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Opposition Day

Volume 33: debated on Monday 6 December 1982

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[2ND ALLOTTED DAY]

Inequalities In Health

3.43 pm

I beg to move,

That this House notes that there is little sign of health inequalities in Great Britain diminishing, according to the Report of the Working Group on Inequalities in Health; endorses their conclusion that the causes of health inequalities are so deep-rooted that only a major and wide-ranging programme of public expenditure is capable of altering the pattern; and condemns both the refusal of the Government to undertake such a programme of public expenditure and their general failure to act on the recommendations of the Report.

In 1977 the then Secretary of State for Social Services, my right hon. Friend the Member for Norwich, North (Mr. Enna1s), set up a working group to consider inequalities in health. To enable the working group to go deeply into this vital subject he gave it the following terms of reference:

  • "(i) To assemble available information about the differences in health status among the social classes and about factors which might contribute to these, including relevant data from other industrial countries;
  • (ii) To analyse this material in order to identify possible casaul relationships … and
  • (iii) to suggest what further research should be initiated."
  • The idea of such an inquiry arose because it had become obvious to many people, including those working in the Health Service, that there was strong evidence of inequalities, not only between one sector and another but between one region and another. I congratulate my right hon. Friend on having understood that such inequalities could not be identified by using the normal statistics but required far more careful examination.

    The working group, which comprised extremely distinguished members under the chairmanship of Sir Douglas Black, decided that it should first examine what was meant by "health". It decided to take as its guideline the concept of health adopted by the World Health Organisation at its inception after the Second World War—that health was not just freedom from pain and discomfort but a positive sense of well-being. That seemed a sensible decision, as it became obvious that only by considering a number of factors could one begin to understand what had happened in this country despite 30 years of the National Health Service.

    The definition of health as a
    "state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"
    summed up exactly what we sought to investigate. The working group realised that its task was complex and that there was no single, simple answer. It decided to base its work on that complex definition, because it believed that it was important to have a mixture of social and medical models.

    For far too long, health care in this country has been merely sickness care without necessarily including prevention or the extension of conditions that would enable people to live with the fullest possible benefit of all of their faculties. Existing information from a number of sources was therefore collated. The working group decided to use the definition of class by occupation that is used by the Registrar-General, as it provided a simple and easily understandable way to present the important facts.

    The large number of in-depth studies involved took a considerable time, so the working group was still sitting when the Conservative Government took office, although it was clear that the work would soon be completed. The Conservative Government found the inquiry at best an embarrassment and at worst a matter to be got rid of as hastily as was decently possible. The reason for that is obvious. Far from being committed to destroying inequalities in society, the Conservatives believe in the maintenance of privilege. The Government soon became uncomfortably aware of the unequivocal nature of many of the findings in the report. It is one thing for the Conservative Party to identify the family as the core of its policy; it is quite another to do anything radical to deal with the real problems and difficulties facing family groups in this country. Child poverty and illness must be prevented.

    Not surprisingly, the Secretary of State and his predecessor found it embarrassing to have the inequalities in health spelt out in such stark detail and they were scarcely enthusiastic in welcoming the report. Indeed, they made sure that very few copies were printed initially and that it was difficult for people wishing to obtain copies to discover where they were available. That ploy, however, did not work, because the TUC was so impressed by the quality of the report and so incensed by the social differences that it revealed that it reprinted the report under the title, "The Unequal Health of the Nation". Furthermore, Penguin Books Ltd. chose to produce a paperback, because it realised that the information concerned every family in the land.

    The Government's response was not to hold a series of press conferences, as they have for many of their more superficial projects, but to suggest that the report put forward answers which were too expensive, too imprecise and, in the words of the previous Secretary of State, the right hon. Member for Wanstead and Woodford (Mr. Jenkin), that some of the matters in the report were the pipe-dreams of Professor Townsend. When such a useful and high-powered report is produced, it is extremely unhelpful if Ministers find it difficult to accept that it is a remarkable social document and cease to support it.

    The report is important to us, because it identifies the real causes of inequalities and the effects of those difficulties on the lives of the people of Britain. First, it identified the inequalities between people—the marked differences between the health care that is available for different classes. In Britain today, at birth and in the first month of life, twice as many babies of unskilled manual workers die as do those of professional parents. In the next 11 months of life, four times as many girls die and five times as many boys. The children of social class I can expect to live, on average, five years longer than the child born into a household where the head is an unskilled manual worker. Those differences are retained all the way through the child's school life and through his early teens. Only in his early twenties does he manage to catch up with the more privileged members of social classes I and II, and then the differences begin to appear again.

    Secondly, the report identified the differences between the provision and the use of health services. It drew attention to the fact that there were inequalities between different areas of the country and, using mortality statistics, made it clear that where one lived and the income that one enjoyed had a direct effect on one's standard of life. That is called the inverse care law—good medical care tends to be least available to those in the greatest need and most available in areas where the need is smallest. The Government have done little to reverse that trend.

    The regional variations in mortality show, for example, that those who live in the South-East have a much lower mortality rate than those in the North-West, while those in the Northern region have a still higher rate.

    The Government tacitly acknowledged that when they appointed Professor Acheson to examine closely what was happening in primary care, because the report also identifed the fact that many of those most in need of good health care go more often to their general practitioner, but for one reason or another do not seem to get the benefit that they should from those visits. Professor Acheson reported that there were many difficulties with general practitioner services in inner cities. There were too many elderly GPs, too many inadequate single-handed practices, too many people with restricted lists and too few practices housed in adequate premises. The Government, who commissioned his report, have so far done little to improve the general practitioner service.

    Thirdly, the working group acknowledged that those were complex factors and that it was not just a matter of health care but, inevitably, bad housing, poverty and lack of preventive medicine, and also that the provision of social services had a direct effect on the health of the community. The group produced careful and considered analyses and many detailed policy recommendations. It said that it was anxious to give children a better start in life and that that was the point at which we could have the most effect on the health of our people. The working group said that it wished to encourage good health among the larger proportion of the population by preventive medicine and by educational action. With regard to the disabled, it said that we should consider not only the provision of services but the quality of life of the people who are suffering from some form of disability.

    The report was, however, merely echoing some other aspects of research that have been commented upon in the House. In June 1980 the Select Committee on Social Services produced a report on perinatal mortality. Although it concluded that there were four main factors, in all but the immediate causes social and economic factors played a major part. Those included poor education and poor housing, although it also stressed the contributory causes such as chemical, environmental and occupational hazards. The Committee said that while the perinatal mortality rate had been falling rapidly in Britain, it was still 50 per cent. above the best world rate, achieved in Scandinavia.

    The Under-Secretary of State, in a written answer on 8 June 1982—two years almost to the day after the publication of the report—listed the Government's responses. He claimed that perinatal mortality was falling more rapidly than ever before, but what he did not say was that the Committee had identified a major difference within that figure between social groups. For example, in 1979 social group I had a death rate of 10·2 per thousand, whereas the same figure for group V was 18·2 per thousand. For illegitimate births the rate rose to 19·3 per thousand.

    The Select Committee described those rates as totally unacceptable and made a number of detailed recommendations. The Government's response was to point out that they were considering various policies and in the meantime were supporting the mother and baby campaign of the Health Education Council. If it were not so sad, that would be so little as to be laughable. In the financial year 1980–81 the Government spent £75,000 on supporting the mother and baby campaign, but in 1981–82 they cut the budget by £50,000, to £325,000. So much for their desire to do something about perinatal deaths.

    The working group report said that resources within the NHS and the personal social services should be shifted more sharply than ever before towards community care, particularly antenatal, postnatal and child health services. It also specified the need for home helps and nursing services for disabled people. It is therefore interesting to examine the Government's policies on personal social services since they came to office.

    The restrictions on local government spending have meant that two-thirds of local authorities have cut their personal social services budget for 1981–82. When the Government expenditure steering group for personal social services was asked to comment on expenditure plans for 1982–83 up to 1985–86, it estimated that there would be cuts of 6·8 per cent. in 1982–83, rising to 12·3 per cent. in 1985–86. Indeed, the group claimed that it would be impossible to achieve the current targets, because of the damage to services that would result.

    Even if the target were reached in later years, there would be compulsory redundancies among social service officers. The group said that as the cuts would inevitably be made at random, they would fall most heavily on those very domiciliary services that have the greatest effect on patient care in the community—meals on wheels, home helps and the fostering services. The group also said that some local authorities had already resorted to charges, even though the Select Committee on Social Services had made it clear that those charges undoubtedly deter some clients.

    However, the cuts do not end there, because, as local authorities are wary of committing themselves to the revenue implications of new buildings, there is an estimated 28 per cent. shortfall on capital spending. In other words, the personal social services—the arm with which the Government have said they are most concerned and which could be used as the spearhead of a campaign to reverse the trends identified in the Black report—are suffering very badly from the Government's economic plans.

    It is true, perhaps, that the Government have been looking at other areas of social spending, but what have they been doing in housing? Not only the Social Services Committee, but the Black report, in very definite terms, says that inadequate housing and inadequate social conditions contribute very strongly to poor health.

    The Government's policies towards local authorities have ensured that housing has suffered the most in successive rounds of public expenditure cuts. The Association of Metropolitan Authorities was so concerned that it carried out its own survey and discovered that there were 1 million dwellings lacking one or more of the basic sanitary amenities, 1·5 million dwellings in need of renovation, 800,000 houses statutorily unfit, 1·2 million council houses suffering from damp, and over 300,000 difficult to let. Last year the number of building starts in the public sector was the lowest for at least 60 years—down to about 37,000. Completions in 1981 were 85,000 down on 1978, and there has been only a bare improvement in 1982. In addition, we see from the newspapers today that there is yet another Think Tank report which seems to be suggesting that only the most poverty-stricken will find it possible to obtain any form of public housing in the future, while others are being pushed increasingly towards taking on the burden of a mortgage, whether or not that is in their general interest.

    Council house rents will soon have increased by 135 per cent. since the Tories came to power. Meanwhile, the sale of good housing stock under the right-to-buy provisions has gone ahead, so that between October 1980 and March 1982 nearly 120,000 houses were sold, without a comparable replacement in the housing stock.

    In my constituency we see increasing numbers of people who, having taken out mortgages on their council houses, are now, because of the loss of employment and the other difficulties that they are suffering, unable to continue to support their own homes. They are in the intolerable position that, being unable to pay for their mortgage, they have to go back to the council authorities and ask if they can come to some arrangement to have the houses taken back. The opportunity to acquire a decent home and ensure that the children are brought up in healthy conditions is becoming much more difficult for those who are most in need.

    The working group says that we must give top priority to measures that will enhance family living standards. It says that one way to do that is to improve the family benefit level and to give a direct improvement in child benefit. The importance of that becomes clear when we not the answer that was given by the Under-Secretary of State to the effect that there are about 1 million children—the figure is not as accurate as it should be—living in families where the head of the family is unemployed and in receipt of unemployment or supplementary benefit. Yet one sees no obvious move on the part of the Government to improve benefits at any level. Indeed, far from doing that, since they came to office they have made it more difficult for those who have children to obtain a decent standard of living.

    The Black report says that top priority must be given to measures that will enhance family living and that the abolition of child poverty should be adopted as a national goal for the 1980s. Yet, since the Government came to power, those on any kind of benefit have been told that in future they will face clawbacks and readjustments and, if need be, a cut in their standard of living. Many other Conservative policies have affected adversely some of the most important needs, such as the level of heat in a home, and are affecting most the poorest in our society.

    It does not seem that the Government are prepared to follow any of the recommendations on matters which they could so easily control—the rate of benefit, the provision of public housing, the provision of health services, and so on.

    There is clear evidence that the Government not only object to the provision of cash but have a firm conviction that those who are receiving aid from the State should in some manner or other be made to feel aware of their inferior status.

    The Black report made it clear that there were several things that could be done apart from improving benefits and providing public housing. It suggested that there should be an action programme for special areas. It mentioned 10 suitable areas and took as a guideline those with very high death rates. It said that in each of those areas experimental programmes could be introduced to see whether the care of mothers and pre-school children, the care of the disabled in their own homes, and preventive care projects could be improved.

    The report said that the results should be closely monitored and that the innovation should be the subject of rigorous experimental assessment. Such a flexible programme should be initiated as quickly as possible and would provide a great deal of useful evidence which could be used in other parts of the country. Inevitably, it would need to be funded by the Government, but the response should be carefully evaluated.

    The report suggested that special funding on the lines of joint funding for health and local authorities would improve the planning and the provision of services for the disabled and for the elderly. The response of the Secretary of State was to announce an extra £80 million this year, of which £60 million is already committed in terms of pay, so that there will be very little left over either for the projects in mental illness that the Secretary of State has identified or, for an improvement in children's services.

    We do not need to be asked what is needed. We know that there is a great divide between those in the higher social classes and those in social classes IV and V—those who suffer from poverty and from the lack of decent housing and education. We know that the Government have no intention of helping them. Indeed, the Government have promoted a positive drive in the opposite direction. They have increased the difficulties of the section of the community that is most in need.

    The Government do not particularly want any kind of publicity for the Black report, precisely because it reveals how those in social classes IV and V suffer throughout Britain. We need a massive injection of public expenditure if we are only to begin to reverse the trends. That expenditure must relate not only to the health services but to the provision of new schools, new hospitals and new personal social services.

    If there is to be a genuine programme to support community health care, we must not cut down on the number of nurses. We must not endure a situation in which 1,400 doctors are still unemployed. We must seek to put the money where it can be used to the best advantage.

    I have been listening with care to the hon. Lady. Did she say that the Government were reducing the number of nurses? Does she not realise that there has been a substantial increase in the number of nurses?

    I was speaking specifically about the provision of primary services and services in the community. What is happening—and will happen increasingly in the inner city areas with the cuts next year—is that community nurses are finding it increasingly difficult to get employment. If the Secretary of State has not understood the effect of the cuts in local authority services and in the National Health Service as a result of his own policies, I assure him that at primary care level there will be a continuous running down of the services that are most needed. He will find that an increase in the number of nurses in the hospital service will mean no provision over large areas where social services in the community are breaking down in the most dramatic fashion.

    Does my hon. Friend recall that the number of unemployed nurses rose in November to 8,800, an increase of nearly 1,000 since June?

    I am grateful to my hon. Friend. That is the case. It is obvious that there will be growing problems of unemployment among nurses when the various regional health authorities find that they are unable to maintain the present standards of services. The Secretary of State constantly tells hon. Members how much money he is spending on the National Health Service. The right hon. Gentleman does not explain how four regional health authorities and the Merseyside region will next year experience difficulty, or how areas such as Oxford, which he has tended to attack for producing plans which he has described as over-dramatised and unreal, will maintain their present level of services when the effect of his economic policies becomes clear in coming years.

    The Government are anxious to achieve cuts in services by stealth. Whenever there is publicity over individual hospitals, such as Tadworth Court, or individual services, such as screening, the Secretary of State finds an interim sum of money to keep those services going. That is not the answer. The right hon. Gentleman knows that what he is doing is far more radical. He is aware that hospitals in areas where the need is desperate will close because they will not receive the same kind of publicity or the same support. Those hospitals will be a major loss to the communities that they serve. One suspects that the Government actually accept a policy of inequalities in health because it is part of their concept that the State should provide only a second-class service and not have universal provision paid out of taxation and free at the point of use.

    I agree with a great deal that the right hon. Lady has said. However, her speech, like the motion, refers to extensive, massive and wide-ranging increases in public expenditure. During the debate on the Loyal Address the Leader of the Opposition also referred to expenditure. Is the hon. Lady able to put a figure on this massive expenditure, so that hon. Members know what she means?

    If the hon. Gentleman will contain himself with his usual patience, I shall explain what the next Labour Government propose. It is obvious that unless there is a change of Government both the personal social services and the National Health Service will face a desert of finance in the coming years. It is our intention to commit 4 per cent. to the increase in personal social services. By improving primary care it will be possible to achieve a direct effect on child poverty and child health. We intend to increase the child benefit as soon as possible, along with the maternity grant. We believe that both those benefits will have a direct effect upon the health of the child.

    If the hon. Member for Newcastle upon Tyne, East (Mr. Thomas) is worried about finance, I suggest that he examines his own Social Democratic Party's plans, which seem to have been largely lifted from the Labour Party, to get rid of the married man's tax allowance. The hon. Gentleman will discover that there is considerable scope for shifting resources from one group of taxation to another to benefit the children, who are our main concern. Our plans for expanding public expenditure allow for the fact that the health services should spearhead the changes that we want to see in the social pattern.

    If we are to build new houses and new schools, to improve our hospitals and to provide a much higher standard of primary care, it will be necessary to start soon on the changes that Black demands as a matter of urgency. Unless we achieve that kind of change, it is obvious that the 1980s will be the year in which social services provided in the community, within the hospital service and by local authorities cease to be the means of improving conditions for the majority of people. They will become the poverty struck, the abandoned and the sad deposit of the hopes of those who are most in need.

    There have been no plans from the Government for an improvement in preventive medicine. Even where action could have been taken—for instance, legislation over tobacco advertisements or sponsorship—it has been funked by the Government. They have accepted whatever the companies have demanded in terms of voluntary arrangements. They have done nothing to change the law. The Government must know that if the companies were to agree to a better warning on the effects of smoking on pregnant women, this would have a direct effect on the health of the children who most concern us. They have done nothing positive. Indeed, they seem to have ran away from the difficulty as fast as possible.

    The Opposition would undertake, as a matter of urgency, a programme to provide at least 10 action areas throughout the country. The areas would be those most in need and those where we could experiment with the provision of far better child services and far better primary care. It is obvious that we must take action to make better general practioner services available across the country. We must not accept that the health services exist only to prevent sickness at the lowest level. Instead, we should encourage the kind of health that gives hope to our people.

    The Black report is a well-thought-out, positive and constructive document. It represents a long-term policy, but it identifies some matters that can be dealt with immediately. The failure of the Government is that since receiving the report they have sought either to ignore it or to pigeon hole it so that it receives no publicity. The Government know better than most that if the real inequalities that exist between one section of the population and another were known the electorate would no longer support their health policies. A direct attack would take place upon a group of people who seem to believe that privilege can be bought and that the market place is the only means of deciding the future of the provision of health services.

    The Government intend, by stealth, to run down the lifeline services that could make all the difference to the health of the nation. One of Labour's first tasks on coming to office will be to see that the Black report is implemented urgently. Only by doing that will we begin at long last to bring some justice and some decency to those most in need, the sick and the old.

    4.18 pm

    I beg to move, to leave out from "House" to the end of the Question and to add instead thereof:

    "notes the content of the Report of the working group on inequalities in health; congratulates the Government on the sustained increase in resources committed to the National Health Service; approves the progress which has been made in allocating resources more fairly between the Health Regions, and the emphasis which as been given to making the best use of the resources available; welcomes the announcement of special initiatives to secure improvements in health services to groups with particular needs; but rejects any programme of massive and damaging increases in public spending, in the knowledge that the maintenance of the Government's economic policy is essential to produce the steady increase in real resources that are required to ensure continued improvements in health care.".

    My first criticism of the speech of the hon. Member for Crewe (Mrs. Dunwoody) is that she appears to believe that, by summarising chunks of the Black report, she has triumphantly overcome all the problems in it.

    It is worth remembering not only that the Black committee was set up by the Labour Government, but that its report set out what were thought to be the defects of a sustem over which the Labour Government had presided for six years.

    The Black committee has set out a comprehensive list of the problems facing Britain. I do not seek to disguise that. However, surely no one suggests that problems such as health care in inner cities and, indeed, the unequal distribution of resources are anything but long-standing. They existed long before the Black report listed them on paper.

    If the hon. Member for Crewe believes that all that is needed is a massive injection of public expenditure, she might explain why the Labour Government tried to control that and explicitly stated that runaway public expenditure would lead to runaway inflation, which would be against the interests of the sick, the elderly and the poor. That point was made by the hon. Member for Newcastle upon Tyne, East (Mr. Thomas).

    The hon. Member for Crewe might also reflect upon the fact that Sir Douglas Black's working group on inequalities in health was established in April 1977 when total spending on the Health Service was £6·8 billion. That constituted about 4·8 per cent. of the gross domestic product. This financial year, total expenditure on the Health Service is £14½ billion. That is a rise, related to the retail prices index, of about 20 per cent. Health spending now constitutes 5½ per cent. of gross domestic product.

    Next year, spending on the Health Service will be £15½ billion. All told, spending on health, social security and the personal social services will be £52 billion—about 43 per cent. of total public spending. The position is that spending on health, social security and the personal social services is taking up not a diminishing but an increasing share of public spending.

    Will the Secretary of State tell the Housé how much of the sum spent on the NHS is net of charges and how much of the sum related to social security is represented by unemployment benefit?

    About half of the social security budget is made up of retirement pensions. However, as unemployment has increased, unemployment benefit has increased. I should have thought that the hon. Lady would wish to applaud the Government for having sought to make provision for social security and personal social services.

    The hon. Lady's figures for personal social services were wrong, as were those for health. However, my major objection to the hon. Lady's speech is that it was too shallow by half. We need to go deeper in our analysis if we are to make progress in tackling many of the problems set out in the Black report.

    No one in the House would deny that an objective of our policy should be to give children a better start in life; to encourage good health by health education and preventive measures; to improve the quality of life of disabled people; to secure a quicker movement from institutional to community care; and to seek to tackle the inequalities in health between different parts of Britain.

    It is, of course, right that we should debate the health needs of the nation. It is equally right that we should debate all the policies which are necessary to tackle those needs. The hon. Lady is utterly wrong, because I in no way want to minimise the areas of need in Britain today. I certainly claim that the Government have taken important steps to tackle those needs. However, no one should be in doubt about the needs of many people in Britain or the demands that there will be over the next decade.

    The Secretary of State will know that I have a great interest in the Black report, having established the group which produced it and being a member of the Select Committee. Apart from the right hon. Gentleman's unfair reference to the speech of my hon. Friend the Member for Crewe (Mrs. Dunwoody) as shallow, I hope that he will not suggest that the study is shallow, because it is one of great depth. Will the right hon. Gentleman say precisely how many of the 37 recommendations in the Black report will be carried out by the Government?

    I shall touch upon many of the recommendations, but the House would be here for a considerable time if I were to go through each one. I am not suggesting that the study carried out by Sir Douglas Black and his working party is shallow. That is not what I said. I said that the so-called solutions suggested by the hon. Member for Crewe were shallow.

    I hope that the Secretary of State accepts that to some extent I agree with him about the money that has been spent by the Government. In the circumstances, is it not extraordinary that lack of priorities—the main thrust of the Black report—and lack of imagination have meant that most of the inequalities during that period have increased rather than diminished?

    Some have, but many have not. I shall deal with those matters later.

    I want to tell the House, and the public generally, that we should be in no doubt about the demands and needs of the Health Service and its connected services, not only today but over the next decade.

    The very elderly are increasing in numbers. By 1991 there will be 3½ million people over the age of 75, including three-quarters of a million over the age of 85. At the other extreme of the age scale, divorce rates have increased, creating one of the major reasons for nearly 1½ million children living in one-parent families. Among the mentally handicapped—neglected for so many years—there are children and adults now in hospital who would be better served in the community.

    That will present an enormous challenge to the NHS and the social services. However, we should recognise—this point was absent from the speech of the hon. Member for Crewe—that parents, relations and neighbours can often give the kind of support that could never be provided by an outside body. Voluntary organisations often provide invaluable assistance, and a wise Government should recognise and encourage that source of help.

    I shall not give way for the moment.

    Central Government and local government cannot do everything by themselves. The aim should be to ensure that the total resources of the community for social care are mobilised.

    I shall not give way for the moment.

    What progress has been made over the past few years in meeting some of the Black report's major objectives? One of its major objectives was that children should have a better start in life. For example, it wanted to see better services for children under five. That is an area in which both the statutory and voluntary sectors have important roles. Already, over 80 per cent. of 3-year-olds and 4-year-olds receive education in nursery or infant classes or attend play groups. However, there are still important groups to help. Accordingly, some of the additional Health Service money that is available to be spent on central initiatives next year will be used for work with pre-school children. I intend to make £2 million available for that purpose in 1983–84.

    The emphasis will be on helping voluntary bodies which work with the under-fives and which support families with very young children. We already support national bodies working with the under-fives, and grants amount to almost £½ million this year. I now want to finance particular projects that would not otherwise get off the ground, such as schemes to help childminders to provide a more effective service by providing them with support, training and equipment. There are also home visiting schemes in which volunteers befriend and assist mothers who find life with small children difficult. These are often very effective and deserve to be encouraged.

    I also want to assist community self-help schemes which seek to provide day care for under-fives and support for mothers. We are still looking at the possibilities, so we may be able to add to the list. However, I stress that I am anxious that such schemes should benefit disadvantaged families: one-parent families, those on low incomes where both parents need to work, and those parents with very young children who need help in order to cope. I also want to see what can be done for young children from ethnic minorities, because we need to encourage schemes which are of particular value to them.

    I share the Secretary of State's desire to maximise voluntary support, but will he discuss an anomaly with the Treasury? Organisations sometimes provide care, especially in the form of residential homes for the disabled, comparable with that provided by the social services department of a local authority. The anomaly is that local authorities are exempt from VAT whereas charities are not. Will the right hon. Gentleman give some incentive in that direction?

    As the hon. Gentleman knows, my right hon. and learned Friend the Chancellor of the Exchequer is considering that matter. It has been put to him several times. However, nothing further can be said until at least the Budget.

    The Black report drew attention to another important area concerning care in childbirth. Again, the Government have taken a number of steps to improve services. First, we have set up the maternity services advisory committee. The committee recently published its first report, on antenatal care. Our objective must be to ensure that the services meet the mother's needs as an individual—and often in a more personal way—and that unnecessary waiting and other inconveniences are overcome through better practice. All women are entitled to a service in which their problems are treated sympathetically and in private. The report offered valuable and practical advice on how to achieve those objectives. Through the process of regional reviews, it will be possible to check that progress is being made in putting those recommendations into practice.

    I welcome the fact that the committee is now undertaking a comprehensive review of the whole range of care from the time that the mother believes that she has started labour until delivery. We are expecting that second report in the summer of 1983. I intend that it should be made the basis of further improvements.

    Secondly, I am extremely grateful to the Social Services Select Committee. I see, at any rate, one of its senior members in the Chamber.

    I am grateful to the Select Committee for its comprehensive report on perinatal and neonatal mortality, to which the Government published their response almost two years ago. We asked health authorities to take note of the Select Committee's recommendations and to work for further progress in improving maternity and neonatal services. Three-quarters of its many recommendations concerning detailed improvements to the NHS were remitted to health authorities for consideration in the light of local priorities and needs. The Select Committee has said that it intends to take evidence from four regional health authorities next spring. I am confident that, when it does, it will be able to confirm that considerable improvements are being made.

    Finally, the House will welcome the fact that perinatal mortality—that is, stillbirths and deaths in the first week of life—has been significantly reduced in the past few years. The latest perinatal mortality figure for England, at 11·7 deaths per thousand, compares favourably with the latest available figures for other European countries. For example, the figure for France is 13·8, for Belgium 14 and for Italy 17·4. For two years running now, perinatal mortality has fallen at the fastest rate since statistics were first kept more than 50 years ago—a drop of about 9 per cent. in 1980, followed by an even bigger fall of 12 per cent. in 1981. I very much hope that that progress will be continued.

    The Secretary of State has not answered my point. Although there is a drop in the death rate, there is a considerable difference, within that figure, between social classes I and V. How does the right hon. Gentleman account for that?

    That is right, and that is what the Black report points out. However, I shall come to that issue. In her selective use of statistics, the hon. Lady should recognise that the general trend—despite what she has said—has been significantly better in the past two years than it was during the past half-century.

    Several of the Black report's recommendations covered the important subject of community care. The report called for a shift towards community care, improvements in general practice, and the development of joint funding. The development of community care is a cornerstone of our policy, and we have made substantial progress. Our approach to it flows directly from a belief in the importance of the individual and the family. People should go to hospital only if their health care needs cannot be met in any other way. Indeed, most people would want that. That approach was stressed in the White Paper on the elderly, entitled "Growing Older", which emphasised the vital role that community services play in enabling the elderly to stay in their own homes. The purpose is to prevent or defer the need for long-term care in a residential home or hospital. Similarly, the review published in 1980 about services in England for the mentally handicapped starts with the fact that most mentally handicapped people live with their families or independently. We have sought to take that philosophy further by increasing expenditure and devising new ways of switching resources to meet the needs of the individual.

    The allocations for joint finance have increased year by year to nearly £85 million in 1982–83. In real terms, that is an increase of more than 35 per cent. in the past four years. However, in several respects the existing rules for joint finance have not provided the necessary flexibility that we all want. They are not doing enough quickly enough. That is the problem. There are still people in long-stay hospitals who would not need to be there if more community care were available.

    That is why we published our consultative document, "Care in the Community", and why we now intend to make changes in the administrative rules so that, for example, health authorities can transfer resources with patients for as long as necessary.

    The Bill that we have introduced in the other place will also enable health authorities to contribute to housing and education services. We shall also make a further £6 million available next year for joint finance to support that initiative. During the next five years, we shall reserve £15 million of joint finance money to support selective pilot projects to show how ideas for care in the community can be made a reality. That is real progress towards a better and more independent life for some of the most disadvantaged in our society. I hope that the whole House will welcome those initiatives.

    We shall also make special finance—more than £3 million—available for the development of primary care in inner cities. The initiative is the result of our consideration of the Acheson report on primary health care in inner London and of the Harding report. Both reports were published last year and were commended to health authorities as a basis for action. Broadly, we accept the diagnoses made by Acheson and Harding on primary care in inner cities. The main problems are the disproportionate number of single-handed and elderly general practitioners, the low standard of some of the premises, the shortage of community nurses—I agree with what the hon. Member for Crewe said about that—and the problems of access experienced by some patients. Our initiatives will be directed towards tackling those problems. I hope to be able to announce our detailed proposals to the House shortly.

    The Black committee also laid great stress on the development of health education and prevention. Again, we have substantially increased the grant to the Health Education Council from £3½ million in 1978–79 to almost £9 million in the current year. Health education and prevention are crucial in a number of areas.

    I shall take one obvious example. The number of reported cases of whooping cough this year has risen to epidemic proportions. The latest figures show that there have been 13 deaths—10 were babies under one year old and two were infants under two years of age. The cause of the resurgence of the disease was the falling off over the years in the number of children who were vaccinated. That is why the Government have made strong efforts over past months to encourage parents to consult their doctors about vaccination. It is too soon to give the House the final figures on the response to the campaign, but there is evidence that parents are seeing the need to protect their own and other people's children and that there is an increased uptake of vaccinations. In one area, for example, take-up following the launch of the campaign increased by 13·8 per cent. for triple vaccination, and single vaccinations rose from 60 to 880. The results of a small national opinion poll in September and October suggested that over 60 per cent. of women with children under five are having those children vaccinated against whooping cough. That means that the take-up has almost doubled since the low point in the mid-1970s. That is an encouraging figure. I hope that it reflects a permanent trend.

    At the same time, there is a whole range of other problems where health education is crucial—for example, alcohol misuse and tobacco, about which my hon. and learned Friend the Minister for Health will say more. The report was right to draw attention to the dangers to health caused by smoking. Smoking is the greatest single preventable cause of disease and early death in this country. What is more, unfortunately, the message about the dangers of smoking has not got through to certain groups, or it has got through less than we would like.

    Following the example of the Labour Government, by agreement with the tobacco industry, we have introduced limits on the amount that can be spent on cigarette advertising on posters and in cinemas. We have given the Health Education Council additional money—over £2 million this year—specifically for anti-smoking campaigns. We have improved the presentation of the Government's health warning on cigarette packets and advertisements.

    I heard what the hon. Member for Crewe said about Labour Party policy, should the Labour Party ever come to power. By following the voluntary path, we have continued in the tradition and policy that the Labour Government laid down.

    I want to make certain that the Secretary of State understands what he is saying. The Labour Government entered into an agreement for three years. When the agreement started, most adults were smokers. We ran a vigorous three-year campaign, and by the end of the voluntary agreement most adults were non-smokers. The intention at the end of the three-year agreement was to take action to stop advertising, except at the point of sale. The right hon. Gentleman must understand that he has gone against that intention.

    I shall look into that matter. Doubtless the right hon. Gentleman will tell me where the Labour Government's policy was made clear on that point when they entered into the voluntary agreement.

    Another problem that should cause concern to the House and the public is the misuse of drugs. A report was produced last week by the Advisory Council on the Misuse of Drugs. It said that the misuse of drugs is a substantial problem. No one knows the exact size of that problem, but our best estimate is that probably about 40,000 people are now dependent on drugs of different kinds. Other countries undoubtedly have larger problems, but that is no reason to underestimate our problem. The experience of other countries shows how rapidly the problem can grow unless action is taken. We have made £2 million immediately available to health and voluntary organisations. We also intend to emphasise the dangers of drug taking, particularly to young people. I do not believe that we or the public should underestimate the danger of the problem that we now face.

    I am delighted that my right hon. Friend has raised this matter. Will he take steps to ensure that all those who are addicted to drugs come under specifically chosen doctors? One trouble is that many doctors are playing an unfortunate part in permitting drug addiction to continue. Therefore, it is of great importance that all drug addicts are properly vetted. Will my right hon. Friend ensure that there are suitable long-stay homes or places for drug addicts so that their addiction can be eradicated? Will he liaise with the Home Office to ensure that any additional powers that are necessary are taken at an early date?

    I give my hon. and learned Friend an assurance, particularly on his final point. We are liaising closely with the Home Office. In the near future, there will be a meeting to which we shall invite representatives of the medical profession. I agree with my hon. and learned Friend that unquestionably there is a problem of irresponsible prescribing by a few doctors. We should not overstate it, but there is undoubtedly such a problem.

    However, the major problem is not over-prescribing but the criminal import of heroin, the illegal manufacture of amphetamines and the illegal trade that has grown up. Whereas in the late 1960s Britain was seen very much as a staging post to the United States, now too many of the illegally imported drugs stay here for users and for the illegal market. I assure my hon. and learned Friend that we shall do everything that we can to tackle an important social as well as criminal problem.

    The allocation of resources is at the heart of the debate. In allocating resources to regional health authorities, the Department has, since 1977, followed principles set out in the report of the resource allocation working party. Since then considerable progress has been made towards a more equitable distribution of resources among the regions. For example, in 1977–78 the most deprived region—the NorthWest—was 11 per cent. below target. In 1982–83, the most deprived regions were only 6 per cent. below target.

    The Black report broadly supports the present method of resource allocation to regional health authorities. It agrees that the standardised mortality ratio used in the national RAWP formula provides the best available indicator of health care need when used in conjunction with information about the size and structure of the population. We accept that inequalities exist within the regions and that action will have to be taken to even them out.

    To what timetable are the Government working to achieve a fair allocation? Will it be five years, 10 years or 15 years before it is achieved?

    The timetable will depend on the spending plans that we are able to afford in the coming years. We want the inequalities between regions and inside the regions to be evened out as quickly as possible. A great deal has been done, but under this Government, as under the last, the policies and the progress of policies, such as resource reallocation, depend upon available resources.

    Before sloganising on the problem we should seek to understand what has happened throughout the Health Service's history. The Beveridge report of November 1942 contained a rough estimate of cost showing a flatline projection between 1945 and 1965 on the basis that the development of the Service would lead to a reduction in the number of cases requiring that service.

    The achievement of the National Health Service—it is a real and important achievement—is that it has developed a service which undoubtedly has made a major contribution to the health of the nation. It has also gone a long way—although as the Black report shows, not the whole way—to achieving the goal set by Churchill's coalition Government in 1944 which stated:
    "The Government want to ensure that in the future every man, woman and child can rely on getting the best medical and other facilities available; that their getting them shall not depend on whether they can pay for them or on any other factor irrelevant to real need."

    At the same time as the Service has developed, the costs of and the demands for it have rocketed. That is not in itself a criticism of the National Health Service. It is important that that is understood. Costs have increased in every country in Western Europe. Although I am sure that we can achieve more in efficiency here, the record of the National Health Service in containing costs stands comparison with virtually any other Western European nation.

    Costs have increased for a variety of reasons Medical advances have meant that many conditions which previously could not be treated successfully can now be treated. The fact that people live longer has meant a consequent increase in demand on both the health and personal social services. At any one time, 45 per cent. of beds in National Health Service hospitals are occupied by elderly people over the age of 65. Those two factors—medical advance and demographic change—taken together mean that there is an increase in demand of about 1·2 per cent. a year even to remain static.

    The problem of increasing, if not infinite, demand is one side of the coin. The other side of the coin involves finite resources. Health spending has to be limited in some way. We can certainly argue about what should be, but there is no question about what has been. Under successive Governments in the past 10 years that has been recognised. In many ways, that is the most disappointing feature, if not of the Black report, of the discussion that has surrounded it. The report provides a statement of the problem. It provides an estimate of the type of resources that the committee believe would be required to put all its policy suggestions into operation. That cost is now about £5 billion a year. But the report says next to nothing about where resources of that size are to come from. In surveying the figures of the 1970s—that is what the Black report has done—it has imported some of the assumptions of the 1960s, one of which is that resources will automatically be available.

    There is no suggestion in either the Black report or in the speech by the hon. Member for Crewe of how the resources will be created. The only suggestions are about redistribution. The report suggests that the married man's tax allowance could be redistributed more effectively in the form of cash payments for children. That would save about £3½ billion, but it would also mean a big increase in tax bills. About 12 million married couples would be worse off because their tax thresholds would be lower. The question how that money is redistributed is at the heart of the discussion on the taxation of husband and wife, which followed the Government's Green Paper.

    The Government are still considering the many different views on the subject, but under any system there would be millions of losers. No system would pay for the proposals in the Black report, let alone the proposals put forward by the Labour Party. On that point, Mr. Peter Townsend, one of the authors of the Black report, is most informative. In his introduction to the Pelican summary of the report he attempts to provide an answer. He says:
    "The money for health is only not there if it is being spent on something else like defence or roads."
    I assume that by that mainly he means defence. I do not believe that even the Labour Party is currently suggesting that we should make further capital cuts that affect the construction industry. On the crucial issue of means, that brings us back to the familiar position. The Labour Party is making promises for increased spending without any idea of how the promises are to be implemented, apart from cutting into the defence budget. The Labour Party promises to do that before every election. It has had little effect, for the very good reason that the economies that can be achieved out of the defence programme do not come remotely near to paying for Labour Party ambitions.

    If any further warning is required, I suggest that the Opposition should examine the experience in France, set out in the newly published book of the Nuffield Provincial Hospitals Trust in which Professor Lacronique, who at the time of writing was the deputy director of health and hospitals in the Ministry of Health, wrote that the newly elected Socialist Government had increased public spending by the distribution of money to low-income families and the creation of 150,000 new Civil Service jobs, thus expanding the public sector. He said that the expected outcome of the new policy was a general growth in consumption which would allow the private sector to invest and create jobs.

    However, after one year of various incentives aimed at convincing private investors that the future was promising, the French Government realised in May 1982 that inflation was becoming a major problem and decided to take drastic measures to fight it. In June 1982, it was therefore decided to devalue the franc, and the three-month freeze on wages and prices was decreed.

    In addition, the French Government have altered the basis of uprating charges to save money and they have introduced a board and lodging charge for hospitals inside the health service.

    Overlying all the specific problems mentioned in the Black report is the central issue of the view taken by the different political parties not only of the needs of the Health Service but of how those needs are to be met. The Government believe that the first essential is to base policy upon an economic strategy, which has resulted in lower inflation, which in itself must aid industrial recovery and which, in its turn, will provide the resources for health care. We reject policies that merely put us back on the road to higher inflation, which will affect the resources that can go to the NHS and the lives of most of those with whom the Black report is concerned.

    The second essential is continued support of the NHS by the Government and by those who work in the service. Over the past three and a half years the Government have shown that commitment and that commitment remains. We should remember that the Health Service is not there as a rallying cry for politicians or for trade union leaders. Its fundamental aim is to develop, to the best extent that resources allow, services to prevent ill-health and to cure or care for the sick and the handicapped. It is the individual patient who must come first in any health policy that is worthy of the name.

    Thirdly, we need to make the best use of available resources. In comparison with other countries in Western Europe, the record of the Health Service is a good one. That does not mean that further improvements cannot be made, and I know of no one in the Health Service who takes that view. The search for efficiency is not a threat to the Health Service. It is a way of ensuring that the maximum amount of resources is devoted directly to patient care. That is why we have taken a number of initiatives over the past 12 months, including the annual review by Ministers of the performance of regional health authorities against agreed management objectives. We are formulating and testing performance indicators and we have introduced a programme of scrutinies, with Sir Derek Rayner's help, into the efficiency of the Health Service's performance.

    Fourthly—I end with the point with which I began—we need to develop a partnership with all agencies in health care, including voluntary organisations and the private sector. It seems that there is beginning to develop an unbridgeable divide between the Government and the Labour Party. We do not agree with the attitude revealed in Labour's "Programme for 1982" towards voluntary organisations.

    That document reveals that the Labour Party wants to give priority to the care of mentally handicapped children but states:

    "We wholly reject the Tory assumption that voluntary organisations can or ought to take major responsibility for the care of mentally handicapped children leaving hospital."
    We applaud the efforts of voluntary organisations and we want to see a closer partnership in care for those who are in need.

    No, I shall not give way.

    The view of the hon. Member for Crewe, who leads for the Opposition, is that private medicine has no place in Britain today. That is the motion that she proposed with enormous gusto and undoubted sincerity at the Cambridge Union only two weeks ago. We are told that there are about 34,000 beds in private hospitals and nursing homes and almost 3,000 private beds in NHS hospitals. That compares with the provision in the NHS of about 380,000 beds in over 2,100 hospitals. In other words, the private sector is small compared with the National Health Service. Yet the bulk of private beds are in small nursing homes and not in private hospitals. They are used to look after well over 20,000 elderly people. Is it seriously being argued that we should turn our back on the provision of care, which by any standards is much needed, merely because it is provided by the private sector?

    It is about time that the hon. Member for Crewe recognised that the private sector is a mixture of voluntary, charitable and commercial enterprises, ranging from small nursing homes to modern hospitals capable of undertaking major surgery. Health authorities have had contracts to use some of these facilities for many years. About 3,000 beds in the private sector are used by Health Service patients. It is absurd to characterise such patients as some form of elderly elite. It is equally absurd for Britain to turn its back on the provision that the private sector offers.

    No, I shall not give way.

    The Black report identifies a number of important needs in our society. I do not seek to minimise those needs but I suggest that the real question is how we care and not whether we care. This is an area for serious policy and not for sloganising. The needs that the Health Service faces are likely to increase over the coming years. They can be met only by a combination of policies and by the development of the Health Service. That is essential and it must be underlined.

    At the same time, we believe that it is not only the Health Service that will meet the needs of society. A joint effort is required and a partnership, and the Government are committed to that approach. I ask the House to reject the motion.

    5.7 pm

    The House is fortunate at last to have an opportunity to discuss the Black report. It is a fairly turbid document. It does not make, by any means, the most pleasant of reading. It bears heavily the stamp of the sociologist's jargon but it is an extremely important report. We should be grateful to those who have sought to make it rather more intelligible and more widely known. The TUC, in its attempt to make the public more aware of the conclusions set out in the report, is doing an important job. The report shows clearly that good health and good treatment depend alarmingly on a person's background, his job and on where he happens to live.

    I regard the Government's attitude to the report as disgraceful. It is summed up all too well in the statement that appears on the first page of the document from the previous Secretary of State. He added together all the proposals in the report, produced a large sum and used that as an excuse for dismissing the entire contents of the report. He showed no willingness to implement any part of the report. It may be that the Secretary of State is trying to pull back a little from the posture taken by his predecessor but that posture has coloured the thinking of the Department ever since the report was produced.

    The same computation—that massive public expenditure would be required to implement all the proposals in the report—has influenced the Labour Party's thinking. It has tabled a motion which is a commitment to exactly that sort of programme. I believe it to be over-optimistic in terms of what any British Government in the next two or three years will be able to mount. I do not regard the scale of the total need as any excuse for not committing Governments to doing as much as they can in the direction of the Black report.

    The Government seem to have dismissed the thinking that lies behind the entire report and the direction which it seeks to impose on our health services. What is more, they are pursuing policies that will make the inequalities even worse. There is a series of Government policies that has clearly been entirely uninfluenced by the demonstration in the report that inequalities based on social class and occupation are extremely severe.

    The emphasis that the Government are placing on private medicine involves the underlying attitude that the Health Service is the safety-net service. Anyone who assumes that private medicine has a major contribution to make to the nation's health is misunderstanding the dependence of the vast majority of people on all of the most important services that the Health Service provides. The emphasis on the private sector that has come to the fore in the Government's thinking on health, as in education, is an indication of a safety-net approach to the service, which is clearly affecting the morale and the enthusiasm of many Health Service workers.

    It is not the Government's attitude that the NHS is a safety-net service. What view does the Liberal Party take? Does it support the right for there to be a private sector?

    The Liberal Party has never challenged the right of the people to spend their own money on what they choose. However, we have challenged from time to time forms of private provision that impinge unfairly on the provision for those who are dependent upon the State system. Some of the ways in which private medicine has operated have encouraged queue-jumping by allowing people effectively to buy consultants' time when that time could have been used better to reduce waiting lists in the State sector. We should never seek, however, to deprive people of the opportunity to make provision for themselves independent of the public service.

    At the same time, one cannot escape the Government's rhetoric which again and again promotes the private as against State provision in every sphere. It is my view and that of my party that the State must be the most important provider of most of the health services for most of the people. That is not reflected by the way in which the Government refer to such matters.

    I have specific complaints about Goverment policies. Their attitude to child benefit has been criticised even by some of their right hon. and hon. Friends. This failure to tackle the poverty trap promotes and increases inequalities in health and welfare. The destrucion of the school meals service and the removal of nutritional standards for school meals is another example. Those examples have helped to contribute to a widening of inequalities. The Black report was written before steps were taken about the school meal service. The report lays heavy emphasis on the value of the school meals service in maintaining basic nutritional standards. It is a tragedy that a school meals service, based on nutritional standards which were built up so well over many years, has been destroyed in such a cavalier way so quickly.

    Furthermore, the Government have shown a feeble attitude towards prevention measures, particularly in relation to the problems created by smoking and alcohol. They have failed to tackle the issue of a ban on the advertising of cigarettes. Similarly, I cannot understand the Government's attitude to alcohol and the measures that need to be taken to deal with the enourmous range of problems that it creates. The Government's Central Policy Review Staff has published a major and significant report on the dangers and costs of alcohol in the community. The Government refuse persistently to publish that report. However, it has been published in Sweden. Why do the Government treat it as some vicious form of pornography, which can be bought only in Sweden and must not be allowed to appear on the home market?

    That fairly searching document costed many of the problems created by alcohol and gave pointers to policies that the Government should pursue to reduce the impact of alcohol. Alcohol has the most enormous consequences for ill-health and is one of the areas in which preventive measures could be readily and quickly undertaken. I appeal to Ministers to challenge the Prime Minister's refusal to publish the report. In a parliamentary answer a few days ago she once again refused to publish it.

    The hon. Gentleman is fair, normally. I am sure that he will concede that the report was written three years ago and has been extensively leaked. For some reason, it is being leaked again. In the intervening period, the Government published a substantial policy document called "Drinking Sensibly". I hope that he will accept that that shows the high priority that we have given to the problem. It suggests a policy equal to that of the Think Tank report.

    The hon. and learned Gentleman has the advantage of me because he has both documents. I suspect that there is an enormous gulf between the innocent little pamphlet "Drinking Sensibly" and the more far-reaching document produced by the Central Policy Review Staff. If the Minister thinks that it is out of date he can add to it, and not keep it concealed in a cupboard and available only on the Swedish black market.

    I criticise also the Government's failure to maintain the full momentum of the resource allocation working party—the RAWP formula—to even out regional inequalities. That is illustrated vividly by an article which appeared in "The Health Services" magazine on 1 October. This showed that every Thames region is over-allocated to a staggering amount totalling over £200 million, while other regions remain substantially under-funded. The Northern region, which has the worst mortality rate, has been climbing the league in terms of its under-funding and is no longer the worst, although it has still only 95 per cent. of its allocation and will not be fully funded until well into the 1990s.

    The article showed the staggering differences in cost per case between hospitals in different parts of the country. Roehampton requires expenditure of £783 per case, whereas the Ashington hospital, which serves my constituency, allows £460 per case. Those are two non-teaching examples. There is a £200 difference in the average costs between teaching hospitals in the Thames areas and those in the rest of the country. The article points out that a difference of £200 per case amounts to £70 million a year
    "and could only be justified in terms of teaching needs if it could be shown that patients are dying like flies from the ministrations of those graduating in the provinces."
    As I assume that the Minister does not take that view, he must be puzzled by the remaining enormous differences in the levels of funding for London and elsewhere.

    The hon. Gentleman has spoken of the disproportion of allocation to the four Thames regions—I am a member of one—and the regions of the North. The cutback that the Government have attempted can be achieved only at a certain rate. Massive cutbacks cannot be made in areas that are still growing in population. That is the position in the Thames regions. Whereas London is becoming depopulated, the areas outside London are increasing in population. The hardships are there, and the cutbacks, that I believe should be made to benefit the Northern regions, can be made only at an acceptable rate.

    We are worried when we see insufficient progress made, and when we see that the Government's attitude to dealing with hard cases is different in different parts of the country. It puzzles hon. Members from more distant parts of the country to see cases in the London area which attract publicity such as Tadworth, producing new money and new commitments relatively quickly, while those in the rest of the country do not seem to have that effect.

    I shall compare the Tadworth example with that of the provision of neonatal care in Newcastle. The Newcastle region is estimated to need about 12 cots for babies weighing under 2½ lb at birth. There are only six. Part of that provision is due to outside funding and the generosity, for example, of the novelist Catherine Cookson, whose novels describe vividly many of the conditions that gave rise to lower health standards in the North.

    The consultants claim that they are being obliged to turn away babies who would live if they had the intensive care facility. The consultant in charge of the facility at Newcastle general hospital has said that since April he has had no alternative but to refuse admission to five critically ill new-born babies, four of whom died, from outlying hospitals. It is the consultant's view that many more babies could be saved, and others saved from lifetime handicap, if there were a larger provision for neonatal intensive care. The region has the smallest provision proportionately of any region in England. That deficiency continues and the RAWP process seems unable to make the recoupment necessary to correct it.

    The more distant regions of the country face other problems. Rural areas have the severe problem of access to medical services because of the costs of travel for patients and those who visit them. Berwick is 65 miles away from the main hospital centres, and there must be many other communities with a similar problem. Travel to hospital from Berwick for a patient who does not need an ambulance can cost between £5 and £10 for each visit. A parent accompanying a child can face similar problems.

    The existing Health Service provision for travel is extremely cumbersome. It tends to work on the passport system—if one is receiving social security or family income supplement help may be provided, but otherwise there is none. I welcome what the development commission, encouraged by the Department of Health and Social Security, is doing to experiment in Cumberland with financial help to get patients and visitors to hospital. I hope that that scheme can be developed rapidly to help all rural areas.

    No one should pretend that limitless funding is available to the NHS. It is misleading for the Labour Party to suggest that we can embark on a massive new programme at this juncture; but we are entitled to ask the Government to do a number of things. They should consider the priorities, about which they say little. Do we at present need to put our money into complex high-technology treatments? Should we be concentrating on elaborate provisions for infertility and expensive test tube baby experiments? Are we getting rid of the big mental institutions fast enough and replacing them with community care? Is sufficient being done about the over-prescription of drugs and the prescribing of expensive brand-name drugs?

    The Government should also accelerate the redistribution to benefit underprivileged areas and make progress on the main strategic commitments in the report. The report says that children should have a better start in life; this involves improving child benefit and doing more about the care of young children. The quality of life should be improved for the disabled in the community, which involves a more constructive attitude to local government spending on such things as home helps. In the Government's terms that is bad spending because it is revenue spending on staff, but it is one of the most valuable forms of community service to enable the disabled and the elderly to live in the community. We should not encourage local authorities to regard it as undesirable expenditure.

    Prevention is the third element in the report's strategy. Most of the major triumphs in eradicating disease in the past century have been through preventive methods. Many more diseases have been cured by good plumbing than by a vast range of drugs. I am critical of the Government's attitude to prevention and their lack of vigour in dealing with smoking and alcohol abuse.

    Not a great deal will be done by a political party which sees State medicine as a safety net. Liberals such as Lloyd George and Beveridge built up the NHS; the post-war Attlee Government played a notable part in its development. An earlier generation of Conservatives came to accept it as an essential part of the nation's fabric. But we now have a new breed of Conservatives, who take a different view. They are wrong. I believe that the public consider them to be wrong and they want a free Health Service. The NHS should be so directed that good health no longer depends on class, wealth or occupation.

    5.22 pm

    I followed with interest what the hon. Member for Berwick-upon-Tweed (Mr. Beith) said. Both he and the hon. Member for Canterbury (Mr. Crouch) mentioned the effect of the RAWP changes.

    The Secretary of State said that a 1·2 per cent. increase in provision was needed to keep pace with last year. For the North-West Thames region the increase has been only 0·7 per cent. Patient services are having to be cut. Sacking a few administrators cannot solve a problem of that scale.

    I pay tribute to the Secretary of State for his fluency and footwork, but I wish that he had a little more heart. He baffles me. On the Health Service, over-the past six months time and again he has made out that we are living in the best of all possible worlds, that the Government are doing more than any other have done and everyone is getting a better deal, and that we have more doctors and nurses and they are getting a better deal. But from our knowledge of our constituencies we know that that is far from true.

    The Black report puts its finger on the fact that the poor and the needy are still at the bottom of the heap. In the inner city area that I represent, my district health authority this week must decide for the financial year 1983–84 how many wards to close at the Central Middlesex hospital; whether to close wards and the casualty department at the Wembley hospital, or to close the whole hospital and lose 127 beds; whether to close the Pound Lane chest clinic; whether to close the Neasden hospital, which deals mainly with geriatric patients and the Leamington Park geriatric hospital; and it will be forced to cut back massively on care for the mentally disabled. It needs to find £1,090,000 from last year's estimates. The administration faces an impossible situation, yet the Secretary of State tells us that everything in the National Health Service is marvellous. I hope that his constituency, Sutton Coldfield, is in a better position than mine in Brent, South and Willesden.

    The right hon. Gentleman says that it is not what we do, but how we do it. It is also a question of how much we spend. If we are spending 5·5 per cent. on health care, 94·5 per cent. is left. The United States spends 9·4 per cent. of GNP on health care. I believe that a Labour Government could budget for an expenditure of 7·5 per cent., which would mean another £4 billion. If we take both private and public expenditure we find that people spend more on smoking, drinking and gambling than the Government spend on health and education. Black has made us look at priorities.

    I agree with much of what the Secretary of State said, but the hon. Member for Berwick-upon-Tweed is right to say that priorities are important. The Beveridge report of 40 years ago made comprehensive health care the basis on which the social programme should rest. Forty years later, this Black report is the most significant of all the many reports on the NHS. It goes straight to first principles. We should not be ashamed of having the highest possible ideals. I still claim that the NHS is second to none in any part of the world. It has a record of marvellous achievement. But we must accept that we have fallen short of the highest ideals, as Black points out. The way forward for the next 40 years is marked by its 37 recommendations. Let us not wait another 40 years before implementing them.

    The Government tried to sweep the report under the carpet, and we are debating it in Opposition time.

    Was not the report slightly tarnished by Professor Peter Townsend, a well-known Left-wing academic, expressing his strong personal views?

    I recommend that the hon. Member for Huddersfield, West (Mr. Dickens) goes to the Library and reads the Pelican edition for himself. Conducting a debate by labelling is elementary. He should read what Peter Townsend said in the preface to that edition. If the hon. Gentleman can challenge him on his factual information, he should do so. Nevertheless, let us not have a red smear approach to the debate. We should discuss the facts, what people have said, not make snap judgments by a mere label.

    The excellent motivation of my right hon. Friend the Member for Norwich, North (Mr. Ennals) on RAWP failed because it was a blunt instrument. RAWP pointed out the need for much better resource allocation according to a number of criteria, but it failed to differentiate between facilities within each region. For example, it failed to differentiate between inner cities, which may be equipped with old Victorian property that lacks the engineering and industrial strength that existed for the previous 20 years, and the more affluent areas.

    RAWP also failed to differentiate between the morbidity demands upon GPs. For example, the figure is three times higher in South Wales than in Surrey. Black has put that right. He has given the House information that will enable us to put the matter right. The matter cannot be considered merely on a geographical basis. It is important to remember that the inequalities arise from social and economic causes. Black analysis occupation and class mortality, race and ethnic inequalities, housing tenure and child mortality, and the illness and class of people between one and five years. The report's findings do not need any argument.

    The Secretary of State realised, as does the House, that health cannot be isolated from housing, social conditions, unemployment and what happens in the community. Black has done that fairly. Higher income groups know how to make better use of the service. They receive more specialist attention and occupy more beds in better hospitals. The report studies consultations with GPs, hospital services and the prevention and promotion services. It reads like a textbook for the Opposition. Further committees to examine the subject are not required; the facts and figures are clear. The conclusion is that class differentials are the main cause of inequalities in health care.

    The courage of the Black report lies in its making comparisons with other countries. Those comparisons are illuminating. The right hon. Gentleman made extremely selective quotations, as usual. He compared what President Mitterrand has done in France with the NHS. Health provision under a clawback system is vastly different from the comprehensive system with which we are working. The right hon. Gentleman is not comparing like with like. I have the good fortune to be a member of the Council of Europe social and health committee. The material that we have examined of health provision in Europe does not bear out the right hon. Gentleman's contentions.

    I was pleased to hear the Secretary of State say that there had been an improvement in perinatal mortality. That did not deny the levels of infant, neonatal and perinatal mortality in Britain since 1975. Until 1975, as Black shows, we were top of the league in child health. Since 1975 we have got worse. Black took up that point in an attempt to do something about it. He also showed how to help resolve this problem.

    Which of the 37 recommendations is the Secretary of State prepared to implement now? I have isolated 14 which I estimate will cost nothing extra. School health statistics, Government Department monitoring of police and accidents, and the national food survey can be coped with by the existing machinery of the Medical Research Council and the Social Services Research Council. The Secretary of State need only modify their programmes. Moreover, Black's recommendation for a research priority in the MRC and the SSRC could be absorbed in their existing budgets.

    I welcome the right hon. Gentleman's comments about trying to do something to help the Health Education Council with its campaign against smoking. Perhaps he will follow his predecessor's lead. The right hon. Gentleman may remember that his predecessor gave me the green light to introduce a Bill to stop all promotion of smoking except at the point of sale. The right hon. Member for Wanstead and Woodford (Mr. Jenkin) now the Secretary of State for Industry, gave that undertaking when he was in the right hon. Gentleman's job and, like a gentleman, he kept it. My Bill was never opposed by the Government Front Bench. When it reappears on 21 January for its Second Reading, if the right hon. Gentleman wants an easy way out he can come to the Dispatch Box and say that the Government will not block the Bill and that the House can make its own decision.

    When the right hon. Gentleman refers to an extra £2 million given to the Health Education Council to combat cigarette smoking, one must bear in mind the £100 million that is now being spent by the tobacco industry to promote sales. I remind the right hon. Gentleman of the way in which the agreement has been broken. No commercial advertising is permitted by the BBC, yet tobacco companies advertise through coverage of sports events.

    The Government's refusal to do anything but say hasty words and take no action about Black is a further erosion of the fundamental principles of the NHS. A recent meeting re-examined the threat of the Think Tank's proposed change for insurance. The Prime Minister said that the NHS was safe in her hands. One of my ambulance drivers gave me a quotation which I promised to put on the record. He said he felt as safe having a haircut by Sweeney Todd as having the NHS in the Government's hands.

    I recently had the opportunity to visit what I consider to be the Rolls-Royce of medicine—the Mayo clinic in the United States of America. It is a fine example of what resources can provide. I also saw the safety net at the bottom of America's health provision in the form of the Cork county hospital, which has 1,100 beds. I have seen nothing quite so bad in Britain in the past 30 years. If the Secretary of State is contemplating advancing an insurance system, the Health Service will be severely cut and a scarcely comprehensible increase in bureaucracy will ensue.

    I hope that the hon. Gentleman is aware—if he is not he will be now—that the Government have specifically rejected the path towards compulsory private insurance.

    I wonder how far and for how long that will remain the case. The Prime Minister rejected any mention of raising charges in the Health Service. Prescriptions cost 20p for five years, but they now cost £1·35. I challenge the right hon. Gentleman to say that he will not raise them again. I could also give figures for dentistry and for opticians' charges. The Prime Minister has said before that she will not implement the Think Tank's recommendations. I can only go by the record.

    The plea from the Opposition to the Government is that they implement at least those recommendations of the Black report that do not require further resources. Secondly, when the Secretary of State pays lip service to changing resources to community care, let him back his words by passing the money over.

    5.39 pm

    I often follow the hon. Member for Brent, South (Mr. Pavitt), but generous as I usually am, I cannot say much in favour of what he said today. The reference by the ambulance driver to Sweeney Todd was rather cheap, and did not fit the hon. Gentleman's normal contribution to this House. He also queried whether the Government were considering a compulsory form of insurance rather than State funding of the NHS. I am glad that my right hon. Friend the Secretary of State put him right yet again. It is no good the Opposition digging that up and believing that it is true, because it is not.

    I make my usual declaration that, as a director of a pharmaceutical company, I have an interest in the drugs industry. When my right hon. Friend spoke about drug dependency, I think that he was speaking about the occasions when drugs are not needed for health provision. He also used the word "over-prescription". It is, of course, possible to have over-prescription of drugs when they are needed for health provision. As a member of a regional health authority for many years, I know that patients are dependent, and happy to be, on drugs for ulcer and heart treatment, arthritis, nervous tension and many other illnesses.

    I hope that my right hon. Friend will make it clear that he is not seeking to hurt those who are benefiting so greatly from the proper prescription of health-saving drugs.

    The 410-page Black report is important and interesting reading, but a document of that size is par for the course in the Health Service, and that worries me. Last week, we considered the Hunt report on cable television. My criticism was that it was too thin and did not say enough. We needed a six-hour debate to learn more about it. Good as the Black report is, it is far too thick and wordy and does not analyse or get to the point as crisply as it could. One must read the report to understand the 37 recommendations.

    The Black report is like many others that have appeared in the Health Service. In some ways, they dismay those of us who are close to the Health Service, because there is almost too much written evidence to digest. Yet it is important that we digest this thinking that affects so many areas of health provision and care. It is, therefore, important that such reports should be better crystallised.

    Many members of community health councils have also complained that they must digest this evidence, and they often find it hard to get to the nub of the arguments put forward for their consideration by specialists, academics, professional men and women and others.

    We have had reports such as the one on cardiothoracic surgery in the South-West Thames region, and important questions must be determined as to where these specialist services should be performed within a region. We have also had studies on the provision of regional specialties. A document was issued about a year ago on the inadequacy of the GP service in London. That is a vital subject, in some ways every bit as important and more immediate than even the Black report, but we have not made much progress on it. I could list many other examples.

    In the last two years we have been overwhelmed with consideration of yet a further reorganisation in the Health Service and the creation of district health authorities. That produced much more paper work than the 410 pages in the Black report. In some ways, the Health Service is over-burdened with paper. We should therefore thank the Opposition for a debate on this report, because we shall at least be able to highlight the most important points that Black brings to our notice.

    Black has disclosed some serious deficiencies in the general provision of health care, but the report also points out that this is not the responsibility of the NHS alone. As every medical man would admit, the greatest contribution to health in the last 100 years has come not from drugs or doctors but from the provision of better drains, housing and general environmental circumstances. That is readily admitted by Black.

    The hon. Member for Crewe (Mrs. Dunwoody) has obviously studied this document carefully. She said that we must implement these recommendations, even though they will cost a great deal of money. We shall have to find £2 billion. It is all very well for the hon. Lady to say that now, but when I was working in the Health Service 12 years ago it was just as difficult to get money out of the Labour Government. In fact, it was more difficult because they introduced cash limits which were strictly applied. They had to be, because the IMF was sitting behind the Government ensuring that they were strictly applied.

    It may be that a future Labour Government would find this extra money, but that has not been so in the past. The old hospitals that existed under Labour are still there. Some of them are now being replaced, because the Conservative Government are building more hospitals. Personal social services were also bad under the last Labour Government. They are now being improved. The allocation of personal social services resources has gone up in real terms. I agree with Black that more resources are needed. The last Labour Government could not afford extra funds for the NHS, but they have been found by the Conservative Government. I cannot criticise the Secretary of State or the Government for not doing enough for the NHS, because, remarkably, provision has been increased in real terms. The cost is now £14 billion a year and will rise by another £1 billion next year.

    These are remarkable figures. In congratulating the Government, I do not feel smug, because I am concerned about the inequalities revealed by the Black report. Even so, at a time when we are strapped for money and cutting back in every Government Department, it is remarkable that the Government have succeeded in understanding that this is one Department in which we cannot afford to cut. We cannot spend as much as we would like, but we realise that we must spend more, and we have done so.

    Moreover, the redistribution of these moneys has been properly studied and much more needs to be done in that direction. We are making progress on evening out the distribution of these limited resources. A total of £14 billion is still limited, but we are trying to do more for the areas in greatest need.

    Many more Government Departments are involved than the DHSS alone. The only reference that I shall make to the Black report is about recommendation No. 8 on page 357:
    "We do not believe there to be any single and simple explanation of the complex data we have assembled."
    That is so right. We should accept that sobering thought. Many Departments are involved and no single Department is responsible. Further on, the same paragraph states:
    "It is this acknowledgment of the multicausal nature of health inequalities, within which inequalities in the material conditions of living loom large, which informs and structures our policy recommendations."
    The recommendation should inform our thinking as to what should be done.

    The penultimate sentence of the paragraph states:
    "We have concluded"—

    taking one aspect that the working group believes is important—
    "that early childhood is the period of life at which intervention could most hopefully weaken the continuing association between health and class."
    That recommendation sums up the Black report and makes it a serious one for us to consider. A vivid point is made about the relation between health and the condition of life of different people in our country. A considerable task lies ahead and many Government Departments are involved.

    There are inequalities in life in Britain today and in health and safety because of the different ways in which different people live and work. There is danger to health in the Armed Forces, but there is also danger to health in other forms of employment. Coal mining and agriculture are two examples of dangerous industries, and in many factories industrial conditions are much more unhealthy than in healthy factories or in offices. Housing inequalities are produced by inadequate accommodation with poor sanitary facilities—even in this day and age—poor heating and poor insulation.

    The Ministers from the Department of the Environment are not here but we should be thinking about our housing conditions. We should consider how to protect people from the cold and from high energy costs. Better insulation of houses would be a big step towards achieving that.

    Are there inequalities in health provision? In theory, no. In practice, I believe that there are—or rather, limited inequalities. I have witnessed them myself. If one can afford it, one sometimes chooses to go to an NHS hospital for consultation or treatment on a private basis. One goes into a private room and sees a consultant, almost at the time that one chooses. A year ago, my wife broke her wrist and was treated as an emergency case. I went with her to the accident centre in Canterbury. She was treated excellently by a leading bone surgeon. At the time there was much ice on the roads and a great many people, both young and old, had fallen and broken their wrists or legs. There was a great queue. In successive weeks, I took my wife back to the hospital as a National Health Service patient. I felt that it was the best way to get the best service since I knew the hospital and consultant well. However, everyone was given the same hour of appointment—10 o'clock. Some were seen at about 1 o'clock. There is no excuse for that.

    I have learnt more about the National Health Service by being a patient or by visiting patients than by sitting around a table in Croydon examining a budget. When one eventually saw the consultant or went into the plaster room, one got excellent service and advice. The setting was right, the X-rays and the treatment were correct and the people were nice, but it is not fair that one must hang around for two or three hours. One should be able to make appointments. We need not only money in the Health Service but better management. We must try to arrange matters so that people need not wait so long once they have entered the hospital.

    Every hon. Member is concerned that everyone should be able to obtain the best service and advice from the National Health Service. The Government must produce the help needed by the National Health Service both in resources and in interest. We must take an interest not just in providing money to build hospitals and health centres but in seeing how those establishments are run and what their real needs are by going there and finding out. We must also find out what the general practitioner needs. He is much too detached from the Health Service, although he provides primary health care. Equality might begin there, because some people may feel that they are not getting far with their general practitioner.

    The Health Service does not need—it is not mentioned in the report—more dedication from those who work in it. I never cease to be impressed by the dedication of Health Service workers, from the medical profession right down the scale to ancillary workers. Their priority is the entire public, not just a paying minority. That has never been suggested in the National Health Service. Some of the distinguished surgeons and consultants whom I have met have never suggested that they approach their patients on a basis of inequality. It goes against the teaching of the medical profession. I have never heard of preferential treatment being given to a person because of his background. However, someone with a disadvantaged background should have the opportunity to consult those persons of quality in the Health Service and should not feel that they cannot get near to them

    I watched the "Horizon" programme on television recently in which Professor Ian McColl was featured. I know him well, and I know how he works. I was impressed with his approach, which shows that such a person, who is professor of surgery at Guy's hospital in London, is concerned about medicine and people and not about the sort of people they are. We need not teach the Health Service that. We know that health workers are dedicated and have the correct approach to their profession.

    As the Black report said, we must continue to improve and support the Health Service with interest, better management and more resources as we can afford them. We must also improve housing, environmental conditions and industrial health. Not enough is done to improve health in industry and the conditions of work. We must educate our children to understand the requirement for better living and the achievement of better health. We must pay even greater attention to the education of the general public through the Health Education Council and other bodies.

    I am not interested in producing inequality. No one in the House is interested in inequality in health provision. I am determined that we should provide a better life and better health for all in our society. In the space of a few years we have succeeded in increasing the provision of resources for the National Health Service and improving the distribution of those resources. Nevertheless, we still have a long way to go and many other Departments will need to be involved.

    5.59 pm

    Some hon. Members may be surprised at my taking part in this debate, as they may imagine that it concerns only England and Wales. On behalf of my party, however, I am delighted to have the opportunity to speak on a matter that affects us all. As the hon. Member for Canterbury (Mr. Crouch) said, not only the Department of Health and Social Services is involved. The report makes it clear that, amongst others, the Secretary of State for Northern Ireland will be involved. In this context, I regret that not only no Minister from the Department of the Environment but no Minister from the Northern Ireland Office is here for a debate that affects the whole kingdom.

    I, too, pay tribute to the work of the National Health Service. I express my thanks to those who cared for me on many occasions. Compared with other countries, we are very fortunate indeed. Nevertheless, there is still room for improvement and I regret that the previous Secretary of State was apt to be dismissive of the Black report. I appreciate that it is a large volume and is perhaps not so specific as some would wish, but to dismiss it on the ground that it has not explained the fundamental causes for some groups suffering worse standards of health than others is a fallacy.

    I believe that the report is honest in not attempting to pin down specific causes. I am happy to share the view of the Royal College of Nursing that we must move towards a model based on caring for health rather than for illness. Can that be done? Certainly it will require a dramatic change in the nation's approach to these matters.

    About 20 years ago a colleague of mine was leaving the Altnagelvin hospital in Londonderry after visiting his wife when he met someone who had been used to the old hospital. That person suggested to him that an amazing amount of money had been wasted on the new hospital. My friend replied, "I suppose you are right. They tell me it was £5 million—just the price of a Vulcan bomber."

    Just recently, the nation marshalled its resources and its forces to protect 1,800 of its people in the South Atlantic. It should not be beyond our capabilities to assemble the necessary resources to provide for the health and care of the other 60 million. In making that comment I in no way deride the Government's defence strategies or the needs of the nation. I merely suggest that we must all give a lead in tackling the problem of caring for the nation's health. I suspect that in so doing we shall ultimately save vast resources, which could then be used in other spheres.

    In studying the report and trying to understand how resources should be allocated, I note that it gives the abolition of child poverty as the priority for the 1980s. I am very concerned that almost one-fifth of the decade has passed without much encouragement to believe that that objective will be realised by the end of the decade.

    Not long ago I spoke to some people engaged in the care of children. They shared with me some of their concerns and problems. I said to them, "Perhaps we need another Tom Barnado to awaken the nation to the needs of young people." We are apt to think that we are living in an affluent society, and that is true if we compare our society with that of the past or with other societies, but we are blind to reality if we miss the heartache of the needs of the many and, particularly at this time, of the young.

    It is said that half a loaf is better than no bread, but I should like to say a word for Gingerbread, the organisation for one-parent families. I understand that Gingerbread members from the north of Ireland have written to the Prime Minister, and they have asked me to speak for them. I understand from them that, in keeping with inflation, as it were, child benefit was increased last month from £3·30 to £3·65—an increase of 35p. They have shown the Prime Minister what that increase will buy, by sending her a toilet roll. They also pointed out how much minced meat 35p will buy.

    The real tragedy, however, is that people on supplementary benefit have the increase deducted from their supplementary benefit and so are no better off. The Government are robbing Peter to pay Paul, and the people for whom the benefit was designed are worse off. Those who are working may gain the full advantage of the increase but a sizeable section of the community in the north of Ireland feel a sense of injustice.

    We are discussing preventive medicine in the care of children, having regard to a proper balance of their needs. I believe that this is one injustice for which the Government could find an immediate remedy. Some hon. Members will argue that funds are not available. I welcome the Government's scrutiny measures for the Health Service, but I suspect—from observation in the north of Ireland and an awareness of human nature elsewhere—that there may still be waste in the Health Service and that there are resources which, if they were not syphoned off in other directions, could provide immediate help for many.

    I give as examples, which can be used regardless of the immediate background of terror in Northern Ireland, and, indeed, echoed in other places, the problem of accountancy in a large department of the Health Service in the Royal Victoria hospital complex in the North of Ireland and the abominable waste as a result of the delayed programme of building the new city hospital block. I suspect that with greater supervision throughout the Health Service we could release large sums of money which could be put to the cutting edge of care as well as preventive medicine.

    I appreciate that Labour Members might not be altogether happy with my next illustration, because they are not keen on privatisation. We had an interesting debate the other day in the Northern Ireland Assembly on an Adjournment motion, the subject of which was the problems of the hospital at Portrush, which is used for elderly people. During that debate we were told that a member of a mixed delegation of local councillors, political leaders and leading citizens had asked the Minister whether, as the hospital had historically strong connections with the town and had been subscribed for by private donations, it would be possible, instead of closing it under the reconstruction proposals for the Health Service in that area, to restore it to the citizens, who would provide for its upkeep themselves. The answer from the Under-Secretary of State for Northern Ireland, who is an exponent of privatisation in the Health Service, was "No".

    I find that response difficult to understand, when those people were genuinely concerned to care for the elderly in their community. The Minister has admitted today that about 20,000 beds in England and Wales are used in the private sector to care for such people. That was an example of an exponent of privatisation refusing people the right to care for the elderly in their community. It would seem that there is room for an advance in Government thinking to implement their concern to give the best service to the community at large.

    I appreciate that a great deal of help has been given to general practitioners by the provision of secretarial assistance. When such help is provided through the NHS for those involved with preventive medicine, the people concerned should undertake a course on the care of patients rather than one on the defence of doctors. Quite often, as a result of the screening process, people telephoning for appointments almost have to certify that they are dying before they will be seen. We must restore care for the patient as well as protection for the physician.

    I have friends in the medical profession, and I pay tribute to what so many of them do, but we are here today to debate a report which focuses the attention of the Government, Parliament, the profession and administrators on the concept of health care for the nation. Anything that can help at that level will be beneficial.

    I have no wish to delay the House unduly. I wish to demonstrate the concern of my party for the need to take steps to remedy the deficiencies in the nation's health services and to show that the redeployment of resources could ultimately save tremendous wastage.

    I understand from some American researchers with whom I have had contact that there is a growing awareness of what is commonly called the Left-Right syndrome, which is more apparent among families on a low income. In that context, a redeployment of educational resources to find the needy children at an early stage so that help could be given could deliver the nation from the apparent delusion that there are a large number of backward children, rather than children who need help to meet their problem at an early age. If such a redeployment were carried out it could in the long run release large resources now tied up in education and health care to be given to other areas. I am delighted to welcome the report and to have participated in the debate.

    6.15 pm

    I am the first Scottish Member to take part in the debate, and I wish to register a protest immediately. It has been the practice of late that the Government automatically presume that a debate of this nature will be an English and Welsh affair. Although the report specifically mentions Scottish problems, no Scottish Minister is present and no Scottish Minister is present to reply to the points that I wish to make.

    In case the Government Whip, the hon. Member for Watford (Mr. Garel-Jones) is looking around to see whether any other Scottish Member is here, I can tell him that no Scottish Tory is present. A Scottish Minister should be here to hear what is being said about the inequalities that are probably more apparent in the Scottish Health Service than even in the English Health Service, as is explained in the Black report.

    Table 3.8 of the report gives some startling figures about neonatal and post-neonatal mortality rates per thousand live births by occupational class in Scotland. In Britain, we divide people into classes I, II, III, IV and V. Class I consists of wealthy privileged people.

    In 1946, the neonatal mortality rate in class I per thousand live births was 16·7, and, at the other end of the scale, in class V, it was 36·9—more than double. By 1975 there had been an overall improvement right down the line but the gap between them was very much the same—twice as bad among the poorest section of the community. The post-neonatal mortality rate tells a worse story. Among the richer people, the post-neonatal mortality rate was 5·5 per thousand live births in 1946 and 36·1 among the poorest section. by 1975, the figure had fallen to 1·8 per thousand live births in class I and 10·8 among the poorest section. I make that point to stress that the position in Scotland is as bad as, and probably worse than, the position in England and Wales.

    The Sunday Mail of 1 January 1980 had an article with the title
    "Cursed by the dram and fish and chips"—
    that was the title; it is not what I am saying. It dealt with the diet of the Scottish people and with their smoking and drinking habits, and argued that they were among the reasons why the health statistics in Scotland are much worse than the health statistics in England and Wales.

    In the article, Professor Ian Bouchier explained the brief of a team that had been established in 1980. It had been given £875,000 over seven years to engage in some research into why the health of the Scottish people was generally worse than that of the English and the Welsh. Professor Bouchier
    "explained the team's brief from the Scottish Office, which has given the seal of approval to the cash flow of £125,000 a year for seven years. 'We will be studying the Scots pattern of life to give us a clue to solving the problem. We will look at the Scots diet, smoking patterns and standard of living. There is evidence to suggest that people who smoke, are overweight and don't take enough exercise are prone to heart disease. Also their blood fat levels are too high'".

    I have referred to that article in order to underline some of the points made in the Black report. The Black report put great emphasis on the need for preventive measures, and the Government can be criticised a great deal for their relative lack of attention to those matters.

    My hon. Friend the Member for Brent, South (Mr. Pavitt) referred to the Government's retreat in the face of the tobacco lobby. It is absolutely disgraceful. There is abundant evidence to show that smoking is a killer, yet the Government have retreated steadily in the face of the tobacco companies. The Prime Minister even took the step of removing from the Department of Health and Social Services the hon. Member for Ealing, Acton (Sir G. Young), who was greatly in favour of dealing firmly with the tobacco companies. In his place the Prime Minister put the lobby fodder for the tobacco companies.

    The hon. Member for Fife, Central (Mr. Hamilton), in his typical way, is making snide attacks on hon. Members. I ask him to compare the size of the health warning on a cigarette packet, today with the size of the health warning that he was content to have when his party was in power. It is substantially larger now than it ever was.

    The Under-Secretary of State should know his facts before he makes interventions of that sort. I have never supported the steps that were taken even by my own Government. I was never a member of that Government. I have always taken the view that we should deal very firmly with the killers in the tobacco industry. That is what they are. They are murderers, and the Government are conniving with them. It is indefensible that that should happen. Having said that, I think that there are other steps to be taken in the preventive field that do not come within the purview of the DHSS.

    The Government's record in the provision of new or adequate housing—by whatever yardstick it is measured—is deplorable and the worst in living memory. The poorer or older the houses, the damper they are and the more difficult they are to heat so the dangers to health become proportionately greater.

    I am glad to see that there is now present a Minister from the Scottish Office, but he does not speak for the health services. The Minister responsible for the health services in Scotland ought to be present in the Chamber to hear what is being said about Scottish health problems. He was here earlier and might well have engagements elsewhere but his prime responsibility is to be here, listening to the debate.

    For several reasons, the Black report is very depressing. It demonstrates how our deeply divided class society reflects those divisions at almost every point in the provision of health care. The poorer a person and the poorer his environment, the worse his health is likely to be and the worse the health provision for him is likely to be.

    Simply by taking a train from King's Cross to the north of Scotland it is possible to find that the way of life, the environment, education, health and housing, become poorer and poorer the further north one goes. The charge that we are two nations becomes increasingly evident, and not least in the matter of health.

    One of the most depressing aspects of the Black report is that, after more than 30 years of the National Health Service, the divisions and inequalities have either remained the same or have in some instances got worse. No less depressing has been the Government's response to the 37 recommendations in the Black report. As my hon. Friend the Member for Crewe (Mrs. Dunwoody) said from the Opposition Front Bench, from the outset the Government were prepared to bury the Black report. At £8, it was hardly likely to be a best seller in Fife. When the report was first produced there was not a copy available for every Member of Parliament, let alone every member of the community who wished to read it. The Government made every effort to prevent its publication. A surgeon in the National Health Service in Newcastle told me yesterday that he did not even know of the existence of the Black report.

    The hon. Member for Berwick-upon-Tweed (Mr. Beith) referred to the statement made by the then Secretary of State for Social Services—now the Secretary of State for Industry—in the foreword to the report, to the effect that the public expenditure involved in implementing the recommendations would be
    "quite unrealistic in present or any foreseeable economic circumstances".
    In that foreword he put the figure at £2 billion. It sounds a lot of money but at that time it represented less than 1 per cent. of the gross national product—an additional tuppence in the pound on public expenditure.

    On 31 July 1981, less than a year later, I initiated an Adjournment debate on the Black report. The Under-Secretary of State, the Member for Hampstead (Mr. Finsberg), who is now listening to the debate, wrote to me on 2 October 1981 explaining how the Government would respond to the 37 recommendations. In his concluding paragraph he said that
    "those recommendations to which we have been able to attach specific costs would exceed £4 billion per annum".

    Within 12 months of the senior Minister stating a figure of £2 billion, the junior Minister was stating that it exceeded £4 billion. Today, the figure of £5 billion has been mentioned. Hon. Members can attach no credibility to those figures. They have varied between £2 billion and £5 billion given by three different Ministers within the space of 18 months. Whatever the figure, my argument is that we can afford it. When anyone, especially a member of the Government, tells me that the money is not there, I challenge it. The money is there. What is absent is the will to spend the money on health rather than on other items.

    I have stated before, and repeat now, that at the time of the Falkland Islands war, started by the Prime Minister, there was no question of cash limits. The right hon. Lady's attitude was "Whatever the cost, we will see it through." To date, that cost has amounted to £2,000 million. All the bills have not yet been paid. When the Government say that the money is not there, I say that it is. It is the political will that is not there to reallocate the wealth that the country produces.

    The Secretary of State, when challenged, says that the Government spend an awful lot—much more than the previous Labour Government did—on the Health Service. Despite those claims, which the right hon. Gentleman never wearies of making, there is abundant, almost daily, evidence that things are happening that are destroying the Health Service. My hon. Friend the Member for Brent, South and the hon. Member for Berwick-upon-Tweed have given examples. An article in The Guardian last Friday was headed "Lack of cash puts 6,000 babies at risk". The article states:
    "Up to 6,000 premature babies are likely to be deprived of the intensive care they need next year because of the shortage of hospital facilities, it was estimated yesterday. A senior paediatrician, who asked not be named, described the situation as a 'disgrace'. One charity has received appeals for help from 55 hospitals. A panel of specialists has found that 22 of those hospitals are so short of money that they are in danger of being unable to treat the babies they have admitted. Intensive care facilities in London were described as terrible by a specialist who is tracking reports from around the country. But he added: 'By and large the more industrialised the region, and the further north you go, the worse it gets.'".
    The article goes on:
    "A survey has shown that a third of premature babies in the South-east who need intensive care are turned away because there are not enough cots or nurses in intensive care units."
    A specialist is quoted as saying
    "'All over the country people are being told that if they run out of money'"—
    he is referring to health authorities—
    "'they must close wards and sack nurses.'"

    As everyone knows—the figures have been given—thousands of nurses and hundreds of doctors are unemployed while those children are in danger of dying because the health authorities are not being given the money to enable them to live. At the same time, the Prime Minister comes along and says that the Government intend to spend £2,000 million on the Falklands Islands war. That is the obscenity of present priorities. The article goes on:
    "Experts estimated that because of the closures"—
    that, is the closing of hospitals and wards—
    "half the 12,000 babies who are likely to need intensive care next year will not get it."
    The article adds
    "Professor Edward Reynolds, head of neonatal paediatrics at University College hospital, identified 22 hospitals where there was not enough money to look after the children that had been admitted."
    I shall give the names of those hospitals listed in The Guardian for the record. I hope that the Minister will refer specifically to them in his reply. The article states
    "Those hospitals are: Newcastle General, Newcastle-upon-Tyne; Morriston, Swansea; Rutherglen Maternity, Glasgow; Doncaster Royal Infirmary; Coventry and Warwickshire hospital, Bellshill Maternity, Lanarkshire; Barnsley District; Vale of Leven District General, Dunbartonshire; County hospital, Hereford; Odstock branch of Salisbury General; Royal Cornwall, Truro; Wexham Park, Slough; Cuckfield, West Sussex; West Kent General, Maidstone; Pembury hospital, Tunbridge Wells; Pilgrim hospital, Boston; Ipswich hospital; Stirling Royal Infirmary; West Suffold, Bury St. Edmunds; and three in London, South London hospital; Newham Maternity and Edgware General. Other hospitals reported to be in trouble include Killingbeck hospital, Leeds, where 30 heart operations on babies were cancelled in the summer, and which still needs £50,000 to hire nurses, and University College hospital, London, which has been forced to send babies to Cambridge because its own facilities are overloaded."

    A senior paediatrician in the South-West was quoted in The Guardian as saying "It's a ruddy disgrace." So it is. That is what Black was all about. Black described in great, some would say boring, detail—it is not boring to me or to those who are interested—the gross disparities of health provision between one class and another, between rich and poor, between North and South and between the industrial areas and the South-East. It is time for some Government to take control of the situation no matter—as the Prime Minister has stated—what the cost. The right hon. Lady was referring to killing people in a war. We are referring to saving people through the Health Service.

    I hope that the Labour Party will give the commitment at the next election, no matter what the cost, that we will implement the Black proposals.

    6.37 pm

    The hon. Member for Fife, Central (Mr. Hamilton) was as provocative as he always is on these occasions. The hon. Gentleman was, however, unjust to my hon. Friends on the Government Front Bench in complaining that there was no Scottish Minister present. I think, in fact, the hon. Gentleman has had the privilege of having in attendance not only one but two Scottish Ministers. My hon. Friend the Member for Argyll (Mr. MacKay) who, I understand, has specific responsibility for health matters, was present for the opening speeches, and my hon. Friend the Member for Renfrewshire, East (Mr. Stewart) came into the Chamber within a minute of the hon. Member for Fife, Central standing up. My hon. Friend has heard the whole of his speech. The hon. Gentleman could not have received a better service.

    In marked contrast, there have rarely been more than two or three Back Bench supporters of the hon. Member for Fife, Central in the Chamber. Yet the House is debating an Opposition motion. It is, we are told, a matter of great interest to the Opposition. However, they do not seem able to muster sufficient numbers to put their views more forcibly and collectively.

    The hon. Member for Fife, Central spoke with vigour about the need for more public expenditure in this area. I pay him the compliment that he is at least consistent on the subject. That is where my agreement with him ends. I find the report disappointing. In many ways, it is a poor report. I agree with my hon. Friend the Member for Canterbury (Mr. Crouch) that it is a turgid document. It consists of over 400 closely typed pages set out in a most boring and ungraphic fashion. There are pages of graphs which could have been presented in a much more interesting and readable way. If those who are responsible for drawing up reports are incapable of doing so in a simpler and more appealing way, they should not be surprised if they have little influence on the course of events.,lb/> Many people would say that to commission a bunch of academics to produce a report on their vision of an equal society is wrong anyway, and that it is hardly surprising that we should have the range of recommendations that we see in the Black report. To my mind the inadequacies are not so much in the report's answers and recommendations as in the very question that the Black committee was asked to consider in the first place.

    It is typical of the Labour Party that it constantly dwells on the issue of class and equality. It seems to have a vested interest in maintaining the dichotomy of the class system. It must keep reminding people about the different social classes, because that is what it relies upon. In reality, the differences have been cut away in so many ways in the post-war years. Yet the Labour Party likes to remind us constantly about its people—the working class—about the image of sections of the community with whom it feels it has traditional affiliations, which it would like to maintain well into the future.

    That is not a realistic assessment of modern society. The question with which the committee was faced is not the real question to which we should be addressing ourselves in the provision of health care in Britain. For example, much is made of the differences which are evidently there in the health provision for the richer and the poorer elements of the community. More important are the differences within those segments of the community. We should be much more concerned about improving the quality and efficiency of the Health Service for everyone rather than concentrating on some of the report's recommendations. In other words, the report is blinkered inasmuch as it only looks at one specific problem—differences between social classes. There are other more pressing priorities in the Health Service that are worthy of attention and with which I shall deal in relation to my constituency.

    The social analysis contained in the report ignores one of the most pressing problems which will have to be dealt with in the future—the care of a much more aged population. That was referred to by my right hon. Friend the Secretary of State today. While it is mentioned in the report, insufficient emphasis is laid on the obligation and responsibility of this generation of politicians to provide now for the future cost of facilities which will be needed by that much older population.

    Although the number of pensioners will rise only slightly by the year 2000, those over the age of 75 are likely to increase by 42 per cent. In other words, there will be nearly half as many elderly people. We also know that elderly people already consume about seven times as much of the cost and facilities of the Health Service as the average person. That will be a major problem, not only nationally, but in those areas of Britain, such as my constituency, which have a higher than average proportion of elderly people.

    Despite my initial criticisms of the report, it made a few useful observations that should be inquired into in more depth and which probably have implications for policy. I noted in particular that mortality rates among women have increased, and that must be a matter of concern to all who try to ensure that there is a steady increase in the quality of health care for all people.

    There has been, and we welcome it, a significant improvement in antenatal facilities in Britain. If there is one area of preventive medicine which has been most markedly successful, it is antenatal care, where so many lives, both of children and mothers, have been saved because of diagnostic facilities and care before the birth of a child. I welcome the emphasis that successive Governments have placed on that most important aspect of health care. Therefore, it is particularly worrying to see that mortality rates among women have increased. I hope that my hon. and learned Friend the Minister will be able to analyse some of the reasons for that when he replies.

    The report makes some interesting comments on school meals. While I supported moves to reduce the significant cost to the taxpayer and the ratepayer of school meals, I am rather worried about the consequences of that change. In a town in my constituency a substantial number of secondary schoolchildren roam around town every lunch break eating potato crisps and drinking Coca-Cola. I can think of few things of less nutritional value than Coca-Cola and chips. Not only are such items expensive, showing that the children could often afford a more nutritious meal, but there are also health implications for the future. I should like to return to that on another occasion.

    We may have to review the system of school meals. I notice from the report that about half a million school children in Britain are not claiming the free school meals to which they are entitled. Conservative Members should ask why that is the case and what efforts are being made to ensure that such children receive what they are entitled to—a proper, nutritious meal at school.

    Another aspect of the report of which I am critical is the extent to which it recommends that further inquiries should be set up. That is something I always look out for. It is interesting to go to a recommendations list and note that the first four or five recommendations are about further studies being undertaken. In the Black report, no fewer than seven recommendations are about changes in data-gathering systems, more information, more research and more studies. If I have a criterion for the value and effectiveness of a report, it is the extent to which it grasps the nettle of dealing with problems and proposing policy changes rather than just proposing further study groups—probably manned by academics once again—to look into the problems further. Not only are they ineffective and costly, but they defer the difficult decision-making process.

    I was also worried—this relates to my criticism of the committee's blinkered approach—about the simplistic way in which shifts of priority within the Health Service are proposed. The report talks about shifting resources to community health. I am in favour of that because it has particular implications for my constituency. However, where should those resources come from? We are not told what area of health provision the report would like to do without. That problem is presumably left for the politicians to solve. It is insufficient for a report simply to identify a problem and demand a shift of resources without saying what criterion is being used to establish that one area of health care is less important and needy than another.

    One must be careful not only about the substantial public expenditure implications of the complete health programme proposed by the Black report, but about the extent to which it blithely calls for shifts of resources without saying from where the money should come.

    I agree with other hon. Members that we should emphasise preventive medicine. We did not need the Black report to tell us that. If we spend more money on that in the future, it will clearly be a good investment. It will reduce the much higher cost of curative medicine in the future. That is particularly applicable to dentistry.

    Some of the most effective and cost-efficient improvements could be made if a preventive dental programme were introduced in Britain. We know that about two-thirds of adults have no teeth. However, caries—dental decay—usually begins in the first 16 years of life. Clearly a fluoride programme would have major and beneficial implications. I am in favour of fluoride in public water supplies and I have argued for that point. I know that it is a highly contentious and emotive subject in the House, but whether or not one is in favour of the fluoridation of public water, a whole range of voluntary fluoridation schemes could be used as part of a preventive dental programme to reduce substantially the incidence of caries in adults.

    I think particularly of such things as fissure sealants, by which fluoride is put into cracks in the teeth, and the topical application of fluoride, which is a relatively expensive process that ensures that a coating of fluoride gives a child useful protection against decay. I encouraged my wife to give my children fluoride tablets every day, which can be purchased from the chemist. That is most important. I am not sure whether they can be obtained on prescription, but they can certainly be purchased.

    We should do much more to draw attention to the benefits of the voluntary use of fluoride. I would be in favour of fluoride mouth washes in schools. Again, the system would be voluntary and, if parents objected, their children could be withdrawn from it. However, it would have a major and beneficial impact on the extent to which children lose their teeth and have fillings. The cost would be relatively minor compared with the cost of dental treatment.

    One of my main reasons for wishing to speak is that I am very concerned about the impact of some of these issues on my constituency at Chichester. I represent a large rural constituency and as a result there are difficulties in the coverage of health care and in financing it. Those difficulties are, of course, common to other areas. In addition, there are many elderly people in my constituency. The number of those aged over 65 in the Chichester health authority area is twice the national average. About 24 per cent. of the population are over 65, compared with 15 per cent. in the country as a whole.

    The difference is even greater when it comes to the over-eighties. About one-fifth of them suffer from considerable senile dementia. For example, in 1981 there were 8,000 people in Chichester over the age of 80. That is about five per cent. of the population and double the national figure. By 1991, there will be another 3,000, of whom 600 will need constant care. That has major implications for the share of health resources that should be devoted to such an area and—as local authorities will be well aware—for housing policy and sheltered accommodation programmes.

    I am particularly concerned about the extent to which the characteristics of my constituency are not reflected in our share of health resources. That observation is relevant, because my area is generally regarded as fairly affluent yet many people are very poor. It is significant that one in three pensioners in my area receives supplementary benefit. I know that the figure is higher elsewhere, but that is still a considerable proportion. Of my constituents, one in 10 claims supplementary benefit, which is some indicator of the lower levels of income that they receive. For them, in particular, the provision of a good Health Service and of community medicine is important. They have nothing else to fall back on.

    In March 1982, I wrote to the chairman of the South-West Thames regional health authority. I subsequently had a meeting with him to express my grave concern about the serious underfunding of my district. That concern is shared by other districts with rural characteristics in the regional health authority area. We strongly believe that we are the poor cousins within our region and that we have suffered not only from the relatively low share-out of resources that the Thames regional health authorities have obtained, but from the distribution of resources within that authority.

    On the basis of the resource allocation working party formula—the system for allocating resources used by the Department—we are about 20 per cent. underfunded. Chichester health authority obtains 5 per cent. of the funds within our region, yet we have 10 per cent. of the population. Comparisons of staffing per head of population show that our staffing levels are by far the lowest in the region. Clearly, we are under a considerable strain in trying to provide facilities for a very far-flung community. We are currently underfunded by about £10 million in relation to the RAWP formula that is used for allocating money to the regions. That is a serious problem, not only because my constituency is treated as a poor cousin, but because, understandably, resources have been concentrated on areas of specialty in London.

    There comes a point at which one must question whether it is right to concentrate more and more money on maintaining highly sophisticated—admittedly much-needed—facilities in central London, when areas such as mine are grossly underfunded. Now that the regional health authorities have rightly been asked to make further efficiency savings, we hope that due account will be taken of the pressing problems in Chichester when deciding how those savings are to be borne by the districts involved.

    The problem of the elderly will not go away. Considerable resources are being mobilised to deal with the problem, but the implications for health policy have not been fully considered. Several hon. Members have criticised the Government's housing policy and have said that it is quite inadequate to meet the problem and to make up some of the differentials referred to in the report. However, I take issue with those remarks. The Government are doing a great deal to improve the position—for example, in help with home improvements—and are encouraging local authorities to pay up. There is an open-ended commitment enabling people to apply for home improvements grants during this financial year. There is evidence that efforts are being made to tackle the problem.

    In the years to come, local authorities may have to do more in providing accommodation for the elderly. Greater stress must be laid on keeping people in their own homes for as long as possible, not only because that is what people want, but because it will prove to be, in practical, logistical terms, about the only way of dealing with the problem. The problems of a much older population will be serious and pressing and it is unsatisfactory solely to demand more of Government, with all the ensuing financial implications. We must also broadcast the implications of that change in the structure of our population. We should emphasise that community and voluntary care are essential if we are to deal with this and other social problems.

    The report is poor and inadequately presented, and it asked the wrong question at the beginning. Its thinly disguised vision of a Socialist nirvana and of a society of full equality is not only impractical but would have major and damaging consequences for public expenditure, which the Government are absolutely right roundly to reject.

    7 pm

    I hope that the hon. Member for Chichester (Mr. Nelson) will forgive me if I do not follow him precisely. I sympathise with the problem that he raised about the pressure of the London and other sophisticated institutions on the budgets of the regions containing those institutions. However, I suspect that the average facilities and health care available to his constituents still exceed those available to my constituents in Newcastle upon Tyne, East and to the constituents of other hon. Members.

    As I listened to the Secretary of State I was reminded of a nostrum by which I have tried to abide in politics—never wholly to believe what the statisticians tell me if all my personal experience, common sense and observations tell me something different. The Secretary of State was honest enough to concede that, despite the resources and cash that have been put into the National Health Service and the social services in the past three years, and indeed in the years since the NHS was founded, gross inequalities in the provision of health care persist throughout the nation. Despite the strictures of the hon. Member for Chichester, I submit that those serious inequalities require redress. One of the functions of the NHS, the Government and the State is to redress some of those inequalities. In a more reflective moment, with a little less perjorative polemic on his mind, the hon. Gentleman might agree with me about that.

    We know that the inequalities are still there. There is evidence that they have been getting worse rather than better in some areas, as the Secretary of State in his reply to my intervention was gracious enough to concede. There are inequalities of geography. It is wrong that where one lives—not just which part of the country, but which street and which neighbourhood—should determine the likelihood of one's dying in the first year of one's life or one's life expectancy. That is a powerful factor, brought out not just by Black, but by other research material. We know that in the regions RAWP is an ineffective mechanism during a period of slow growth. It produces the problems that the hon. Member for Chichester described in areas where there is already above-average provision. It does not do much to redress the problems of the below-average regions.

    We know that differences relating to jobs, income and what might be called social class still persist. Those differences were outlined correctly by the hon. Member for Crewe (Mrs. Dunwoody). The unpopularity of the group into which one's illness falls is a powerful factor in the quality of the health care that one receives under the NHS. It is fatal to be in an unpopular state of ill health. The patient will find himself or herself in a long-stay institution where the provisions are rudimentary. Despite the best efforts of the staff, the patient will be less well cared for than if he were in an acute hospital with a dramatic condition.

    The essence of the Black report, which the two-party criss-cross which is part of the functioning of the House has obscured today, was that it presented to us the challenges of priorities and imagination that face us if we try to do something about the inequalities that Black, however imprecisely, managed to document for us. The Government have had little sense of priority or imagination. I shall give one or two examples.

    The Government have worthy objectives and have made worthy statements and issued worthy publications on community care. However, to take the simplest example, we know that in many areas there are now fewer home helps and less capacity to conduct proper community care because of the Government's approach to local government spending. It would be nice if the Minister would tell us in his reply, or in the Official Report, how many local authorities have more and how many have fewer home helps than in 1979. The Association of Directors of Social Services has told us repeatedly in reports that there have been cuts in those areas, despite the statistical three-card trick that the Government continually pull on us.

    When we consider the NHS today, common sense tells us that it is remarkable that the Government have managed to spend so much money and have so little impact on the volume and quality of service provided. I suspect that there is little to show for the money that has been spent. If we spent more time in the NHS measuring the output and a little less time measuring the input, we might have a better understanding of what has been achieved by the input of cash in real terms since the Government came to office.

    A classic example relates to the employment of nurses. Statistically the number of whole-time equivalent nurses may have gone up since the Government came to power, but I doubt whether the amount of nursing care that is available to patients has increased.

    Why do we not talk about that rather than the nonsensical statistics about whole-time equivalent nurses, which hide a number of other factors connected with the reduction in nurses' working hours and other matters? The figures do not relate to the amount of nursing care that is available to patients.

    The classic example of the irrelevance of the Government's approach lies in privatisation. We constantly hear the Government say that there should be privatisation, private medicine and private health care—all hollow phrases. I do not believe that private health care should be banned. If people want to spend their post-tax income on private health care, they should be free to do so. We should not seek to prevent the facilities being provided for them to do so. However, the idea that that brings more resources to health care for the vast majority of people is utter rot. If the Secretary of State does not believe that, let him come to areas such as Newcastle upon Tyne and say how private health care is assisting people in the inner cities who are living in some of the most difficult circumstances, in some of the most inadequate housing and with some of the most severe problems of unemployment. None of the people in my constituency or in hundreds of others would benefit in any way from the extension of private health care. It would do nothing to redress inequality.

    The Labour Party's approach, personified in its motion, is perilously little better than the Government's approach. It is not right to give the impression to the House and the country that in some way a magic wand can be waved and the resources will be available to solve all the problems. Let us look at the list that was given today. The hon. Member for Crewe stated that 4 per cent. more would be spent on personal social services. She stated that the Labour Party wants to increase child benefit. We are in favour of increasing it and of keeping up its real value. The hon. Lady referred to the maternity allowance. Social security commitments were made, but the downside political cost was not mentioned. The Secretary of State referred to it and to who would be the losers if one were to make rearrangements on the lines suggested by the Social Democratic Party to attack poverty. We propose to move towards more benefits for children and families with children. We have quantified the situation precisely. We have said who the losers would be. We are prepared to state that honestly. The Secretary of State was right to criticise the Labour Party, which has studiously avoided doing so.

    We have said that if our proposals, which are only in "Green Paper" form at the moment, were to be implemented, people on one and a half or two times average earnings might pay in tax and national insurance contributions about £5 a week more in 1982 terms. That is the price that must be paid if we want to redistribute in favour of families with children and the poorest families.

    We shall have to consider the precise form in which we put our proposals to the electorate. We have made no secret of the downside cost of them. Such honesty to the electorate is extraordinarily important. All we know from the Labour Party is the increases in spending that it says it would make. We know none of the costs and none of the tax and public expenditure implications.

    The hon. Member for Crewe has committed her party to "massive"—and that was her word, not mine—increases in expenditure on health, education and housing. The other day I asked somebody to cost the proposals in Labour's programme and the first shot estimate, at 1981 prices, was £35 billion. That is a negation of the Black report approach. Black says that we should accept that one cannot by magic increase real expenditure. We must decide our priorities and have the courage and skill to deploy finances towards those priorities. The Labour Party estimates that to take account of demographic change would require increased spending of 1 per cent. per annum. The Secretary of State today said it should be 1·2 per cent. I accept that. Abolishing charges—as the Labour Party proposes—would cost another £450 million. Labour's programme is not credible. It is dishonest to speak to the House and the country in such terms.

    Social Democrats want to be honest about cost and resources. Let us be honest about the motion. No Government, whether Conservative, Labour, Liberal, Social Democratic or Nationalist in the next Parliament will be able suddenly to undertake
    "a major and wide-ranging programme of public expenditure".
    The money will not be there, and it is wrong to kid people that it will.

    One can observe procedures working as they should not when people troop in and out of the official Opposition spokesmen's offices. We must be honest and say that priority given to one area means that less priority will be given to another. That is not the approach of the Labour Party. Any group or organisation, voluntary or not, will be told by the Front Bench that all is well and that everyone will win and have prizes. In the real world not everyone can win.

    The hon. Member for Chichester mentioned the dilemma of deciding how much money we spend on improving long-stay facilities and how much we spend on high-tech medicine—the most expensive and sophisticated part of the NHS. Such decisions are extraordinarily difficult. We have to be clear. My party wishes to tilt the balance away from high-tech towards proven procedures which improve the quality of life for many more people. But we do not pretend that it is possible to do both.

    That is worthy, but does the hon. Gentleman realise what he is saying? He is saying that he would restrict renal dialysis and kidney transplant operations, for example. He is saying that he would restrict cardio-thoracic surgery, which means condemning people to an earlier death. Does he mean that? The public are beginning to accept that, because of advanced scientific achievement, life can be prolonged. Does the hon. Gemtleman mean to deny that? I understand his thinking, but he must be realistic.

    The hon. Gentleman knows from his extensive experience that already we have to make such decisions. Renal dialysis and heart and kidney transplants are already subject to political decision. The Secretary of State, in his unenviable seat, and his colleagues in the regional health authorities have to decide how many heart transplants can be afforded in a year. They have to decide how much dialysis can be afforded and how many kidney transplants can take place. That happens now. Such questions must be faced, not ducked, if we are to talk seriously about redistributing resources.

    The first priority of any incoming Government in 1983 or 1984 will be to reduce unemployment. Thank goodness that is a "win-win" game. We must regard employment generation and putting people back in work in the context of the great need for manpower in the caring services. That may be a cost-effective way to put people back in work.

    The home help service is a simple example. For relatively small sums we could recruit substantial numbers of home helps and so improve for many the quality of life and their ability to stay in their own homes. I hope that women's liberationists will forgive me for mentioning another benefit. Home helps tend to be women, and that means that we could also increase the incomes of some of the poorest families. Often, if the husband is a low earner or unemployed, the ability of his wife to find a part-time job, in home helping for example, could make the difference between a family living on the bread line and having a reasonable existence and some budget flexibility. In that respect a number of priorities walk hand-in-hand, and we should look for more examples of this.

    The construction industry is experiencing grave economic problems. Putting money into rehabilitation projects—not just homes, but in some of the outdated buildings in the NHS—would be an ideal way of combining the priority of employment generation and improving health and social services.

    We must examine the capacity to make savings in other NHS areas. It is a terrible condemnation of the Government that they have not yet seen fit to publish the Greenfield report on more effective prescribing. That report recommended an extension of the practice, commonly used in NHS hospitals, of substituting the cheapest available variety of a drug for the brand name written on a prescription to general practice and community pharmacy. It is possible to do that. If it happened over a period, it would save us substantial sums.

    The Government cannot have it both ways. They constantly tell us that they want to save money on the drugs bill, but they refuse to do anything about it. It is no use falling back on the argument about the turnover of the pharmaceutical industry and its relationship with research. Nobody wants to inhibit genuine innovative research by the industry. But one cannot save money on drugs without the NHS spending less on drugs and therefore the pharmaceutical industry's income being less than it would otherwise be. If the Government do not seriously intend to save money on the drugs bill, they should say so. If they do not intend to save money that way, we must be clear that we shall probably spend 20 per cent.—£200 million to £300 million—a year more than we would otherwise have to spend.

    Apart from being honest about resources and costs, we must stop assuming that we must work from the top down when trying to redress inequality. One of the reasons for continuing inequalities in the Health Service and social services is that the administrative arrangements are inadequate. We are familiar with the problem in relation to urban aid. The RAWP formula is not dissimilar. When urban aid became part of the Government's administrative machinery, long discussions took place and, by the time that everyone had been squared, the redistribution almost did not happen. I recall that Barnsley suddenly found itself getting the least urban aid in the country while Bournemouth was getting the most per head of population.

    We are in dire danger of that happening again. That is why we propose an independent body running what we have called an employment and innovation fund, which would receive applications from below, judge them against criteria laid down by Parliament and make grants to health authorities, local authorities, voluntary and private organisations when such organisations made applications that met the criteria that had been laid down.

    There is a reason why some of the areas listed in the Black report stay at the bottom of the pecking order, and that is in part related to administrative arrangements. We know that they have problems, but surely they would have tended to rise at least slightly up the scale in the absence of difficulties with the existing administration. We must also be prepared to experiment.

    Let us say that Age Concern has found a successful way to help certain categories of elderly person to stay in their homes in, for example, Chichester. Age Concern could apply for some funds for the purpose of undertaking an experiment to ascertain whether that approach would work in, for instance, Newcastle upon Tyne. We seem never to be prepared to do anything, unless we can do it for everyone. We never experiment. We never reorganise part of the NHS to see whether a new method will work before spreading the reorganisation to the rest of the Service. The reorganisation is always wholesale. The Conservative Party seems to engage in wholesale reorganisation every time that it comes into office. We must familiarise ourselves with local experiments. If they work, we can spread them. If they are unsuccessful, we can stop them. This will enable us to adopt a more flexible approach to problems. We must try to break some of the problems that have existed, despite everyone's best intentions, for the past 30 or 40 years.

    Lastly, we must put greater emphasis on prevention. The key to the overuse of the Health Service by children of blue collar workers and of the poorest groups in the community is their underuse of the preventive end of the Service, in so far as it exists, in the early part of their lives. For example, we are all aware of the real problems involved in getting proper antenatal care in some of the poorest areas of Britain and in getting people to use available services. The Black report's health action area proposals and take-up would be most valuable in trying to engender a greater awareness of the available services.

    It is ridiculous that we continue to allow the tobacco industry, which we know produces a product that is harmful to the health of almost everyone who uses it, to associate its products with sport, youth and glamour through sponsorship. We allow it to evade the ban on television advertising by having signs naming its products and even replicas of packets of its products at the back of every snooker hall, cricket ground and tennis court. The funds that the industry makes available could not be cut off at the drop of a hat. A method would have to be devised of replacing its funds with others over a period. The approach of successive Governments to prevention has been ambivalent. I cannot believe that, with the present Government, it is unconnected with the contributions of the companies concerned to the Conservative Party's election fund and running expenses.

    No one will solve any of these problems overnight, but we should try to do much better in tackling them. We should not kid the electors, as the Government do, that effective action is being taken. That is manifestly not right. However, we should not, as the Labour Party tries to pretend, believe that a change of Government and a massive influx of public expenditure would also solve the problem overnight. That will not happen either.

    The two-party battle tends to become more and more irrelevant to the real problem. The argument in the House becomes less and less an argument about realities. The only solution is to elect either a Government composed of Social Democrats and Liberals, or a group of Social Democrats and Liberals large enough to prevent either of the two old parties from taking the position that it would like to adopt on its own.

    7.25 pm

    Whatever view one, might take of the report that we are discussing, this is a useful debate, and one that we should have held before. There are indeed inequalities in the provision of health facilities between one area and another, and there have been since the inception of the National Health Service. It has been the business of successive Governments to try to reduce them and even them out. It should be the business of Governments to continue to do so.

    I listened with great interest to the speech of the hon. Member for Fife, Central (Mr. Hamilton). I was unable to square his strictures with the fact, whatever the other failings of the Government may have been, that there has been an increase of 5½ per cent. in real terms in health expenditure and that there are more nurses and doctors in our hospitals than ever before. Of course, there are still not enough, but we must keep matters in perspective. I shall look forward, therefore, to hearing what my hon. Friend the Minister has to say in reply. The speech of the hon. Member for Newcastle upon Tyne, East (Mr. Thomas) was more to my taste. It seems that he at least has his feet on the ground.

    I intervene on one aspect which has been dear to my heart since I left the Ministry of Health some 18 years ago. The report that we are discussing correctly emphasises the need for the prevention of ill-health. In paragraph 8.88 it recommends
    "that national health goals should be established and stated by Government after wide consultation and debate. Measures that might encourage the desirable changes in people's diet, exercise and smoking and drinking behaviour should be agreed among relevant agencies."

    I agree.

    The House knows that for nine years I was the chairman of the National Council on Alcoholism. I have consistently advocated such a programme. Yet it has been largely ignored where alcohol education has been concerned and the problem of abuse has grown rather than diminished. I am sorry to say that there is a direct correlation between the level of consumption of alcohol and the volume of alcohol abuse. The consumption of alcohol has risen by one-third since 1971.

    In official quarters it is now believed that there are about 750,000 people in Britain who have a serious drinking problem and need help. If one adds to that figure their spouses and children, the probability is that one in 15 of the population is experiencing the true cost of alcohol excess. Pressure upon our health services, as a consequence, is becoming intolerable. In the past 10 years admissions to NHS hospitals for the treatment of alcoholism have doubled, deaths from alcoholism have trebled and deaths from liver cirrhosis have increased by a third. What is significant is that more women are requiring treatment and children are becoming increasingly affected.

    We have had warning after warning on this subject. The Royal College of Psychiatrists in a notable report a few years ago stated:
    "Society is in many ways trying to have its pleasure, deny its responsibilities and hand the problem over to the courts or the caring agencies. We believe that an undoubted message for the future is that prevention has to be strengthened and that this will eventually mean all of us drinking somewhat less."
    It warned against any weakening of licensing law and any proliferation of outlets for the dispensing of alcohol. How many more agencies have to issue similar warnings before Government, Parliament and responsible bodies take note? The Government's own advisory committee on alcohol included among its strategies the recommendation that:
    "Legal restrictions on the availability of alcohol should be reinforced vigorously and should not be changed until there is sufficient evidence to do so without causing increased harm."
    The Government's Think Tank said exactly the same and its report was suppressed.

    It is ironic that those who call for a relaxation of our drinking laws often cite what they describe as the civilised drinking of the French. That belief has even been advocated in this House. During the past 20 years successive French Governments have attempted to introduce more stringent controls. The present position in France shows the magnitude of the damage which can be caused by alcohol when there is insufficient control. Consider the facts: 40 per cent. of the deaths on the road are alcohol-related compared with 20 per cent. so far in Britain; deaths from cirrhosis of the liver are 10 per cent. greater than in Britain; half of all general hospital beds are occupied by patients with alcohol-related illnesses and 40 per cent of the expenditure on health care is for the treatment of such illnesses.

    One does not have to look into the crystal ball to see what is likely to happen when one consults such a record. We are on the same road. No doubt we shall be told that the Minister has sought to influence public opinion by the publication of his discussion document on prevention and health called "Drinking Sensibly". It is a useful document. It says:
    "The consequences of alcohol misuse for the individual include accidents of all kinds, long-term ill health, damaged family life, social isolation, loss of career and job prospects, violence and crime."

    If we wanted to find a common denominator between road accidents, the filling of hospital beds, marital breakup, non-accidental injury to children, assaults on children, and crime generally, the police and magistrates would tell us that it is alcohol misuse. The social cost is immeasurable.

    The warnings in the Government's pamphlet are not misplaced. It tells us that programmes to help widen understanding among the general public of the health risks of alcohol misuse are important to any emerging strategy. It calls for continued recognition by Parliament and Government of the fact that health and social implications should be among the factors taken into account when any action affecting consumption of alcoholic drinks is under consideration.

    Thus, the Government appear to take seriously the implications of alcohol misuse, but I find a complete contradiction between their words and their actions. During the past 10 years the licensing laws have been progressively weakened. Magistrates now grant licences virtually at the drop of a hat. We have allowed drink to be purchased in supermarkets at whatever hours they choose to be open. The latest development is that of the Unigate company, which brings milk to the doorstep, and which is now experimenting with the selling of wine on the doorstep. It seeks to become an agent of the drink trade.

    I asked the Home Secretary whether the Home Office had been consulted about the experimental sale of alcohol by milk roundsmen in certain areas of Essex and other counties in the South-East; the possible legal implications, and whether any approval had been given to such a scheme. The answer was:
    "The company has not consulted the Home Office about the legality of the scheme, which we have no power to approve or disapprove. It has provided the Department with only limited details of it. The responsibility for enforcing the law falls on the police."—[Official Report, 1 December 1982; Vol. 33, c. 196.]
    We are talking here about prevention, yet the Home Office, which is responsible for the licensing laws, has been presiding over the steady weakening of such laws and washing its hands of developments which may have dire consequences for a problem that the Department of Health and Social Security sees of major importance.

    I understand my hon. Friend to be saying that the fact that magistrates are not tough enough when dishing out licences bears some relation to drink abuse. How does my hon. Friend account for the fact that in Sweden, where advertising and dispensing of alcohol are more restricted, the problems of drink abuse are much worse per capita than in this country?

    It is controversial whether advertising has any impact on the problem. Sweden is a bad example. If one looks at this country's drink abuse problems in relation to those of other countries, one sees that we are well down the league table. France, Germany, Russia and Scandinavia are well ahead. We should learn from that.

    Between the two wars we were regarded as being one of the most sober nations on earth, whereas before 1914 we had the reputation of being heavy drinkers. The improvement was due to our model licensing laws. It is only during the past 10 years or so that we have deliberately started to weaken them. It has been the policy of successive Governments not to intervene. The Minister knows the consequences: increased pressure on hospital beds, increased abuse and complaints by teachers of children engaged in under-age drinking coming back to school in the afternoon the worse for drink; more deaths on the road. Many hon. Members know the facts. They are no laughing matter. Drink abuse is one of the most serious social problems facing our country. It is not good enough for the Department of Health and Social Security to issue documents such as "Drinking Sensibly", impeccable in its argument and unchallengeable in its facts, when it is the policy of other Departments, and the country's attitude, to be utterly indifferent to the consequences.

    Is the hon. Gentleman saying that he does not believe that the advertising of the product has any effect upon its sales? Surely the reason we want a severe ban on the advertising of cigarettes except at the point of sale is that we know that it will have a great effect. Why does he think that that is not true of alcohol?

    The hon. Lady misunderstands me. Perhaps I did not make myself clear. My hon. Friend the Member for Abingdon (Mr. Benyon) was seeking to get me to admit that advertising did not have a great influence, using the example of the Swedish experience. I believe that liquor advertising should be banned, but I did not see how his intervention helped the argument.

    The Royal College of Psychiatrists has already warned us, in a most sensible and frightening report, that either we control alcohol or it will control us; that we are reaching a stage where there will be severe health damage. In the light of the French experience, we should draw back; the time is now. The Government cannot, by themselves, change people's drinking habits, but they can ensure that the facts are laid before them. Children should be taught the facts about alcohol in school and teachers must be made aware of the problem. Magistrates should not grant licences ad lib. We need more than the publication of documents. The Government should give a positive lead and condemn the way in which our defences against alcohol abuse are being progressively lowered.

    7.41 pm

    The length of the last speech may be due to the fact that less than 2 per cent. of the Conservative Party is in the Chamber. That has been true almost throughout the debate. More than 2 per cent. of the Labour Party is in the Chamber. The Conservatives are prepared to filibuster on a subject that is extremely important to the majority of the British people.

    The Black report conclusively shows that disease is a class issue. Data on social class first published following the 1911 census drew attention to the problem. Even before that Professor Benjamin Moore wrote about the prevalence of a disease called chlorosis, which is a form of anaemia and is, happily, no longer seen. Domestic servants, shop girls and other indoor female workers were particularly prone to the disease.

    A lecture by Sir John Brotherston, the chief medical officer for Scotland, in 1976 gave prominence to the class incidence of disease. He underlined evidence that the gap between the incidence of disease in social classes I and V might have been widening compared with a generation ago, and the finding was confirmed by the Black report.

    It may be said that the report revealed nothing new, but it presented its evidence in a challenging and telling form:
    "Recent data show … at birth and in the first month of life twice as many babies of unskilled manual parents (class V) die as do babies pf professional class parents (class I) … a class gradient can be observed for most causes of death, being particularly steep in the case of diseases of the respiratory system. Available data on chronic sickness tend to parallel those on mortality."
    The report concluded that
    "much of the evidence on social inequalities in health can be adequately understood in terms of specific features of the socio-economic environment; features (such as work accidents, overcrowding, cigarette smoking) which are strongly class related in Britain."
    The conclusions merely update Benjamin Moore's observations over 70 years ago.

    The thrust of the Black report is clear: material deprivation is a significant factor in differing disease rate. The health of a foetus, birth deficiencies, death from chest diseases and from accidents are all class related. Some poor people may live in Chichester. In my constituency many are forced to live in high-rise flats in Avenham and St John's, or in bad housing in Preston, North. For many Lancashire working-class people, material deprivation lasts through life. The report uses statistics derived from one part of Lancashire. The present Government and past Governments have urged people to look after their health, but they are not given the means to do so.

    At Question Time recently the £11 million given by the tobacco manufacturers was referred to. It may have been by this Minister. The money was conditional on its not being used for anti-smoking propaganda. What a commentary on the morality of our capitalist system! The sooner that we have a total ban on cigarette advertising the better will be the prospects for good health, particularly among the young. I am so convinced of that that I recently gave up the habit and have suffered no adverse consequences, hon. Members will be sorry to hear.

    The situation revealed by the Black report has considerably worsened since the Government came to power. Cash limits and local authority services cuts as a result of the reduced block grant mean that many more people on unemployment or supplementary benefit, and one-parent families trying to care for two or three children on the fourteenth floor of a block of flats, are likely to suffer ill health. The problem is concentrated in certain areas and is considerably exacerbated by the Government's performance.

    Arising from the doubling of unemployment in the Preston area and for the historical reasons shown in some of the geographical area investigations, the report shows that material deprivation has escalated. One of the major recommendations of the Black report is action to eliminate child poverty. I welcome the speech of my hon. Friend the Member for Crewe (Mrs. Dunwoody). I only hope that when Labour is returned to power—as it will be next year—we shall fully grasp some of the remedies that she suggested. They are unlikely to emerge from the present Government.

    Labour must recognise the real urgency that will exist when it takes office next year. It must be prepared for the pressure that will be imposed by the privilege who are anxious to protect their economic interests. Just as the Prime Minister has refused to be moved from her policies that are designed to extend the life of capitalism, so must Labour adopt an equally ruthless approach in the interests of working-class people, which includes the 5 million unemployed.

    There should be no doubt that Labour will have to take forceful action to attack poverty. Local authority services are especially relevant in that context. Many hon. Members have described the areas in which we are failing miserably to provide adequate services. Only a real Socialist programme of a planned economy, with a shift in motives and values from private profit to public use, can achieve a major change in poverty and health in Britain. It is towards that goal that the next Labour Government must work.

    7.52 pm

    The debate opened in the traditional way. The Opposition gave us the impression that if only they were in power they would implement the entire Black report in a short time. I have yet to see any evidence to suggest that they could do any better than the Conservative Party, if only because of the considerable difficulty that even they would have in finding the wherewithal to do it. I wonder whether they would hack away at the hospital building programme and other capital programmes that we, as a Government, are now embarking on, to find the additional money. Several Opposition speeches inveighed against the Government's lack of progress in implementing the report. One of the principal reasons why we have not made faster progress is entirely to do with the Opposition. They have backed the debilitating health dispute. That dispute has diverted the Government from constructive work to ensure that the pounds that are spent on the Health Service go on health care, dealing with the problems of the aged and implementing the programme outlined in the report. If there has been delay and if we have had difficulties in implementing the report, the Opposition are partly responsible. They have backed the incredibly time-wasting and debilitating health dispute that the country has suffered unnecessarily for almost the whole of 1982. The amount of political energy that has been wasted on that entirely unnecessary dispute is to a large extent the Opposition's responsibility—the same Opposition who are crowding the Chamber.

    I should like to get stuck in a bit more. I hope that the hon. Gentleman will forgive me if I get a little more into the swing of things. The Labour Party backed the strike with the same enthusiasm as it backs every strike. Perhaps when I allow the hon. Member for Stockport, North (Mr. Bennett) to intervene with his characteristic persuasiveness, he would like to tell me what strikes the Labour Party has not supported. Perhaps he would like to do that now.

    I wanted to ask the hon. Gentleman whether he is convinced that health workers are getting an adequate sum of money or whether they should get a little more. I should have thought that if he studied the jobs that were being done by many people in the Health Service, he would not be prepared to do them for the money that they receive. What is more, I suspect that he would be only too willing to go on strike for more. Most strikes are justified and most people do not like giving up their money. They like to receive their income. It is extremely difficult to persuade people to go on strike. They usually do so only if they are provoked.

    Although I find the hon. Gentleman's intervention of considerable interest, I believe that the health workers as a group are the greatest beneficiaries of the lower levels of inflation that we are currently enjoying. I also think that if the Government's cash limits were smashed down—that is the intention of both the Labour Party and the trade union movement—the people who would suffer most would be the health workers, whom the party of which the hon. Gentleman is a member and the trade union movement purport to support. I thought that the way in which the miners backed the health workers for a 12 per cent. increase yet wanted a 32 per cent. increase themselves was extremely cynical. If they really believed that they could persuade the sensible people in my constituency that they were sincere in that backing, they set about in a peculiar way.

    Unfortunately, the hon. Member for Stockport, North could not name one strike that the Labour Party has not backed. Its popularity is so low that it hoped to win some support by climbing on the bandwagon of sympathy for the nurses and the other health workers. We hear many dream policies from the Opposition. Trying to obtain a coherent spending policy or any words of financial confidence is as difficult as trying to nail a jelly upon the ceiling. We have been diverted by the dispute from the problems that are encapsulated in this excellent report.

    As we have been operating against a background of a substantial recession, the Government's record is one to be reasonably content with, although a great deal of progress remains to be made. I am pleased that there is increased spending in the joint finance programme to the extent of 35 per cent. I am also pleased to see that there has been progress with regard to reducing infant mortality. Another relatively small but nevertheless important point is the extension of the distribution of maternity grant to the 16-year-olds, the unmarrieds, the wives of prisoners and students.

    Much has rightly been said about the need to spend more money and time on preventive medicine. The amount of money that is wasted on, and caused by, smoking, drinking, lack of exercise and eating unsuitable foods is a major contributing factor to the problems of ill-health in Britain. As far as I am able, I would like, with a great deal of humility, to make a original suggestions about how we might make a small contribution to improving the health of the nation and persuading the young not to smoke. First, it would be a good thing if the doctors could also take upon themselves the role of educating the patients who go to their surgeries. They are in the best possible position to explain to their client the dangers of lack of exercise, excessive alcohol consumption, smoking and eating nothing but crisps, tomato ketchup and more crisps. When doctors see their clients, they should perhaps give some unsolicited advice.

    Why cannot we persuade British Rail to have carriages called "Smokers"? At present, British Rail has "No smoking" carriages which give the impression that the status quo is to smoke. People who wish to emit disgusting smells can then do so in a carriage marked "Smoker", which will give the rest of the population the correct impression that no smoking is the norm and the status quo. That may seem a small point, but at least it is constructive and original. In addition, it would cost nothing and I believe that it might even persuade the young and susceptible that no smoking is the norm. That would be a small step forward.

    I should also like to see a tightening up on cigarette advertising. I believe that if adults wish to smoke, it is none of my business to try to stop them and, indeed, that I would be wasting my time were I to do so. I am also worried about attempts to snuff out all our national vices, because I am convinced that if we stop one, another, probably more harmful, vice will manifest itself.

    On the other hand, I am against the young being deluded into smoking or drinking by mendacious advertising which suggests that somehow smoking and drinking is glamorous, enables people to get jobs and attract the opposite sex. More effort, particularly with regard to liquor advertising, is called for.

    I also hope that the Government will encourage the purchase or production of a product called Nicorette—a nicotine-flavoured chewing gum whose success in the prevention of smoking has been remarkable. Currently, doctors are not allowed to prescribe Nicorette, and only private patients are able to avail themselves of its beneficial effects. Such people are broadly in socio-economic groups A, B and C plus, and I doubt whether they benefit most of all from Nicorette. The ones for whom I am concerned are in socio-economic groups E, F and G. Given a wider audience, I believe that Nicorette would have a beneficial effect.

    I also agree with hon. Members who have spoke against alcohol abuse. We can overdo our anxieties about cigarette abuse, although we should strive substantially to reduce the incidence of smoking. On the other hand, alcohol abuse is much more serious. I have yet to hear of anyone beat his wife, fall downstairs, smash up cars, kill people in motor accidents or commit child battering because of smoking, but I have heard all those stories about alcohol abuse.

    I have also read the DHSS pamphlet, and I am aware that when a Government are concerned about something they produce a book on the subject. At the end of their foreword, the four Secretaries of State optimistically state:
    "We hope that the booklet will be widely read and discussed."
    With the title "Drinking Sensibly", with such an author as the DHSS, and at a price of £2·95, post extra, I am sure that booklet No. ISBN O 11 will be the toast of the saloon bars up and down the country.

    This exciting booklet could perhaps be the first of a series. Propriety stops me imagining what the title of the next booklet might be. However, there is a fundamental flaw in this publication. I am sure that it is a serious attempt to get at the root causes of alcohol abuse, but it fails to mention the incidence of unemployment which I regard as one of the most important reasons for alcohol abuse. I cannot imagine how such an omission can be made in what is reported to be a serious production.

    To talk about the problems of drink without talking about the problems of unemployment is like talking about the problems of hunger without referring to the absence of food. If anyone wants to know why people drink so much, he can do no better than watch a video of that excellent television programme "The Boys from the Black Stuff' which encapsulated more of the despair and misery faced by the unemployed than anything contained in the DHSS booklet.

    I should like to suggest some practical steps that the Government could take to improve the welfare of those in severe distress. They should seriously consider the removal of VAT from charities, many of which are trying to battle with the enormous problems which are outlined in the Black report and with which the DHSS cannot cope.

    I should also like the Government to increase the grants to many of the voluntary agencies. All of them do superb work. I mention in particular the charity New Horizon, the creation of Lord Longford, who has worked tirelessly and long in the maintenance in New Horizon, which looks after the young and dispossessed in central London. Many of those young people are victims of drug and drink abuse. Other agencies, such as Centrepoint and Girls Alone in London, all come under the umbrella of the West End Co-ordinating Voluntary Services Group which was doing sterling work long before Ken Livingstone and his excesses at county hall. The Government should consider more generous provision for those agencies. As the problems of unemployment and drug and drink abuse mount, the pressure on our voluntary agencies becomes tougher. I pay public tribute to the people who work in those agencies. The Government have done much, but I hope that they will again look at the budgets of those organisations, read their reports, realise how much their work loads and client lists have increased, and do what they can to ease the position as fast as possible.

    There are ways of helping to implement parts of the Black report which the Government cannot afford at present. One such way is to release more cash within the present NHS structure, which I believe to be enormously wasteful. The Government should look again at the possibilities of privatising the NHS cleaning and catering services. Why cannot that be done? Is it yet another step in what has been called "manic Thatcherite monetarism" that we must abide by cash limits to such an extent that we must start dismantling the NHS? Will such emotive phrases flow around this Chamber? That would be a tragedy. In the Socialist paradise of Sweden and other Scandinavian countries, cleaning and catering services have been privatised and are run far more efficiently than ours. As we examine ways of saving money, we can improve patient care and implement more of an excellent report. We must examine ways of streamlining services and reducing waste as far as possible.

    One thing that we must not do is to give the impression to the loyal and excellent administrative and auxiliary staff in the NHS—the argument can be widened to the entire Civil Service—that, in our search for economies, they are at fault because they are working in inefficient structures. In Oxfordshire, many of those who work in the Health Service and many civil servants, who do an excellent job, believe—the Government did not intend them to get this impression but none the less they have received it—that because they work in a structure that does not enable them to give of their best, it is their fault. The Government should take steps to ensure that those people, who give loyally of their time, do not believe that we are blaming them for the waste problems in the public sector. It would be a great injustice to do so and it would also be electoral folly, because many of them voted Conservative at the general election and must do so again if—as I am sure we shall—we are to remain in office. We must be extremely careful how we tackle waste problems.

    When we have solved, or come near to solving, some of the waste problems in the social services, I hope that some of the money that will be released will go to improving the lot of many who are seriously socially deprived because of the severe economic problems that they face. Some of the elderly—certainly some people in Oxfordshire—are immensely short of money and live incredibly frugal lives. The lives of many of those people would be made much happier and healthier if they had more money to spend on warmth and proper food. Part of preventive medicine should ensure that those who live on tiny incomes have the wherewithal to supply themselves with warmth and food so that they do not finish up in hospital.

    Some war widows in my constituency and elsewhere, who are over the age of 80, do not receive State retirement pensions. There were 5,300 such people recorded on 18 September 1981. It is incredibly sad to see such ladies, whose husbands have given their lives to the service of this country, being completely neglected by successive Governments since the War. Such people are not in a position to lobby me or any Member of the House. They cannot march into our Lobby and protest. How disgraceful it is that they have been completely forgotten. Yet they have been forgotten. It would cost about £2 billion to eradicate all the health inequalities, but, instead of begging for the moon, we should consider that it would cost only—I have more respect for these figures than for some that we bandy about the House with such gay abandon—£5·4 million a year to pay a full annual pension to the war widows. The money spent would be a reducing commitment for the Government who decided to pay it. It could be used to provide an age allowance of approximately £140 at the age of 75 and double the sum at the age of 80. If the Government decide to do that, it will strike a chord in hon. Members on both sides of the House and no one will believe that the Government have not done an excellent job.

    8.14 pm

    The report "Inequalities in Health" was published in 1980. In the same year the Social Services Committee published its second report "Perinatal and Neonatal Mortality", paragraph 102 of which states:

    "We were extremely concerned to hear repeatedly from witnesses that mothers with high-risk pregnancies, and seriously ill infants, were being turned away from neonatal intensive care units and associated maternity hospitals because these units were full."
    My hon. Friend the Member for Fife, Central (Mr. Hamilton) referred to an article in The Guardian last Friday. It stated:
    "Up to 6,000 premature babies are likely to be deprived of the intensive care they need next year because of the shortage of hospital facilities."
    That article also contains a description of the charity Baby Life Support Systems—BLISS—receiving appeals for help from 55 hospitals because they have been forced to turn away babies.

    Already 22 hospitals have been identified as having insufficient funds to look after the children that have been admitted. One such hospital is Morriston hospital in West Glamorgan, just over the border from my constituency. Yet on 29 November, in answer to my question about which centres that provide perinatal and neonatal care do not provide intensive care facilities, the Under-Secretary of State for Wales said:
    "Each special care baby unit in Wales provides some degree of intensive care facilities."—[Official Report, 29 November 1982; Vol. 32, c. 50.]
    If the information in The Guardian is accurate,
    "some degree of intensive care facilities"
    at Morriston hospital, at the very minimum, leaves a great deal to be desired.

    The serious growth of long-term unemployment also affects health. I shall refer especially to West Glamorgan. Since the publication of the Black report, the rate of increase between October 1979 and October 1982 in the number of persons registered as unemployed for more than 52 weeks was 280·6 per cent.—the fastest rate of growth of any Welsh county. In the Gorseinon unemployment office area, 19·8 per cent. of persons registered as unemployed had been unemployed for more than 52 weeks in October 1979, but the figure rose to a staggering 38·5 per cent. in October 1982. The figures for the Pontardawe employment office area were 22·3 per cent. and 38·4 per cent. respectively.

    The Manpower Services Commission paper of October 1982, entitled "Long-Term Unemployed", states on page 8:
    "There is some evidence that long-term unemployment has indirect effects on health, particularly mental health and psychosomatic complaints and that the health of the dependants, particularly wives, may suffer as much or more than that of the long-term unemployed individual."

    The report of 10 May 1982 by the House of Lords Select Committee on Unemployment states on page 56:
    "When visiting Northern Ireland, the Committee were given evidence suggesting that rates of infant mortality, which are higher there than the rest of the UK anyway, became higher still in unemployed families, perhaps because of low nutrition resulting from loss of income."
    The Black report highlighted the difference in the infant mortality rate between socioeconomic groups. In West Glamorgan in 1979–80 the infant mortality rate in socioeconomic group I was 7·2. In group V it was 18·8.

    I view with trepidation the future gap in infant mortality rates consequent upon the health effects of the scourge of long-term unemployment that we are now experiencing. If the work of Professor Dugald Baird, the distinguished professor of obstetrics at Aberdeen university, is taken to heart, we should be even more worried about what will happen when the girls now being born themselves give birth in 16, 17 or 18 years' time

    We have heard very little today about the Black report's prescription for an anti-poverty strategy. That is now more urgent than ever, given the scale of long-term unemployment.

    A key statement—perhaps the key statement—in the Black report appears on page 302. It is that
    "we believe that pride of place in a comprehensive anti-poverty strategy must be given to the greater equalisation of wealth and of other resources".

    In a parliamentary reply to me on 2 December the Secretary of State for Wales gave the distribution of gross weekly earnings for male workers over the age of 21 years in full-time work in the Principality. According to his reply, 9·5 per cent. of males earned less than £80 per week and 28·5 per cent. earned more than £150 per week. In West Glamorgan in 1979–80 the perinatal mortality for socio-economic group I was 7·2. For group V it was 27·1.

    In paragraph 20 of the Government's reply to the second report of the Select Committee on Social Services on perinatal and neonatal mortality, referring specifically to the perinatal mortality rate, this crucial statement appears:
    "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."
    As the Government agree with the need to eliminate social class variations in order to reduce the perinatal mortality rate, perhaps the delay will end when the Minister replies to today's debate. We hope that he will give notice of the Government's intention to apply the central message of the Black report by launching a massive programme to achieve greater equalisation of wealth and other resources. I am sure that the people of Britain will benefit tremendously as a consequence.

    8.25 pm

    I am happy to follow the hon. Member for Gower (Mr. Wardell). I agree with everything that he said, especially his analysis of the economic causes of health and social inequalities. I was also pleased to hear a Conservative—the hon. Member for Abingdon (Mr. Benyon)—stress unemployment as a cause of alcohol abuse. I certainly endorse all that has been said about that and press the Government for action. It is clearly unacceptable to hon. Members on both sides that major reports on these matters should be suppressed or not properly published. The Government should respond adequately to the demands of hon. Members on both sides of the House and take further the campaign initiated in "Drinking Sensibly".

    Inequalities are increasingly to be seen both in the health care needs of the population and in the resources made available to meet those needs. There are geographical and spatial inequalities between the relatively deprived rural and inner city areas and the rather better endowed surburban areas. There are also class, income and educational inequalities, from which further cultural inequalities arise. Conservative Members persist in saying that they are not in the business of creating inequality, but inequality reproduces itself. Indeed, a thesis of a leading intellectual light of the Conservative Party—the Secretary of State for Education and Science—is the so-called deprivation cycle. Although I do not subscribe to his particular version of that cycle, I believe that inequalities are being reproduced through economic and social policies that are inadequate to meet the needs of the population.

    The importance of the Black report lies in the fact that it dealt with social policy not in isolation as a client-based policy relating to a particular section of the population, but as a subject closely linked with the economic context in which social policy is paid for. Indeed, the expenditure-led policy—or rather, the cuts-led policy—of the Conservative Government has shown how dependent social policy is on the economic context in which it operates.

    I wish to stress the regional and national disparities within Britain that emerge clearly from the data set out in the report. I draw attention to the data on mortality rates in the various regions and nations of the United Kingdom. Paragraph 2.4 points out that there have been historical changes in the regions, and says:
    "Using mortality as an indicator of health the healthiest part of Britain appears to be the southern belt (below a line drawn across the country from the Wash to the Bristol Channel)."
    That part of Britain was not always an area of low mortality. In the middle of the nineteenth century there were comparatively high death rates in the South East of England while nations, such as Wales, and regions, such as the north of England, had a better health profile. Over the years the position has changed. Indeed, it has reversed itself. Natural factors do not determine mortality as an indicator of health. Social, industrial and occupational factors create the inequalities in the standardised mortality ratios for each part of the United Kingdom.

    The figures of 117 for Wales I and 113 for Wales II are particularly appalling. One of the reasons for the theme figures is the incidence of extractive occupations, heavy industry and metal working in Wales. Studies made by the Welsh Office and medical sociologists show the contribution made by employment in heavy industries to the incidence of mortality and ill health in Wales.

    What concerns me about the figures is the absence of analysis which would enable us to determine precisely the causal links between class and health. Conservative Members have stressed in interventions that too often in the Black report there is a demand for reliable statistics, but it is clear that, without reliable statistics, it is not possible to monitor the effects of policy. We do not have reliable statistics which link the need for medical treatment with the social or occupational class of the patient. Neither do we have that information available in the health and personal social services statistics. Indeed, the Welsh data are even less reliable than the English data.

    As we do not have reliable data, we are not always able to pinpoint the changes that take place over a period and the link between the causes of ill health and lack of health provision and the class make-up of our society. We are not able to examine how the NHS has acted as an agent of equality or inequality in contemporary Britain. We are not able to evaluate the changes that have taken place, because of the lack of official statistics of the rate of outcome of medical therapy by occupation or social class of the patient. Until we have such data, we shall be unable to examine the implications of the NHS as an agency for greater health equality.

    Taking the basic indicator used by Black and RAWP, which I have outlined tonight, mortality rises inversely with the falling occupational rank or status of both sexes and at all ages. For the first month of life, twice as many babies of unskilled parents die as babies of professional parents. In the next 11 months of life four times as many girls and five times as many boys die. Those who have been or are currently the parents of young children must be moved by such statistics because in our personal and family lives we always seek to do the best we can for our children. However, we realise that we are bringing up children in a society where class divisions make the life chances of other people's children worse than our own. The inequalities continue from the cradle to the grave.

    Inequalities of the division of labour within society are causes of greater ill health among working-class people, many of whom are involved in hard physical labour. Unemployment and job insecurity result in an inability to prepare for old age. Old age is a time when lack of resources affects health more directly than at any other part of the life cycle.

    Two years ago, a DHSS report estimated 7 per cent. malnutrition among a sample of elderly people. I suspect that, with the more harsh operation of DHSS rules on supplementary benefit and exceptional needs and so on, that figure will have increased. The relatively wealthy. the upper middle class, are better able, having had a stable job pattern, to prepare for retirement through their index-linked pensions. They are able to have a relatively healthy retirement or old age, whereas people who have not had those advantages during the work cycle suffer and often do not have very good health in old age or retirement.

    Throughout the life cycle there are clear indications of deep inequalities, and they are getting worse. One of the most disturbing sections of the report is the analysis of the trends of inequalities. Not only are we starting from the base of a class-divided society in terms of the level of health and the provision of care, but there is a progressive deterioration. There has been a lack of improvement. Indeed, there has been a real deterioration in the health experience not only of class V but of class IV relative to class I, judged by mortality indicators during the 1960s and the early 1970s. I shall not detail that information. It is available for hon. Members who want to consider it.

    The mortality rates for males are higher at every age than those for females, and in recent decades sex differences have become relatively greater. For men of economically active age there is greater inequality between classes I and V in the 1970s than there was in the 1950s and the late 1940s.

    We are witnessing a deterioration and a widening of the class gap in our society. Conservative Members who attack Opposition Members' experience of a class—divided society should read the statistics and realise that in some senses—in terms of health care, education policy and so on—we are becoming more of a class—divided society. When the statistics for the period of the Conservative Government are published, it will be seen that class divisions have sharpened. It will also be seen that regional and national divisions have sharpened.

    I am glad to see the Under-Secretary of State for Wales in his place, because one of the most disturbing statistics is that life expectancy in Wales is not improving relative to Great Britain as it is in Scotland. Throughout the 1970s, in Wales the life expectancy at birth increased by 0·6 years, in Scotland by 0·9 years, and in England by 1·2 years.

    We need from the Welsh Office a study of the reasons for the far higher level of mortality and morbidity in Wales. We also need a specific study of why life expectancy in Wales is not improving, and why the gap in life expectancy between England and Wales is increasing. We need, in effect, a study by the Welsh Office in similar terms to the Black report, so that we may know the reasons for the inequality of provision between Wales and the rest of Britain, and for the inequalities within Wales.

    It is essential to look not only at the definitions of health need but at the way in which health care is delivered. This is an aspect of inequality which has always concerned those who represent regions or areas of relative deprivation, whether inner city or rural. The use-need ratio in terms of social groups and also in terms of regions and localities aggravates the situation. This is the inverse care law to which the hon. Member for Crewe (Mrs. Dunwoody) referred specifically in opening the debate.

    One aspect of the problem has been set out by Cartwright and O'Brien in their paper on social class variation in health care. Some hon. Members have suggested that there are no general practitioners or health care personnel who differentiate in favour of middle-class patients, but the evidence seems to be otherwise.

    Studies of the way in which patients are treated show that middle-class patients tend to have longer consultations than working-class patients. More problems are discussed with middle-class patients. In the study, general practitioners were shown to know more about the background of their middle-class patients. They had more information from them and communicated more information to them. Although working-class patients tended to have spent a longer time within the practice, doctors seemed to know far more about the middle-class patients. Even at the point of receiving care, it seems that there is an imbalance in the distribution and availability of the service.

    As in other aspects of education and social policy, middle-class parents tend to make better use of the National Health Service than working-class people. There is a need to examine the manner in which these services operate at the point of delivery. Many hon. Members will have talked to clients of the social and the health services who have experienced difficulty in relating to the professions. They often feel that there is a professional domination of the client. It is necessary to see how the services can be made more democratic at the point of delivery so that people do not feel inhibited by the presence of professionals, whether social workers or doctors.

    I have already referred to trends showing a greater and widening degree of inequality in various areas. One of the most disturbing figures is that for infant mortality. The Government rightly state that there has been some improvement in infant mortality rates, although the Black report stresses that in this area Britain lags behind. In Wales, the position is becoming worse. I see that the Welsh Office Minister is already consulting about this matter.

    Statistics issued by the Office of Population Censuses and Surveys on 23 November show a higher number of deaths among children before the age of one in Wales. The figure was 12·6 per thousand for Wales and 10·9 per thousand for England. The figures for Clwyd and Gwent are particularly distressing at 16·5 per thousand and 15·2 per thousand, respectively. The Welsh Office should use its equivalent of the Black study to explain why the figures for Gwent and Clwyd are among the highest in Britain.

    There is a need also to initiate health education campaigns. The appalling incidence of heart disease in Wales make it one of the worst areas in Britain in this respect. I echo what was said in relation to Scotland by the hon. Member for Fife, Central (Mr. Hamilton). The Welsh Office should take a more active campaigning role in health education in Wales.

    There is a need especially to examine child development. It is crucial that the Black report's recommendations on school health statistics should be carried out by the Department of Health and Social Security and the Welsh Office. On such matters as the measurement of height and weight, there is a need for clear class-based distinctions to be assessed if we are to tackle inequality. There should also be more effective research into the routine collection and reporting of accidents among children. It is necessary to ensure that the priorities set out for the school health services and child care should be implemented.

    The Government's failure to come to terms with the recommendations made in the Black report and by the Select Committee on Education, Science and Arts on school meals must be stressed. I was disgusted by the response to the unanimous Select Committee recommendation that basic nutritional standards should be assessed by a working party. The Government threw out that idea. In an inadequate response, they suggested that, even if there were recommended standards, it could not be guaranteed that pupils would eat the food prescribed and that previous experience of national standards showed that most of the food provided was wasted. Paragraph 954 of the Black report states:
    "School meals are intended to provide about one third of the daily allowance of nutrients and energy for a child."
    The ham sandwiches offered in Leicestershire and elsewhere provide barely one-sixth, let alone one-third, of the daily allowance of nutrients. Therefore, it is essential to consider the report's recommendations on free school meals. We should revive that campaign. In addition, we should stress the need for day care for pre-school children. It is at that age that we can intervene most effectively to put right the gross inequalities that are still being encountered in our society.

    8.45 pm

    The House is indebted to Sir Douglas Black and his committee for the report. I am particularly indebted, as are my hon. Friends, to my right hon. Friend the Member for Norwich, North (Mr. Ennals) for his initiative in commissioning the report some years ago.

    I am particularly thankful for the way in which the report spells out the regional variations in health care throughout the United Kingdom. We are debating tonight the same old issue that has been debated on many occasions—the problem of the two nations. There are those whose health, relative to their occupational class, is worse. I do not blame the Government for that problem. It has taken many decades to develop, and successive Government have presided over surges and contractions in health care. However, in the present condition of high unemployment the problems that are thrown up need extra special consideration and solution.

    The Labour Party argues that the Government have failed to come forward with policies to tackle the problem. There is a need to redress the imbalance that have been created within our system. One of the most notable imbalances that has emerged from the report relates to life expectancy. I am one of those who were brought up to believe that life expectancy was not relevant to social conditions at home but was more a thought that passed through one's mind when considering the problems in the Far East—certainly in India and Pakistan, where we hear that it is commonplace for people to live only into their late thirties and early forties.

    The report throws up the problem as it arises in the United Kingdom. Paragraph 2.22 says:
    "Average life expectancy provides a useful summary of the cumulative impact of these advantages and disadvantages throughout life. A child born to professional parents, if he or she is not socially mobile, can expect to spend over 5 years more as a living person than a child born to an unskilled manual household."
    That is a dramatic statement. It suggests that occupational class and its effect on a person's maturing will have a direct impact on life span.

    Those factors will have motivated such people as Aneurin Bevan in the 'thirties, when he was considering the embryo National Health Service, which was eventually set up as a result of his help and forceful debate in the 1940s.

    Those anxieties are perhaps eclipsed in the report by the problems identified in the section on stillbirths and infant deaths by sex, age and occupational class. I shall not go into that matter now, because it has already been commented upon by many hon. Members. In the post-neonatal period—that is, babies aged between 1 and 11 months—there is a five to one greater probability per 1,000 female children of those born into occupational class I surviving as against those in class V. That is a dramatic statistic.

    Some weeks ago an argument seemed to be taking place in the media. The Minister was required to reply to statements by the Baby Life Support Systems group. It apparently found that one-third of premature babies in the South-East in need of intensive care were being turned away. As has been mentioned, 55 of the hospitals contacted during the survey had appealed for additional resources. I am told that a radio interview took place within hours of the statement being made on the survey. I am sure that the Minister will intervene to tell me if I am wrong, but I believe he said that the problem was worse in the Northern region. He might care to qualify that in his concluding speech, but he appeared to suggest that in other parts of the country the problem was worse. He seemed to be trying to allay the anxiety of those in the South-East in that way.

    It is right that I said that, but the hon. Gentleman has put my remarks in a false context. I pointed out that the report had been commissioned by the region, which had identified the problem. I also pointed out that we had accepted the report and that we were hoping to deal with it. I think that I answered a question that implied that London was particularly badly served. I pointed out that London was by no means the worst area and that the Northern and Yorkshire regions were both in greater difficulties. I was trying to answer points made earlier about the tendency of the media—the radio and the press—to concentrate excessively on the problems of London while disregarding the fact that there are often more pressing needs elsewhere. The hon. Gentleman should agree with me about that.

    I am glad that the Minister has intervened. His comments on that occasion were raised with me by several people in the region and I told them that I would raise the issue on the Floor of the House in the hope that he would intervene. That is precisely what the hon. and learned Gentleman has done and I am sure that all those in the region who are interested in this subject will take note of his remarks.

    Hon. Members should consider the research carried out into problems in the North. Problems of health care within the region relate, to some extent, to unemployment. Mr. Malcolm College, an academic at the polytechnic in Newcastle, has carried out some interesting research. He surveyed the medical records of about 200,000 people living in the North Tyneside area. He established that there was a strong correlation between early death and unemployment. He found that the number of deaths due to heart disease was up to 50 per cent. higher in areas that were characterised by chronic unemployment, with deaths from bronchitis and lung disease twice the average, and deaths from lung cancer three times the average.

    Mr. College theorises that joblessness creates stress that leads to high blood pressure and physical deterioration. He also found that the health of the whole family is affected by the breadwinner's loss of employment and that often there are increases in perinatal care.

    In another recent study of unemployment and health—the subject of many contributions in the House—Leonard Fagin found that health problems played an important part in the adjustment to unemployed life. He did case studies based on family interviews. Because of the small size of his sample and the exploratory nature of the study, he could draw only speculative conclusions about the link between the health histories of the case families and employment status. Yet his discussion introduces many of the foundations for such a link. He describes the psychological effect of joblessness on the individual and the family, and indicates that stress may be the mechanism by which unemployment can lead to illness. On page 113 of "Unemployment and Health in Families", he says:
    "Stress may be related not only to what is lost, for instance, the financial and psychosocial rewards of work, but also to the difficulties subsequently imposed on the family by unemployment such as poverty, worrying about making ends meet, changes of roles and conflict within the family, resentment about depending on the state, social condemnation, pressures to find a new job, and accepting lower standards. Stress is sometimes dealt with by an increased consumption of alcohol and tobacco".
    That was the point made by the hon. Member for Essex, South-East (Sir B. Braine).

    He stated further:
    "The sick role, as we have seen, offers too many a spurious and temporary respite from the tension experienced by being out of work, due to the reduced responsibilities and the care and attention that accompanies it."

    Both those pieces of research show that there is a clear link between unemployment and ill health. The objectives of the report are to consider possible causes of inequality and the implications for policy. Further research is suggested. A considerable amount of research should be done on a more formal and in-depth basis by a research team sponsored by the Department of Health and Social Security.

    In the debate we have talked about how health care has developed and the link of mortality with unemployment. The Government have always sought not to respond. I remember many occasions in the past few years when we have asked questions about the link between ill health and unemployment and the Government have sought to avoid making it appear that they accept that that link is of any relevance and that it should be a determinant in the way in which resources are allocated.

    In the areas of highest unemployment—whether it is the South, the North or Scotland—special problems exist in the communities. Somehow a responsibility must be placed on the Government to respond by ensuring that adequate resources are made available to deal with the problems.

    The report makes some recommendations on school meals. One is that they be provided in schools, without charge. How do the Government respond to that? If, as we are led to believe, an examination is going on in the Treasury and the Cabinet of the married woman's allowance, and if resources are to be made available—the Secretary of State said that £.3½ billion might be made available if the changes were to be proceeded with—might it not be in order for some of that money, instead of being allocated to child benefit, to be channelled direct to the schools meals service to work towards the introduction of a free school meals service throughout the United Kingdom, not just for those without, but for those with, so that everyone enjoys free provision irrespective of income?

    There are a number of other recommendations on health education. I wonder what the Government's response is to them. There is also the provision of additional moneys for housing in deprived areas. Some of my hon. Friends referred to the relationship between respiratory conditions and bad housing. Surely there can be a consensus in the House that if that link is proven money should be provided for the deprived communities where the incidence of that form of ill health is highest.

    8.57 pm

    I am pleased to have a few minutes to stress my view that there is a major unfairness in the way in which resources for health are allocated. We need to do much more to reallocate them fairly.

    The Labour Government did well to set up the RAWP and to start to implement its recommendations. I am convinced that not only is it a question of reallocating health resources between the better and less well-off regions and then reallocating in the regions so that the deprived areas in the regions get their fair share of resources is equally important that we reallocate resources between the well-off—those who are able to take full advantage of the Health Service—and the least well-off, who cannot take full advantage of it.

    This morning I visited Shawfold, a special school in my constituency. It deals with children with learning difficulties. I talked to some children who were about to leave school. I was struck by the fact that the majority appeared to have a health problem. It is a happy school, but the children are not in good health. In conversation I discovered that the majority come from areas with the worst housing in the constituency. The children have three handicaps—learning difficulties, health problems and living in poor housing.

    We should try to take away the multiple disadvantages of such children. The Black report stresses the disadvantages that so many people suffer. Most of the debate has been depressing, but as a result of concerted efforts by both parties in the past 20 years progress has been made.

    Early this morning I looked out and was depressed by the mist. But then I remembered that at least the mist was relatively clean. Twenty years ago that mist would have been appalling, thick, black smog. By a concerted effort Governments have given the country relatively clean air, not just for the rich, but for everyone. That has made a tremendous difference to everybody's life prospects. If we can rid the atmosphere of smog surely we can do the same in relation to tobacco and lead in the atmosphere. It is a question of will. We could do a great deal if we remembered the clean air campaign.

    The campaign was based on the carrot as well as the stick. The Government should offer some carrots to encourage people to give up smoking. They could ask for smaller national insurance contributions from people who can honestly say that they do not smoke. They certainly cost the Health Service less money. Why cannot the Government decide that people using lead-free petrol pay less tax on it? The Government should offer a few more carrots as well as using sticks to improve public health generally. Prevention is better than cure.

    We should ensure that the Black recommendations are implemented and that we have equality of opportunity in health rather than the inequalities brought to light in the Black report.

    9.4 pm

    The Black report is the report that the Government did not want. As my hon. Friend the Member for Fife, Central (Mr. Hamilton) said today, and several newspapers and magazines in the national and professional press said at the time, the report by the working group on inequalities in health was made available by the Government—I do not say published—only grudgingly, with bad grace and with as little publicity as possible. Only a handful of copies were produced initially. Not enough were produced to provide one for each hon. Member. The Secretary of State for Industry, said that it was being made available for discussion, but I understand that he did not even bother to send a copy to the major health authorities.

    Frankly, I must tell the hon. Member for Chichester (Mr. Nelson) that if he looks into what happened he will find that his strictures on the authors of the Black report for its poor layout and presentation are misplaced. It is his Government who bear the responsibility for its appalling layout, its poor reproduction and the failure even to correct typing errors.

    Although more than two years have passed, the Government have still not arranged a debate on the report in the House of Commons. That has been left to the initiative of the Opposition and the initiative of individual Labour Members—notably my hon. Friend the Member for Fife, Central.

    Nevertheless, however much the Government dislike it, the Black report will not go away. It does exist, and however great the embarrassment of the Government when confronted with its findings, they cannot successfully question the validity of those findings.

    As my hon. Friends have explained, the working group found that there were tremendous inequalities in the health of people in different occupational classes. These inequalities exist for both sexes and at all ages. At birth and in the first month of life a baby born into the family of an unskilled labourer is twice as likely to die as a child born into the family of an accountant or lawyer. During the next 11 months the position gets worse. Four or five times as many children die in the families of unskilled labourers than in those of accountants and lawyers. The ratio fluctuates at different ages but this inequality exists throughout life in all age groups and for almost all diseases and causes of death.

    The statistic which perhaps best illustrates the problem is the calculation of what this inequality meant in terms of deaths from 1972 to 1974. The working group compared death rates in families of professionals such as accountants and lawyers with those among the families of the partly skilled and unskilled. The latter group included the families of agricultural labourers and postmen as well as labourers and cleaners. The Black report records the results, which cannot be challenged. If both groups of families had experienced the same death rate, 74,000 people would not have died. There were nearly 10,000 children among the 74,000.

    The Black report also shows that although the health of all social groups improved during the first 20 years of the National Health Service, the improvement was less for those in partly skilled and unskilled jobs than for professionals. It follows that the inequality has actually increased.

    All these points have been drawn to the attention of the House by my hon. Friends during this debate, but I should like to emphasise one other point. The Black report shows that there is not only inequality between the families of professionals and those of the partly skilled and unskilled. There is not a simple division. In fact, there is a gradient. The health of the family of a bus driver or of a skilled engineering worker may be slightly better than the family of an agricultural worker or an unskilled labourer but it will still be worse than the health of the family of a clerical worker, whose health in turn will be worse than the family of a school teacher, and there is still a gap between the health of that family and the family of an accountant or lawyer. So the true cost of inequality in health is much more than 74,000 lives as shown in the Black report.

    The evidence of these findings is so overwhelming that it cannot be denied. This was admitted by the previous Secretary of State, who is now the Secretary of State for Industry, in a speech delivered in Cardiff 18 months ago. His Under-Secretary of State tried subsequently to suggest during an Adjournment debate arranged by my hon. Friend the Member for Fife, Central that death rates might not be the right way of measuring health and ill-health. To some extent the Under-Secretary of State is right. There is a difference between mortality and morbidity. Mortality statistics are an imperfect measure of ill-health. As the Black report explains, the statistics on morbidity are entirely inadequate. In the absence of anything better we must use death rates. This has the advantage of emphasising that we are discussing matters of life and death. In any case, it is not open to the Government to cast doubt on the analysis in the Black report because it is based on mortality. This Government and previous Governments have used standard mortality ratios as a basis for the RAWP formula and an attempt to achieve a fairer allocation of resources in the National Health Service.

    However, the Black report is concerned not only with inequalities in health. It is clear from the report that these inequalities—indeed much of the ill-health that afflicts the British people—are themselves the result of other inequalities.

    The Black report could well have been called "Inequalities and Health" because it attributes inequality of ill-health and the worse health of the families of unskilled people to a combination of disadvantages inherent in being poor. It is not just the inadequate income, which my hon. Friend the Member for Gower (Mr. Wardell) described, but also bad working conditions, worse housing, worse education and inadequate nutrition. Since the report was published, Sir Douglas Black has said that his view is that it is an inescapable fact that poverty leads to ill-health. However much the Government may squirm, they cannot deny the truth of that statement—that there is inequality in health and a connection between ill-health and other inequalities. The question therefore is: What shall we do about it?

    I will come to the Secretary of State's speech, but first let us examine the Government's immediate reaction to the proposals of the Black report. "Reaction" is the right word to describe the report's foreward. The previous Secretary of State simply rejected all 37 proposals out of hand because he said that the amount involved could he more than £2 billion a year. He suggested that that was "unrealistic in present or any foreseeable economic circumstances". He did not say "not yet" or "not this year" or "not next year". He said "not in any foreseeable circumstances". There was no attempt in the foreword to cost each recommendation for public discussion. There was no attempt to take account of the possible savings to be derived from people's better health. There was just the bald statement that it would cost £2 billion which could not be afforded now or in the foreseeable future. In other words, the Government accept that inequality exists and will always exist and that nothing can be done about it. In short, we had the politics of no hope. It was an inadequate response and the Government soon switched to a different tack. It became fashionable for Conservative spokesmen to say that they did not intend to act on the recommendations of the Black report because there was no guarantee that the recommendations would work. As we all know, that is a classic excuse for inaction. Two more years have passed; another 74,000 people have died; and we have this debate.

    We expected the Secretary of State to tell the House exactly what the Government intend to do about the 37 recommendations. We have been disappointed, of course. Let me emphasise that we do not expect any Government, and certainly not this one, to implement all the recommendations in their entirety or overnight, but we do expect Government, including this one, to make a start and to make progress. Instead, we have the usual mixture of self-justifying assertions and careful evasions of the point.

    The Secretary of State says that the budget for the National Health Service has been increased under this Government. Putting aside the fact that it is always necessary to spend more on the National Health Service in order to stand still, as the Secretary of State admitted during his speech, it is now clear that the Secretary of State has simply not understood the Black report. It is not a matter of spending more on the National Health Service. That may well improve the nation's health, but the point is that we need to spend some extra money in such a way as to attack the inequality of ill-health. We need to concentrate some extra resources on improving the health of the poorest people in our society. It is not a matter of spending more on treatment; we must concentrate on prevention. We applaud the extra resources for the National Health Service, but we are debating inequality in ill-health and the Black report says that if we look at the experience of the past 30 years, we see that a general improvement in health does not affect the pattern of ill-health. I repeat that the Secretary of State has misunderstood the whole point of the Black report.

    Instead of telling us what the Government have done or intend to do about each recommendation, or why they reject most of the recommendations, the Secretary of State simply rehashed the speech that he made a month ago on the Gracious Speech. He said something specific on only two or possibly three of the recommendations. The Secretary of State announced the provision of £2 million to expand the care of under-fives and he told us that he would ensure that the money benefited the most disadvantaged families. That is very welcome, but what else did the right hon. Gentleman say about the recommendations? He told us that the Government have established an advisory committee on the problem of perinatal and neonatal mortality, but he showed a profound misunderstanding of the report in referring to the welcome and rapid decline in perinatal mortality in the past two years. He does not understand that we are anxious, not only about the rate but about the pattern. That is the inequality and he did not even mention it.

    The Secretary of State referred to community care, about which there is a great deal in the report, but again he understands that section of the report only imperfectly. He simply outlined an extension of the policies of this and the previous Government. The report suggested something else. The right hon. Gentleman referred exclusively to the transfer of mentally handicapped or elderly people from hospitals to the community. That was the policy of the previous Government and has been the policy of this Government since the election. The authors of the report argued for more resources to be devoted to care in the community for people already in the community. They recommended extra resources as part of the strategy to break the links between poverty and ill-health. That was not what the Secretary of State was discussing.

    The right hon. Gentleman referred to even more extraneous issues, such as the misuse of drugs. From my correspondence with the Minister for Health he will know that I share the Government's anxiety about drug abuse. I have pressed them to take action against those who encourage the misuse of drugs and other substances. But that important problem has nothing to do with inequality, health and the Black report. That part of the Secretary of State's speech was irrelevant to the debate.

    The hon. Gentleman is solidly lecturing the House about everyone's understanding of the report but his own. First, the report deals with health education and disease prevention. Does he not understand that health education would help to prevent the misuse of drugs? Secondly, when will he deal with the central point about resources? If he does not deal with it, everything that he has said is a fraud.

    If the right hon. Gentleman will contain himself, I shall not only answer his point in my own time, but explain in a little more detail what the Black report is about as he has obviously not read it thoroughly. He is quite right to say that the Black report refers to health education and prevention. It refers to those subjects in such a way as to reduce inequality in health care. It is irrelevant to say that we should therefore discuss the misuse of drugs in today's debate.

    The hon. Gentleman has not answered the second part of the Secretary of State's question. We should like an answer. He underestimates the Government's estimate of the cost of implementing the Black report which, as of 31 July 1981, was £4,800 million according to the Under-Secretary of State for the Environment. There is much talk of a major, wide-ranging and massive programme of public expenditure. Will the hon. Gentleman now tell the electorate how much it will cost?

    I have already said that that is precisely what I propose to do. If the hon. Member for Newcastle upon Tyne, East (Mr. Thomas) had not intervened, my next words would have been "I shall now deal with the alternative." As the hon. Gentleman has raised other points, I shall try to remember them. I shall discuss what the next Labour Government will do and the costs later. Regarding the detailed point of £4·8 billion, or the £5·5 billion that was mentioned today, I mentioned £2 billion because, as the hon. Gentleman will find if he reads my speech in Hansard tomorrow, I was referring to a response by the previous Secretary of State, who is now the Secretary of State for Industry and who estimated that the cost would be £2 billion. I was making a direct reference. That is why I referred to £2 billion.

    It did not escape me that the Secretary of State today referred to the cost of implementing Black as being £5·5 billion. Every time the Government mention the matter, their estimate of the cost of implementing the Black report escalates. What is more, we have no details about how the £5·5 billion was calculated.

    I shall now deal with the alternative.

    If the Government cannot or will not act on the message of the Black report, at least the Opposition can make it clear that the next Labour Government will put the attack on inequality at the centre of their programme.

    That does not mean that we will implement all the recommedations overnight. That was made clear by my right hon. Friend the Member for Salford, West (Mr. Orme) in a debate two years ago. Some of the recommendations are extremely expensive and constitute what the previous Secretary of State described as a major and wide-ranging programme of public expenditure. No one in the Labour Party claims that we can do everything at once. The difference is that, unlike the present Government, we do not rule out expenditure on that scale in any forseeable economic circumstances.

    What we do promise is that the next Labour Government will make an immediate start.

    First, I shall deal with the recommendations for specific measures that are to be undertaken by those who are responsible for health and social services.

    There seems to be some controversy as to whether £2 billion or £5 billion will he spent on implementing the Black report. The hon. Gentleman said that if his party ever gained office, it would make a start on implementing the report. If a Labour Government will make a start, whether with £2 billion or £3 billion, from where will they get the cash? Will they increase the standard rate of tax or VAT, or will they borrow more money?

    I should pay more attention to the hon. Gentleman's intervention if he had been present throughout the debate.

    I shall answer in my own time. I am running out of time because of interventions from the Secretary of State's hon. Friends who are anxious to avoid the Government being embarrassed any more. The emphasis of the next Labour Government's policy will be on prevention of illness and the measurement of progress in achieving that aim.

    The next Labour Government will take immediate action on the recommendation for the programme of health education to be greatly enlarged, with a special focus on schools. We shall therefore involve not only the Department of Health and Social Security and the Department of Education and Science, but district health authorities and local education authorities.

    In this general area of health policy, we recognise the importance of cigarette smoking as a cause of illness and death. Indeed, it is probably the most important cause of ill-health in Britain today.

    The Black report shows that whereas people working in the professions have drastically reduced their smoking, there has been an increase among unskilled workers and their families. This is probably one of the most important causes of inequality in ill-health as well as one of the most important causes of illness. The next Labour Government will therefore ban all cigarette advertising. The cost to the Health Service budget will be nil. In terms of reduced demands on the Health Service, the benefits over the years will be enormous.

    We have been asked to vote on a motion that refers to

    "a major and wide-ranging programme of public expenditure".
    I agree that we should ban cigarette advertising, hut where is this programme and when will the Labour Party be honest enough to tell the electorate what it will cost?

    If the hon. Gentleman will contain himself, I shall outline the whole programme. My hon. Friend did not interrupt him, but he seems constantly to be making speeches. Hon. Members on both sides of the House recognise that the hon. Gentleman is engaged in a constant search for self-justification. If he contains himself, he may learn something to his advantage. Indeed, he seemed to echo the speech of my hon. Friend the Member for Crewe (Mrs. Dunwoody), with one exception—that we could not afford it. The hon. Gentleman and his allies stand convicted of willing the end but not the means. That is not surprising, because whereas Conservative Members represent those who have and Labour Members those who have not, the hon. Member for Newcastle upon Tyne, East merely represents his own ambition.

    The next Labour Government will also legislate, if necessary, for a stronger health warning on all packets of cigarettes and pursue the other recommendations in the Black report relating to the tobacco industry.

    The Black report also contains a group of recommendations for a wider strategy of social measures affecting working conditions and the need for more emphasis on occupational health, better housing and improvements in the care of elderly and disabled people. Had I not been interrupted so often, I would have outlined more of our action on those recommendations. Instead I shall turn to the third and most important group of recommendations affecting children.

    It is not only a matter of the 10,000 unnecessary child deaths that took place between 1972 and 1974. Ill health in childhood affects health later in life. An impoverished childhood increases the likelihood of an early death. That is why the Black report urges that the abolition of child poverty should be adopted as a national goal for the 1980s. What has been the Government's response? There has been nothing but silence. There was not a single reference to that challenge in the Secretary of State's speech.

    The Labour Party accepts that challenge, and the next Labour Government will adopt the abolition of child poverty as a national goal.

    As a first step, the next Labour Government will act on the recommendation to increase child benefit. We are committed to an increase of £2 a week for each child, which today would mean a child benefit of £7·85 per week. That would cost £1·1 billion.

    Mrs. Elaine Kellett-Bowman (Lancaster) rose—

    That compares with £5·70 recommended by the Black report, but that was at November 1979 prices. Its figure today would be £8·70. I am anxious that we should have a fair comparison of what the next Labour Government will do and what the Black report recommended. A sum of £7·85 is not £8·70 in anyone's money, but it is a lot better than £5·85, and we shall not stop there. We shall continue to increase child benefit in real terms, not only in line with the cost of living.

    It is not only a question of providing more money for families with children and the attack on child poverty. The Black report makes many other recommendations to improve the health of children, such as better access to antenatal and child health clinics, better day care facilities and closer links between the school health services and general practitioners.

    The Secretary of State said that he would provide money next year for some of those things. However, what about the provision of school meals for all children as a right, and at no charge? Of course, school meals provision is expensive. The Government have estimated that the cost would be £200 million at Black report prices.

    No one could give a commitment that the next Labour Government will immediately find the necessary money for such a major step forward in social provision, but we shall restore the school meals service to the same level in real terms as existed when the Labour Government left office. That restoration will be directly contrary to the direction in which the Government have travelled. The Government have removed the duty placed on local education authorities to provide meals at a standard price of a prescribed nutritional standard and they have allowed the authorities to provide what they like and to charge as much as they wish, which has inevitably resulted in a reduction in nutritional content and higher prices, with fewer children taking the meals.

    Finally, I turn to one of the least expensive but most far-reaching recommendations in the Black report—that the Government should finance a special health programme in a few selected areas. The working group suggested that there should be 10 such areas, where the death rate is highest, and that £30 million should be set aside for the programme.

    The Secretary of State did not refer to the recommendation at any point in his speech. He did say that he would provide £3 million for the development of primary care in inner cities. That provision is welcome, but the Secretary of State made it clear that it was a response to the Acheson report and not the Black report. The distinction is important because the whole emphasis of the Acheson report is put on the general practitioner and the ancillary services surrounding the family doctor. The Black report recommends something different. The authors recommend that the special programmes in selected areas should include better and more specialised clinics for children and their mothers, with more health visitors and special attention given to health education in those schools. There would be experimental anti-smoking programmes and a special screening service aimed at those groups at special risk.

    The Labour Government will go much further. We shall develop primary care in its widest sense in those selected areas. Primary care will include not only general practitioners and community nurses but dentists, dental therapists, opticians, pharmacists, home helps and chiropodists. We shall develop the NHS as it should be developed and we shall do it in those areas that have the worst health in the country.

    My hon. Friend the Member for Crewe gave a firm commitment to act on that recommendation of the Black report, and act on it we shall.

    The only Conservative Member to grasp the importance of the Black report is the hon. Member for Chichester. He is absolutely right that this report is about equality and inequality. The attitudes of the Conservative Party and the Labour Party to the Black report reflect their differing approaches to equality. However, the hon. Gentleman is completely wrong to suggest that the Labour Party wishes to maintain the existing class system. On the contrary, the Black report's message, which the Labour Party accepts, is that if we wish to attack inequality of ill-health, we must attack the other inequalities between the social classes. By working to reduce the differences between the social classes, we attack the whole class structure of our society.

    The Conservative Government did not want the Black report. They are embarrassed by its conclusions and their policies are in direct conflict with its most important recommendations. By contrast, the Labour Government commissioned the report and we accept its conclusions without reservation. We regard the report's recommendations as a challenge to be taken up by the next Labour Government. The theme of the report will run through the work of that Government in all Departments.

    9.34 pm

    The speech of the hon. Member for Birmingham, Stechford (Mr. Davis) was that of a political strip-tease artiste. He promised much, but in the end he revealed little. He revealed little of what matters most of all—how much public expenditure he would commit a future Labour Government to. By implication, that means expenditure additional to the growing public expenditure on the Health Service that this Government have undertaken.

    I am not sure why the hon. Member for Stechford felt so inhibited because, as the hon. Member for Crewe (Mrs. Dunwoody) showed in her speech, she is rarely inhibited by such matters when she puts forward figures for suggested growth percentages year by year. If she does not believe that our figures are enough, she adds a little more. One always gets the feeling that the hon. Lady will add a nought to any figure that is disappointing to her audience. Public expenditure is the key question that underlines all the ambitious points made in the debate and, for obvious reasons, the Labour Party failed to answer it.

    The Black report and the debate did not receive the reception that the hon. Member for Stechford alleged. It was not rejected wholeheartedly by the Conservative Party. We made no attempt to conceal the report, and we are making no such attempt now.

    No, not yet. My time has been curtailed a little and for understandable reasons, I wish to continue my remarks a little longer.

    The report was commissioned by the Labour Government in 1977. That was an appropriate time for them to commission it because they had cut NHS expenditure in 1975 and in 1976. The report was finished and ready for publication during the lifetime of this Government. The then Secretary of State is accused of hiding it, but it was publicised. More than 100 copies were circulated to every newspaper, which is not the usual way of keeping a report secret. It has been published and reprinted, and about 2,600 copies have been sold. More than 1,000 free copies were distributed. I am sorry that there has been a last-minute rush on the report and that no copies are available in the Vote Office, but we shall make more available. It is nonsense to suggest that any attempt has been made to suppress it.

    The debate concentrated on inequalities in health care between social classes. The debate is directed totally towards the difference in health care received by the social classes. That led to my hon. Friend the Member for Chichester (Mr. Nelson) to complain about the excessive emphasis on class distinctions in health care, although it became obvious that the hon. Member for Preston, South (Mr. Thorne) regarded health as entirely a class issue, and the hon. Member for Merioneth (Mr. Thomas), on behalf of Plaid Cymru, was not far behind him.

    However, the Government do not criticise Professor Black and his colleagues for concentrating on class distinctions, because that was the only remit given to them by the Labour Government. They were instructed to examine differences in health status between the social classes, and that is what they attempted to analyse. Not every Member of the Conservative Party tried to challenge the conclusions of the report. There are inequalities, there always have been inequalities but there should not be such great inequalities between social classes. The Black report sheds some light on them. It may have disappointed some Labour Members who read the report that its class-based analysis is hedged about with more qualifications than most of them were prepared to acknowledge.

    It is unfortunate that the only category that can be used for convenience is occupation. The report is full of explanations as to why that is not a wholly reliable basis. For example, it does not always reflect differences in income. Class I includes clergymen, while class V includes dock labourers, yet the average docker receives more income, whatever other problems he may have, than the average clergyman.

    Comparisons were also made of mortality rates. Some hon. Members were prepared to concede that that, too, is a rough and ready guide to health inequalities, but no one is denying or trying to minimise the problems. I hope that the Labour Party Front Bench representatives are not saying that the only criterion that they will adopt in deciding all their health priorities is inequality based on social class. The report is of value only in shedding light on that one aspect of the many problems and inequalities that must be taken into account in making policy.

    I take one obvious example of the difficulties that arise if one relates only poverty or social class to need and health care. For a long time, East Anglia has had lower average earnings than the rest of the country. Certainly, it has far less than the RAWP target in funding for health services. Yet longevity there is greater than anywhere else in the country and the rates for ulcers, coronary heart disease and many other major killers are lower than elsewhere. That is not surprising when one considers the general environment of East Anglia, but it emphasises the problems that arise if all one's priorities are based on the assumption that a narrow analysis of social class will solve all the problems of health care.

    The inequalities and deficiencies in health care with which the Government seek to deal include not only inequalities between social groups but inequalities between regions, between districts within regions and between different services and types of care and the way in which they have developed in the past. Our policy therefore takes into account not only the social inequalities and the recommendations of the Black report but the fact that, in allocating extra resources for the Health Service, we must work out better planned overall priorities to deal with all the various needs and inequalities. Indiscriminate spending in pursuit of just one aim will not get us very far.

    The hon. Member for Stechford claimed that the Government's increased spending on the Health Service was in some way irrelevant to the Black report. Nevertheless, however unwelcome this may be to the hon. Gentleman, that increased spending is an essential background to the debate. Presumably, in his tentative remarks about higher expenditure, he was talking about even greater expenditure than the Government have achieved. We are therefore entitled to point out that since we came to office spending has been 16 per cent of RPI, with a 5·5 per cent. real growth in services, and the share of GDP going to health has been increased from 4·7 per cent. to 5·5 per cent.

    The hon. Member for Newcastle upon Tyne, East (Mr. Thomas) said that we should stop talking about financial input into the Health Service and start talking about output in terms of patients. I am glad to tell him that in each of the three years 1978–81—the period for which we have figures relevant to the Conservative Government—the number of patients has increased by 3 per cent., accident and outpatient cases by 1 per cent., day cases by 3 per cent., obstetrics cases by 2·9 per cent., and geriatric cases by 5·1 per cent. The number of persons visited by health visitors has increased by 1·3 per cent. and the number treated by home nurses has increased by 1·7 per cent. Those are all annual increases. Therefore, not only has the Health Service never had more money and resources and never employed more doctors and nurses but it has never treated more patients both in hospital and through the domiciliary services.

    The Minister may be pulling the statistical three card trick satisfactorily, but here the hon. Member for Birmingham, Stechford (Mr. Davis) is right. None of those results, whether or not they have been achieved, explains the fact that, so far as we can tell—and this is the serious purpose of today's debate—the inequalities in the Health Service remain largely untouched because within that blanket provision a reorientation of priorities towards the groups that need it most, which I agree are not necessarily class groups, has not taken place.

    It was the hon. Gentleman himself who asked for those figures. As for redistribution, I shall explain exactly what we are doing. The major inequality highlighted by both sides in a debate of this kind is in the regional distribution of resources, and that is what has concerned Governments most. The Government have concentrated on the application of RAWP principles within those growth figures and have continued to redistribute growth money between the relatively better off and the relatively deprived. The moment one tries to go faster, as was pointed out by my hon. Friend the Member for Canterbury (Mr. Crouch), who was supported by the hon. Member for Brent, South (Mr. Pavitt), one runs up against the sheer practicality of trying to speed up the redistribution in the face of the real problems in London and the surrounding areas. Within those restraints, and following RAWP principles, we have altered the share away from Thames regions in favour of the Northern, the North-Western and the Trent regions, which are deprived and always have been, and the Anglia and Oxford regions, where there are growing populations.

    Within the regions there is also a need to shift priority between districts. It is not only in the South-East that some city areas have had a declining population and comparatively good resource provision whereas the population outside the city area has grown and not been served. When one examines the Government's legitimate claims for increased spending on the Health Service and then considers why one hears so much from outside by way of protest and complaint, one finds that the difficulty faced by the Government or by any Government who seriously try to tackle, as we do, the alteration of the balance of resources in the tackling of inequalities is that those who are at the lesser end of priorities begin to complain and react. Hon. Members on the Labour Benches are by no means among the last to react.

    The distribution within regions is as difficult as the distribution between regions. Central London, central Manchester and central Liverpool have falling populations and quite good levels of resources going to their hospitals while the populations of Essex and Medway in the South-East are increasing. One can compare Liverpool, which has a declining population but is somewhat over-resourced in RAWP terms, with Warrington, a poverty-stricken town nearby—[Interruption.] The hon. Member for Liverpool, Walton (Mr. Heffer) should refer to his hon. Friend the Member for Warrington (Mr. Hoyle), who has not spoken in the debate but is waiting for a redistribution to Warrington.

    This illustrates the complexity of policy and explains why we still have conflict against a background of increased resources. Even those arguments about geographical redistributions disguise other complications. Provincial Members are apt to say about, for instance, inner London, that it is plainly over-resourced in hospital services and in acute beds. That is correct, but inner London is underprivileged in primary care, particularly in the provision of general practice. That is why the Government commissioned the Acheson report and will act upon it. My right hon. Friend the Secretary of State has earmarked £3 million of new money specifically for that purpose next year.

    We have also tried to make priorities between resources. In competing for growing funds, if one is eliminating inequalities one must make a judgment about which particular services need to be advanced. The House knows that we have been trying, as we feel we must, to give higher priority to comparatively neglected problem areas—for example, the care of the elderly, the care of the mentally ill and the care of the mentally handicapped. We have concentrated on care in the community, as the Black report emphasised. My right hon. Friend dealt with that perfectly relevantly in his speech by showing the increased spending on joint finance and so on.

    Black recommended that people should be given a better start in life. The Government have not rejected that recommendation. One way to get to the root of inequalities is to do something about perinatal care and to ensure that children are not deprived of health care. The hon. Member for Crewe derided the Government's support for the Mother and Baby campaign of the Health Education Council. That was perfectly valuable support. The hon. Lady did not mention the other action that we have taken since then in other areas of health to improve perinatal care.

    The Government's new Employment Act requires firms to give mothers time off to visit antenatal clinics. The maternity grant we pay by way of income has been made non-contributory, so that this year about 60,000 more women—mainly single and low-income women—will qualify for maternity grant that they would not previously have received. In particular, following the Select Committee's report, we have given added impetus to the setting of better perinatal standards. We have set up the Maternity Services Advice Committee, which has produced its first excellent report on antenatal care and is now preparing a report on care in labour. We are discussing with the committee how best to handle progress towards a check list of good practice in maternity care to enable health authorities to improve their maternity care. The fact is that perinatal mortality rates are improving, and they have improved more over the past two years than ever in our history.

    It was asserted by Opposition Members that although perinatal mortality rates were dropping, somehow the class basis remained. Of course there remains a gap, but it is not true that the gradient of relationship between social classes has remained unchanged. It is because the perinatal figures were worse for classes IV and V that the biggest improvements in perinatal figures have come in the lower social classes.

    I can give figures for six years going back to 1975–76. In social class I, the figure dropped from 13 to 9·7 per 1,000, and in social class V from 26 to 17·5 per 1,000. We have all concentrated on classes I and V, which are numerically very small. The better comparison is between classes II, III and IV, which are much larger.

    Wherever we can, we are giving higher priority to perinatal care and identifying where the real inequalities exist. The combination of our regional policy and our service policy can be seen in the North-West region, where we find the highest incidence of under-weight births and very bad perinatal statistics. That is why, in our new accountability system of regional reviews, where we discuss regional strategies with each of our regional health authorities, we have concentrated with the North-West region on giving particular attention over the next year to the improvement of everything from the availability of family planning to the provision and use of special care baby units. That is the kind of choice of priority objective that we have to pursue.

    I was asked by the hon. Member for Fife, Central (Mr. Hamilton) and the hon. Member for Workington (Mr. Campbell-Savours) about the problem of premature babies. Of course we are trying to tackle that problem. I was accused of having said that the problem is worse in the North. I said that in answer to the inevitable London-based lobby that exists on all these subjects, because some of the London-based specialists in hospitals are nearer to the television studios and it costs less for the Fleet Street cameras to get there. [Interruption.] If the Opposition are led into following every populist campaign in this cause, they will increase the inequalities between regions and not make them less.

    The problem of premature babies was identified in a report in the South-East produced by the regional authority, which had already said that it was accepting it. We are glad that the authority is accepting it. The problem arises because of the pace of medical advance. We are now able to deal with very underweight premature babies who would have died or been regarded as untreatable five and 10 years ago. All over the country we must now seek to keep up with medical advance. We shall give the matter higher priority in the North-West and in the North as well as in the Thames region, in order to keep up with medical progress.

    Will the Minister confirm that the figures he has given, particularly in relation to the ratio between social classes, show that there has been no change, and that even though the decline overall has been real, the ratio is still the same? Also, the North-West contains Mersey, which will have direct cuts next year.

    The North-West does not contain Mersey for Health Service purposes. The hon. Lady and I exchange figures frequently. It may be perverse, but there is a Merseyside regional health authority, which is Liverpool, and there is a North-West regional health authority, which is Manchester and its environs. [Interruption.] If the hon. Lady will table a parliamentary question, I shall publish the full figures, from which it will be seen that the ratio has not changed significantly. There has been some improvement, and because the figures were so much worse for the lower social classes compared with the higher social classes, the biggest per capita improvements have been for the lower social classes. No purpose is served by arguing over the figures. Both the Opposition and the Government want the pattern to improve in the manner that the hon. Member for Stechford has urged. Over the periods of the previous Labour Government and ours, the pattern has improved slightly in the right direction. There has been a dramatic improvement nationally in perinatal mortality rates. This has happened as a result of the policies that the Government continue to pursue.

    There is insufficient time to describe the Government's other priority areas. We cannot be accused of pursuing a health policy that does not seek to deal with inequality. We have chosen priority areas for which we have reserved expenditure for next year to improve standards up and down the country. We are especially keen on the pump-priming schemes recommended by the hon. Member for Berwick-upon-Tweed (Mr. Beith) to establish good practice on an experimental basis in one area which can then be extended.

    In next year's spending, the Government have been able to provide full provision for the pay settlement and for some growth. We are funding from a sum of £22 million new initiatives for the elderly, the mentally ill, the senile and the demented. Those groups have suffered inequality in the Health Service regardless of social class. There is a need to get mentally handicapped children out of hospital. In addition, drug abuse, improved health care in the inner cities, day care for the under-fives and intermediate and non-custodial treatment for young offenders are disparate areas but all selected on a basis of comparative past neglect and service need. This is a much better approach to health policy than to allow ourselves to be carried away by an analysis of social class and the basing of all priorities on that analysis, as the Opposition have done.

    I have been asked a number of questions about prevention. There have been claims that the Government should impose a total ban on cigarette advertising. The Government have tightened up significantly the restrictions on advertising. Our approach means that cigarette advertising is accompanied by a much more prominent warning and a reminder every time someone sees an advertisement. I invite those hon. Members who believe that a ban on advertising would cause a drop in consumption to study the experience of Norway—

    The figures for Norway show a tremendous difference in the number of under-15s starting to smoke.

    I have the figures for Norway, where cigarette advertising was banned in 1973. Since that time, smoking by men has reduced from 51 per cent. to 43 per cent., but smoking by women has increased from 32 per cent. to 33 per cent. In this country, there has been a reduction in smoking during the same period from 52 per cent. to 42 per cent. among men. and from 41 per cent. to 37 per cent. among women. A bigger reduction in smoking has occurred in Britain with our restrictions while in Norway there has been an increase in smoking by women. This shows that it is not the case that a ban would stop smoking.

    My hon. Friend the Member for Essex, South-East (Sir B. Braine) made a formidable speech about alcohol abuse. My hon. Friend mentioned licensing hours, which have been a matter of some controversy in the past. He referred to the Think Tank report and also to "Drinking Sensibly", He remarked that "Drinking Sensibly", produced by the Government, was impeccable in argument and unchallengable on facts. That, coupled with the additional assistance given to voluntary organisations, plus the reform in drinking and driving legislation, with which my right hon. Friend the Secretary of State and I were engaged in our previous Department, is evidence of the Government's commitment. It has been claimed that "Drinking Sensibly" is not selling adequately. Perhaps we should have had the document leaked, like the Think Tank report. That would have created a great deal of interest. Perhaps we should have leaked the Black report. Then we should not have been accused of concealing its contents from the newspapers. We have done the report justice and we do not dispute its analysis. We have a sensible, rational and planned approach to health, not the class-dominated approach of the Labour Party, drawing the wrong conclusions.

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

    The House divided: Ayes 210, Noes 289.

    Division No. 24]

    [10 pm

    AYES

    Abse, LeoAtkinson, N.(H'gey,)
    Adams, AllenBagier, Gordon A.T.
    Allaun, FrankBarnett, Guy (Greenwich)
    Alton, DavidBarnett, Rt Hon Joel (H'wd)
    Archer, Rt Hon PeterBenn, Rt Hon Tony
    Ashley, Rt Hon JackBennett, Andrew(St'kp't N)
    Ashton, JoeBidwell, Sydney

    Booth, Rt Hon AlbertHomewood, William
    Boothroyd, Miss BettyHooley, Frank
    Bottomley, Rt Hon A.(M'b'ro)Howell, Rt Hon D.
    Bray, Dr JeremyHoyle, Douglas
    Brown, Hugh D. (Proven)Huckfield, Les
    Brown, R. C. (N'castle W)Hughes, Mark (Durham)
    Brown, Ron (E'burgh, Leith)Hughes, Robert (Aberdeen N)
    Buchan, NormanJanner, Hon Greville
    Callaghan, Jim (Midd't'n & P)Jay, Rt Hon Douglas
    Campbell, IanJohn, Brynmor
    Campbell-Savours, DaleJohnson, James (Hull West)
    Canavan, DennisJohnson, Walter (Derby S)
    Cant, R. B.Jones, Rt Hon Alec (Rh'dda)
    Carmichael, NeilJones, Barry (East Flint)
    Carter-Jones, LewisJones, Dan (Burnley)
    Clark, Dr David (S Shields)Kaufman, Rt Hon Gerald
    Clarke,Thomas(C'b'dge, A'rie)Kerr, Russell
    Cocks, Rt Hon M. (B'stol S)Kilroy-Silk, Robert
    Cohen, StanleyKinnock, Neil
    Coleman, DonaldLambie, David
    Concannon, Rt Hon J. D.Lamond, James
    Conlan, BernardLeadbitter, Ted
    Cook, Robin F.Leighton, Ronald
    Cowans, HarryLitherland, Robert
    Cox, T. (W'dsw'th, Toot'g)Lofthouse, Geoffrey
    Craigen, J. M. (G'gow, M'hill)McCartney, Hugh
    Crowther, StanMcDonald, Dr Oonagh
    Cryer, BobMcKelvey, William
    Cunliffe, LawrenceMacKenzie, Rt Hon Gregor
    Cunningham, Dr J. (W'h'n)McMahon, Andrew
    Dalyell, TamMcTaggart, Robert
    Davidson, ArthurMcWilliam, John
    Davies, Rt Hon Denzil (L'lli)Marks, Kenneth
    Davis, Terry (B'ham, Stechf'd)Marshall, D(G'gow S'ton)
    Deakins, EricMarshall, Dr Edmund (Goole)
    Dean, Joseph (Leeds West)Marshall, Jim (Leicester S)
    Dewar, DonaldMartin, M (G'gow S'burn)
    Dixon, DonaldMason, Rt Hon Roy
    Dobson, FrankMaynard, Miss Joan
    Dormand, JackMeacher, Michael
    Douglas, DickMikardo, Ian
    Dubs, AlfredMillan, Rt Hon Bruce
    Duffy, A. E. P.Miller, Dr M. S. (E Kilbride)
    Dunnett, JackMitchell, Austin (Grimsby)
    Dunwoody, Hon Mrs G.Morris, Rt Hon A. (W'shawe)
    Eadie, AlexMorris, Rt Hon C. (O'shaw)
    Ellis, R. (NE D'bysh're)Morris, Rt Hon J. (Aberavon)
    English, MichaelMoyle, Rt Hon Roland
    Ennals, Rt Hon DavidMulley, Rt Hon Frederick
    Evans, loan (Aberdare)Newens, Stanley
    Evans, John (Newton)Oakes, Rt Hon Gordon
    Ewing, HarryO'Neill, Martin
    Faulds, AndrewOrme, Rt Hon Stanley
    Field, FrankPalmer, Arthur
    Fitch, AlanPark, George
    Flannery, MartinParker, John
    Foot, Rt Hon MichaelParry, Robert
    Ford, BenPavitt, Laurie
    Forrester, JohnPendry, Tom
    Foster, DerekPowell, Raymond (Ogmore)
    Foulkes, GeorgePrice, C. (Lewisham W)
    Fraser, J. (Lamb'th, N'w'd)Race, Reg
    Freeson, Rt Hon ReginaldRadice, Giles
    Garrett, W. E. (Wallsend)Rees, Rt Hon M (Leeds S)
    George, BruceRichardson, Jo
    Gilbert, Rt Hon Dr JohnRoberts, Albert (Normanton)
    Golding, JohnRoberts, Allan (Bootle)
    Gourlay, HarryRoberts, Ernest (Hackney N)
    Graham, TedRoberts, Gwilym (Cannock)
    Hamilton, James (Bothwell)Robertson, George
    Hamilton, W. W. (C'tral Fife)Ross, Ernest (Dundee West)
    Harman, Harriet (Peckham)Rowlands, Ted
    Harrison, Rt Hon WalterSheerman, Barry
    Hart, Rt Hon Dame JudithSheldon, Rt Hon R.
    Hattersley, Rt Hon RoySilkin, Rt Hon J. (Deptford)
    Healey, Rt Hon DenisSilkin, Rt Hon S. C. (Dulwich)
    Heffer, Eric S.Silverman, Julius
    Hogg, N. (E Dunb't'nshire)Skinner, Dennis
    Holland, S. (L'b'th, Vauxh'll)Smith, Rt Hon J. (N Lanark)
    Home Robertson, JohnSoley, Clive

    Spearing, NigelWeetch, Ken
    Spellar, John Francis (B'ham)Welsh, Michael
    Spriggs, LeslieWhite, Frank R.
    Stallard, A. W.White, J. (G'gow Pollok)
    Stewart, Rt Hon D. (W Isles)Whitehead, Phillip
    Stoddart, DavidWhitlock, William
    Stott, RogerWigley, Dafydd
    Strang, GavinWilley, Rt Hon Frederick
    Summerskill, Hon Dr ShirleyWilliams, Rt Hon A. (S'sea W)
    Taylor, Mrs Ann (Bolton W)Wilson, Rt Hon Sir H. (H'ton)
    Thomas, Dafydd (Merioneth)Wilson, William (C'try SE)
    Thorne, Stan (Preston South)Winnick, David
    Tilley, JohnWoodall, Alec
    Tinn, JamesWoolmer, Kenneth
    Torney, TomWright, Sheila
    Varley, Rt Hon Eric G.Young, David (Bolton E)
    Wainwright, E.(Dearne V)
    Walker, Rt Hon H.(D'caster)Tellers for the Ayes:
    Wardell, GarethMr. Allen McKay and
    Watkins, DavidMr. George Morton.

    NOES

    Adley, RobertCostain, Sir Albert
    Aitken, JonathanCranborne, Viscount
    Alexander, RichardCritchley, Julian
    Alison, Rt Hon MichaelCrouch, David
    Amery, Rt Hon JulianDickens, Geoffrey
    Ancram, MichaelDorrell, Stephen
    Arnold, TomDouglas-Hamilton, Lord J.
    Aspinwall, JackDover, Denshore
    Atkins, Rt Hon H.(S'thorne)du Cann, Rt Hon Edward
    Atkins, Robert(Preston N)Dunn, Robert (Dartford)
    Baker, Kenneth (St.M'bone)Durant, Tony
    Baker, Nicholas (N Dorset)Dykes, Hugh
    Banks, RobertEden, Rt Hon Sir John
    Bendall, VivianEdwards, Rt Hon N. (P'broke)
    Benyon, Thomas (A'don)Eggar, Tim
    Benyon, W. (Buckingham)Elliott, Sir William
    Best, KeithEyre, Reginald
    Bevan, David GilroyFairbairn, Nicholas
    Biffen, Rt Hon JohnFairgrieve, Sir Russell
    Biggs-Davison, Sir JohnFarr, John
    Blackburn, JohnFell, Sir Anthony
    Blaker, PeterFenner, Mrs Peggy
    Body, RichardFinsberg, Geoffrey
    Bonsor, Sir NicholasFisher, Sir Nigel
    Boscawen, Hon RobertFeltcher, A. (Ed'nb'gh N)
    Bottomley, Peter (W'wich W)Fletcher-Cooke, Sir Charles
    Bowden, AndrewFookes, Miss Janet
    Boyson, Dr RhodesForman, Nigel
    Braine, Sir BernardFowler, Rt Hon Norman
    Bright, GrahamFox, Marcus
    Brinton, TimFraser, Rt Hon Sir Hugh
    Brittan, Rt. Hon. LeonFraser, Peter (South Angus)
    Brooke, Hon PeterFry, Peter
    Brotherton, MichaelGardiner, George (Reigate)
    Brown, Michael(Brigg & Sc'n)Gardner, Edward (S Fylde)
    Browne, John (Winchester)Garel-Jones, Tristan
    Bruce-Gardyne, JohnGilmour, Rt Hon Sir Ian
    Bryan, Sir PaulGlyn, Dr Alan
    Buchanan-Smith, Rt. Hon. A.Goodhart, Sir Philip
    Buck, AntonyGoodhew, Sir Victor
    Budgen, NickGoodland, Alastair
    Bulmer, EsmondGorst, John
    Burden, Sir FrederickGow, Ian
    Butcher, JohnGower, Sir Raymond
    Butler, Hon AdamGray, Rt Hon Hamish
    Carlisle, Kenneth (Lincoln)Greenway, Harry
    Chalker, Mrs. LyndaGrieve, percy
    Channon, Rt. Hon. PaulGriffiths, Peter Portsm'th N)
    Chapman, SydneyGrylls, Michael
    Churchill, W. S.Gummer, John Selwyn
    Clark, Hon A. (Plym'th, S'n)Hamilton, Hon A.
    Clark, Sir W. (Croydon S)Hamilton, Michael (Salisbury)
    Clarke, Kenneth (Rushcliffe)Hampson, Dr Keith
    Clegg, Sir WalterHannam, John
    Cockeram, EricHaselhurst, Alan
    Cope, JohnHaselhurst, Alan
    Cormack, PatrickHawkins, Sir Paul
    Corrie, JohnHawksley, Warren

    Hayhoe, BarneyPage, John (Harrow, West)
    Heath, Rt Hon EdwardPage, Richard (SW Herts)
    Heddle, JohnParkinson, Rt Hon Cecil
    Heseltine, Rt Hon MichaelParris, Matthew
    Hicks, RobertPatten, Christopher (Bath)
    Higgins, Rt Hon Terence L.Patten, John (Oxford)
    Hogg, Hon Douglas (Gr'th'm)Pattie, Geoffrey
    Holland, Philip (Carlton)Pawsey, James
    Hordern, PeterPercival, Sir Ian
    Howe, Rt Hon Sir GeoffreyPeyton, Rt Hon John
    Howell, Rt Hon D. (G'ldf'd)Pink, R. Bonner
    Howell, Ralph (N Norfolk)Pollock, Alexander
    Hunt, David (Wirral)Porter, Barry
    Hunt, John (Ravensbourne)Prentice, Rt Hon Reg
    Hurd, Rt Hon DouglasPrice, Sir David (Eastleigh)
    Irving, Charles (Cheltenham)Proctor, K. Harvey
    Jessel, TobyRaison, Rt Hon Timothy
    Johnson Smith, Sir GeoffreyRathbone, Tim
    Jopling, Rt Hon MichaelRees, Peter (Dover and Deal)
    Joseph, Rt Hon Sir KeithRees-Davies, W. R.
    Kaberry, Sir DonaldRenton, Tim
    Kellett-Bowman, Mrs ElaineRhodes James, Robert
    Kershaw, Sir AnthonyRhys Williams, Sir Brandon
    Kimball, Sir MarcusRidley, Hon Nicholas
    Kitson, Sir TimothyRidsdale, Sir Julian
    Knox, DavidRifkind, Malcolm
    Lamont, NormanRippon, Rt Hon Geoffrey
    Lang, IanRoberts, M. (Cardiff NW)
    Lawrence, IvanRoberts, Wyn (Conway)
    Lawson, Rt Hon NigelRossi, Hugh
    Lee, JohnRost, Peter
    Lennox-Boyd, Hon MarkRoyle, Sir Anthony
    Lester, Jim (Beeston)Sainsbury, Hon Timothy
    Lewis, Kenneth (Rutland)St. John-Stevas, Rt Hon N.
    Lloyd, Ian (Havant & W'loo)Shaw, Giles (Pudsey)
    Lloyd, Peter (Fareham)Shaw, Sir Michael (Scarb')
    Luce, RichardShelton, William (Streatham)
    Lyell, NicholasShepherd, Colin (Hereford)
    Macfarlane, NeilShepherd, Richard
    MacGregor, JohnSilvester, Fred
    MacKay, John (Argyll)Sims, Roger
    Macmillan, Rt Hon M.Skeet, T. H. H.
    McNair-Wilson, M. (N'bury)Smith, Dudley
    McNair-Wilson, P. (New F'st)Speed, Keith
    McQuarrie, AlbertSpeller, Tony
    Madel, DavidSpence, John
    Major, JohnSpicer, Jim (West Dorset)
    Marland, PaulSpicer, Michael (S Worcs)
    Marlow, AntonySproat, Iain
    Marten, Rt Hon NeilSquire, Robin
    Mates, MichaelStainton, Keith
    Maude, Rt Hon Sir AngusStanbrook, Ivor
    Mawby, RayStanley, John
    Mawhinney, Dr BrianSteen, Anthony
    Maxwell-Hyslop, RobinStevens, Martin
    Mayhew, PatrickStewart, A.(E Renfrewshire)
    Mellor, DavidStewart, Ian (Hitchin)
    Miller, Hal (B'grove)Stokes, John
    Mills, Iain (Meriden)Stradling Thomas J.
    Mills, Sir Peter (West Devon)Tapsell, Peter
    Miscampbell, NormanTaylor, Teddy (S'end E)
    Moate, RogerTebbit, Rt hon Norman
    Monro, Sir HectorThatcher, Rt Hon Mrs M.
    Montgomery, FergusThomas, Rt Hon Peter
    Moore, JohnThompson, Donald
    Morris, M. (N'hampton S)Thorne, Neil (Ilford South)
    Morrison, Hon C.(Devizes)Thornton, Malcolm
    Morrison, Hon P. (Chester)Townend, John (Bridlington)
    Mudd, DavidTrippier, David
    Murphy, ChristopherTrotter, Neville
    Myles, DavidVaughan, Dr Gerard
    Neale, GerrardViggers, Peter
    Needham, RichardWaddington, David
    Nelson, AnthonyWakeham, John
    Neubert, MichaelWaldegrave, Hon William
    Newton, TonyWalker, Rt Hon P.(W'cester)
    Normanton, TomWalker, B. (Perth)
    Nott, Rt Hon JohnWalker-Smith, Rt Hon Sir D.
    Onslow, CranleyWall, Sir Patrick
    Oppenheim, Rt Hon Mrs S.Waller, Gary

    Walters, DennisWiggin, Jerry
    Ward, JohnWilkinson, John
    Warren, KennethYoung, Sir George (Acton)
    Watson, JohnYounger, Rt Hon George
    Wells, Bowen
    Wells, John (Maidstone)Tellers for the Noes:
    Wheeler, JohnMr. Carol Mather and
    Whitelaw, Rt Hon WilliamMr. Anthony Berry.
    Whitney, Raymond

    Question accordingly negatived.

    Question, That the proposed words be there added, put forthwith pursuant to Standing Order No. 32 (Questions on amendments):

    The House divided: Ayes 288, Noes 245.

    Division No. 25]

    [10.14 pm

    AYES

    Adley, RobertCrouch, David
    Aitken, JonathanDickens, Geoffrey
    Alexander, RichardDorrell, Stephen
    Alison, Rt Hon MichaelDouglas-Hamilton, Lord J.
    Amery, Rt Hon JulianDover, Denshore
    Ancram, Michaeldu Cann, Rt Hon Edward
    Arnold, TomDunn, Robert (Dartford)
    Aspinwall, JackDurant, Tony
    Atkins, Rt Hon H.(S'thorne)Dykes, Hugh
    Atkins, Robert(Preston N)Edwards, Rt Hon N.(P'broke)
    Baker, Kenneth(St.M'bone)Eggar, Tim
    Baker, Nicholas (N Dorset)Elliott, Sir William
    Banks, RobertEyre, Reginald
    Bendall, VivianFairbairn, Nicholas
    Benyon, Thomas (A'don)Fairgrieve, Sir Russell
    Benyon, W. (Buckingham)Farr, John
    Best, KeithFell, Sir Anthony
    Bevan, David GilroyFenner, Mrs Peggy
    Biffen, Rt Hon JohnFinsberg, Geoffrey
    Biggs-Davison, Sir JohnFisher, Sir Nigel
    Blackburn, JohnFletcher, A. (Ed'nb'gh N)
    Blaker, PeterFletcher-Cooke, Sir Charles
    Body, RichardFookes, Miss Janet
    Bonsor, Sir NicholasForman, Nigel
    Boscawen, Hon RobertFowler, Rt Hon Norman
    Bottomley, Peter (W'wich W)Fox, Marcus
    Bowden, AndrewFraser, Rt Hon Sir Hugh
    Boyson, Dr RhodesFraser, Peter (South Angus)
    Braine, Sir BernardFry, Peter
    Bright, GrahamGardiner, George (Reigate)
    Brinton, TimGardner, Edward (S Fylde)
    Brittan, Rt. Hon. LeonGarel-Jones, Tristan
    Brooke, Hon PeterGilmour, Rt Hon Sir Ian
    Brotherton, MichaelGlyn, Dr Alan
    Brown, Michael(Brigg & Sc'n)Goodhart, Sir Philip
    Browne, John (Winchester)Goodhew, Sir Victor
    Bruce-Gardyne, JohnGoodlad, Alastair
    Bryan, Sir PaulGorst, John
    Buchanan-Smith, Rt. Hon. A.Gow, Ian
    Buck, AntonyGower, Sir Raymond
    Budgen, NickGray, Rt Hon Hamish
    Bulmer, EsmondGreenway, Harry
    Burden, Sir FrederickGrieve, Percy
    Butcher, JohnGriffiths, Peter Portsm'th N)
    Butler, Hon AdamGrylls, Michael
    Carlisle, Kenneth (Lincoln)Gummer, John Selwyn
    Chalker, Mrs. LyndaHamilton, Hon A.
    Channon, Rt. Hon. PaulHamilton, Michael (Salisbury)
    Chapman, SydneyHampson, Dr Keith
    Churchill, W. S.Hannam, John
    Clark, Hon A. (Plym'th, S'n)Haselhurst, Alan
    Clark, Sir W. (Croydon S)Havers, Rt Hon Sir Michael
    Clarke, Kenneth (Rushcliffe)Hawkins, Sir Paul
    Clegg, Sir WalterHawksley, Warren
    Cockeram, EricHayhoe, Barney
    Cope, JohnHeath, Rt Hon Edward
    Cormack, PatrickHeddle, John
    Corrie, JohnHeseltine, Rt Hon Michael
    Costain, Sir AlbertHicks, Robert
    Cranborne, ViscountHiggins, Rt Hon Terence L.
    Critchley, JulianHogg, Hon Douglas (Gr'th'm)

    Holland, Philip (Carlton)Pawsey, James
    Hordern, PeterPercival, Sir Ian
    Howe, Rt Hon Sir GeoffreyPeyton, Rt Hon John
    Howell, Rt Hon D. (G'ldf'd)Pink, R. Bonner
    Howell, Ralph (N Norfolk)Pollock, Alexander
    Hunt, David (Wirral)Porter, Barry
    Hunt, John (Ravensbourne)Prentice, Rt Hon Reg
    Hurd, Rt Hon DouglasPrice, Sir David (Eastleigh)
    Irving, Charles (Cheltenham)Proctor, K. Harvey
    Jessel, TobyRaison, Rt Hon Timothy
    Johnson Smith, Sir GeoffreyRathbone, Tim
    Jopling, Rt Hon MichaelRees, Peter (Dover and Deal)
    Joseph, Rt Hon Sir KeithRees-Davies, W. R.
    Kaberry, Sir DonaldRenton, Tim
    Kellett-Bowman, Mrs ElaineRhodes James, Robert
    Kershaw, Sir AnthonyRhys Williams, Sir Brandon
    Kimball, Sir MarcusRidley, Hon Nicholas
    Kitson, Sir TimothyRidsdale, Sir Julian
    Knox, DavidRifkind, Malcolm
    Lamont, NormanRippon, Rt Hon Geoffrey
    Lang, IanRoberts, M. (Cardiff NW)
    Lawrence, IvanRoberts, Wyn (Conway)
    Lawson, Rt Hon NigelRossi, Hugh
    Lee, JohnRost, Peter
    Lennox-Boyd, Hon MarkRoyle, Sir Anthony
    Lester, Jim (Beeston)Sainsbury, Hon Timothy
    Lewis, Kenneth (Rutland)St. John-Stevas, Rt Hon N.
    Lloyd, Ian (Havant & W'loo)Shaw, Giles (Pudsey)
    Lloyd, Peter (Fareham)Shaw, Sir Michael (Scarb')
    Lewis, Kenneth (Rutland)St. John-Stevas, Rt Hon N.
    Lloyd, Ian (Havant & W'loo)Shaw, Giles (Pudsey)
    Lloyd, Peter (Fareham)Shaw, Sir Michael (Scarb')
    Luce, RichardShelton, William (Streatham)
    Macfarlane, NeilShepherd, Richard
    MacGregor, JohnSilvester, Fred
    MacKay, John (Argyll)Sims, Roger
    Macmillan, Rt Hon M.Skeet, T. H. H.
    McNair-Wilson, M. (N'bury)Smith, Dudley
    McNair-Wilson, P. (New F'st)Speed, Keith
    McQuarrie, AlbertSpeller, Tony
    Madel, DavidSpence, John
    Major, JohnSpicer, Jim (West Dorset)
    Marland, PaulSpicer, Michael (S Worcs)
    Marlow, AntonySproat, Iain
    Marten, Rt Hon NeilSquire, Robin
    Mates, MichaelStainton, Keith
    Maude, Rt Hon Sir AngusStanbrook, Ivor
    Mawby, RayStanley, John
    Mawhinney, Dr BrianSteen, Anthony
    Maxwell-Hyslop, RobinStevens, Martin
    Mayhew, PatrickStewart, A.(E Renfrewshire)
    Mellor, DavidStewart, Ian (Hitchin)
    Miller, Hal (B'grove)Stokes, John
    Mills, Iain (Meriden)Stradling Thomas, J.
    Mills, Sir Peter (West Devon)Tapsell, Peter
    Miscampbell, NormanTaylor, Teddy (S'end E)
    Moate, RogerTebbit, Rt Hon Norman
    Monro, Sir HectorThatcher, Rt Hon Mrs M.
    Montgomery, FergusThomas, Rt Hon Peter
    Moore, JohnThompson, Donald
    Morris, M. (N'hampton S)Thorne, Neil (Ilford South)
    Morrison, Hon C. (Devizes)Thornton, Malcolm
    Morrison, Hon P. (Chester)Townend, John (Bridlington)
    Mudd, DavidTrippier, David
    Murphy, ChristopherTrotter, Neville
    Myles, DavidVaughan, Dr Gerard
    Neale, GerrardViggers, Peter
    Needham, RichardWaddington, David
    Nelson, AnthonyWakeham, John
    Neubert, MichaelWaldegrave, Hon William
    Newton, TonyWalker, Rt Hon P.(W'cester)
    Normanton, TomWalker, B. (Perth )
    Nott, Rt Hon JohnWalker-Smith, Rt Hon Sir D.
    Onslow, CranleyWall, Sir Patrick
    Oppenheim, Rt Hon Mrs S.Waller, Gary
    Page, John (Harrow, West)Walters, Dennis
    Page, Richard (SW Herts)Ward, John
    Parkinson, Rt Hon CecilWarren, Kenneth
    Parris, MatthewWatson, John
    Patten, Christopher (Bath)Wells, Bowen
    Patten, John (Oxford)Wells, John (Maidstone)
    Pattie, GeoffreyWheeler, John

    Whitelaw, Rt Hon WilliamYounger, Rt Hon George
    Whitney, Raymond
    Wiggin, JerryTellers for the Ayes
    Wilkinson, JohnMr. Anthony Berry and
    Young, Sir George (Acton)Mr. Carol Mather

    NOES

    Abse, LeoFaulds, Andrew
    Adams, AllenField, Frank
    Allaun, FrankFitch, Alan
    Alton, DavidFlannery, Martin
    Archer, Rt Hon PeterFoot, Rt Hon Michael
    Ashley, Rt Hon JackFord, Ben
    Ashton, JoeForrester, John
    Atkinson, N.(H'gey,)Foulkes, George
    Bagier, Gordon A.T.Fraser, J. (Lamb'th, N'w'd)
    Barnett, Guy (Greenwich)Freeson, Rt Hon Reginald
    Barnett, Rt Hon Joel (H'wd)Freud, Clement
    Beith, A. J.Garrett, W. E. (Wallsend)
    Benn, Rt Hon TonyGeorge, Bruce
    Bennett, Andrew (St'kp't N)Gilbert, Rt Hon Dr John
    Bidwell, SydneyGinsburg, David
    Booth, Rt Hon AlbertGolding, John
    Boothroyd, Miss BettyGourlay, Harry
    Bottomley, Rt Hon A.(M'b'ro)Graham, Ted
    Bradley, TomGrant, John (Islington C)
    Bray, Dr JeremyHamilton, James (Bothwell)
    Brocklebank-Fowler, C.Hamilton, W. W. (C'tral Fife)
    Brown, Hugh D. (Provan)Harman, Harriet (Peckham)
    Brown, R. C. (N'castle W)Harrison, Rt Hon Walter
    Brown, Ron (E'burgh, Leith)Hattersley, Rt Hon Roy
    Buchan, NormanHealey, Rt Hon Denis
    Callaghan, Jim (Midd't'n & P)Heffer, Eric S.
    Campbell, IanHogg, N. (E Dunb't'nshire)
    Campbell-Savours, DaleHolland, S. (L'b'th, Vauxh'll)
    Canavan, DennisHome Robertson, John
    Cant, R. B.Homewood, William
    Carmichael, NeilHooley, Frank
    Carter-Jones, LewisHoram, John
    Cartwright, JohnHowell, Rt Hon D.
    Clark, Dr David (S Shields)Howells, Geraint
    Clarke, Thomas(C'b'dge, A'rie)Hoyle, Douglas
    Cocks, Rt Hon M. (B'stol S)Huckfield, Les
    Cohen, StanleyHudson Davies, Gwilym E.
    Coleman, DonaldHughes, Mark (Durham)
    Concannon, Rt Hon J. D.Hughes, Robert (Aberdeen N)
    Conlan, BernardJanner, Hon Greville
    Cook, Robin F.Jay, Rt Hon Douglas
    Cowans, HarryJohn, Brynmor
    Cox, T. (W'dsw'th, Toot'g)Johnson, James (Hull West)
    Craigen, J. M. (G'gow, M'hill)Johnson, Walter (Derby S)
    Crawshaw, RichardJones, Rt Hon Alec (Rh'dda)
    Crowther, StanJones, Barry (East Flint)
    Cryer, BobJones, Dan (Burnley)
    Cunningham, G. (Islington S)Kaufman, Rt Hon Gerald
    Cunningham, Dr J. (W'h'n)Kerr, Russell
    Dalyell, TamKilroy-Silk, Robert
    Davidson, ArthurKinnock, Neil
    Davies, Rt Hon Denzil (L'lli)Lambie, David
    Davis, Terry (B'ham, Stechf'd)Lamond, James
    Deakins, EricLeadbitter, Ted
    Dean, Joseph (Leeds West)Leighton, Ronald
    Dewar, DonaldLitherland, Robert
    Dixon, DonaldLofthouse, Geoffrey
    Dobson, FrankLyons, Edward (Bradf'd W)
    Dormand, JackMabon, Rt Hon Dr J. Dickson
    Douglas, DickMcCartney, Hugh
    Dubs, AlfredMcDonald, Dr Oonagh
    Duffy, A. E. P.McKay, Allen (Penistone)
    Dunnett, JackMcKelvey, William
    Dunwoody, Hon Mrs G.MacKenzie, Rt Hon Gregor
    Eadie, AlexMaclennan, Rober
    Ellis, R. (NE D'bysh're)McMahon, Andrew
    Ellis, Tom (Wrexham)McNally, Thomas
    English, MichaelMcTaggart, Robert
    Ennals, Rt Hon DavidMcWilliam, John
    Evans, Loan (Aberdare)Magee, Bryan
    Evans, John (Newton)Marks, Kenneth
    Ewing, HarryMarshall, D(G'gow S'ton)

    Marshall, Dr Edmund (Goole)Silverman, Julius
    Marshall, Jim (Leicester S)Skinner, Dennis
    Martin, M(G'gow S'burn)Smith, Rt Hon J. (N Lanark)
    Mason, Rt Hon RoySoley, Clive
    Maynard, Miss JoanSpearing, Nigel
    Meacher, MichaelSpellar, John Francis (B'ham)
    Mikardo, IanSpriggs, Leslie
    Millan, Rt Hon BruceStallard, A. W.
    Miller, Dr M. S. (E Kilbride)Steel, Rt Hon David
    Mitchell, Austin (Grimsby)Stewart, Rt Hon D. (W Isles)
    Mitchell, R. C. (Soton Itchen)Stoddart, David
    Morris, Rt Hon A. (W'shawe)Stott, Roger
    Morris, Rt Hon C. (O'shaw)Strang, Gavin
    Morris, Rt Hon J. (Aberavon)Summerskill, Hon Dr Shirley
    Morton, GeorgeTaylor, Mrs Ann (Bolton W)
    Moyle, Rt Hon RolandThomas, Dafydd (Merioneth)
    Mulley, Rt Hon FrederickThomas, Jeffrey (Abertillery)
    Newens, StanleyThomas, Mike (Newcastle E)
    Oakes, Rt Hon GordonThorne, Stan (Preston South)
    Ogden, EricTilley, John
    O'Halloran, MichaelTinn, James
    O'Neill, MartinTorney, Tom
    Orme, Rt Hon StanleyVarley, Rt Hon Eric G.
    Owen, Rt Hon Dr DavidWainwright, E.(Dearne V)
    Palmer, ArthurWainwright, R.(Colne V)
    Park, GeorgeWalker, Rt Hon H.(D'caster)
    Parker, JohnWardell, Gareth
    Parry, RobertWatkins, David
    Pavitt, LaurieWeetch, Ken
    Pendry, TomWellbeloved, James
    Penhaigon, DavidWelsh, Michael
    Pitt, William HenryWhite, Frank R.
    Powell, Raymond (Ogmore)White, J. (G'gow Pollok)
    Price, C. (Lewisham W)Whitehead, Phillip
    Race, RegWhitlock, William
    Radice, GilesWigley, Dafydd
    Rees, Rt Hon M (Leeds S)Willey, Rt Hon Frederick
    Richardson, JoWilliams, Rt Hon A.(S'sea W)
    Roberts, Albert (Normanton)Williams, Rt Hon Mrs (Crosby)
    Roberts, Allan (Bootle)Wilson, Rt Hon Sir H.(H'ton)
    Roberts, Ernest (Hackney N)Wilson, William (C'try SE)
    Roberts, Gwilym (Cannock)Winnick, David
    Robertson, GeorgeWoodall, Alec
    Rodgers, Rt Hon WilliamWoolmer, Kenneth
    Roper, JohnWrigglesworth, Ian
    Ross, Ernest (Dundee West)Wright, Sheila
    Rowlands, TedYoung, David (Bolton E)
    Sandelson, Neville
    Sheerman, BarryTellers for the Noes:
    Sheldon, Rt Hon R.Mr. Lawrence Cunliffe and
    Silkin, Rt Hon J. (Deptford)Mr. Derek Foster.
    Silkin, Rt Hon S. C. (Dulwich)

    Question accordingly agreed to.

    Resolved,

    That this House notes the content of the Report of the working group on inequalities in health; congratulates the Government on the sustained increase in resources committed to the National Health Service; approves the progress which has been made in allocating resources more fairly between the Health Regions, and the emphasis which has been given to making the best use of the resources available; welcomes the announcement of special initiatives to secure improvements in health services to groups with particular needs; but rejects any programme of massive and damaging increases in public spending, in the knowledge that the maintenance of the Government's economic policy is essential to produce the steady increase in real resources that are required to ensure continued improvements in health care.

    Customs And Excise

    10.26 pm

    I beg to move,

    That the Customs Duty (Personal Reliefs) (No. 1) Order 1968 (Amendment) Order 1982 (S.I., 1982, No. 1591), a copy of which was laid before this House on 16th November, be approved.

    The order has essentially two purposes. One is to call a halt to the practice that has developed of substantial imports of beer and lighters under duty-free concessions in circumstances which give rise to the strong suspicion that they are being imported for commercial rather than for personal use. The second is to make a modest amendment in the rules governing the duty on particular types of spirit. I shall deal with the two aspects in succession.

    First, the imports of beer and lighters. Under the Customs Duty (Personal Relief) (No. 1) Order 1968, beer and mechanical lighters come within the allowances which are granted for goods other than tobacco, spirits, wines, perfumes and toilet water for which tight limits are prescribed. For goods other than those that I have specified, there is an allowance for up to £120 worth of goods that United Kingdom residents returning with purchases made in another member State of the European Community may import. A great deal of beer and many mechanical lighters can be bought for £120. At present £120 will buy about 300 litres of beer.

    In recent months enterprising groups of three or four people have been sharing a van to bring back several hundred pounds worth of beer at a time. The frequency of such importations leaves no doubt that significant quantities of beer are being imported for resale. That also applies to lighters. The amount of beer imported through Dover and neighbouring Channel ports grew from 32,000 litres in May to over 430,000 litres in October. To stop the abuse article 2(3) restricts the permissible import of duty-free beer to 50 litres and duty-free mechanical lighters to 25 in number.

    Is it merely speculation, or does the Minister have clear evidence about the use of imported commodities?

    It is difficult to collect specific evidence. Customs and Excise could only establish beyond peradventure that commodities were being used for commercial purposes if it followed them through to their eventual destination and consumption. That is not practicable for the quantities involved. An increase from 32,000 litres to 430,000 litres in five months suggests something more than personal consumption.

    The limits restrict traffic to a generous level for personal use.

    The order also covers the quantity of spirit that may be imported duty and tax-free. The quantity differs according to alcoholic strength. Under the 1968 order, three litres of spirit not exceeding "38·8 degrees of proof' or one and a half litres of spirit exceeding that strength may be imported. The amending order provides for the dividing line to be expressed as "22% by volume". The change comes into effect from the beginning of next year. It was provided for by section 7 of the Finance Act 1977, which was thereafter implemented by the 1979 order introduced by the Labour Government. An order made under section 13 of the Customs and Excise Duties (General Reliefs) Act 1979 requires an affirmative resolution if it restricts the amount of relief given by a previous order. That is why this provision requires approval by the affirmative resolution procedure. The 22 per cent. is not an absolutely strict conversion of 38·8 degrees proof. The strict conversion would be 22·2 per cent. by volume, but the House might accept that 22 per cent. is a more convenient figure. I emphasise that, so far as we know, there is no spirit in normal commercial traffic that will be caught between the old limit equivalent of 22·2 per cent. and the new 22 per cent. limit.

    The practical effect in terms of trade and imports is zero. Because there is a small downward correction, it is necessary for the order to receive the approval of the House under the affimative resolution procedure.

    The major issue relates to the traffic in beer and lighters. I hope that the House will agree that the commissioners of Customs and Excise could not allow the exploitation of allowances for beer and mechanical lighters to continue on the scale that it has reached. The limits are not ungenerous. They cater adequately for the reasonable needs of travellers.

    The House will be aware that the Select Committee on Statutory Instruments, in its fourth report, has queried the compatibility of the order with the relevant Community directive. I am advised that the order is intra vires, because the need to ensure that duty-free imports are intended for the personal use of the importer is deemed to be overriding.

    On that basis, I ask the House to approve the order.

    10.36 p.m.

    The history of duty-free concessions shows that there has been greater clarity and accuracy since they became statutory. This is a much more sensible way of operating.

    The order limits the amount of duty-free beer to 50 litres and the number of duty-free mechanical lighters to 25. It may be thought that this is comparable because there must be abuse in respect of both items. The Minister has not dealt with lighters. He gave the relevant figures for imported beer. That was useful, and showed how such importation had undergone a startling increase, but he did not give comparable figures for lighters. I am as worried about lighters as I am about beer.

    The figures in the ready reckoner produced in the Autumn forecast show that duty relief is about 14·3 per cent. per pint on beer. That excludes the extra charge of VAT. Fifty litres would yield a duty rebate of 50 times the 14·3 per cent, and then the pints must be converted into litres. I calculate that, exclusive of VAT, bringing in 50 litres of beer would save 12·63.

    In section 3(2) of the Finance Act, the duty on lighters was increased from 20p to 50p under protest from the Opposition. If someone brought in 25 cigarette lighters bearing a duty of 50p each, the duty saving, exclusive of VAT, would be £12·50. The two concessions amount to £12·63 for beer and £12·50 for mechanical lighters. The hon. Gentleman has not given the figures—I should like him to do so now—to show how the importation of mechanical lighters has become the problem that he says it now is. The main consideration—which the Minister completely left out—appears to be rough equality in duty advantage. Should that be the consideration in bringing about these changes, or is it really because the goods are being imported in quantities for a commercial purpose? The Minister must give the figures for mechanical lighters to show that they are being imported for a commercial purpose.

    The 50 litres of beer could be brought in for other than a commercial purpose. Several people could well bring in that amount for one or two parties, particularly during Christmas time, and they could consume that beer within a week or so. It is not an unusual quantity, However, if someone were to bring in 25 lighters, it is difficult to imagine anything other than a commercial purpose. There is a marked difference between the use that can be made of 50 litres of beer and the use that can be made of 25 lighters.

    Last year, we sharply increased the duty on lighters. It is up to the Minister to show that the increase in duty on lighters has led to the possibility of abuse. There may well be some slipshod thinking here, because the two amounts of duty relief are so close that people may mistakenly think that these two items are comparable.

    What other articles are being considered for limitation? If there is abuse in respect of cigarette lighters and beer, there may well be so in other areas. What other articles have been considered for limitation, and are the Government thinking in terms of future regulations on this point? Matches could be one possibility, because thanks to the Finance Act 1982, there has been a considerable increase in the duty on matches. That struck us at the time, and still does, as ludicrous. Nevertheless, it could have certain consequences about which the Minister should inform the House.

    The second proposal is that there should be a change from proof to percentage volume. Is this the last flicker of the Sikes proof system, or does it exist elsewhere in our legislation? I recall that 100 proof measured the alcoholic content which when mixed with a quantity of gunpowder sustained a flame. There was a certain romance about that and it lasted for a considerable time, but, although that system was efficacious, it needed to give way to a more precise measurement.

    Under the old Sikes system, any weaker or stronger liquid could be compared with the 100 proof. That system lasted through many years of increasing accuracy in measurement, and all who have a nostalgic interest in the subject will feel that the percentage of alcohol does not convey the same kind of awe as degrees proof.

    The Minister said that 38·8 proof was not precisely equal to 22 per cent. by volume. The Economic Secretary said that there was nothing on the borderline. I do not know the extent of his consultations, but if he were to be shown that there is a borderline figure he may wish to reconsider the matter. The new system will come into force in one month's time. How much notice was given to the trade for the purpose of changing labels to adjust to the new regime?

    Those are my main points, but, depending on the Economic Secretary's replies, I may need to raise the matter again with the Leader of the House.

    10.45 pm

    I share the anxiety of the right hon. Member for Ashton-under-Lyne (Mr. Sheldon) about lighters. I shall air the matter briefly and try to provide further reasons why the House should reconsider the matter carefully, notwithstanding the fact that it was considered in the Statutory Instruments Select Committee. I hope that my hon. Friend the Economic Secretary to the Treasury will consider this aspect of the matter in his reply.

    Whatever protests were made in 1981, when the Finance Act brought in a swingeing increase in duty, the present duty on lighters is irrational. The matter must be reconsidered because of the European Community aspect. The Government have the opportunity, even if this order is passed, to reconsider the plight of the distributors of lighters and the consumers who wish to purchase cheap lighters but who find it increasingly difficult to do so.

    It is interesting that four countries in the Community levy customs duties as well as VAT on both matches and mechanical lighters. The two have always been linked in the past. Those four countries are Denmark, Ireland, Italy and the United Kingdom. The British excise duty is heavier than that of any other country. The tax on matches is now £1·15 per short standard—or 7,200 matches—and 50p on each lighter, as opposed to 20p before the Finance Act 1981. On disposable lighters, which normally retail at about £1 to £1·25, the tax is now an onerous proportion of the total retail price, excluding VAT.

    In April 1981 there was a 150 per cent. increase in duty, but it must be extremely frustrating to the Treasury that the revenue from that tax is negligible. Despite some reluctance in the Treasury, I managed to extract from it last week the fact that the yield for 1981–82 was £16·4 million and in 1980–81 it was £9·6 million. However, most of that revenue comes from matches and only £3 million comes from mechanical lighters.

    The European Commission has always taken the view—quite legitimately—as do many people in Britain, that the main aim of an excise duty is to raise revenue and that the duty is valid only if the yield is sufficiently great, bearing in mind the expenses incurred in obtaining it. For beer and other main consumption items, that is probably unarguable, but it does not apply to mechanical lighters, which have a small market that is growing smaller as a result of the imposition of this onerous duty.

    A colleague of mine who is a European Member of Parliament recently asked in the European Parliament whether the Commission was still in pursuit of the objective of harmonising duties on tobacco, alcohol, wines, beer and oil and abolishing duties that produce negligible or tiny revenues. The answer was an emphatic "Yes". That is indeed the aim, and it should surely also be the aim of the domestic Exchequer.

    The duty on lighters remains a significant irritant for consumers, importers and manufacturers alike. People in the business in Britain rightly point out that the Commission's proposals for harmonising consumer taxes other than VAT provide that member States should bear it in mind that excise duty should not affect products which may be regarded as essential or ordinary everyday products for normal living. Although beer might come into that category, the yield makes it impossible for the domestic Exchequer to consider abolition. Matches and lighters, however, should surely fall into that category.

    There is now overwhelming evidence that the heavy duty imposed has almost entirely destroyed the market in Britain. Alas, there are now no significant domestic manufacturers of cheaper lighters. Indeed, one of the reasons for the order is that the extremely heavy duty encourages smuggling. In every way, therefore, the duty seems illogical and irrational and no more than a bureaucratic continuation to please the Treasury of a duty that is indefensible in all inherent terms. That is the whole purpose of the special order.

    The Government still have the opportunity to reconsider the duty on lighters whenever they like. It is entirely unsatisfactory for all concerned. Consumers wishing to buy a cheap product have to pay far more because of a duty that yields less to the Treasury than it costs to raise. Manufacturers and importers are selling far fewer lighters. Even well-known companies in this country have either already gone out of business or are on the verge of doing so, so the Exchequer is left to collect a diminishing amount of money. If one or more United Kingdom companies manufactured a cheap lighter to help consumers, the situation might be different in that there might be a case at the margin for protecting a domestic industry, particularly a re-emergent industry. That is not the case, however, as I believe that the only lighters now manufactured in the United Kingdom are high price luxery lighters.

    The Economic Secretary is a wise and sensible person. Therefore, even if he cannot make any changes on the other imported products covered by the order and the abuse that I freely concede goes with them, I hope that he will seriously reconsider the plight of the cheap lighter sector.

    10.52 pm

    I wish to comment on the fourth report of the Select Committee on Statutory Instruments, of which I am Chairman. The Committee drew special attention to the order because

    "there appears to be a doubt whether it is intra."
    The Minister, not unexpectedly, took the view that it was indeed intra vires.

    Paragraph 4 of the report states:
    "Council Directive 69/169/EEC provides that goods in travellers' personal luggage shall be exempt from VAT and excise duty if they have no commercial character and their total value does not exceed a specified monetary limit."
    Here, however, in addition to the specified monetary limit a limit of 50 litres of beer and 25 lighters is being imposed.

    Article 3.2 of the directive states:
    "Importation shall have no commercial character if they
  • (a) take place occasionally and
  • (b) consist exclusively of goods for the personal or family use of travellers, or of goods intended as presents; the nature or quantity of such goods must not be such as might indicate that they are beig imported for commercial reasons".
  • That is a general guideline. It is perhaps unsatisfactory, but it is all that the Treasury has.

    As the Select Committee report makes clear, the provisions of that directive
    "have direct effect in accordance with the principles laid down by the European Court, and … give rise to rights enforceable in the courts of the United Kingdom in accordance with sections 2(1) and (3) of the European Communities Act 1972."

    The Committee does not make a judgment about the merits of the order; it is concerned simply with whether the order is within the framework of the legislation on which the Minister has to operate.

    The Commissioners of Customs and Excise gave a curious explanation in the supplementary memorandum, which is printed in the report to the House and which has been mentioned by the Minister. The directive states that
    "importations shall have no commercial character".
    A number of qualifications are then given. The Commissioners of Customs and Excise say that
    "imported goods are subject to the rule that their nature or quantity must not be such as might indicate that they are being imported for commercial reasons. This constitutes an overriding qualification which is not capable of being displaced by evidence that the goods in question were in fact imported for non-commercial reasons."
    That is an extraordinary explanation.

    A person may arrive with 60 litres of beer for a party which a dozen people will attend. They would be capable of absorbing such a quantity of beer. As he has never done this before, it will be occasional use. But, even if he provides the customs officer with an invitation to the party and with the names and addresses of all those likely to be present, such evidence is not capable of displacing the authority that the Treasury has produced to limit the importation to 50 litres. Therefore, the Committee reported to the House that there did not appear to be any sound basis for the application of the limit either on beer or on lighters beyond the qualifications laid down in article 3.2 of the directive. The Minister may say that that is unsatisfactory.

    Many of us—this was not the common view of the Committee—regard directives from the Common Market with no great affection. None the less, the Committee has a duty to examine the authority of such orders and to report. The Minister has had his advice and we have had our advice. Our advice, from the Speaker's Counsel, is that there is a doubt about the vires of the order. The Committee had to take that matter seriously. I hope the Minister will take the report seriously as the Committee was established to ensure that Ministers excercise their powers accurately and do not produce instruments that go beyond the defined powers.

    The Committee has drawn the attention of the House to this matter. I do not propose to divide the House. I hope that, at the conclusion of our short debate, the Minister will go back to his advisers to see whether an amending instrument is required to conform to the directive and the recommendations of the Committee.

    10.58 pm

    We have had a useful short debate on the order in which a number of questions have been raised and comments made. I should like to deal with them in a somewhat reverse order by beginning with the comments of the hon. Member for Keighley (Mr. Cryer).

    I freely confess to him that when one is among lawyers one is on dangerous ground. It has to be conceded that establishing beyond a peradventure when items are imported for a commercial purpose rather than a personal use presents considerable problems.

    The hon. Gentleman has fairly quoted from the directive which lays upon us the obligation to ensure that duty-free importations should not have a commercial character. The problem we are up against is that once one is dealing for example, with substantial quantities of beer, it is extremely difficult for the Customs and Excise to judge in the period available, without severely delaying traffic, precisely how much is being brought in. The limit of 50 litres has been chosen with a view to establishing a fairly generous point that would be amply adequate for any conceivable personal use.

    The hon. Gentleman suggested that someone coming in with 60 litres of beer—that is quite a large amount—might invite the officer of Customs and Excise to attend the party to see that the beer was consumed on the premises. Unfortunately, the Customs and Excise has neither the time nor the manpower to respond enthusiastically to invitations of that kind. I recognise the authority with which the hon. Gentleman speaks as chairman of the Select Committee. I shall study his remarks. The best legal advice I am given is that the order is intra vires and that it is necessary in the light of recent developments to fulfil our obligations under the directive, especially the obligation to ensure that importation is not for commercial purposes.

    It was for the reasons set out by my hon. Friend the Member for Harrow, East (Mr. Dykes) that I looked sceptically at an import duty on lighters. Although my hon. Friend is correct in saying that lighters manufactured in this country are essentially those at the top of the range, it has to be recognised that the manufacturers would not take enthusiastically to the abolition of the duty. My hon. Friend was suggesting, I believe, that the yield from the duty was less than the cost of collection. I assure him that that is not the case, certainly following the increase in duty in the 1981 Budget.

    This is one aspect of our duty structure that needs to be kept under review for the reasons that my hon. Friend has explained. I cannot give any undertakings, but I accept the argument advanced by my hon. Friend for considering whether the yield and the cost of collection and the risk of smuggling justify the continued imposition of the duty. We must also bear in mind the position of the domestic manufacturers of lighters, who, as I said, would not be keen to see the duty go.

    I apologise to the House for dealing with these points in reverse order, but it is easier to do so. The right hon. Member for Ashton-under-Lyne (Mr. Sheldon) mentioned consultations and the possibility that certain spirits might fall within the gulch between 22·2 per cent. and 20 per cent. or, to put it the other way round, between 38·8 per cent. and 22 per cent., which is the amended order in this range.

    The alcoholic strength of whisky, brandy, rum, gin and vodka is at least 36 per cent. by volume, so they are miles over the top and could not possibly be affected. Most liqueurs also have a strength well in excess of 22 per cent. by volume, with the two exceptions of advocaat and anisette. I must admit that they are not my normal bedtime drinking, but some people have acquired a taste for them. The percentage of alcohol in advocaat is 20·5 per cent., which, again, is well short of the margin between the old and the new dividing line, and in anisette it is 26·3 per cent., which, again, is substantially above the dividing line.

    I am assured that there is no known instance of the 22 per cent. dividing line in practice detracting from the existing duty-free entitlements under the legislation which this order will replace. It was not felt necessary to conduct consultations because the order did not seem to have any impact on the trade.

    A variety of new cream liqueurs have come on the market this year. I should have thought that it would be essential to have consultations about those innovations which were designed for sale in the Christmas trade this year.

    I shall certainly see if there are any exceptions, but I am assured that there are no spirits or liqueurs at or about this dividing line, and, therefore, no known instance where the trade would be affected. However if the right hon. Member for Ashton-under-Lyne, or any other hon. Member, has evidence to the contrary I shall be happy to examine it.

    The right hon. Gentleman asked whether degrees proof still survived in any shape or form and asked about the Sikes system. I must admit that he caught me wholly off-guard on that. However, I am advised that the Sikes system has now been removed from general revenue law and that Customs and Excise has sold off its Sikes hydrometers as souvenirs. If the right hon. Gentleman would like one, I am sure that we could find him one. I cannot, off the cuff, say whether proof exists in any other non-Revenue legislation, but, if it does, I am not aware of it.

    The right hon. Gentleman's main point was that mechanical lighters had been dragged in on the coat tails of the new regulation to control imports of duty-free beer. I understand that recently there have been several instances in which travellers have been found with substantial quantities of manufactured lighters. I have not got any up-to-date figure for the rate of growth in such traffic, but there was a prosecution after a traveller came into the country with 600 lighters. By any stretch of the imagination, that was hardly likely to be for personal use.

    The right hon. Member for Ashton-under-Lyne suggested that 25 might be too handsome a limit to have for lighters and that nobody would want to bring in 25 lighters for personal use. I must admit that in bygone days, when the differential between the cost of lighters in France and the United Kingdom was much greater than it is today, I brought in perhaps half a dozen lighters for my own personal use. I found it well worth doing, because the lighters did not last long and were easily lost. Therefore, a certain number of lighters can reasonably be expected to be imported for personal use. However, I accept that 25 is a pretty handsome limit.

    My argument was not so much that 25 was a handsome limit but that, while it was hard to imagine bringing in 25 lighters for anything other than commercial use, it was easy to see that, in practice, 50 litres of beer could be brought in for personal use. Indeed, my hon. Friend the Member for Keighley (Mr. Cryer) went into the details. The amount of duty saved is such a coincidence that it almost seems as if equality of duty saved was the motive.

    There is no particularly sacrosanct figure for either commodity. After all, 50 litres of beer is a pretty handsome allowance for anybody. If I met the right hon. Gentleman on the quayside at Dover and he was bringing in 50 litres of beer, I would be mildly surprised. [Interruption.] I would not dispute that 25 lighters is perhaps on the generous side, but the line has to be drawn somewhere. The line should be drawn at the point at which people would have considerable difficulty in proving that they were really bringing in a greater quantity for personal use. In the circumstances, the limit of 25 lighters and 50 litres is not unreasonable.

    On that basis, I hope that the House will give the order a fair wind.

    Question put and agreed to.

    Resolved,

    That the Customs Duty (Personal Reliefs) (No. 1) Order 1968 (Amendment) Order 1982 (S.I., 1982, No. 1591), a copy of which was laid before this House on 16th November, be approved.