to that matter.
At the end of the day, if I were asked to judge between the advice that the right hon. Gentleman has got and is getting—I am not decrying it—the advice that I have received during, the campaign, the advice which was received by the Committee and the advice which has been given in previous reports, I would say that the right hon. Gentleman is too pessimistic in his view.
I take issue with the right hon. Gentleman on one item. In his press release he said:
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"Continuing differences between the perinatal mortality rate in this country and in Scandinavian countries are largely explained by the higher incidence here of congenital malformations and low birth weight"—
that is correct—
"and there is no means of preventing this in the present state of knowledge."
That is incorrect. The classic example is that of Scandinavia. We always assume that only the Nordic element lives there. Sweden, for example, has drawn in substantial numbers of female labour from the poorer countries of the southern Mediterranean. The Swedes have discriminated positively in favour of those in need. The figure for immigration from southern Mediterranean countries to Sweden is as good as our best.
I hope that the Secretary of State and the Minister for Health will find my remarks encouraging. I believe that they have an extremely strong case for going back and asking for at least £25 million more.
Mr. Nicholas Winterton: Does the hon. Gentleman also accept that this is the first time that a report such as this has been issued for which all the professions involved in the maternity services have been united in their welcome? This is surely unique and should give the Secretary of State the encouragement that the hon. Gentleman is urging upon him to go back to the Treasury and seek additional funding.
Mr. Carter-Jones: I entirely agree If the Secretary of State would like me to finance a lunch or dinner for himself and the Chancellor of the Exchequer in order to bend his ear appropriately, I would gladly do so.
I end as I normally end. What we are asking for to reduce perinatal death and handicap is technically and medically possible, economically sound and morally just. The Secretary of State must go to it and demand more.
11.57 am
Mr. Clement Freud: I think that the most uplifting part of the debate has been that it has gone across political boundaries. Hon. Members on both sides of the House have agreed significantly with the words uttered by their party political enemies. I cannot remember when I felt more friendly towards the hon. Member for Macclesfield (Mr. Winterton) than I did today, when I agreed with virtually everything that he said.
I believe that the Committee deserves the gratitude of the House to a substantial extent. I share the many plaudits that have come from many organisations—for example, the National Childbirth Trust. Obviously, one has reservations. However, I hope that the Committee will realise that the reservations are made in a spirit of helpfulness, not because one disagrees.
We all wish the Secretary of State well in his efforts to get more money from the Cabinet, but surely the argument, must be that money for perinatal death and handicap is an investment. As the hon. Member for Belper (Mrs. Faith) said, it is an investment which must be looked at in the view that four severely handicapped children, living to the age to which the average handicapped child now lives with the drugs available, cost the State £1 million. With the figures for handicapped children who are born but who need not be born handicapped, surely that is an argument to which even the right hon Gentleman's Cabinet will listen.
I have talked about the report being open to criticism. What I was most unhappy about was that it seemed to be

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weighted upon evidence from hospital personnel rather than from those who have their experience on the ground. I think it can rightly be criticised for relying on non-proven data. The report is based upon statistics. What we really need in this country is complete statistics. That is very much what we have not got. I am not sure whether the registrar of births and deaths should demand that his forms should be more complete. Perhaps that would be a danger, because those forms can be looked at and inspected by anyone, and there must remain a degree of confidentiality in the sort of information that is available. But great care must be taken to see that we know what is going on and that we can identify the reasons why social classes and regions of England have a greater or lesser incidence of perinatal death and handicap.
I come to the report. As I have said, I accept that it is easy to criticise. But I mind the blanket coverage of the approach, the probable effectiveness of which is not really supported by evidence from other countries. In paragraph 63, it is recommended that more mothers should be delivered in large maternity units than in home confinements. Yet a higher proportion of hospital births does not automatically mean a lower perinatal mortality rate. Sweden and the United States of America both have over 90 per cent. hospital confinements, but their perinatal mortality rates are vastly different.
Paragraph 80 recommends the continuous recording of the foetal heart rate during labour and recommends that this should become part of the surveillance for all babies. The Secretary of State knows that this is a process which requires expensive equipment and a high concentration of nursing staff. It is vital to the birth where there is risk of death or handicap to the baby, but not to most normal labours, of which there is a very high proportion.
We have mentioned that the report is rightly concerned about the number of midwives leaving the National Health Service, and, perhaps more importantly, the lack of new trainees coming in. In a maternity service which is increasingly hospital-oriented, some midwives feel that their responsibilities are being taken over by junior hospital staff and that their own training and clinical skills are being wasted.
The Association of Radical Midwives—the Minister will know that the word "radical" is used not in its political sense but in the approach to obstetrics — submitted a paper to the Committee which, it claims, was not even acknowledged.
I should like to deal with the concentration of resources. Necessary modifications of existing hospital facilities and staffing systems must be made if we are to lower perinatal and neonatal mortality and decrease the incidence of handicap in babies who survive. The mothers who stand in most need of these facilities must be identified at the earliest stage, preferably during the ante-natal period, so that they can make the best use of them. An attempt to achieve more efficient ante-natal care for those at risk must result in the reduction of deaths, but there is no real evidence that a reduction is automatically achieved by compelling mothers who anticipate a normal labour and a healthy baby to have their babies in hospital.
Holland, which has one of the lowest perinatal mortality rates, also has a very high proportion of home confinements, and the Dutch standard of ante-natal care is amazingly high. Home confinements are cheaper than
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hospital births. They need not present an unacceptable risk if midwives are supported by adequate emergency services. They are necessary—
Mrs. Renée Short: It is very important that people understand the risks of what the hon. Gentleman is advocating. When we talk about saving a baby in distress at birth, we are talking about minutes; minutes are essential. If the birth is taking place at home, the midwife is working singlehanded and has to summon an ambulance. It could be much longer than minutes before the ambulance arrives, and then there is the journey to hospital, by which time the baby has gone. The mother may have gone, too.
Mr. Freud: I totally accept that, and—
Mrs. Short: That is the risk.
Mr. Freud: —I referred to it earlier. Obviously, there is a risk there. There is equally a risk if a mother is in an ambulance on the way to hospital. No one would maintain that, whatever we do, children will be born without any risk and that we shall ever be able to cut out perinatal mortality. Whether the figure for perinatal mortality is 5,000, 3,000, 2,000 or whatever, it is too high. Anything that we can do to lower it must be done.
I want to try to identify the problem. Between 9,000 and 10,000 babies die in the perinatal and neonatal period each year in England and Wales. Our figures are still 50 per cent. above the best figures—14·6 deaths per thousand births in England and Wales as compared with 9·4 in Sweden. Those are the figures for 1979 and 1978, the latest available. The report estimates that between one-third and one-half of those deaths are preventable. What we must concentrate on is simply the prevention of children dying, or surviving with grave handicaps for the future, and we must find out why it is that children are dying now.
In 1970 in England and Wales, no more than 60 per cent. of the children who died in this period after birth received an autopsy from a properly qualified perinatal pathologist. In some regions the figure for autopsies was far lower than 60 per cent. There is little reason to believe that things are better now. It is quite clear that there should be more perinatal pathologists. The methods of inquiry into deaths vary widely according to the policy of the health authority in question. The report recommends that several regions should pilot a system of inquiries based on confidential inquiries at district level but reviewed at regional and national level. The Committee has said that this would cost £750,000—which is, we have said, the support side for three severely handicapped children throughout their lives.
Only a very small number of research units specialise in perinatal research. The Nuffield Institute for Medical Research in Oxford is one of them. Yet the research there may be transferred to another field after 30 years of continuous productivity. Is this a wise move? The general opinion is that it is far from that.
Only three out of 90 projects in the perinatal and neonatal fields currently funded by the Medical Research Council were for the development or evaluation of equipment. By joint agreement, the MRC accepts primary responsibility for biomedical research and the Health Departments accept similar responsibility for health services research—that is, equipment. The DHSS has

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funds available for evaluation. Yet co-ordination between researchers, equipment manufacturers, the MRC and the DHSS is still totally inadequate.
One of the gravest handicaps to research in this field seems to be that there is no consistent policy for collection, evaluation and dissemination of relevant study. This is not surprising. The report is criticised for placing too much reliance on unproven data. When the Committee asked for information about place of birth, number of deliveries a year in a unit and facilities available in relation to mortality figures, it was told that no such figures existed.
I want to speak about smoking during pregnancy, which is an important contributory cause of poor foetal growth. Authorities differ about the importance that should be given to poor diet as a cause. It is, however, doubtful whether present maternity benefits and allowances are adequate to maintain either mothers from families on supplementary benefit or single mothers. What is wrong—the Child Poverty Action Group is to be complimented on the papers that it has produced—is not that we should make people who have paid for insufficient benefit suffer for having a child. The very opposite should apply. We should reward someone who has paid for full benefit and have a minimum less than which no one will get.
The report's idea of commando groups of health visitors and social workers to go into the community to seek those at risk is a possible way of ensuring better maternity care. There is evidence that those who are most in need are also most likely to reject care because they are put off by many aspects of the existing system. Out-patient clinics are badly organised, with inefficient appointment systems, no facilities for small children, nowhere to leave friends who accompany people, poor staffing and no canteens. The same applies to a lesser extent in many neighbourhood clinics.
It would be wrong not to mention the report's reference to the fact that there is no specialist paediatric surgical service in East Anglia and inadequate cover at consultant level in Bristol, Leeds and Cardiff. I hope very much that the Minister, in his reply, will deal with these matters. Nothing will work unless people support the system. They will not support a system unless it is made a little more attractive to join. Maternity care is part and parcel of the process of having a baby. Communication is a two-way system. People will not join in communication until the doctor plays his part and until the doctor listens to the patient as well as simply having a patient listen to the doctor, world without end. We must identify the cause of death or handicap more efficiently. We must also bear in mind the expense.
The National Childbirth Trust says wisely:
"Care must be taken that over-zealous concern for the minority for whom very real problems exist does not spill over to harm the majority for whom birth is a normal and not a pathological process requiring medical intervention".
I hope that the Minister will pursuade his right hon. Friend to go to the Cabinet. The sum of £25 million with which so much can be done is a small amount of money in real terms and an investment that the whole House would feel it was shameful not to make available for the future of the children of this country.
12.13 pm
Mr. Jonathan Aitken: The hon. Member for Isle of Ely (Mr. Freud) was right to draw
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attention to the fact that the debate has cut completely across party lines. In the same spirit, I begin by congratulating, with genuine warmth, the Chairman of the Social Services Committee and all the members of the Committee on doing what I believe was an outstanding job in assembling a mass of detailed evidence, drawing the right conclusions from it and making the right recommendations. They made their case convincingly.
In the interests of time, I shall concentrate on those parts of the report that offer the Government the opportunity to implement a number of recommendations which the Committee says could reduce the number of annual baby deaths by between 3,000 and 5,000 and the number of babies born handicapped by at least 5,000. If those recommendations were accepted, the Committee says that our perinatal and neonatal mortality rate would be one of the lowest in Europe.
Of course, in today's economic climate there were difficulties for the Government in accepting all the recommendations and implementing them, notably the public expenditure arguments. But, bearing in mind the important fact, as the hon. Member for Isle of Ely said, that every child born handicapped costs the State between £½ million and £1 million in medical costs in its often tragically shortened lifetime, there were also powerful public expenditure savings arguments in favour of the Committee's recommendations, and we have not heard anything remotely resembling a convincing answer to those arguments today or in the Government's reply.
I believe that, in one way or the other, the Government had a number of policy options open to them, even on the narrow front of public expenditure. A great reforming Secretary of State for Social Services would have seized the opportunity to invest in the health of future generations by giving perinatal care, which is the epitome of preventive medicine at its best, the highest possible priority in the Government's policy thinking.
Therefore, I picked up the Government's reply to the report of the Social Services Committee with eager anticipation. I must tell my right hon. and hon. Friends that, after reading it, I felt an acute sense of disappointment. The Government's reply is a feeble answer to the passionate and very professional cri de coeur that came from the Committee. As I hope to show, it is a reply that may well make matters worse by dithering between possible policies and creating a half-way house and half measures which could result in a sad increase in the number of handicapped children being born.
That is a serious charge, and I shall return to the gravamen of it in a moment. First, however, I feel that I must comment unfavourably on the poor quality of several parts of the Government's argument in reply to the Committee's report. The least that one can say about the report is that all five volumes of it are extremely well detailed and extremely well argued and have what the Victorians called "bottoms".
I refer the House to the Government's reply to some of the most central parts of the Committee's report. I look, for example, at paragraph 21, which questions the Committee's assertion that there are 5,000 avoidable handicaps a year. The Committee did not just pluck that figure of 5,000 out of the air. There are pages of detailed evidence in its report. My hon. Friend the Member for Macclesfield (Mr. Winterton) was right to draw attention to the evidence of Dr. Wiggles worm, of Hammersmith

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hospital, widely acknowledged to be the leading perinatal pathologist in the world, who, among other experts, testified to the avoidable deaths.
If Her Majesty's Government assert that those figures from those experts are wrong, they owe it to the public to give as good evidence and as good grounds for their conclusion as the Committee did. How did the Government back up their assertion that the Committee's figure was wrong? Paragraph 21 simply quotes a couple of one-line or two-line remarks from two obstetricians. It is as though, after a great deal of hard pounding from heavy artillery, the Government answered with a couple of quick bursts from a peashooter.
It is not, however, just a question of lightweight statistics versus heavyweight statistics. Let us look at paragraph 96 of the reply, taken in conjunction with the important paragraph 181 of the Committee's report, which recommends that neonatal paediatrics should be recognised formally as a sub-specialty within paediatrics. Again, there is a mass of weighty evidence to support that recommendation.
This sub-specialty of neonatal paediatrics is considered essential throughout all the advanced countries in the Western world. In Canada and the United States, neonatal paediatricians must pass rigorous examinations before they can begin to practise it. In all European countries, neonatal paediatrics is a separate sub-specialty.
I know how true that is because, for reasons to which I shall return, I spent over a month this year in day-and-night vigil in a premature baby unit in Switzerland presided over by specialist neonatal paediatricians. It is a completely different ball game from ordinary paediatrics. The world accepts it. Why do the Government not accept it? Where are the carefully considered arguments for rejecting this sub-specialty? Where is the evidence? In just three lines in paragraph 96, that recommendation is rejected. The civil servant who wrote that part of the reply must have had the same mentality as the journalist who wrote the famous headline "Storms in Channel-Continent isolated". We cannot cut ourselves off from the medical practice of the rest of the Western world.
The dismissive and. lightweight tone of the Government's reply becomes worse as one digs deeper into it. Paragraph 76 seems to reject yet another fundamental and essential principle of perinatal medicine—round-the-clock, 24-hour care. It seems to suggest that 24-hour care may or may not be available, that doctors and consultants can somehow be miles away in other hospitals and can be called to cope with emergencies. To anyone who has ever watched, let alone worked, in a serious neonatal paediatric unit, the assumption that babies who are desperately ill in those critical first days can be satisfactorily nursed, watched and treated by doctors who are on call from other hospitals is pure moonshine.
Finally, there is a failure in the Government's reply to support the Committee's recommendation that the number of neonatal intensive care cots in this country should be increased from 176 to 400. Instead, in paragraphs 12 and 13 of the reply, the Department seems to congratulate itself on increasing the number of special care cots. The Committee's evidence, at page 200 of volume 4, draws a
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sharp distinction between intensive and special care cots. The former are under-provided and the latter are over-provided.
The picture that emerges from the Government's reply to the Select Committee's report is that the Department does not accept the Committee's figures. Instead, it wants to run a neonatal medical service with no sub-specialty of neonatal paediatrics, with no genuine 24-hour cover in many hospitals, with no increase in the already inadequate number of intensive care cots and with no proper regional structure of neonatal paediatric specialised units.
I believe that the Government's view on all these key issues is wrong. I believe it with all the conviction and commitment that any layman speaking on this highly technical subject can possess. I believe it because—if the House will bear with me while I give a personal experience—I saw earlier this year exactly what it means to have a critically ill baby under intensive neonatal care. I understand in human terms the flesh-and-blood realities behind the statistics and all the technical jargon.
Earlier this year my wife, happily, gave birth to twin daughters. As many twins do, they arrived inconveniently early—eight or nine weeks premature, at a weight of just over 31b. As an accident of geography, they were born in Switzerland. My first act as a father was not to crack open the champagne but to get into a car and follow an ambulance taking those infants off to a specialised neonatal paediatric unit in another hospital in Lausanne, in the canton of Vaud.
Those babies had very common complaints—lung immaturities, respiratory distress and what is known as hyaline membrane disease. Their lives hung by a thread for over three weeks. They were in intensive care cots and were breathing by mechanical ventilators, a highly sophisticated technique requiring minute-by-minute oxygen monitoring. It is a very difficult operation, involving measuring the fluctuating oxygen and carbon dioxide levels. If the hospital gets it wrong, if there is too much oxygen for a minute or two, the babies go blind; if there is too little oxygen for a minute or two, they suffer brain damage.
There were other complications—infection, which so many premature babies can have, and oedema. One of my twins required a blood change. The other, worst of all, had a sudden cardiac arrest. A doctor on the spot gave her a stimulant injection within seconds and got the heart going again.
What I saw in that hospital in Lausanne was neonatal care at its best. The end of our story is a happy one. My wife and I now have two entirely normal, entirely healthy six-month-old daughters. But, as the Duke of Wellington said about the Battle of Waterloo, it was "a damned close-run thing".
All that drama took place in Switzerland, and during those long nights of anguished vigil I asked myself what would have happened here in England. What would have been the conditions? I had not read it at the time, but the answer lay in the Committee's report. When I asked the question in Switzerland of the distinguished neonatal paediatrician in charge of that unit, Dr. Jean Leopold Michaeli, he gave a most surprising answer. He said that all the techniques in that unit came from England and that most of the equipment—for example, the ventilators—were designed and invented in England and

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that some of its best gadgets—for example, the transcutaneous monitor—were invented in England, and came from University College hospital.
In his opening speech, my right hon. Friend the Secretary of State said that Professor Osmond Reynolds and his like do not grow on trees, but the fruits of Professor Osmond Reynolds and his colleagues are growing all over Europe. They are not growing in this country, and that is a source of shame for our arrangements by comparison. Units, such as that at University College hospital, which have been so brilliantly built up by Professor Reynolds are, alas, only isolated centres of excellence. UCH, the Radcliffe infirmary at Oxford and others turn away babies today, and they have a smaller geographical catchment area. So what happens if some of the problems that I have been describing happen to babies born in provincial centres, seaside towns or even some of the bigger provincial centres, such as Liverpool?
When we look again at the Department's reply, searching for a hope for the future, we see that there will be no sub specialisation of neonatal paediatricians to look after them. They will not get continuous minute-by-minute monitoring of their oxygen levels or a 24-hour coverage. If they have cardiac arrests, the doctor will have to come from another hospital miles away to give stimulant injections. Babies in the same condition who are born in the wrong geographical area of this country would not have a hope. No, I exaggerate. They would have a hope. The non-specialist paediatricians would do their best for babies in comparable situations, but doing their best without the right equipment, and without the right 24-hour day coverage, can almost be worse than doing nothing.
That is why I return to the point that the failure to accept many of the Committee"s recommendations on neonatal care may lead to more handicapped births. Half-measures, inadequate equipment and facilities, and non-specialised paediatricians will half save critically ill new-born infants, and half saving a critically ill newborn infant may mean brain damage, blindness and other handicaps.
I do not believe that the Government have adequately answered the points made by the Committee and the human examples that I have tried to give. The money side of the question is obviously crucial. The total figure given by the Secretary of State is £162 milion to implement all the recommendations. Bearing in mind that the prevention of a child being born handicapped could save the State up to £1 million in his lifetime's medical costs, we deserve a far better answer on the financial costs than we have had today. The Secretary of State is one of the most humane, thoughtful and politically courageous members of the Government. His Department's reply is unworthy and inadequate. I hope that he will think again.
12·30 pm
Mr. Jack Ashley: The fine speech by the hon. Member for Thanet, East (Mr. Aitken) was a severe indictment of the Government's response to the report. The hon. Gentleman rightly quoted the Duke of Wellington. In view of the speeches from Government Members, if we had a vote on the Government's reply this afternoon it would be a pretty "damned close-run thing" for the Government. Fortunately for the Secretary of State, a vote is not to be taken.
I feel bitter about the Government's reply because of its deplorable tone and tenor. Instead of a constructive
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response to a constructive report, the Secretary of State has made himself a hatchet man, hacking at the foundations of a report which has involved much hard work.
On page 1 of his reply, the Secretary of State says that he "welcomes" the report. However, the Government are blatantly misleading the House by saying that. In most of the following pages the reply takes a snide, hypercritical approach to many of the basic problems. That is regrettable. The Secretary of State's response will knock the heart out of those who have worked so hard.
I pay tribute to the Committee members and their work. Hon. Members who have spoken today have shown an intimate knowledge and a great mastery of the subject. I appreciate the brilliant speech by the hon. Member for Macclesfield (Mr. Winterton). He will not agree with all that I say, because I am unable to be as restrained as he, although his speech was a severe indictment of the Government's failure to accept the report. I pay tribute to the Chairman of the Committee and to all the people who have campaigned for many years. I think of the Spastics Society, the "Save a Baby" campaign, the Maternity Alliance, the National Council for One Parent Families and such people as my hon. Friend the Member for Eccles (Mr. Carter-Jones), who has worked so hard on the campaign. It is a pity that the reply does such scant justice to their work.
"Save a baby", says the Spastics Society. "All, yes", say the Government. "Save a baby, but you must not raise unrealistic expectations." Ministers should know that the problem is not that of raising false expectations. The real problem is that the people who are most affected, in social class V—I hate that jargon—are poor and under-privileged and have no unrealistic expectations. Such people are dispirited. Their expectations will remain low unless and until the Government make a better response to recommendations.
The real problem is to ensure that people do not accept passively a scandal when they should be rejecting it passionately. Some women have twice the risk of their babies dying or being disabled than mothers in other areas of the country or in other classes. It is preposterous that that should be accepted. We should show the will and the energy to change that. There has so far been no determination by the Government to change that situation.
A primary objective of the Government should be to raise the expectations of the in social class V and the other social classes. A great virtue of the report, which will be of tremendous value, is that it has made the mothers in social class V who have endured such shocking, conditions aware that they need not accept them and that something can be done. That awareness will lead to progress.
A great advantage of the Chronically Sick and Disabled Persons Act was that, by raising the expectations of disabled people, it changed the public's attitude and, therefore, the attitude of hon. Members. That in turn led to legislation, which has helped millions of disabled people. It is part of our duty to raise expectations, and I hope that the House will press for the implementation of the report.
The report argues that about
"one-half of the deaths are preventable, if modern knowledge and care were universally applied."
Instead of analysing that proposition sympathetically, the Government quote approvingly the reply of one witness who said that about half the perinatal deaths
"are, at the level of present knowledge, unavoidable"

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but that the remaining half
"are preventable by perfect medical management, but it is rather like saying that all road accidents are 'preventable'."
The Government's reply is hot on selective quotations, as has been pointed out, and that is a divisive response by the Government. It implies that the proposals in the report are a waste of time.
The Government's choice of comparison is inappropriate. We go to great trouble to try to prevent road accidents. We spend a great deal of money on it. We have speed limits, traffic lights and safety belts. We should adopt the same attitude to perinatal care. These deaths are unacceptable. We should do all that we can to prevent them and spend as much money as is necessary.
Earlier in the debate, socio-economic factors were referred to. The Government's reply gives the impression that we are dealing with immutable problems. I concede that socio-economic factors cannot be changed in a short time.
Page 5 of the reply states:
"There are, however, a number of well documented reasons why this country's perinatal mortality rate is higher than those of Scandinavia and some other countries on the Europen mainland. If the causes of perinatal deaths in this country are compared with those with lower perinatal death rates, it is immediately clear that major congenital malformations (particularly of the central nervous system) occur much more frequently in this country, and that we have also a higher incidence of low birthweight infants among whom deaths in all countries are more common. The survival of low birthweight babies born in this country compares favourably with other European countries."
But the Black report spoke of socio-economic factors, and when the Proposals in it were brought forward the Government explained in great detail why they found them unacceptable—because of prevailing economic difficulties. They made it quite clear that there would be very little progress on socio-economic factors in Britain today. Therefore, if there are to be no improvements in socioeconomic factors, that is a powerful case for an immediate increase in ante-natal care.
I believe that the Government are wrong to use the device of setting up Aunt Sallies of their own and knocking them down. For example, page 7 of their reply talks about "any hasty or inadequately prepared expansion of intensive care"
increasing rather than reducing the number of handicapped children. That is a kind of Dr. Goebbels technique, because no one has ever suggested an inadequately prepared expansion of intensive care. That was not suggested in the report. No hon. Member has suggested that, and neither has any voluntary organisation. For the Government to imply that we have suggested that is to twist and distort the proposals that have been put to them.
We could equally argue that hasty or inadequately prepared attempts to reduce the money supply would increase it rather than reduce it. There may be an argument for putting that point of view, but I doubt whether the Government would be prepared to argue such a case. Yet by making that kind of comment and by making this kind of response the Government are damaging the whole ethos of the report and undermining it.
Some of the particular reasons put forward by the Government for rejecting parts of the report are quite fatuous. For example, they have rejected the proposal for a maternity supplement because it would interfere with their aim of simplifying the social security system. We
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must not interfere with the ease and the comfort of Ministers and civil servants, so we do not bother with a maternity supplement. A maternity supplement could significantly contribute to the reduction of death and disablement among young babies, but the Government will not grant it simply because it would interfere with the simplification of the social security system. I find that an outrageous response, which cannot be justified in any circumstances.
I intend to make a short speech as a lot of other hon. Members wish to participate. We are also waiting for a further response from the Government. I appreciate that Conservative Members have been critical, and I shall try to avoid making a party political response. However, the problems of perinatal mortality and unnecessary death and disablement among babies illuminates more vividly than can the rhetoric of the class warriors on both sides of the House the great class divide in Britain today.
The Government's reply illuminates their failure to act decisively in order to help the depressed and the deprived. They blame socio-economic factors for many of the problems. Yet by their policies they are creating unemployment. They are preventing the building of better housing stock. They are cutting vital welfare benefits. They are also refusing on spurious grounds to fund antenatal care.
I had hoped that from today's debate four ingredients would emerge which could save the lives and prevent the handicaps of many children. Those four ingredients are: a little cash, some good will, some firm political will and a lot of common sense. But from the Secretary of State we have had very little. In his reply to this constructive and compassionate report, he and his colleagues have shown themselves to be anti-science, anti-medicine, anti-pregnant women and anti-progress. It is not a policy of which any of them can be proud.
I regret and deplore the Government's response. I have tried to avoid party political comment, and I admire Conservative Members who have spoken frankly and fearlessly. We are dealing with a matter of life or death. We should not be mealy-mouthed about the Government's failure to do something about it. Excuses are not good enough. When the Minister replies, he must tell us why the Government are failing to find adequate funds instead of giving mealy-mouthed excuses for failing to act on this vital report.
12.47 pm
Mr. Richard Alexander: I do not wish to take up the remarks of the right hon. Member for Stoke-on-Trent, South (Mr. Ashley), who has introduced what I fear is a regrettable party political element into what otherwise has been a good-natured debate.
I take issue with whoever organises these debates about the time that we have had for proper consideration of the report. The report was ready at 3.30 on Wednesday afternoon, and at 9.30 on Friday morning we had to start the debate. That is not good enough. Hon. Members cannot possibly take proper soundings and representations form the wide range of people and organisations that would wish to brief them properly. Consequently, some may be slightly less well informed than they ought to be. When we are dealing with an issue involving nearly 9,000 deaths a year, that is to be regretted.
I welcome my right hon. Friend's preliminary statement that there has been an enormous increase in the

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effectiveness of maternity and neonatal services over the past few years. My right hon. Friend has taken a great deal of stick this morning. I am afraid that I cannot promise significantly to lighten his load, and that is about as far as I shall go in praise of his view.
The Select Committees' report indicates beyond peradventure that substantial scope remains for the reduction of perinatal deaths and handicaps of perinatal origin. We are talking about scope for reduction of almost 5,000 avoidable baby deaths and a further 5,000 preventable handicaps at birth. To be fair to my right hon. Friend, it must be said that he has disputed whether the figures are as high as that. Be that as it may, we are talking about a considerable amount of preventable baby death and baby handicap.
I welcome my right hon. Friend's expressed concern that there should be continued and sustained action on perinatal mortality. We have his commitment in the Government's reply. He therefore accepts the problem and, presumably, wills the end. I am not unaware of the present restraints on public expenditure, and if we are to will the end it is not sufficient to say that the responsibility for carrying out resource planning will be entrusted to district health authorities and left at that.
At an early date my right hon. Friend must make a promise that a small amount of means will be voted towards the end that the report recognises. The whole point of the report is that a small amount of additional public expenditure within the total health provision will go a long way towards curing the evil that we are considering.
The report did not ask the Government to shuffle responsibility on to the district health authorities, although they will cam' out the Government's will, given the resources. In common with one or two hon. Members I shall consider paragraph 16, in which an analogy is drawn with road deaths. It is said that they, too, are preventable. Of course they are, and everyone is doing a great deal to reduce the number of road deaths. A great deal of money is being spent to make them preventable. In fact, everything is being done that is possible. That should be done with child life and child handicap.
It is said in paragraph 23 that unrealistic expectations should be discouraged. In this century it should be the realistic expectation of every parent, regardless of class, social background or intelligence, to have a healthy living child. It is wrong to say that that is an unjustified expectation. The paragraph and the statement to which I have drawn attention will be ridiculed by successive generations. They will marvel at our inhumanity. The fact is that the chance of a wife of a labourer in the North of England having a healthy living baby is only half as great as that of the wife of a professional man living in the Home Counties. That is wrong, and I cannot accept it. I believe that my right hon. Friend does not accept it either.
My right hon. Friend said that there was a correlation between the standard of living of individual countries and baby life and the extent of baby handicap. We should say that because these factors exist, and because there is inequality, between various parts of the country, we must aim to do even more rather than nothing and merely comment on certain expectations as being unrealistic.
The Government's reply sums to damn the Select Committee with faint praise. It congratulates it on its work but hints that there is no real problem that requires stern action even when funds can be found. It is unrealistic to say to health authorities "Please try to reduce your waiting
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time from four hours." That is the waiting time within some authorities. Is it too much to ask them to have adequate staff and to have time to enable women to ask questions about matters that bear on their babies having a healthy life? It is unrealistic to say to them "These are your objectives." We must be able to say to them "We shall soon will you funds to carry out these objectives." It is the high-risk women whom we wish to encourage to attend the clinics. The support for them and the time that they spend there are essential if they are to be reached and helped. That point was put very well on page 66 of the Government's reply by Professor Davis, who is professor of paediatrics at Cambridge University and a member of the Health Education Council. He said:
"It is easy to identify the groups at risk: they are young women of social class 4–5 with a number of children, as regards neonatal deaths; and older women of the same social class having their first or last baby, as regards stillbirth. Probably, but not certainly, clinic attendance is the key to success in both cases—antenatal and post-natal."
That was followed on the same page by a study by the Health Education Council, which was carried out only this year. The reasons for the low level of satisfaction at clinics were stated as:

(i) mothers found the manner of clinic staff impersonal and brusque when they had hoped for a personal and caring approach;

(ii) the organisation of the clinic visit was broken into a number of specialised tasks each performed by a different member of staff in a different, but usually semi-public place;

(iii) the contact between staff and mother was orientated to the task, and the part of the body on which it was to be performed, rather than to the mother. Interaction worked against the asking of questions and the giving of full and comprehensive answers.

Those comments identify the problem today. The Government's reply is less than enthusiastic.
Which parents among us today have not felt anxiety at the time of our children's birth about whether the child would be born well, fit, healthy and sound in all limbs? I well remember that time. My hon. Friend the Member for Thanet, East (Mr. Aitken) mentioned his experience. For myself, I shall never cease to be thankful that on the two occasions when I had children mine were normal in all respects. I shall never forget the dread anxiety in case they were not.
The report of the Select Committee and its recommendations were exciting. It captures the imagination of both the medical and the non-medical world in Britain in a way that the reply never will. It was an enormous piece of work and many people, not least the Spastics Society, put in a great deal of research. I expected that suffused through every page of the Government's reply there would be a feeling of "Good for you, Select Committee. Congratulations Strathleven Bonded Warehouses and Park Cakes Ltd." I expected the reply to say that as soon as financial circumstances permitted the money would be found to implement the findings. Instead, the reply reacts like a Treasury brief arguing why we should or should not close down an obsolescent railway line. Perhaps I expected too much. Perhaps I am still too new in this place. Perhaps the DHSS does not become excited about anything new or helpful.
I am not arguing for Government spending today, although some Opposition Members quite properly propose that. I simply say to my right hon. Friend that, as soon as resources permit, will he please give a warmer response to the Select Committee report than he has done in the reply today. I ask him to recognise that there is a problem and to recognise also that the Select Committee

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points a way towards a solution. If he does, for generations to come he will have the gratitude of thousands of disadvantaged women and otherwise handicapped children.
12.59 pm
Mr. Robert J. Bradford: It is impossible for me, in the very short time at my disposal, even to embark on the speech that I had prepared. This is very serious, because the plight in Northern Ireland with regard to infant mortality is much greater than in any other part of the United Kingdom. It would be an insult to the people of Northern Ireland for me to try to push into five or six minutes the important matters which are involved. So it is with the utmost contempt for the lack of coordination between the occupants of the Chair that I have to withdraw from the debate.
Mr. Deputy Speaker (Mr. Bernard Weatherill): That is not something that the hon. Gentleman can say. He knows what to do if he does not like the way in which hon. Members are called.
1 pm
Sir Brandon Rhys Williams: I have had the honour to be a member of the Select Committee since the general election. It produced the report that is before the House, and I am very proud of it. I cannot claim to have contributed much to it because so much of the work had already been done before the election; but I should like to pay a tribute to our Chairman, and also to our Clerk and the three professional advisers, who made a most notable and dedicated contribution to the report and deserve the highest praise.
I have also for a number of years had the honour to be the chairman of the National Birthday Trust, which sponsored the national perinatal survey of 1958 and also the British births survey of 1970, so I can claim to have a long-established interest in the subject of the report, which I most warmly support.
I should like to draw particular attention to what we say in our paragraph 314, from which I shall read some short quotations. The report says:
"In the long term an overall improvement and levelling out of standards of living must be the answer to the problem we are considering."
Had I written that myself, I think I would have said "levelling up" rather than "levelling out". But the point that we are seeking to make is extremely important. We went on to say:
"For the short term it became clear during the course of the inquiry that medical care can to some extent compensate for social deficiencies, although this may be an expensive remedy."
In the course of our report, we went on to make a large number of specific recommendations for the improvement of medical care. But it is of interest that in its paragraph 52 the Department refers to the indispensable part that wider policies of economic and social progress have to play.
I hope, therefore, that the House today will not think that I am out of order if I try to lay stress on the importance, in improving the perinatal performance in this country, of looking at the general health of the British people—what our predecessors 100 years ago might have called "the condition of the people question".
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The figures are improving in a way that everybody welcomes, but there is an unacceptable range of outcomes of pregnancies corresponding to social class. The Committee found it difficult to obtain concrete evidence as to the particular cause or causes of this association of handicap and poor perinatal performance with social class, but, obviously, we ought to follow up the various leads.
Is it due to chronic ill health of the mother in poor families? Is is due to the incidence of infection? Or is it perhaps some handicap in inherited physique? Is it a matter of diet, or the unwise choice of foods, even within the restrictions imposed by a limited income? Is is perhaps a matter of the level of available care to people who live in the poorer parts of the country? Is it a question of the take-up of services? Are people in the poorer families less motivated to take advantage of the services which would be provided if they made better use of them? Is it a matter of the patterns of work? Do poor mothers continue to work, for instance, too long during pregnancy, when they ought to be resting, because they need the money to provide for the child when it comes? Or are they forced back into employment too soon, when they ought to be attending to their first-born, so that they begin their next pregnancy already exhausted and out of condition? Perhaps there is a lack of parental guidance and support due to the breakdown of the extended family. Or is it a sheer lack of knowledge of prudent self-care?
I do not think that anyone could with confidence say what weight we should put on all these different factors, but the follow-up of the British births survey cohort of 1970 should provide much reliable evidence on these questions. I have great hopes for the work being done by Professor Neville Butler and his colleagues at Bristol university.
While we are waiting for convincing data, we need to follow up such leads as we have as best we can. The central problem must surely be related to the availability of cash to the family and the ability of the mother to exercise her best judgment of how it is spent even while she is unable to earn.
The Green Paper on the taxation of husband and wife—which, I suppose, by pure coincidence was published this week—is here directly relevant. Everyone who is interested in social reform must want to follow up the leads given in that Green Paper and to relate its intentions to the solution of the class-related disadvantages we know to exist in perinatal performance.
I believe that we need an effective tax credit scheme that ensures a reasonable minimum income guarantee and enables the mother to relate her expenditure to her needs, bearing in mind the actual circumstances of families, including one-parent households, child motherhood and other problem cases.
Turning to the recommendations that we made for the improvement of medical care and the Department's response, I share the disappointment that has been expressed on both sides of the House that the Department has not been more forthcoming. I suppose that in the present climate it is to be expected that the Department would resist recommendations which would add immediately to expenditure. I should like to think that the Committee's recommendations represent not something to be done at once but a rolling programme to be implemented over the whole of the 1980s and not to be forgotten.

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It is possible today to give only an interim and general reaction to the Department's response to our scores of recommendations, because of the short time that we had to study its reply and the impossibility of consulting adequately those whose advice we would like to take.
We must not allow ourselves to be too dismayed that the Department's response is damping, because the necessary qualified staff and essential equipment cannot be deployed at a moment's notice to give effect to our recommendations. But we must not give up We must continue the battle.
The Secretary of State said that the Committee's report points the way. I believe that all who care about these problems have a duty to ensure that the way is not merely pointed to but is actually followed. There must be no loss of momentum in implementing the Committee's recommendations.
In a general sense, we are now in the process of refounding the National Health Service. I should like the Department to accept the maxim that prevention is cheaper than care. The cost of caring for a handicapped child throughout his life, bearing in mind the loss of earnings and the attention that he must have, is incalculable. Even if we think of handicap only in cash terms—even if we are so godless as to think that money is more important than people—we must calculate that the prevention of handicap must have priority in the Health Service.
The Committee's report stands as a claim for high priority to be given to the improvement of perinatal provision throughout the NHS so as to achieve the levels of performance everywhere which have been shown in practice to be attainable in certain notable districts and identifiable spots.
In reforming the Health Service, I think that everyone in the House must know that there are very large opportunities for cutting out waste. I do not think that there can be an hon. Member who would deny that he or she has personal experience of phenomenal, tragic waste of resources in the way the Health Service's money has been spent in recent years. The opportunities certainly will be with the regional and district authorities to find the money for implementing the recommendations of our report as they bend their attention to the problem of eliminating waste.
The reduction of unnecessary expenditure and the prevention of faulty and ill-conceived expenditure in the Health Service have not in recent years had the priority that they should have had, with the result that the nation's resources are not being applied in the Health Service nearly as effectively as they should.
I do not quarrel with the Department's view that many of the Committee's recommendations should be passed down to the local health authorities for them to implement according to their own judgment as best they can I accept that it must be a matter of judgment over time at regional and district level—at any rate, to a great extent. But the Department itself must not seek to devolve all responsibility for implementing the improvement of the perinatal services to local health authorities. The Department must continue to stimulate improvement and to keep its own conceptions of what must be done up to date with the advance of medical and social knowledge. It must ensure that standards everywhere are levelled up in the ways that are most likely to be effective within the
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constraints of availability of staff, equipment and funds. It should also keep fully in touch with developments in other civilised countries.
Lastly, I welcome what the Department says in paragraph 39 of the reply. I am not normally a believer in appointing more committees as a remedy for an urgent problem, but I welcome the reply to the Committee's recommendation in this respect. I am glad to see that the Secretary of State is favourable to setting up a new national advisory committee for parental services. I believe that if such a body were appointed, provided that it were highly motivated, it could' succeed in bringing to the regions and districts in the Health Service the necessary impulse to improve our perinatal services. I hope that such a body will be set up and specifically charged with the duty of mounting—in the Secretary of State's words today—a sustained campaign.
1.12 pm
Dr. Roger Thomas: It was with grave disappointment that I read Cmnd. 8084, until I reached page 60 onwards, from where, at least in annexes A and B, one was given some solid recommendations, and some recommendations of which I hope the Department will take great notice.
During the past decade, or even the past five years, there have been great strides forward in many of the fields of activity that we are discussing, but the current situation is not one that we should face with any degree of complacency or blinding self-congratulation. The incidence of foetal abnormality is still about 2 per cent. of all births, and we are still witnessing and tolerating class and racial variations which should no longer be acceptable.
About 20 per cent. of foetuses that are stillborn are malformed, and a further 20 per cent. of neonatal deaths have major abnormalities.
All parents want and deserve normal babies. It is our duty to come as near to achieving that as possible—not within our available resources; the resources must be found. Many, but not all, areas have, for example, facilities for the detection of certain complicated proteins in maternal blood, the presence of which is much in evidence where there are foetal spinal abnormalities. In my part of West Wales, there is a high incidence of this condition. We are able to offer and advise the parents of the advisability of therapeutic termination. This early detection and subsequent action prevents an abnormal live birth, but we should concentrate at a much earlier stage on the prevention of foetal abnormalities.
Rubella is often a mild and poorly recognised illness, but whether a person has or has not had the disease cannot be easily ascertained without an accurate blood test. Rubella during the first eight weeks of pregnancy produces defects—often multiple defects—in two-thirds of the foetuses. The risk is therefore over by 18 weeks. I implore the Minister to institute a scheme whereby all 11 to 13-year-old girls are immunised or offered immunisation against rubella. By doing that, we would do away with probably about 1,300 foetal abnormalities during a year when there is a rubella epidemic and about 400 abnormalities during an ordinary year.
It is estimated that about 1,000 children are born with serious hearing defects because their mothers have not had immunity against rubella and have contracted the disease during the first two or three months of carrying the child.

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The test for rubella, to be absolutely certain, has to be carried out before the pregnancy is suspected. A history, or relying on a history, of having had the disease is unreliable. During my 25 years in general practice, I have known it to lead to quite a number of disasters.
It is essential to test young girls for rubella immunity when they start their secondary education. It involves a simple blood test. In its absence—that is, when there is immunity and it is confirmed—the problem is at an end. When there is an absence of immunity, vaccination must be carried out and no amount of persuasion must be left unused to try to achieve 100 per cent. success.
There has been a sad neglect in making the public aware of the possible eradication of the effects of congenital rubella. It appears that the repeated questioning of Ministers on my part from time to time over the past 18 months has made little more than a slight indentation upon their complacency. It is disastrous to vaccinate a pregnant woman, for we could then be responsible for causing the abnormalities. Once a woman has sought and obtained rubella vaccination after a negative pregnancy test, it is necessary to make sure that conception does not take place for at least four months.
It is important to avoid the wide range of drugs that are known to produce foetal abnormalities. There is still a tendency for women to take far too many unnecessary drugs during pregnancy. A recent survey revealed that, in addition to essential drugs such as vitamins and iron, the average number of drugs being taken during the course of a pregnancy varies between three and 10. There is a need for free and easy availability of genetic counselling. This counselling is not universally provided throughout the United Kingdom. There are regions in which such counselling is very poor. Those needing help include not only the parents of abnormal children but couples with a history of abnormalities within their immediate families, not forgetting married couples who are close relatives—cousins, for example.
There is also the increased risk of Down's syndrome, known formerly as mongolism, with increasing maternal age. It should never be forgotten that a mother aged 45 is 100 times more likely to produce a child suffering from Down's syndrome than is a mother under the age of 30.
Parents prefer and deserve information on the avoidance of the conception of abnormal babies. But, having decided upon and having conceived a baby, it is essential that that baby is then healthy, fit and well cared for right up to the end of the pregnancy.
It is important that such advice is available to those who are less likely to seek information. This is essential. Parents who are educated will seek and obtain information. It is, therefore, the young girl who is unmarried and who has no family support who will probably find that she is being denied essential information of that nature. Until we have the universal availability of such information, we shall continue to have these disparities in class and race in our neonatal mortality rates.
1.21 pm
Mr. Nicholas Lyell: I am grateful for an opportunity to make a small contribution to this debate. Unlike almost every other hon. Member to have
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spoken, I do not claim to be an expert on the subject, and I look with gratitude at the work of those who served on the Social Services Committee.
I speak from the standpoint of a constituency Member for whom hospital services are one of the most important aspects. My hon. Friend the Under-Secretary of State has visited my constituency, as has my hon. Friend the Minister for Health, and my right hon. Friend the Secretary of State is himself well aware of our concern for our hospitals.
In that context, I look carefully at an important report of this nature. The Committee's work, which I praise, is and will be a mine of information for the future for all those who are interested in this important subject of perinatal mortality.
I can understand why the members of the Committee may feel that the Government's response seems somewhat muted. But, although I understand that, in the context of this debate, where hon. Members have been beating the Government about the head in a rather unnecessary and exaggerated way, it is important to say that it is remarkable that the Government have managed to hold up spending on the Health Service to such a high level, in view of the overall economic circumstances.
When we discuss this matter in public throughout the country, we should not do it on the basis that the Government have been slashing expenditure on the Health Service, because they have not. They have very nearly kept up with the figures, including the growth figures, laid down by the previous Government, and we should be thankful for that. Against that background, I look at the report and the overall problems. As I say, I speak as a constituency Member with hospital problems like everyone else's.
What comes through from the Committee's report is that the problem of perinatal mortality has to be treated at all levels, from the regional and sub-regional centres of excellence—hospitals such as Northwick Park in my area and some of the great London teaching hospitals such as University College—which do invaluable work in saving lives and preventing handicap amongst babies at the time of their birth, to the important contribution which will be made by the district general hospitals and hospitals serving communities, such as my own hospital at Hemel Hempstead, which is not in itself strictly a district general hospital but which we are extremely anxious to keep as a full hospital to serve Hemel Hempstead, and down through the community as a whole.
The report goes on to emphasise the vital importance of health education and the part which schools and places of work can play. It should be noted that the Government's response rightly welcomes those aspects, although it indicates the difficulties of transferring funds, perhaps to the centres of excellence.
I want the Government to take careful note of the investment argument which was put forward for improving the facilities in our regional centres of excellence. Professor Tizard mentioned this topic in his evidence to the Committee. In cases where there are significant numbers of handicapped children, there is a real payback for investment in first-class facilities, particularly in neonatal care.
At the next level—district general hospitals and hospitals serving individual communities—I hope that the Government will continue to do what they have been doing since they came to office, namely, to give priority to

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hospitals which give full service to their own communities. It is not only the excellence provided by the hospitals but the accessibility of the hospitals to the people whom they serve which is of critical importance in ensuring not merely that the facilities are available but that they are taken up by the mothers who need them.
That brings us to the next level—health education. It is a subject of vital importance. It has been said often that it is the poorer people, people in difficult circumstances, referred to as social classes IV and V in the jargon of today, who do not take up the services and who are most at risk. We must have a continuing campaign to make sure that we get across to every mother, whether she be young or older—an elderly primate, as my wife was referred to, and she was young enough when our first child was born—that she must go early for ante-natal care. Therefore, the ante-natal care must be readily accessible. I believe it is much more likely to be used if it is linked to a hospital where the mother knows she is likely to have the baby than if it is simply an ante-natal care clinic which is divorced and far away in distance from the hospital.
We need to educate people to go to these clinics. The work of the Select Committee has produced the striking statistic that only 46 per cent. of girls leaving school are given any education about the need for ante-natal care. There is no reason why it should cost a penny piece to bring that percentage effectively up to 100 per cent. I am sure that. the advice can be made available either for nil or it minimal cost, and it will mean that in future our young mothers, many of whom are young—and the youngest are those who are most at risk—will have the information brought home to them in an area where they are likely to ix receptive. Poorer children, perhaps less intelligent children, still want to have families and will listen to this kind of advice if it is put in front of them.
Good communication goes further. It has been rightly said that ante-natal clinics must be more hospitable and friendly. As the hon. Member for Isle of Ely (Mr. Freud) said, doctors must communicate better. I say that although had the privilege of marrying into a medical family and one where Professor Fletcher is particularly concerned not only about smoking but about communication in medicine. The problems of communicating with the mother-to-be are very real. It is difficult for the mother to express her anxieties, and it is extremely important that doctors and medical staff should be receptive to those anxieties and ready to draw out the problem from the patient, the mother-to-be.
The problem does not occur only with poorer and less-educated people. My wife had considerable difficulty in getting her anxieties across, though she was privileged to attend a superb doctor becauase we had problems of likely premature birth. Difficulties of communication exist at all levels. I am glad that the medical profession is looking into them and I hope that it will with ever-increasing urgency teach its young doctors the importance of communicating.
In paragraph 3.1.2 of the reply, at page 65, which quotes the work of the Health Education Council, there is the following interesting statement, which should be emphasised:
"Evidence suggests that persuading expectant mothers not to smoke cigarettes would do more to reduce infant mortality in the united Kingdom than any other single action."
Those words should go out to the country loud and clear. I have seen posters in ante-atal clinics showing the dangers
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of smoking, but they do not necessarily get the message across. The campaign could be increased and the message could be put in the most vivid terms.
Smoking is damaging. I notice the somewhat muted response of my right hon. Friend in his discussions with the tobacco manufacturers. I am sure that we shall return to the question of smoking in another debate. I urge the Government to take strenuous action to get across to the public the real dangers of smoking, including, as we are talking about perinatal mortality, the overwhelming dangers to the baby of a mother-to-be who smokes throughout pregnancy.
I am glad that we have had the debate, which concerns all levels—from centres of excellence right down to communication with the individual and education of the mother-to-be—and I am grateful for having been able to take part.
1.32 pm
Mr. Dafydd Wigley: I also welcome the debate, and I congratulate the Social Services Committee on its excellent work. I hope that the Government will note the view expressed by hon. Members on both sides of the House. Parliament looks for an early and more adequate response to the points made in the Committee's report.
I should like at the outset to speak of the personal circumstances that are the background to my following the debate. My wife and I have four children. The two older boys—Alun and Geraint—are mentally handicapped. Mercifully, the two younger children are very healthy. We discovered simultaneously that the two boys had Hunter's disease, one of the polysaccharide group of disorders, with a very poor prognosis, when they were 2½ years old and 1½ years old respectively. Incidentally, that was in the week that the general election of February 1974 was called. At that time my wife was four months pregnant with our third child, so the House can imagine what a traumatic experience it was for us.
I have hesitated in the past to base any argument in the House on this personal experience, but I feel that in this debate it would be wrong not to do so, not because of what we have learnt from our misfortunes but because of opportunity that we have had subsequently to learn very well of the strains and worries that afflict many other parents who have similar, and even worse, problems.
When we discovered our problems, it was possible to screen my wife for the condition of our third child, Eluned, and of our fourth child, Hywel. We have asked ourselves many times why the condition of our two elder boys was not identified earlier. This has persuaded us of the tremendous importance of ante-natal screening to avoid the birth of severely handicapped children. The experience of the past few years has brought starkly to our attention the facilities—particularly the lack of them—for looking after mentally handicapped persons.
We can speak only with great respect and admiration for the doctors, social workers and teachers who have helped us. Those dedicated people are hampered by the desperate shortage of facilities in so many areas. That is important in the context of the report. There is a desperate need for many millions of pounds to be spent on additional facilities in specialised schools, in ordinary schools, adult training centres for the handicapped, day centres, short-term stay hostels, sheltered housing within the community, better facilities in hospitals and intensive care units. That means that we would need to spend £50 million

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a year over the next 20 years in order to look after the mentally and other handicapped children. That should be taken on board by the Government when they consider the amount of money to be spent on prevention rather than taking care of the problem after it has arisen.
In that context, it is not only the cost to the Government that should be taken into account but also the substantial costs that are borne by local government in relation to social services and educational expenditure. The Committee is asking for an additional £25 million—a modest sum. At a time when it is possible to find an extra 2½ per cent. increase in defence expenditure, surely it is possible to find this extra £25 million.
In opening the debate, the Secretary of State said that all the indications were of a momentum towards further improvement. But are they indications of a move in the right direction, with the greater social stresses and the housing and unemployment problems that are facing the community?
I accept the point that was made by the hon. Member for Hemel Hampstead (Mr. Lyell) on the question of low-weight babies and the need for strong action on smoking. The Department and the Government must stress the dangers to all those involved so that the message gets home loud and clear.
The Secretary of State said that 18 research projects were being funded. But is that anything like enough to meet the needs?
What, then, can be done? There is a need to identify parents at risk before they become pregnant, particularly those who are open to congenital problems. There is also a need to identify abnormal pregnancies early on, and it is therefore important to maximise the amount of screening that takes place. I know that facilities vary greatly from area to area in terms of screening capability. There is also a need to induce people to make early and regular visits to ante-natal clinics. If resources are available, there is a case for giving a pregnancy grant, geared to visits to such clinics. I know that the Committee did not go all the way with that suggestion, but I think that it should be considered if resources are available.
There is also an urgent demand for greater foetal monitoring. The Secretary of State expressed some doubts about that and said that it might cause anxiety, but if it were a routine procedure it would not cause anxiety. In fact, it would reduce anxiety amongst the group who are outside the normal category.
The report indicates the importance of information for pregnant women. There should be a development of antenatal classes, perhaps linked with routine visits to clinics. I hope that the Government will act on recommendation 1, which states that all pressures should be put on women to visit such clinics and that more information should be passed over by
"health visitors, community midwives and social workers."
I hope that that will be incorporated in the circulars that will be sent out. Although the report covers England only, I ask the Secretary of State whether the circulars will be sent out in Wales also through the Welsh Office. Obviously the problems are similar, and we do not want to wait for another report before those steps are taken.
There are groups that need special consideration. For example, people in social classes IV and V—a term that I do not like—and single and working mothers are most
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vulnerable and are less likely to attend ante-natal clinics. In consequence, there is less likelihood of monitoring of blood pressure in those groups, and yet those people are often under more stress and they need it most. That group also has the greater propensity to smoke during pregnancy. A pregnancy allowance, for instance, would induce these women in particular to go to the clinics regularly and in good time.
We need 50 more neonatalogists and more nurses with special training in neonatal care. We need more skilled obstetricians for monitoring labour, delivery and pregnancy. It is important to use skilled doctors and nurses during monitoring. We need more modern equipment at existing units, which should be updated. More people should be trained in interpreting ultra-sound machines. The machines are useless without correct interpretation. There is also a need for more screening of the newborn for hyperthyroidism. The condition is fairly simple and treatable in the newborn, but it results in brain damage if left untreated.
I have reservations about paragraphs 453 and 454 of the report. Paragraph 454 contains the recommendation for medico-legal discussions with a view to amending the law as it relates to research on newborn infants.
That is a difficult, ethical question which must be handled with great sensitivity. The main principle is that research technique should be related to the well-being of the child and should not be harmful either physically or psychologically. We must be careful about taking on board the concept of experimentation. The opinions of the parents and doctors must be given considerable weight.
The Committee calls for £25 million as a minimum. Surely that is not much for the Secretary of State to find. Then we can see whether some progress can be made. The cost is well worth bearing for the community and would be an investment for the Government.
1.43 pm
Mr. Tom Benyon: I congratulate members of the Committee on the enormous amount of work that they have done on this comprehensive and detailed report. The problem for the last or the penultimate speaker is that everything that he was going to say has already been said at least twice with great vehemence and eloquence by other hon. Members. Therefore, I shall be brief.
Everybody has a great interest in this subject. My interest is probably more recent than that of other hon. Members because my wife nearly had our child in Westminster hospital last week and actually had him in the John Radcliffe hospital, at Oxford three days later. That was to the relief of the emergency staff at Westminster hospital. I pay tribute to the kind help that was given to my wife and myself at both the Westminster hospital—thank goodness it was not closed—and at the John Radcliffe hospital where my beautiful baby boy was delivered by a constituent, an extremely able midwife who lives close to Abingdon. I also thank her.
My wife is fortunate because she is a highly intelligent person. Consequently, my child is much blessed. If my wife was in socio-economic group V or VI, my child's future would be much less happy. My wife would probably have dietary problems because she would have lived on appalling food for much of her life. She would probably smoke. That danger has been described most recently and ably by my hon. Friend the Member for Hemel Hempstead (Mr. Lyell).

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On Monday I talked at great length to the doctors at the hospital about their experience of babies born to mothers who smoke. They told me of the torment that they experience when mothers chain-smoke up to the day of delivery. They told me how most babies born of such mothers are so markedly small that they can tell that the mother smokes. I add my plea to the many that have been made today to mothers not to smoke during confinement, because of damage to the unborn child.
A mother in that class will probably also drink alcohol. Newborn babies can be born showing the effects of alcoholism. It is important for mothers to drink only in moderation during confinement, if they have to drink at all.
Such mothers will probably also have hygiene problems, through lack of education. They are desperately in need of the maternity grant. It has been stressed that that grant has not been increased by Governments of either party in the past 10 years. The Government's response to the Black report was depressing. The grant will stay at £25 when it should be £120. We all know how little £25 will buy for a newborn baby. It is important for a mother to know at that crucial time in her life that the immediate needs of her baby will be met. They cannot be met at present. The mother will also be in desperate need of her child benefit. It is sad that that was not fully uprated previously. We await with great anticipation the next ministerial announcement.
Such a mother north of the Wash could well be in bad housing. It is far more likely in that area than in the lusher Southern pastures. Birth problems are closely linked to housing and social problems and social security benefits. Such matters go hand in hand.
It becomes more likely every day that the father could be unemployed, when the stress on the mother and the family will be even more acute. Every debate in the past months has emphasised that that problem is increasing. The stress and sometimes violence associated with unemployment problems can affect the unborn child, so the future is bleak.
The message that is coming from the House to my right hon. Friend is that money spent on preventive medicine will save money in the future, as well as alleviating much suffering. I am sure that those who wrote the reply to the report have visited schools for handicapped children and talked to parents. They must know of the enormous stress and misery, which can easily be prevented if we educate people and spend money on communication so that they realise that simple preventive measures can reduce the chances of a stillborn or mentally or physically damaged child.
My right hon. Friend may say that fine words butter no parsnips. Where can he get the money from? There are many areas of the National Health Service where considerable savings can and should be made. I am not asking for more and more money. It is a question of priorities.
The hon. Member for Isle of Ely (Mr. Freud) mentioned the decline of midwifery. I hope that that can be reversed. Those in charge of the purse strings should read the excellent Reith lectures given by Ian Kennedy, which are reported in The Listener. He deals with the misuse of pubic funds in the NHS. Although I do not have first-hand knowledge of the subject, the articles have the ring of truth. I shall be writing to my right hon. Friend to ask for his comments on those lectures and to ask also how
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money could be spent on areas of most need and how much could be saved by not spending huge sums on highly sophisticated machinery for tiny areas of medicine when those sums could be spent to so much greater effect in areas such as the one that we are discussing.
If the drug companies sold drugs to the NHS by compound and not by brand names, there would be enormous savings. Lastly, our hospitals are clogged up, and have been for a long time, by many who would not need to be in hospital if only we could persuade the public to wear seat belts. That would produce enormous financial savings to the country and the NHS. From an answer on 1 July 1980 by my hon. and learned Friend the Parliamentary Secretary to the Ministry of Transport, it appears that about £1,730 million could be saved if that were done. The answer set out in precise detail the huge financial costs, apart from the misery, of not wearing seat belts.
If we are to find money to do really important things in the NHS, let us cut out, once and for all, the bogus and stupid arguments about how many angels are dancing on the head of the freedom of the individual or liberty pin, and let us make people wear seat belts, fast.
1.53 pm
Mr. Roland Moyle: This will be the only speech from the Opposition Front Bench during this debate. I hope, therefore, that the House will forgive me if I do not confine myself to replying to the debate, interesting and stimulating though it has been. I shall put forward the Opposition's view on the Select Committee's report and on the Government's response to it.
First, I join the chorus of tributes to my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) for presiding so effectively over a hard-working and worthwhile Select Committee that produced such a valuable report to inform our deliberations today. I was especially impressed by the Select Committee's willingness to go beyond generalities and to get down to the details of the problem. It has put forward a host of important recommendations for the Government and the rest of us to consider.
I also take this opportunity of paying a tribute to my hon. Friend the Member for Eccles (Mr. Carter-Jones). My hon. Friend has had to leave his place for a speaking engagement elsewhere, but I have little hesitation in putting on record that it was his representations to me in the early part of 1978 that restored this subject to a high place on the NHS agenda.
My hon. Friend persuaded me to identify the 33 area health authorities whose perinatal mortality rate was worse than the average and to write to them to ask them within six months to produce schemes and plans that would be directed, from the medical and health care point of view, towards raising their levels of perinatal care to that prevailing in the better-off parts of the country.
I wrote to the authorities at the beginning of August 1978 and I received the replies in January 1979. The Department was processing the plans with a view to producing action when, unfortunately, the events of the general election intervened. I ask the Minister for Health to let us know how the exercise has developed. My hon. Friend the Member for Eccles said that he tried to obtain that information and had been unsuccessful. Perhaps the Minister will be able to enlighten us when he replies to the debate.

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I found extremely useful the classification of the recommendations by cost category. One does not have to be a full-blooded Thatcherite to get some advantage from such an approach. It is extremely valuable.
Occasionally, I thought that the cost classification was eccentric. It might well have been a little optimistic at times, especially to someone who was not a party to the deliberations of the Committee. At the end of it all, however, there can be little doubt that a large number of recommendations can readily be applied in this crucial area with a minimum cost factor. Very much will depend on the professions involved revising their practices as a result of the advice of the Committee. There will be a tremendous burden of follow-up work.
There are two points on which I should particularly like to comment. The first relates to what was an emotional issue during my time at the Department. It is the question of births at home. Here I should like to distance myself a little from the Committee, which emphasised the importance of births in well-equipped maternity units. I do not necessarily disagree with that. I should like to see women have their babies in such units, but at the same time I agree with the Secretary of State that provision and facilities must be made for women who wish to have their babies at home.
I agree with everything that has been said about smoking during pregnancy. As I hope we shall be debating smoking on another occasion, I shall make no further reference to it now.
The Government's response to the Committee's report has been cautious. In fact, the Secretary of State said that he was uttering a note of caution. I would take it a little further than that. I believe that the Government's response, particularly when viewed in the context of policy development, demonstrates a disturbing lack of will. In that respect, although I did not hear the speech of my right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley)—I received a report of it from my hon. Friend the Member for Edmonton (Mr. Graham)—I substantially agree with it.
The Government's response can be paraphrased by saying that much has been dome to improve performance in this area. They admit that much remains to be done but that there will be resource constraints. I should like to put the question of resource constraints in context, because almost every hon. Member has urged the Secretary of State to ask the Chancellor of the Exchequer for a further £25 million for action in this regard. I hope that the right hon. Gentleman will not regard the Chancellor's refusal as an alibi for not putting extra resources into this sector.
The Secretary of State's minimum figure is £60 million, whereas hon. Members have asked for £25 million. But that £60 million figure should be compared with the figures given by the Minister in a letter to The Times on Monday. In it, he said that next year 12,000 million debilitated pound notes would be poured on the NHS. It seems that what we are asking for is a reordering of about 0·5 per cent. of the health and personal social services budget in order to meet the Secretary of State's minimum figure of £60 million. That is all that we are asking for—0·5 per cent.
We must consider that against the background of the interventions by the hon. Member for Newark (Mr. Alexander) and the hon. Member for Kensington (Sir B.
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Rhys Williams), both of whom stressed that we are not expecting the Secretary of State to find that sort of money by next Friday. It must be reordered over a considerable period—a matter of some years—in order to bring facilities up to scratch.
The Secretary of State always asks "Where will you get the money from?" I thought that the hon. Member for Abingdon (Mr. Benyon) gave him a good start in that direction, with which most of us would agree, if the right hon. Gentleman is thinking of transferring money from one aspect of the NHS to this particularly vital area.
The Government's response would not have been too bad had it not been made in the context of their response to the Black report. I refer the House to paragraph 20 of the Government's response to the Committee's report. It said:
"The Committee made it clear that they saw the greatest scope for improvement in the elimination of regional and social class variations. The Government agree."
Yet the Black report dealt with exactly those social and regional inequalities in health care. What was the Secretary of State's reply to Black? He said:
"I must make it clear that additional expenditure on the scale which would result from the report's recommendations … is quite unrealistic".
That is bad enough, but, even worse, he followed up by saying:
"quite apart from any judgment that may be formed of the effectiveness of such expenditure in dealing with the problems identified. I cannot therefore endorse the group's recommendations."
The Secretary of State had the chance to meet the Select Committee on the matters that he dealt with in paragraph 20 of his response. His rejection was not only on grounds of cost but on grounds of principle.
Mr. William Hamilton: Will my right hon. Friend address his mind to another aspect of the problem, namely, the enormous current expenditure on defence? Does he recall that I elicited from the Secretary of State for Defence that we are spending about £1,000 million on a torpedo project for use—although it may never be used—by the Royal Navy and the Royal Air Force? In this debate we are talking about £25 million, which would be about the cost of painting the torpedo.
Mr. Moyle: I agree with my hon. Friend that the Government have no difficulty in finding money for defence and for giving tax concessions to people who are already earning high incomes. However, they find a great deal of difficulty in obtaining money for matters of this nature.
Mr. Patrick Jenkin: The right hon. Gentleman says that the Government do not have difficulty in finding money for certain things. Does he recognise that the expenditure reductions announced last week by my right hon. and learned Friend the Chancellor of the Exchequer included £200 million for defence, whereas we have virtually entirely protected the spending on the Health Service, which will continue to grow next year by 1½ per cent. in real terms?
Mr. Moyle: The right hon. Gentlema may say that, but his argument does not stand up. The third report of the Select Committee said that at the end of 1979–80 the Health Service expenditure was £160 million smaller than at the beginning of 1979. This year, with inflation running at between 15 and 20 per cent. and cash limits of only 14

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per cent., the Government have allowed only ½ per cent. growth. That means that the Health Service will be smaller at the end of 1980–81 than it was at the beginning. Unless something drastic happens, the position will carry through to 1982–83. However, I do not want to be distracted from the debate about perinatal mortality.
On 12 November the right hon. Gentleman answered a batch of questions which clearly indicated that many of the Black report's recommendations could be more cheaply implemented. The pay-off was in the debate on 27 October, when he said:
"I have never regarded it as a fundamental part of my political philosophy to achieve a greater equality. I have devoted my political life to raising the quality of service for everyone."—[Official Report, 27 October 1980; Vol. 991, c. 101.]
The last sentence must be claptrap. In view of his unwillingness to take action, what is the quality of service in the case of the 3,000 to 5,000 perinatal deaths, some of which are avoidable? I think that that is common ground between us. They will not be avoided, which again is Common ground between us. What credibility does paragraph 20 of the Government's response have, and what does it mean in the light of the right hon. Gentleman's attitude to the Black report? The two cannot be reconciled.
This is the third major report in the past three or four years—apart from all the other reports that have been referred to—which shows that the key target for action in the Health Service must be the period just before and just after birth. That would lead to a great deal of human happiness. It would lead also to long-term savings for the Health Service.
I thought that the Secretary of State's comment on that aspect of the matter was less than comprehensive when I questioned him during his speech. The Court report, the Black report and the Select Committee report all hang together. They all say the same thing. Indeed, the Black report on page 228 makes children at the start of life one of its top priorities for action. In paragraph 8.3, the Black report says that
"inequalities between the occupational classes in mortality rates are greatest in infancy".
It also says that
"action needs to be taken within the health services to improve access and facilities in particular for pregnant mothers and others with infants."
My hon. Friend's report has spelt out in greater detail the matters to which the Black report was alluding in more general terms. So either the Government can say why they agree with the Select Committee and then try to explain their attitude to the Black report, or they can say that they stand by their attitude to the Black report and then try to explain how they can possibly go along with their response to the Select Committee.
Indeed, the matter can be taken further than that. They should have been applying already both the Black report and the Select Committee report to the National Health Service since May 1979, because the Government have said that their priorities are the same as the priorities for health care that the Labour Government developed.
The Black report, in paragraph 8.9, says:
"Our concerns are very much within the spirit of the two documents on priorities: 'Priorities for the Health and Social Services and 'The Way Forward."'
The Secretary of State read an extract from the first of those reports. "The Way Forward" was a subsequent
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document produced in 1978. Those documents were produced by the Labour Government. It was stated in "The Way Forward" that
"It is important to seek to achieve a further reduction of mortality rates."
It also said that
"it does require better equipped units with enough staff and relevant training."
Both quotations refer to the period of birth and the perinatal period. They are really an encapsulation of my hon. Friend's Select Committee report. So the Government's response to the Select Committee report should have been to say "Great stuff. We are proceeding down these lines already. Thanks for the help with advice on detail."
Doubts about the political will of the Government stem not only from the context and the background but from the response itself. For example, the Government's response in paragraph 5, on page 2, is:
"However, the Government see the great majority of the recommendations as falling to health authorities and professional and other bodies."
I sometimes wonder why someone has not said that the present Government are the great Government of buck-passers. If unemployment goes up, that is all due to the workers' pay claims. If there are poor export performances, they are due to interest rates. Everything that happens seems to be due to some act of God over which the Government have no control. The matter of saving lives and losing lives is, they say, for the health authorities.
I remind Ministers that they are paid large salaries. They are paid to take responsibility, they are paid to solve problems and they are paid to intervene and to take action. If they do not do so, they should forfeit office and salary and make way for someone else who is prepared to do it.
I should utter a word of warning here. We are all in favour—(Interruption.) Our record on perinatal mortality will stand up very well to anything that Conservative Back Benchers can bring forward. I was about to say that we are all in favour of delegation in the Health Service, but we have gone a little too far. I sometimes had the feeling that, if he was not too careful in trying to direct the Health Service, it was sometimes as if a Minister was shouting in a cathedral. His voice echoed loudly down the empty nave but the grand structure remained utterly unimpressed. I warn Ministers that unless there is a will at the start of the exercise they will fail, and it looks to me as though the political will is failing.
Before I conclude, I should like to refer to the response made in paragraph 17 on page 5 of the report, where it says:
'There are a number of well-documented reasons why this country's perinatal mortality rate is higher than those in Scandinavia, etc."
Later, in paragraph 19, the report says:
"While these and other adverse demographic factors continue, it is realistic to expect that the perinatal rate in this country can be reduced to the same level as, for example, Sweden,"
What are the Government hinting at there? Are they hinting that we have a large number of immigrants? If so, why do they not say so? We cannot accept lower targets in this country just because some of our citizens are brown or black and may be first or second-generation immigrants who have come from areas where the standards of feeding and housing and so on are much lower than in this country.
Much remains to be done in talking to the professions on the action to be taken. For example, midwives will

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want to talk closely to the Government about their general indication that the burden on midwives seems to be becoming lighter. I am sure that right hon. and hon. Members will find out that midwives have other views.
I would have hoped that the Government would initiate discussions with the professions and the local authorities and would prodce a scheme for talking to these bodies about the action to be taken in the follow-up to the report. I hope that I am wrong, but, along with many hon. Members who have spoken in the debate today, I fear that the Government lack elan, faith, and the will to act in what is probably the single most important area of saction in health matters.
We cannot take our decisions on human life entirely on the basis of cost-effectiveness, because usually human life is not cost-effective. There are other considerations, including humanity. I hope that the Government will have second thoughts and pay more consideration to that aspect of the matter.
2.11 p.m.
The Minister for Health (Dr. Gerard Vaughan): I understand very well the problems for hon. Members and for a number of professional groups outside over the short period between the Government's reply and the debate today. It was because of the importance that we attached to this subject that it seemed reasonable to hold the debate at the first opportunity. In a sense, it is a tribute to the urgency and significance of the subject.
A number of hon. Members who have spoken, or who wished to hear the full debate, have had to send me messages saying that they have been compelled to leave because of various engagements which they were unable to cancel.
The hon Member for Belfast, South (Mr. Bradford), unfortunately in my view, found it necessary to leave the Chamber without giving the House the benefit of his views. He said that he did not have enough time to do justice to Northern Ireland's interests in the report. In fact, having been called at 1 o'clock, he could, had he wished, have spoken for one and a half hours. His reference to five or six minutes presumably referred to some personal commitments. I should point out that the report is not about Northern Ireland. My right hon. Friend the Secretary of State for Northern Ireland recently issued a separate report on perinatal mortality in the Province—the Baird report. No doubt the hon. Member for Belfast, South will wish to make his views on that report known to my right hon Friend the Secretary of State for Northern Ireland
Mr. Moyle: Indeed, the Baird report is equally as good a piece of work as the report that we are considering this afternoon. I knew Dr. Baird when he was the chief medical officer in Northern Ireland. He has done a first-class job.
Dr. Vaughan: I am glad that the right hon. Member for Lewisham, East, (Mr. Moyle) said that. I support his comments.
Despite the short notice, the debate has been extremely interesting and useful, with a number of outstanding speeches. The speeches by my hon. Friends the Members for Macclesfield (Mr. Winterton) and for Thanet, East (Mr. Aitken) and that of the hon. Member for Eccles (Mr.
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Carter-Jones) particularly impressed me. The right hon. Member for Lewisham, East also made a very constructive speech.
I was impressed the other day when the right hon. Gentleman said that he thought that the Labour Government had been too complacent about the National Health Service. I agree with him. I thought that he was courageous to make that speech when he was commenting on the Black report. Today we are discussing a subject about which the previous Government were far too complacent and on which they did not take the action that many hon. Members, on both sides of the House, would have liked to see.
This has been such a useful debate because it has been based on an unusually literate and comprehensive report from the Social Services Committee. I congratulate its members, and I add my tribute to the chairmanship of that Committee by the hon. Member for Wolverhampton, North-East (Mrs. Short).
As my hon. Friend the Member for Thanet, East said, the report is a passionate cri de coeur. It adds up to a powerful and most persuasive message, of which we all take note. My hon. Friend the Member for Macclesfield pointed out that part of the value of the report was the very high level of advice that was available to the Committee, based on the experience of the professional advisers. That is important to note in the House.
The Government are not at all complacent in this matter. As my right hon. Friend the Secretary of State said, we see a sustained campaign in this field, with no letting up of improvements wherever they can be made. It fits in very well with the Government's emphasis on the importance of the family and all family matters. As my right hon. Friend said, when looking at the things that go wrong we must not overlook the majority of births that progress through as a completely normal and natural process. This was also commented on by the hon. Member for Isle of Ely (Mr. Freud).
I am sure that the House will understand when I say that there can be no complacency on my part. I shall gladly take up the suggestion of my hon. Friend the Member for Macclesfield that I should get deeply involved in this matter. I am pleased to be doing so, because I understand very well the strength of feeling on the matter.
A baby born dead or handicapped is an intensely emotional, disturbing and appalling event. I have been present when severely damaged children have been born. I have seen the expressions on the faces of the staff who have been actively involved in the birth. I have been present when mothers have been shown their deformed children for the first time—a moment of terrible pathetic anguish, which one has to see, of which one has to be a part and even begin to understand. My hon. Friend the member for Belper (Mrs. Faith) also referred to this. I remember, too, being present when a beautiful—"beautiful" is no exaggeration—young child died because the necessary resuscitation equipment was not available.
I mention that only because I believe that one has to remember that aspect to understand the feelings among many people that if something can be done it must be done—and done not in the days ahead, but now. If these situations are avoidable we must take every step to avoid them, and there is no justification for not doing whatever is necessary to avoid them. With a short period of a lack of oxygen or too much pressure on the child's head at the

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time of birth, a normal child will instantly be changed into an invalid for the rest of his life. We all appreciate that. The Committee did a great service in bringing out these aspects in its report.
As my hon. friend the Member for Belper said, there is the whole family aspect. Many a mother before giving birth wonders anxiously whether the child that she is about to produce will be all right. If there are any steps that we can take during pregnancy to enable mothers to know, to be reassured, that at least nothing very serious is going wrong, clearly we all want them to be taken.
After the birth, the first question that someome with a handicapped child asks is "Why has it happened?" I have met many mothers who, years later, still feel a sense of guilt and anxiety about whether, had they done something slightly different, they could have avoided the tragedy in the family. It is not only important from a research and scientific point of view to be able to explain to people what was unavoidable; it is also important from the individual mother's and the parents' point of view. We are not overlooking that aspect of the matter.
It has been said that some parts of the country have a very different level of services from others. The Guardian this week pointed out the enormous discrepancy between, for example, Oxford and Sandwell. Clearly, there are differences in the classes of people and the mix of the population in those areas. The question immediately arises whether geography, because of lack of equipment or something of that sort, should be allowed to determine whether a child is born handicapped. Of course, it should not.
My right hon. Friend the Secretary of State and the right hon. Member for Norwich, North (Mr. Ennals) have indicated how the figures have come down dramatically in recent years. This is a matter for satisfaction. The fall in perinatal mortality shows a drop from 29·1 per thousand in 1963 to less than 15 per thousand now, and the figure is still falling. It has fallen in the early months of this year. I believe that it will continue to fall—this is the advice that the Department gives—as a natural trend, following the steps already taken.
Comparisons have been made between this country and Scandinavia and Japan. As the debate has shown, there is a higher incidence of anencephaly in this country than in France. We have a higher level of low birth-weight, which carries with it so many problems, than one finds in Scandinavia.
There are signs, however, as the hon. Member for Eccles mentioned, that immigrants to Sweden also benefit from the services there. Birth weights improve. This raises the question whether it is a procedural difference, as the Committee would like us to believe—it may be right—or a demographic difference. It is a matter that the Government undertake to examine.
An excellent article on 22 March in the British Medical Journal dealt with the French situation. On the face of it, the French have made rather better progress than we have. We do, however, expect that in the near future the Welsh situation will approach very closely the best figures in France. This it; not my province, but I shall answer in writing any points that Welsh hon. Members would like to raise.
The French figures are difficult to interpret. The French have a category "death before registration", which puts so many of their figures in a different context. I cannot help noticing that the maternal death rate in France is twice that
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in this country. One should not always look overseas in criticism of ourselves. Our maternal death rate figures have fallen dramatically. They are very satisfactory, although not perfect.
The House has rightly pursued the Secretary of State's argument that we cannot have it both ways. We cannot ask local health authorities to exercise their judgment about where local priorities lie and, at the same time, keep intervening from central Government to tell them exactly how they should spend this or that part of their resources. This is a matter that we have very much in mind with the new district health authorities.
Mr. Ashley: Is it not possible to have it both ways by giving the local authorities more money and leaving them to get on with improving perinatal care?
Dr. Vaughan: I am glad the right hon. Gentleman raised that, because there will be more money available in real terms. It is then for the health authorities to decide how to allocate it. However, the essential theme that we are discussing is whether the Government should provide specified money and impose the spending of it on the health authorities or whether we should do what we believe to be right, which is to distribute the money to the authorities with some guidance about how we think it should be spent and leave it to them to judge the priority in their areas.
Mrs. Renée Short: Are the new authorities likely to have the increased money to which the Minister has referred? When will they know how much they have, and what is to happen to the £30 million which will be saved through reorganisation? That would pay for this.
Dr. Vaughan: The latter point is a matter that we must debate on another day, but the volume of spending will be known in the figures early next year. This year alone, as the right hon. Member for Lewisham, East said, we have got to a figure of £11·9 billion, of which about £200 million is an increase in real cash terms, which the health authorities are spending as they think best.
This is really the central theme that has run through so much of the debate. It has been put to us as though the health authorities in various parts of the country were doing nothing. That is not true. In the Birmingham area, for example, the capital development has gone up enormously. It has just produced a new ambulance service specially equipped for neonates and also a special ambulance for mothers to be taken to the Birmingham maternity hospital when they are in labour.
In Croydon, in capital development terms, there is £2 million to improve the maternity hospital and special care baby unit. There is £70,000 of additional funds for the regional neonatal intensive care unit at Newcastle. The hon. Member for Wolverhampton, North-East will be pleased to hear that in Wolverhampton the sub-regional intensive care unit is running its own training courses and that a consultatnt paediatrician with special interest in neonatal paediatrics has just been appointed. In Coventry, again in the sub-regional intensive care unit, an additional consultant has been appointed, but is not yet in post. He will have major responsibility again for neonatalogy.
I could go through a long list, and I should be glad to let the hon. Member for Wolverhampton, North-East have the list of the various parts of the country where some real

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extra provision is being made. I ask her not to decry what is going on but to realise that this is happening across the country.
A good deal of comment has been made on the need to establish norms and standards. When the Government publish the strategy document next year, we shall make it clear that we intend to establish minimum standards. Over the past 10 years there have been five major reports which have recommended this. The minimum standards that we envisage setting up must be those that are attainable within a reasonable time and with reasonable staffing and finance. The hon. Lady will realise, for example, that 224 additional cots mean more than 1,200 highly skilled nurses and back-up staff and 50 neonatal consultant posts to go with them. Such staff need to be recruited, trained and retained. That is a problem. It is arduous work, and there is a high staff turnover. Therefore, it is not a question of simply asking for additional equipment, although I support that. It is also a matter of training and recruitment of the staff to back it up.
Question put and agreed to.
Resolved,
That this House takes note of the Second Report from the Social Services Committee, Session 1979–80, on Perinatal and Neonatal Mortality (House of Commons Paper No. 663) and the relevant Government Observations (Cmnd. 8084).

Perinatal and Neonatal Mortality
  STATUTORY INSTRUMENTS, &c.
  Motion made, and Question put forthwith pursuant to Standing Order No. 73A (Standing Committee on Statutory Instruments, &c.),

  VETERINARY SURGEONS
  That the draft Veterinary Surgeons Qualifications (EEC Recognition) Order 1980, which was laid before this House on 29 October 1980 in the last Session of Parliament, be approved.—[Mr. Brooke.]
  Question agreed to.

Open University
Motion made, and Question proposed, That this House do now adjourn.—[Mr. Brooke.]
2.30 pm
Mr. Ted Graham: I am delighted to see that the Under-Secretary of State for Education and Science with responsibility for higher education is to respond to this short debate. I know of his support and admiration for the Open University, and I at once exonerate him from any of the charges that I shall make about the broad policies that I shall attack. He will have opportunities to prove his support for the Open University today and in the future. I very much hope that he will take advantage of those opportunities.
The real villain is the Government and their financial policies, particularly their slashing of public expenditure. An irony about the way in which we conduct our affairs is that, while the Department of Education and Science is the subject of the criticism of those policies, I am reasonably certain that the prime protagonist is the Treasury, with the DES the hapless instrument of its demands.
I am concerned today about some of the victims of those policies—the Open University, its students, its staff,
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its future and its ability to enhance and enrich countless thousands of lives in the future. They will all be the poorer, and so will Britain.
This debate could do worse than to take as a text the definitions used by Lord Crowther-Hunt more than 10 years ago, when he explained why our university would not rest amid cloisters, which means closed, but would be open. He said:
"We are open as to people. We are open as to places. We are open as to methods. We are open as to ideas."
The diktat of the DES in compelling the university to raise tuition fees from £67 to £98—a whopping increase of 46 per cent. in one year—strikes at the very root of the openness of the Open University. Faced now with an annual outlay of more than £200 a course, how many prospective students will decide that it is too much? Are we now to cease to measure the value of the Open University by its ability to stretch dormant talent but to open it only to those who can afford it?
I want the Minister to take this opportunity to dispel any impression that the Conservative Government are hostile or antipathetic to the continuing development of the Open University. I believe that the ethic of self-help has a certain attraction to the Conservative philosophy and that the concept of value for money and comparative cost for the same product should commend the Open University to this Minister and this Government.
When the Prime Minister told the House yesterday that even with the increase in fees the university was still good value for money, of course she was right, but that now applies only if one can afford the purchase price. The Under-Secretary, above all other Ministers, knows that the cost to the taxpayer of supporting a graduate at the Open University to degree level and beyond is much less than at a conventional university. He above all other Ministers knows that the university has been economising for some time. In order that cash limits be observed, a series of measures have been taken resulting in the curtailment of many services to the students.
Does the hon. Gentleman appreciate the implications of the tuition fee increases for the nature of the university? I was told at a lobby from the university in the House yesterday that the science and technology-based courses would suffer most. This year 5,000 students are enrolled for statistics and computer courses. It becomes cheaper to switch to social science and arts courses. Is that what the Minister really wants? Do the Government really want to starve industry of that sort of training?
I am one of the 39,000 graduates who have left the university with a qualification in the past 10 years. Currently there are 60,000 men and women of all ages and in all places studying for degrees. This year, 43,000 people applied to join a course. Only half of them are likely to get places, but I am told that this year it is proving even more difficult than in the past to fill the 21,000 places because of the high number of refusals at a late stage.
How many of the 21,000 students who are newly enrolled and who have paid a registraton fees of £92 will withdraw, not only because of the steep increase but because of the lateness of notification? Due to the generally deteriorating economic situation, there is an annual increase in the percentage of students who are offered courses but decline them. I strongly suspect that that trend will accelerate.
The Under-Secretary, above all others, knows that the basis of funding the university rests substantially on the

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number of students. There is a spiral: increased fees equals decreased student intake, equals increased cost per student, equals less grant from the Department. The spiral continues to go down, down and down.
I remind the Minister of his welcome words on the role of the university at the Bath summer school in August. He said:
"At a time of rapid social and technological change there was a growing need for retraining to enable people to learn new skills. Here the Open University has an important part to play. During its development period the institution had faced novel problems, for which existing universities could offer little guide. The Open University is now in a position to build on its experience in first degree courses, in distance teaching techniques and post experience course work."
It is against that background of professed public support that the recent actions by the Minister came as such a shock, not least because it was as recently as 15 August that the acting vice-chancellor wrote to the Minister in the following terms:
"We continue to be concerned that the costs of study within the Open University are excluding a significant number of students and potential students. Very few students receive financial support of any kind with their course tuition fees, and we therefore urge Government to keep any future increases in fees to the absolute minimum.
To increase these costs by assuming a fee in 1981 higher in real terms than 1980's will certainly deter new applicants from joining—and encourage continuing students to become dormant, to drop out or to drop down from, say, two half credit courses to one."
The reply from the Minister, which was read to the last meeting of the council—I have the privilege to serve on that council—was received with dismay. As a consequence of that decision, the acting vice-chancellor wrote to every student in the Open University in the following terms:
"On 7 November I was informed by the DES that our grant for 1981 was to be cut by what would amount to £1·36 milion, and that our students should be asked to make an increased contribution to the cost of study by an increase in fees to compensate for this cut in Government grant. I wrote immediately objecting to what was proposed in the strongest possible terms, expressing my great dismay on behalf of students and asking that the decision be reconsidered. The reply was that there was no possibility of that decision being reconsidered—but reffirming the importance which the Government attaches to the university."
Let us look at the history of the increased fees for a one-year credit course. In 1977 they were £45; in 1978, £52; in 1979, £55; in 1980, £67; and in 1981 they will be £98. That amounts to an increase in the past two years of 68 per cent., and an increase over four years of 101 per cent. Those are steep and unjustifiable increases. The cost to a student of obtaining a BA in 1979 was £868. In 1981 it will be £1,322—an increase of 52 per cent. in two years.
Few students at the Open University receive any assistance towards tuition fees, but many enjoy some assistance with the cost of the summer schools. In 1978 79 per cent. of summer school students received some a assistance. By 1979 the number had declined to 68 per cent., by 1980 to 53 per cent., and by 1981 it could be down to 30 per cent.
Pressure from the Government has resulted in local authorities re-examining their budgets for adult education. Does the Minister really believe that the mandatory increase in fees will lead to an increase in income or an increase in students? The, pro-vice-chancellor of the Open University, in the journal "Sesame", stated:
"It could be the law of diminishing returns. The Open University is deeply concerned about the effect of such steep increases on individual students. I also worry that in the long
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term fees of this order will shift our student population towards the affluent South-East and away from the North. There are already trends in that direction."
Helen Turnbull, president of the Open University students' association, was even more blunt. She said:
"It is clear this Government regard part-time students as second-class citizens."
Will the Minister put his mind to other ways of helping the Open University? Can he help by reviewing the methods of financing the Open University? That would help without putting an additional burden on the Government. Can more working capital be provided to fund the preparation, development, printing and warehousing of courses? More effective use of Open University resources would be achieved if it were told about its grant much earlier than the March after the January when its financial year begins. Can consideration be given to the inhibition on the Open University to carry forward funds? That restricts the Open University in taking a reasonably long-term view of its financial resources.
In practice, the university's grant-in-aid is a cash limit. However, the Open University financial-academic year does not match the Government's year. As a result, the Open University is subject to two cash limits. Can that be examined?
Within the Open University there is still a deep sense of gratitude that, miraculously for so many thousands of people, the gift of access to learning is possible as a result of support from Governments of both political persuasions. I stress how, in my knowledge, the present Minister defends the university and its place in higher education. The action of the DES in arbitrarily increasing fees without consultation has caused dismay, resentment and unease about future intentions. I want the Minister to assure us that that will not happen in a similar way again.
The Minister will be familiar with the practice of issuing reports on good conduct and progress at the end of a school term. The Open University, and particularly its students, would want me to say that, at the end of a gruelling term, this Minister has disappointed. He could do much better if he tried harder. He is prone to making sympathetic noises only to blot his copy in the examination room. He must learn to stand his ground and fight off the bullies from the Treasury. He may be uncertain about where his friends are. We believe that he will respond to encouragement from outside the Westminster classrooms. He will continue to enjoy our support in the belief that his commitment to education will triumph over his flirtation with monetaristic dogma.
2.44 pm
The Under-Secretary of State for Education and Science (Dr. Rhodes Boyson): I pay tribute to the speech of the hon. Member for Edmonton (Mr. Graham). His courtesy, clear thinking and quotation of my words—which I am always delighted to hear again—demonstrate his great taste and discretion. The hon. Gentleman was one of the vintage entry to this House of 1974, when I, too, had the privilege of becoming a Member. We made our maiden speeches at roughly the same time. We have since moved to different sides of the House, but our friendship has not deteriorated. The change of side was not through boredom but because of the views of the electorate.
No one is better qualified than the hon. Gentleman to speak about the Open University. He became a

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distinguished graduate of that institution in 1975. It is praiseworthy that, despite the pressures of the House, he managed to obtain a degree. I know the hon. Gentleman's interest in education. We both served on the Education Bill Committee, when we spent about 130 hours facing each other across a gangway narrower than the present one. In my private office I have a graduate of the Open University.
The Wembley Observer must be read over the length and breadth of the country. On the front page today it mentioned the man who started the talking newspaper in Brent. The mayor has initiated an appeal this year for cassettes to help the scheme. The man who started the scheme has been blind since the age of 35. He was a humanities graduate of the Open University, who unfortunately died last year.
As the hon. Gentleman said, my right hon. Friend the Prime Minister referred yesterday to the respect for the Open University on both sides of the House. When the Open University started, I was dubious about it. I do not suggest that the hon. Gentleman should read the article, but at that time I wrote regularly for the Spectator. In an article in that publication I pointed out all the handicaps. I hope that I have an open mind and sometimes a closed mouth, although I am never reluctant to speak. I have totally changed my mind about the Open University, and I am not the only Conservative Member to do so. Its standards are good and it offers a second opportunity for people to retrain in middle life. It has helped to develop learning techniques. It is one of the most interesting developments in our education system over the past 20 years.
I have visited the Open University twice. My right hon. and learned Friend the Secretary of State has also visited it. I have seen the students in summer school. Only three weeks ago I participated in a transcontinental broadcast concerning the Open University and similar institutions in America. I was in Sweden this week and in America three or four months ago. Wherever I go, tribute is paid to the innovatory techniques of the Open University.
The amount of money that the Government can spend is at present limited. The hon. Gentleman is a straightforward individual. He will accept that if his party was in power it would be restraining public expenditure. We must pay our way and order our priorities. I remind the hon. Gentleman, cheerfully and in no way unpleasantly, that between 1976–77 and 1977–78 public expenditure on education was cut by £350 million, when his Government were attempting to balance their budget. In 1975 and 1976 they were unable to provide funds to meet all the aspirations of the Open University. I do not think that the hon. Gentleman will disagree with that.
A limited amount of money is coming out of the tap and there is considerable demand for many cups to be filled. There may be some disagreement on where priorities should lie, but there is no doubt that the limitation of resources means that we have to restrict the areas to which the available money goes if our resources are to be used successfully.
We are having to look for cuts in many areas. However, last year expenditure in real terms for the Open University was £45.6 million. Spending in real terms this year will be £45.4 million. That is basically level funding. Certain
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sums have been put in by the transference of broadcasting from one year to another. We have tried to establish level funding with that of last year.
The hon. Gentleman is right to say that more students are paying more of their own fees.
Mr. Graham: In the past there have been discussions when there have been financial problems. A Minister or the Government could have said to the Open University "We require you to make economies. Please make them where you will." The council was especially distressed because without consultation—I used the word "arbitrary", which may have been the right or the wrong word—the Department came to a decision. It used the phrase "We therefore assume". That referred to a fee of £98. I accept that for presentational purposes it is better that the fee should be less than £100. However, instead of increasing the fee from £67 to £80 to take account of the rate of inflation, the Department decided to increase it to £98. It is not what the Government have done but the way in which they have done it that has caused the most offence.
Dr. Boyson: I shall deal with that issue, which is extremely important. There has been a cut in real terms of £1.36 million—about 2 per cent.—at a time when we are looking for cuts in Government expenditure in many areas far in excess of that percentage. The money that we have made available this year will allow new course production towards the Open University's target of about 87 full credit courses.
Secondly, money is available for the maintenance and remaking of existing courses. I appreciate that they must be brought up to date. A lecturer can change his notes—I know that myself from lecturing at universities—and that can be done each year. However, the Open University makes printed notes available and remaking has to take place.
Thirdly, the money that we have made available will allow an increase in the number of students from 61,000 to 62,700 next year. That means that next year the Open University will be able to admit 21,000 new students.
I pay a tribute to the Open University. In conversations that have taken place between officials of my Department and those of the Open University and between myself and the Open University, it has been made clear that Open University officials are attempting to continue advancement in difficult circumstances. There has been little grumbling from them. They realise the position in which the Government find themselves, or in which any Government would find themselves, and they are attempting to get the most value from the money that is being put in. There has been not a word of criticism of them in that respect.
I have only one word of criticism. The only delegation which has failed to arrive on time has been that of tutors from the Open University yesterday. As I could not come to the House, I changed the time in my diary in order to give them half an hour to come and see me. I allocated a half hour between 5 pm and 5.30 pm. Unfortunately, they did not arrive until 5.35 pm. Delegations of students always arrive a quarter of an hour early, sometimes, I think, because they fear that I shall get out before they arrive. The delegation of tutors has been the only delegation that has been late. They said that they could not

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find the Department, so perhaps a new credit in geography should be contemplated. I make that suggestion in all pleasantness as an afterthought.
We have arranged with the acting vice-chancellor, whom I meet fairly regularly, means whereby the Open University will be given greater flexibility over the use of its money. It will also be given more discretion as to how it should be used. At one stage, the Government decided how many students there could be and what courses should be followed. Those arrangements have been changed considerably this year. The lump sum will be given to the Open University for it to use and control. It will be able to decide how many courses there should be. I am sure that the hon. Gentleman will be pleased that such discretion has been given to the Open University.
The one thing on which they gave a specific indication was on the question of a fee, about which the hon. Gentleman has already talked to me. This is an important question. At present 90 per cent of the cost of the Open University is carried by the Government, and only 10 per cent. is covered by the fee. In all other institutions of higher education, 20 per cent. of the cost is carried by the fee. Indeed, the Select Committee on Education, Science and the Arts, which is chaired by a Labour Member, recommended that the fee should go up to 30 per cent.
Mr. Graham: Does not the Minister realise that fees in respect of conventional universities are invariably paid by another source—the local authority—and that they are mandatory, whereas fees in respect of the Open University invariably come out of the pocket of the student?
Dr. Boyson: There is no doubt that the hon. Gentleman and I think along the same lines, because that was the next point that I was coming to. The hon. Gentleman has given roe guidance which I am rarely given whenever I speak from the Dispatch Box, which shows how much we both respect not only the Open University but also the present lines of approach.
We attempted to relate the fees of the Open University to the way in which other fees are charged throughout the higher education system, bearing in mind that in further and higher education in this country fees account for more than 10 per cent. of the cost.
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I turn to the question of mandatory fees, and I appreciate its importance. I know that there is a sense of deep grievance among many Open University students. It is something that I fully understand. If someone gets two E grades at A level and goes on to read some obscure subject at university, there is a mandatory Brant, irrespective of the view of the local authority about the usefulness of such a course, but when Open University students decide to continue working and to study in their free time in order to lessen demand upon the public exchequer there is no mandatory grant.
I believe that there will have to be some form of reassessment of higher and further education in this country in order to decide where the limited sum of money available should be spent. The hon. Gentleman will probably disagree with me on the question of loans, but many Socialists, including a Socialist professor with whom I ate last night, agree about some form of loan so that the money can be spread wider. We must assess how much money is available for further and higher education and decide where it should be spent. As part of that reassessment, we shall have to ask whether it is a priority to give mandatory grants to speech therapists, forestry workers, chiropodists and Open University students or whether the money should be spread wider.
I hope that we can proceed to a wider debate on this matter, but I should make it clear that the Government are not indulging in a vendetta against the Open University, any more than the previous Government did.
My time is running out, but there is no doubt that if our dialogue could continue all the problems of higher education in this country could be solved by 4 o'clock today. What a loss to the country that such a solution will not be achieved on this occasion.
Like the Opposition, we respect the work that is done by the Open University. It is doing a splendid job. It will have our support. We shall have to look at the way in which we finance higher education as well as the way in which we finance both mandatory and discretionary grants. In doing so, we shall bear in mind the needs of the Open University.
Question put and agreed to.
Adjourned accordingly at Three o'clock.

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