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Statutory Instruments, &C

Volume 933: debated on Friday 24 June 1977

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Rating And Valuation

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

That the Valuation and Rating (Exempted Classes) (Scotland) Order 1977, a draft of which was laid before this House on 24th May, be approved.— [Mr. Graham]

Question agreed to.

Administration Of Justice Bill Lords

Order for Second Reading read.

Motion made, and Question put forthwith, pursuant to Standing Order No. 66 (Second Reading Committees), That the Bill be now read a Second time.

Question agreed to.

Bill accordingly read a Second time.

Bill committed to a Standing Committee pursuant to Standing Order No. 40 (Committal of Bills).

Administration Of Justice Money

Queen's Recommendation having been signified—


That, for the purposes of any Act of the present Session to make further provision with respect to the administration of justice and matters connected therewith, to alter the method of protecting mortgages of registered land and to amend the law relating to oaths and affirmations and to the interest of a surviving spouse in an intestate's estate, it is expedient to authorise the payment out of money provided by Parliament of all expenses incurred by any Minister of the Crown in consequence of the provisions of the said Act.—[Mr. Graham.]

Northern Ireland (Emergency Provisions) (Amendment) Bill


That in respect of the Northern Ireland (Emergency Provisions) (Amendment) Bill, notices of Amendments, new Clauses and new Schedules to be moved in Committee may be accepted by the Clerks at the Table before the Bill has been read a second time.—[Mr. Graham.}

House Of Commons (Services)


That any Sub-Committee on Computers that may be appointed by the Select Committee on House of Commons (Services) shall have power to join with any Sub-Committee thereon that may be appointed by the Select Committee of the House of Lords on House of Lords Offices:


That any such Sub-Committee shall have power to appoint persons with technical knowledge either to supply information which is not readily available or to elucidate matters of complexity relating to the matter referred to them:


That any such Sub-Committee shall have power to adjourn from place to place within the United Kingdom:


That these Orders be Standing Orders of the House until the end of this Parliament.— [Mr. Graham.]

National Health Service (Chiropody)

Motion made, and Question proposed, That this House do now adjourn.— [Mr. Graham.]

5.26 p.m.

I want to raise the subject of the National Health Service chiropody service, and in particular to point out the great anxiety that exists in many parts of the country —indeed, probably throughout the country—about the shortage of properlytrained chiropodists and the effects that it is having on all sorts of people, particularly the aged, and those folk who were born with feet difficulties and sometimes do not receive the services that ought to be given.

There is also great anxiety amongst many people, not to mention the chiropodists themselves, that the burden of work is increasing and that the number of properly-trained chiropodists is not rising fast enough to meet the challenge. There is also the danger of people practising who are not properly qualified, thereby creating a menace to people who suffer from some form of foot ailment.

I acknowledge readily that there are many people both inside and outside the House who wish to see a considerable improvement in the chiropody service but I hope that there will be no cases of that venomous and reprehensible behaviour by those who, when exercising their double standards, will support this call for an improved chiropody service and later join in the screams for cuts in public expenditure. I find such an attitude reprehensible in style, hypocritical in standard and abominable in practice.

I am continually being made aware by my constituents of the shortage of chiropodists available to treat the elderly. There are long delays in their obtaining treatment under the National Health Service. Many are suffering from painful foot conditions, which adversely affect their mobility and, in consequence, their enjoyment of life. I place high value on the chiropody service.

I have raised this subject on a number of occasions over the past few years and I hope that I have made some contribution to the small improvements that have occurred from time to time. I raised this matter in January 1975, when my hon. Friend the Member for Rhondda (Mr. Jones) had responsibility within the Department. Later, there were a number of improvements. So I hope that as a result of this debate there will be a brand-new look at the chiropody service and that some of the recommendations that I intend to make will be taken very seriously.

The total expenditure on the service is about £9 million. It is a very small item in the overall budget of the National Health Service. Here is a cost-effective service in terms of patient care, and I strongly recommend to my hon. Friend the Minister of State that a substantial increase in the allocation to the chiropody service would not come amiss.

If I may, I shall quote from the original NHS Reorganisation Circular on the Operation and Development of the Chiropody Services. It says that authorities.
"will no doubt have regard to the potential reductions in pressures on other treatment services, especially for the elderly, that effective chiropody can bring about."
The key phrase is "effective chiropody." I am aware that in a more recent circular the Department of Health and Social Security has given advice to area authorities on the employment of foot care assistants to undertake, as it says,
"simple foot care and hygiene, such as the cutting of toenails."
The Society of Chiropodists has already given notice to its members that foot care assistants should be used only to cut the normal nails of patients who are unable to do it for themselves because of blindness or some other disability. In other cases it is questionable whether normal toe nail cutting, which can be carried out by relatives or other nursing auxiliaries, is in fact the responsibility of the chiropody service at all. In practice, the great majority of patients requiring NHS chiropody will be suffering also from some other underlying dermatological, medical, pathological or surgical conditions. I know that my hon. Friend will take special note of that, because it applies particularly in the case of the elderly. It is essential that such patients should receive treatment from a properly qualified chiropodist.

I am, therefore, equally concerned with the supply of chiropodists. Quite rightly, the State insists by regulation that only State-registered chiropodists should be employed in the National Health Service. This ensures that the chiropodist will have at least a minimum standard of competence and/or training before being allowed to treat a patient.

However, there is no protection for the public generally. Any person, however trained or not trained, may call himself a chiropodist and treat patients privately. This is not only wrong and absurd; it becomes even more absurd when it is appreciated that only recently the House passed legislation to make sure that only qualified blacksmiths could shoe horses. Anyone can pose as a chiropodist and treat the feet of human beings. This is particularly hard on people who suffer, as many thousands do, from some form of foot ailment. They should be treated only by qualified chiropodists.

As I say, I am equally concerned about the supply of chiropodists and that although the State rightly insists by regulation that only State-registered chiropodists should be employed in the NHS, because they are so few in number it permits non-qualified chiropodists to masquerade as chiropodists. This means that the great majority of working people, since the NHS chiropody service is at present, by and large, restricted to the priority classes—the elderly, the physically handicapped and expectant mothers— could be easy prey for the fake chiropodist. Indeed, I suppose that those who are within the categories to which I have referred could similarly be easy prey.

A "chiropodist"—I put the word in inverted commas—may set up in practice after a correspondence course consisting of 15 lessons, with, possibly, a month's practical tuition at the end. In contrast, to become State-registered and to acquire a recognised professional qualification today, a person must complete a three-year full-time course at a school recognised by the Chiropodists Board and the Society of Chiropodists.

At present, 694 students are training in the United Kingdom. Perhaps, as a long-term policy, my right hon. Friends the Secretaries of State for Education and Science and for Social Services will consider financing more training places for chiropodists. In the meantime, I shall be glad to know what proposals the Secretary of State for Social Services has in mind to close the profession of chiropody in order to protect the public and, by an amendment to the present Act, that is, the Professions Supplementary to Medicine Act 1960, to bring in a State roll for those chiropodists currently earning their livelihood by chiropody but not able to become State-registered because of lack of training or practical experience at the relevant date for the initial State register, which was as long ago as 30th June 1963.

I am advised that if such a roll were introduced it would be possible, by regulation, to allow for employment of enrolled chiropodists in the NHS working under the supervision of State-registered chiropodists, and that this would go far to alleviate the current shortage of chiropodists for the treatment of the elderly and other priority cases, which is my immediate concern.

I have already said that the problem is nation-wide. It is affecting a wide range of our community. The solution is effective chiropody, which involves principles of both curative and preventive medicine —to relieve pain and to prevent pain. In my judgment, it is essential that Britain's chiropodists be qualified professionals entitled to their distinction, as is, for example, a State-registered nurse. It is essential also that more training establishments be created.

The achievement of these desiderata which I have outlined will, I believe, bring to the service of the community qualified practitioners whose skill and ability will not only relieve and prevent pain but will also increase the mobility of thousands of our fellow citizens and, what is more, enrich the quality of their lives.

5.39 p.m.

I am glad that my hon. Friend the Member for Ealing, North (Mr. Molloy) has taken the opportunity of this Adjournment debate to raise again the subject of chiropody services within the National Health Service. He has raised the matter on many occasions in the past and his contribution in this respect has been noteworthy.

Chiropody is an important preventive service which, as my hon. Friend says, greatly enhances the enjoyment of life by promoting mobility, especially among the elderly and the housebound. Moreover, as he said, it is a service upon which the spotlight rarely falls. I welcome this opportunity to discuss its rôle within the National Health Service generally and to comment on the points that my hon. Friend made.

I am well aware of the deficiencies of the existing chiropody provision and of the tremendous leeway that must be made good before we have a good chiropody service within the NHS.

Under the reorganisation of the National Health Service in 1974, responsibility for the provision of chiropody services was concentrated in the hands of the new area health authorities. They inherited a disparate gathering of chiropody services, which had previously been administered, with varying degrees of effectiveness, by a range of bodies, including local health authorities, education authorities, personal social services departments, hospitals and voluntary organisations. They were faced with a situation involving a wide variation in the resources then being devoted to chiropody. There was a patchwork of arrangements for charging for the service as well. In some areas no charge was made, in others a means test was applied, and in others there was a general restriction of treatment to a small priority group including the elderly, the handicapped and expectant mothers.

The immediate task facing area health authorities, when they took over responsibility for the service, was to merge this mixed bag of separate services into a single co-ordinated service within each locality. This has been no easy undertaking. Given the fragmented and under-developed nature of the local services at the time of reorganisation I do not think it would have been reasonable to demand, at the same time as this rationalisation and amalgamation was taking place, that there should have been a general expansion and improvement of the service.

Indeed, all that could be expected of area health authorities at that time was to concentrate on maintaining existing standards and on ensuring that a continuing service was provided for the priority groups, the elderly and so on. It should not be overlooked that when the National Health Service was reorganised chiropody for the first time was made available free of charge at the time of use. That, in itself, was a great step forward.

Of course, if the great principles of Aneurin Bevan and the miracle that he performed in 18 months in establishing our free NHS had been maintained the probability is that my hon. Friend and I would not be having this exchange this afternoon. Will he take on board the question of the range of charges and the reprehensible means tests? If my hon. Friend can eliminate those I believe that we shall get a nod of approval from Nye Bevan.

I would very much appreciate such a nod. As I understand it, these have, of course, now gone and one can obtain a free chiropody service if one is fortunate enough to be able to get in contact with the service in one's own locality.

My hon. Friend made an important point about manpower and resources. Manpower is certainly a complicating factor in the provision of the NHS chiropody service. The major part of the working time of the profession in this country is devoted to the provision of services outside the NHS. There are currently about 5,000 State-registered chiropodists in the country. The majority work in private practice, but about two-thirds undertake work for the NHS although this is usually on a part-time basis.

In 1975, the latest year for which we have figures, there were 1,253 whole-time equivalent chiropodists working in the NHS. About 809 of these were working full-time for the NHS. On top of that, there was an unknown number of chiropodists providing services through voluntary organisations on an agency basis.

We must conclude that the service is seriously undermanned on any reasonable estimate of demand. It is better in some areas than in others, but the overall national shortage is difficult to quantify. However, one estimate is that if the present work force in the NHS was increased by half, or even doubled, the needs of the priority groups would be met.

Of course, there are people lying outside those priority groups who have the right to the chiropody service. We therefore have a long way to go, although there have been considerable improvements over recent years. A much better chiropody service is now being provided than a few years ago. We are now faced with the question of finding additional personnel to fill this gap, but it is difficult for area health authorities easily to find the necessary funds in the present period of severe financial restraints.

I agree with my hon. Friend that there is a nauseating type of politican who calls for more chiropody services and, at the same time, for public expenditure cuts. I do not know how he manages to reconcile these attitudes.

It is impossible to quantify with any degree of precision the extent of untreated foot disability, but a study carried out some years ago suggested that at least half and possibly as many as nine-tenths of adults had foot defects. Just over one-third of the adult population was estimated to be in need of chiropody treatment. The role of health education is important. Many of the foot conditions treated by chiropodists are a result of self-neglect and a general unawareness of the importance of wearing correctlyfitted shoes. Fashion plays a part here. The Health Education Council is conscious of the problem and is taking action to combat it.

Effective chiropody can achieve a significant reduction in the demand for other treatment services, especially for the elderly. The Department's aim has been to encourage area health authorities to expand and improve the local services to acceptable standards as soon as manpower and resources permit. We have to think in terms of how to organise and deploy existing resources to the best effect and to plan for a gradual rate of growth, consistent with the current economic situation.

The consultative document on Priorities for Health and Personal Social Services in England, published last year, recommended a national annual growth rate of 3 per cent. per annum for chiropody services. We are looking forward to a gradual improvement in this area. Within the overall national target, the actual rate of development is a matter for decision by individual health authorities in the light of local assessment of needs and resources. In April last year we introduced a national planning system for the NHS that will enable my right hon. Friend and I to monitor, for the first time, the levels of service provision across the board.

We have consulted health authorities and professional bodies and issued a circular on the organisation and management of NHS chiropody services. My hon. Friend referred to the circular in his speech. One of the suggestions in the circular was that a valuable contribution could be made to the NHS by chiropodists in private practice and that the NHS would continue to need their services for the foreseeable future.

There is general agreement that a significant part of a trained chiropodists' time is spent on minor work that does not require his skills and expertise, but which cannot be undertaken by the patients themselves. My hon. Friend mentioned, in this regard, blind people and arthritics. The circular foresaw a need for the introduction of a new grade of foot care assistant to undertake minor footcare work, especially for the elderly arthritic and other handicapped persons including the blind and the partially sighted. The tasks which they might carry out, under the supervision of a qualified chiropodist, could include simple foot care and hygiene, such as the cutting of toenails. Patients with underlying dematological medical, pathological and surgical conditions must be treated by properly qualified chiropodists.

The substantial increase in pay and significant improvements in career structure which followed the recommendations of the Halsbury Committee of Inquiry into the pay and related conditions of service of the professions supplementary to medicine and speech therapists, published in January 1975 will, I hope, encourage more chiropodists to seek both full-time and part-time employment in the NHS. Indeed, we have some en-encouraging evidence that that is taking place. At the same time, area health authorities have been given advice on the employment of foot care assistants, including a salary scale and terms and conditions of service.

My hon. Friend said that he was keen to look into the training and supply of chiropodists. We are anxious to see that the supply is increased. If the anticipated demands for these professionals are to be met, we shall need to see some expansion in the number of training places in chiropody schools. In fact, a new school, opened in Durham in 1975, now provides 22 additional training places each year. Proposals to establish other schools in colleges and polytechnics are under consideration, but I confess that economic difficulties are an inhibiting factor. While student intake fluctuate from year to year, about 150 to 200 students qualify each year from the eight recognised schools in Great Britain. There are encouraging signs that a higher proportion of those qualifying each year are taking up National Health Service appointments.

My hon. Friend made an important point—with some suggestions, too—about the protection of the public. The NHS protects the public by ensuring that only properly qualified chiropodists are employed. Outside the NHS it is a matter for the profession to regulate and to make provisions. The Government would certainly encourage any proposals which it was able to bring forward.

My hon. Friend made the useful suggestion that perhaps persons practising chiropody who had many years' experience but who were not qualified and could not therefore be employed as chiropodists by the National Health Service could possibly be enrolled on an official roll and that if that were done they could become acceptable for employment by the NHS provided that they were supervised by properly qualified chiropodists. If a roll of such people could be compiled by and was acceptable to the profession, my right hon. Friend and I would certainly be prepared to discuss with the profession what use we could make of it.

My right hon. Friend and I are concerned that the present level of chiropody service falls very short of what we would like to see. The numbers of elderly people in the population, who are the prime users in a priority sense of these services, are continuing to rise year by year at a rate of 1 per cent. Because of improved diet, housing and medical care, we are on average living much longer.

I hope that health authorities, in planning their policies and in the allocation of resources, will take account of the priority attached to chiropody services by the consultative document and that the suggestions on organisation and management contained in the recent circular will enable them to effect improvements in local services.

Question put and agreed to.

Adjourned accordingly at six minutes to Six o'clock.